Neurocognitive Rehabilitation

Introduction to Neurocognitive Rehabilitation

A personalized care experience
Prof. Paolo Montenero

The neurocognitive approach to rehabilitation is based on theories of motor control and learning developed during the twentieth century. Rehabilitation is a clinical discipline that encompasses models resulting from the development of various basic sciences, from neurophysiology to psychology, which can provide interpretative criteria for functional deficits and recovery strategies. After an injury event that has resulted in damage, neurocognitive rehabilitation faces the problem of how new learning can occur under pathological conditions.

In other words, if learning involves acquiring new skills in a stable manner adaptable to multiple contexts, through complex and variable biobehavioral dynamics, theories developed at the beginning of the twentieth century such as Sherrington’s reflex theory and Jackson’s hierarchical theory cannot account for such processes.

Conversely, the studies of contemporary Soviet researchers, A.R. Luria, P.K. Anochin, N. Bernstein, along with those of the American J. Gibson, the German naturalized American U. Neisser, those of H. Maturana and F. Varela of the Santiago School, and the British G. Bateson, while differing in their contributions, can provide the theoretical foundations for neurocognitive clinical rehabilitation methodology. Clinical rehabilitative methodology has found conceptual elaboration and application directions in the thinking of C. Perfetti and his collaborators from the 1970s to the present day.

We can identify some core aspects of these foundations: the perceptual hypothesis, autopoiesis, cognitive processes, and consciousness.

Perceptual Hypothesis

Neisser proposed that the function of the human mind involves information processing (HIP model, Human Information Processing), through cortical functions such as attention, perception, memory, language, and thought. He argued that movement cannot be dissociated from perception, and vice versa. The subject is not a blank slate on which the world writes its stimuli but engages in an ecological-mental relationship with the world, transforming, reducing, correlating, processing, storing, and retrieving intercepted sensory information.

This process is not passive but intentional, involving active and selective information seeking relevant to functional goals. Gibson similarly believed that individuals actively seek what they need in their environment, driven by an interest in a purpose. For instance, if we have various items in our pocket and need to find one, our fingertips, guided by the wrist, will start the search. Attention will be directed to critical tactile-kinesthetic perceptions, as well as thermal and pressure sensations, arising from the finger-object relationship. Selection will be based on anticipatory informational hypotheses, informed by previous experience/knowledge/memory of the sought object and the degree of correspondence between these hypotheses and the collected information. Upon satisfactory confirmation of the perceptual hypothesis, we will retrieve the sought object from our pocket. Repeated search experiences will lead to progressive skill improvement, as palpation will more easily and effectively target critical informational sources essential for object identification. Learning will become quicker and more satisfying as redundant elements are pruned, focusing on the essential experience corresponding to the anticipatory hypothesis. This simple task of recognizing objects by palpating them in a pocket, amidst chaos, represents a cognitive way to reduce informational chaos to order—a cognitive way of making sense of the world.

Luria argued that the initial component of human movement is always an intention or motor task based on a model of future need. Every motor task is constant or invariant and requires an equally invariant outcome, even if the latter is achieved with variations in the series of movements that ultimately lead to a constant, invariant effect. In other words, to fulfill the intention of picking up an object from a pocket, we can palpate in different ways, but the result must still be to extract the object. Therefore, to ensure the achievement of the desired invariant result given this execution variability, a plastic and adaptive innervation of the muscular action components is necessary, maintaining the regulatory role of the motor task. Responsibility thus shifts from efferent impulses to afferent ones, or rather to afferent syntheses regarding the limb’s moving position in space and muscle status. Anochin’s action acceptor is an action control apparatus capable of correcting errors by comparing the ongoing action with the original intention. Motor errors are corrected through constant inspection aided by feedback (retractions) regarding the original plan. An uncorrected error results from the failure of this control system and the mismatch between the anticipatory action model and the executed action due to feedback ineffectiveness or the inadequacy of the anticipatory model relative to the action’s real context. Neurocognitive rehabilitation employs these models for understanding and clinically improving motor acts through perceptual hypotheses concerning the relationship between the body, understood as a receptive surface, and the world. Movement is knowledge. Through progressive cognitive experience and increasing overlap between hypotheses and reality, motor components that hinder this concordance due to damage can evolve.

Autopoiesis, Cognitive Process

According to Maturana and Varela, living systems are autopoietic in that they self-produce and self-organize. Cognition is an emerging process in the living-world relationship that characterizes such self-production and compensates for any environmental disturbance tending towards life disintegration. Neurocognitive rehabilitation values this capacity for self-regulation and self-healing, mobilizing attention, memory, language resources, and considering the patient as an active recipient rather than a passive recipient of external techniques.

Every knowledge is a solution to a cognitive problem. Every cognitive problem is context-dependent and aimed at the living being’s better adaptability (bio-logic). Every knowledge is therefore variable, dynamic, interactive. Thus, the living being constructs its possible world. Neurocognitive rehabilitation thus sets up contexts where, through guided experience by the operator, the person can acquire knowledge, meaning effective actions in the self-world relationship.

Consciousness

Knowledge and interest, namely feeling, affection, motivation, are inseparable.

The etymology of the term “knowledge” comes from the Latin cognosco, meaning “to become aware, learn,” where cum means “with,” gno means “to become aware,” and sco means “to begin to.”

This is quite different from the etymology of the term “consciousness,” which also derives from Latin but from cum scire, meaning “to know with,” signifying awareness, a quality that profoundly characterizes human beings.

In this regard, neurocognitive rehabilitation seeks to answer the question: how does the individual (in their feelings, experiences, thoughts, language, metaphorical creations) and their nervous system change in cognitive interaction with the world and themselves? To answer this question, it is necessary to privilege not only the subjective act of knowing but the conscious experience correlated with knowing, including somatic and psycho-emotional pain.

The rehabilitation operator thus serves as a facilitation interface between the patient and their world, guiding cognitive processes, fragmenting the act of knowing itself, valuing the psycho-physical whole, to foster the patient’s construction of new interactions with the world and the acquisition of new functions.

According to Bateson, every piece of information is a difference that, in turn, produces a difference; these differences generate mental maps that do not identify with the starting territory.

In neurocognitive rehabilitation, sharing objectives, seeking tasks, and setting up contexts represent the method for the patient, in the post-injury experience, to give new meaning to their world.