Cuevas MEDEK Exercises (C.M.E.) is a powerful pediatric physical therapy approach for treating infants and children with gross motor delays resulting from neurological delays or damage. This can include a wide range of diagnoses including, but not limited to, cerebral palsy, Down Syndrome, global developmental delays, metabolic and genetic abnormalities, spinal cord lesions, and prenatal, perinatal, and postnatal acquired brain lesions. It is unique in its methodology and theory. There are practitioners around the world who have been trained by CME creator, Ramon Cuevas.
C.M.E. was created by Ramon Cuevas in the early 1970’s. After graduating as a physical therapist, he worked in a facility called AVEPANE
(Venezuelan Association of Parents and Friends of Exceptional Children). This facility focused on kids diagnosed with Cerebral Palsy or Down Syndrome, between the ages of 8-13 years old.
At the time, pediatric physical therapy treatment for children with cerebral palsy required 2 important prerequisites:
- The child should be older than 2 years old.
- The child must be able to cooperate with the rehabilitation process.
At the time most pediatric physical therapy treatment was based on 3 principles or modalities.
- Passive Range Of Motion (PROM) and exercises mostly in supine to maintain or improve joint integrity and mobility.
- Reflex inhibition and facilitation exercises for spastic diplegia.
- Patterning following the Glenn Doman approach. This included crawling simulation with up to 5 people assisting the child, and exposing the child to strong visual, auditory, and tactile input.
After practicing for two years, Ramon noticed a few things:
⠂He wasn’t producing noticeable motor improvements with his treatment.
⠂He was repeating skills the kids could already do.
⠂He realized that waiting for a child to be cooperative and motivated were unrealistic for the Early Intervention and pediatric populations.
So, in 1972, as buzz about the benefits of “early stimulation” began to gain traction, babies under a year old began coming to AVEPANE, some as young as 3-4 months old. The children had a variety of diagnoses.
It was then that Ramon began to explore his own method and theories that could affect more significant changes.
He realized that waiting for changes to happen was pointless- he would need to find a way to provoke change.
Through specific dynamic exercises he would create a method that would use distal support to provoke stronger antigravity reactions.
Based on this approach, Ramon’s theory began to take shape and he began to create exercises to help the new influx of children at the facility.
The results began to speak for themselves. His work attracted attention and the practice grew to a new center and a larger group of professionals.
He continued to create more and more exercises and began to teach others.
He named his method MEDEK (a Spanish acronym for the Dynamic Method of Kinetic Stimulation) and later included his name to finalize the name to Cuevas MEDEK Exercises.
CME practice is based on characteristics that shape how the method is implemented:
CME provokes the appearance of absent motor function.
While this statement seems simple, it is really quite profound.
CME believes everything we do has an effect on the brain. We seek to create new connections, improve neurological maturity, and help kids reach their milestones.
We do this by constantly working on the next set of skills the child should be doing. However, when possible we also try to work on the most advanced milestone a child SHOULD be up to chronologically, even if there are milestones missing in between.
So we work on higher order skills to make the emergence of lower order skills easier.
Think of development as a totem pole. The most advanced skills like dynamic balance while walking are at the top. By stimulating the child at the highest levels possible, skills lower on the totem pole emerge easier.
Let’s look at an example. Many times in my career I have been assigned to a typically developing child who, demonstrating delays, is referred to the Early Intervention program. The baby is in the 13-15 month range and is not yet crawling. While I address crawling, it is not my primary focus. Instead, I make standing and walking the primary focus. More often than not, the child will begin crawling within a couple of weeks.
How does this work? It is because we are improving the brain’s maturity by provoking absent motor responses. While results may vary, working in this way can yield stronger and more positive gross motor progress.
CME exposes the child to gravity forces with gradual progression to distal support.
How do we get our kids to be independent? We try to prepare them for what they will experience in life!
When it comes to movement, to make them independent, we need to expose them to gravity’s forces. The key to postural activation is to overcome gravity’s forces. Once the brain achieves this level of independence, it can be replicated in every position and situation.
