Facts, Theories, Values: Shaping the Course of Neurorehabilitation. The 60th John Stanley Coulter Memorial Lecture

Cicerone KD. Facts, theories, values: shaping the course of neurorehabilitation. The 60th John Stanley Coulter memorial lecture.We have seen an increase in efforts to establish evidence-based parameters for the practice of rehabilitation. This effort has been placed in a broader context involving the role of theory in advancing rehabilitation science, particularly in relation to specifying the active ingredients and mechanisms of action of interventions. One approach to cognitive rehabilitation is through direct training of cognitive functions such as working memory, which purportedly relies on mechanisms of neuroplasticity. However, this approach is also shown to be dependent on qualities of active attention and learning, feedback, effort, and motivation. Changes in functional and structural connectivity after cognitive rehabilitation suggest that the dynamic adjustment of task-related and resting activity in areas connected to the site of injury is the most likely mechanism underlying recovery of function. Behavioral interventions that address this process have emphasized the role of metacognitive and emotional regulation, as well as an appreciation of the role of subjective experience and beliefs, as central to the rehabilitation process. Our understanding of these processes occurs in the context of scientific values that influence judgments about how much evidence is sufficient to support the evaluation and acceptance of scientific results, including judgments about the effectiveness of rehabilitation. Evidence and theory are necessary to understanding rehabilitation, but we also need to acknowledge the values that directly and indirectly guide our research and practice.