The Hierarchy of Healing: Understanding Complex Neurological Recovery with Dr. Matt Antonucci | E31

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Carrick Institute

Show Description:

Ever wonder why your concussion symptoms persist despite seeing multiple specialists and undergoing countless tests? In this illuminating conversation, Dr. Matthew Antonucci reveals the systematic approach that's transformed the lives of thousands of patients with complex neurological conditions.

Dr. Antonucci approaches each patient like a detective, meticulously gathering clues without contaminating the evidence or jumping to conclusions. This data-driven method allows him to identify precisely where dysfunctions overlap across multiple neurological systems. As he explains, "It becomes like hundreds, if not thousands, of Venn diagrams, circles that overlap with each other. If you can figure out where all somebody's findings overlap, fixing that one thing fixes all the circles."

The discussion delves into the hierarchical nature of our nervous system, beginning with the bedrock of metabolic function and the often-overlooked autonomic nervous system. Dr. Antonucci emphasizes the critical role of the vestibular system - one of our oldest sensory systems - which is uniquely integrated throughout the entire brain. Unlike our visual or auditory systems that occupy specific regions, vestibular processing influences everything from eye movements to posture, hormones, and sleep cycles.

What makes concussion patients so challenging? "They are depression patients, headache patients, movement disorder patients, dysautonomia patients, chronic pain patients... take all the different patients you would have in a neurology practice and pop them together in one person," Dr. Antonucci explains. Yet with his structured framework, these complex cases become opportunities rather than overwhelming challenges.

Perhaps most powerful is his emphasis on patient education and empowerment. By helping patients understand what's happening in their nervous systems, he transforms their experience from one filled with "I can't do's" to one where they control their own recovery journey.

Whether you're a healthcare provi

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Chapters

• 0:00 The Detective Approach to Neurology
• 5:10 Understanding the Neurological Framework
• 14:22 Collecting Patient Data for Better Outcomes
• 22:25 The Autonomic Nervous System Foundation
• 30:22 The Vestibular System's Critical Role
• 39:57 Cognitive Function and Sensory Integration
• 45:24 Patient Education as Powerful Medicine
• 51:07 Wrap-up and Resources

Transcript

Dr. Matt Antonucci: 0:00

It becomes like hundreds, if not thousands, of Venn diagrams, circles that overlap with each other. And that's what somebody who's really good at functional neurology is able to do. They're able to have all of these circles where they test things and then they figure out where they overlap. And if you can figure out where all somebody's findings. Remember when I said I play detective for a day, when I lay out all of my clues in my mind and I figure out where they all overlap and I can say you know what these all overlap, right there.

Dr. Ayla Wolf: 0:32

Welcome to Life After Impact the concussion recovery podcast. I'm Dr Ayla Wolf and I will be hosting today's episode, where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information, whether you're dealing with a recent concussion, struggling with post-concussion syndrome or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact.

Dr. Ayla Wolf: 1:32

Today, we're joined by one of the leading voices in functional neurology and traumatic brain injury care Dr Matthew Antonucci. Dr Antonucci is a distinguished chiropractic, neurologist, clinician and researcher with more than 15 years of experience transforming the lives of patients with complex neurological conditions. Over his career, he has guided thousands of individuals through personalized functional neurology rehabilitation programs, helping them not only recover from challenges like traumatic brain injury, but also unlock higher levels of performance Beyond the clinic. Dr Antonucci is an internationally recognized educator, having delivered thousands of hours of advanced training to tens of thousands of healthcare providers across the globe. He has also contributed extensively to the scientific community with numerous peer-reviewed publications. Contributed extensively to the scientific community with numerous peer-reviewed publications. Widely regarded as one of the top chiropractic neurologists in the world, his expertise and dedication have set new standards for what's possible in brain health and recovery. Dr Matt Antonucci, welcome to Life After Impact. I'm so excited to have you on the show today.

Dr. Matt Antonucci: 2:42

Yeah, I'm so grateful to be here. It's so great to see you, and you know we always have a fun time when we get together, so I'm excited to see what we create together today.

Dr. Ayla Wolf: 2:49

Yeah well, one of the reasons why I wanted to have you on is because you have worked so diligently with patients with really complex cases and many of these people that come to see you they've already been to lots of other doctors, they've had lots of tests done, and I know that you love data, and so when these people come to you, you collect a ton of data ahead of time, you sift through all of it and then, when they're in your office, you're spending a lot of time doing very hands-on functional exams, trying to figure out what got missed, why are these people still highly symptomatic, and how you can help them.

Dr. Ayla Wolf: 3:29

But because you're also a world-class instructor, in the back of your mind I know you're also always thinking how can I teach other people what it is that I do? And even though you're very much giving people individualized treatment plans, you've kind of created a hierarchy or a way with which you can teach other clinicians how to do what you do. But you've also really figured out what do these patients need? What does their nervous system need to start out, to take them from point A to point B in a safe way where you're not pushing them too hard, you're not frying their brain in the process, and so I really wanted to have you talk a little bit about this hierarchy within the nervous system and how you've integrated that approach into all of this complex care that you do with people with persistent post-concussion syndrome.

Dr. Matt Antonucci: 4:23

Yeah, absolutely. It's very exciting and you hit the nail on the head that. You know I really love helping people and you know I can help a couple people here and there, or I can train lots of doctors to help lots of patients. The challenge with the second of the two things is that there has to be some standardization. It has to be some sort of a system.

