Aaron Macpherson’s car was at best his second-favorite mode of transportation. He’d much rather have been on his bike, as he had been over the weekend, pedaling up and down the single-track trails above Horsetooth Reservoir. When you commute 40 miles to work from Fort Collins to Longmont, though, you drive it, which is what Macpherson had done on this July Monday in 2015. It’s a 50-minute commute, typically. This trip home would take a month.

As he approached the intersection at Interstate 25, Macpherson, 53, noticed that things sounded like he had seashells on his ears. He merged into traffic, then merged right back out of it, pulling onto the right shoulder and scraping against the guardrail. He got out of his car to check for damage, stumbling as his brain lost control of his right side. He stood, leaning against his car with a fist he couldn’t open. A woman driving on the service drive opposite the guardrail saw him and stopped. She asked if he was OK.

Macpherson, a senior engineer running a six-person team at Seagate Technology, heard her and understood her but stood mute. It was as if a cable between brain and his mouth had been unplugged. The woman called 9-1-1; the Colorado State Patrol arrived not long before the paramedics, who rushed Macpherson to UCHealth Medical Center of the Rockies (MCR), where he was whisked into a CT scanner. It showed a stroke on the left side of his brain; MCR neurologist Sheri Friedman, MD, administered clot-busting tissue plasminogen activator (tPA) about 45 minutes after Macpherson scraped his sedan against that I-25 guardrail. Given the circumstances, it couldn’t have happened much faster.

With the clot obliterated, Macpherson could speak again. By then his wife, Marie, had arrived. The first thing she heard him say was a question to the neurologist: “Am I going to be able to ride my bike again?”

“It wasn’t ‘I’ve had a stroke and what’s happening to me,’” Marie Macpherson said. “It was ‘Can I ride my bike again?’”

No one could say. Two things were certain. One, Macpherson had lost brain cells at a rate of about 2 million per minute during the stroke, and it had left a two-centimeter by four-centimeter white dead spot on CT scans. And two, his dedication to the speech, occupational and physical therapy in the weeks, months and perhaps years ahead would be crucial to his getting back in the saddle of life in general.

Different strokes

Stroke recovery is as deliberate, concerted and evidence-based as the medical interventions done to limit the initial damage. For Macpherson, it started with a three-week inpatient rehabilitation unit stay in which he spent three hours a day, at least five days a week. Then, in the months that followed he continued as an outpatient at UCHealth Physical Therapy and Rehabilitation Clinic – Fort Collins with occupational therapist Patricia Kuyper, OT, physical therapist Carol Gertsch, PT, DPT, and speech therapist Nancy Malley.

His stroke had been serious, but with varying severity across those disciplines. Malley noted slackness in the right side of his face and mild to moderate Broca’s aphasia. It’s characterized by slow speech, problems finding the right word, and in Macpherson’s case slight problems processing complex information he heard. Gertsch, focusing on the legs, saw a man who could walk, but poorly, his gait seriously disrupted on the right side. Kuyper saw a largely disobedient right arm and a thoroughly aloof right hand. And Macpherson was right-handed.

“Every stroke is like a fingerprint,” said Kuyper, who has worked with perhaps 3,000 stroke patients since 1996. “We never know how that person’s going to respond.”

For all the damage done, the stroke had left Macpherson cognitively whole, with full command of the intelligence and drive that had propelled him to become a high-performing technical professional and a serious recreational cyclist. Not everyone is so lucky. He harnessed those advantages in approaching his own stroke recovery as he might tackle a tough engineering problem, and with the same determination that had pedaled him over so many uphill trails. In an email, Gertsch described what she saw:

“He was accustomed to thinking about complex problems and knew that they usually take a long time to solve. He recognized that there was a benefit to working on individual components part of the time (e.g. increased knee flexion) so that there could be a focus on that specific problem, and that there is also a need to trial that component as part of a larger system (how well can I flex my knee during the swing phase of gait?) and shift back and forth between refining performance of a component in isolation and then finding a way to incorporate that improvement into the function of the system.”

Work to do

Macpherson found himself exhausted his first few weeks at home. He couldn’t hold a spoon, much less a pen, couldn’t tie his shoes, couldn’t put on a shirt without Marie’s help. His right leg swung wildly when he walked. To get in bed, he lifted it with his left leg. In the early days, his outdoor walks consisted of a slow shuffle from front door to sidewalk and back, at which point the exhaustion had him sleeping again. That’s normal, Kuyper said.

“I tell people, even if they’re used to five hours of sleep a night, they’re going to need nine or ten hours,” she said.

