Absence of evidence is not evidence of absence

I am responding to Melissa Trudinger’s recent InMotion article ‘No evidence for CME effectiveness alarms physios’ (Trudinger 2026), which critiques Dynamic Movement Intervention (DMI) therapy and the Cuevas Medek Exercises (CME). 

This article, along with an article in Pediatric Physical Therapy’s Special Communications (Paleg et al 2026) and a subsequent Letter to the Editor (Kreindler & Weltman 2026) in the same journal by the DMI co-founders addressing scientific misrepresentation, has initiated an important discussion within our profession.

This conversation is vital for physiotherapists using DMI and highlights the need for fairer representation of paediatric physiotherapy in Australia – showcasing the profession’s innovation, clinical reasoning, ethics and evidence-based care for a vulnerable population. 

A call for balanced representation 

Australian paediatric physiotherapists who specialise in neurodisability are highly skilled clinicians who integrate the best available evidence, their clinical expertise and their clients’ families’ values and context to guide decision-making. 

This evidence-based practice triad guides decision-making even when research evidence is limited or absent. 

Evidence-based practice is not a hierarchy that dismisses clinical reasoning; it is a framework that requires it. 

Importantly, as Reverend William Wright (Wright et al 1886) famously noted, ‘absence of evidence is not evidence of absence’ – a principle highly relevant to emerging paediatric interventions, where research is still developing. This signals the need for rigorous research – not the assumption of ineffectiveness or harm. 

This nuance is essential when discussing any emerging intervention, including DMI. 

Scientific accuracy matters 

The Pediatric Physical Therapy Letter to the Editor (Kreindler & Weltman 2026) published in April this year raised several important points that apply equally to the InMotion Trudinger article: scientific commentary regarding emerging and innovative therapeutic techniques must be accurate, fair and grounded in verifiable data. 

It is imperative that authors and researchers unfamiliar with the therapeutic method in focus use their considerable research skills to examine the available research evidence, or lack thereof, and that critiques of therapeutic approaches be grounded in subject-matter expertise and supported by a comprehensive understanding of the methodology in question, derived from direct communication with experts in the innovative method (Kreindler & Weltman 2026). 

These principles should guide discussions of emerging paediatric interventions carefully and fairly. Relying on superficial internet research risks misrepresenting the intervention. 

Misrepresentation harms families and clinicians. 

Transparency without alarmism 

Founded in 2021, DMI is a comprehensive therapeutic method in physical and occupational therapy focused on infants and children with neuromotor delays. 

The therapist’s primary aim is to promote purposeful, active, task-specific, goal-oriented motor responses by selecting dynamic exercises that leverage gravitational forces to challenge and stimulate the child’s active motor behaviour, informed by a thorough gross motor and postural assessment. 

It is in no way a passive therapeutic approach as was implied in the Trudinger article. 

DMI employs experience-dependent plasticity, emphasising key concepts such as specificity, repetition, intensity, the importance of timing and interference (Kleim & Jones 2008). 

DMI is a proprietary method delivered by physiotherapists – not physiotherapy itself. 

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 sensorimotor, vestibular and somatosensory systems. 

Therefore, DMI therapy aligns with the International Classification of Functioning, Disability and Health framework (World Health Organization 2007), highlighting the fact 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 (Ryan et al 2025). 

A recent systematic review on facilitation techniques in paediatric neuromotor rehabilitation underlines strong support for hands-on methods that encourage active movement. 

Marsico et al (2021) define facilitation as ‘guiding, accompanying, and reducing manual sensory-motor input during a meaningful task chosen by the child’, including ‘manual or bodily support of positioning in alignment to enable activity and participation’. 

Their review showed ‘strong evidence for’ [improvements in] ‘body function and activity outcomes’ when facilitation was applied to children from birth to age two, including gains in motor development, strength, postural control and gross motor skills. These findings are based on 11 studies with 695 children with cerebral palsy. 

Notably, studies involving passive handling were excluded, emphasising that effective facilitation should prompt active, child-generated motor responses consistent with motor learning principles. 

Similarly, established principles of paediatric neurorehabilitation – including strength training; motor learning; goal-oriented, task-specific practice; neuroplasticity; and postural control – consistently emphasise active, child-generated movement. Strength training research demonstrates that active muscle recruitment and graded challenge improve strength and function without increasing spasticity (Damiano & Abel 1998). 

The motor learning and neuroplasticity literature highlights the importance of specificity, repetition, intensity and active problem‑solving (Kleim & Jones 2008, Hadders-Algra 2018). Task‑specific practice is one of the strongest evidence‑based interventions for children with cerebral palsy (Law et al 2011, Novak et al 2020). 

Postural control improves through active, dynamic balance challenges supported by graded facilitation (Sah et al 2019). These principles align with hands‑on facilitation when it is used to enable – not replace – active motor responses. 