Dr. Matt Antonucci: 4:43

You know, we always know, and it doesn't really matter what your discipline is, whether you're a medical doctor, a chiropractor, a physical therapist, acupuncturist, even a personal trainer or whatever, there's always an art and a science to what you do. People can be taught the rules like you do one, two and three when you see A. That's very methodical, very science-based, but there's always going to be some artistry in there. There's going to be experience that comes into it. There's going to be. You know that I've failed doing this in the past, so I do it differently now. That's where the art comes in and different disciplines have different, let's just say, uh, proportions of artistry versus science. Um, you know, you know, it's very much like, um, when we look at chiropractors I'm a chiropractic by training uh, chiropractors have a lot of science behind what they do, but there's a lot of art. You go to a hundred chiropractors and you'll find 200 different ways of treating somebody. Um, that's because there is a lot of art in in in chiropractic. And the opposite is also true with medicine. If you have strep throat, there is one or two antibiotics for strep throat, and that's the science of it. So, realistically, in order for us to make something scalable, like medicine is, I really feel there has to be a systematization for it or some sort of a I don't want to call it a protocol, but at least a framework, a structure to approaching a complex patient.

Dr. Matt Antonucci: 6:07

And when you start talking about concussions, in my humble opinion, concussions are the most complex patient. They are depression patients, they are headache patients, they are movement disorder patients, they are dysautonomia patients, they are chronic pain patients. It's literally take all the different patients you would have in a neurology practice and pop them together in one person and that's what you get when you get a concussion. So it's a lot of times for providers it's daunting to see oh boy, here's another concussion patient. What am I getting? But if you have a structure or a framework that you can follow, every single of those patients don't become intimidating. They become an opportunity to help somebody with confidence. So that's kind of what I've been trying to develop. You know, over the past and realistically, 15 years that I've been doing this. It started off as following my instructor, my mentor, Dr Carrick, and then learning what he did, and then trying to make it so that it's much, not much more. It's systematized in a way that's reproducible and teachable.

Dr. Ayla Wolf: 7:08

Yeah, and I know too, every time I get a new patient coming into my clinic, it's always that little bit of nervousness of saying, gosh, I know I really want to help this person. I'm not quite sure what's coming in my door, door, and so it is so helpful to have, like you said, not necessarily a protocol, because we're not doing the same thing on everybody, but to have the framework with which to approach a complex problem is so important.

Dr. Matt Antonucci: 7:33

Yeah, and think about it from the patient's perspective too. You're not the only one they've seen, and they know that. Look on your face when they walk in the door and you're like, oh man, another one of these patients. They know that, they feel it. Imagine how much different it feels to be in the patient's scenario where you're walking into a doctor's office that has a structure, that has a system that says, hey, I'm excited to work with you. I love these types of challenges and I know exactly where to start so that confidence exudes from you. The patients receive it and that's the start of the healing process.

Dr. Ayla Wolf: 8:09

I love that, yeah, so talk maybe a little bit about all the data you collect ahead of time and how that guides you when you first start working with somebody, when they walk into your office.

Dr. Matt Antonucci: 8:19

Yeah, so I I straight up tell my patients that the person I am today will not be the person I am today will not be the person I am tomorrow. Today I'm Detective Matt, tomorrow I'll be Dr Matt. And the thing is, when you have a detective, one of the hallmarks of a detective is they're very careful about collecting clues not to contaminate the information that they have. And the other thing a detective doesn't do is they don't make any preconceived decisions before they collect all their data. They're just a data collector at that point in time. So when somebody first comes and sees me, it all starts actually before they see me. With the questionnaires and intake forms that we put together. I've created a packet of probably 12 or 13 different medical based we call them PROMS patient reported outcome measurement tools where the patients can fill them out and it scores them behind the scenes to give me an idea of what systems are dysfunctional, what systems are functional. And then, of course, we take together their goals, which are so important. I can't even begin to stress enough how important patients' goals are into becoming successful with them. And super little tangent here. If you have a certain goal, let's just say to make somebody's eyes work better or their balance better, and they have certain goals where it's like I want to be out of pain. Well, you might be successful at fixing their eyes and their balance, but they still might be in a lot of pain and that patient will not see the benefits and it'll be a failure for them. So if you're working from a different sheet of music, singing from a different sheet of music, you're ultimately always going to fail. So I always put my patient's goals as number one priority and then I try to figure out what data is going to be their support. So once we have the goals in the history and we also look at like a metabolic assessment form because I should probably make a t-shirt that says it is I I always tell my patients god didn't only say you can have one problem, right, but we're here to figure out what problems you have and figure out which ones we can address and which ones other people will have to address. And by putting that out there first, you'll literally see patients shoulders just go oh, okay. So it's okay if I have more than one thing, you're not maybe going to solve everything, but you're going to solve what you can. So we go through all the metabolic stuff just to make sure that all that stuff is good. And then that's when they get there and we start doing testing.

Dr. Matt Antonucci: 10:39

And the way that I do testing is part of this whole framework and the structure that I do. Testing is part of this whole framework in the structure, and it involves things like autonomic testing, cognitive testing, vision testing, ocular motor testing, balance testing. You know it's, it's like everything. But just saying it like that once again becomes like the pain patient that walks in the door saying, oh my goodness, I got to do all this testing. Well, like the pain patient that walks in the door saying, oh my goodness, I got to do all this testing. Well, it's, it's not that it's a lot, because it's. It creates a picture for you.

