Annual Update #1

As is typical, this update is a few days late, so instead of marking exactly a year since I first had a stroke, this is closer to a year since I had the last stroke. For those keeping score, or just catching up, I started with a big old haemorrhage of the pons (that would be a burst, blood vessel in the brain stem), and then over the next few days had a bunch of ischaemic attacks all over my frontal lobes (those would be clots), the largest of which was in my right frontal lobe, the rest dotted about the place.

None of the tiny ones was transient (small enough to go away before causing cell death), also known as TIAs or mini-strokes. However, they were small enough that their effects are likely too small to be noticeable, once the swelling (caused by the damage) went down. The best guess any doctor has had since is that my strokes were caused by high blood pressure. This seems reasonable, since it turned out that my blood pressure was easily high enough to cause my brain to pop. I am not lying when I say the paramedic in the ambulance said he "didn't know it went that high." Whence, my first bit of wisdom:

1. Check your blood pressure. If it's consistently over 140/90 then see your doctor and badger her or him until you figure out why and get some medication. If you're not already, start getting fit and staying that way: It will take at least a year before you get the beneficial effects reaching your blood pressure, but the other benefits come sooner.

They don't call hypertension (high blood pressure) "the silent killer" for nothing. If you read on to the rest of my progress report, think for a minute about the odds of any given bit of blood vessel in the brain bursting, and how a millimeter or two either way would have stopped my heart. I forget the numbers, but many people who have haemorrhagic strokes just die on the spot, and 37.5% die within 30 days (I remember those numbers).

Statistically, making it to a year is good going, although I did not feel the danger, and still don't. Perhaps because it's too terrible to contemplate having another stroke (they really do suck), or because I have focused my energies on being alive for another 40 years (I had the stroke at 40), but I simply don't entertain the possibility of another traumatic brain injury. That  doesn't mean, however, that I am not aware that I had a lot of help surviving the first year. Heck, I had help surviving the first hour. There is a Buddhist virtue of having the humility to accept charity, and I have learned a lot about that virtue through experience over the last year. Part of what I have learned is that you should:

2. Be generous in life. On one level, purely selfishly, generosity is a sort of insurance: if you have been generous, then should you get screwed by fate or misfortune, that generosity returns to you many times over. More than that, though, generosity and the compassion that feeds it, is rewarding in and of itself, because by practicing it (in the sense of doing it repeatedly), we become better people: We can like ourselves more.

One of the trickiest things to deal with is the label disabled and what it means to me now, as well as what it meant before I had a stroke. It has thrown some of my prejudices into rather sharp relief, before stamping them out (mostly). So much of my energy and attention is spent on "getting better" that it can be hard to step back and say 'actually, I'm physically kind of fucked, and may be that way for good.' I try to be honest with myself in these posts, but it leads to a discontinuity of perception that when I think and say, for example, "my balance has improved," that means that I've noticed a tiny improvement, but I still walk like a wretched drunk.

While I would be the first to say that I have been very lucky to have no detectable cognitive deficits (my mind is still fine), and that I have been very lucky that I am able enough to work out at the gym, and not be chair-bound or worse, it sometimes makes it harder. If you saw me, for example, waiting to cross the street, from the right side, I would not be surprised if you saw a buff, able-bodied guy, and would forgive you for wondering why I have a walking stick. I find myself thinking I don't carry this damn thing for fun, you know a lot, often while resisting the temptation to compare the durability of a tibia with that of 3/4" of willow. So, wisdom (or plea) cometh:

3. Make room for the guy with a stick. If only to protect your shins. Just as you have no idea why someone else is lifting that weight, that way in the gym, you have no idea why someone else is carrying a walking stick and may not even be obviously using it. What matters is only your response, and trust me, I am grateful to anyone who accommodates me and my disability.

I realise this has all been rather general, and is in danger of sounding a bit "poor me, my life is so saaaaaad nowwwwww!" but if it come across as whiny, you'll just have to suck it up as though you were watching Star Wars, and trust that by and large, I do not feel sorry for myself. Life is too damn short for pity parties. To specifics:

Vision
I still have one and a half syndrome, so my left eye does not track all the way to the left, and my right eye has a nystagmus when tracking right. (You're online, look it up.) This is not particularly debilitating, because I also have double vision (diplopia), which is debilitating. To have only a single image, I have an occluding filter on the left eye, which is just basically a cloudy filter stuck to my glasses. This lets me function, where double vision did not, but being monocular has its own drawbacks: sidewalks all look flat, I'm bad at judging distance, I have no idea how fast vehicles are travelling towards me, and so on.

