A conversation with Dr. Matt Antonucci, board-certified chiropractic neurologist
Dr. Matt Antonucci is a board-certified chiropractic neurologist, educator and researcher who specializes in concussion rehabilitation and has worked with hundreds of professional athletes. We talked about why no two brains are the same, how to test and train the basic reflexes every sport depends on, what stress does to the brain under pressure, and why writing out my intentions before I play might actually work.
Could you give a brief overview of who you are and what you've researched?
I'm a board-certified chiropractic neurologist, an educator and a researcher. Most of my research is outcomes analysis, largely retrospective case reviews, because what we do in clinical practice is really hard to study as a randomized controlled trial. Your practice discipline determines the data you collect. If you're organized and methodical about capturing and keeping data, and you have the right tools, analyzing your patients' outcomes is pretty easy.
My primary specialty is concussion rehabilitation. Concussions fall into a group we call functional disorders. There are no lesions and no bleeding in the brain, nothing you can see on any imaging. It's a disorder of function, and that's trickier to treat. We call it black box modeling. You have a box and you can't see inside it. You shake it, it bounces, it rolls, and you use your senses to figure out what's in there. When a patient has a functional condition, that box is the patient. You have to query them and measure their outcomes.
So I look for correlations between findings, and between findings and treatments, and I run responder analyses to see what worked and what didn't. Research is probably secondary for me. What fulfills me as a human being is helping people. But it's great to be able to show someone, with data, that you helped them, not just that they feel better.
What have you learned from treating patients and athletes about how the brain recovers or learns?
The biggest thing is something everybody knows but everybody ignores: everybody's brain is completely different. Genetically, human beings are 99.9 percent the same. Our kidneys, lungs and hearts are basically the same. Our brains are the same anatomically and at the level of cells, and yet we all act and think very differently. Something has to explain that difference.
When something goes wrong in the brain, no two injuries are the same. Sure, we can put people in boxes, a dementia box or a bipolar box, because they share things. But no two people are ever the same. So I've stopped treating diagnoses. I don't treat labels. I treat people. That means collecting data on the person sitting in front of you, understanding what it means, and figuring out what action will move it in the direction you and the patient want.
So everyone reacts differently?
It's more than that. Everything about everybody is different, but those differences sit on top of a lot of similarities. We should all perceive gravity the same way. We all see the same color spectrum. But the way those inputs come in through your senses and meet each other creates an experience, that experience changes the way you react, and that reaction changes the way you experience the same thing the next time.
Say you've lived in the Caribbean your whole life, and you spend a month in northern Norway in the winter. When you go back home to the exact same temperature, it's going to feel different. The humidity, the sun, the length of the day. It only feels different because you experienced Norway in the winter. You'll never experience home the same way again. That's what's cool about the brain.
Would those differences change how athletes should train?
Absolutely. This is my personal opinion, and I know not everybody would agree with me. You've probably heard “practice makes perfect.” We all know that's wrong. Practice doesn't make perfect. Perfect practice makes perfect, because you can practice something the wrong way.
Athletes test how strong their biceps, quads, hamstrings and glutes are, and their range of motion. If they also assessed their neurology, they could train a lot differently, because we all change over time. One person got sick and spent two weeks in bed, another didn't. All of that changes the way we process the world. If an athlete could evaluate their neurological function, and find someone who understands how the brain works, they could train physically and train neurologically. And I'm being specific: training neurologically is not the same as training mentally. One is physical and one is not.
How would an athlete evaluate how they're doing neurologically?
You start with how the brain works in its simplest form. Every animal with a nervous system, down to a worm, does three things: there's an input, there's an interpretation, and there's a response. Input, processing, output. So you devise a strategy for that athlete that looks at their important inputs and their important outputs.
Take ball sports: baseball, basketball, tennis. Athletes track with their eyes and they turn their heads, and those are two very different things. So I'd say, you turn your head a lot, so let's see how well you handle a head turn. Keep your eyes on a dot, and I'll turn your head quickly to one side and then the other. Your eyes should stay on the dot. That's the vestibulo-ocular reflex, a three-neuron reflex in the brainstem. Babies have it, old people have it. It only breaks if you get injured. But if an athlete turns their head and their eyes don't stay on that point, that's going to compromise their sport.
A lot of athletes look in the mirror and see they're strong, watch videos of themselves and see they're fast, and think they're above the basics. Look at the Leaning Tower of Pisa. They didn't fortify the foundation, they built a beautiful monument on top of it, and all these years later it's held up by cables. Nobody is beyond the basics. On top of reflexes we build voluntary function, on top of voluntary function we build coordinated function, and on top of coordinated function we build behaviors. If the basic reflexes are broken, everything built on top of them is leaning to the side.
How do you train the neurological side? How would you fix someone whose eyes come off the dot?
The same way you'd fix a weak bicep. You pick up a weight that's heavy, but not so heavy you can't lift it. If someone can't keep their eyes on my nose when I turn their head quickly, I find the fastest speed where they still can. Then I give them a goal: don't let your eyes come off my nose. Everybody is goal driven. It's wired into our nervous system, and dopamine is a motivational neurotransmitter. I move their head a little faster, and a little faster, until their eyes come off, then I slow down again, and we do repetitions. Neuroplasticity is very similar to muscle strength. Instead of building muscle proteins, you're building neuronal proteins.