Dr. Matt Antonucci: 11:09

And I always tell my patients, because they always ask me why are you collecting so many pieces of data? Like I go to my other doctor. I'm there for 15 minutes, they do a couple of little tests and then that's it. You're sitting here spending three hours of testing. Why and I'm like a metaphor guy, that's it. You're sitting here spending three hours of testing. Why and I'm like a metaphor guy.

Dr. Matt Antonucci: 11:26

It's just how I work, you know, I always tell my patients well, you're going to go out and buy a brand new TV to watch your favorite movie. Do you want it to have three pixels or do you want it to be 4k? Right, so doing three tests gives you three pixels. Doing three hours of testing gives me a 4k television, so I can see exactly what I'm trying to see. So the more data, the better. So, yeah, you're right, I am a little bit of a data freak because you know there's all these sayings, cliches. You know data has data doesn't have opinions. It's just what is. So I just like to see the facts and then from there we can extrapolate how to use them.

Dr. Ayla Wolf: 13:12

Yeah, amazing. And within this hierarchy that you've developed, or that you've kind of noticed works really well with people with nervous system dysfunction. At the root of that is kind of step one, which is the brain needs fuel, it needs oxygen. If it's not getting these basic essentials, it can't work. And so talk a little bit about the basis of this foundation.

Dr. Matt Antonucci: 13:37

Yeah, absolutely so. I would say metabolic function is like if once again the metaphor guy if we're looking at a house, right, metabolic function is the bedrock that the house is built on. If you don't have good oxygen transport, if you have inflammation, if you don't have neural substrates like you know, for example, folate is the backbone of most neurotransmitters If you have metabolic deficiencies, no matter how much you do for somebody whether it's spinning them in a chair or giving them eye exercises or sticking needles in them or adjusting them, whatever it is no matter how much of that you do, you might get them a little bit better, but ultimately they're going to come back. So that's where, like the metabolic assessment form that I'd have in my patient's paperwork where they fill out, we can. We can ask tons of questions about the fundamentals, like do you feel cold? Do you feel tired, you know? Do you have pale skin? Do you find that you know all these different things? Do you feel like your nails are not? You know not how they should be? All of these things kind of tell us if somebody has an anemia or something like that.

Dr. Matt Antonucci: 14:38

But I have to say, the majority of the time the patients that I see they've gone to great doctors, they've screened a lot of those things out and ultimately what they have is they have not a hardware problem, they have a software problem. Like the brain, it was beautiful, it's just not working right. It's like this amazing computer that's for some reason the software got corrupted and it's just. Every time you hit the letter b, the letter k pops up on the screen. How frustrating is that. To have a perfect computer. You wanted to do what you wanted to do and it doesn't do it. So ultimately, that's where this kind of a hierarchy comes in and we start looking at this hierarchy, um, from we don't necessarily look at humans to find out this hierarchy. We look at animals. Like we fast for rewind all the way back four or five million years ago, um, or maybe more than that, four or five hundred million years ago, and we start to look at the different creatures that lived on the planet and how simple they were, even though they had nervous systems. So I always like to weigh. The way I like to look at this is if we can break down the nervous system to its most basic components and if we find dysfunction there. There's no way the basic function can be broken and the high function works well. It just doesn't work that way. So that's where I go.

Dr. Matt Antonucci: 15:51

Looking all the way down to the beginning, which we, the very essential functions of humankind, is to take sensory information in, to process it and create a motor output. And that motor output is going to be involuntary. It's going to be things that are subconscious and things that you have no control over, like your heart beating, your blood vessels contracting, your pupils contracting. These are all called autonomic reflexes, and autonomos means self-governing, so you have no control over these things. They're simply there just to react to either your internal and external environment, and if those reflexes are not working right, you can't expect to be able to think well or move well or anything like that. So that's where we start, at the bottom of our hierarchy or at the foundation of our home, is going to be autonomic function and the reflexes that are built into that.

Dr. Ayla Wolf: 16:43

And can you talk a little bit about the tests that you do to assess that? Because we've got kind of the big clinics like Mayo that have their autonomic reflex panel. They've got their kind of key tests. I know you do some things differently, so maybe talk a little bit about all the things that you're looking at to assess this autonomic nervous system from slightly different angles.

Dr. Matt Antonucci: 17:06

Yeah. So there's a way to do it that's efficient and there's a way to do it that's comprehensive. And then somewhere in between there's where you have to shoot, for you go to Mayo Clinic. You will get the most comprehensive evaluation, but it's going to take hours and hours and hours just to understand how your autonomic system is functioning, nevermind your vestibular system, your visual system, your proprioceptive system, your you know everything else that you need to assess. So typically what I do is I screen first and I have indications that tell me to look further or not. So, Mayo Clinic, now that you mentioned it, they created something a while ago called the autonomic symptom profile. It was like 169 question survey that will ask you questions about your autonomic function. Well, they found out that people didn't want to complete 169 questions. So, yeah, go figure right. So they did a factor analysis and what they said is 31 of these questions actually cluster together. So if we ask these 31 questions, we get just as good as a result. This is called the Compass 31. So the Compass 31 is a screening tool that patients can complete and if they score higher than a 20 on that, it almost guarantees that they have moderate autonomic dysfunction.

