Where’s the Evidence? Challenging Therapists to Stop Legitimizing Dynamic Movement Intervention and Cuevas Medek Exercises

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INTRODUCTION

In pediatric rehabilitation, approaches such as Cuevas Medek Exercises (CME) and Dynamic Movement Intervention (DMI) have gained use for their purported benefits in improving motor function in children with neurological impairments. However, their theoretical underpinnings, empirical support, and ethical implications remain controversial.

Proponents purport that these interventions harness neuroplasticity to drive functional gains, while critics express strong concerns regarding their reliance on outdated motor control theories, lack of high-quality evidence, significant financial burden on families, and ethical issues regarding therapists providing nonevidence-based interventions. This commentary examines the origins, principles, evidence base, and ethical considerations associated with these interventions to support informed decision-making among clinicians and families.

Cuevas Medek Exercises

Origins and therapeutic approach

Cuevas Medek Exercises (CME) was developed by Ramón Cuevas in 1972 in Caracas, Venezuela, with the stated objective of eliciting absent postural and functional reactions in children with motor impairments, irrespective of the severity of neurological damage or the child’s level of awareness.¹ The foundational premise of CME involves exposing children to antigravity positions to facilitate postural control and is based on reflex-based theories of motor control.

CME uses manual facilitation techniques, wherein therapists provide hands-on guidance (in very prescriptive and often distal positions) to elicit specific reflexive (automatic) motor responses. Typical CME includes reciprocal stepping on wooden planks designed to resemble an elliptical trainer and lateral stepping in and out of wooden boxes, while the therapist manually aligns the lower limbs. Many exercises involve balancing a child in the air on a plank without contact from the adult. A distinguishing feature of CME is the stimulation of postural reactions through dynamic movements, such as suspending a child by their distal tibia in a deep squat position while rotating them 360 degrees in the air above the therapist’s head. The primary therapeutic focus is on the International Classification of Functioning, Disability and Health dimension of body structures and functions with goals that include promoting head control, spinal extension, and weight-bearing through the lower limbs.² Notably, signs of distress, including crying, are interpreted within CME as indicators of exertion and effort.

CME does not incorporate orthotic devices or assistive technologies such as supported standing or stepping aids, nor does it emphasize whole-task practice within functionally relevant contexts. Historically, CME was administered by a limited number of highly trained providers, requiring families to travel to locations such as Costa Rica, Chile, United States, and Canada to participate in intensive 1–2-week therapy programs. These intensives were supplemented by structured home exercise regimens, often necessitating 3–4 hours of daily practice. Currently, CME-certified practitioners are available in multiple regions, and certification programs for therapists are accessible, although they require financial investment and extensive training.

Evidence base

Despite CME’s long history, empirical support remains limited. Three sources provided by Mr. Cuevas in response to requests for research include the following: (1) An abstract from a Chilean journal that describes CME, but does not report study outcomes.³ (2) A case report of a child with neonatal hypoxic-ischemic encephalopathy who received CME from 6 to 17 months of age and was reported to be walking independently at 7 years.⁴ However, no validated outcome measures were used, making it impossible to determine whether improvements were due to therapy or natural developmental progression. (3) A nonrandomized comparative study (n = 7 per group) comparing CME with Bobath therapy.⁵ Children receiving CME demonstrated greater progress in CME assessments of muscle tone and postural balance, but the study lacks methodological rigor due to selection bias, unvalidated outcome measures, and confounding variables.

Additionally, 2 separate case reports of a 2-month-old infant with congenital hydrocephalus and a 9-month-old infant with corpus callosum abnormalities and congenital heart disease who underwent CME reported developmental gains on a nonvalidated CME motor scale and the Alberta Infant Motor Scale over uncontrolled 16- and 11-month periods respectively.^6,7 Another comparative study of children with autism spectrum disorder (ASD) (n = 16 per group) found no difference between CME and control interventions on children’s posture using the Posture and Postural Abilities Scale (PPAS), and an advantage to the CME group on balance using the Pediatric Balance Scale.⁸ There are significant concerns, however, regarding selection and detection bias as well as accuracy of reporting, and the nonpeer reviewed status of the journal. Authors cite studies that do not exist within the referenced journals, and there are strong indicators that artificial intelligence and large language models were used to generate the study in part or in whole. Furthermore, questions should be raised about the ethics of having children who can walk and with ASD wear solid ankle foot orthoses full time with no clinical indication, as well as the use of the PPAS for children who walk with ASD. The lead, all other authors, and the journal editor were unable to provide documentation or data in response to our inquiries.

