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December 2012 Volume 6

STROKE: THE ACQUIRED BRAIN INJURY Stroke affects over 795,000 Americans each year and remains the number 1 cause of severe disability. These statistics are frightening! There are two types of stroke and both cause brain injury in different ways. The brain receives blood flow through the carotid arteries which are located on either side of the neck. During an ischemic stroke, the blood vessels which supply oxygen rich blood to the brain tissue become occluded or blocked. This blockage stops blood flow and causes tissue death to the area of the brain not receiving the blood flow. When the tissue dies, that specific area of the brain will not recover. The brain is divided into different lobes, or sections, and each section is responsible for different body functions. If the damaged area is responsible for memories, then some memories may be lost. If the area of the brain affected is responsible for movement, then there may be loss of movement. Depending on which area is affected, the person suffering from stroke can suffer grave disability. The same loss of brain tissue can occur with Hemorrhagic stroke. A hemorrhagic stroke is caused by bleeding into the brain tissue. The blood vessel wall becomes damaged in some way and begins to leak blood into the brain tissue. Trauma can also cause bleeding into the brain. Regardless of how the blood escapes from the blood vessels, we still see death of brain tissue. The blood leaks out into the brain and the tissue is flooded by blood, which is generally contained in the blood vessels, and the tissue begins to die. Although there is no blockage to the blood flow, the tissues are still not getting oxygen rich blood and thus the tissue begins to die. The brain tissue does not mix well with blood. Swelling occurs and pressures in the brain rise which causes more brain injury. Stroke is considered an acquired brain injury. Unlike traumatic brain injury, most strokes can be prevented with changes in our lifestyle. The primary cause of both types of stroke is high blood pressure. Blood Pressure Management High blood pressure (BP) is the number one contributing factor to having a stroke. The most recent recommendations for blood pressure management suggests that a healthy blood pressure should be less than 120 systolic (the top number) over 80 diastolic (the bottom number). Once the blood pressure reaches 120-139 systolic and 80-89 diastolic this is considered “prehypertension.” This is where the trouble starts.

Inside this issue… Walk for Brain Injury - 24 Helping Brother and Sisters - 8-9 BIACAL Meeting of the Members - 12  Casino Night - 18 CA Department of Insurance - News Release - 20-21


If our blood vessels remain under this high pressure there is increased risk for stroke. The vessel walls become weakened and the risk for rupture is greatly increased. The best way to treat prehypertension is through weight loss, a low sodium diet, high fruit and vegetable intake, a low fat diet, and moderate use of alcoholic beverages (American Stroke Association, 2008).

Around 795,000 Americans suffer each year from the effects of a Stroke. When BP increases to the hypertension range (>139 systolic or >89 diastolic), and cannot be controlled with diet and exercise, doctors may prescribe a combination of many different medications to help to lower BP. According to the American Stroke Association, (2008), these are the major BP lowering medications: ACE Inhibitors – A hormone that constricts vessel walls is neutralized to relax the arteries. This medication is also used to treat some types of heart failure, heart disease and diabetes. Often it is the first choice of drugs unless you experience cough as a side effect. Examples of medications –Lisinopril and Enalopril (side effect of dry persistent cough). Angiotensin II Receptor Blockers – Works similar to ACE Inhibitors but without the side effect of a persistent dry cough. Some examples of medicines are Cozaar and Benicar. Diuretics – Lowers BP by increasing urine output to help get rid of extra fluid in the body. An example from this group is Lasix. Beta-Blockers – Lowers pulse rate by blocking adrenaline from binding to the heart muscle. Other uses include treatment of heart palpitation, migraine headaches, and heart disease. Medications include metoprolol, Alpha-Blockers – Works about the same as Beta-Blocker by blocking adrenaline. Also used for prostate problems. Calcium Channel Blockers – Opens blood vessels up to increase blood flow. Vasodilators – Relaxes the blood vessels to increase blood flow. All of the above medication works on various factors responsible for maintaining blood pressure in the body. When taking any blood pressure medication, always remember to check your BP regularly, take medications as directed, and follow up with your doctor on a regular basis. Exercise-Let’s Get Moving! Exercise is the best way to ensure heart and brain health, and can help to lower blood pressure. According to the American Heart Association, "all healthy adults aged 18 to 65 years old need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min three days each week" (Bauman, et al., 2007). The intensity of the workout can be combined in any number of ways to get the required amount of exercise each week. A moderate-intensity workout can be a brisk walk that accelerates the heart rate. A vigorous-intensity workout is one that causes rapid breathing and a considerably accelerated heart rate such as in jogging or running. According to the American Heart Association Stroke kills form 150,000 people each year. Muscle strengthening exercises are also recommended two days a week. These exercises include progressive weighttraining program, weight bearing calisthenics, stair climbing, and similar resistance exercises that use the major muscle groups (Bauman, et al., 2007). Exercise is beneficial all around. A healthy diet and exercise can help keep your blood pressure under control and help prevent stroke. So get out there and move, for yourself and your loved ones. Everyone benefits from exercise! Making Good Food Choices If you are overweight, a good start to controlling your blood pressure is to lose those extra pounds. According to the JNC 7 report (2007) losing approximately 20 pounds will cause about at 5-20 point drop in systolic (top number) blood pressure. Also, if you eat a diet rich in fruits, vegetables and low fat dairy and minimize saturated fat you might further help drop systolic pressure by another 8-14 points. If your physician identifies 2 a specific diet for you, look for ways to make it fit your lifestyle! There are many resources available, including those to help “lighten up” traditional recipes. Pay special attention to the ingredients that need to be controlled in your particular diet such as sodium (salt) or cholesterol (fats). 2


