DMI Clinical Commentary

DMI Therapy: A Neuroscience Approach to Neurodevelopmental Disability

Dynamic Movement Intervention (DMI) encompasses a comprehensive therapeutic technique in Physical and Occupational Therapy, a treatment approach for infants and children with neuromotor delay such as Cerebral Palsy (CP), neurogenetic and neuromotor disorders. One of the doctrines of DMI involves improving automatic postural responses diminished by the child’s overarching neuromotor disorder. The goal of DMI is to provoke a specified active motor response from the child in response to defined dynamic exercises prescribed by the therapist. DMI harnesses gravitational forces to support further or challenge the provoked motor behavior. This intervention approach considers various factors contributing to childhood-onset disability, namely the neurodevelopmental variables associated with sensorimotor dysfunction and their interconnections. [1] It also considers recent research in Neurorehabilitation, supportive technologies, and related methodologies to provide a comprehensive understanding of neuromotor disorders and the ensuing expression of movement dysfunction.

THEORETICAL CONSIDERATIONS 

DMI is based on a thorough understanding of the factors that lead to childhood-onset disability, with a particular focus on neurodevelopmental aspects, including sensorimotor deficits and their interconnections among the sensory-motor, vestibular, and somatosensory systems. Therefore, DMI Therapy aligns with the International Classification of Functioning, Disability and Health framework,[2] highlighting that enhancing the body's structure and function is crucial to encouraging the child’s potential participation and activity and respecting the increased risk of chronic pain as a result of skeletal malalignment. Emerging research on the prevalence of chronic pain in adults with Cerebral palsy highlights the importance of focusing on postural alignment early and examining how musculoskeletal pain and aging affect this group. [3,4]

NEUROPLASTICITY 

The critical period for developing gross motor skills in neurotypical infants extends from prenatal development through age 5 years. During this time, toddlers and young children actively explore their surroundings through diverse movements, engaging in varied practices that foster learning and growth. [5] The infant's motor skills develop due to their sensorimotor experiences, which are influenced by the environment and the innate neuroplastic potential that supports the child in adapting and learning.

DMI Therapy, follows the principles of Neuroplasticity, specifically that it may facilitate new neuronal connections demonstrated by the emergence of improved motor behaviors by providing novel, varied, task-specific, challenging and repetitive challenges to the child’s motor and sensory systems as demonstrated by the emergence of improved motor behaviours. [6,7] Neuroscience research indicates that brain development and motor refinement continue after birth, influenced heavily by movement. Early intervention and active movement are vital for infants with brain injuries, as inactivity can lead to the loss or pruning of cortical connections and functions. [8] Additionally, an infant's motor behaviors, facilitated through exploration and interaction with their environment, promote growth in muscles, ligaments, and bones, thus supporting ongoing sensorimotor development. [9]

Population data indicate that gross motor performance for children with CP stabilizes and becomes less responsive to motor intervention after 3.5–5 years of age, since 90% of motor potential has been attained.[10] Therefore, late intervention probably restricts optimal motor outcomes because nearly the entire neuroplastic window for motor learning is missed.[8,11] Furthermore, without early intervention, there is a risk of deterioration and maladaptive neural plasticity. Data from the Swedish CP population show that children who do not receive timely early interventions develop significantly worse musculoskeletal deformities—less than 1% hip dislocations in those treated early, compared to 30% in untreated or late-treated individuals. They also experience higher rates of contractures and scoliosis.[12] Therefore, as these principles align with DMI Therapy, this treatment approach is well-positioned to serve as an early conduit between the child’s brain injury and the emergence of new motor behaviors, with a strong foundation in body alignment and postural control. This approach may also support the development of cortical mapping of body schema and spatial awareness, consistent with established models of dynamic systems theory and sensory-motor adaptation. [13,14,15,16] Early intervention in young children with brain injury is essential to improve function and reduce later maladaptive complications in both connections within the brain and musculoskeletal concerns. [8] As such, DMI strongly advocates for early intervention in pediatric populations to capitalize on critical windows of neuroplasticity and maximize each child’s developmental potential. 