Being monocular makes walking harder, but it's probably not as bad as the final piece of my visual problems, which is oscillopsia. That's just what it sounds like: my eyeballs oscillate.  It's not as crazy and fun as Mad-Eye Moody (I now have an intimate understanding of why he's nuts), but it is difficult. Because life should not have simple problems, my left eye seems to oscillate horizontally, while my right oscillates vertically. Also it's sometimes better, sometimes worse.

This all means that I read slower, and I read less, which is a considerable blow. When the oscillation is very bad, or text is relatively small, or I'm in a hurry, I can't read text directly: If I concentrate on a sentence or word, my eye skitters about. Instead, I have to allow the sentence to form in my mind, and read the words from a short term memory of the image. It's hard to describe, and hard to do.

The neurologists and ophthalmologists reckon that it's 'very unlikely' or just 'impossible' for any of these visual conditions to improve. I think that's bollocks, because since they first told me that, I've had independent (i.e. I'm not delusional) verification that they have improved. One thing I am sure of is that, if I believed the experts on this, then there would be no possibility of improvement. Instead I have learned to:

4. Be patient and persistent. My vision is not going to fix magically overnight; the days when brain swelling might subside and sudden improvement occur are over. If it's going to improve, and I have to persist in the belief that it will, then it will take years to improve. Just as it may be years before the hip flexor stretching I'm doing will be really obviously beneficial, and just as it took months for the exercise I've done to pay off. For the important things, patience starts at weeks.

Facial Palsy
Probably the most obvious sign of my stroke is the left-side facial paralysis (or palsy). A year ago, it was as though I had had Botox injected in exactly half of my face. Over the last 12 months, it has improved substantially, but I still have an obvious droop which affects my speech and is, frankly, ugly. I have never considered myself a particularly handsome adult, but until now, I have never made someone scream in shock and terror. (She was a dumb teenager, it was funny.)

The palsy extends to my left eyelids, and is, I suppose, one of the factors screwing up my left oculo-motor muscles (as described above; I should be clear that my field of vision is fine, and I think my visual cortex is fine, if a little stressed). The paralysis of my lower left eyelid in particular means that my left eye does not close properly, ever, although it tears just fine and is thus wet enough. 

So far, acupuncture has been the only treatment that seems to have had a concrete effect on the facial palsy. Again it is slow, and I now have the problem that the relevant muscles are well and truly atrophied, as well as not yet controlled by my brain, but it is working. So,

5. Do what works. Take effectiveness over expert opinion every time, whether it's diet, gym. gaming or health, if something is working for you, keep doing it. The natural corollary is to keep looking for what works. I have done this now with Acupuncture (shout out to Olo Acupuncture!) and I've done it with games: I don't play with people I don't like, and I don't play games I think are garbage. Which doesn't mean I think that the people I don't like, or the games I think are garbage are invalid or wrong. I'm just not in any hurry to take pills that have only marginal efficacy.

Right-side weakness
While the facial palsy is obvious, the right-side damage is less so. My bicep and quadriceps are above average now, and my body fat is well below average, but I am far weaker than I used to be. Worse, my right side is far less coordinated, which contributes to my poor balance. I can't, for example, stand on my right leg alone for any length of time (although I keep practicing). So I look pretty good (the six-pack is starting to show), but I have to or I fall over.

All the strength training, stretching, swimming, tai chi, Pilates and now yoga are aimed at making my right side more effectively functional. Almost all of my right side below the neck seems to have been affected, from muscles that lost all motor control in the brain, and in some cases, sensory input as well, to muscles that are working at a percentage of what they were, because some of the controlling brain matter was lost.

