JHTR 18:4 is about thinking differently. Thinking "outside the box," which has helped expand our notion of the possibilities for recovery after head injury, is a story that has become better known in recent years. Central to that story is the concept of neuroplasticity, a concept that was alien to Magendie when he offered his famous dictum two centuries ago that neural neogenesis in the adult was not possible. We are born with all the neurons we will ever have and regeneration after injury cannot be the basis of functional recovery. Functional recovery does not occur after brain injury, but rather tricks, substitutions, and compensatory behaviors are the order of the day. Magendie's views prevailed well into the 20th century when people such as Donald Hobbs, Paul Bach-y-Rita, Fernando Nottebohm, and others researched and formulated novel ideas about brain neuroplasticity. Based on reviews of a number of lines of evidence, this issue of JHTR, ably edited by Flora Hammond, explores many ideas on the frontier of neuroplasticity that will eventually change our approach to rehabilitation therapeutics.

In contrast, there is a story based on thinking "outside the box" that has helped prevent head injuries-but that story is not generally known. Recent reviews of the accomplishments of Senator Daniel Patrick Moynihan, who died this year, have reminded us of how his different way of thinking about national issues helped unpack them to benefit us all. As the story goes, Moynihan published an "outside the box" article entitled "Epidemic on the Highways" that appeared in the Reporter in 1959. As an aide to then-Governor Averell Harriman of New York, Moynihan had gotten interested in the problem of auto accidents. Before this, auto accidents were thought to be a problem of engineering (build safer highways) or law enforcement (enforce the speed limit). Moynihan studied the issues and thought differently. He viewed auto accidents on our nation's highways as an epidemic (many years later, head injury took on epidemic as an appellation) and he used an epidemiologic perspective when characterizing the problem of auto accidents and formulating its potential solutions. Accidents and injuries should be thought of as public health issues; statistics should be collected (he was a trained sociologist); action should be taken by government (he was a future Senator), by automobile manufacturers and by drivers and passengers, that would reduce the number of accidents and injuries. And that is what happened. From 1965 to 1993, the death rate per 100 million vehicles was reduced by two-thirds. The future Senator Moynihan, not a driver himself, pointed the way by thinking about auto accidents as a problem of public health, an approach familiar to all of us today but thought of very differently before 1959.

I think the reader will enjoy leafing through Stein and Hoffman's sharp and incisive concepts regarding plasticity in a context of brain damage and repair; Smith, Meaney, and Shull's physical explication of diffuse axonal injury, a hallmark of traumatic brain injury (TBI) in an age of high-speed automobile accidents; Phillips, Feeney, and Devier's innovative rehabilitation pharmacology approach; and Lu, Mahmood, and Chopp's discussion of biological transplantation and neurotrophin-induced neuroplasticity after TBI. The reader may also find interesting "thinking outside the box" in the Ethics special feature by Kothari and Kirschner. With the recent implementation of protected health information regulations emerging from a 1996 Congressional law known as HIPAA (Health Information Portability and Accountability Act), all health care professionals now must have an enhanced awareness that they must obtain informed consent from patients before going ahead with diagnosis, treatment, or research. Kothari and Kirschner begin their discussion with the commonly vexing problem of how one obtains informed consent from persons with impairment of decision-making capacity by TBI. In many situations, a person with TBI may be deemed unable to give informed consent because of incompetent decision-making capacity. Kothari and Kirschner go beyond this by raising the following question: even if patients with TBI are unable to give full informed consent, are there still ways to involve them in treatment decisions? "Beyond consent" is a provocative and timely exposition of "out of the box" thinking on a subject of great social importance that is ultimately connected to issues of personal dignity, privacy and the protection of individual rights. JHTR 18:4 is definitely about thinking differently.