Level 1 of the Carrick Institute’s Functional Neurology Management of Concussion was dedicated to understanding, identifying, and managing the acute phase of concussion. Level 2 picks up where Level 1 leaves off and builds a comprehensive understanding of concussion’s sub-acute and persisting phases. Under the guidance and leadership of our lead instructor, Dr. Matthew Antonucci, our medical advisory board of expert multidiscipline providers has developed a curriculum including over 500 Entrustable Professional Activities (EPAs) in 10 chapters necessary to understand, disentangle and correct the complex neurological remodeling that occurs with persisting concussion dysfunction.

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Chapter 1: The Entanglement of Neurological Hubs and Edges after Concussion Dr. Antonucci masterfully sets the stage for this next Level of the Functional Neurology Management of Concussion by exploring the unique and complex ways our brains react to these injuries. Taking a controversial detour from the popular localization theory of neurological rehabilitation, he creates a compelling case for the rehabilitation of functional-networks, by deconstructing how the brain processes information. He delves into the nuanced interplay between neurological networks, sensory inputs, and individual physiological differences. This chapter is the foundational underpinning for the creation of a case-specific concussion rehabilitation program. Whether you are an aspiring concussion expert with Level 1 under your belt, or a seasoned healthcare professional, buckle in and prepare to jump in the deep end of concussion management.

• Recapitulation and expansion on the dynamics of the pathophysiology, feedback loops, and persistence of concussion symptoms, with correlation to patient presentations and complaints
• Individual Variability – “N of 1” Concept
• Sex Differences in Brain Anatomy
• Genetic Factors in Concussion Recovery
• Applying the Lashley’s principle of equipotentiality and sensory reorganization to understanding the protraction of concussion signs and symptoms
• Identifying and understanding cortical processing networks and their relationship to concussion
• Sensory Circuits and Thalamocortical Function
• Understanding the cyclical influences of sensory-cognitive-motor processing and neural plasticity
• Sensory Circuits and Thalamocortical Function
• Diaschisis and Transneuronal Degeneration
• Fundamentals of functional imaging and entry-level interpretation
• Resting State fMRI Analysis
• Topographical vs Functional Organizations in the Brain
• Properties of Sensory Receptors and Their Implications
• The Thalamus as a Functional Hub in Concussion Rehab
• Graph Theory in Neurology
• Central Vertices and Functional Decompensation
• Kleim’s 10 Principles of Experience-Dependent Neuroplasticity and Brain Injury
• Applying Kleim’s Principles in Concussion Rehabilitation
• Review literature surrounding neuromodulation technologies and their appropriateness for the treatment of concussion
• Discuss the research on uni-modal vs. multi-modal rehabilitation programs
• Applying concepts in neuro-ontology in the creation of concussion treatment programs
•  The transition from concussion screening and examination to special testing.

Chapter 2: Autonomic/Physiologic Dysfunction After Concussion  Research supports that more than 85% of all concussions have varying degrees of autonomic dysfunction. Autonomic function may be primary or secondary to other sensory processing abnormalities. Understanding how to critically evaluate autonomic function and compare outcomes to other sensory aberrancies allows a clinician to be more effective and efficient. This chapter delves into the intricate workings of the autonomic nervous system (ANS), how it works, breaks down, and its critical role in concussion management and rehabilitation. To craft case-specific rehabilitation programs, a provider must understand the historical evolution, physiological nuances, and the latest research findings in the field of autonomic neuroscience. This compendium of research and clinical experience is perfect for the healthcare professional looking for a blend of theoretical knowledge and practical insights, equipping you with the tools to enhance patient care and contribute to ongoing research in neuroscience.

• Introduction to the Autonomic Nervous System (ANS)
• The Autonomic Outflow
• A Schematic of the ANS from 1918
• Deeper Understanding of ANS Origins
•  Dysautonomia and Related Conditions
• Testing Autonomic Function
• The Primitive ANS
• The Central Autonomic System
• Explaining the Autonomic Network
• Modulating the Output of the ANS
• Common Clinical Symptoms/Signs of ANS Dysfunction
• Direct Central Autonomic Network
• Chemical Influences on Dysautonomia
• Hypothalamic-Pituitary Interaction
• Cerebral and Somatic Blood Flow
• Postural Dysautonomia Syndromes
• Pupillometry and the Pupil
• Cervical Spine and Dysautonomia

Chapter 3: The Cognitive Neuroscience of Concussion Explore the complex world of cognitive function and its vulnerability to concussion in this expansive chapter of the Functional Neurology Management of Concussion. After reviewing the medical literature for topic relevance, and foundation, we begin a dive deep into the brain’s intricate workings that summate to the cognitive experience. Dr. Antonucci introduces and expands on his 5-level hierarchy of cognitive processing, including concussion’s effects, the effects of commonly prescribed medications, domain assessments, technology, and the clinical relevance of each level. Embark on a journey through cutting-edge research and clinical findings, unraveling the subtle ways in which concussions can reshape cognitive processes. This course is not just a learning experience; it’s an invitation to join the frontline of cognitive neuroscience, empowering you with knowledge that can make a real difference in the lives of those impacted by concussions.