As we all know diabetes increases the chances of a person developing not only stroke but also a heart attack. According to the American Diabetes Association 2 out of 3 people with diabetes die from stroke or heart disease. Diabetes causes stroke by forming plaques when blood glucose levels are persistently elevated. Plaque is a pasty substance made up of cholesterol, calcium, cellular waste and protein that not only sticks to the walls of blood vessels but can also impair blood flow to brain causing stroke. Therefore keeping blood glucose levels within target range is vital to preventing stroke. A balance of activity with health eating is a key to keeping blood glucose levels within target ranges. The following applications are great resources for someone to keep track of their healthy life style patterns. However one could learn over time to use their own pen and diary to maintain the life style patterns which might come in handy when devices are not available. ASomeone dies every 3-4 minutes of a stroke Phone Applications Sparkpeople Food & Fitness: For people looking to lose ½-2 lbs per week. Online tracking available. MyFitnessPal Calorie Counter & Diet Tracker: Tracks Fitness & Nutrition goals. Also available online. Calorie Counter: Diets & Activities: Track calories, water intake and fitness. Make your own plan. Calorie Tracker by Livestrong: Designed to help you achieve your goals. Fooducate: Is a shopping companion to identify the benefits of the foods you choose and help you buy the food the next time you shop. Calorie Counter by MyNetDiary: Allows to record meals, water intake, exercise, and weight loss. Is also available online. It includes a library of more than 400,000 foods including restaurants. Online Trackers Fitday.com: Set goals, log your food, track activity and see progress. Mypyramid.gov: Super Tracker can help you plan, analyze and track your diet and physical activity. Myfooddiary.com: Food & exercise log, motivator and support groups available. Thedailyplate.com: Calorie tracker & information tailored to fit your individual needs. It’s all about taking control and staying that way!

Michelle Hartshorn, BSN, RN, CNRN, Stroke Program Coordinator, San Joaquin Community Hospital Ruth Jayaprakash, MSN, RN, Inpatient Diabetes Coordinator, San Joaquin Community Hospital

References American Heart Association. (2008). Heart disease and stroke statistics — 2008 update. Retrieved March 15, 2008, from http:// www.americanheart.org/downloadable/heart/1200078608862HS American Stroke Association. (2008). African Americans power to end stroke. Retrieved March 14, 2008, from http://www.strokeassociation.org/ presenter.jhtml?identifyer=303038 American Stroke Association. (2008). Blood pressure and its relationship to stroke. Retrieved March 13, 2008, from http:// www.strokeassociation.org/presenter.jhtml(?)identifyer=3030891 Bauman, P., Blair, S., Franklin, B., Macera, C., Pate, R., Powell, K., & Thompson, P. (2007). Physical activity and public health: updated recommendations for adults from American College of Sports Medicine and the American Heart Association. Circulation 116(9):1081-93 Retrieved March 12, 2008 from http://circ.ahajournals.org Preventative Cardiovascular Nurses Association. (2007). National guidelines and tools for cardiovascular risk reduction: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003; 289:2561.

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The 2nd Annual Golf for Brain Injury was on October 8th, 2012 at the Bakersfield Country Club. It was a beautiful day and lots of fun. We thank all of our sponsors, participants and volunteers for making this event a big success. We look forward to next year’s tournament on October 14, 2013. SPONSORS BHK Barbich Hooper King Dill Hoffman Advanced Beverage Albertson’s (Coffee & Olive) American General Media Baker Hughes Bakersfield Blaze Bakersfield Building Maintenance Co. Bakersfield Condors Bakersfield Pipe & Supply BMW of Bakersfield

Carpet Outlet Plus Centre for Neuro Skills Costco—Rosedale Driltek, Inc. El Sombrero Restaurant George Culver Global CTI Group, Inc. Hall Commercial Vehicle Service, Inc. Image Tech Advertising Specialties In-Shape Health Clubs

Indian Wells Brewing, Inc. Kern Law Enforcement Association KERO 23 ABC Kohl’s Log Cabin Florist Lonnie & Dawn Kerley Loop Electric, Inc. Mama Tosca’s Ristorante Italiano Mayor Harvey L. Hall My Husband’s Nuts

Pacseis, Inc. Pepsi Soli-Bond, Inc. Sportclips Haircuts for Men Surface Pumps, Inc. T.D. Produce Sales Tel-Tec Security Systems, Inc. Tony’s Pizza The Law Offices of Young Wooldridge Valley Perforating Co. Wells Fargo

SAVE THE DATE Next Golf Tournament is Scheduled October 14, 2013

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Revolutionary apps for simplifying everyday life with brain injury Almost everyday, we hear of new smartphone applications (“apps”) developed for just about everything, from staying organized to finding pharmacies or restaurants while on the road. These iPhone, iTouch, and iPad apps can be very useful to people with a brain injury and their families and caregivers.

