We commend Jo-Ann Weltman for opening up discussion on the topic of Dynamic Movement Intervention (DMI) and Cuevas Medek Exercises (CME) in this manner. The ResearchWorks team welcomes robust conversation - where we can articulate ideas and research in our field. It has not always been the case where conversation is kept civil when fundamental differences in approach are noted.
Constructive conversation is always welcome - we would encourage readers to leave their own commentary on this topic in the comments section below.
Warning: Comments are moderated. Constructive conversation is welcome, but derogatory, insulting, wholly argumentative or destructive commentary will be deleted along with any off-topic material/s.
JO-ANN WELTMAN (co-founder of DMI, Dynamic Movement Intervention).
Thank you for mentioning DMI in your podcast. My name is Jo-Anne Weltman and along with my Co-Founder, Jake Kreindler, we created DMI in January of 2021. Our mission is to improve access of this quality therapy for children, their families, and therapists around the world.
One of the many reasons that DMI was started was because in 50 years since its creation, CME had not done research. This is something that we are working on changing.
We understand the value of evidence based practice and are actively pursuing this goal. We are currently collaborating with a research team in California but would love to invite other researchers to help out. The anecdotal evidence is there. Parents report significant change in their kids.
If I may, I would like to comment about some of the wonderful points you touched upon in your podcast.
With regards to the 10 principles of Neuroplasticity, DMI address all 10 points.
Saliency is an interesting point in children under 2 or those who have neurological immaturity. Our inner intrinsic drive and genetic blue print as human beings is what controls development. We don’t need motivation or purpose to want to move or achieve motor independence at this age.
Unfortunately, some children will not have the neurological maturity due to neurological dysfunction or damage, or may be sensory defensive. This may cause them to fight an upright sitting position, crawling, or even showing desire to stand.
Another point you touched on is important when discussing young children with neurological damage or delay.
Emotional regulation is learnt through maturation, human interaction, movement experience, environmental exploration, and play. Babies and young toddlers need us to help them regulate. It is through developing motor control and thus independence, that children can start to regulate. At younger ages when movement is hard, children will cry. It is very rare that a child will be content with any type of therapy in these early stages. As they develop more strength and control and with sensory modulation, children begin to enjoy the movement and therapy.
Children can learn in stressful environments. I always remind parents of the best example of this - school! When a child enters school for the first time and is met with new challenges, this can be stressful for many, but over time they learn how to emotionally regulate. Overcoming difficult tasks gives us all a sense of pride and feeling of accomplishment.
Experience of different challenges and creating solutions helps our brain adapt more quickly and efficiently in the future as similar stimuli are presented. Pediatric therapy modalities that provoke an active response, such as DMI, may elicit more emotional responses initially, but yield powerful regulation skills as the child improves.
We look forward to your reply. Thank you again for mentioning us. We are grateful to be part of conversations toward a brighter future for children with disabilities and delays.
We all know that babies are not robots and don’t merely react to stimuli!
Motivation and salience are relevant for even the youngest of infants. One longitudinal study in infants 7-12 months of age demonstrated that infants already have different motivational orientations towards movement (i.e. they can be more or less motivated to move).(1) Motivation for movement was positively correlated with motor development; infants who had stronger motivation for movement acquired skills faster than infants who had weaker motivation.(1) This relationship was reciprocal, with each gain in motor ability further increasing the motivation to move.(1)
Perceiving the mere space and ability to explore may spur motivation for movement; toddlers will explore an empty space almost as much as a space full of toys.(2) However, toddlers in a toy-filled room move differently – further away from their caregivers, in more locations in the room, and in increasingly varied and complex ways.(2) Motivation to move is therefore not just intrinsic for many children but is influenced by the environment (especially the visual environment) and perhaps other factors such as the child’s temperament and interests.(3)
Studies of infants who are blind and developmentally delayed suggest that motivation to move is on average lower in these groups when compared to typically developing infants,(3) however this doesn’t mean that this motivation should be encouraged by repeatedly subjecting an infant or child to situations that they find distressing.
But what is distress and why should we aim for physical therapy to be as free as possible from distress? There has been increasing recognition of the concept of infant mental health. Infants and young children are uniquely dependent on caregivers to help them regulate during periods of physiological and emotional distress.