These are the key principles of DMI. DMI co-founders are committed to investing in research on the clinical effects and impact of DMI, recognising that clinicians must contribute to research. 

While foundational research on DMI is emerging, this places DMI at Sackett level 5 – theoretical and experiential only. But this does not mean DMI is ineffective. 

It means we do not yet know and we must communicate that honestly. Balanced reporting acknowledges both the evidence gap and the clinical reasoning guiding physiotherapists who choose to integrate DMI principles into broader, evidence-based clinical frameworks. 

Responsible use, responsible science 

DMI should be subject to objective evaluation. 

These procedures enhance professional accountability and guarantee that families get clear, accurate and balanced information. 

When research evidence is scarce, physiotherapists depend on the other two pillars of evidence-based practice: clinical expertise and patient values. 

Clinical expertise includes pattern recognition, developmental understanding, motor learning principles, risk–benefit analysis and experience with similar patients. 

This approach is structured and justifiable, not guesswork. 

Likewise, physiotherapists honour child and family values, considering families’ goals, preferences and cultural backgrounds. 

Shared decision-making makes choices transparent, collaborative and ethically sound. 

As with all physical therapy techniques, children with limited mobility may face risks like osteopaenia or injury due to decreased skeletal loading (Uddenfeldt Wort et al 2013). 

As such, risk mitigation is integrated into DMI protocols, with safety precautions clearly outlined in each training course. 

As a paediatric physiotherapist and PhD candidate with 33 years of clinical experience and having completed the full complement of DMI professional training over four years, I incorporate DMI principles within my broader evidence-based framework in my clinical practice every day. 

I encourage researchers and clinicians to actively engage with the DMI community. 

Critiques that are dismissive and lack experiential insight could hinder therapeutic progress and slow down access to helpful interventions for vulnerable groups. 

The DMI community is committed to open dialogue and invites researchers to join DMI training and collaborative research efforts.

Triston Hunter APAM owns Step Ahead Physiotherapy, a paediatric practice specialising in neurodisability. Triston and colleagues also developed the Skillz Lab, a multidisciplinary centre helping children with disabilities.

 

 

 

 

 

 

 

 

 

I am replying to the letter to the editor from Triston Hunter, which was in response to an article published by Melissa Trudinger, ‘No evidence for CME effectiveness alarms physios’ (Trudinger 2026). 

In her letter to the editor, Hunter calls for a balanced representation of paediatric physiotherapy and shares the underlying rationale and theory behind Dynamic Movement Intervention (DMI). 

She seeks to be transparent about the history of DMI (‘a proprietary method’) and wishes to reduce alarmism, which she believes the original article by Trudinger creates. 

In her letter, Hunter provides a number of statements about DMI being focused on neurodevelopmental aspects of care and being aligned with the International Classification of Functioning, Disability and Health framework (World Health Organization 2007). 

While she indicates that the DMI cofounders are committed to investing in research on the clinical effectiveness of DMI, she is, at this time, still unable to share any evidence of effectiveness. 

Hunter goes on to say, ‘When research evidence is scarce, physiotherapists depend on the other two pillars of evidence-based practice: clinical expertise and patient values. 

Clinical expertise includes pattern recognition, developmental understanding, motor learning principles, risk–benefit analysis and experience with similar patients.’ 

This I agree with. However, this situation should be for a relatively brief period only. 

Focused, high-quality research to fill the gap should be undertaken before selling the method across the world and risking financial and precious time loss for children and families who believe DMI is an evidence-based approach to therapy. 

At this point in time, it is not. Practice methods without empirical research evidence to support their effectiveness are like a three-legged stool, with one broken leg. 

Without the third leg, it will eventually fall over. 

So the evidence-based practitioners around the world are waiting keenly for evidence exploring the effectiveness of DMI to emerge. 

Until then, we should, as Trudinger stated in her article about Cuevas Medek Exercises (CME), uphold our obligations regarding informed legal consent and disclose to parents and caregivers, in shared decision-making conversations, that there is no published high-quality evidence to suggest that DMI is effective and that there is a risk of harm from DMI – eg, fractured femur, hip dislocation and potentially time toxicity (Frumberg et al 2026) – noting that we cannot at this time quantify that risk.

 We also have an obligation to be informed about other, evidencebased options and to honestly present them to families during shared decision-making conversations, before families settle on a therapy plan. 

Additionally, we should ensure that we do not leverage parental hope or desperation in this decision-making process. Hunter’s letter indicates that the original article by Trudinger assumes that DMI is ineffective, as the article states that DMI is an evolution of CME. 

This is a claim that was never made. Rather, the article states the overall findings of the scoping review by our research team (currently under review), that there is ‘no high-quality evidence supporting therapeutic claims that CME can improve motor development, gait, mobility, posture and control, balance, communication or swallowing’. 