CLICK HERE FOR LIST OF “APPS” 4

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Mild Brain Injury and Concussion Definition The term “mild brain injury” can be misleading. The term “mild” is used in reference to the severity of the initial physical trauma that caused the injury. It does not indicate the severity of the consequences of the injury. Read Anne's story about a person who sustained a mild brain injury and the challenges she faced in understanding this injury. The Centers for Disease Control as part of its Report to Congress on Mild Traumatic Brain Injury in the United States developed the following definition of mild brain injury: A case of mild traumatic brain injury is an occurrence of injury to the head resulting from blunt trauma or acceleration or deceleration forces with one or more of the following conditions attributable to the head injury during the surveillance period: Any period of observed or self-reported transient confusion, disorientation, or impaired consciousness; Any period of observed or self-reported dysfunction of memory (amnesia) around the time of injury; Observed signs of other neurological or neuropsychological dysfunction, such as— Seizures acutely following head injury; Among infants and very young children: irritability, lethargy, or vomiting following head injury; Symptoms among older children and adults such as headache, dizziness, irritability, fatigue, or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness. Further research may provide additional guidance in this area. Any period of observed or self-reported loss of consciousness lasting 30 minutes or less. The definition focuses on the actual injury or symptoms, not the possible consequences. For many people, there are challenges in getting an accurate diagnosis and treatment, especially when there is no documented or observed loss of consciousness. There does not need to be a loss of consciousness for a brain injury to occur. What can I do if I have a mild brain injury? Understanding the changes that have occurred from a brain injury is an important part of the recovery process. This makes education and awareness crucial for both the person with a brain injury as well as family and friends. The person with an injury and others need to understand that a “mild” brain injury can result in changes in thinking and memory that can affect a person’s ability to return to their life. While a person can “look fine,” brain injury is an invisible injury. Research has shown that education and information about the possible consequences can be helpful to the person with an injury and family members. Some basic symptoms for family and friends to be aware of include: Early Symptoms: Headache Dizziness or vertigo Lack of awareness of surroundings Nausea with or without memory dysfunction / Vomiting Later Symptoms: Persistent low grade headache Lightheadedness Poor attention and concentration Excessiveness or easy fatigue Intolerance of bright light or difficulty focusing vision Intolerance of loud noises Ringing in the ears Anxiety and depressed mood Irrability and low frustration tolerance Mild Brain Injury Issues (Some important information to share, from families and people who have sustained a mild brain injury) The recovery from a mild injury is not always quick. For mild brain injury, the issues are the same as moderate to severe brain injury. While there are general guidelines for recovery, there can be wide individual variations in the timeframe for recovery. It can take several weeks, or several months for symptoms to fully resolve. Recovery is often uneven. There will be “good days” and “bad days.” This is normal in recovering from a brain injury. An important thing to keep in mind: on the “good days”, people want to get as much done as they can. Often, this can lead to overdoing it, which can bring back symptoms that were previously gone. Even on the good days, it is important to give yourself more time to complete tasks, and to listen to your body. You cannot “tough out” a brain injury.

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Create the best possible environment for recovery Substances like caffeine, alcohol and nicotine can affect a person with a brain injury much more than it did before the injury. Be aware of the possible consequences of alcohol on recovery post injury. It is recommended to abstain from alcohol consumption during the recovery period post injury. Give yourself more time to complete things. Issues like fatigue, attention and memory issues can cause delays in completing tasks that were easily done before the injury. Allowing additional time to do things like laundry, menu planning, shopping, bill paying can help. Thinking out the steps needed to complete tasks and writing them down can be helpful too. Better planning can decrease stress and anxiety. Professional help is important It is important to understand the effects of a brain injury. The injury itself can impair the ability of a person to accurately assess their abilities. And once problems are identified, often a person with a mild brain injury struggles with figuring out effective strategies to compensate for problem areas. Working with a trained brain injury professional can help identify specific problem areas, and can help implement effective strategies. You do not need to figure out brain injury all on your own. There are useful books and resources available. Support groups can be helpful. Brain injury can be isolating. People say things like “you look fine,” with the implication that you should be fine. It is an invisible injury. Sometimes talking with others who have experienced similar experiences can help a person with a brain injury understand they are not the only one dealing with these issues. Mild Brain Injury and Concussion It is important to understand that a concussion is a physical injury to the brain that causes a disruption of normal functioning just like any other physical injury disrupts your normal functioning. For example, some ankle injuries (i.e., sprains and fractures) are more disruptive than others, just as some brain injuries are more disruptive than others. The better we understand any injury, the better our chances are for a speedier and healthier recovery. There is some confusion as to the definition of a concussion and the definition of a mild traumatic brain injury (mTBI). Brain injury can be viewed along a continuum that incorporates concussion, mild brain injury, moderate brain injury and severe brain injury. Each type of brain injury varies depending upon: (1) whether the person was unconscious; (2) how long he/she was unconscious; (3) the length of their amnesia; (4) the resulting cognitive, behavioral and physical problems; and (5) the recovery. The definition for a concussion and a mTBI tend to overlap. To further clarify, a concussion is defined as a trauma (i.e., a blow to the head or a serious whiplash) that induces an alteration in mental status (physical or cognitive abilities) that may or may not involve a loss of consciousness. Concussion as detailed by guidelines developed by the American Academy of Neurology (AAN) and the Brain Injury Association (BIA), commonly is divided into three different types. Grade 1 Concussion Person is confused but remains conscious SIGNS: Temporarily confused, dazed, unable to think clearly, has trouble following directions TIME: Symptoms clear within 15 minutes Grade 2 Concussion Person remains conscious, but develops amnesia SIGNS: Similar to Grade 1 TIME: Symptoms last more than 15 minutes Grade 3 Concussion Person loses consciousness SIGNS: Noticeable disruption of brain function exhibited in physical, cognitive and behavioral ways. TIME: Unconsciousness for seconds or minutes If concussion and mTBI are seen as part of the brain injury continuum, with Grade 3 concussion and mTBI overlapping, one can get a better understanding of how these definitions compliment each other and enhance our understanding. The Brain Injury Association estimates that approximately 75% of all brain injuries fall in the “concussion-mTBI continuum.” For the majority of people who sustain a concussion, a full recovery is possible with appropriate diagnosis and management. (Information courtesy of Brain Injury Association of America)