We also identified a comprehensive scoping review protocol and confirmed that no additional quality evidence was identified in their recent search update. Authors are in the process of submitting for publication, and the lead author provided us with the following quotation: “based on the lack of high-quality evidence to support the effectiveness of CME, clinicians who choose to continue to use CME without evidence of effectiveness, should work with researchers to establish an evidence base and transparently report adverse events to their registration/licensing body. Further, clinicians should meet their clinical practice obligations to utilise evidence-informed practice and share with parents, the lack of evidence for effectiveness of CME during shared decision-making conversations about treatment” (Personal Communication, March 13, 2025, Dr Nikki Milne).

Given these limitations, there is no quality evidence to support CME’s efficacy beyond anecdotal reports.

Dynamic Movement Intervention

Origins and certification

DMI was cofounded in 2021 by CME Level III-certified physical therapists Jake Kreindler (New York, United States) and Jo-Anne Weltman (Toronto, Canada). The intervention encompasses therapy, practitioner training, and certification programs delivered globally. According to the official DMI website, the approach shares similarities with CME, utilizing comparable exercises.⁹ DMI positions itself as a neurorehabilitation technique rooted in neuroplasticity—the brain’s ability to reorganize and form new neural connections. DMI claims to integrate “current research on neurorehabilitation, technologies, and methodologies.”⁹ Furthermore, their official website and social media platforms emphasize stimulating plasticity through dynamic, therapist-guided exercises to provoke active motor responses in children with gross motor impairments.

DMI certification follows a tiered structure, consisting of 3 introductory levels, 2 intermediate levels, and a masters/teachers level, with each course requiring 2 days of training (15 hours) costing approximately $800 USD.⁹ The official DMI website asserts that its certification structure represents an advancement over CME by offering a more comprehensive curriculum at the foundational and intermediate levels, alongside greater accessibility to advanced training. In 2024, over 3300 therapists were trained in DMI in more than 61 countries around the world.¹⁰ Families reportedly pay between $2500 and $5000 USD for week-long intensive therapy programs (not including travel, housing, or time off work) with many programs only partially or not covered by third-party payers (insurance).

Evidence base

A search of the scientific literature identified 1 conference abstract describing 2 young children with spinal muscular atrophy type 1 (aged 13 and 15 months) who participated in DMI therapy following gene replacement therapy.¹¹ The most that can be concluded from this case report is that the children gained motor skills following gene therapy (and treatment with another disease-modifying agent in the case of the 13-month-old), while also tolerating intensive DMI intervention.

Apart from the conference abstract, there is no published empirical data on DMI, and while the founders have made comments that “things are under way,” as of March 5, 2025, no prospectively registered studies on DMI appear in major clinical trial registries. In an interview published on DMI’s Instagram page in 2022, co-founder Jake Kreindler said, “one of the huge reasons we evolved from where we started from the CME method to DMI was the lack of research.… of course we want to be evidence-based … we are only 2 years old and that is why there isn’t any research.” In the same interview, co-founder Jo-Anne Weltman commented, “evidence-based practice is often very very, very behind what’s going on in the world.”¹² While it should be acknowledged that knowledge translation from research to practice can be as long as 17 years,¹³ it is important to note that the origins of DMI go back as far as 1972 with the development of CME.

On the surface, DMI may appear like child-active therapy. DMI is self-described as applying principles of neuroplasticity by engaging children in structured movement patterns aimed at improving mobility. However, a closer look at the official descriptions of the intervention suggests that it is based on motor learning theories originating from the mid-20th century, ie, early reflex-based models that focused on hierarchical therapist driven control.^14,15 In these earlier motor learning theories, reflexes were considered the fundamental precursors to voluntary movement, with motor skills emerging through therapist-initiated facilitation. DMI’s practice involves therapists manually guiding children through exercises, often against gravity, with repeated movements to elicit specific responses. The therapist’s role was to guide movement by shaping responses through hands-on positioning and handling. These same theories underpin the Bobath or Neurodevelopmental Approach (NDT), developed in the 1950s and despite its continued use across parts of the world, a recent systematic review found no difference between the NDT and control groups that were not dose dependent.¹⁵ As such, the authors called for the deimplementation of NDT, emphasizing the need to adopt therapies based on contemporary motor learning models¹⁶: (1) By contrast, contemporary motor learning models of therapy are active, and goal-oriented with contextually meaningful tasks led by the child, rather than adult or therapist-initiated movement patterns.¹⁷ Providing an environment for individuals to problem solve within meaningful contexts, rather than react to external cues, not only facilitates development across all domains but also aligns with the principles of neuroplasticity.^18,19 A substantial body of high-quality research and large-scale systematic reviews over the past decade^20-22 has provided strong empirical support for interventions grounded in contemporary motor learning principles, with established efficacy and safety. Notably, the State of the Evidence Traffic Lights 2019 systematic review categorizes “Green Light—Do It” interventions as the most effective, providing clinicians and families with evidence-based options for therapeutic decision-making.²³ As stated in this paper: “All these interventions have the following features in common: practice of real-life tasks and activities, using self-generated active movements, at a high intensity. The mechanism of action is experience-dependent plasticity. Motivation and attention are vital modulators of neuroplasticity, and successful task-specific practice is rewarding and enjoyable to children, producing spontaneously regular practice.” Several of the components of DMI, as stated in their introductory manual,²⁴ are inconsistent with these features; eg, DMI “Stimulates postural control/verticality,” “Develops automatic motor movements,” “The child’s cooperation or motivation are not always required,” “DMI modifies tone, primitive reflexes, and abnormal patterns of movement.”