Procedural distress is a strong negative reaction to a health intervention.(4) Procedural distress may relate to pain, anxiety, or fear, and may be observed in movements of the body (rigidity, withdrawing, kicking, thrashing, back arching), facial expressions, vocalizations (crying, screaming), and verbalizations (expressing verbal resistance).(4)
Healthcare procedures can be traumatic for children, with painful and distressing procedures having enduring impacts on adherence to treatment, functional outcomes, mental health and health-related quality of life.(5) Infants and young children do not have the cognitive capacity to understand that distressing procedures may be required, and instead may perceive the event to be traumatic and in some cases life-threatening.(4)
Unless evidence is produced to the contrary, the safest assumption to make is that physical therapy procedures provoking obvious signs of pain and/or distress in infants and children would have similar deleterious effects.(6) All possible steps should be taken to minimize, and where possible, eliminate distress during physical therapy.(6)
Caregiver attentiveness to infant cues, including signs of distress, is strongly related to infant development including expression of genes that regulate stress system function and brain growth.(7) The idea that children should be allowed to cry because they need to learn to tolerate distress is an unhelpful belief that should be proactively addressed to promote infant mental health.(8)
Our instinct as clinicians should be to immediately stop distressing procedures where possible, or take swift action to minimize distress if stopping the procedure is not appropriate. We should always work to optimise the task and environment to create a therapy situation that has all the right ingredients for motivation: one that is joyful, curious, reciprocal, successful, and aligned to the interests of the child.
1. Atun-Einy O, Berger SE, Scher A. Assessing motivation to move and its relationship to motor development in infancy. Infant Behavior and Development. 2013;36(3):457-69.
2. Hoch JE, O'Grady SM, Adolph KE. It's the journey, not the destination: Locomotor exploration in infants. Developmental Science. 2019;22(2):e12740.
3. Doralp S, Bartlett D. Infant Movement Motivation Questionnaire: Development of a measure evaluating infant characteristics relating to motor development in the first year of life. Infant Behavior and Development. 2014;37(3):326-33.
4. Brown EA, De Young A, Kimble R, Kenardy J. Review of a Parent’s Influence on Pediatric Procedural Distress and Recovery. Clinical Child and Family Psychology Review. 2018;21(2):224-45.
5. Moss KM, Healy KL, Ziviani J, Newcombe P, Cobham VE, McCutcheon H, et al. Trauma-informed care in practice: Observed use of psychosocial care practices with children and families in a large pediatric hospital. Psychol Serv. 2019;16(1):16-28.
6. Von Baeyer CL, Tupper SM. Procedural Pain Management for Children Receiving Physiotherapy. Physiotherapy Canada. 2010;62(4):327-37.
7. Lyons-Ruth K, Todd Manly J, Von Klitzing K, Tamminen T, Emde R, Fitzgerald H, et al. THE WORLDWIDE BURDEN OF INFANT MENTAL AND EMOTIONAL DISORDER: REPORT OF THE TASK FORCE OF THE WORLD ASSOCIATION FOR INFANT MENTAL HEALTH. Infant Mental Health Journal. 2017;38(6):695-705.
8. Clinton J, Feller AF, Williams RC. The importance of infant mental health. Paediatrics & Child Health. 2016;21(5):239-41.
Implementing the motor learning principles that drive neuroplastic changes forms the foundations of contemporary therapeutic interventions for children with neurodisabilities.
Since the notable publications of Kleim and Jones (2008)(1) and Johnston 2009,(2) clinical trials have been conducted to test how these principles can be incorporated into our interventions as an intervention cannot claim to be effective unless it is tested. As it currently stands, the weight of the evidence supports that all the principles are important, no matter the age. The breadth and depth of clinical trials over the past decade in particular, have yielded consistent messaging which have been captured in comprehensive systematic reviews.(3-7)
The mounting evidence that has been gathered by independent clinical researchers globally have identified common features of effective interventions as well as of course, common features of ineffective interventions.(5 6) These features describe how interventions should be delivered if we are to claim adherence to the principles of motor learning that in turn drive the desired neuroplastic changes.
The features of effective interventions consistently support that learning best occurs with active, self-generated movement within real-life meaningful goals that promote the child’s ability to problem solve.(5 6) These key features reflect the vital nature of salience and task specificity and the two are intrinsically connected. The active desire to explore, problem solve and initiate movement – in the child’s own unique way, is the key to any lasting changes that importantly, translate from a clinical setting into the everyday.
The context of effective interventions that promote learning is one where there is active engagement without distress, and the voice of the child is the centrepiece.(6 7) Young children with neurodisabilities may be trying to learn with suboptimal background of pain, low caloric fuel and irritability, yet we also know that crying increases cortisol which can affect brain development, learning and attachment.(6) Therefore, an intervention cannot be effective if there is distress and continuing to persist is detrimental on multiple fronts.
Likening the distress of a child attending school for the first time, being anxious to be separated from their parent to obvious distress in a therapy session is demonstrably not the same. The sheer physical toll and raised cortisol levels from a distressed state is a physiological response and has a far greater detrimental effect on children with a neurodisability.