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Helping Brothers and Sisters A brain injury affects everyone in the family, including brothers and sisters. Siblings often feel abandoned or forgotten as parents spend long hours, days, weeks and even months at the hospital or rehabilitation program. As they are shuttled to school, stay with friends or relatives and overhear conversations, things often just don’t make much sense. Common questions are: Will my brother live? What does it mean to have a brain injury? Will he be different now? How long will it take for him to get better? The unspoken question is “What about me?” The following essay by Katie Beck is a poignant reminder to parents and clinicians that children of all ages need comfort, time, attention, information and support not only during the initial crisis of injury but over time as well. When Katie, now 13 years old and entering eighth grade, recently was given a school assignment to write about conflict, even her parents were surprised to learn how deeply she had been affected by her brother’s brain injury eight years ago. The Accident (by Katie Beck) A long time ago, when I was four years old, my brother got hit by a car. It happened on Kensington Road when he and my sister were on their way back to school after going home for lunch. I remember that day well. It's not something that could be easily forgotten. That day my brother's pet bird had died and he didn't even want to go to school but my mom made him as she thought it would be good for him. Well, he went to school, complaining all the way and when he and my sister Maria came home for lunch, everything was back to normal. I even remember what we had for lunch (Spaghettio's). My brother was still sad about his bird but school helped take his mind off it. When it was time for them to go back to school we walked with Lewie and Maria for a block and said goodbye. We went back home and after a couple minutes decided to catch up with them on bike, so we got my mom's bike and some helmets and rode to school. When we got to Kensington Road we saw a crowd of people around two people that had been hit by a car. As soon as my mom saw it was my brother and sister she screamed louder than I have ever heard anyone scream. The weird part is I know I saw my brother before he was taken to the hospital but I had so much counseling I don't remember what he looked like. My sister was hit too but didn't get injured permanently. She drifted in and out of consciousness. They were both rushed to the hospital while I was taken from house to house not knowing most of the people that helped out my mom by watching me. It scared me a lot. Even though I didn't know exactly what was happening, I knew it was really bad. Hours later my dad picked me up and took me to my aunt's where I stayed for the night. The next day I was taken to the hospital to see my parents but I was not allowed anywhere near Maria or Lewie. I was taken to a lot of social workers who talked to me about what happened and what was probably going to happen. They said my brother would probably die but I didn't understand that either. About four days after the accident, Lewie was finally cleaned up enough for me to see him. When I went into his room, he was surrounded by tubes, machines and blinking lights. I went up to his bed, sat down and began to talk to him though I didn't know why he wasn't talking to me and I was kind of hurt. My sister was fine and got to go home about two weeks after she was hit and I was very jealous of her. [Mom's note: actually, she was released one day after the accident.] She got tons of attention, presents, visitors and she got to ride in an ambulance with the lights flashing even though she wasn't that hurt. It was all very depressing for me. My parents hardly paid attention to me and when they did they were tired and exhausted and got mad at me for no reason. It really hurt! My brother got out of his coma a month after the accident but he still couldn't talk. He got lots of visitors and many prayed for him. Windsor School made a thousand cranes and strung them together because it is said that a thousand cranes makes a dream come true. Lewie's first words were "Ay, carumba" because he was wearing a Bart Simpson shirt and a nurse asked what it said on it. My mom screamed almost as loud as before and ran to tell the doctors. When Lewie went home, Windsor had a huge homecoming and party for him. His homecoming was on TV and everyone made a big deal about it. I felt left out and hurt even though I was happy my brother was home. When Lewie got home everything changed. My parents had no time for my sister and me. Lewie had to go to the hospital for treatments and we had no time to do anything fun. All this created a strain on my family's relationship and I found out that my whole family had changed after the accident. My sister was depressed, my mom was sad and tired all the time, my brother was not loud and hyper all the time and my dad didn't talk as much. I didn't like it at all. Then things got better. My aunts and grandma either helped out my parents or did fun stuff with my sister and me. My bother's speech improved and my parents were under less strain. Now things are much better. My brother goes to a regular school, I don't want my parents' attention and Lewie can do things on his own so my parents are under less stress. I know Lewie wishes the accident never happened but I 4think if it didn't he would get himself in a lot of trouble because before the accident Lewie got into lots of trouble and showed no signs of slowing down any time soon.


Helpful tips for siblings Brothers and sisters need information to understand what has happened and what it means to have a brain injury. You can help by doing the following: Explain exactly what happened in understandable language Explain medical terms, tests and procedures Answer questions directly, but simply Admit what you don’t know Give information as soon as you can Reassure them that the injured child is getting good care Siblings need to be prepared for hospital visits, especially the first time. Let them choose when to visit and for how long Tell them it’s okay to feel nervous or scared Before the visit, describe how their brother or sister looks and behaves Describe equipment such as monitors, ventilators, IV lines and catheters Help siblings, even young children, feel included by: Introducing them to people caring for your child Showing them what to do or how to help with care or therapy Drawing pictures for hospital rooms Making cassette tapes Sending cards, pictures or letters Starting a diary or journal Coming Home Brothers or sisters may think that coming home from the hospital or rehabilitation program means that the brain injury has been “fixed” or “cured.” Discharge from the hospital doesn’t mean that life is “back to normal.” The future still is uncertain. Siblings have many feelings to sort out as life at home changes. Parents may argue more, or be quiet, moody or tearful. They may be exhausted by the end of the day. This leaves less time and attention for siblings even though the family is together again. Siblings can feel resentful and angry if life at home still revolves around the injured child. Siblings may even wish the child had died or that parents would divorce. These are not “bad” thoughts that deserve punishment. They are normal reactions to loss. They are signs that siblings need emotional support and information to adjust to changes in their family. Some siblings cope by being “extra good,” while others rebel, act out and create even more stress for already exhausted parents. Signs that siblings are troubled and need help are nightmares, unusually quiet behavior, changes in eating, increased quarrels or fights, tearfulness, moodiness or difficulty at school. Counseling with a psychologist or social worker experienced in brain injury can help siblings sort out complicated feelings. Some trauma centers and rehabilitation programs have support groups or special meetings for siblings. The following checklist can be used by parents, relatives and professionals to help siblings: Prepare them before visiting the hospital or rehabilitation program Give them verbal and written information about brain injury Encourage them to talk about their feelings Include them in the child’s care if they want to help Take some special time to be with them Include siblings in discharge planning Include them in rehabilitation team meetings Ask about groups or special programs for siblings Have school guidance staff watch for signs of change Consider counseling to help adjustment Discuss the future Information courtesy of Brain Injury Association of America) (originally published in TBI Challenge! Vol.3, No. 4, 1999) By Marilyn Lash, MSW

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HOW DOES A TBI AFFECT THE BRAIN AND BODY? When a TBI occurs, anything having to do with your brain is potentially affected. That means your basic body functions, like eating and sleeping, can be altered. It also means that the complex parts of your life, your emotions, your thoughts, and your ability to communicate can also be disrupted. In serious cases, TBI can also affect the brain’s electrical system, causing seizures. Such a condition is commonly known as epilepsy. TBI is also known to increase the risk for other conditions such as Alzheimer’s and Parkinson disease.