In essence, I am trying to accelerate the process of the brain learning to use muscle, a process that happens over many years of infancy and childhood, and is not optimized until adolescence. Of course it is tricky to do buttons up with my right hand; it takes a child four or five years to acquire the dexterity to do that. Again, I have to be patient (which I have never, I think, been known for), and persist with everything that human beings do, and at the same time,

6. Pick battles carefully and consciously. I think it is not OK to pick up the slack of my right hand's clumsiness with my left; in only five or six weeks, I am better at handling the bunch of keys to my apartment. It's still slow, and I still sometimes drop them, but that is a battle I am fighting and winning. I chose to fight it, though, because I am 41, not 81, and it is worth regaining full use of my right hand, even if it takes years to do so. Be conscious about whether fighting a battle is worth your time.

I say it is worth fighting these battles, and maintain that it is, but I am aware, and frankly scared, of the possibility that the tasks I have set myself may be Sisyphean. I may never consolidate any of the gains I have made. While I walk better, to walk well, I must pay attention to walking, down to the level of the muscles and bones involved. I find myself wondering if the childhood reality we forget is filled with the very boring job of learning to use our bodies and minds, and the idea that children are living the best years of our lives is total bullshit.

Maybe it's just that sometimes, I just want to walk casually up a street, chatting to my friends, and I can't do that yet. It doesn't really matter, I am under no illusion that life is or should be easy, or that the universe owes me anything; it doesn't. That makes it all the more important, though, to:

7. Celebrate your victories. All of them, especially the little ones. Remember to observe your victoriousness over entropy when you set foot in the gym, finish a set, rack a weight, walk up the stairs, do your shopping, do your laundry, even write a long update. 

Tremor
I have an intention tremor in my right side that is most obvious in my right arm and hand when I spill fluid or drop cutlery. It makes handwriting very slow and difficult, typing tricky, and is more of a nuisance than you would expect from a 'minor' ailment. I think it's getting better, but I'm not certain, and it's binary like the diplopia: big or small, it's just as debilitating. I don't think about it much, because I can't do anything about it, so why worry?

Balance
When you see me walking, it's like I'm really blasted. There is no danger of me passing any balance-based sobriety test any time soon. I believe this is mostly due to the weakness and lack of motor control in my right side, but it may also be vestibular (in the ear), which will be harder to correct for. I think this is improving, I think the tai chi particularly, but also Pilates and yoga will help keep it improving, but for now the ataxia is why I walk with a stick, and I am quite likely to be very, very sober.

Blood Pressure
A year and a few days ago, when I had just had a blood vessel in my brain go 'pop,' my blood pressure was measured at 250/160. If you halve that figure, you get to roughly human normal for my age. It would also have been decreasing since the actual stroke. Now, my blood pressure is under 130/80 consistently, but that's thanks to no fewer than four medications. I take a couple more that are more generally related to having a stroke, but four are just to keep my hypertension in check.

Finally, after many months of exercise, my cardiovascular system is showing some signs of one of the desired effects: my blood pressure is starting to come down. I still have no explanation of why it was so damn high, except "shit happens" and "genetics," but I do have an optimistic expectation that I will be able to reduce some of the pharmacological load on my system. A load that might have been substantially lower if I had understood that I had to:

8. Get fit and stay fit. Or die. In most cases, die younger, in more discomfort, and with greater indignity. Exercise correlates with a happier, longer life. Start now. Every time you choose to defer getting fit or losing weight if you need to, you are choosing to die sooner, and it is not worth it if you ask me. You may decide that being fat, or unfit, or smoking or binge drinking is worth doing, even if it cuts decades off your life, but make that decision consciously, and be aware that you are choosing pleasure now at the cost of years later. It's your choice to make, but I have lived side-by-side with people who had avoidable strokes, and had a largely avoidable stroke myself, and I would rather go to the gym.

That's it for the anniversary update. I may not have made it clear, but I welcome any questions you have. The anniversary party was good fun (even though I only had one mimsy bottle of beer)!

Standing Desk

I made my own with random bits of wood and old computer text books. It's taking a while to get used to, but the change was worth it.

Wired Science: Get a Standing Desk

Exercise Made Easy

Since +Terry Romero and +John Stavropoulos said they've been getting back to exercise with [my] swole kick ass workout, I think it only fair to come clean about what I'm doing, and the simple rules of thumb I've been using. Bear in mind that my goal has been to get fit and healthy, but I have to be patient with my post-stroke body, so I haven't set any time or weight targets.

