INTERVIEW WITH A CERTIFIED STROKE REHABILITATION SPECIALIST

Recently, I interviewed Crystal Cabrera. A friend, co-worker, and certified stroke rehabilitation specialist. Below Crystal provides a glimpse into her career thus far, and answers some of the most common questions submitted by fellow OT’s. Hopefully, after reading this post you will have a better understanding of the certification process, the benefits of specializing, and the challenges of working with this population. 

Happy Stroke Awareness Month!

Crystal Cabrera, MS, OT/L, CSRS @thebrainyot

Hi fellow OT’s! My name is Crystal Cabrera. I graduated from Florida International University in 2014 and have been practicing since early 2015. My first practice area was in the Prescribed Pediatric Extended Care (PPEC) center that I completed my last Level II rotation in. I worked with medically fragile children who had various diagnoses, most of which being neurologically based. I also worked in an outpatient center, primarily serving children with Autism, Down syndrome, and developmental delay. I was a pediatric therapist through and through, and I didn’t think that working with adults would ever be my “cup of tea”. However, the financial burden of being a PRN/per-diem therapist eventually got to me (due to inconsistent hours and fluctuations in pay), and so I eventually broadened my job search parameters to include any and all OT positions that could lead to full-time employment. 

In summer of 2016, I landed an interview for a large inner city hospital near my home. I fell in love with the position as my soon to be supervisor explained to me that accepting a position in this facility would eventually lead me to be become a well-versed, adaptable therapist. In this hospital therapists rotate through different areas, which facilitates learning and experience with a variety of diagnoses, settings, and patient populations. I was hired to start off in the neuro inpatient rehab part of the hospital. I have since been rotated through neuro outpatient, neuro acute care, and the medical surgical acute care unit. I currently work in the surgical intensive care unit. Despite the constant change in placement and practice areas, neuro continues to have my heart. However, I value each rotation as I truly believe it builds me to be a better therapist as a whole. I became a Certified Stroke Rehabilitation Specialist after finishing the 4 seminars and passing the test in March 2019. 

So… that’s my “career” story. Outside of work, I am a wife to my amazing high school sweetheart and I’m a fur-mom to a cat named Leo and a dog named Koopa. I enjoy quality time with friends and family, singing, dancing, and traveling. I love to laugh and I love to make others laugh and smile. 

Certification Process:

What prior requirements are needed prior to pursuing a stroke certification? Is the stroke certification only for occupational therapists?

There are no requirements to pursue stroke certification at this time. Ideally, you want to have some stroke experience because the lectures are not exactly entry-level. The CSRS target audience includes all of the following: Physical Therapists, Physical Therapy Assistants, Occupational Therapists and Occupational Therapy Assistants.

What are the benefits of being a stroke certified therapist?

The greatest benefit of becoming a stroke certified therapist, in my opinion, is the access and awareness one gains to resources and evidence based practice during the training. In addition to this, the CSRS title adds to one’s professional development and effectively communicates one’s advanced training to patients, their caregivers, and fellow health care professionals. 

How much does it cost? 

The cost of the four-tiered, seminar-based, stroke educational program is $800. There is also a fee for the certification exam which is $150 for National Stroke Association members and $175 for non-members.

How long is the course?

The course, in its current format, is four days long and spans over two separate weekends. However, there has been discussion in changing the layout of the course. It is currently 32 hours in its entirety. 

Where can you sign up to take course? Where is it offered?

You can sign up for the course at https://www.strokecertification.com/. It is offered in various cities throughout the United States. There are approximately 4-5 course offerings a year. These courses are highly sought out and as such, they become full to capacity quickly after being posted. It is beneficial to sign up for the mailing list to be alerted once new courses become available. I was alerted to my course opening by a good friend of mine and within 24 hours the course was full. 

What is the structure of the course? (lecture, hands-on, exams?)

This course is structured to be evidence based and hands-on. There are multiple presenters, some of which are the actual founders of the course. Each presenter is an established seasoned therapist in stroke rehab and offers a wealth of knowledge for the attendees to learn from. 

Clinical Practice:

What textbooks, reading materials, or resources do you recommend for an OT working with stroke patients?

I recommend reading evidence based research articles weekly. For me, the beauty of stroke rehab is just when I familiarize myself with something, another question or idea comes to mind. It is a very active learning process because stroke rehabilitation is multi-dimensional and always changing. Off the top of my head, here are some books that I have found especially helpful: 

  • Stroke Rehabilitation: A Function-Based Approach by Glen Gillen
  • Occupational Therapy and Stroke by Judi Edmans
  • The Brain that Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science by Norman Doidge

What is a stroke and who does it most commonly affect?

  • A stroke is a medical condition which occurs when the supply of blood to the brain is reduced or blocked completely. There are two types of stroke: ischemic (caused by blockage in the artery) and hemorrhagic (caused by a rupture or leakage from an artery). There is also something known as a “mini-stroke”, which is called a transient ischemic attack (blood flow is impeded for a short period of time). 
  • Stroke risk increases with age but a stroke can occur at any point in an individual’s life. Per literature, strokes are more common in Hispanics and Blacks than Whites. Men have a higher incidence of stroke, however women are more likely to die as a result of stroke. Since women tend to live longer, more women than men die each year due to stroke. 

What are deficits often faced by individuals who have suffered a stroke?

