When your incompetent? doctor uses this word ask then to EXPLAIN EXACTLY what needs to happen for a neuron to drop a current task and take on a neighbors!
NO explanation; PURE FUCKING INCOMPETENCE! Not knowing that makes neuroplasticity non repeatable on demand!
Patient-Centered Neuroplasticity: Transforming Self-Concept and Engagement in Cognitive Rehabilitation After Brain Injury
PhD, CCC-SLP e Affiliations & Notes Article Info
Abstract
Self-concept, the perceptions and beliefs that comprise identity, is often diminished after acquired brain injury (ABI) and can limit participation, effort, and collaboration in rehabilitation. Diminished self-concept undermines rehabilitation engagement: active, sustained participation is necessary for meaningful recovery but remains a persistent clinical challenge in ABI care. Unlike improvements in mobility, neurocognitive change is often internal and difficult to recognize without structured support.“What's measured, improves.” So said management legend and author Peter F. Drucker !
If you can't measure it you can't improve it and make it repeatable!
This challenge is compounded by injury-related cognitive and communication impairments. Cognitive rehabilitation may be enhanced by explicitly addressing patients’ beliefs about their capacity for recovery and by grounding treatment in accessible explanations of experience-dependent neuroplasticity. Patient-centered neuroplasticity (PCN) is a novel clinical framework that builds on established rehabilitation theory and evidence-based cognitive rehabilitation while explicitly integrating neuroplasticity education into treatment. PCN promotes engagement by increasing patients’ understanding of the brain’s capacity for change, structuring interventions to make cognitive improvements visible, and reinforcing self-efficacy through clear communication about biological recovery mechanisms. Through neuroplasticity psychoeducation, a shared clinical language, and rehabilitation activities designed to make progress visible, patients begin to recognize their own capacity for recovery. This recognition creates a reinforcing cycle in which understanding promotes engagement, engagement facilitates neuroplastic change, and observable improvement strengthens a more adaptive self-concept. By making cognitive recovery understandable and personally meaningful, PCN shifts patients from passive recipients of rehabilitation to active participants in their recovery. This manuscript describes the PCN framework, outlines its clinical components across treatment phases, and presents a case study illustrating its application in cognitive rehabilitation after ABI.IADL (instrumental activity of daily living) PCN (patient-centered neuroplasticity Rehabilitation engagement—patients’ active, sustained participation in the therapeutic process—is among the most important yet most difficult targets in acquired brain injury (ABI) care.1 ABI2-4 affects hundreds of thousands of people annually in the United States,5-7 resulting in neurocognitive impairments2,8 that are addressed through cognitive rehabilitation, an efficacious and diverse set of interventions9-11 that rely on engagement as both a prerequisite for benefit and a persistent clinical challenge that limits the reach of even well-supported interventions in practice.1 Engagement, in this sense, sits upstream of technique, rooted in the relationship between patient understanding and therapeutic effort.
KEYWORDS
Acquired brain injury Cognitive trainingMetacognitionPatient-centered care Rehabilitation Self-compassion Self-concept Self-efficacy List of abbreviations ABI (acquired brain injury)In rehabilitation contexts, experience-dependent neuroplasticity provides the biological foundation for recovery: repeated engagement in activities of increasing difficulty drives changes in neural organization and supports improved cognitive and functional performance, including strategy acquisition.12-14 However, unlike improvements in physical function, where changes in gait, mobility, or daily living activities often serve as tangible markers of progress, cognitive gains are often internal, abstract, and difficult for patients to perceive without deliberate, structured support. Although clinicians often have a strong understanding of these neuroplastic principles, a considerable disconnect remains between clinicians’ knowledge and patients’ understanding of how these processes shape their own brain functioning. This gap matters beyond the clinical relationship; factors such as salience, self-agency, engagement, and attention have been shown to directly influence neuroplastic change,15 and self-agency—the belief that one’s own actions drive outcomes—is a key determinant of rehabilitation motivation and behavior in neurologic populations.16 Engagement is not only a prerequisite for neuroplastic benefit but also a neuroplastic variable. Consistent with this, experimental evidence shows that clinician-delivered ingredients that specifically target patient engagement and therapeutic alliance produce meaningful improvements in cognitive rehabilitation performance, including attention span tasks, strategy learning, and home program adherence.1,17