If I can't do a set of 8 reps, with good form then the weight is too heavy.
If I can do a set of 12 reps with good form then the weight is too light.
If I hurt and thus can't function the next day, the weight is too heavy,
If I get the weight wrong but do a set anyway, i.e. the weight was too light, then that's the set I did that day. I know better for next time.
If I did better than the last time on at least one exercise, then that is progress, and that's all I ask for.
If I look at what anybody else is doing, then I'm an idiot: I have no idea if they even have a clue, nor what their goals are, nor what their history is.
If I am comfortable, rather than putting in a somewhat uncomfortable amount of work, then I am doing it wrong.
If I am not certain how to use a piece of equipment, then I ask. Not only are there people paid to tell me, but they are also glad to help.
If I weigh a pound or two more or less, I don't care. A 5-day moving average is a better measure. (Same with BP which I track more.)

The first two are really the core of what I have been doing when it comes to free weights. I'm doing an upper body/lower body split program, with each half twice a week and going to Pilates on the other days. I was swimming on the Pilates days, but my stuff got nicked; I'll be back either when I find my old goggles, or can afford new ones.

For a workout, I warm up for 5 minutes on a recumbent bike (the other kind hurts my ass), always following the rule about not getting comfortable. If you can read while doing anything at the gym, you are doing it wrong. Then I go straight in to the weights; I'm using dumbbells more than anything else, because that works my stability most. I do two sets to go for a low volume, high intensity program that is quite efficient. The first is a warm-up set at about 60% of the weight of the second set, and I'm aiming for muscle failure in the second. Then I add some cardio: rowing machine on lower body days. 

Finally, I stretch for about 40-60 minutes a day, covering all of the major muscle groups. This seems pretty essential for me, if I want my right side to function correctly, but unless you want a laughable range of motion, you will stretch, too.

Because I'm a big nerd, I want to be as efficient as possible, and to be measurable. Two sites in particular have been helpful: +Fitocracy, and ExRx. Fitocracy has been great for keeping me honest, but also for tracking what exercise I did at what weight, and allowing me to see clear improvement, week on week. The community is cool, and knowledgeable, and has something to offer pretty much every fitness goal. You can find me as Ironcinder.

ExRx is an equally valuable site that has imagery for almost every imaginable exercise. When I put together the program I use now, I went there. When it's time to change it up, I'll go back. Also useful was the /fitness sub-Reddit.

Allow months to pass before you feel the benefits. Avoid pain, concentrate on feeling good (because you should be), and don't be crazy: I loved my uncle, but I'm still mad at him for having a fatal coronary on an exercise bike. There is no excuse for not starting now. Your future self is more likely to be around to thank you.

The Brain That Changes Itself

At +Ralph Mazza's suggestion I recently read The Brain That Changes Itself, which sings a paean to the wonders of modern neuroscience, and in particular neural plasticity, which would seem to offer, say, someone who had a stroke, cause for optimism.

To get the bad out of the way, I didn't like at all the chapters that were thin on science, or relied to much on the author's experience as a psychoanalyst. The conclusions may be accurate, but the chapter on Internet porn came across to me like the author banging a well-worn sensationalist drum of titillation and puritanical propriety. Also, I haven't waded through the annotations, which seem to take up half the eBook, since reading is a bit slower at the moment, and I couldn't be bothered at the time. I still have them to read at my leisure, though.

Other than that, I thought it was an excellent book whose implications matched my personal experience very well. For example, the first chapter described a woman who--due to a poorly prescribed antibiotic and an almost total loss of vestibular function--had had the sensation of falling for five years, even suffering the same sensation when she had already fallen over. Miserable. The chapter describes how she was successfully treated using principles of neural plasticity.

Using the ideas in the first chapter (but lacking expensive equipment) I derived a way to experiment upon myself, potentially improving my own poor balance; it could do little harm. It worked. My balance improved noticeably. Score one for the principles the author was describing.

As I read more, it became clearer that everything I knew about neurology from high school (my A-level Biology 20-odd years ago) was wrong, or at best an inaccurate approximation. The implication for me is evident: recovery is not only possible, but attainable; it takes time and hard work, it will often be boring. My relative youth and the quite small amount of lost brain matter are an advantage. I suspect that never learning to drive will also help.

