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I would like to begin this review with a brief introduction.

I am a Chiropractic Physician who practices in Chicago, Illinois, and has been utilizing the principles of Dynamic Neuromuscular Stabilization (DNS) since 2007. I have taken all formal DNS courses (A-C) multiple times, as well as many Advanced Skills Courses over the years, and having already registered for the Part D Course given in Prague in September of this year, will become the only Chiropractor in Illinois to be formally recognized as a DNS Certified Practitioner. I have also studied Vojta Therapy, offered by Dr. Richard Cohen, in addition to Dr. Ryan Van Matres Pediatric Rehabilitation courses which are also devoted primarily to Vojta Therapy. While I do not consider myself an expert, I have received a considerable education regarding Developmental Kinesiology (DK) and natural movement and stabilization patterns, which is why I consider myself qualified to critique Dr. Spinas philosophy on foot function and rehabilitation. First, let me preface this review by stating that as of yet, I have not been able to attend any of Dr. Spinas formal seminars. So while my indirect experience with his work is purely limited to what can be found in his videos and statements on social media and YouTube, I feel comfortable to critique what Ive observed since he is evidently confident enough to have made it available for public scrutiny. After much praise by leaders of the rehab and performance industries via social media, and due to my own personal interest in foot/ankle function, I decided to watch Dr. Spinas video regarding foot rehab to see for myself if it was, in fact, as revolutionary and game-changing as everyone was making it out to be. After multiple viewings and discussions with colleagues, I truly do not understand the fuss being made and unfortunately, from what I observed, it seems that Dr. Spinas approach to foot rehabilitation is simply anachronistic at best. All rehab professionals ought to believe that ultimately, our main goal is to teach our patients how to move and stabilize efficiently and effectively. That poor motor and stabilization patterns are the primary cause of all nontraumatic musculoskeletal

dysfunction, whether it is observed as muscle inhibition, hypertonicity, pain, postural abnormality, or joint restriction. For that reason, I cannot support the exercises demonstrated in Dr. Spinas video as I do not see how they correlate to the natural function of the lower extremity. To begin, I completely agree with Dr. Spinas opening remarks characterizing the exercise gap and current misconceptions about foot rehab (the first four minutes of the video), which is why I soon found myself utterly confused to see the myriad of exercises he was demonstrating to supposedly combat foot pain and restore normal function. I do not believe it controversial to state that most, if not all, foot/ankle problems stem from an aberrant, insufficient loading pattern during the stance phase of gait. Basically, foot dysfunction originates during weightbearing. With that being said, most, if not all, of the exercises that Dr. Spina promotes are as artificial and dysfunctional as the spinal bracing and foot orthotics that he discredits in his opening remarks. He speaks of the importance of the intrinsic foot musculature and arch control, and then goes on to demonstrate a number of essentially open-chain exercises for individual foot muscles that have no relation to their true function during the gait cycle. Exercises such as extension of the Hallux with simultaneous plantarflexion of the remaining toes, or toe splaying? While these are certainly biomechanical actions of some of the muscles of the foot, it serves no real purpose to isolate these muscles without properly loading the foot, or the entire lower extremity for that matter. If our main concern is to reinvigorate proper, natural motor patterns of the lower extremity to promote correct loading of the foot during gait, then I just dont understand how an essentially open-chain exercise for Extensor Hallucis Longus can be useful, let alone, functional. Or, for that matter, how performing Great Toe calf raises off a stair will help you to better eccentrically control your medial longitudinal arch. While these feats of dexterity, strength, and body awareness are definitely interesting and impressive, I cannot see how they translate to reestablishing the natural movement and stabilization pattern of the lower extremity during gait since they have no relation to how the foot actually functions during locomotion. To view gait rehab in terms of isolated, biomechanical foot exercises as Dr. Spina seems to, is myopic and lacks a truly functional approach. It would be analogous to isolating the infraspinatus in a rotator cuff patient and

performing useless reps of external rotation (as seen below) to stabilize and strengthen the shoulder.