Patients with ABI often undergo rehabilitation without a clear understanding of what is happening or why. They typically cannot explain the purpose of their rehabilitation, what has already been done, or why they are being asked to continue.18,19 The problem is pervasive enough that several systematic reviews have shown that communication between rehabilitation staff and people with brain injury is frequently inadequate, leaving patients without individualized information about their condition and recovery, and often feeling excluded from shaping their own care.20-22 These dynamics are compounded by cognitive-communication disorders that accompany ABI, which can make rehabilitation discussions overwhelming when information is not explained, paced, and explicitly scaffolded.23,24 Unfortunately, providers rarely implement necessary communication modifications, such as plain language or visual support, even when they are aware of patients’ communication deficits,25 and patients with communication disorders consistently report feeling excluded from health care decision-making.18,26 These are not incidental concerns; patient-provider communication quality affects rehabilitation outcomes by shaping key mediating processes, namely, therapeutic engagement and adjustment to disability. Evidence-based communication elements such as individualized information exchange, transparent goal setting, and honest reframing of recovery influence outcomes by strengthening patient engagement in the rehabilitation process.27 Developing an accurate understanding of what has changed after ABI and what continues to change during rehabilitation is a slow and effortful process, shaped by injury-related factors, the gradual recognition of change through rehabilitation, and, critically, how clinicians communicate that process.28 When patients lack this understanding, rehabilitation can feel opaque and disconnected from their lived experience, particularly in cognitive rehabilitation, where the absence of concrete, observable progress markers (unlike the visible milestones of gait or mobility in physical rehabilitation) makes it difficult to recognize meaningful change is occurring at all, thereby weakening engagement with the processes that drive recovery.
Patient-centered neuroplasticity: rationale and foundation
Taken together, the preceding evidence points to a specific, underaddressed need in cognitive rehabilitation: a systematic approach to embedding explicit clinician–patient communication about neuroplastic mechanisms. To address this need, the multidisciplinary Patient-Centered Neuroplasticity Networking Group within the American Congress of Rehabilitation Medicine Neuroplasticity Task Force developed patient-centered neuroplasticity (PCN), a novel clinical approach that guides clinicians in integrating effective clinician–patient communication and deliberately structured rehabilitation activities that make neuroplastic change observable into cognitive rehabilitation. The overall purpose of PCN is to strengthen patient understanding and self-agency by grounding rehabilitation in concrete evidence of neuroplastic change and activating therapeutic engagement as the pathway through which cognitive rehabilitation can produce meaningful functional outcomes after ABI. PCN is designed primarily for integration during the postacute phase of rehabilitation, when patients have transitioned beyond acute hospitalization and can actively engage in the rehabilitation process. In the days immediately after injury, spontaneous recovery processes, including the resolution of edema and blood toxicity, may temporarily overwhelm the neuroplastic response, limiting the extent to which patients can meaningfully engage in neuroplasticity-focused psychoeducation. PCN is therefore best applied once this period has passed and patients begin to develop awareness of cognitive changes. Notably, the emergence of deficit awareness, often accompanied by demoralization, diminished hope, and reduced motivation for engagement, creates a clinical context in which PCN’s emphasis on self-agency, neuroplastic understanding, and sustained participation is most relevant.
Rationale: the challenge of making neuroplastic change visible
“What's measured, improves.” So said management legend and author Peter F. Drucker !
If you can't measure it you can't improve it and make it repeatable!
PCN is grounded in the premise that patients’ knowledge of experience-dependent neuroplasticity fosters self-agency—the sense of being able to affect change—promoting patient engagement, motivation, and therapeutic outcomes after ABI.1 PCN works fundamentally through communication, meaning explicit, accessible sharing and concrete demonstration of neuroplasticity concepts between clinician and patient serve as an active component in rehabilitation. A central challenge in cognitive rehabilitation is that neurocognitive change, unlike physical recovery, where changes in strength, mobility, or endurance are often directly observable, is frequently internal and difficult for patients to perceive without structured support. Consistent with this, studies of impaired self-awareness after ABI show that patients tend to judge physical abilities more accurately while systematically overestimating cognitive, emotional, and behavioral functioning, all of which represent domains that require internalized, nonvisible self-assessment and monitoring.29-32 PCN was developed in direct response to this challenge, aiming to make otherwise imperceptible neuroplastic processes more observable, identifiable, and personally meaningful to patients.