NEURONAL GROUP SELECTION THEORY (NGST) 

In contrast, children born with a brain injury are often viewed as fragile, restricting the child’s movement experiences and resulting in further delays in brain development. Supporting this is the work done by Gerald Edelman on Neuronal Group Selection Theory. NGST proposes that unused neuronal groups are pruned as part of the normal brain maturational process. [17,18] Physical activity is crucial for early brain development, directly impacting motor and postural control, and resultant cognitive skills. As children explore their environment through movement and inquisitive play, they build essential skills in spatial relationships, timing, motor planning, communication, coordination, and a foundation for math and language. [19] Additionally, gross motor development and core muscle strength are vital for acquiring fine motor skills and manual dexterity. [20] DMI Therapy exercises may help to synchronize brain development, help the child practice task-specific movements, and facilitate neural pathways in each stage of brain development, as per the NGST framework. DMI can be started as early as 1 month of age and in the step down unit of the NICU, using gentle facilitation.

MATURATIONAL THEORY

 Reflecting Maturational Theory, the progression of facilitation of DMI exercises generally follow:

• A head to toe or cephalic to caudal direction.

• A proximal hold that progresses to a distal hold requiring the child to control and complete more of the movement themselves, thus achieving segmental postural control. The child actively controls everything above our hand placement while we facilitate below, allowing for gradual segmental exposure to gravity, in the development of targeted segmental control.

• A general symmetrical motor response (i.e. extension, flexion) to a more specific disassociated motor response (i.e. flexion of one limb while extension the other)

• Facilitation of rotary and transitional muscle control built upon stability of head and trunk postural control

ORGANIZED SENSORY INPUT 

Children with known gross motor delays, no matter the etiology, must exercise movements congruent with developmental positions of stability, mobility skills, and transitions to support and provoke brain development. Physical exercise triggers the release of Brain Derived Neurotrophic Factor (BDNF) which promotes the survival, maintenance and growth of neurons. According to a multivariate analysis, BDNF levels and rehabilitation could constitute independent predictors for better neuropsychomotor development outcomes. [21]

DMI Therapy focuses on eliciting new neural connections and may strengthen synaptic connections through novel exercises that provide strong sensory input, prompting active postural responses.[22,23] DMI exercises, guided by practitioners and supplemented with home programs, may help shape and enhance neuronal pathways over time. Strong sensory information may assist in forming specialized synapses that enhance balance, muscle control, and movement. DMI Therapy may stimulate the proprioceptive receptors by including dynamic stretching, loading and compression forces, and task-specific weight-bearing activities within functional tasks, especially at end ranges of motion. Although established principles of neurology and neuroplasticity suggest that DMI likely promotes synaptic formation and neural connectivity, further research is needed to confirm and clarify its neurological and neurophysiological effects.

Specific DMI Therapy exercises that harness vestibular input through controlled head movements activate the inner ear's vestibular system, further enhancing vestibular and proprioceptive input. Through extensive practice over several years, neurotypical toddlers and young children utilize all these sensory systems to develop and refine their motor skills. Children with sensory processing delays often have altered brain microstructure, resulting in underactive sensory systems that require increased sensory input for effective information processing and learning. [24]

DMI Therapy leverages sensory information to support these children's development. 

