Friday, March 15, 2013

What Video Games Taught Me About Brains

I used to play World of Warcraft. It's a long story and all Justine Larbalestier's fault but by the end I was raiding seriously four times a week, and casually a couple of times, too. I quit when I'd got a world ranking in a fight, but was bored and offended by Blizzard's content in the Cataclysm expansion.

I killed this guy. A lot. Took his stuff, too.
For my current purposes it doesn't matter why I quit, only that I played the game seriously, and I was good at it. I used a mouse that had 8 or so buttons, and combined with Shift, Ctrl, and Alt keys could cast spells and run commands with a combination of my left hand on the keyboard and my right on the mouse.

Long before I quit, I was not thinking "I should cast this spell, so I should click that button with my right thumb while holding down Ctrl with my left pinky." Instead, I was just thinking "cast this spell," and the rest was taken care of by muscle memory.

The idea of muscle memory is familiar to most people: musicians drill scales, dancers learn sequences of moves, gymnasts learn floor routines, and video gamers learn to do what the game asks of them with their controllers. Whether it's casting spells or driving cars, at some point players go from thinking "press X" to thinking "accelerate" because muscle memory takes over.

Driving a car is a good example of this process, whether in the virtual or physical worlds. Drivers' responses become automatic, eventually. You notice this in new drivers when you stop crapping your pants every time they get behind the wheel.

Of course "muscle memory" is utter bollocks. Your muscles don't remember anything. That's not how they're put together, not how they work, and not what they do. It's not the nerves activating the muscles that remember, either. It's your brain that's doing the magic, and it's a bit more involved than just remembering how to do something.

It turns out that there are several layers of intention and execution between thought and act. At a high level, the mind is thinking "reach for that glass" and that impulse is translated into arm and hand movements, and thence into the appropriate muscle contractions. If reaching for glasses is something you do often enough, then the whole process gets optimized by the brain. You really notice this in driving when not only have you optimized the various actions of driving, but you have travelled the same route so often that the whole journey is an automatic sequence that you don't remember carrying out.

Who cares? I do. Because as well as remembering keyboard fingerings from my teenage years (I'm sure I could still dock in a Dodec at full speed), my brain learned how to be very good at WoW in my late 30s. In other words, far from the idea that our brains are done with developing in late adolescence, they still go on adapting and making physical changes to optimize our performance against the outside world far into adulthood. A leopard may not be able to change his spots, but a human can change his brain.

This matters to me because it means that recovery is not only possible, but inevitable given the right conditions. My job at the moment is finding those conditions and ruthlessly pursuing them. Games are part of the solution, too: they are a compelling medium in which the player frequently repeats physical action intently, has to get them right, and has to pay attention to the action and the result.

Sadly, this is where my frustration with the video game industry and the medical industry lie: for opposite sides of the same coin. Recovery games are shit as games. They're boring. Normal games miss the opportunity to make their players interact in ways that make them more physically active in good ways.

I'm still not going to touch WoW again with a 10' pole, though.

Tuesday, March 12, 2013

How the world looks to me.

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Normal vision
Since pictures substitute for words in many cases, I thought I would try to illustrate how I'm seeing at the moment. I'll build up separate images with each effect of the brain damage, so you can get an idea of how things look to me. I'll stick to the images that my eyes are sending back to my brain, which perceives the world slightly better, but works poorly with text.

First, here's the image I'm going to work from. Bear in mind that most of you would see this in 3D, but I don't. It's the cabinet in my living room that's full of games and game books. Notice that it's not hard to read Hoity Toity or Goa, and many of you will recognise Settlers of Catan.

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Myopic version
I have been myopic (short-sighted) for over 30 years, so without glasses, the view would be blurred. I am very myopic so things are very fuzzy. Not so bad that my glasses look like the bottoms of milk bottles, but headed in that direction, for sure.

Of course I wear glasses, and used to wear contact lenses, so the world is not so blurry until bedtime, but since the strokes, I have had double vision (diplopia) which confuses things. I have diagonal diplopia, which is oddly more confusing than just horizontal or vertical displacement. Because my diplopia is rooted in the coordination and function of my oculomotor muscles, the muscles that move my eyeball, rather than in the visual cortex, the displacement is not fixed, it swims around.

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Diplopia version
I also have 1.5 syndrome, which for our purposes here means that the displacement differs depending on where an object is in my field of vision. The syndrome has affected my left laterus rectus primarily, but some of the other muscles too, so the doubled image is both translated diagonally, and slightly rotated. The image to the right is a reasonable approximation to what I would see wearing glasses, almost. Read on for more wrinkles! It's not quite accurate because my image manipulation skills are not mad enough to convey the contention of the two images. You can clearly see the Goa there, but the picture doesn't give a sense of the other Goa wanting to be read first and foremost.