Dr. Matt Antonucci: 18:21

If somebody scores higher than a 20, I say, all right, thought pattern changes, we need to dive into more comprehensive autonomic screening. If they're 19 or less, I just say, okay, let's move on, because the autonomic nervous system fundamentally is an uncontrollable system that responds to environmental perturbation. So if there's something wrong, you're going to be more fight and flight. If everything's right, you're going to be more rest and digest. And that's super simple. And I know some people that study neurology might be going. That's not exactly right. I know it's not exactly right, but that's the direction that we move. And if we start to look at where there's errors, whether that's your inner ears are not processing movement properly, well then you're going to have a fight or flight autonomic response. If you have two eyes that are supposed to be looking straight ahead and one eye is pointing out to the side and you're constantly trying to bring your eye in, well that's going to drain energy out of you, make you tired and it's going to make your blood pressure go up and your heart rate increase. So these autonomic reflexes, they basically become slaves to dysfunction. They get entrapped by dysfunction and they stop working appropriately. And then the problem is that then your sensory system re-ingests those issues and now creates a distorted sense of reality. So it becomes pervasive.

Dr. Matt Antonucci: 19:46

So, once again, binary, greater than 20, we do a full autonomic assessment, looking at heart rate variability, you know, seated, supine and standing blood pressure. We're going to look at things like Valsalva maneuvers, so some of the doctors watching this will know what those are For those that are not doctors. Basically it's when you increase your pressure inside your thoracic cavity your heart responds a certain way. So we study all those things and we understand what normal is and abnormal and then we start to look at the different receptors that trigger those. Whether that's a lying down to standing might be a baroreceptor problem, it might be a vestibular problem, it might be a proprioceptive problem, it might be a kidney problem where you're not producing enough blood. So we just really have to consider all those things. But less than 20, we acknowledge it and move on and assess the rest of the hierarchy.

Dr. Ayla Wolf: 20:36

So you feel like if somebody's scoring below 20, you're likely going to find other things in the process of testing and very likely, when you correct those imbalances, then the autonomic nervous system is going to be able to return back to its healthy, responsive nature without you having to necessarily hammer at it directly.

Dr. Matt Antonucci: 20:55

Exactly. It's secondary to something that's primary. Otherwise the symptoms would be much higher if it's primary. So you're looking at a result rather than a cause. So let's go find the cause.

Dr. Ayla Wolf: 21:07

Yeah, excellent, okay. So then the next step.

Dr. Matt Antonucci: 21:11

Yeah, so when we start looking at autonomic function, realistically what we're looking at is motor responses. So remember we talked about the purpose of the brain is to take the inside and outside world and to process and create a motor response. That motor response can be involuntary or voluntary, and then it's kind of like it's a gradual change. So the next thing after autonomic function is going to be tone, right, so that is slightly more controllable but slightly involuntary. So right now you and I both have tone in our spine because we're sitting up and we're not thinking about it.

Dr. Matt Antonucci: 21:45

You have tone of your eye muscles because normally your eye muscles, your eyes would point out and because you're engaging, you get tonus in your eye muscles to let you look straight ahead. You're not telling your eyes to do that, but it's there. So we start looking at tone and we start looking at postural changes like how well somebody can regulate those tones involuntary. On top of that, then we start looking at skeletal motor reflexes, right, when you know, when you maybe tap a knee or leg kicks or when you turn your head, your eyes move. And then this is where the hierarchy starts to build. And after that we start looking at voluntary motion and then coordinated motion, and then we start looking at thought and then emotions, emotional control, and that's kind of one of the pyramids, if you will, of function. I call that the motor pyramid. And then we have a sensory pyramid that complements that.

Dr. Ayla Wolf: 22:36

And you kind of mentioned this concept of looking back in time at these creatures that exist, that don't necessarily have all of the emotional stuff that we deal with, and saying, well, how are their systems designed? And I know that one of the kind of oldest sensory systems is the vestibular system and that in fish they have what are called lateral lines, which is kind of like their version of a vestibular system. So can you talk a little bit about that importance of the foundation of the vestibular system, because you kind of cued into it a little bit earlier when you said if the inner ear is kind of telling the brain the wrong information, we're going to have an autonomic response to that and it's kind of like this constant drain on the battery.

Dr. Matt Antonucci: 23:17

Yeah, absolutely. I can't even stress enough how important the vestibular system is. I'm starting to do a bit more work now with aerospace medicine and we're kind of stating the effects of microgravity and zero gravity and the results keep coming back that humans are designed to live on earth, right, that's what it comes down to. And whenever you look at an organism that was designed to be in some place the ocean, for example, when you take a ocean animal out of the ocean, what happens to it? They die. Yeah, you put a land animal inside the ocean, what happens to it? They die.

Dr. Matt Antonucci: 23:59

Right, so we've adapted to live into environments that have been adaptations over hundreds of millions of years. Well, the one thing that has never changed in billions of years is the fact that Earth has a gravitational field. So since life form has started, from single cell organisms all the way up to humans, which we believe are the epitome of complex species, everything has one anchor on this planet and it's gravity. The weather changes, barometric pressure changes, everything changes except for gravity. So that kind of leads to the importance of what it's like to have this gravity septive or gravity sensors in our inner ears, and it's so important that you know, I kind of look at it as like a I'm not a super religious person, but this is person. But once you start learning more about human anatomy and physiology, it's kind of hard to deny that there's some sort of intelligence out there that created us, whether you call that God or Allah or whatever, whatever you call it this supreme power that created us in an organized fashion Because the reality is is that when a sperm eats an egg, the first sensory system that develops when we study embryology is the vestibular system, and that happens to develop right at the same time as our nerves start to myelinate.