  • Depending on what area of the brain has been affected, there can be many deficits. Below are some of the most common:
    • Hemiplegia- Paralysis to one side of the body, usually the opposite side of where to injury happened in the brain
    • Hemiparesis- Weakness to one side of the body
    • Visual deficits
    • Sensation deficits
    • Speech deficits- Can be expressive (producing speech), receptive (understanding speech), or global (both receptive and expressive)
    • Dysphagia- troubling swallowing
    • Cognitive deficits
    • Changes to temperament, personality, and/or mood
    • Pain
    • Spasticity/Flaccidity- A change in muscle tone

What does the stroke rehabilitation process look like?

  • The stroke rehabilitation process is different for every individual as no two strokes are alike. Even if two individuals were to have the same stroke in the exact same part of the brain, they’d likely differ tremendously in their rehabilitation due to a variety of factors: age, prior level of function, physical health, emotional health, support system, level of motivation, etc.
  • However for a typical view of how the stroke rehabilitation process ideally goes, we often refer to the Brunnstrom Stages of Stroke Recovery. Keep in mind not every person goes through every stage and some people never progress past the beginning stages (for a variety of reasons/factors).
    • Flaccidity- no movement
    • Spasticity Appears- increased reflexes and synergistic movement patterns
    • Increased Spasticity- voluntary control of synergy pattern
    • Decreased Spasticity- person is able to move more, however still within synergy
    • Complex Movement Combinations- moves freely from synergy patterns, demonstrates isolated joint movements
    • Spasticity Disappears- near normal to normal movement and coordination

Which assessment tools are most commonly used with the stroke population? Which one is your favorite?

  • Common assessments used (my favorites underlined):
    • Fugl-Meyer 
    • Box and Block Test
    • Action Reach and Arm Test
    • Arm Motor Ability Test
    • Stroke Rehabilitation Assessment of Movement
    • Motor Assessment Scale

What is the best acute assessment to assess visual neglect/scanning?

  1. Confrontation test for peripheral vision to discover if the patient has field cuts
  2. Cancellation tests for visual scanning
  3. Screen the following by having the patient perform the task as you present the stimulus:
    • Pursuits
    • Saccades
    • Convergence
    • Accommodation

What is the difference between neglect and inattention?

  • Neglect and inattention are often used interchangeably and later differentiated among practitioners by the severity of the deficit. 
  • When an individual completely lacks awareness of, ignores, or even disowns their hemi-body side in functional tasks despite all cues and hand over hand assistance, they would be exhibiting what is known as neglect
  • Inattention is a more appropriate term for someone who initially does not use or look to the affected side, however is able to overcome this initial lack of awareness with cueing. 
  • Neglect is very common in individuals that have a visual deficit known as homonymous hemianopsia. With this visual deficit, both eyes have a loss of vision on the same side. For example, no vision in the left half of both the right and left eye. 

What are the protocols for advancing treatment for a flaccid arm vs. an arm with flexor synergy?

  • When working with a flaccid upper extremity focus on the following:
    • Increase tone/strength to promote functional motor recovery. Facilitation methods (i.e. vibration, joint compressions, brushing, tapping, etc.) and weight-bearing can be effective tools in this stage (to increase proprioceptive input). Integrate occupation/ADLs by using the affected extremity as a stabilizer with additional assistance as needed (dycem, weights, etc).
    • Joint protection to prevent or minimize shoulder pain. Positioning of the affected upper extremity is important! Make sure that the patient and their caregivers are always aware of the placement of the affected arm to prevent injuring it. No pulling on that arm nor allowing it to experience the full effect of gravity via hanging. 
    • Passive range of motion in a safe, pain-free range. No passive range over 90 degrees of shoulder flexion. There is about a 2:1 ratio of movement in the glenohumeral joint to that of the scapulothoracic articulation. With a neurological patient, their scapula may not move to coincide with this scapulothoracicrhythm, leading to subacromial trauma and the development of impingement. 
    • NMES, electrical stimulation can be used to “jump-start” muscle contractions and prevent muscle atrophy. However, some patients may not be able to use e-stim due to contraindications (i.e. defibrillator, pacemaker, history of cancer, etc.) so one must check with their doctor first.
  • When working with a spastic upper extremity focus on the following:
    • Work toward normalizing tone. Low load prolonged stretch via serial casting or splinting often assists in increasing muscle length and reducing hyperactivity of the spastic muscle. 
    • Cold modalities can lead to an overall inhibition of the over-active muscle, decrease spindle activity, and slow nerve conduction. 
    • Electrical stimulation can be used to allow for functional repetition, as well as in conjunction with other methods for decreasing spasticity.
    • You can also speak to the patient’s doctor regarding medication to address spasticity such as Botox or baclofen. Once the patient has received the pharmacological intervention, aggressive therapy utilizing functional tasks should be started to optimize outcomes and results. 

What do you find most challenging about working with this population?

  • I feel that one of the most difficult things about stroke rehabilitation is when the patient hits a plateau despite not having reached their full potential or their personal goals. In these situations, I always make sure that they are doing what needs to be done at home, in addition to our sessions. If someone comes to outpatient 2-3 times a week but doesn’t put what they’ve learned into practice while at home, they are not as likely to make great improvement. However, despite the amount of time and efforts applied, at times progress may halt. In these cases, I provide an excellent home exercise program and we take a “break” from therapy. Sometimes, the patient comes back months later, rejuvenated and with new skills that we can further hone in therapy. Sometimes, they’ve met their maximum recovery. The psychosocial and emotional component of a stroke can be very taxing on an individual. For these reasons, it is important to take into consideration community reintegration and introduce the person to resources to promote engagement and empowerment. In many communities support groups exist for both stroke survivors and their caregivers, which serve as an excellent opportunity for education, networking, and for a sense of belonging/community. 

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