• Concussion and Cognition
• The Role of Intelligence in Cognitive Function
• Cognitive Domains as Components of Intelligence
• IQ and Cognitive Function Post-Concussion:
• Cognitive Domains Affected by Concussion:
• Neuropsychological Impact of Sports-Related Concussion:
• Self-Reported Symptoms vs. Objective Neurocognitive Testing
• Assessment Tools in Concussion Management
• Network Connectivity and Cognitive Function Post-Concussion
• The Hierarchical Organization of Cognitive Functions and Their Interplay
• Perception, Motor Skills, and Sensory Processing
• Attention and Executive Function Post-Concussion
• Language and Communication After Concussion
• Memory and Learning Post-Concussion
• Emotional Intelligence and Social Cognition
• Introduction to Therapeutic and Rehabilitation Strategies
• Clinical Implications of Congitive Neuroscience and Patient Care

Chapter 4: Implications of Peripheral and Central Vestibular Dysfunction in Concussion This chapter provides a comprehensive exploration of the vestibular system, delving into its anatomy and physiology from the peripheral components to the central processing areas. It emphasizes the significance of understanding common vestibular conditions and pathologies, particularly those that often coexist with or result from concussions. The chapter thoroughly examines various vestibular reflexes, detailing both their normal functioning and the manifestations of their dysfunction. It also highlights the critical role of diagnostic procedures in pinpointing vestibular decompensation, covering techniques such as Computerized Posturography, Rotary Chair Testing, Video Head Impulse Testing, Videonystagmography (VNG), and Caloric Irrigation. Furthermore, the chapter addresses the intricate relationship between the vestibular system and different subtypes of concussion, along with associated conditions, underscoring the complex interplay that affects patient management.

• Explore the anatomy and physiology of the vestibular system from peripheral to central, including more common vestibular presentations/pathologies that are connected to or comorbid with a concussion
• Review and comprehend all vestibular reflexes, their normal and abnormal presentations
• Implications of common and special diagnostic procedures and their results on localization of vestibular decompensation:

• Computerized Posturography
• Rotary Chair Testing
• Video Head Impulse Testing
• Videonystagmography (VNG)
• Caloric Irrigation

• Understanding the interplay between the vestibular system and the concussion subtypes and associated conditions

Chapter 5:   Alterations in Sensory-Motor Processing in Concussion:     Chapter 5 in “Functional Neurology for Manual Therapies (FN-MOC)” provides a profound insight into proprioception, a key sensory system that is the second to develop during fetal growth and fundamental to human biomechanics and embodiment. It begins by exploring the anatomy of proprioception, tracing its intricate pathways from peripheral receptors to central nervous system processing. This foundation allows for a detailed discussion on various assessments of proprioception, with an emphasis on interpreting these evaluations in a clinical setting, particularly in relation to concussion. The chapter then addresses the critical integration of proprioception with vestibuloception, highlighting the synergy between these systems in maintaining spatial awareness and balance. It delves into common proprioceptive deficits observed following concussions, examining how these impairments can disrupt muscle coordination, tactile processing, and the individual’s interaction with the external world. These deficits are connected to broader somatic syndromes commonly associated with concussions. In addition to proprioception, the chapter expands its scope to discuss the role and impact of olfaction and gustation, senses that are often overlooked but can be significantly altered in the event of a concussion. Furthermore, it explores auditory processing in concussion, emphasizing the potential changes in auditory perception and processing that can occur. Overall, this chapter aims to equip scholars with a comprehensive understanding of the neurology of proprioception and its critical relationship with concussion, emphasizing its role in balance, spatial awareness, and the overall sense of self. It underscores the multidimensional effects of concussions on sensory systems and the importance of a holistic approach in concussion management.

• The anatomy of proprioception from peripheral to central
• Assessments of proprioception and their interpretation
• The integration between proprioception and vestibuloception
• Common proprioceptive deficits in concussion
• Somatic syndromes associated with concussion
• The contribution to proprioception to balance and spatial awareness
• Olfaction and Gustation in Concussion
• Auditory Processing in Concussion

Chapter 6: Quantifying Visual and Oculomotor Dysfunction in Concussion  Chapter 6 of “Functional Neurology Management of Concussion” (FN-MOC)” focuses on the quantification of visual and oculomotor dysfunctions commonly associated with concussions. Acknowledging the human visual system as the most dominant sense, the chapter emphasizes that about 80% of the brain’s environmental information is derived from visual input. It explores the complex coordination of intra-ocular, extra-ocular, facial, and neck muscles that the brain employs to control this visual input. The chapter provides a detailed look at the anatomy and physiology of the visual and oculomotor systems, mapping their journey from peripheral mechanisms to central processing. It covers the basics of visual refraction and delves into special testing methods for the visual system, including color processing, stereopsis, accommodative range, ocular alignment, VEPs (Visual Evoked Potentials), ERGs (Electroretinograph), and more. Significantly, the chapter examines various oculomotor functions and pathologies such as accommodation, ocular alignment, ocular reflexes, gaze maintenance, saccades, pursuits, and vergence. Each aspect is explored in the context of their impact on human functioning and their alteration following a concussion. Finally, the chapter addresses rehabilitation strategies for visual and oculomotor pathologies that are commonly associated with concussions. These strategies are crucial for restoring and improving visual and oculomotor functions, which are essential for daily activities and overall quality of life. This chapter aims to provide a comprehensive understanding of the visual and oculomotor systems in relation to concussion, enabling effective assessment and treatment.

