Monday, March 3, 2014

The Limits of Neuroplasticity: Brain-injured War Veterans


GERMANTOWN, Md.— Pete Bunce walked into a room at a U.S. military hospital in Germany in March 2004, and stared hard at the unconscious young Marine on the bed. His head, gouged by shrapnel from an insurgent bomb in Iraq, was grotesquely swollen. His face was distorted and his right eye was near blind.

Mr. Bunce spoke his first thought: "This is not my son."
      Former Marine Justin Bunce, who got a brain injury serving in Iraq, works with Niemah Bowins, a life-skills trainer. Jonathan Hanson for The Wall Street Journal
The Bunce family and their doctors have spent the decade since trying to restore Justin Bunce to the man they knew, with limited success.

Cpl. Bunce remains intelligent and funny. But his brain no longer sends the messages that allow him to walk smoothly, or to warn him when his behavior might offend or frighten people. "I can't dream anymore," he said. "I would even be happy with nightmares, but I don't even have those."

The wars in Afghanistan and Iraq have left a generation of brain-injured veterans who, like Cpl. Bunce, may get better, but never well.
Between Jan. 1, 2001, and Sept. 30, 2013, more than 265,000 U.S. troops suffered traumatic brain injuries, according to the Defense and Veterans Brain Injury Center. Most were mild concussions. Some 26,250 troops, however, suffered penetrating head wounds or brain injuries classified as moderate or severe, which caused unconsciousness from 30 minutes to more than a day. 
Cpl. Bunce is one of 119 brain-injured veterans that the VA has placed in privately run group homes around the U.S., immersing them in therapies for movement, memory and speech, while gently exposing them to civilian life.
Recent advances in battlefield medicine keep alive troops with head wounds that might have killed them in World War II, Korea or Vietnam. But science hasn't kept pace in its ability to cure.
Soldiers who lose arms or legs can, in many cases, learn to use prosthetic limbs. Those with serious brain injuries will likely always need someone by their side.
Cpl. Bunce and five other veterans share the split-level ranch on 5 acres on a bucolic lane. There is a soldier who, after two tours in Iraq, shot himself in the head; he rolls his wheelchair onto the front porch of the group home to smoke. Another housemate, a 57-year-old Virginia National Guardsman, whose brain was damaged by too many close calls with incoming mortars in Iraq, wonders if he will work again as a long-haul trucker. A helicopter pilot, confined to a wheelchair after a crash in Afghanistan, is relearning to talk.
The house is set up to resemble more home than hospital. But it has 24-hour attendants, community activities, in-house therapies and access to VA medical care. The vets socialize and can cook their own meals, if they are inclined. Each resident has a trainer to teach such ordinary life skills as shopping and going to the movies.
The group-home program is a five-year pilot that finishes on Sept. 30 unless Congress extends it. The program has some powerful friends on Capitol Hill. But if Congress doesn't act, it is unclear where Cpl. Bunce and the others will live next. VA officials expect to start drawing contingency plans for the veterans next month.
Cpl. Bunce, at right, with fellow Marines in Iraq before his injury. Bunce Family
At times, Cpl. Bunce seems to adapt well. His group-home trainer, Katie Gorman, takes him to a facility where he helps train companion dogs for other disabled veterans. He enjoys the company of elderly veterans at a nursing home. He gets a kick telling grade-school jokes to anyone who will listen: "What do you call a grizzly bear with no teeth? A gummy bear."
But the brain injury has left him with personality quirks the group-home staff and his doctors struggle to address. He speaks profanely and uses sexual innuendo when it isn't welcome. He can't seem to read facial expressions that would tell him he is making people uncomfortable when he touches them or holds them for too long.
He often makes threats—apparently empty ones—against people who annoy him. During one recent session with his neuropsychologist, Mark Sementilli, Cpl. Bunce complained angrily about a doctor who, he said, refused to prescribe sufficient painkillers.
"He better pray I never find out where he lives," Cpl. Bunce said.
"What would happen?" Dr. Sementilli asked.
"Back of a milk carton," Cpl. Bunce replied.
He tells stories that sound made-up: punching out a lieutenant colonel or jabbing a brain specialist in the throat.
Cpl. Bunce "generally has the ability to control behaviors," Dr. Sementilli said. "I've seen him show amazing compassion toward children, vets and pets, of course. On the other side, I've seen hostile vulgarities."
During an outing to an Italian restaurant last week, Cpl. Bunce stuffed crème brûlée into his immobile left hand, saving it to eat later. He filled his pockets with Sweet'N Low packets and stuffed a bag of Doritos in his sleeve. He eats so much candy and takes so little care of his teeth that on Tuesday a dentist had to pull many of them out.
One day last week, a physical therapist, Michelle Wilson, sat next to Cpl. Bunce and tried to gently pry open his left hand.
He stroked Ms. Wilson's gloved hand as she worked. "You're going to be my wife," he told her. She brushed off the suggestion. He cooperated briefly then stopped to take a few drags of nicotine on an electronic cigarette.
"I know it's not what you want," Ms. Wilson said. "You want it to work like your right hand." 
He shot back a vulgarity, and threatened, with no apparent malice, to get a hookah and stick it in her eye. During a break he picked up her shoe, held it to his face and inhaled deeply.
His family believes he has made progress at the group home. They also recognize the limits to his recovery.
His mother sees signs of depression in her son, and, despite his optimistic talk, believes he now realizes that life has only so much in store for him.
"They won't ever be well," Ms. Bunce said of her son and others with serious brain injuries. "It has taken me 10 years to be able to say that and not cry."

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