THE LEADING CAUSES OF TBI Falls (35.2%)

Motor vehicle/traffic crashes (17.3%)

Struck by/against (16.5%)

Assaults (11%)

Unknown/other (21%)

Blasts are a leading cause of TBI for active duty military personnel in war zones.

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13th Annual NEUROSCIENCE OF BRAIN INJURY CONFERENCE The 13th Annual Neuroscience of Brain Injury: Research Informing Medical Treatment & Legal Practice Conference was held at the Silverado Resort in Napa, California, over the weekend of November 9-10, 2012. A favorite among brain injury conferences for professionals, we are happy to say that space was once again sold out. The Brain Injury Association of California thanks the speaking faculty who donated their time and travel expenses to present in their area of expertise, affording attendees the opportunity to receive continuing education credits. Watch the BIACAL website for early registration opportunities for the 2013 conference.

2012 AWARD RECIPIENTS

SILENT AUCTION Thank you Bruce and Helen Nelson For procuring the silent auction items

Jeffrey Englander, M.D. Dennis Hays, Esq., CPA

SPONSORS Robert Ludlow, Jr.. Esq.

WINE EVENT SPONSORS

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Brain Injury Association of America Policy Corner Dear Pa ula,

BIACAL

Policy Corner E-Newsletter - September 14, 2012 a weekly update on federal policy activity relatedMEMBERS to traumatic brain injury MEETING OF THE __________________________________________________________________

a special InAtThis Issue: meeting of the members on November 9, 2012, the members unanimously approved Pass to amend the Bylaws as recommended by the Board House of Representatives a Continuing Resolution TBI Act Reauthorization 2012 of Directors. Executive Order from the President on TBI _____________________________________________________ To see a copy of the revised bylaws, go to our website at biacal.org _______________ The Policy Corner is made possible by the Centre for Neuro Skills and Lakeview Neurorehabilitation Centers & Specialty Hospital. Brain Injury Association of America gratefully acknowledges their support for legislative action.

Brain Injury Association of America Policy Corner Dear Pa ula, Continuing Reso lution Fisca l Year 2013 Policy Corner E-Newsletter - September 14, 2012 Onweekly September 13, the House of Representatives passed brain a Continuing a update on2012, federal policy activity related to traumatic injury Resolution (CR) for Fiscal Year 2013 which will continue funding government __________________________________________________________________ programs and services until March 27, 2013 or until final Appropriations legislation canThis be approved. In Issue: House of Representatives Pass a Continuing Resolution The Act CR continues funding at the current rate of operations for federal agencies, TBI Reauthorization 2012 programs, Order and services asPresident provided on in applicable appropriations acts for fiscal year Executive from the TBI 2012 "and under the authority and conditions provided in such acts. " Some changes _____________________________________________________ to current law (not applicable to programs of interest) are included to prevent _______________ catastrophic, irreversible, or detrimental changes to government programs, or to ensure government The by United States Senate is expected to take up the The Policy Corner is oversight. made possible the Centre for Neuro Skills bill next week.Neurorehabilitation Centers & Specialty and Lakeview Hospital. Brain Injury Association of America gratefully TBI Act Rea uthorization acknowledges their support2012 for legislative action.

The Traumatic Brain Injury (TBI) Act, H.R. 4238 was introduced by Representative Bill Pascrell, Jr. (D-NJ) and Representative Todd Russell Platts (R-PA) on Wednesday, March 21, 2012 in the House of Representatives. Please ask your Representative to Continuing Reso Fisca l Year co-sponsor the TBIlution Act, H.R. 4238 and2013 also to serve on the Congressional Brain Injury Task Force if they do not already participate. On September 13, 2012, the House of Representatives passed a Continuing Resolution for Fiscallike Year 2013 whichofwill government Specifically,(CR) BIAA would constituents thecontinue followingfunding members to call their programs and services until to March 27, 2013 until final Appropriations legislation Representative to ask them cosponsor theor bill. The Representatives listed below can be approved. are members of the House Committee on Energy and Commerce, Subcommittee on Health. The CR continues funding at the current rate of operations for federal agencies, programs, and 12services as provided in applicable appropriations acts for fiscal year 2012 "and under the authority and conditions provided in such acts. " Some changes to current law (not applicable to programs of interest) are included to prevent


UPCOMING HOLIDAYS & IMPORTANT DATES TO REMEMBER DECEMBER 22 DECEMBER 25 JANUARY 1 JANUARY 21 FEBRUARY 12 FEBRUARY 14 FEBRUARY 18

“How

FIRST DAY OF WINTER CHRISTMAS DAY NEW YEARS DAY MARTIN LUTHER KING BIRTHDAY LINCOLNS BIRTHDAY VALENTINES DAY PRESIDENTS DAY

you think about a problem is more important than the problem itself. So always think positively.” - NORMAN VINCENT PEALE

BOOKSTORE AND MARKETPLACE

ACBIS Attorneys Awareness and Prevention BIAA and ACBIS Jewelry BIAA Signature Items Booklets Books Brain Injury Source Back Issues Bulk Orders

Business of Brain Injury Webinars Caregivers Education Series Concussion in Sports Conferences and Seminars DVD's, CD's & Videos Educators Family and Caregivers For Children For Persons with Brain Injury Legal Issues Business & Professional Council

CLICK HERE TO GO TO BOOKSTORE & MARKETPLACE

National Brain Injury Information Center Personal Accounts Posters Recorded Webinars Spanish Materials Support Group Resources Treatment and Rehabilitation Upcoming Webinars

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SUPPORT GROUPS IN CALIFORNIA For a list of support groups, contact Ursula Pesta at upesta@biacal.org

SLOW DOWN YOUR LISTENING How many times do you find your mind wandering when someone is talking to you? No, you don’t have attention deficit disorder. The average person speaks at an average rate of about 120 words a minute but most people can listen about four times faster. So your mind fills in the gaps by thinking of other things. Be aware of this and slow down your listening. Force yourself to stay focused, so that you can really comprehend everything the speaker is saying.