In short, exposure to gravity is the main ingredient to trigger a neuromuscular response and help children succeed.
CME provokes automatic motor responses.
In CME, we don’t use toys or frequent verbal cues. The reason is because gross motor movement is meant to be automatic. We don’t think about walking, climbing the stairs, or any other function we do. Once our brains have made those connections, we are able to reproduce those outcomes without any voluntary input on our part. When working with children, we provide a physical cue, one that exposes the child to gravity and provokes a gross motor response, and let the child’s brain sort out how to get it done. When we add in all kinds of external cues such as reaching for toys, verbal
cues, and other distractions, we are adding unnecessary factors to a seamless learning process that get in the way of their efficacy. Simple verbal cues to guide the child’s direction like “up” and “down” are sufficient.
In CME, the child’s cooperation is not necessary.
While in a perfect world we would love if children didn’t cry during physical therapy sessions, we need to stay focused on why it happens.
Firstly, it’s really hard work! If you go to the gym and work with a personal trainer, you know the feeling of being pushed to your limits.
Second, CME is never painful. New experiences are sometimes scary. This should not deter parents from giving their child the best chance at making physical gains.
Third, many children with underlying sensory issues take longer to stop crying.
Lastly, from a neurological perspective, children with gross motor delays and neurological damage have a unique challenge. Their brains, following damage, have lots of “static”. This manifests itself as brain disorganization, immaturity, and difficulty with emotional regulation. Thus, many such children cry excessively in the beginning of their journey with CME. As their brains mature and new neuronal connections are made, they begin to regulate better and cry less.
Stretches are incorporated into functional movements.
We don’t do static stretches in CME. Rather, we incorporate the stretches into functional movements. This allows for not only better stretches, but for longer lasting changes.
A few examples:
Walking up a ramp to stretch tight gastroc/soleus muscles.
Supported ring sitting for tight adductors.
Provoking neck extension in prone and isolating head control against gravity for treatment of torticollis.
CME uses a trial period to determine if the child is a candidate for this approach.
At the time of the evaluation, the practitioner identifies the child’s gross motor weaknesses and deficits. Working with the parents, we make short term goals for the next 8 weeks. These will be addressed both in direct treatment sessions and for the home exercise program. If the child reaches or comes close to reaching a short term goal that was set during the initial evaluation, the child is determined to be a good candidate. If not, the parent is suggested to seek another approach.
In my career, I have never found a child with gross motor delays from neurological damage who was not a candidate for the CME approach!
When performing CME, no assistive devices are used.
This includes walkers, canes, crutches, and all orthotics. The reason for this requires an understanding of how balance works on a moment to moment basis.
In each joint there are receptors called proprioceptors. They send information to the brain, specifically the cerebellum, about where the body part is in space. These receptors work best with movement. When we move, the proprioceptors send moment to moment information that the brain uses to make adjustments to our posture. Thus, these proprioceptors are a major factor in functional balance!
When a child is in an orthotic, it provides alignment, but since it significantly limits movement of the joint, it essentially shuts down the proprioceptors and thus breaks the feedback loop the brain needs to balance!
This rule must sometimes be broken in cases of significant orthopedic malformations and misalignments, but we try to adhere to it in most cases.
This is sometimes a huge surprise to parents. When starting with CME with children of ambulatory age, I will ask parents to bring shoes that fit the child’s feet, without the orthotics. What surprises parents even more is when their kid stands or takes their first steps without the orthotics!
This is a true testament to the power of the brain and how CME taps into it!
In summary, CME is a powerful approach that can help your child reach their milestones. It works by tapping into the brain’s potential. It makes your child do more of the work to achieve movement. This makes the brain make new neuronal connections, provoking maturity and brain organization. Every child can make improvements.
You believe in your child and so do I!!
Check out the gallery for more CME exercises or on my Instagram page @getyourbabymoving.