To manage the diplopia by reducing my visual signal to a single useful image, I have an occluding filter on the left lens of my glasses. Or, in English, I have a disc of translucent plastic that sticks to the inside of my left lens and makes it all blurry. Peripherally, my left eye has the benefit of my glasses without the filter, which should be of some use looking down, but because of the 1.5 syndrome, is not much cop on the left side. Dashing as a patch might make me, keeping my left eye essentially uncovered like this keeps it moving in (broken) concert with my right eye, and can only help with recovery. The effect of the filter is that I see something like the image below.

Occluded version
The irony of making one side of my vision so useless that my brain ignores its input is not lost on me. It's not always effective, either; sometimes, especially when I am tired, my brain seems more interested in the garbage coming from my left eye than the more useful stuff from my right.

The final, and frankly most debilitating visual deficit I have is oscillopsia; my right eyeball moves up and down a little, rapidly and regularly. As the size of the movement is usually at least a line of regular text at my comfortable reading distance, this makes reading difficult. It's also better or worse variably, but it's never better than below in terms of distance moved. The jitter is also quite a bit faster in my eye than in the animation.

Of course, it's not the eyes that do the seeing, it's the brain. What I've tried to illustrate is what  my eyes are sending on to the brain. What I actually perceive has changed over the last seventeen months, so I'm better at seeing a steady field of view, especially for rooms that are familiar. It's worth noting that I'm discarding the information from one eye completely, so I don't have binocular vision. I can't tell how far away things are, how fast they are moving, or how flat they are. Sidewalks are exciting! One of the notable effects is that the brain evidently retains a working model of the world, and uses that when there's no depth or distance information available: I can reach for a glass that I put down recently, but if you move it, I will miss.
Oscillopsia version

I seem to have learnt that the world is not constantly shaking, so the oscillopsia is usually (but not always) ignored in familiar spaces, but it is in full effect when I try to read. One trick I have used to read signage or subway advertising and the like is not to try to read a line of text from, say, a poster, but to allow the image of the text to be assembled coherently in my brain, and to read it from there. This trick is fiddly to execute!

One other thing I have learned from my ocular odyssey is that I infer a lot of the actual text in many novels; the word choices are so often obvious that I don't actually read them, but assume the word given the context. This is less easy with non-fiction, and I find any reading tiring regardless.

EDIT: Over on Google+ a friend was asking how I could even prepare these images given the way my eyesight is at the moment. I've had longer for my brain to get used to the way my eyes behave, I know what my eyes do, and I'm pretty familiar with my computer. The image manipulation is fairly simple. It still took more than a day, mostly because I was tired. Looking at unfamiliar things is most like the last image. 

Later, I likened it to looking at things from a very rattly moving vehicle. Distance stuff is easier and more solid, because the brain is used to the eye moving rapidly over near things and assembling a distant image. That image is not always correct, because the brain interpolates things (one of the reasons that a lot of eye-witness testimony is bollocks), and sometimes it fills in the gaps with things that should or might be there, but aren't.

Nearer stuff is impossible to perceive at a glance because I am having to do pretty much the same thing for near vision as the brain does for distance perception, and that's not instantaneous. It takes me enough time to check cross streets for oncoming traffic that I might as well just wait for the lights. I almost never jaywalk alone. Similarly, as I'm typing, I know what words should appear, and in what font, so my brain has an easier time of adding new words to a page of typing. Reading a previous paragraph, though, sets me back again. END OF EDIT

As usual, questions are welcome!

Monday, March 11, 2013

Spring 2013 Monthly Update

It's time for another monthly update, and I looked back at my first March update for an idea of how I've progressed. In one thing, my weight, I've taken a step backwards, since I'm heavier now than I was then, but my pants (trousers) still fit, and I'm pretty sure some of that weight is muscle mass, since I am stronger now than I was then: I have the record from the last ASPIRE session, and where I was doing a lat pulldown of about 35lb (it was all in kg), now I do them at 140lb. Also, I'm pretty sure I couldn't do two sets of eight pull-ups then, so by that simple measure things have improved.

A friend pointed out at a birthday party on Saturday that I seem to do much better on pull exercises than on push ones. Apart from the fact that we were talking about fitness at a pancake party, this makes a lot of sense: the push exercises I do are almost all dumbbell exercises that take more stabilization than the pull exercises which tend towards raw strength. If I can strengthen the stabilizing muscles with pull exercise, then I might be able to accelerate recovery of the pushing motions. The push is already improving though; a 20lb dumbbell bench press is now as stable as a 10lb once was, and a 30lb dumbbell press as stable as a 20 used to be (not very).

I used to be able to bench over 200lb, but barbell exercises tend to use more weight, anyway, and I went and had a bunch of strokes, so it's no great surprise that I'm just managing 30% of that weight with dumbbells. Another reminder that comparing my performance to that of 20 years ago is stupid, futile, and a sure way to be disheartened. Now, I just make sure I'm improving week on week.

