“To a man with a hammer, everything looks like a nail”

In neurorehabilitation, there are far too many clinicians wielding hammers and seeing nails. It’s the seductive lure of reductionism—an urge to simplify what’s deeply complex, to align one’s perspective with what’s already known, rather than grapple with the messiness that real recovery entails. This tendency, while human, can be a significant impediment in neurorehabilitation, especially when we consider the elderly, who are often the recipients of these services.

Neurorehabilitation requires a shift away from our entrenched, linear thinking. It demands a paradigm that embraces complex systems—where the interaction of diverse variables, rather than singular interventions, leads to recovery. I've encountered several new cases recently that make this point strikingly clear, cases that underscore the shortcomings of treating each patient with a narrow focus when the reality is anything but straightforward.

Take the typical elderly patient in our neurorehabilitation unit. Most often, these are individuals over 65, many of whom have experienced a stroke, alongside comorbidities such as heart disease. These patients are not clean slates; they come with histories, ongoing pathologies, and biological changes intrinsic to aging itself. It’s not just a stroke that’s shaping their outcomes; it’s the whole constellation of their medical and physiological contexts.

Let’s delineate this clearly: factors related to disease versus factors related to aging. The disease-specific factors include medication side effects, immobility leading to deconditioning, anabolic resistance, persistent inflammatory states, barriers to adequate nutrition, and even the malnutrition that our own medical interventions can inadvertently exacerbate. The age-related factors? We’re talking about physical inactivity, oxidative stress, hormonal changes, chronic low-grade inflammation, mitochondrial dysfunction, and the progressive reduction of muscle mass and strength.

These factors are not isolated phenomena. They interact, amplify, and entangle with one another, creating a network of challenges that don’t respect the neat divisions of medical textbooks. If we’re only bringing a hammer, if we’re only focused on stroke-specific sequelae without understanding the broader physiological context, we’re doing our patients a disservice. Neurorehabilitation is not just about neurology—it’s about the body as a system, a collection of systems.

So at CEN - Centro Europeo de Neurociencias CENNEURO , we’ve adopted a different model. Our neurologists investigate the neurological aftermath of stroke, but they’re also part of a larger multidisciplinary assessment team. We use objective metrics—evaluating body composition, vascular health, and autonomic function. These assessments are then when necessary complemented by insights from nutritionists, geriatricians, cardiologists, endocrinologists, and more. Each expert adds a piece to the puzzle, ensuring that we understand our patients in their full, complex context.

The problem is that many professionals, armed with the hammer of their favored approach, fail to see beyond it. They attribute every difficulty in walking to the hip or believe in the near-mythical properties of the latest therapeutic concept they’ve invested in—often with little evidence to back it up. They become specialists in Technique X, Robot Y, or Muscle Z. But muscles, techniques, and robots don’t exist in isolation. They are part of a broader whole, and recovery is about reconnecting the myriad components of an individual, not just "fixing" one piece at a time.

Neurorehabilitation needs to evolve into a discipline that respects complex systems theory. Our toolbox must be diverse: it should include a multidisciplinary team—neurologists, nurses, physiotherapists, occupational therapists, neuropsychologists, nutritionists, speech therapists, optometrists and more. It requires objective assessment tools and treatment techniques that are supported by scientific evidence. It also necessitates an understanding of how advanced rehabilitation technologies can assist, without being taken as panaceas.

Above all, what we need is intellectual humility—an openness to learning, to being wrong, to adapting our methods when new evidence presents itself. Neuroscience and neurorehabilitation should not be static; they must be dynamic, reflective disciplines. Our passion for learning must be, as Carl Sagan said, our "survival tool." For patients and professionals alike, this openness—this willingness to navigate complexity rather than simplify it away—is the true key to effective rehabilitation.