Hunter, in her letter, says, ‘Relying on superficial internet research risks misrepresenting the [DMI] intervention. Misrepresentation harms families and clinicians.’ 

This comment demonstrates naivety regarding the transparent steps and time required to undertake such a review and critical appraisal of the literature. 

Our research team has undertaken a very detailed systematic scoping review, utilising several healthrelated databases, exploring the empirical research and grey literature following PRISMA Scoping Review methodology (Tricco et al 2018), with additional steps to critically appraise available scientific literature.

A systematic review and meta-analysis were not possible, due to the paucity of available research on this topic and its inherently low methodological quality. 

Our deliberate inclusion of grey literature allowed us to capture definitions and claims of CME as well as adverse events and family and therapist perspectives that empirical research literature did not capture. 

Our research team also started a review of the literature for DMI. However, we paused that review as there was no empirical literature to review at the time. 

Consequently, it is our research team’s position that we have not misrepresented anything, nor has Trudinger in her article about our review. 

Instead, we have represented the findings from all available empirical research as well as all accessible grey literature on the topic of CME to give a balanced synthesis of these findings to clinicians and families via a research manuscript (currently under review). 

The synthesis is intended to be used by therapists and families during shared decision-making conversations. In her letter to the editor, Hunter argues that DMI elicits active, child-generated motor responses and is therefore aligned with motor learning principles. 

However, the CME website (cuevasmedek.com) states that the founding premise of the method was to provoke postural reactions ‘regardless of the level of awareness of the child’, with Ramón Cuevas explicitly concluding that requiring cooperation and motivation from the child was an ‘unfair and illusory’ requirement for the method. 

We believe these to be reflexive responses to therapist-imposed gravitational challenges, not volitionally initiated, goal-directed movement. Additionally, the DMI website (dmitherapy.com) describes ‘defined dynamic exercises prescribed by the therapist’. This is a set of pre-prescribed exercises, which is a very different clinical proposition from the individualised, child-led, goal-directed facilitation that Hunter describes in her letter. 

DMI is a proprietary set of exercises (with a set start and finish) at each level of training. The Hunter letter cites Marsico et al (2021) to support DMI’s alignment with facilitation evidence. Marsico et al (2021) explicitly excluded passive handling and defined facilitation as guiding tasks chosen by the child. 

It is difficult to reconcile the findings of this review with a method that explicitly removes the requirement for child awareness, cooperation and motivation or with a method that is described as a set of pre-prescribed exercises. 

We are pleased to read Hunter’s statement that DMI protocols encompass risk mitigation including safety precautions in their manual and that these are referenced in their course. 

Unfortunately, though, there continue to be real-world adverse events reported in the clinical community that directly support the safety concerns raised. 

Since Trudinger’s InMotion article was published, an NHS physiotherapist posted in the iCSP paediatric network social media site reporting two children in the past six months who experienced serious adverse events following DMI treatment blocks: a femoral fracture in a six-year-old and a hip dislocation in a two-and-a-halfyear- old. 

Both children were reported to have severe hypotonia and full postural support needs. The therapist reported that neither condition was present before the intervention. 

The DMI founders responded online to this post, stating that ‘DMI therapy itself cannot cause hip displacement’. 

However, their own training materials include a documented precaution stating that hip subluxation should be considered when placing torque on the hip in children who cannot actively control more than 50 per cent of movement during facilitation below the knee or at the ankle. 

This is a specific, identified contraindication within their own training program/manual, yet the DMI method is promoted for children with hypotonia on their website. 

Concerningly, these risks are not publicly available as families cannot access training manuals or professional social media sites to make their own informed decisions. 

They rely on what is publicly disclosed and what therapists share with them. 

The gap between the DMI founders’ public denial of hip risk and their internal training precautions and promotion of the DMI method for hypotonia on their website is representative of the informed consent problem the InMotion article was raising. 

To state, as Hunter has, that ‘critiques that are dismissive and lack experiential insight could hinder therapeutic progress and slow down access to helpful interventions for vulnerable groups’ is suggesting that DMI is helpful, yet there is no empirical evidence to support this claim and parents and caregivers, as well as funders, deserve to know this. 

Until there is evidence of effectiveness for the DMI method, our research team would urge clinicians to focus their time and money on professional development that has established evidence to support its clinical efficacy for improving outcomes for children. 

If therapists wish to continue utilising DMI practices, they could engage with researchers to work collaboratively to address this evidence gap. 

Dr Nikki Milne FACP is a Specialist Research Physiotherapist (as awarded by the Australian College of Physiotherapists in 2025) and an associate professor of physiotherapy (paediatrics) in the Faculty of Health Sciences and Medicine at Bond University.

 

 

 

 

 

 

 

 

 

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