Yesterday, I was asked to speak as the "expert patient" or graduate of the ASPIRE program I mentioned in an earlier post and I found that I was unable to be as coddling as some medics seem to be. Sure it's horrible having a stroke, and sure it's tough, and for sure sometimes there's so much damage that recovery is going to take decades at best, if it's possible at all, but given all that we have a conscious choice to make, and we should be damn sure we make that choice consciously: Do I want to sit in an armchair and fester for the rest of my life, or do I want to get better? If the answer is "get better" then we do the hard work. 

The book lays out some of the principles and, I think, gives a pretty coherent and sensible view of how our neural matter really works, why localization made sense at the time, and most importantly for me, some ideas about how best to use those principles to effect a faster recovery. As an example, I now go to the gym quite a bit, and I was already concentrating on form over apparent brute strength, but understanding more about plasticity has meant that I pay more attention to my right leg while cycling, for example.

Another example that cuts to the heart of the recovery vs rehab dilemma, is that it matters when my left hand compensates for my right hand. Early on, I was compensating enormously and didn't know it, which partly accounts for my wildly over-optimistic expectations of how long it would take to recover. Now, I work hard to notice when my left hand has quietly assumed an automatic task that my right hand should be doing, and force myself to use my right. Even though it's often much slower. When I pay attention to forcing my right hand to do the things it used to, it improves. Any other improvement is as good as accidental.

If you've read the book and have thoughts or questions or whatever about chapters in it, let's talk about it! (Except the internet one. Can't be bothered. Not relevant to me.)

(Originally posted on Google+ with some commentary.)

ASPIRE

I said I had a bunch of posts owing, and this is the first of them, about the ASPIRE program I was fortunate to take part in, at nearby Yeovil District Hospital.

ASPIRE stand for "Acute stroke Self-management support, secondary stroke Prevention, Information, Rehabilitation and Exercise" program. Too many letters, but trust me it looks better on the page, and you end up with ASPIRE. Which I thought was lame as all hell, but I was game to try anything to aid my recovery when I was assessed on Christmas Eve 2011.

As far as I know, it was the first and for a while the only such program in the country; I've not heard of anything like it in the US. It proved to be almost indescribably useful for me.

The program is simple enough to grasp: It runs for twelve weeks, and participants, who have all had strokes and are encouraged to attend with their primary carer if there is one, do an hour of exercise, choosing whether that's before or after the half-hour chat with a cup of tea and a biscuit.

The chats are directed, and cover the bases of providing information about stroke itself, as well as things like medication, nutrition, stress, exercise and relationships, and how they relate particularly to stroke. The conversation often drifted (particularly when I got involved).

The exercise was tailored to people's deficits, and always seemed included a combination of rehabilitation, simple cardio and strength. We were helped into machines if we needed it, encouraged and cheered on by the two stroke ward nurses who run the program, Debbie and Caroline, and a physiotherapist, Donna, as well as the volunteers, all of whom had had strokes in the past.

I never thought that I would be glad to get on a treadmill, but the feeling of being able to walk, even slowly, and even holding on desperately was magnificent. Being in the hospital gym gave me the confidence to start going to a regular gym again, and gave me measurable results for the work I was putting in (see below for details).

Both have proven very useful: I have been enjoying going to the gym and pool four times a week for a while now, and making measurable gains in fitness means I have something to point myself to when I feel like I'm making no progress. The pace of neurological change and recovery is sometimes so slow that the effort it requires seems almost not to be worth it. So I stagger, I think, is that so bad? Can I live with double vision, after all, I'm functioning? 

I refuse to accept neurological deficits, though, and making progress at the gym or pool, however small, gives me enough feedback to persist until my brain does a lot better job of recovery than just good enough.

At least as useful as the exercise, though, were the tea'n'biscuit (cookie!) chats. Less for their content, which was still excellent pragmatic advice of the sort you're more likely to get from a nurse or therapist than you are from a doctor. More for the fact of being in a room with a couple of dozen other people who had had strokes too.

I'm not much of one for support groups. I mean, sure, in theory, but for me? I would have said not, and I would have been wrong. I had underestimated how isolating my stay in the hospital and in-patient rehab facility had been. I think in the twelve weeks before ASPIRE I talked to maybe three people who had had strokes, and that just wasn't enough.

