Letter to the Editor: Clarifying the Scientific Basis and Clinical Relevance of DMI Therapy

Dear Editor, We are writing in response to the recent article critiquing Dynamic Movement Intervention (DMI) Therapy: Paleg, Ginny PT, MPT, DScPT; Pool, Dayna PT, PhD; Hidalgo-Robles, Álvaro PT, MSc; Frumberg, David MD; Livingstone, Roslyn OT, MSc (RS) ; Damiano, Diane PT, PhD. Where’s the Evidence? Challenging Therapists to Stop Legitimizing Dynamic Movement Intervention and Cuevas Medek Exercises. Pediatric Physical Therapy 2026;38 (1): 138-143: 10. 1097/PEP. 0000000000001261. While we support open academic dialogue, we believe that critiques of therapeutic approaches must be grounded in subject–matter expertise and supported by a comprehensive understanding of the methodology in question, derived from direct communication with experts in DMI, undertaking DMI courses, including clinical practice, and direct review of DMI treatment sessions by trained DMI practitioners. LACK OF SUBJECT EXPERTISE DMI represents a comprehensive therapeutic approach within Physical and Occupational Therapy, specifically for infants and children with neuromotor delays. The primary objective of DMI is to elicit purposeful, active motor responses from the child through therapist-prescribed dynamic exercises, utilizing gravitational forces to challenge and stimulate active motor behavior. In this way, DMI harnesses experience-dependent plasticity as the DMI approach assists the child in developing selective motor control that contributes to the acquisition of gross motor skills. This theoretical approach is based on the principles of neuroplasticity, with particular reference to the key principles of specificity, repetition, intensity, time matters and interference. 1 This intervention method is grounded in a holistic consideration of the multifaceted factors contributing to childhood-onset disability, with particular emphasis on neurodevelopmental variables linked to sensorimotor dysfunction and their interrelationships, namely sensory-motor, vestibular, and somatosensory systems. As a result, DMI Therapy is closely aligned with the International Classification of Functioning, Disability and Health framework, underscoring that improvements in body structure and function are instrumental in fostering the child’s engagement in activities and participation. 2 Anecdotally, parents and DMI practitioners report that following a block of DMI Therapy, some children will spontaneously and actively produce gross motor skills based on the repeated practice of “splinter skills. ” Again, this suggests that experience-dependent plasticity results from autonomous motivation and focused attention. When an impairment in body function or structure limits the achievement of desired gross motor outcomes, it is advisable to employ targeted interventions addressing these specific deficits alongside task-oriented training to enhance overall task performance. 3 DMI Therapy is positioned as a vital conduit between childhood brain injury and the emergence of new motor behaviors, underpinned by robust foundations in body alignment and postural control. It is essential to recognize that none of the authors of the recent Paleg et al critique have undertaken formal DMI training or coursework, nor have they engaged in direct communication with DMI practitioners or observed DMI sessions. As a result, their commentary lacks the requisite foundational knowledge to accurately evaluate DMI’s theoretical framework, clinical application, or underlying principles. Reliance on superficial keyword searches does not constitute a thorough or informed analysis, and risks misrepresenting the intervention to clinicians and families. DISTINCTION FROM CUEVAS MEDEK EXERCISES AND NEURODEVELOPMENTAL TREATMENT The authors state that there has been limited research in Cuevas MEDEK Exercises (CME) and has positioned DMI together with CME. DMI Therapy, established in 2021, is a distinct modality that integrates principles of motor learning, neuroplasticity, and biomechanical challenge. It differs significantly from CME and Neurodevelopmental Treatment in both its structure and scientific rationale, and it is therefore inappropriate to draw any comparisons or conclusions. NEURODEVELOPMENTAL FOUNDATIONS AND SENSORY-MOTOR INTEGRATION Early motor development is driven by central pattern generators, primitive reflexes, and subsequently develops into voluntary movement. 4 Children with significant motor delays often lack the intrinsic motivation or ability to initiate and refine movement. DMI addresses this by presenting graded challenges that elicit active responses. Passive facilitation is explicitly avoided. DMI exercises are designed to stimulate proprioceptive and vestibular systems through manipulation of gravitational and ground reaction forces. 5 This approach supports the development of body schema and spatial awareness, consistent with established models of dynamic systems theory and sensory-motor adaptation. 