Many patients arrive at rehabilitation with some familiarity with the concept of neuroplasticity, having encountered it in popular media or wellness contexts; however, few understand how it applies to their own brain in the context of injury and recovery. While clinicians often introduce neuroplasticity concepts as part of general psychoeducation or explain specific exercises, PCN goes beyond these incidental mentions by systematically translating neuroplasticity concepts into patient-centered language throughout treatment, paired with experiential examples embedded in treatment sessions that make neuroplastic change visible and meaningful. This approach helps patients perceive change as an internally attributable process, shifting the locus of control to the patient and positioning them as active agents in their own neuroplastic change.
Theoretical foundations
The concept that the self is not fixed after injury, and that identity and capability can continue to evolve, is central to PCN.33 PCN reinforces the cognitive and psychological flexibility that underpins both acceptance of current realities and hope for continued improvement.34,35 Through this process, patients develop a postinjury sense of self that integrates acknowledgment of current changes with belief in ongoing neuroplastic capacity, moving beyond catastrophic thinking about permanent disability toward a recovery identity built on personal agency. PCN helps patients develop awareness of their brain’s capacity for change, which may have operated without conscious recognition before injury but becomes disrupted and clinically salient after ABI.28,36-41
PCN builds on converging evidence emphasizing personal agency and an internal locus of control in rehabilitation.1,42-44 Self-efficacy beliefs directly affect health behavior engagement and treatment adherence across populations.45-48 In neurologic populations specifically, stronger self-efficacy and a sense of agency are consistently associated with greater rehabilitation engagement, more effective self-management, and improved functional outcomes.16,49 Beyond self-efficacy, metacognitive awareness (the ability to understand and monitor cognitive processes) has been shown to influence rehabilitation outcomes, while disruption of self-concept diminishes motivation and engagement by reducing patients’ beliefs about recovery capacity and persistence.28,39,50-52 Psychoeducation interventions have also been shown to improve engagement and rehabilitation outcomes in neurologic populations.1,17 PCN synthesizes these converging lines of evidence into a unified approach, adding explicit communication of neuroplastic mechanisms as the integrating thread connecting patient understanding, self-agency, and therapeutic engagement.
Proposed clinical integration of PCN into cognitive rehabilitation
PCN proposes the purposeful use of patients’ knowledge of experience-dependent neuroplasticity related to therapy effort to strengthen beliefs about recovery capacity, sustain engagement, and promote functional improvement. Consistent with established behavior change frameworks that describe the interaction of capability, opportunity, and motivation,53-57 PCN operationalizes these processes through explicit neuroplasticity communication and deliberately structured rehabilitation experiences. When integrated into a rehabilitation treatment episode, PCN initiates a reinforcing cycle in which patients understand neuroplastic mechanisms (how change occurs), observe change through structured practice (what change looks like), and increasingly recognize themselves as active agents in recovery (who drives change). As engagement deepens, experience-dependent neuroplastic changes are further reinforced, supporting improved rehabilitation outcomes (see PCN logic model in fig 1). The sections below outline a proposed implementation map for integrating PCN across 3 standard treatment phases: initial, middle, and late, organized by treatment phase and grounded in existing evidence from the neuroplasticity, cognitive rehabilitation, and behavior change literature (see examples of PCN components in table 1).9-12,17,50,53,58-68 These phases refer to postacute episodes of cognitive rehabilitation rather than the acute hospitalization or early inpatient period, when physiological processes may limit how much patients can meaningfully engage with neuroplasticity-focused psychoeducation. This map is intended as a theoretical foundation for future empirical investigation, not a prescriptive protocol.
Fig 1 PCN logic model for cognitive rehabilitation after ABI. Clinician-directed PCN components are theorized to foster patient understanding of the rehabilitation process as a foundational mechanism that activates therapeutic engagement and the working alliance, the proximal mechanisms driving self-agency and attributing change to effort. These emerging psychological mechanisms are proposed to support improved rehabilitative gains, including sustained engagement in cognitive rehabilitation, which is theorized to increase experience-dependent neuroplastic change and contribute to meaningful functional outcomes in daily life.