Dr. Matt Antonucci: 25:26

And as our nerves start to create this protective sheath around them that makes nerves travel faster, as they're myelinating, these primitive muscles start to contract and twitch right. So all of a sudden, now we have movement, and now we have finally a receptor that can feel that movement. At the same time, you're inside your mom's womb and gravity is affecting that. Even though you're floating inside of a fluid, there's gravity there. So you can kind of start to realize that, man, this is really important and if we don't process that constant force, we're constantly going to be dysfunctional. So and that's what we see in astronauts, but that's also what we see in individuals who have concussions that affect their vestibular system. So yeah, it's very important.

Dr. Ayla Wolf: 26:12

And it's such a delicate system I mean those like everything in that system is just so delicate that it's like no wonder you hit your head and that system is going to be compromised in some way.

Dr. Matt Antonucci: 26:25

And the nice thing about the vestibular system, which is different than other systems, for example our visual system or our auditory system. Our visual system has a specific real estate in the back of our brain called our occipital lobe, where we see. The auditory system has very specific real estate in the part of our brain that's like over here in our temporal lobe. Our vestibular system is profusely, pervasively integrated in our entire brain. There is no area of our brain that the vestibular nucleus doesn't have influence on. So that's good and bad.

Dr. Matt Antonucci: 27:01

We'll never lose vestibular function altogether unless we injure our inner ears themselves.

Dr. Matt Antonucci: 27:07

But as long as these organs in our inner ears work, we're always going to be able to perceive gravity in some extent. However, the downside about that is because it's everywhere. No matter where you injure in your brain, you're going to affect your ability to perceive it accurately. And specifically in the back of our brainstem we have a part of our brain called the little brain or cerebellum, that basically sits on our brainstem, which is like a stock, and it sits over here, and when you have a concussion it moves around and these fibers get stretched and we damage the ability to perceive and regulate that vestibular system. So it's a. It's at a vulnerable place, but it's also so redundantly integrated that it never breaks completely, which may be a bad. A good thing that it doesn't break completely, but it's also a bad thing that it never breaks completely, which may be a bad. A good thing that it doesn't break completely, but it's also a bad thing that it never breaks completely, because then you have dysfunction rather than just not working.

Dr. Ayla Wolf: 27:59

Yeah, and the vestibular system also being yoked to the nuclei that then control our eye muscles means that that imbalance often spills over into the visual system and I think that connection often gets missed too. I know like one of the things I love to do, because when patients come in again, there's usually I'm hunting for those little things that got missed in the past and I pop these infrared goggles on and when they don't have anything to fixate on, all of a sudden you get to see this push pull happen between what the vestibular system is trying to do to the eyes and where the eyes think they are in space, and I always find really interesting things happen when I pop those goggles on and I'm looking at someone's eyes in the dark.

Dr. Matt Antonucci: 28:46

Yeah, absolutely, and that's kind of what we were sharing're sharing a little earlier is that you know what you're going to see is that faulty sensory integration results in motor dysfunction and then the eyes moving when they're not supposed to move as a consequence of either a perception of movement that's not there or a misinterpretation of movement that is there causes all of these motor imbalances. And you know that the eyes you know you've heard the expression maybe for the eyes are the window to the soul, but realistically, that the eyes are the window to the brain, because you can see all sorts of things from. You know involuntary reflex function, autonomic function, like pupils to you know tone, which is your eye, your eye position, and especially when you remove vision, what happens to your eyes. You can see voluntary function, like ability to move your eyes side to side. You can also see complex function, like tracking targets that move in space in three dimensions. But you also see that individuals who have mental health disorders a lot of things change with their eyes. A lot of times when people have things like schizophrenia, their eyes will move a lot more than somebody who doesn't. So we can really look at the eyes as biomarkers of all sorts of things.

Dr. Matt Antonucci: 29:52

But, yeah, the vestibular ocular connection is very strong, as well as the vestibulospinal connection, so the vestibular system sets the tone of all of our spinal musculature. So we have good posture, and I'm not mean like posture, like you know, sit up straight, because it does affect that, but also dynamic posture when we're standing up, to control our body, sway all sorts of different things. And there's also vestibular autonomic functions and we have, you know, there's even more than that. There's almost a direct pathway from your vestibular nucleus to a part of your brain called your hypothalamus, which basically sets your hormonal rhythms. Your sleep-wake cycles, your hunger cycles, even breathing cycles are affected by your vestibular system. So, yeah, when we say it's important, it really is.

Dr. Ayla Wolf: 30:41

Yeah, absolutely. And so you're looking at all these different sensory systems, you're kind of testing them in isolation, but then also together in terms of saying how is this system functioning? And then how is it functioning in the context of when we're looking at it with other systems. So it's like, okay, I have some motor control if I'm touching my finger to happens, if I roll my head to the left or the right, and then all of a sudden you see that motor system break down. And so I think that's just. That's really the power of this functional mindset in saying we don't want to just know if someone can perform a task one way, we want to see how they perform that task 10 different ways in 10 different scenarios.