Now transfer that mode of thinking back to the foot, and ask yourself if it makes sense to isolate the toe adductors with your foot off the ground and perform reps of squeezes as Dr. Spina suggests?? Additionally, there is never a mention of the necessary alignment of the lower extremity while performing these exerciseswe are never instructed where our hips or knees should be while performing these movements. A useful foot exercise must include instruction regarding the corresponding posture of the ankle, knee, and hip (and technically the entire body) if you intend to get the necessary sensory stimulation that our nervous system requires in order to actually get the intrinsic foot muscle activation that we are striving for. From what I have seen, Dr. Spina seems to be very knowledgeable when it comes to anatomy and function, so for him to completely disregard these aspects of foot rehab was unfortunate, as I am sure he understands that all play a vital role in foot stabilization. While I am open to discussion regarding the validity of certain exercises suggested by Dr. Spina, one exercise in particular that I found outrageously archaic was the towel grab that he performed with his toes. For one thing, lower extremity positioning is never discussed, and maybe I am confused, but I cannot understand why I would need to strengthen and facilitate the long flexors of the toes, considering it is the short flexors that are typically inhibited due to clawing and gripping of the long flexors during ambulation. Also, while the forward lean

exercise he demonstrates is obviously a weightbearing position, once again it is not natural, and therefore not functional, to load both lower extremities in this way. I cannot think of one instance where I would need to attain a dorsiflexed position of both ankles, while simultaneously fully extending at both knees and maintaining a relatively neutral position at both hips, therefore why would I want to create and train that specific motor pattern? Again, not a horrible way to eccentrically load the Triceps Surae muscle group or to activate them in an alternative way (having the muscle pull contract toward the fixed heel), but accomplished in this particular manner, doesnt make functional sense. Finally, on a positive note, I found his use of the deep squat position very useful for a basic activation of intrinsic and extrinsic foot musculature. The deep squat, while difficult to accomplish, is a natural, functional posture utilized during development of locomotion and verticalization, and like he demonstrated allows for initiating of eccentric and concentric activation of foot musculature. As he stated, focusing on consciously activating these muscles to cause the movement, rather than simply leaning into different directions is the key.

So, rather than isolating individual toe muscles, I suggest that if one wants to strengthen and groove the loading pattern of the foot and lower extremity (the two cannot be separated), then it would make justifiable sense to look to the stereotypes actually used during development that built your arches and trained your feet. For example, the soles of your feet do not touch the ground in any functional way until about 8 months of age, where the infant is transitioning from an oblique sitting position, as pictured below.

As you can see, in this posture, the entire tripod of the foot is loaded, and care is taken to assess and stress the proper positioning of everything from the knee and hip to the thoracic spine and neck. In this position we can stress our patients ability to control his foot in many different ways, but the important thing to realize is that since this is a natural movement stereotype for loading of the foot, it doesnt make a difference where or how I stress him (as long as I stick to the anticipated movements of that stereotype), activation of intrinsic foot musculature and arch control will be stimulated. A more advanced position that can also be used to enhance your ability to properly load your foot is the high-kneeling posture used by 11-month olds during verticalization as pictured below.

Again, attention is paid to all aspects of posture, and resistance can be added to any of the anticipated movements of that stereotype in order to enhance and stimulate lower extremity loading capabilities. I want to stress again that I have only experienced the material that Dr. Spina has made available on the internet, so he very well may address many of the issues that I raised here in his formal seminars and I am just ignorant. However, since this video has been circulating throughout the rehab and performance industries to mass uncritical acclaim, I felt it necessary to question and evaluate what was being propagated, especially since I had difficulties with what I observed. In fact, I

seemed to be the only person that was not utterly awed by what I saw, so I wanted to hopefully stimulate some discussion regarding the topic of gait rehab and also clarify my own rationale so that hopefully we all can gain some clinically relevant knowledge when it comes to lower extremity function and training.

William Tortoriello, D.C.

*I would like to thank the Prague School for allowing me to use the images from their posters **Information regarding Dynamic Neuromuscular Stabilization and their posters can be found here: www.rehabps.com http://www.rehabps.com/REHABILITATION/Posters.html

***Dr. Spinas Intrinsic Foot Strengthening video can be found here: http://www.youtube.com/watch?v=2OOJ9AQ1AEg ****Information about my office can be attained through my website: www.integrative-chiropractic.com