| Phase | Activities | Components |
|---|---|---|
| Early in therapy | Building neuroplasticity knowledge | • Describe key concepts of neuroplasticity. • Review concepts related to behavior change, self-efficacy, and rehabilitation processes, emphasizing that the self contains a brain capable of change. • Facilitate identity reconstruction by exploring how the patient’s sense of self can evolve to incorporate both their current changes and their brain’s ongoing capacity for growth and adaptation. • Address catastrophic thinking about permanent disability while helping patients develop a balanced perspective that acknowledges current challenges without foreclosing future possibilities. • Support development of a “recovery identity” that emphasizes personal agency and the potential for meaningful improvement through neuroplastic change. • Explicitly link goals, anticipated progress, and rehabilitation activities to principles of neuroplasticity. |
| Middle of therapy | Making neuroplastic change observable | • Use predict-review cycles to support metacognitive awareness and self-regulation in relation to current skill levels and evolving performance. • Design therapy tasks to make cognitive processes and outcomes concrete and observable. • Scaffold performance reviews to highlight direct experiential evidence of neuroplastic change. • Integrate feedback that reinforces experience-dependent plasticity (eg, “Your brain is changing—we can see it right here.”). • Reinforce empowerment and personal agency by highlighting effortful practice and self-directed change (eg, “That was hard work, and that’s what changes the brain.”). |
| Later in therapy | Consolidating neuroplastic self-agency and generalization | • Review personalized examples from therapy that demonstrate neuroplastic change, and emphasize the patient’s ongoing capacity to sustain this growth. • Plan future tasks and self-directed activities to promote lifelong engagement with experience-dependent plasticity and reinforce it as a habitual process. • Reinforce that engaging in challenging daily activities creates ongoing opportunities for neuroplasticity, emphasizing that cooking, work tasks, social interactions, and hobbies can continue driving brain change beyond formal rehabilitation. • Develop heightened awareness of neuroplasticity in everyday life so patients can recognize improvements in functional activities like remembering appointments, following conversations, or managing complex tasks at home or work. • Frame successful use of compensatory strategies and self-monitoring in daily living as evidence of neuroplasticity, helping patients understand that adapting their approach to household management or workplace demands demonstrates ongoing brain adaptation. • Establish neuroplasticity as a self-sustaining cycle in daily life, where motivation to engage in meaningful activities creates opportunities for continued brain change that patients can observe as improved functional performance. |
Examples of PCN integrated across a cognitive rehabilitation treatment episode.
Early phase: establishing a shared understanding of neuroplastic potential
During the early stages of postacute neurorehabilitation, patients often feel overwhelmed, vulnerable, and uncertain about their ability to influence recovery given the inherent unpredictability of ABI. Negative metacognitive beliefs (eg, “My memory is so bad now”) can progressively erode perceptions of capability (“rehabilitation can’t help me”), diminishing willingness to engage in treatment. PCN is designed to address this vulnerability by targeting the psychological knowledge and metacognitive awareness patients need to understand how recovery occurs and how their own efforts contribute to change.
Accordingly, psychoeducation is proposed as a foundational component of early PCN, ideally introduced at intake. This education focuses on building a conceptual understanding of neural recovery, including how injured neural tissue relates to functional impairment, how symptoms emerge, and how experience-dependent neuroplasticity supports improvement through practice. Establishing this shared understanding provides a foundation for all subsequent PCN processes. Treatment goals may be explicitly framed in the context of PCN concepts including experience-dependent neuroplasticity, and care partners are engaged to support a shared understanding and reinforcement of these concepts beyond therapy sessions.
Because mechanistic descriptions of neuroplasticity are often highly technical, clinicians need to understand the physiological basis of experience-dependent neuroplasticity and translate these concepts into clear, accessible language appropriate for a wide range of cognitive and communication abilities. Clinician scripts (table 2) provide an entry point for this translation, while visuals, infographics, and teach-back strategies further support patient comprehension and retention.69,70 During goal setting, clinicians are encouraged to explicitly link rehabilitation activities to the underlying neuroplastic mechanisms, highlighting how specific patient behaviors may influence functional outcomes.