Dr. Matt Antonucci: 31:29

Exactly. And that's kind of where you get the motor pyramid right. Where we had the bottom, we had autonomic function, at the top we had cognitive and emotional regulation. What you really want to do is you want to study the senses and then in isolation, at the bottom, so you have your vestibular autonomic, your proprioceptive autonomic integration. Then you want to look at your auditory and gustatory and olfactory and then your visual autonomic responses and then you want to start looking like, okay, well, how do these responses play together? How does the vestibular system, sensory system, play with the visual processing system?

Dr. Matt Antonucci: 32:11

And if that's playing good, but the vestibular and proprioceptive systems are playing bad, well then you know it's not a problem with the vestibular system, it has to be a problem with the integration, which is a different part of the brain. So it becomes like hundreds, if not thousands, of Venn diagrams, circles that overlap with each other. And that's what somebody who's really good at functional neurology is able to do. They're able to have all of these circles where they test things and then they figure out where they overlap. And if you can figure out where all somebody's findings, remember when I said I play detective for a day, when I lay out all of my clues in my mind and I figure out where they all overlap and I can say you know what these all overlap right there. What that's going to do is it's going to allow me to be uber precise in whatever I'm going to do. And that one thing, because it touches every one of those hundreds or thousands of circles, fixing that one thing fixes all the circles.

Dr. Ayla Wolf: 33:08

Yeah, and isn't that awesome when you can like just knock over the one domino and everything falls in line.

Dr. Matt Antonucci: 33:14

Yeah, and the only thing I could really think of is, like you know, I kind of use this metaphor in some of our courses. You know, it's like if you're going to go into the army, there's two different peoples. There's people that carry machine guns and there's people that carry sniper rifles. Um, the only difference between the two they'll both get their job done. One's going to use a lot more ammunition and there's probably going to be some collateral damage with the guy in the machine gun. Uh, where the sniper gets their job done with one pole and one projectile, right? So it's not that one's bad and one's good. There are two different styles of practice. I just like being a sniper.

Dr. Ayla Wolf: 33:52

Yeah, there's a lot of math involved with being a sniper. There's a lot of physics. I like math. There you go, there you go, and so I'll throw a little curveball at you, because this wasn't I mean, you mentioned it on your hierarchy, but I have read that when people have a brain injury, that up to 55% of people can actually have alterations in their smell within the first year, and so I'm curious how much do you pay attention to smell Now that it's extremely smoky out all day long? Yesterday I used that as a test because it smelled like a campfire outside. So every single patient that walked in my door I said, oh, is it still smoky out? And I was fascinated by the answers because they were very different from patient to patient.

Dr. Matt Antonucci: 34:35

Yeah, and that's a. That's a good one. You know there's there's multiple different things to look at. So if you're looking at somebody in the acute phase of traumatic brain injury, concussion or more serious, the way that our olfactory bulb sits in the part of our skull called the cribriform plate, it's basically behind our nose. There's, like your olfactory bulb, which is basically where the neurons live for smell, and they've got these little hair cells that go and go through the bone into our nose so that we can catch all these odor molecules. Well, when you hit your head, sometimes the shearing, the moving your head back and forth on those olfactory nerves, they get sheared and you basically lose your sense of smell. Post-traumatic anosmia is actually pretty high. You said like 55%. There's some that say a little higher, some that say a little lower, but that's probably smack in the middle as a consequence of that shearing. But if you have somebody who has had concussive symptoms for months or years, they'll say that it happened way early on. If they know it. Some people don't even know they lost their sense of smell. But often if you go to a really good acute concussion specialist, they're going to evaluate smell, even if something as simple as taking some coffee. That's the real simple thing. But they've got tests that the University of Pennsylvania has created called the UPSIT test, where you buy these kits and it has like 20 different odors in it and the person has to identify a certain number of them to meet the threshold. And the University of Florida also did something called the. I think it's called the UPBOT test. It's a United Peanut Butter Odor Test or something like that olfaction test, basically just using peanut butter in a ruler to figure out where somebody can smell the scent of peanut butter. Both of these are evidence-based screening for smells and it's so simple to do that realistically anybody who sees a concussion should do it.

Dr. Matt Antonucci: 36:31

And the more chronic phase one of the things that we get worried about is somebody who still has chronic loss of smell.

Dr. Matt Antonucci: 36:37

Sometimes neuroinflammation deposits proteins in that olfactory bulb that causes them to lose their sense of smell, and not from trauma but from inflammation. And you know, a lot of times people had that with COVID as well, where you know the virus went in there and kind of used it as a factory and kind of created viral loads in that area. But a lot of people will understand that I had COVID. I lost my smell for a couple of months but then it came back because those olfactory bulbs can regenerate tissue, like we can lose that and it can regenerate. But if it's not regenerating, we're concerned about, you know, the cells being completely damaged as a consequence of protein deposition. So that's concerning. But you know that's what we want to correlate that also with motor findings, with cognitive findings, before we get scared Because there's also a. It's actually, I think it's like 11 percent of the population actually has congenital anosmia, like where they just were born with those pretty high number.

Dr. Matt Antonucci: 37:35

Yeah.

Dr. Ayla Wolf: 37:37

Yeah, I feel like after I got COVID I actually became a super smeller afterwards and I heard that from other people too, which is kind of an interesting concept. So maybe there was some damage and then I kind of just like hyper, responded by making all kinds of new nerves.

Dr. Matt Antonucci: 37:52

Yeah, absolutely. You turned up the sensitivity of the system for a loss of function, which is, you know, it happens to a lot of different people for many reasons.