When I wrote an update a year ago, it was before the neuro-ophthalmologist said my eyesight and balance wouldn't improve and I said that:
My guess is that the maculae will get lined up first, so I have binocular vision at the focal point, and then the eyes will work on twisting so they have the same horizon, and my hope is that somewhere in there, the oscillopsia will go away. Hope springs eternal.
I still think I am right and the neurologist wrong, because my balance has improved, and my diplopia is gradually improving, contradicting him. The diplopia is muscular, so I still see no reason why it shouldn't continue to get better. Unfortunately it's pretty binary, like the tremor: it can improve lots, but until it's gone, it's as wretched as ever. I'm going to try to post soon about how I see the world at the moment, which might explain why, although these posts seem cogent enough (I hope!), working is extremely hard. I wouldn't hire me!

The irritation with nomenclature must be seasonal, because it bugged me a year ago, too. I still think it matters, though: once you've established the cause of a stroke, and are treating it, the person concerned is left dealing with the brain damage, and that's the more significant long-term thing. It also means that we can recover. As I've said before, if I'm outpacing a baby born when I had the stroke, I'm happy.

I'm doing less physically than I was a year ago, on paper, but at the same time I'm trying to lead a regular New York City life. It turns out that my life back in Dorset relied very heavily on other people doing things for me, and a lot of sitting down recuperating. Here in NYC, I've found that I don't yet have the endurance to lead a full, busy existence, so I'm getting used to leaving early, caffeinating with care and exercising a bit less, while working a bit harder generally.

On the material plane, things are rough. I just heard it's going to be at least a month before I get any Disability Insurance loot, and even then it's not certain. That means its normal for the process to last nearly a year after an event. (Six months before you can apply, then four months processing, then at least a month handling, plus go-see-our-doctor trips.) This is insurance for people who can't work; I have no idea how anyone is expected to go a year without income. I've survived through the generosity and kindness of family and friends, I don't know how else one does it.

The wait puts me in a strange sort of Schrödinger's Cat state of being broke now, but potentially fine in a month or so, which is weird and uncomfortable. I hate not being able to get my metaphorical round in, but I have to accept my reality at the moment, just as I accept that I can't go out without a stick, my fight hand sends coffee flying, and my eyes are weird. For now!

Saturday, March 9, 2013

Stroke Survivor? Victim? Sufferer? None of the above.

Within a week of having the first stroke, the nomenclature around it vexed me. "Stroke patient" worked while I was in hospital, but that was it, and the terms that replace it are rubbish.

I can't abide "stroke victim." The brain event I had didn't select me for victimisation, and I'm not now, nor have I ever been, a victim of any singularly malign force. I had the stroke because I was fat, lazy and have a genetic predisposition to high blood pressure that, coupled with my obesity and sedentary indolence made my head explode. No victimisation there.

Whenever I hear "stroke victim" I am reminded of a scene in the movie Addams Family Values, where Wednesday is trapped at summer camp and is enduring a swimming rescue lesson. She's shown on the end of a pier in a black Victorian bathing costume, next to her tween nemesis, the preppy, peppy, pretty bland and blond girl. The instructor asks for a volunteer to be the victim. The blond girl's hand shoots up and she squeals "me, me, me." The camera cuts to a close-up of Christina Ricci deadpanning "all your life."

The popular alternative is "stroke survivor." I reject this because it's tautological. I'm either a stroke survivor, or I'm dead, and if I were a corpse, you wouldn't be reading my writing. "Survivor" is way better than "victim" but it's  still rubbish, because it adds nothing to the conversation.

Until recently, I had settled on "stroke sufferer." There's certainly been some suffering involved; recovery isn't really that fun. The term is at least accurate, but a problem still obtains: the word "stroke." Having a stroke is significant, and it matters a lot when the underlying cause is strange and unusual. But seventeen months later, I find 'stroke' as a magic word troublesome. Sure, I will use it to my advantage whenever I can, because frankly, I need the help and consideration, but it implies that there is something particular and unusual about my condition, and I see that as more of a problem than a perquisite.

I'm not recovering from strokes, you see. They were what caused it, but what vexes me now is simply brain damage. Differentiating stroke from being shot in the head or getting your brain damage some other way serves only to make excuses for not recovering, and sod that.

So, I'm left without a snappy term, and default to "stroke sufferer" for the time being, until I  can think of a good way to encapsulate "ordinary guy recovering from brain damage."

Wednesday, March 6, 2013

Acupuncture and Stroke

Why I Pay To Have Over 50 Needles Shoved in Me Every Week

It works.

I go to the gym, go to the pool, and go to acupuncture, all things I have to pay for, and all things that involve varying degrees of discomfort, because they are all working, demonstrably, to hasten my recovery from brain damage.

