As rehabilitation clinicians, we spend a great deal of time trying to understand why a patient's autonomic nervous system behaves the way it does.
We assess heart rate variability. We evaluate eye movements, balance, vestibular function, cervical proprioception, and breathing patterns. We identify sympathetic dominance, vagal dysfunction, exercise intolerance, and orthostatic changes. We develop treatment plans designed to restore function and improve autonomic regulation.
Yet many of us have experienced a frustrating clinical reality:
Two patients present with nearly identical injuries...
Nearly identical examination findings...
Nearly identical rehabilitation plans...
…and completely different outcomes.
Why?
Certainly, injury severity matters. Inflammation matters. Sleep matters. Hormones matter.
But what if another variable has been shaping autonomic regulation for decades before the concussion ever occurred?
That question led me to one of the most fascinating conversations I've had on the Life After Impact Podcast with psychologist, somatic therapist, Chinese medicine practitioner, and educator Dr. Matthew Tolstoy.
Beyond Physiology Alone
One of the most important ideas Dr. Tolstoy presents is that psychology and physiology are not competing explanations for autonomic dysfunction.
They are different expressions of the same nervous system.
As physical medicine providers, we often think about autonomic regulation through the lens of brainstem circuitry, vagal pathways, hypothalamic regulation, baroreflexes, inflammatory signaling, cervical afferentation, vestibular function, and cortical modulation.
Those mechanisms absolutely matter.
But the autonomic nervous system is also constantly integrating another source of information:
Relationship.
Not simply current relationships...
…but decades of learned predictions about safety, vulnerability, trust, and connection.
Those predictions influence autonomic output just as surely as vestibular input or cervical proprioception.
Attachment Theory Is Really a Theory of Autonomic Regulation
Many clinicians think of attachment theory as belonging exclusively to psychology.
Dr. Tolstoy argues something much more interesting.
Attachment theory may actually describe how the autonomic nervous system learned to organize itself under conditions of stress.
From infancy onward, the developing nervous system continuously asks:
"When I become distressed, what happens next?"
Do caregivers respond?
Do they withdraw?
Do they become unpredictable?
Do I need to suppress distress?
Do I need to amplify distress?
Those repeated experiences become procedural memories—deeply encoded autonomic strategies that operate largely outside conscious awareness.
Four Different Nervous Systems
One of my favorite parts of our conversation was Dr. Tolstoy's description of the four attachment styles—not as personality types, but as physiological organizations of stress.
Secure Attachment
The nervous system remains relatively flexible. Patients tolerate stress without becoming overwhelmed. They can ask for help, receive care, and recover after stressful experiences.
Avoidant Attachment
The strategy becomes deactivation. Suppress distress. Increase self-reliance. Distance from vulnerability.
One particularly fascinating finding is that individuals with avoidant attachment often demonstrate robust physiological stress responses while reporting very little subjective stress. Their body is activated even when their conscious awareness tells a different story.
Anxious Attachment
The strategy becomes amplification. Increase distress. Seek proximity. Maintain connection.
Dr. Tolstoy describes this as a predominantly sympathetic strategy that evolved because heightened expression of distress was historically more likely to restore caregiver engagement.
Disorganized Attachment
Perhaps the most clinically challenging pattern.
Sympathetic activation and parasympathetic withdrawal begin occurring in conflicting ways. Patients simultaneously seek closeness while fearing it. Approach and avoidance coexist. The autonomic nervous system loses a coherent organizational strategy.
Why This Matters in Clinical Practice
As Dr. Tolstoy described these concepts, something remarkable occurred to me.
Most rehabilitation protocols assume that every patient's nervous system interprets treatment similarly.
But what if it doesn't?
What if your therapeutic touch...
Your manual therapy...
Your exercise prescription...
Your verbal reassurance...
Your encouragement...
Or even your own presence...
are being filtered through decades of unconscious autonomic prediction?
Suddenly many of the confusing clinical moments we've all experienced begin making more sense.
Why does one patient immediately trust the treatment plan while another withdraws?
Why does one patient become increasingly dependent on the therapeutic relationship while another struggles to receive help despite clearly needing it?
Why do some patients become physiologically calmer after treatment while others appear unexpectedly activated?
Attachment theory offers one possible framework for understanding these differences.
The Therapeutic Relationship Is Also Part of the Treatment
Perhaps the most thought-provoking moment in our conversation came when Dr. Tolstoy pointed out something many rehabilitation providers have experienced but rarely discuss.
The therapeutic relationship itself becomes a physiological stimulus.
Patients don't simply respond to spinal adjustments. Or acupuncture needles. Or vestibular rehabilitation. Or balance exercises. Or soft tissue treatment.
They respond to you.
Your tone of voice. Your consistency. Your emotional regulation. Your availability. Your confidence. Your boundaries.
For some patients, those interactions activate deeply established attachment patterns that can either facilitate or complicate rehabilitation.
That realization isn't meant to make clinicians anxious.
It's meant to make us curious.
This Is Where Rehabilitation Becomes More Than Technique
One reason this conversation resonated so strongly with me is because every physical medicine profession recognizes that healing is more than simply applying the correct technique.
Whether your approach involves rehabilitation exercises, chiropractic care, acupuncture, occupational therapy, physical therapy, massage therapy, or functional neurology, we all work with the same nervous system.
The treatment may differ.
The physiology does not.
Attachment theory provides another scientific framework for understanding why two patients with the same diagnosis may experience treatment in profoundly different ways.
It doesn't replace biomechanics.
It doesn't replace neuroscience.
It expands both.
My Perspective
After nearly two decades of treating complex neurological conditions, I've become increasingly convinced that persistent dysautonomia rarely has a single cause.
Brain injury matters. The cervical spine matters. Vision matters. Vestibular function matters. Inflammation matters. Sleep matters. Hormones matter.
And increasingly, I believe we must also consider how the nervous system has learned to organize itself around stress long before the injury occurred.
That doesn't mean every patient needs psychotherapy.
Nor does it mean every rehabilitation provider needs to become a psychologist.
But it does mean we become more curious about the person sitting in front of us.
When a patient doesn't respond the way we expected, perhaps the question isn't simply:
"What's the best technique?"
Perhaps it's also:
"How is this patient's nervous system interpreting the care I'm providing?"
Sometimes the most important intervention isn't changing the treatment.
It's changing our understanding of the nervous system receiving it.
Listen to the Full Conversation
This episode with Dr. Matthew Tolstoy is one of the most intellectually stimulating conversations I've had on the podcast. We explore the neuroscience of attachment, autonomic regulation, dysautonomia, concussion recovery, somatic therapy, and why understanding the patient's nervous system may require us to look beyond physiology alone.
If you work with patients experiencing concussion, chronic pain, dizziness, dysautonomia, POTS, functional neurological disorders, or other complex neurological conditions, I think you'll find this conversation both challenging and deeply rewarding. It may fundamentally change how you think about the nervous system sitting across from you in the treatment room.
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