• The anatomy and physiology of the visual and oculomotor system from peripheral to central
• Basics of visual refraction
• Special testing of the visual system

1. Visual Evoked Potentials
2. Electroretinography
3. Utilizing a Phoropter to Measure Orthoptic Dysfunction

• Oculomotor Functions and Pathologies:

1. Binocular Vision
2. Depth Perception
3. Accommodation
4. Ocular alignment
5. Ocular reflexes
6. Gaze Maintenance
7. Saccades
8. Pursuits
9. Vergence

Neuro-Skill Laboratory 2.7: Developing and Performing a Comprehensive Concussion Evaluation:(3 Days of Onsite Training) This three-day on-site course designed for the implementation of all diagnostic testing taught in Chapters 1-5 offers an intensive, hands-on learning experience for healthcare practitioners. This course is meticulously structured to cover the comprehensive range of diagnostic tests and procedures outlined in the first five chapters of the curriculum, providing a practical, real-world application of theoretical knowledge. Each day is dedicated to in-depth sessions focusing on different sets of diagnostics, ensuring a thorough understanding and hands-on experience in each area. Participants will have the opportunity to work with state-of-the-art diagnostic equipment and tools, under the guidance of expert instructors who provide personalized feedback and instruction. This interactive environment is ideal for reinforcing learning, allowing practitioners to refine their diagnostic skills through practice and direct application. The course is especially beneficial for those looking to enhance their proficiency in a wide array of diagnostic techniques, from basic assessments to more complex procedures, ensuring they are well-equipped to apply these skills in their clinical practice.   Chapter 8: Incorporating Autonomic and Vestibular Rehabilitation: This chapter offers a comprehensive and practical approach to understanding and treating concussion-related vestibular issues. It provides a blend of theoretical knowledge and practical training, focusing on the autonomic and vestibular systems’ roles in concussion. Attendees learn applications to treat dysfunctions in these systems, which are often impacted by concussive injuries. The chapter offers a blend of scientific theory and evidence-based practices, ensuring participants come away with a thorough understanding of how to effectively manage and rehabilitate concussions with a focus on autonomic and vestibular dysfunctions. Chapter 9: Sensory Integrative Therapies, Orthoptic Exercises, and Layering Cognitive Function Therapies: In Chapter 9, learners will explore the nuances of sensory integration therapy, understanding how to address sensory processing issues that often arise post-concussion. The course also delves into orthoptic exercises, teaching participants how to implement these eye exercises to improve vision problems and eye coordination affected by concussive injuries. Additionally, the course covers the layering of cognitive function therapies, a crucial aspect of concussion rehabilitation. Participants will learn strategies to enhance cognitive recovery, including memory, attention, and executive function exercises, tailored to the needs of individuals recovering from concussion. NeuroSkills Laboratory 2.10: Therapeutic Procedures, Clinical Workflows, Patient Management, and Treatment Plan Creation Workshop (3 Days of Onsite Training) This intensive workshop for professionals who have completed Chapters 1-9, studied the theoretical aspects in these chapters, and are now eager to translate this knowledge into practical skills. Throughout the three days, attendees engage in a series of workshops and exercises that focus on the core rehabilitation strategies, principles, and techniques outlined in the chapters. The course structure allows for proficiency and hands-on practice under the guidance of experienced instructors. Participants will work in small groups to ensure personalized attention and an opportunity to practice and refine their skills. This course is particularly beneficial for those looking to apply complex concepts in a real-world setting, as it bridges the gap between theoretical learning and practical application. By the end of the workshop, attendees will have gained not only a deeper understanding of the material from Chapters 8 and 9 but also the confidence to implement these strategies in their professional practices.Dr. Antonucci masterfully sets the stage for this next Level of the Functional Neurology Management of Concussion by exploring the unique and complex ways our brains react to these injuries. Taking a controversial detour from the popular localization theory of neurological rehabilitation, he creates a compelling case for the rehabilitation of functional-networks, by deconstructing how the brain processes information. He delves into the nuanced interplay between neurological networks, sensory inputs, and individual physiological differences. This chapter is the foundational underpinning for the creation of a case-specific concussion rehabilitation program. Whether you are an aspiring concussion expert with Level 1 under your belt, or a seasoned healthcare professional, buckle in and prepare to jump in the deep end of concussion management.