Photos by Cameron Wittig
Dr. Michael Armstrong
Dr. Michael Armstrong is a local expert in the treatment of traumatic brain injuries.
Owen Rice was one of the lucky ones. In 2005, the then-39-year-old Army Reserve staff sergeant returned to Minnesota after a tour of service in Afghanistan that included surviving a roadside bomb. His unit was patrolling the roads near polling places in the days before the country’s presidential elections when an improvised explosive device, or IED, rocked the armored vehicle he was riding in. Rice awoke moments later with his head against the windshield and managed to scramble out of the vehicle—along with four other occupants—as the wreck burst into flames.
In the aftermath of the close call, Rice recalls, “Basically, the medevac doctor looked at me and said, ‘Nothing’s broken and you’re not bleeding anywhere, so you must be fine.’”
He had survived unscathed—or so it seemed.
But upon his return to Minnesota, readjusting to normal life proved unusually problematic. Rice had trouble focusing. He tripped over his words and had difficulty making decisions. Sensing his frustration, a veteran services officer suggested Rice get screened for brain damage.
Rice sought help from the Minneapolis branch of the U.S. Department of Veterans Affairs, which turned out to be a stroke of good fortune. Despite all the bad news currently surrounding the VA on the national level, the local VA has emerged as a leader in recent years in the diagnosis and innovative treatment of traumatic brain injury, or TBI.
In Rice’s case, it turned out his challenges adjusting were rooted in something more: The blast in Afghanistan had left an invisible wound. “Once they started checking me out, it turned out there was something wrong. My brain was slightly torn from the brain stem on the right side,” Rice recalls. Once diagnosed, he was able to get the specific treatment he needed to heal and start rebuilding his life.
Both of Dr. Michael Armstrong’s grandfathers served in World War II. His father was in the Air Force; his brother joined the Navy. But Armstrong chose to serve his country in a different capacity: After earning a medical degree from the University of Minnesota Medical School, he joined the Minneapolis VA, where he now serves as both chief of physical medicine and rehabilitation and as the local VA’s primary expert in TBI.
“Working with veterans is truly inspiring,” he says. “I can’t think of a more deserving group of individuals.”
A concussion is a traumatic brain injury caused by a blow to the head that can result in unconsciousness—even if only briefly. The blow may not penetrate or even crack the skull, Armstrong notes, but the impact can bruise, sheer, and even sever nerves as the organ ricochets against its protective housing. Most concussions heal in 30 days or less, and sometimes nerves regrow. But in cases where damage is permanent, patients may experience sleeplessness, irritation, speech problems, social anxiety, short-term memory loss, loss of executive function (which helps us make decisions), or worse.
Concerns about the lasting effects of concussions have made headlines in recent years, especially in professional sports and high school athletics. The attention has helped educate people—veterans included—about the causes and effects of TBI. Armstrong says, “We’ve come to understand that people who have milder injuries—professional athletes like Justin Morneau—don’t necessarily look like something is wrong. But that doesn’t mean they’re not having problems.”
Experts estimate that roughly 10 percent of all soldiers deployed to Iraq and Afghanistan have returned home with some form of TBI. Head injuries have always been a combat risk, of course, but the widespread use of IEDs in recent conflicts has elevated worries in particular about blast-related concussions. The shock waves emitted by IEDs can travel more than a mile, forcefully rattling the human brain within its skull yet leaving no outward signs of damage. Such TBIs are often mild enough to go undetected except by trained physicians, but they can still impair mental function and affect social behavior.
To some degree, treating TBI in veterans is no different than treating athletes or other civilians with brain injuries. Rehabilitation involves therapy and exercises that improve speech and cognition. Recording devices, digital calendars, and smartphones are recommended as memory aids (the VA used to issue PalmPilots to veterans with mild TBI and recently switched to iPads). Students who have trouble concentrating are encouraged to ask their teachers for extra time while taking tests—and may even inquire whether they can move to a distraction-free space. Individuals whose TBI makes them anxious in crowds and social situations are schooled in self-calming skills.
Photo courtesy of Marcus Kuboy
Armstrong’s polytrauma team, which addresses TBI, numbers 98 employees—making it among the largest groups dedicated to the issue in the entire VA system. The local VA’s capabilities make it “very comparable to the best rehab system in the country,” Armstrong says, with access to specialized equipment for testing balance, gait and mobility, speech, and other TBI-related dysfunctions.
Soldiers with TBI could certainly obtain care outside the VA system, Armstrong notes—and some do. But there’s a contextual difference between, say, a sports-related TBI and a combat-inflicted TBI. “If you’ve been deployed for several months, you’re wearing 100-plus pounds of body armor, and you’ve just seen your best friend killed—all those factors really differentiate the combat concussion from the soccer concussion or the hockey hit,” he says. The contextual implications for effective treatment may be significant, Armstrong says. Yet, to a large degree, the effects of context on TBI treatment and recovery remain largely unknown.
