Coulter Memorial Lecture

Neuroscience is providing us with remarkable data on brain functioning. A reductionist dilemma. Everything from chemistry to sociology could be explained in terms of physics, at least theoretically. Yet, "I ran the car into the wood chopping block" is a far more evocative story than any precise description of the physics of the event. While supplying a complex mathematical equation might most precisely define the effect on the car, it is the story that enables my wife to picture the damage I have caused. Ah, but what if the story was, "I think I ran the car into the wood chopping block"? And (humor me here) what if you couldn't go and look at the car to check? A description of the forces on the car would help separate a liaison with a former tree from the bump of just running over a pothole.

Dr. Keith Cicerone presented the Facts, Theories, Values: Shaping the course of neurorehabilitation. The 60th John Stanley Coulter Memorial Lecture. Many valuable points in that lecture you'll need to read yourself. He observed, however, our growing understanding of neuroplasticity, informed primarily by advances in neuroscience:
The roles of behavioral variability and predictability are central to recent investigations of executive functioning in relation to the frontal lobes. In this framework, executive functioning (task setting and monitoring) is related to the dorsolateral frontal cortex; emotional and behavioral regulation is related to the medial and lateral orbitofrontal cortex; and the rostral prefrontal cortex is related to "metacognition" involving the integration of motivational, emotional and cognitive activities. These same processes—involving the supervisory attentional system and anticipatory neural network—are central to the rehabilitation of cognitive impairments through meta-cognitive strategy training, characterized by interventions to foster anticipation and planning, response monitoring, and self-evaluation. This may represent at least the beginning of a theory of cognitive remediation that integrates neurologic, neuropsychological, and rehabilitation concepts and mechanisms…

In our own work, we have suggested that meta-cognitive strategy training directed at improving patients' self-regulation of both cognitive and emotional processes leads to increases in patients' self-efficacy beliefs, specifically in their confidence in managing residual cognitive and emotional symptoms. Improvements in perceived self-efficacy (and related concepts, such as maintaining a positive problem orientation) are directly related to positive outcomes, particularly patients' subjective well-being and life satisfaction.

This approach to rehabilitation puts the patient's subjective experience and beliefs at the center of the rehabilitation process.

Returning to physicists vs. chopping blocks, our neurorehabilitation practice often seems most like the uncertain story—"I think… perhaps it could be..." Our formulations of the difficulties facing the people we work with are informed by many things. We draw on theory, on observation, on formal assessments, on information about the impairment to the brain, and hopefully by listening to the person's own experiences and perceptions, as well as those of the people around them. We make our best attempts to draw a connection between these explanations and our knowledge of what works in neurorehabilitation interventions. And then we do whatever it takes. And that's not so bad.

A clearer neurobiological model of brain processes after impairment, and how they change in rehabilitation, could plausibly turn much of this on its head. We might discover some chopping blocks were potholes, and some potholes were something else altogether. But a clinician can't solely be a physicist (or a neuroscientist). Higher level subjective human experience is imbued with meaning not circumscribed by neurobiology. It seems to me that in order to apply advanced neuroscience insights into neurorehabilitation practice, we're going to need a much clearer map to guide us.