DYNAMIC FUNCTIONAL STRETCHING 

Neurotypical children are born with a limited range of motion due to space constraints in the womb, but they expand their movement capabilities in response to their gravitational environment. Regular movement and muscle contraction are crucial for maintaining tissue flexibility. Children who cannot move adequately due to neuromotor challenges may face soft tissue and orthopedic issues as they grow into their disability. DMI Therapy allows for controlled dynamic functional stretching to facilitate the child’s active movement of joints, soft tissues, and muscles. DMI exercises target specific muscle groups to improve strength, postural control, flexibility, tissue extensibility, and range of motion, supporting the child’s musculoskeletal alignment. [25]

TASK SPECIFICITY

Task specificity is one of the guiding principles of neuroplasticity and an intrinsic component of the implementation of DMI Therapy. When performing exercises that target active participation to achieve a gross motor milestones such as rolling, sitting, standing, walking, etc, the DMI practitioner taps into mapping the task within the brain. DMI Therapy provides stimulation to the brain that may provoke synaptic and neuronal connections vital to support independence in that task or function. As that skill is practiced with the child’s active engagement, pathways and mapping for the skill become more robust, leading to increased functional independence, fluidity, and increased quality of movement. DMI Therapy addresses all developmental milestones.

Each task is practiced in the correct position in space to coordinate and capitalize on the different parts of the brain required to create efficient motor function. For example, in a standing position, the coordination of our visual, vestibular, proprioceptive, musculoskeletal, cognitive, and emotional centers of the brain allows us to maintain this position. We cannot learn to stand lying down and we cannot learn to crawl by lying in supine. Our brains need to trigger and time the agonists and antagonists to create a smooth, energy efficient pattern of movement that becomes more complex over time. By actively practicing the gross motor skills the child needs to learn to do independently, DMI Therapy can help the child achieve new levels of independence. In DMI therapy the child is challenged at a very high level, demanding many areas of the brain to respond together. As a result, musculoskeletal alignment, coordination, and strengthening of muscular activation are of tantamount importance in DMI Therapy.

DMI aim to enhance gross motor outcomes by identifying the child’s impairments, by breaking down each individual milestone or task into its most basic components or splinter skills. Because sensory and motor deficits can limit a child’s ability to resolve gross motor challenges independently in daily life, the practitioner addresses these challenges through specific, carefully selected exercises. The DMI practitioner is always working on the general functional skill, but breaks down movements into their smallest component parts to solve each gross motor impairment with greater task specificity. By varying the sensory demands within each task, the practitioner continues to target the broader functional skill while refining its component movements with greater precision. This approach gives the brain multiple ways to solve motor challenges and select the most efficient neuronal pathways for each situation. As the child builds a stronger neural foundation and gains flexibility in responding to diverse environmental demands, they may achieve a level of independence that was previously inaccessible.

NEUROLOGICAL MATURITY 

Neurological maturity in gross motor development does not require strict sequential mastery of lower‑level skills before practising higher‑level ones. When viewed through Gesell’s maturational theory, neurological development provides biological readiness for increasingly complex postural and motor behaviours, but does not limit children to a linear progression. Neuronal Group Selection Theory further demonstrates that exposure to higher‑level tasks promotes variation, selection, and integration of neuronal groups, strengthening emerging motor pathways even when foundational skills remain immature. Consistent with this evidence, DMI employs both top‑down and bottom‑up facilitation: higher‑level tasks stimulate cortical mapping, vestibular‑proprioceptive integration, and selective motor control, while lower‑level skills continue to refine through repeated active practice. This non‑linear approach supports optimal neural development, prevents pruning of under‑used neuronal groups, and aligns with contemporary models of neuroplasticity and sensorimotor learning.

VERTICALITY 

Paramount to DMI intervention is the facilitation of postural control and the ability of the child to stabilize the body in space against gravity. This is known as verticality. Verticality relies strongly on influencing the vestibular and proprioceptive systems. Gravity is the driving force for the development of all life on Earth. Land-dwelling living organisms work daily to move against gravity to survive. Developing postural and antigravity muscles in humans supports our bones and joints in maintaining postural alignment against this constant force. Humans, as bi-pedal creatures, maximize mobility efficiency by walking. In contrast, with inactivity or inability to fully stabilize and move in an upright position our antigravity muscles atrophy, resulting in a deteriorating relationship with gravity as we lose our sensitivity to its force. [26]