With ASPIRE we had people to share notes with, tips, gripes, and everything else. People who understood in a way that nobody who hasn't had a brain injury truly can what it is like to be recovering from neurological deficits. How it feels when you're worse at everything you put your hand to, if you can even do that. And more, the volunteers were two or three years past having had their strokes and were back doing some of the ordinary things that are still beyond me.

It's hard to say which aspect of the program benefited me the most; they worked together to set me on a solid path of recovery. I recognise that there's quite a way to go, but I'm far better equipped for the journey, now.

Penultimately, the posts I'm making about stroke recovery and so on are now public, whereas before you had to be a special flower just to see them. As soon as I figure out how to make the old ones public, even the Ultimate Urine Victory, I shall.

Addendum: boring progress part (weeks 1 -> 12)
Treadmill: 10mins @ 2kph, no incline -> 10mins @ 4.5kph, 5.0 incline.
Cycle: 10mins @ L2 flat, 58rpm, 5.88km -> 15mins @ L7 Hill, 80+rpm 8.07km
Rowing machine: 3.29m/500m for 500m R5 -> 2.09m/500m for 1500m, R7.
Trampette: 4'30" holding on for dear life -> 5m, no hands
Free weights: 3 x 10 x 1kg curls -> 10,8 x 8kg, super: hammer curls, raise, squat
Lat pull-down: 3 x 10 x 6.25kg -> 3 x 12 x 16.25kg
Weight: 91.4kg -> 85.7kg

I'm fitter and stronger now. Find me on Fitocracy.

Neurologist Visit

Yesterday, I took a trip up to London to see a consultant neurologist with a specialty in dealing with vision. I'm due to go up to the regular got-referred-in-early-December eye clinic in two weeks' time, but when I got the appointment for that clinic, nearly a month ago, I was desperate to see someone about my sight, and so I shelled out to see this guy privately. He's one of the pre-eminent neuro guys around, all the people at the eye clinic will know him, his name was given to me back when I was in hospital in the US, so he's definitely the right guy to go see.

Except I don't believe him, and I think he's wrong, and while I don't for a second feel like I wasted the money (on the order of $500, thank you disability allowance), I got more out of seeing old friends and teachers from drama school in the afternoon.

He was professional, thorough and on the ball, and thought that I'd probably seen all the improvement in my double vision that I was going to. The one and a half syndrome might improve. The oscillopsia (vertically wobbling eyes) could maybe be treated with a drug... that would have a deleterious effect on my stability, making it challenging at best. My balance issues are likely unrelated to my vision, but daily balance exercise for ever will help. So:

• Diplopia - tough shit, carry on.
• One and a half syndrome - tough shit, carry on.
• Oscillopsia - there's a drug, it sucks, probably tough shit, carry on.
• Balance - tough shit, carry on with your walking stick.

Also, since the one and a half syndrome is so rare these days would I mind coming up for a half day with some students... they'd reimburse travel. Of course.

Now, I'm in no rush to dismiss the expert opinion of an eminent neurologist (I'm still going to, it's coming), and I'm genuinely happy to have someone pay for me to go up to London and amuse medical students for SCIENCE, and I may just be in deep denial about the whole thing, but I respectfully decline to take his word for it, for two major reasons:

First, he quoted to me the neurological canard about there being negligible progress after about six months. Since I have seen walk into my hospital room (with a stick, and with difficulty, but walk) someone who could move only the toes of one side at six months, I consider this, on its face, false.

Second, I continue to see change and progress in my vision. Slow, for sure, and inconstant, but I am certain that the double vision is gradually improving, as I mentioned a week or so ago. My left eye can look slightly to the left of the midline which says either my left LR is weak but working, or the diagonal muscles are working hard to try and compensate.

Underlying my dissent from neurological orthodoxy is a question that remains unresolved for me, mostly because I'm not asking it hard enough, or of the right people, or because we just don't know. It is this: how are the nerves and muscles of my eye different to all the other damaged nerves?This is crucial. My eyeballs themselves are fine, it's the nerves connecting to and controlling the extra-ocular muscles that are damaged (or dead) and must be worked around. Going to the gym, as well as making me fitter and stronger, has improved the musculature, control and nerves of my right side.Why should it be somehow less effective to work the the muscles of the eye? Show me the science.