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THE BRAIN INJURY ASSOCIATION OF CALIFORNIA WISHES EVERYONE A VERY HAPPY HOLIDAY During holidays, leisure replaces work as a priority. You are filled ENJOYING THE HOLIDAYS with the enthusiasm to explore, AFTER BRAIN INJURY travel and learn. So indulge in laziness. Spend time with your The holidays can be distressing and emotionloved ones and let your heart ally charged with pitfalls for someone with a brain injury. It is not unusual for a person with dance. - Roger Bannister

BRAIN INJURY ASSOCIATION OF AMERICA

a brain injury to have their communication and social skills worsen at parties. For starters, routines are disrupted and there can be an increased number of social functions with less time to rest in between. Things can get even more challenging if alcohol is added to the mix. And for individuals prone to seizure activity, holiday lighting could increase the risk of a seizure. A social setting, like a party with many people engaged in conversation, eating, and drinking, can easily become over-stimulating and even upsetting to a person with TBI. To help deal with all these issues, you might try limiting the number of engagements during the holidays. Limit the time that you attend parties as all of the activity can probably tire you out. For someone with TBI, it can be exhausting trying to converse in crowds, with strangers, and in overstimulating settings.

EASY GINGERBREAD FRIENDS INGREDIENTS 1 roll (16.5 oz) PillsburyÂŽ refrigerated gingerbread cookies 1/2 cup ready-to-spread frosting 100 red cinnamon candies or other small red candies

DIRECTIONS Heat oven to 350°F. Remove half of cookie dough from wrapper; refrigerate remaining dough until needed. Sprinkle about 1/4 cup of flour onto work surface; coat sides of half of dough with flour. With rolling pin, roll out dough to 1/4-inch thickness, adding additional flour as needed to prevent sticking. With floured 2 1/2- to 3-inch gingerbread boy or girl cutter, cut out dough boys or girls. Gently brush excess flour from shapes; place 2 inches apart on ungreased cookie sheet. Repeat with remaining half of dough. Bake 7 to 9 minutes or until light golden brown. Cool 1 mi4 racks. Cool comnute; remove from cookie sheet to cooling pletely. Place icing in piping bag, decorate with icing and candies for eyes and buttons, as desired.

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SETTLEMENT EASES RULES FOR SOME MEDICARE PATIENTS By ROBERT PEAR

WASHINGTON — Tens of thousands of people with chronic conditions and disabilities may find it easier to qualify for Medicare coverage of potentially costly home health care, skilled nursing home stays and outpatient therapy under policy changes planned by the Obama administration. In a proposed settlement of a nationwide class-action lawsuit, the administration has agreed to scrap a decades-old practice that required many beneficiaries to show a likelihood of medical or functional improvement before Medicare would pay for skilled nursing and therapy services. Under the agreement, which amounts to a significant change in Medicare coverage rules; Medicare will pay for such services if they are needed to "maintain the patient's current condition or prevent or slow further deterioration," regardless of whether the patient's condition is expected to improve. Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services "does not turn on the presence or absence of an individual's potential for improvement," but is based on the beneficiary's need for skilled care. Judith A. Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for the beneficiaries, said the proposed settlement could help people with chronic conditions like Alzheimer's disease, multiple sclerosis, Parkinson's disease, stroke, spinal cord injuries and traumatic brain injury. It could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care. "As the population ages and people live longer with chronic and long-term conditions," Ms. Stein said, "the government's insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people." In many cases, she said, the denial of coverage led to a denial of care because most people cannot afford to pay for these services on their own. Neither she nor Medicare officials could say how much the settlement might cost the government, but the price of expanding such coverage could be substantial. Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, called the settlement "a landmark decision for Medicare recipients with chronic illness and especially those with disability."

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"Disability frequently accompanies many chronic conditions," Dr. Gerber said, "and we often have no cures, so people are likely to experience progressive disability. Rehabilitation, physical and occupational therapy and skilled care are incredibly important in maintaining a person's functional ability, performance and quality of life." The lead plaintiff, Glenda R. Jimmo, 76, of Bristol, Vt., has been blind since childhood. Her right leg was amputated below the knee because of blood circulation problems related to diabetes, and she is in a wheelchair. She received visits from nurses and home health aides who provided wound care and other treatment, but Medicare denied coverage for those services, saying her condition was unlikely to improve. Another plaintiff, Rosalie J. Berkowitz, 81, of Stamford, Conn., has multiple sclerosis, but Medicare denied coverage for home health visits and physical therapy, on the ground that her condition was not improving. Her family said she would have to go into a nursing home if Medicare did not cover the services. The proposed settlement, negotiated with lawyers from the Justice Department and the Department of Health and Human Services, was submitted last week to Christina C. Reiss, the chief judge of the Federal District Court in Vermont. If she approves it, as expected, she would have authority to enforce it for up to four years. Asked about the proposed settlement, Robert D. Reischauer, a public trustee of the Medicare program, said: "Unquestionably that would increase costs. How much, I can't say." Other independent experts expressed similar views. While the settlement is likely to generate additional costs for the government, it might save some money too. For example, physical therapy and home health care might allow some people to avoid more expensive care in hospitals and nursing homes. Charles S. Miller, a Justice Department spokesman, and Erin Shields Britt, a spokeswoman for the Health and Human Services Department, said government lawyers had no comment. The changes will apply to the traditional Medicare program and to private Medicare Advantage plans. They apply to people 65 and older, as well as to people under 65 who qualify for Medicare because of disabilities. The Obama administration initially urged the judge to dismiss the lawsuit. Medicare officials denied that they had a formal policy requiring beneficiaries to show their conditions would improve. However, in a separate lawsuit in Pennsylvania, Medicare officials argued the reverse. In order for Medicare to cover skilled nursing care, they said in a legal brief, "there must be an expectation that the beneficiary's condition will improve materially in a reasonable and generally predictable period of time." The same standard, in nearly identical language, is found in guidelines used by some Medicare contractors, which review and pay claims on behalf of the government. In a typical case, Medicare terminated coverage of skilled nursing care and physical therapy for an 81-year-old woman because she had "exhibited a decline in functional status." Under the settlement, the federal court in Vermont will certify a nationwide class of more than 10,000 Medicare beneficiaries whose claims for skilled nursing and therapy services were denied before Jan. 18, 2011, when the lawsuit was filed. Many of them will have an opportunity to have their claims re-examined under the revised standards. Plaintiffs in the case include the National Multiple Sclerosis Society, the Parkinson's Action Network, Paralyzed Veterans of America and the National Committee to Preserve Social Security and Medicare, an advocacy group. Neither the Medicare law nor regulations require beneficiaries to show a likelihood of improvement. But some provisions of the Medicare manual and guidelines used by Medicare contractors establish more restrictive standards, which suggest coverage should be denied or terminated if a patient reaches a plateau or is not improving or is stable. In most cases, the contractors' decisions denying coverage become the final decisions of the federal government. 17