Dr. Ayla Wolf: 38:01

Yeah, we talk about this idea that at the top of the pyramid you've got cognition, emotions. So when people lose their sense of smell or any of their senses, that always creates a certain amount of anxiety. So another reason why that kind of needs to be assessed, maybe beforehand. But then let's now talk about the top of the pyramid here where you're looking at cognition. You had mentioned in one of the courses I took with you recently how you had a patient who filled out all of your questionnaires and data ahead of time and they scored really, really high on a lot of their cognitive assessments and their mood assessments, which kind of gave you a green light to say this person's going to be able to handle certain therapies. And so I kind of like the way that, again, you are looking at the data ahead of time and helping that to inform how you work with somebody over the course of a five-day intensive.

Dr. Matt Antonucci: 38:53

Yeah, yeah, and that's right, because when we look at cognitive function, when something cognitively aligns, there's an expression that pretty much everybody says they say, oh, that makes what. That makes sense, right. So it's not by random explanation that we say that, but it makes sense because all the sensory systems added up to agreeing right. So where I'm going with this is cognitive function is an accumulation of sensory information that agrees with each other. If your sensory processing is dysfunctional as a consequence for an injury, nothing makes sense anymore because you've got one system saying one thing, another system saying something else. So when we look at somebody's cognitive testing and it's really high there's two possibilities. Number one is that they were super high to begin with and what they lost made them normal or maybe above normal, and there's really no way to know that unless they've had prior cognitive testing. The other is that, well, maybe that whatever they lost didn't impede their ability to make sense of things. So you can still have broken reflexes in that situation, whether that person is well compensated or they have what's called a high cognitive reserve. I mean, they've got a little bit extra money in the bank to spend it and blow it on things that you really shouldn't be spending. So they've just got a little extra cognitive reserve and that usually suggests to me that people will have a better response to the treatment that we do, because they can cognitively engage, they can process the information.

Dr. Matt Antonucci: 40:35

And when we process information, we talked about it being bottom up, meaning making sense from sensory systems up, but we also know that there's a very large contribution of what we call top-down influence and anybody who's in some sort of mind-body connection, medicine, where it's like affirmations and putting things out into the universe and manifestations all of those things come from top-down neurological function.

Dr. Matt Antonucci: 40:57

That requires good cognitive abilities. So, for example, you can say you know what? Oh, I want to. I want to get a new jacket. Nobody I know has a lime green jacket. I'm going to stand out and all of a sudden you're going to the jacket store to buy a store and all of a sudden you see three guys walking out with lime green jackets. Right, because you were going there for the lime green jacket. All of a sudden your brain was attuned to it and you start seeing it elsewhere in the world. So people that have better cognitive function when we're doing sensory-based modalities, they seem to have a better ability to assimilate that information and create the neuroplasticity to rewire the reflexes that are not really working properly.

Dr. Ayla Wolf: 41:38

And so in that case you might be able to say, stack different therapies on top of each other or make different rehab more challenging, Whereas with somebody who's struggling cognitively, that might be that indicator of like. Let's kind of take this and simplify it a little bit and start in a little different place compared to somebody else, for example.

Dr. Matt Antonucci: 42:00

Yeah, absolutely. The concept in neuroplasticity is called convergent facilitation. So basically what we do is we take different things that all meet in the same place and we use all X number of those things to facilitate the broken function. Well, if you don't have good cognitive function, it's X minus at least one. You know. How many different cognitive functions do you have? Deficient will be, you know, x minus however many cognitive functions you have deficient in to promote convergent facilitation or facilitated convergence.

Dr. Matt Antonucci: 42:31

So, just like you said, when somebody has a really good cognitive brain, you know, instead of just making them, let's just say a very generic exercise that every physical therapist in the world basically does or knows of most chiropractors know, just vestibular rehab, with looking at a dot, moving your head back and forth.

Dr. Matt Antonucci: 42:47

Well, that's called times one viewing or gaze stabilization exercises. But somebody who has really good neurological function, we can give them dual tasking with that. We can make them think about certain things, like when you're going to the right, think about spinning to the right. When you go to the left, don't think about anything, so you can bias it there's also, it almost becomes exponentially uh, your, your tool set becomes exponential in amounts when you have some other cognitive systems that are working, and then also it's exponential when you have other sensory systems that are working. So if you've got a very good visual system but a poor, dysfunctional vestibular system, well we can use vision to promote function in the vestibular system with cognition as well, and we can even use auditory cueing right when we can play sounds from a different aspect or even loud sounds from one size, shift your spatial image of where you are in space. There's all sorts of cool things that you can do once you understand how the systems work.

Dr. Ayla Wolf: 43:43

Yeah and talk a little bit, explain kind of how you would just okay. Let me back up. One of the things that I see is when people come in to see me and they say, well, I was referred to PT and I went through PT and I say, okay, so what did they have you do? What have you already done so far? Many, many times people say, well, I don't know, and they can't describe the exercises, they don't know why they were doing them. And so what is your thought process on? How much do you educate your patients while you're doing the therapy? Because I really feel like having a patient understand why they're doing something, it adds a whole nother level to it versus just saying I'm going to tell you what to do and without you knowing why I want you to perform this exercise. So how do you walk that fine line between not burdening people with too much information but making sure, like that, there is a bit of a buy in and an understanding of why am I doing this weird thing that you're having me do?