| Terminology | Definition | Patient-Centered Explanation |
|---|---|---|
| Experience-dependent neuroplasticity | Neural changes that occur as a direct result of specific experiences, practice, or environmental stimulation. | “Your brain learns what you practice. The more you work on something, the stronger those brain connections become. It’s like building a muscle—the more you use it, the stronger it gets. This is why what you do in therapy, and how hard you work at it, directly shapes how your brain recovers.” |
| New neural pathway formation (neuronal regeneration; collateral sprouting) | The growth of new connections between brain cells and the sprouting of new branches from existing neurons to compensate for damaged pathways after injury. | “After a brain injury, your healthy brain cells can grow new connections to reach out to other brain cells and send messages. Your brain is constantly working to build new pathways—and practice helps that process along. Your brain is constantly working to build new pathways.” |
| Hebbian learning (synaptic plasticity) | The principle that neurons that repeatedly activate together strengthen their connection. | “When brain cells work together repeatedly, they form stronger partnerships. You may have heard the saying, ‘Cells that fire together wire together.’ This is why consistent practice of the same skill helps your brain get better at it. That practice is reinforcing those connections.” |
| Neuroplastic windows (critical periods; sensitive periods) | Periods of heightened plasticity after brain injury when the brain is particularly responsive to learning and recovery, though plasticity continues throughout the lifespan. | “Right after an injury, and at certain points during recovery, your brain is especially ready to learn and change. This is when rehabilitation can be most powerful. But it is important to know that your brain remains capable of change throughout your life, not just in those early windows.” |
| Massed vs distributed practice | The difference between concentrated, intensive practice sessions (massed) used to establish new skills and neural pathways, and practice spread over time (distributed) to consolidate and stabilize those pathways for long-term retention. | “There are two ways we use practice in rehabilitation, and both serve a purpose. When you are first learning something new, we practice it a lot in a short time—this helps your brain start building those new connections. Once your brain has the basic pathway, we spread practice out over time so your brain can lock it in for the long haul. Think of it like planting a garden: at first you water it every day to get the roots established, then once it takes hold, regular but less frequent watering keeps it healthy.” |
| Metaplasticity | The brain’s ability to regulate its capacity for change based on previous experience, so that the brain becomes more efficient at learning the more it is challenged. | “Your brain gets smarter about learning as you practice more. Each time you push yourself in rehabilitation, your brain is not just learning that specific skill, it is also getting better at the process of learning itself.” |
| Cross-modal plasticity | The ability of a sensory system to take over functions typically performed by another system. | “If one part of your brain that handles a particular skill is damaged, other parts can step in to help. Think of it like a company where one department is short-staffed. Employees from another department step in and learn new tasks they wouldn’t normally handle. Your brain can do something similar, reassigning areas to cover for regions that were affected by the injury.” |
| Structural vs functional plasticity | The difference between physical changes in brain structure and how brain networks operate. | “Your brain can change in two ways: it can actually grow new connections (like building new roads), or it can use existing connections more efficiently (like improving traffic flow on current roads). Rehabilitation can help with both kinds of change.” |
| Cognitive reserve | The brain’s accumulated resilience and capacity to maintain function despite injury, built through education, complex experiences, and ongoing cognitive engagement across the lifespan. | “Throughout your life, your brain has been building up strength and backup systems through everything you have learned and experienced. This reserve helps protect you and supports recovery after injury, and continuing to challenge your brain through rehabilitation adds to it.” |
| Environmental enrichment | The positive influence of stimulating, varied, and socially engaging environments on neuroplastic processes and recovery. | “Everything you do outside of therapy is an opportunity for your brain to practice and grow. Conversations, new experiences, hobbies, and everyday problem-solving all stimulate the same neuroplastic processes we work on here. A rich, engaged daily life is part of your recovery.” |
| The neurophilosophical concept of the brain | A philosophical understanding of the brain as an organ capable of self-directed change through conscious effort and choice. | “Your brain is capable of big changes. That is true even after a brain injury. The choices you make to use your brain and challenge yourself can help you improve more and more quickly.” |
Examples of patient-centered scripts for key neuroplasticity concepts.
PCN is further designed to strengthen beliefs about recovery capacity by pairing psychoeducation with structured, appropriately challenging practice. Clinicians should select exercises calibrated to extend patients’ capabilities (eg, emphasizing external memory aids rather than internal strategies when impairments are severe).10,71 They can then provide specific, concrete feedback that explicitly links observed improvements to neuroplastic change (eg, “You can do this now because your brain has changed through practice”). At this early stage, PCN proposes integrating education, structured practice, and biologically grounded feedback to build realistic hope, foster self-agency, and prepare patients for deeper engagement as rehabilitation progresses.
Middle phase: making neuroplastic change observable
Cognitive rehabilitation effects are often indirect, reflecting improvements in internal cognitive processes and strategy use rather than immediately visible external outcomes. In addition, patients’ ability to monitor their own progress depends on frontal lobe functions that are often impaired after brain injury.28 As a result, patients may fail to perceive meaningful gains from rehabilitation, diminishing their belief in their capacity to influence recovery and undermining engagement.39 A core hypothesized contribution of PCN is its deliberate focus on making experience-dependent neuroplastic change visible to patients. PCN synthesizes neuroplasticity and rehabilitation principles into intentionally designed treatment activities that externalize change and provide a shared framework for patients and clinicians to name, interpret, and track progress over time. Through this process, abstract biological mechanisms are theorized to become concrete evidence of change, shifting rehabilitation from clinician reassurance alone to a collaborative partnership grounded in a shared understanding of how and why recovery occurs.