In the spring of 2007, Marcus Kuboy, a medic with the Minnesota National Guard, woke from a coma at a hospital near a U.S. Army base in Germany. His last memory was of being a solider in Iraq, but that career had halted a few days earlier when he suffered multiple broken bones, tissue damage, and a bruised spleen—injuries inflicted by an unexpected IED blast. Doctors predicted the 29-year-old medic would never walk again without a cane or specially designed shoes, but after 10 months at the Walter Reed military hospital in Maryland and six months in the Minneapolis VA, Kuboy surprised physicians by walking again unaided. Since then, he has moved into a new house, gotten married, and returned to school to pursue a master’s degree in social work.
“Every time they said something would never happen again, I’d say, ‘Right now it looks that way, but I have no idea what it’s going to be like,’” Kuboy says. “I was going to work my hardest to recover.”
His list of injuries also included a TBI and a PTSD diagnosis. “If you’re not looking for [TBI], it’s easy to miss,” Kuboy says. The perceptible symptoms of his TBI are mostly limited to occasional hesitations in his speech. Less visible are the distractions and distress that occasionally flood his mind.
On a recent trip to Walmart, for example, Kuboy was walking the aisles when he suddenly felt like he was being pushed and crowded. His heart raced. His palms began to sweat. “I just locked up,” he says. Using coping tools learned at the VA, he managed to quiet his mind and calm himself, but one question remained: Was the experience he’d just had caused by his brain injury or by the post-traumatic stress disorder?
Post-traumatic stress disorder was officially recognized as a form of mental illness by the American Psychological Association in 1980. But only recently, as young soldiers have returned from the conflicts in Iraq and Afghanistan, has the stigma associated with a PTSD diagnosis begun to diminish somewhat. Previously dismissed as “it’s all in your head,” the disorder has been legitimized in part by the discovery of patterns in brain activity, known as biomarkers, that correlate with a PTSD diagnosis.
As PTSD has emerged as a complicating factor in veterans’ care, VA doctors in the Twin Cities have been at the forefront of initiating research studies to unravel and reconcile the complex connections between TBI and PTSD—a key factor when it comes to delivering effective and efficient care.
Over the last decade, Dr. Scott Sponheim, a staff psychologist with the Minneapolis VA and a professor of psychiatry with the University of Minnesota, has sought to find similar biomarkers that correlate with TBI—and to compare them with neuroimages of PTSD. “What’s the signature pattern in the brain of a concussion and how does that differ from the signature of PTSD?”
In 2008, Sponheim undertook a four-year study of 180 troops, mostly from the Minnesota National Guard, who had come back from Iraq with mild TBI, PTSD, both conditions, or neither. Using an EEG machine at the VA as well as the 3 Tesla scanners at the University of Minnesota’s Center for Magnetic Resonance Research, Sponheim hoped to find patterns that would predict the presence or absence of each condition in soldiers.
Mapping such patterns could help psychologists and medical doctors develop more precise approaches to each condition. “It’s very difficult to tease them apart just by looking at symptoms,” Sponheim says. “That creates a challenge in prescribing treatments. Is this predominantly PTSD and we should use the types of exposure therapies shown to be effective in treating PTSD, or should we take a more neurological approach, focusing more on the brain injury and its physical effects?”
Photo courtesy of Owen Rice
While studying the neuroimages, Sponheim focused narrowly on white matter that was, according to one hypothesis, likely to fray—“it’s like cabling,” he says—after a brain injury. Initially, he was able to document some difference between the brains of individuals with TBI and those without. But when images of individuals with both TBI and PTSD were added to the mix, the pattern was less pronounced.
“It seems like this combined condition—post-traumatic stress and TBI—is a much dicier problem that we don’t fully understand,” Sponheim says. In hopes of deciphering more, the VA launched a more complex study of TBI/PTSD patterns in 2012, which is still underway.
Owen Rice earned a Purple Heart for his service in Afghanistan. He lives in Blaine, currently works as a deputy sheriff with Hennepin County, and says most of the people he meets and interacts with on a daily basis wouldn’t guess he has a brain injury.
“I consider myself lucky . . . in that my brain has basically rewired itself,” he says.
But Rice doesn’t hide his TBI, and he routinely speaks to veterans’ groups about his diagnosis and treatment. He believes that veterans, families, employers, and the media would all benefit from a better understanding of how brain injuries—especially mild to moderate ones—affect concentration, memory, mood, and brain function in former soldiers. Such understanding might make the public more sympathetic when ex-military people seem to have trouble fitting into civilian life. Greater education might also lead to earlier diagnosis of TBI in returning soldiers.
In the army, Rice says, the impairments of TBI were difficult to discern. How TBI affected his ability to make decisions, for example, was covered up by the fact that army life was structured and disciplined and didn’t involve many choices.
“I didn’t realize anything was wrong until I came home,” Rice says. “That’s when the real chaos began.”
Joel Hoekstra is a Twin Cities writer and editor.