Ground Reaction Force (GRF) stems from Newton’s concept that for every action, there is an opposite and equal reaction. Gravity and GRF are forces of nature that are always impacting us. Gravity and GRF work together to stabilize the body regardless of direction or angle. Our bodies dynamically calibrate to these forces via our intricate sensory system, specifically the joint and muscle receptors of the proprioceptive system. Reducing the downward force of gravity makes it easier for us to move in space. Increasing the ground force reaction gives us more information about where we are in space. DMI Therapy embeds these two concepts in this therapeutic approach. The DMI therapist leverages these two forces to increase the child’s sensorimotor awareness and alerts the sensory system receptors to facilitate a motor response. The DMI Therapist shifts these forces' balance thus increasing the GRF and transference of kinetic energy to postural muscles, while also decreasing the gravitational forces, allowing the child to achieve an upright posture with less effort, to momentarily experience the posture. The increase in upward force triggers a stronger postural reaction and alignment by increasing the input to the proprioceptive system. The practitioner finds a continuous interplay and balance between creating a functional postural response and normalizing movement patterns, alignment, and stability to create variable movement patterns and maximize cortical function. At times, the DMI therapist may reduce the amount of gravitational pull by giving extra support or upward pressure and other times they may add additional gravitational information. Aerial, and other maneuvers that may look strange to the untrained eye, are not all “circus tricks”, but rather, mindful and intentional maneuvers based in science to help children learn new gross motor skills.

 PRIMITIVE REFLEXES 

Primitive reflexes originate in the brain stem and are involuntary innate motor movements. They aid basic survival and assist a baby in learning movement. Primitive reflexes are the foundation upon which higher brain function is built. [27,28] Primitive motor reflexes are often large, mass movements. With increasing motor practice, primitive reflexes integrate, and more complex disassociated movements develop as controlled movement patterns emerge. DMI Therapy addresses primitive reflexes in a very unique way. By fostering the expression of primitive reflexes, the child learns a new movement. With graded and repeated practice, the child becomes less reliant on primitive reflexes to move and begins incorporating new movements into their motor repertoire with improved movement quality. In DMI therapy, we work on the dissociating pelvic girdle movement from head and neck movements to allow the child with a high level of motor dysfunction to actively achieve postural control and develop selective motor control while integrating the reflex. 

EMOTIONAL REGULATION 

Babies are born dependent with limited ability to regulate their emotions. Infants, toddlers and children face stressful events in their everyday lives, just as adults do. Parents and caregivers help teach children to develop emotional regulation to manage life’s challenges as they grow and become more independent. Infants and young children with brain lesions are easily overstimulated and have difficulty in dealing with environmental stimuli, exhibiting neurobehavioral disorganization including poor self-regulation. DMI Therapy can be challenging for young children; the therapist acts as that supportive adult to help the child modulate their emotions and become successful and confident in mastering new skills. Short periods of increased cortisol levels do not interfere in learning. In fact, cortisol is the hormone that wakes our body and brain up every day so that we can function and learn. Prolonged periods of increased cortisol can be concerning, but this does not occur with DMI Therapy. Also, children who are totally protected from stress were found to have increased anxiety and depression, poor life satisfaction, physical health and self-efficacy. [29]

Cortisol production helps to alert the system and can be also be used productively in therapy to switch on the brain and body for children who have significant low levels of arousal. Anecdotally, children who have received regular DMI therapy often show great emotional maturity and focus. Stress in childhood cannot be avoided. The encounters with stress (” Eustress” ) are learning experiences and help children learn resilience to cope with further challenges in life. [30] 