It is puzzling to understand how, as treatments with strong supporting evidence have increased dramatically in the past decade, interventions lacking support or even those shown not to be effective still manage to thrive.

The core principles of DMI are derived from frameworks such as NDT and CME, both of which are based on outdated motor control theories. In a recent blog post, Jake Kreindler asserts that DMI is aligned with 17 interventions classified as “Green Light” in evidence-based frameworks.²⁵ This is misleading, as these interventions (including bimanual hand function, goal-directed training, and task-specific training) are grounded in contemporary motor learning principles that differ fundamentally from the theoretical underpinnings of DMI. They also require distinct ingredients that are not typically part of DMI.

In summary, evidence level (adapted from Sackett)²⁶ for both DMI and CME is considered level 5 or no evidence. There are no well-designed experimental studies, only case report evidence.

Risks and precautions

Although there are currently no published data about harms from CME or DMI, therapists are reminded that reporting adverse events is a mandatory part of their practice. If a licensed therapist were to suspect a fracture or any adverse event, they are required by law in most jurisdictions to report this to child protective services, as are emergency room/urgent care staff. Nondisclosure or waivers are not applicable when a child has been injured.

Individual therapist and professional association responsibility

Therapy practices, unlike drugs or medical devices, are not required to demonstrate efficacy prior to their use with patients. However, physical therapists are supposed to abide by a code of ethics which includes using sound clinical judgment based on current literature and best practices. Promoting or utilizing an intervention not supported by evidence clearly deviates from this professional responsibility.

Some therapists and clinics report using selected elements of CME or DMI within routine physical therapy sessions under the rationale of drawing from their “therapeutic box.” While this may make their use appear less controversial and clinically acceptable by not delivering them intensively or by blending them with some evidence-based therapies, it nonetheless raises concerns. This narrative suggests CME and DMI are evidence-based practices and risks misleading both families and professionals about their scientific legitimacy.

Families of children with disabilities are a vulnerable population and may be misled by scientific sounding claims on a website or in an interview. The role of therapists is to support families in their therapeutic decision-making process by making them aware of the evidence for different interventions, and to provide interventions that meet the highest standards of practice. We propose here that our professional societies be more proactive in speaking out against, and withholding accreditation for, educational programs for therapists that do not meet best-practice standards.

Ethical considerations in reflex-based interventions for neurodisability

The shift away from “fixing” neurodisability aligns with modern perspectives that prioritize function over form, recognizing disability as an integral aspect of identity rather than an impairment to be overcome. Adults with cerebral palsy have described how early-life rehabilitation efforts, often framed as necessary for achieving independence and happiness, may inadvertently contribute to social alienation and feelings of inferiority.²⁷ The ethical implications of intensive therapy models also warrant scrutiny, particularly concerning the opportunity costs for the child. Engaging in high-dose, unproven interventions may come at the expense of participation in school, social activities, and family life—experiences that contribute significantly to educational, emotional, and social well-being. The decision to allocate substantial time to an intervention should be guided by robust evidence demonstrating its superiority in improving health outcomes, rather than by anecdotal success stories or outdated theoretical rationales.

Financial accessibility and equity further complicate the debate. Families often bear significant financial burdens to access CME and DMI, with costs for intensive programs costing thousands of dollars per week. Given the limited insurance coverage and lack of regulatory oversight for these interventions, families may experience financial strain in pursuit of uncertain benefits.

In conclusion, reflex-based hands-on interventions such as CME and DMI must be critically appraised within the broader context of motor learning science, opportunity costs, financial equity, and ethical considerations. A shift toward holistic, evidence-based, and participatory approaches in which the child’s agency, contextual engagement, and broader well-being are prioritized will offer a more balanced and inclusive framework for pediatric rehabilitation.