During the middle phase of treatment, rehabilitation activities should be structured so progress is quantifiable within a PCN approach. For example, when teaching a memory strategy such as spaced retrieval, clinicians can track and graph increasing recall intervals across sessions. Clinicians are encouraged to explicitly link this documented progress to neuroplasticity (eg, “Four weeks ago you could recall three items; now, you’re at six. That practice has built stronger brain pathways”). Measurable short-term goals are designed to provide repeated opportunities to connect observable gains to experience-dependent neuroplastic change and to reinforce awareness of progress, which can further sustain engagement. Ecologically valid tasks drawn from patients’ daily roles and environments should also be tracked across sessions, with documented performance reviewed as concrete evidence of functional neuroplastic change.
After strategy practice, clinicians can provide specific, concrete feedback that highlights reduced support needs (eg, “You no longer need the worksheet to use this reminder app; you can do it independently now”). PCN is designed to explicitly link these improvements to neuroplastic mechanisms (“You can do this now because your brain has changed through practice”). Observable metrics (eg, frequency of cueing or worksheet use) can be tracked to further reinforce change. Through this structured feedback, PCN is theorized to move beyond general encouragement and provide experiential proof of recovery capacity, strengthening patients’ recognition of their own ability to influence recovery through effort.
PCN also proposes greater transparency in how rehabilitation activities are structured to promote neuroplastic change. Clinicians can make practice parameters explicit—such as the use of massed vs distributed practice, gradations in task difficulty, and error-control strategies—and explain why these elements optimize brain change. For example, clinicians may explain, “We started with massed practice to jump-start new connections with lots of practice to get used to this new skill. Now we’re spreading practice out so your brain can stabilize and make those changes last.” By turning routine therapy decisions into teaching moments, PCN seeks to reinforce patients’ understanding of recovery mechanisms. Patients may also be prompted to reflect on how structured practice conditions contribute to observed gains, further supporting the internalization and generalization of PCN principles.
Late phase: consolidating neuroplastic self-agency and generalization
In later stages of rehabilitation, repeated exposure to PCN principles—understanding how change occurs, observing improvement through structured practice, and explicitly linking progress to neuroplastic mechanisms—is theorized to support the development of a durable sense of self-agency. Patients are hypothesized to increasingly recognize themselves as active contributors to their own recovery rather than passive recipients of care. PCN reinforces this shift by consistently linking effort, strategy use, and observed improvements to experience-dependent neuroplastic change, supporting the internalization of recovery capacity.
During this phase, PCN should be deliberately tailored to the discharge context. Clinicians are encouraged to review the rehabilitation process alongside documented evidence of change (eg, reduced support, improved performance, and goal attainment) to reinforce that change has occurred and that the patient played an active role in producing it. These reviews are intended to emphasize how neuroplastic mechanisms continue to operate beyond formal therapy, positioning everyday activities as ongoing opportunities for brain change.
In multidisciplinary rehabilitation settings, patients are encouraged to apply PCN principles across domains (eg, physical, cognitive, psychological, and functional activities) to support skill generalization and self-understanding. Discharge planning may include structured opportunities for continued practice, with clear expectations for applying neuroplasticity-informed strategies in daily life, work, and social roles. Patients can set functional goals at discharge in a stepwise, paced manner, integrating their acquired knowledge of experience-dependent neuroplasticity to understand that real-world behavior can induce the neuroplastic changes needed to achieve their goals.
Case vignette of PCN to facilitate engagement
Patient baseline presentation
A 48-year-old right-handed woman who had undergone surgical resection of a ruptured left parieto-occipital arteriovenous malformation and cranioplasty presented to a neurosurgical department 3 months postoperatively for a neuropsychological evaluation and a 10-week trial of cognitive rehabilitation. Cognitively, she endorsed significant memory and language difficulties (ie, recalling recent events during the day and expressing herself), corroborated by clinician observation. Psychologically, she reported significant anxiety and depression related to awareness of her deficits, hopelessness about the potential to regain memory and language function, and worry about future vascular events (pretreatment Beck Depression Inventory72=20 [moderate]; Beck Anxiety Inventory73=15 [low]; endorsement of hopelessness about the future item). She also reported hopelessness regarding her potential to recover or benefit from rehabilitation, stating that it “would not matter.”