More nebulously, and rather irritatingly foo-foo-ey, I am arriving at another conclusion about our neurology and the brain's rather amazing ability to recover function: believing we can or should heal some part of the brain, or re-learn some useful skill makes it possible to recover that function or skill. I can't be doing with some of the deficits I have, and I'm determined to eliminate them, and I think that that choice, that mental direction, influences the actual neurology of recovery. Again, I want evidence beyond the anecdotal, and my personal, and again I have arrived at a question I would love answered:

Is there a significant difference between the expected and actual outcomes predicted and observed by neurologists when treating stroke patients as compared with treating victims of external brain injuries. Do we have higher expectations of, say, Gabrielle Giffords, who was shot in the head, than we do of a stroke sufferer, and does it make a difference?

On Exercise, Weight and Weight Loss

I've been thinking about exercise lately, since it's one of the things in my life that is more-or-less under my control (unlike my vision, say, or my balance).

Five months ago, the idea of going to the gym for an hour five times a week, followed by a 30 minute swim seemed plausible, but was far too much effort. My primary motivation then was to lose weight in order to get laid (more).

Twelve weeks ago, the idea of ever working out in a gym again seemed impossibly remote. I was still struggling to walk even a step or two unaided, and a half hour of physio would wipe me out for much of the day. The stroke damage was still overwhelming.

Six weeks ago, I began to feel like the standard fitness goal of doing 5x30m a week* was going to be difficult, but achievable within the nine remaining weeks of my excellent post-stroke program.

Today I'm about to do my 30 minutes of physio exercises this morning, and looking forward to getting to the gym a bit earlier, so I can do more work before the time allowed for supervised swimming. It's the third week I'll have been five times. Achievement unlocked!

Obviously, my persistence and determination have played a part, and it's hard to replicate my sense that my current physical deficits are unacceptable, but I think there's more going on that is generally useful.

First, my motivation has changed from "get laid" to "don't die," For me, this was a fairly easy shift to make. Having some strokes was less of a warning shot, and more of a breach at water level. It's harder if you're like the me of five months ago, where the statistics about stroke, heart disease and diabetes are difficult to absorb on a personal level. That's your problem, and not one I can really help with, except to say many of you, my friends, are too fat, and that's making you sicker, and more likely to drop dead.

Second, and actually maybe useful, has been that with the physical deficits I find so intolerable, my ability in the gym had to be completely recalibrated. I simply couldn't run on the treadmill (I still can't actually run, or even let go). That meant that I had to throw out every expectation I had about what I could reasonably do, start listening to my body, and be fine with being a pathetic cripple loser: not easy.

A year or so ago, when I re-joined the gym on my block, I took the free session of personal training. At the time, I weighed in excess of 230lb, and I hurt so much afterwards, that even though I already knew experientially that I could work through the discomfort, I still didn't want to go back three days later, let alone the next day.

Now I have to tread a balance between doing enough and exhausting myself (when everything, speech, motion, thought, it all slows down), I find I do enough to feel like I've worked, and I do notice days off, but never so much that I've been in pain. The results have been excellent. I got fitter faster than I expected, I've continuously lost weight, and I want to go to the gym more than ever.

By concentrating on the extremely low bar of basic aerobic fitness (the 5x30), and being unable to care that the person next to me might be running along at full tilt while I'm working hard to walk 2km/h, I've met goals that I couldn't otherwise have met, and not lost my motivation. You can do this, too.

TL;DR: You're too fat, my friends, lose weight or die. Care only about what you can do in the gym. Screw those other people, they're probably doing it wrong**.

* That's 30 minutes of moderate aerobic exercise, five times a week. You should be slightly hot, slightly sweaty; that's all. The 30 minutes can be broken into chunks within a day, but nothing shorter than 10 minutes, or you no longer gain the cardiovascular benefit. That's enough to get continuously fitter. As the nurse said, "it's better to be fit and fat, than just fat."

** I pay a lot more attention to form these days, than weight. It's paid off.

Sage Advice

That thing that's got a bit harder because, maybe you're a bit older or a bit stiffer than you were? Notice it, stop avoiding it or working around it. Do it more. Embrace it, find out why it's that way, and work to undo that slowness or stiffness. Now is your only chance.