To get why they are having a positive effect, I think it helps to understand what's going on with me. When I had the strokes, bits of my brain died. The bits that died mostly controlled motor function: the movement of muscles. In some cases, like the left side of  my face, although sensation remained, I lost all the brain matter that was sent signals to move the muscles. In other cases I lost sensation and control, like in part of my right butt; it felt like I was sitting on something in my back pocket, but in fact I was just sitting on my ass, and couldn't feel it (I can now, no need to kick me). In most cases, I lost some of the brain matter controlling some of the muscle, with the result of making almost every part of my right side below the neck weaker and less coordinated. The secondary problem, in some cases, is that of atrophy: it's been a long time since some muscles saw use. My right hand is visibly thinner than my left, and there are muscles in my face that can only be felt on the right side.

At this point, some seventeen months after the strokes, to recover, I have to get other parts of my brain to do the jobs that the dead bits used to do. This is a process that is similar to a baby learning to use its body, a process that takes many years, and is eventually optimized in adolescence, which is why teenagers can be great klutzes, but suddenly graceful by their late teens. I'm hoping it doesn't take me as long as a decade, but it might.

Using the brain's plasticity to get live bits to do the work of dead can only happen when there is stimulus in the brain in the live bits. That's why function now improves slowly, and improvement only happens in muscles whose controlling brain parts were adjacent to living brain tissue. Their signals were reaching still-living brain matter, but it has to learn not to ignore the signals as irrelevant, and take responsibility for new muscle.

Gym work both requires muscles to work, and the brain to control them, more often than not in the stabilisation; that's why I do mostly dumbbell work. In the pool, I'm requiring muscular control and coordination, and also parenthetically working on my endurance which is pretty low. The benefits are clearly noticeable: despite being tired after swimming, I walk better. So, what does acupuncture do?

Here's what an acupuncture session is like, if you've never had one. You take off varying amounts of clothing, sometimes  lie face up, sometimes face down, and the acupuncturist puts a bunch of needles in you. Then you rest for a while, often falling asleep. Finally the acupuncturist removes all the needles and you're done. Yes, some of the needles hurt some of the time, but usually for no more than a second or two. Also, I've had a lumbar puncture (a.k.a. spinal tap), and these are nothing in comparison.

Often, you're booked in for an hour's session, and the acupuncturist will come and wake you up so they can get the needles out and get you dressed before their next client. I've been going to a great place called Olo Acupuncture in New York, that practices community acupuncture: the treatment happens in a communal space with a bunch of table and chairs to lie in. Apart from the price, the best thing for me is that they let you rest (or snooze) for as long as the treatment takes. On a recent trip, when one of the needles was damn sore, I slept for over two hours, and it's not like I'm running a sleep deficit.

There's a lot about traditional Chinese medicine that is alien to my skeptical self, and as a result I find it useful to think of much of the approach as having a very good, but rather peculiar, working metaphor. Frankly, I don't care if a practitioner is balancing my chi, clearing wind from my trembling limb, or just poking me with needles: it works. I feel better afterwards, more even, more symmetrical.

What about the placebo effect? Perhaps it's just me thinking that acupuncture is going to work, and so it does. For many of the benefits I perceive that could be the case, and the mind is certainly significant in changing the brain, but not all. The left side of my face has gradually been moving thanks to acupuncture. I have no doubt about it. Before I had needles in my face and left orbit, my left side did not visibly move. It does now.

What I think is going on is that the needles are stimulating the atrophied muscles, or nerves into those muscles, and my brain is recognising that stimulation as requiring response. Perhaps it's as simple as the needle being fine enough to be an irritant without causing damage. Perhaps it's something else: acupuncture anesthesia seems to work on a different principle. No matter, I can't stimulate those muscles any other way; believe me, I've tried.

In the end, what matters to me, is that acupuncture is helping me to recover, and to recover faster from the brain damage caused by stroke. It works.

Sunday, March 3, 2013

Sucky Progress Report

Several weeks of progress report obviously went missing largely because they sucked. I've gained a bit of weight (which I don't care about that much), and just not been to the gym or swam enough, let alone written enough, and so on.

Part of the problem was undoubtedly that I was off my depression meds for about two weeks, which was plenty long enough to start feeling the effects. It was all due to a preposterous series of cocks-up between my nearest pharmacy (the slowest Rite Aid in the world) and my doctor, and is at last sorted out. In the meantime I discovered that, even knowing that short-term discomfort or not-fun was better for me long-term than short-term pleasure intellectually, without the anti-depressants I made the wrong choice every time. With them, I make better choices.

On the other hand, I've noticed several small improvements that tell me that, slowly but surely, I am recovering. They are all attributable to some activity on my part, about which more anon, but they are still happening.