In the instance of limited communication (due to age or functional communication ability), the ability to obtain consent to continue with an intervention when distress is evident limits any possibility of identifying the source of distress. Distress could be attributed to pain, and persisting in any form is harmful.(4) Once again, an inability to clearly indicate pain or discomfort is another factor that differs to neurotypical children that are more able to reason their anxiety or insecurity when adapting into the school setting.
When persevering with an intervention when a child is clearly in distress, there is a tremendous risk of ignoring the wishes of the child to stop the intervention. The child accepting pain and discomfort in the therapy session is not indicative of progress, it is a resignation that there is no ability to voice opposition.
When a child is crying or in distress, the question is always whether there is a valid reason for that response. The reality is that there is always a better way. Persevering in this manner is still not gaining the greatest neuroplastic response when all the evidence shows that active engagement, self-initiation and understanding in context, appealing to the natural sense of play and exploration in children is a far more powerful approach to neuroplasticity.(5)
These features are also protective in that it places greater emphasis on the child. This means children can learn at their own pace, respecting their own individual nature and characteristics, working with what motivates them and considers their own emotional regulation.
This contrasts with the features of ineffective (or far less effective) interventions which include facilitation, handling and positioning, reflexes and reactions, sensory support and vestibular input.(3 5 6) All of these features rely heavily on external input which not only defies the motor learning principles that drive neuroplasticity but also minimises the child’s role to control the pace on the background of potentially suboptimal conditions of pain and discomfort.(3 6)
Whilst neurodevelopmental therapy (NDT) has been named as having more features within the ineffective category, there are other interventions that share these features including Vojta and CME(8). Clinical researchers have called for “deimplementation” and to be “discontinued based on current evidence” simply because the weight of the evidence is pointing in another direction.(5 8)
DMI is certainly a new intervention having started in 2021 that has as stated (dmitherapy.com and associated social media channels), consistently referred to as being based on CME (originating in the 1970’s). We appreciate that there are planned endeavours of participating in research and we look forward to following this progress. However, it must be stated that the interpretation of the motor learning principles that drive neuroplasticity contrasts significantly with the current weight of the evidence – not the opinion of one but of hundreds of researchers that have published their work so far.
1. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research 2008;51(1) doi: 10.1044/1092-4388(2008/018)
2. Johnston MV. Plasticity in the developing brain: implications for rehabilitation.
Developmental disabilities research reviews 2009;15(2):94-101. doi: 10.1002/ddrr.64
3. Damiano DL, Longo E. Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews. Dev Med Child Neurol 2021;63(7):771-84. doi: 10.1111/dmcn.14855
4. Jackman M, Sakzewski L, Morgan C, et al. Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline. Developmental medicine and child neurology 2021 doi: 10.1111/dmcn.15055
5. Te Velde A, Morgan C, Finch-Edmondson M, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics (Evanston) 2022;149(6):1. doi: 10.1542/peds.2021-055061
6. Morgan C, Fetters L, Adde L, et al. Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews. JAMA pediatrics 2021;175(8):846-58. doi: 10.1001/jamapediatrics.2021.0878
7. Novak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 2020;20(2):3. doi: 10.1007/s11910-020-1022-z
8. Longo E, de Campos AC, Palisano RJ. Let's make pediatric physical therapy a true evidence-based field! Can we count on you? Braz J Phys Ther 2019;23(3):187-88. doi: 10.1016/j.bjpt.2018.10.011
A laymans perspective....
I'm currently learning french. 🇫🇷
I love the culture, the food, the people, the language. I have a great interest in all things french, I've traveled there a dozen times and will one day retire there.
My interest and passion feeds my want and need to learn the language. I can't rely on translators, tour guides or even Google translate to "teach" me the language by osmosis.
Of course, I'll pick up a handful of words by listening, watching and having others speak the language in front of me. The best way to learn the language however, the way I'll use my brain the most, is by speaking the language myself.
Learning phrases that have a personal connection for me seems the most powerful way to gain fluency. The phrases that I can use out shopping, at work, at home. It's about context and learning how sentences and responses are formed in the context of what is important to me. Sounds a bit like task specific, goal directed therapy and active engagement right?
I have to try and experiment, enjoy the journey of learning a new skill (ie, a language) and there I have the greatest and most impactful growth. If I don't understand the context, or if it's not meaningful to me - like say, rote learning words out of a french dictionary - it will be a long and painful journey and my results won't be the same as an immersive language experience.
Now, no two people will learn a language the same way but there are key concepts and techniques that will grow my vocabulary and fluency and they are very similar across the board. It's the same with the out-workings of research and science. It is the value of the expertise of 100s and 1000s of researchers, all working to improve each other's understanding of the field.
From a lay persons perspective, (my field is Computer Science, not the health care kind), I can see how teaching the patient to initiate on their own rather than actioning a movement for a patient is more effective. Learning, in whatever capacity - should be fun, interesting, explorative and connected.