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NEWS RELEASE Notice Issued to Health Insurers Reminding Them of Legal Obligation to Consumers When Claim Is Denied Insurance Commissioner Educates Consumers About Their Right to Appeal Treatment Denials Insurance Commissioner Dave Jones today issued a Notice to Insurers reminding them they are legally obligated to fully disclose to consumers why a claim for treatment has been denied. According to the California Insurance Code, when insurers deny requested treatment as not a covered benefit they are required to give policyholders the specific provisions in their policy that excludes coverage. In addition, if companies deny coverage for a treatment as not medically necessary, they are required to outline the facts and law on which they based their denial. "Consumers have the right to full disclosure by their health insurer as to why they are being denied coverage," said Commissioner Jones. "That way they can make a fully informed decision about whether they agree with the decision, or whether they want to contest it." The California Department of Insurance (CDI) receives nearly 9,000 health insurance complaints a year-about 7,000 involve health claims issues. Commissioner Jones also issued a consumer alert, educating policyholders about their right to appeal to the Department of Insurance when an insurer denies their claim for treatment. There is a fair chance a review of the decision could go in their favor. He reminds policyholders they have a right to appeal to the company and also ask CDI to review the denial. "Dealing with a complicated medical condition for yourself or a loved one is stressful enough," said Commissioner Jones. "If your health insurer won't initially cover your treatment, that's not the end of it. As a consumer, you have options. You may file a Request for Assistance with my Department whenever you have problems with an insurer involving a claim. Denial by an insurance company is not the final word." If your claim was denied because the insurer determined the treatment is not medically necessary or was experimental, you may request an Independent Medical Review (IMR) from the Department at no cost to you. However, you must first file an appeal of the denial with your insurance company, using the company's internal appeals/grievance process while keeping several important steps in mind: Find out Review the reason for the denial and review the policy language supporting the denial; Submit all necessary support for treatment, with doctors statements and medical records; Provide research showing the treatment requested is accepted and appropriate, if 24 possible.

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BOARD OF DIRECTORS Richard Adams, MD J. Ashley, CCC-SLP, If Commissioner Jones reminds consumers it's important to be aware Mark of all IMRSc.D., deadlines. CCM, CBIST the insurance company upholds its decision or delays its response to the appeal/grievance, Doreen Casuto, RN, CRRN, CCMsix then file a Request for Assistance or an IMR with CDI. This request must be made within Deborah Doherty, MD months of the insurance company upholding its decision on appeal. The IMR process Lynda Eaton,decisions PT involves an expert independent medical professional reviewing the medical made Sharon Grandinette, MS, Ed, CBIST by the health insurer. Michelle Hartshorn, MSN, RN Dennis Hays, JD, CPA An IMR can be requested if the insurance company's decision involves health claims that David Hovda, Ph.D. have been denied, modified, or delayed by the insurance company because a covered Ph.D., service or treatment was not considered medically necessary; healthStephanie claimsKolakowsky-Hayner, that have been CBIST denied for urgent or emergency services that a provider recommended was medically Claude Munday, Ph.D. necessary; health claims that have been denied as being investigational or experimental. Ann Perkins, MA Randall H. Scarlett, J.D. Six Steps to IMR Patsy Sholders, MA

Notify CDI to request an IMR by filling out an application; 1. Agree and provide written consent to participate in IMR; 2. The CDI determines if the request is eligible for IMR; 3. The IMR Organization will have 30 days to review once all information is gathered-unless

the request involves an imminent and serious threat to health, which can be expedited and a decision to the insured, the insurance company, and the Insurance Commissioner 4. The IMR organization will send the decision to the insured, the insurance company, and the Insurance Commissioner 5. The Commissioner will adopt the recommendation of the IMR organization and promptly notify the insured and the insurance company. The decision is binding on the company. 6. If the company denies treatment as not a covered benefit, or if CDI finds that the issue does not involve a disputed health care service, CDI will review the company's decision to make sure it's accurate. BIACAL wants to know the outcome of your appeal. Please contact Administrative Director, Paula Daoutis, at pdaoutis@biacal.org if you were successful in overturning the original denial or if you continue to be denied medical treatment. Please contact Paula directly at (661) 873-6555 with questions.