Malley, the speech therapist, focused on cognition and expressive language skills. Speech therapy, while it does deal with speech production, is often dedicated to improving swallowing, voice, cognition, language comprehension and expression. They worked on speech fluency – Macpherson spoke haltingly after the stroke – and, with time, higher-level cognitive tasks such as working memory (for example counting backwards by sevens), problem solving, and verbal-processing tasks.

“It’s not just hearing,” Malley said. “It’s that the message is heard but then it has to be processed in the brain in order to fully understand the meaning.”

An example of the latter might be to ask, “A sweatshirt is not something you wear when it is cold outside: true or false?” This particular statement is more difficult because it is stated in the negative.

Macpherson’s drive to ride a bike was unwavering, and it influenced not only his dedication to the grind of rehabilitation – Kuyper wants patients to repeat new movements 200 times throughout a day – but also the nature of it. Gertsch, for example, had him work a bit extra on external hip rotator and abductor muscles, which he would need on a bike. Stroke-recovery progress seems to slow with time, Gertsch said. The neurological improvement may be accruing at the same pace, but the results are a lot less obvious.

It takes less improvement in motor control, and so fewer neurons, to get from a wheelchair to walking slowly with a cane than it does to go from walking slowly with a cane to walking briskly without one, Gertsch said. That translates into more time: it might be three months to get walking with a cane and 18 months to losing the cane and walking fast, she said. She likened it to a piano student doing a simple arrangement of Beethoven’s “Moonlight Sonata” versus a concert pianist playing the original with speed, smoothness, and touch.

Small steps

With Macpherson’s stroke recovery, occupational therapy was the most involved. Kuyper worked with him on fine motor skills, with a focus on the arms and hands as well as ways to compensate for lost function as he worked to regain it. Macpherson had to learn how to button things again, how to use his shoulder, his elbow, his forearm. There were countless exercises, all aimed at reminding his mind that he knew how to do these things. Outside of his prescribed rehabilitation exercises, he made a point of using his right hand despite its misbehavior and the frustration it could cause him. It all led to incremental improvement. Kuyper made a point of noting even the smallest gains. That made a difference, Macpherson said.

“That was key, because I couldn’t see it day-to-day,” he said.

Support at home is another key to long-term stroke recovery. It might range from buying a recumbent three-wheeled bike three months after a spouse’s stroke to marking milestones the patient might otherwise not notice. Marie did both of these things.

“I do make a point of celebrating every little bitty functionality return,” she said. “It could be hugs or sticky notes.”

Macpherson was back at work full-time six months after the stroke, with speech-to-text software in place of typing. He came home exhausted, but it got better with time. At seven months, he got back on his two-wheeled bike. His right hand was making progress, but it gripped the handlebar and declined to let go. That, combined with weakness in his right arm and a right leg that bonked against the top tube with each pedal, caused him to wait on riding two wheels for now. He went back to the three-wheeler for a time, but by the summer after his stroke, he and Marie were riding a paved bike trail seven miles into Old Town Fort Collins, where they treated themselves to mochas and almond croissants. His right hand would ungrip when he focused on it, but using the handbrake and shifting gears wasn’t happening yet.

Find your passion

By late 2017, two-and-a-half years after the stroke, Macpherson was writing with a pen and could, with some concentration, command his right index finger to open after squeezing a brake lever. He was also back riding single track, his knee having lost any affinity for his bike’s top tube. In November, he and Marie visited London, riding the 2012 Olympics mountain bike course in Hadleigh during the trip.

The answer to his first question in the ER that evening in July 2015 has been answered. The MCR rehab staff give the credit to Macpherson.

“He’s amazing. This guy has worked his buns off,” Kuyper said.

“He was extremely motivated. Follow-through was excellent. He was his own best therapist,” Malley added.

Her husband deserves kudos, Marie Macpherson admits. But so does the UCHealth rehab staff, whom she described as “stellar.”

“They were very progressive, with all kinds of cool techniques to challenge him every step of the way,” she said.

His right hand remains a work in progress, but he intends to regain full control of it.

“My goal is to get to the point where I’m not thinking about it anymore. I don’t know how many years it will take,” he said. “I just have to be patient, though it’s not easy for me to be patient.”

Her husband has been unwavering in his desire to return to his competent, athletic, pre-stroke self, Marie said. Getting back on his mountain bike provided a concrete target. She says that can be a lesson to others in stroke recovery.

“It could be ‘I want to pick up my grandchildren,’ or ‘I want to be able to continue to paint,’” she said. “What is that passion that helps provide a life goal for them?”