It is important to distinguish between the brief, expected increase in cortisol that may occur when a child becomes upset during therapy and the chronic elevation in cortisol associated with prolonged adverse life experiences. While a child may experience a short-lived stress response during a challenging therapeutic activity, that response resolves as the therapist and caregiver help the child self-regulate. This is fundamentally different from the persistent, toxic stress seen in children living in chronically unsafe or neglectful environments. In fact, therapeutic sessions provide opportunities for children to experience challenges in a safe, supportive setting while developing the foundations of emotional regulation and resilience. [31]

INTERVENTION DOSING

DMI is best applied as a strong or intensive intervention. This means there is strong sensory input and high demand for motor output, along with repetition of each exercise and frequent intervention sessions. [32] Anecdotally, these parameters contribute to significant changes occurring in the child in many areas of development over a short period of time. Therapy can be completed once or twice a week, or every day for a period of time, as part of a therapy intensive. Daily implementation of a home exercise program (HEP) is also included for optimal outcomes. [33]

 EQUIPMENT

No equipment other than a DMI table and the box set are required. Orthotics and walking aids are not used during the therapy session. Compression garments and other interventions like whole body vibration or muscle stimulation can be used in conjunction with DMI, to enhance sensory information and alignment, as long as they allow for freedom of full range movement.

INDICATIONS AND PRECAUTIONS 

Children diagnosed with motor delay, including conditions such as Down Syndrome, Cerebral Palsy, Global Developmental Delay, hypotonia, chromosomal abnormalities/genetic disorders, orthopedic conditions, motor delay, spinal cord lesions or acquired brain injury, may benefit from this form of therapeutic approach. DMI is contraindicated for children with severe brittle bone diseases such as Osteogenesis Imperfecta. Any child with spina bifida, SMA, extreme low tone or at risk for osteopenia/osteoporosis must be treated with extreme precaution when using DMI. This includes children who have received very limited therapy and are starting DMI or an intensive for the first time or have had a long break from therapy. DMI can still be used, however proximal support and very controlled maneuvers must be used. As with any therapeutic approach, therapists must be mindful of the bony stress associated with facilitating active movement.

DMI Is Distinct from CME

 Dynamic Movement Intervention (DMI) was originally developed as an evolution of the Cuevas Medek Exercises (CME) approach. While the two methodologies may appear similar at first glance, particularly in photographs or short social media clips, DMI reflects decades of clinical experience, refinement, and an ongoing commitment to improving outcomes for the children we serve.

As our understanding of neuroscience, biomechanics, motor learning, and neuroplasticity has advanced, DMI has continued to evolve. The changes have gone well beyond modifying individual exercises. They have shaped the way children are assessed, treated, taught, and, most importantly, how safety is incorporated throughout the entire methodology.

One of the strengths of DMI is the emphasis placed on consistency in education. The organization maintains a deliberately small faculty of twelve certified instructors, each with many years of clinical and teaching experience. This allows the curriculum to remain closely monitored and ensures that practitioners receive the same high standard of instruction regardless of where they are trained.

The educational pathway is intentionally progressive. Foundational handling skills, safety principles, and basic exercises are introduced first, with more advanced techniques added only as competence develops. The curriculum is divided into five progressive levels that require clinical practice between courses, recognizing that proficiency develops through experience, not simply course attendance.

Learning DMI extends far beyond memorizing exercises. Practitioners are expected to understand why each exercise is performed, the scientific principles supporting it, the movement problem it addresses, and the functional goal it is intended to achieve. Courses combine lectures, demonstrations, video analysis, instructor discussion, and extensive hands-on practice within a highly structured curriculum designed to accommodate different learning styles.

Assessment and treatment planning are equally structured. Therapists are taught standardized methods for evaluating movement quality, identifying limiting factors, prioritizing goals, and selecting interventions based on each child's individual presentation rather than following predetermined treatment routines.

Safety is reinforced throughout every level of training. Precautions, contraindications, appropriate handling, and biomechanical considerations are reviewed repeatedly as new exercises are introduced. Mentorship between courses provides additional guidance as therapists begin applying DMI in clinical practice, and reports of unsafe practice are addressed by the organization to help maintain high standards for both children and practitioners.