Functionally, she reported significant difficulties engaging in activities of daily living because of hemiparesis, along with reduced engagement in instrumental activities of daily living (IADLs) and rehabilitation treatment because of fear of confronting her own disability (“I just want to get back to normal”). She and her informant reported significant reluctance to engage in home exercises outside sessions provided by physical, occupational, and speech therapy (“what’s the point”). From a clinical perspective, this patient’s sense of postinjury self was negatively impacting her ability to engage in treatment essential to her recovery (“this is how I will be forever”).
The patient had difficulty engaging in the neuropsychological evaluation because of markedly elevated levels of distress and repeatedly made self-deprecating comments about her current cognitive functioning; therefore, the data were deemed invalid (ie, “I am so disabled”). Furthermore, she expressed “feeling out of control” because of increased dependence on others, which she interpreted as further evidence of potential chronic disability. Cognitive rehabilitation treatment involved behavioral activation through goal-management strategies and pacing. Notably, the patient exhibited significant resistance to the effort required to consistently learn and apply cognitive remediation strategies, stating that her actions would “not matter” to her recovery because she could not engage in tasks relative to baseline.
PCN implementation to support neurorehabilitation engagement
The clinician integrated PCN components throughout treatment, explicitly explaining how rehabilitation activities were designed to target and modify the patient’s beliefs about her recovery capacity while addressing diminished self-concept and engagement barriers. PCN-based identity reconstruction balanced realistic acknowledgment of current challenges with hope for ongoing neuroplastic change and functional improvement, positioning her as an active participant in recovery.
Addressing capability: weeks 1-3
The clinician provided PCN psychoeducation on experience-dependent plasticity to build the patient’s and family’s understanding of the brain’s capacity for healing. The educational approach emphasized that repetitive behaviors strengthen neural pathways and form new connections over time (see table 1 for examples). The patient was encouraged to understand how adult brains retain the capacity for change and how this relates to her specific injury and recovery potential. To demonstrate this concretely, the clinician implemented a structured digit span task in which the patient recalled number sequences of varying lengths.74 Through careful scaffolding and repetition, the patient progressed from an initial inability to complete the task to successful independent completion. The clinician used this performance improvement as direct experiential evidence of experience-dependent neuroplasticity, explicitly linking observable behavioral change to underlying neural processes occurring in real time.
Creating opportunity: weeks 3-6
The clinician systematically structured practice to be observable, using established PCN principles, and explained how specific practice characteristics optimize neuroplastic change (ie, scaffolding and errorless learning). The clinician implemented scaffolded, error-controlled working memory practice protocols (ie, attention process training, digit span, and letter sequencing exercises) designed to promote neural pathway development while maintaining sufficient success to sustain motivation. Visual graphs allowed the patient to observe concrete improvements across sessions, creating opportunities to self-monitor neuroplastic change. Through repeated PCN messaging and in-session examples linking neuroplasticity directly to her role in the process, she modified her self-representation, contributing to a reinforcing cycle of engagement with challenging neurorehabilitation exercises (“You improved on this. What role do you think you played in that improvement?” [pause] “When you see yourself getting better at something, how does that change what you believe about your recovery?”). Home practice programs were explicitly framed around neuroplasticity principles, and family members were trained to support structured practice opportunities outside sessions. Family support included charting IADL tasks (ie, standing and washing dishes for longer periods) and providing concrete demonstrations of generalization.
Enhancing self-agency and motivation: weeks 6-10
The clinician implemented systematic predict-review cycles to build metacognitive awareness and self-agency, encouraging realistic performance expectations and building recognition of her active role in creating positive change. After the patient successfully completed a task, the clinician provided specific feedback that reinforced connections between her efforts and neuroplastic change. Treatment incorporated PCN-grounded self-affirmation statements. When the patient demonstrated incremental progress, she stated aloud, “I just got better,” which the clinician reinforced. The clinician used metaphor-based explanations to conceptualize experience-dependent neuroplasticity as an active process similar to physical conditioning (“It’s just like building muscle—the more you practice something, the stronger those brain pathways get. You just made your brain stronger at this”) or learning new skills (“Think about learning to ride a bike or drive a car—at first, it’s hard, but the more you practice, the easier it gets because your brain builds those connections. That’s exactly what just happened here.”), emphasizing the importance of consistent, effortful practice in building neural strength and connectivity. Motivational enhancement strategies included comparative imagining exercises that helped her envision different recovery trajectories based on engagement level, reinforcing her sense of personal agency and motivation to engage outside sessions.