Dr. Matt Antonucci: 44:44

Yeah Well, I mean, some people are probably listening or watching this and say, man, this just flows out of this guy he's. So I'm not that smart. I mean, the thing is is I've said this so many times because I teach all of my patients what I'm teaching you. Maybe not to the degree that we talk about it, and, of course, you know any. The hallmark of a good teacher is being able to read their student. You know, it's like. You know, look at body language. When are they spacing out? When do you see deer in headlights? When are they engaging? When do they want more? You know.

Dr. Matt Antonucci: 45:12

So I do that with my patients because you know, ultimately, you know the term doctor originates from educator, right, and doctors are supposed to be educators, not necessarily healers. In many parts of the world, you can't call yourself a doctor unless you have a PhD, which means that you're an educator. So the reality is, I feel like we have a duty to educate our patients, and it comes with informed consent as well. You know, if you're going to ask somebody to do something, they need to know what they're doing, and you can't just tell people to do something and make them do it. So I think that's a really important thing, and patient empowerment is probably one of the biggest, the biggest but least known effective tools that you can do with a patient, having them control their own destiny. Think about this They've been indentured to their condition for a certain period of time whether it's days, months, weeks or years that I can't go to the movies because my head hurts, I can't play with my kids because I get a headache, I can't read a book because my eyes hurt, I can't watch TV. Their life is filled with I can't do's. And it all of a sudden. If you as a provider give them control over what they can and cannot do, that itself has become really pretty powerful.

Dr. Matt Antonucci: 46:24

So I do educate my patients a lot. I've got the liberty and ability to do that because my practice model doesn't say hey, you have 15 minutes with Dr A and then he's on to the next patient. You know my average session is about an hour and 15 minutes and my patients know that, hey, I might go over with my patient and I might go under with you one visit. We might get things done faster and there might be visits where I take more time with you and less time with them. So it's this give and take sort of thing, because everybody needs to get what they need out of a session. So maybe a part of the time will be just talking and letting them understand. And if you're my patient, I'm going to tell you hey, listen, we're going to talk for 15 minutes. That's not going to necessarily mean that you're getting 15 less treatment minutes less treatment because I don't do anything in my sessions. That's not directly goal-directed for whatever you want to accomplish. So you understanding what we're about to do is going to pay dividends on when we do it. So taking five minutes now of talking is probably equal to doing 50 minutes of therapy. So it's just about making sure that people understand it.

Dr. Matt Antonucci: 47:30

And it comes down to more of a scientific basis as well. When we talked about the autonomic nervous system. There's one way to explain how the autonomic nervous system responds. It responds to error. Okay, normally it's just regulating itself, nice and balanced until it perceives error. When it perceives error, it goes into its repertoire of increasing heart rate, increasing cortisol, increasing adrenaline, norepinephrine. It goes into this, what we call the fight and flight state. Well, if you do something to a patient and they don't know what you're doing, their brain is going to say there's error here. I'm not. I wasn't expecting this, I didn't know what's going on and now, all of a sudden, your outcomes go down because you didn't explain it. So I think there's there's a huge superpower in explanation and education.

Dr. Ayla Wolf: 48:18

I love that answer. Well, thank you so much. I know I've taken up a lot of your time today, so this was amazing. You shared so much valuable information. Where can people find you?

Dr. Matt Antonucci: 48:31

So three weeks a month I teach for the Carrick Institute. I teach doctors all over the world about this type of information. We really aim to help as many patients as possible through our doctors, through education. So I teach a bunch of courses for the Carrick Institute.

Dr. Ayla Wolf: 48:45

And we all thank you for doing that.

Dr. Matt Antonucci: 48:48

Yeah, yeah, my pleasure. So if you're a doctor and you're interested in learning more about the stuff we're talking about, carrickinstitutecom. And as far as patients, one week a month I see patients up where you are in Minnesota, drantinuccicom. Doctor is not spelled out, just d-R-A-N-T-O-N-U-C-C-Icom, and we have a bunch of information on there. I try to keep up my blog. I try to make really different novel types of blog posts. So if anything is appealing to you, just let us know, and if you need any help, let us know as well.

Dr. Ayla Wolf: 49:20

Yeah, I will add all of that to the show notes. And I just want to say you posted a blog post that went into this whole in-depth physiology of how to shut down hiccups, and so I have a friend who gets them all the time, and so I shared with her the technique that you described and boom, they were gone.

Dr. Matt Antonucci: 49:40

It literally works every time I like I literally maybe I'll get a Nobel Prize or something for curing hiccups. It literally works every time I like, I literally maybe I'll get a Nobel prize or something for curing hiccups. It literally works every single time. And if you want to know how to do it, go to my blog post.

Dr. Ayla Wolf: 49:51

I'll put that link in there too. Oh, thank you so much, this was great.

Dr. Matt Antonucci: 49:56

Pleasure Great speaking with you and I guess we'll see everybody next time maybe.

Dr. Ayla Wolf: 50:00

Excellent yeah.

Dr. Matt Antonucci: 50:05

Oh cause, we may have an exciting announcement. Fingers crossed. We got a paper in review that we're hoping gets published, and if it does get published, I would love to share that with you and all of your subscribers.

Dr. Ayla Wolf: 50:17

Yeah, we will absolutely get you back on to talk about that, because that is like the cutting edge and I'm just so excited to hear more about it. So I'm sure it's going to get published, because you guys are just doing incredible work and the world needs it. So thank you.

Dr. Matt Antonucci: 50:32

Thank you.

Dr. Ayla Wolf: 50:37

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