Beyond the educational framework, DMI differs from its predecessor in several important clinical ways. It embraces contemporary principles of neuroscience, motor learning, and neuroplasticity while emphasizing optimal alignment and postural control before challenging movement. Treatment is centered on task-specific, active movement that promotes meaningful functional change. Non-functional "magic tricks" have been eliminated in favor of exercises with clear therapeutic purpose. DMI also recognizes the influence of retained primitive reflexes on motor development and incorporates strategies that facilitate their functional integration while progressing children toward selective motor control. Finally, because DMI is a hands-on neurorehabilitation approach, therapist ergonomics and healthy body mechanics are taught throughout the curriculum to promote safe and sustainable clinical practice.

Therapists are encouraged to be holistic practitioners and use and combine other tools to address each child's unique impairments and ensure that musculoskeletal alignment is enhanced and maintained throughout each movement. DMI works closely with other experts to continue to enhance outcomes for this population group.

Collectively, these refinements represent the continued evolution of DMI into a comprehensive pediatric neurorehabilitation methodology. The emphasis on scientific rationale, structured education, standardized assessment, mentorship, and ongoing quality assurance reflects a commitment to continually improving clinical practice while maintaining the highest standards of safety and patient care.

CONCLUSION 

Parents and therapists worldwide who have embraced DMI and implemented this therapeutic approach in the field are reporting quicker and stronger treatment effects. First introduced in 2021, research into this technique is emerging.

As with standard clinical practice, DMI practitioners use standardized neurodevelopmental assessment tools such as the Gross Motor Function Measure (GMFM), [34,35] The Early Clinical Assessment of Balance (ECAB) [36] and the Segmental Assessment of Trunk Control (SATCo) [37-39] among other standardized assessment tools to assess treatment outcomes. Anecdotally, reports from practitioners and parents have demonstrated meaningful and frequently more rapid improvements in gross motor function than previously expected.

Facilitation in DMI exercises differs from other therapeutic approaches. Rather than passively guiding the child through movement, the therapist introduces movement cues that provide clear, specific information about the direction of activation, then waits for the child to produce an active response. This allows the child to experience purposeful, guided movement grounded in neurodevelopmental principles described. DMI therapy focuses on vestibulo-sensorimotor development in children. Due to its rigorous demands on the child’s sensory and motor systems, it may allow children with sensorimotor delays the potential to generate neuroplastic change.

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, a phenomenon which cannot be disregarded or understated.

Dynamic Movement Intervention (DMI) represents a contemporary, neuroscience‑aligned therapeutic framework that integrates principles of neuroplasticity, sensorimotor learning, and postural control to support children with neurodevelopmental disabilities. Throughout this commentary, DMI is positioned as an approach that not only facilitates movement but also actively provokes adaptive motor responses through targeted sensory input, gravitational manipulation, and task‑specific practice.

By drawing on established theories—including Neuronal Group Selection Theory, dynamic systems theory, and motor learning research—DMI offers a structured way to harness early neuroplastic potential, particularly in infants and young children for whom timely intervention is critical. Its emphasis on active participation, graded challenge, and repeated exposure to meaningful sensory experiences aligns with evidence‑based rehabilitation principles and supports the emergence of more refined, efficient, and independent motor behaviours.

Overall, DMI emerges as a promising, evolving therapeutic modality that bridges neuroscience, motor learning, and pediatric rehabilitation. While formal research is still developing, early clinical reports suggest meaningful functional gains. As the field advances, continued empirical investigation will be essential to further validate DMI’s mechanisms, optimize its application, and clarify its role within multidisciplinary neurorehabilitation for children with motor delay.

Jake Kreindler and Jo-Anne Weltman, the authors of this article, are the co-founders of DMI Therapy.

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