Outcome
Through systematic implementation of PCN strategies, the patient demonstrated progressive changes in self-representation and engagement in rehabilitation (“I can see ways that I helped myself get better”). Neuroplasticity education, structured observable practice, and motivational enhancement throughout treatment enabled her to reconceptualize herself as an active participant in her recovery rather than a passive recipient of care. This shift contributed to a cycle of increased engagement in challenging rehabilitation exercises and IADLs, along with improved mood on self-report measures (Beck Depression Inventory=14 [minimal]; Beck Anxiety Inventory=8 [low]).
Limitations and future directions
This special communication presents a theoretically grounded approach to integrating PCN into cognitive rehabilitation after ABI. As a conceptual article, it is important to acknowledge its limitations and outline the necessary next steps for empirical validation. The PCN approach proposed here synthesizes existing evidence from neuroimaging, health psychology, and rehabilitation science but has not yet been empirically tested as a unified intervention. Although individual components such as psychoeducation, goal setting, and performance monitoring are common in rehabilitation, the specific contribution of making neuroplasticity explicit and observable throughout rehabilitation remains to be evaluated. Additionally, the current PCN approach focuses primarily on cognitive rehabilitation for adults with ABI; its applicability to other rehabilitation domains of ABI (eg, gait, activities of daily living, and swallowing) or to other clinical populations requires investigation.
Future research should pursue multiple complementary directions guided by systematic intervention development principles.75-77 First, qualitative research with patients and clinicians can refine PCN components and inform implementation by identifying barriers, facilitators, preferred delivery methods and materials, and cultural considerations across diverse populations and settings. Such formative work would guide targeted intervention development and clinician training protocols. Second, initial efficacy studies should examine whether PCN influences the proposed mechanisms, including increased neuroplasticity knowledge, enhanced rehabilitation self-efficacy, hope, self-concept, and perceived agency, as well as stronger treatment engagement, and whether these mechanisms translate into improved cognitive rehabilitation outcomes. Understanding whether and how PCN affects psychological processes and cognitive performance would clarify the underlying mechanisms of action and identify who benefits most. Third, comparative effectiveness studies are needed to evaluate PCN-enhanced rehabilitation against usual care and related interventions, examining both traditional cognitive outcomes (attention, memory, executive function) and functional daily performance. Establishing PCN’s empirical foundation through this systematic research trajectory will enable rigorous evaluation of its clinical utility and refine implementation strategies across rehabilitation contexts. Additionally, this proposed implementation map is tailored to the postacute phase of rehabilitation; its applicability to acute hospitalization or early inpatient recovery, when physiological factors may limit active engagement with psychoeducation, warrants separate consideration.
Conclusions
After brain injury, negative beliefs about brain function and feelings of hopelessness toward change often undermine engagement with and benefit from cognitive rehabilitation. This manuscript describes how PCN addresses these barriers by explicitly teaching experience-dependent neuroplasticity and deliberately structuring rehabilitation to make cognitive change visible to patients. By grounding rehabilitation in a shared biological understanding, PCN transforms beliefs about recovery capacity, strengthens engagement, and supports functional improvement.
PCN positions patients as active agents in their own recovery, shifting the traditional expert-patient dynamic to a collaborative partnership centered on effort, understanding, and change. The clinical implementation guidance presented here offers a practical roadmap for integrating PCN into rehabilitation phases, and the outlined future research directions provide a foundation for evaluating its mechanisms and effectiveness. By making neuroplasticity explicit rather than implicit in rehabilitation, PCN offers a clinically actionable approach to improving engagement and outcomes after ABI.
Acknowledgments
Disclosures
The investigators have no financial or nonfinancial disclosures to make in relation to this project.
Data statements
The data that support the findings discussed in this manuscript are available from the corresponding author upon reasonable request. The data are not publicly available because the authors seek to uphold the privacy of patient information.
Acknowledgments
We thank the American Congress of Rehabilitation Medicine Neuroplasticity Networking Group for their support. We also thank Shan-Pin Fanchiang at Rancho Los Amigos Rehabilitation for contributing to discussions on the applicability of the concept of patient-centered neuroplasticity to occupational therapy practice.
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