6–9 As with standard clinical practice, following DMI intervention, DMI practitioners use standardized neurodevelopmental assessment tools such as the Gross Motor Function Measure, 10, 11 The Early Clinical Assessment of Balance12 and the Segmental Assessment of Trunk Control 13–15 to assess treatment outcomes. Anecdotally, reports from practitioners and parents have demonstrated meaningful improvements in gross motor function. TASK SPECIFIC AND FOUNDATIONAL SKILLS Human development is unique in that babies are born dependent and need to develop foundational skills until the final milestone or task is achieved. Tasks are practiced as a whole or in parts. Paleg et al16 have criticized DMI suggesting that not all DMI exercises are functional tasks; however, human babies are not born standing and walking and there are many smaller pieces that need to be learned to achieve this very high level skill. 17 Milestones are the cumulative effect of many biomechanical, sensory, and motor experiences and connections. They require varied and repeated experiences and interventions to become solidified as a reproducible and reliable movement pattern in a child’s repertoire. DMI does not claim to “fix” a child, however, does clearly state that even small gross motor changes can affect quality of life, no matter how affected a child is. For example, a child who lacks head control and learns to hold their head erectly, can sit at a dinner table in their adaptive chair engaging with their family or become more effective at using an eye gaze system to communicate. A child who improves in their postural control in sitting can engage in play with their siblings, with a potential ripple impact to improving communication skills, visual attention, and cardiorespiratory function. Improvements in gross motor skills may not always translate to milestone changes, but those “inch-stones” will always result in quality of life improvements and this cannot be disregarded or understated. Emerging research on the statistics related to the prevalence of chronic pain in adults with cerebral palsy warrants significant attention to postural alignment and the impact of musculoskeletal pain and aging in this population. 18 SAFETY CONSIDERATIONS As with any physical therapy modality, children with limited mobility may be at risk for osteopenia or injury due to reduced skeletal loading. However, there is no evidence to suggest that DMI carries a higher risk profile compared with other interventions and such claims should not be insinuated by the authors. Risk mitigation strategies are embedded within DMI protocols and safety precautions are discussed in each DMI course. 19 RESEARCH ACTIVITY AND FUNDING While foundational research on DMI is emerging and is currently in planning phase, it is inaccurate to equate limited publication volume with a lack of intervention effcacy. Evidence-based practice comprises 3 pillars: best available research, clinical expertise, and patient values. 20 DMI is supported anecdotally by high levels of both DMI practitioner and caregiver satisfaction. This is based on the development and continual revision of our comprehensive professional development pathway, which provides practitioners with extensive theoretical and practical skills. Inherently, our goal is to assist and support in the scientific evaluation of the DMI method and we continue to do that. DMI Therapy works to address the needs and rights of parents and children. Over the past 5 years, DMI’s reported therapy outcomes have led some insurance companies and Medicaid programs in several states in the United States to provide financial coverage for DMI sessions and intensives, reducing therapy costs for families. Internationally, our practitioners collaborate with researchers to evaluate therapy outcomes that may inform government funding models for this population group. Over a year ago, the DMI co-founders had a conversation with one of the authors of this article16 and requested support for research in DMI Therapy, but unfortunately the request was declined. Contrary to statements in the referenced article, research initiatives are underway, and collaborative opportunities have been extended to the academic community. There are great concerns in the pediatric community that our profession is being undermined by government organizations who are cutting funding. 21 However it is also the researchers who question our clinical integrity instead of supporting their colleagues. The co-founders of DMI are huge proponents of evidence and investigating the effcacy of DMI through scientific rigor. It was one of the main reasons DMI was established. However, attempting to invalidate valuable work in turn threatens funding grants for researchers’ future research projects. CALL FOR COLLABORATION We invite researchers and clinicians to engage constructively with the DMI community. Dismissive critiques devoid of experiential insight risk undermining therapeutic innovation and delaying access to beneficial interventions for our vulnerable populations. We remain open to dialogue and welcome researchers to participate in DMI training and research partnerships. Sincerely, Jake Kreindler and Jo-Anne Weltman Co-Founders, DMI Therapy Editor’s Note: The authors report to the editorial office that “The course cost is US 800 per participant for a 2 day course, 16 hours”.