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FOR MORE INFORMATION, GO TO THE BRAIN INJURY ASSOCIATION OF AMERICA’S WEBSITE AT BIAUSA.ORG

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INTRODUCING OUR NEW NAME AND LOGO The Brain Injury Association of California is pleased to introduce our new name and logo for the 2013 Walks across the state. The former Walk For Thought will now be billed as WALK FOR BRAIN INJURY. This change is taking place as part of our continuing effort to brand with the Brain Injury Association of America. This new logo will be used by all state affiliates that hold walks around the nation with the goal of becoming a nationally recognized logo that better represents our cause. 2013 will be our 6th year of hosting Walks across the state and we are very excited to announce the dates and locations of all 13 Walks, which start off in March 2nd and end on May 5th. With so many walks, it has become impossible to complete all walks in the month of March (Brain Injury Awareness Month) so this gives everybody an opportunity to attend one or more walks. Please see the dates and locations below: 2013 WALK SCHEDULE March 2 Fresno March 3 San Francisco March 9 Bakersfield March 16 Yuba City March 23 San Diego March 24 Sacramento April 6 Santa Barbara April 13 Rancho Cucamonga April 14 Torrance April 19 Downey April 20 San Jose April 28 Fullerton May 5 Oxnard

Online Registration is now available on our BIACAL website at www.biacal.org DON’T DELAY - REGISTER TODAY!

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MISSION STATEMENT Our mission is to be the voice of brain injury. Through advocacy, education and research, we bring help, hope and healing to thousands of Californians living with brain injury, their families and the professionals that serve them.

ABOUT BIACAL As a chartered state affiliate of the Brain Injury Association of America, the Brain Injury Association of California promotes awareness of brain injury on a state, regional, and local level; provides education and training to individuals with brain injury, to family members and professionals; delivers timely and accurate information and access to resources through the BIACAL website, help line and news letters; and promotes progressive public policy while carrying out community and legislative advocacy. In all of these endeavors, BIACAL receives no federal, state or other municipal funding. The organization relies solely on donations, membership dues, sponsorships and proceeds from fund raising events to carry out its extensive programs and services.

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Newsletter Advertisement Opportunities SEND US YOUR ARTICLES AND UPCOMING EVENT INFORMATION Advertisement opportunities are also available that will help to support the distribution of the BIACAL Newsletter. Advertisement rates are noted below: $2,500 – Full Page Ad (includes logo placement on email blast with click thru to your website) $1,500 – Half Page Ad (also includes logo placement on the email blast) $750 – Quarter Page Ad (also includes name recognition on the email blast) $250 – Business Card Ad To place your Advertisement, please send your camera ready artwork and logo in a jpg file to upesta@biacal.org. Payment for Ads can be made online at www.biacal.org. Follow the steps below: 1. Click on the green DONATE & SUPPORT button. 2. Fill out the “Personal Information” section. 3. Under the section “Please Select an Option”, select “Donation” and choose your advertising option. 4. Enter your credit card information OR To pay by check, please make check out to BIACAL and mail to the following address: Brain Injury Association of California 1800 30th Street, Suite 250 Bakersfield, CA 93301


BIACAL MEMBERSHIP Making A Personal and Collective Impact The advantages of being a BIACAL member include access to educational information and a wide range of other resources, legislative representation, collaboration with a comprehensive group of brain injury clinical and social service specialists, the personal experiences of brain injury survivors and care givers and a steadfast and ongoing commitment to injury prevention and improving the quality of life for individuals with brain injury and their families. BIACAL annual membership levels are listed below: $10 $25 $50 $100 $500

Person with Brain Injury Student Individual Professional Corporate

Brain Injury Association of California 1800 30th Street, Suite 250 Bakersfield, California 93301 (661) 872-4903

BOARD OF DIRECTORS Richard Adams, MD Mark J. Ashley, Sc.D., CCC-SLP, CCM, CBIST Doreen Casuto, RN, CRRN, CCM Deborah Doherty, MD Lynda Eaton, PT Sharon Grandinette, MS, Ed, CBIST Michelle Hartshorn, MSN, RN Dennis Hays, JD, CPA David Hovda, Ph.D. Henry Huie, MD Stephanie Kolakowsky-Hayner, Ph.D., CBIST Michael Lobatz, MD Claude Munday, Ph.D. Ann Perkins, MA Randall H. Scarlett, J.D. Patsy Sholders, MA

BIACAL STAFF

Paula Daoutis, Administrative Director Ursula Pesta, Project Coordinator Elaine Solan, Community Liaison ………………….…………………………………………….………………….....CUT HERE...………………..……..……………...………………………………………………..

MEMBERSHIP FORM Name: Address: City/State/Zip: Phone:

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PAYMENT OPTIONS: Membership Amount: $ Payable to BIACAL – Mail to: 1800 30TH St., #250, BAKERSFIELD, CA 93301

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Mail to the above address or FAX to (661) 840-6160

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Other Events Around the State ORGANIZATION Santa Clara Valley Medical Center

EVENT

DATE

ADDRESS

CONTACT

3rd Annual Santa Clara Valley Brain Injury 2/28-3/2 Dolce Hayes Mansion Conference 200 Edenvale Avenue San Jose, California

Rehabilitation Center at 8th Annual Brain Injury Rehabilitation Con- 3/22Scripps Memorial Hospital ference 2013 3/23 Encinitas

408-226-3200

Sheraton Carlsbad Resort 5480 Grand Pacific Drive, Carlsbad, CA

858-652-5486

NON-PROFIT ORGANIZATIONS MAY SEND THEIR EVENT INFORMATION TO URSULA PESTA AT UPESTA@BIACAL.ORG FOR INCLUSION IN BIACAL’s QUARTERLY NEWSLETTER.

MARKETPLACE Brain Injury Association of California TO PURCHASE CONTACT: URSULA PESTA (661) 872-4903

UMBRELLA $8.00 each + S&H

SIGNED PRINT BY ARTIST LEE BERMEJO $100 INCLUDES S&H

TOTE BAG $8.00 each + S&H

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Newsletter - 12/12