That's the simple version. The brain has a lot of redundancy, which is a good thing, because if we had one input and it broke, we'd be in trouble. An athlete whose inner ear isn't doing its job can lean on their eyes and on their muscles' sense of where they are. But someone with a compensation is never as good as someone without one. Nobody wants to be the fastest guy in the race running with a crutch. So we look for those functional deficits and try to fix them. I've seen hundreds of pro athletes. Some come for rehabilitation after an injury, but a lot of them come because they understand their competitive advantage is something nobody else is doing. Everybody's training their body. They want to train their brain.
I've been reading research on pressure. When athletes are under pressure, does anything change neurologically? Do their reflexes break down?
Ooh, that's a fun question, because what is pressure? What you're calling pressure is stress, and you make your own stress. What I've found is that the good athletes aren't stressed. Russell Wilson talks about what he calls a neutral mindset: nothing's good, nothing's bad, things just are. You get into that zone where everything slows down, almost like it's standing still. Your brain is processing so fast and you're so in the moment that stress doesn't apply.
But it would be robotic to never have stress. When you're stressed, your body releases adrenaline and cortisol. Cortisol gives you a quick burst of energy to get you out of danger. It isn't designed to sustain you, and when it stays high for a long time, it's harmful to the brain.
We did some preliminary research that we never published, measuring cortisol in the saliva of athletes and of Special Forces operators, two groups that go into combat-like situations. We looked at errors. For an operator in a training scenario, an error was shooting someone who was supposed to be innocent. The players and the operators who made more errors had higher cortisol levels in their saliva. So maybe there is something to training your mind not to go into a fight-or-flight state, or, if it does, how to get out of it quickly.
How would someone train to keep cortisol low?
A part of your brain called the anterior cingulate cortex notices when something isn't right. If I said, “I'm having a heart attack,” for a split second it would say, “What? Something's wrong.” Then your prefrontal cortex says, “Calm down, he's just giving an example.” That happens in milliseconds. But if the anterior cingulate keeps sensing that something is wrong, it starts triggering the pathways that release cortisol.
So the goal is to make sure everything is right. If someone is pointing a gun at you, it's never going to be right, but you can train for that scenario so it doesn't fire up the anterior cingulate. And here's the more important part, and where our funding ran out. We wanted to see whether the operators with unusually high cortisol also had other things outside the normal range, like their vestibulo-ocular reflex, their vision or their eye movements. What we believe is that errors compound each other. If your balance is a little off, and your vision is a little off, and your eye tracking is a little off, someone pointing a water pistol at you can frighten you. If they're all right, it doesn't do anything.
Leonardo da Vinci wrote about this. He called it common sense: when all of the senses line up, there's harmony inside the body, and when they don't, there's disharmony. That's why we say something “makes sense” when it adds up. People whose basic sensory processing or reflexes are off get into that stressed, fight-or-flight state more easily than someone with good common sense, and their high-level performance suffers.
On the pages I write before I play
You mentioned that before you play, you write out your intentions. There's something to that. Everything your senses take in, your vision, smell, taste, touch and hearing, routes through a part of the brain called the thalamus. In school, your teacher will say the thalamus is the brain's switchboard operator. That's an oversimplification. The thalamus is the part of the brain that generates our reality.
There are pathways from the thalamus to the cortex, where we perceive things. We call them thalamocortical pathways, and they bring sensory information to our conscious reality. But there are also corticothalamic pathways that go the opposite direction, and they're about ten times more numerous. So if one set carries sensation up to your conscious brain, what does the other set do? It brings intention down to the thalamus, so it knows what to focus its sensory input on.
Say the new Jordans just came out. Nobody at your school has them. You buy a pair, you go back to school, and suddenly everybody has them. They probably always had them. You just didn't notice until you set your intention on that pair of shoes. Intention makes your thalamus far more sensitive to the things your senses will then process.
The thalamus doesn't only relay sensory information. It also helps control movement, through a part of your brain called the basal ganglia, which is like the gas pedal and the brake of your brain. So when you set an intention, you're tuning your senses to the things you intend, and the basal ganglia stop the behaviors that are in opposition to it and activate the behaviors that support it. That's the whole loop behind affirmations and intentions. And the more senses you involve, the more robust it will be. If you write it down, read it, and say it out loud so you hear your own voice, it goes from something only in your head to something that uses sound and vision too, and you create a loop that reinforces it. Russell Wilson was really big on this. Before a game he'd say, “This is how we're going to win.”
So it loops back to common sense: involving more than one sense when you set your intentions?
Same thing. Multi means more than one, poly means many. As many senses as you can possibly integrate will make it more robust. And you can take it to another level by doing it inside a behavior.
For a long time, neuroplasticity meant repetition. Donald Hebb gave us the idea that neurons that fire together, wire together. A few years ago, researchers described something called behavioral timescale plasticity. I've been to a restaurant near here twice, and I can tell you exactly how to walk from the front door to the bathroom. I didn't need the repetition everybody thought you needed. You can rewire your brain inside a behavior much faster than through repetition alone. So you can keep saying, “I'm going to get a Ferrari,” or you can say it and then go look at the Ferrari. When the sensory input is inside a behavior, it becomes much more ingrained in your brain.
It's like classical conditioning.
Exactly. That's Pavlov. And this year's Nobel Prize in medicine went to scientists who used light to control specific brain cells, a method called optogenetics. Researchers could see which part of a rat's brain lit up when it was anxious, then shine light on that same part and make a rat anxious. So input, processing and output isn't a one-way street. Output becomes input again. It's a cycle. That's basically what my paper this January argued about persisting concussion symptoms.
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