CUEVAS MEDEK EXERCISE
Cuevas MEDEK Exercise (CME) / MEDEK is a form of physiotherapy treatment used to treat children with Motor Delay. Children whose birth history may place them at risk for Motor Delay (e.g. premature birth) or children diagnosed with Down Syndrome, Cerebral palsy, global developmental delay, hypotonia, chromosomal abnormalities, spinal cord lesions or acquired brain injury may benefit from this form of therapy.
CME was created by Ramon Cuevas in Caracas, Venezuela between 1971 and 1973. MEDEK comes from the Spanish acronym that means dynamic method for motor stimulation.
The basic CME assumption is that in a gravitational environment, we require postural control and the ability to pull up against gravity, to stabilize our body in space. Gravity is considered the main stimulus that triggers the neuromuscular system to react. CME relies strongly on the vestibular and proprioceptor systems. Children who receive CME therapy are known to have strong postures and core strength.
CME provokes automatic motor movements – no verbal instruction or physical guidance is required – only physical provocation.Although movement is learned, we are not conscience of all the detailed, coordinated movements we make all day. Our brains automatically react to our environment. We live in a world with gravity and our brain is designed with many automatic responses to gravity, as well as adjustments in tone.
In CME therapy we place the child in a position where gravity is requiring a response, and then we wait for them to complete it, with gradually less assistance over time. In this way the brain practices these normal automatic responses and develops the appropriate synapses to make the response a consistent reaction.
The child’s co-operation or motivation are not required during CME treatment. In everyday life we experience a range of emotions. These emotions do not affect our ability to walk and talk. Many children who start any therapy that is challenging may cry initially during the first several sessions, because they are unsure and afraid of something new. It is also very hard physically. As soon as they are physically stronger the crying soon stops and the children end up feeling confident and proud and love coming to therapy. If you have ever gone to a very good personal trainer – you may have experienced this. Some children who have sensory issues may take longer to settle.
The child is exposed to increasing gravitational forces with graduation achieved by moving support from proximal to distal. Hands are not held in standing and walking as this decreases the gravitational force.CME therapy sequentially starts with head control, then trunk control, then standing and walking. In the same developmental sequence as our brain is programmed to complete. As we work further down the body we hold the child so that everything above our hands has to be exposed to and work against gravity. When working on standing and walking, we do not hold the child’s hands nor do we allow them to hold onto anything. We expect that the head and trunk should at this point make the correct and automatic responses to gravity.
MEDEK works on the essential factors required for:
- Extensor tone/strength
- Postural control and balance
- Joint dissociation
- Coordination and motor planning
- Muscle tone
- Muscle strength
Stretching of muscles are achieved through active functional movement. Muscles stretched this way remain stretched out for longer periods and allow for strengthening of opposing muscles which results in permanent changes.A good example of a functional stretch during CME therapy is gastocnemius/soleus stretching and dorsiflexion strengthening. One of the exercises to achieve this is using a ramp. A ramp of varying heights, according to ability and stretch required, is set up using the boxes and the child is assisted, by being held at the thighs/knees or ankles, to walk up the hill. The child’s full weight is through the legs, gravity and the therapist assist in getting the heels to make contact with the surface. It is very difficult for the child to walk on their toes to go up a steep incline in this way. In a more traditional therapy setting because the child may be holding onto a therapists hands they can pull up onto their toes to walk, but not during CME therapy. For the child to move up the incline he/she has to transfer their weight forwards so as not to fall backwards towards the pull of gravity, to do so they need to use their abdominals and dorsiflexor muscles.
CME does not focus directly on modifying tone, primitive reflexes or abnormal patterns of movement. These improve as a by-product of the therapy. Certain exercise positions require the child to achieve active movement out of the abnormal pattern.Abnormal hyper-extension and functional extension are two very separate entities. CME therapy works on functional extension and corrects the abnormal hyper-extension. The STNR (Symmetrical Tonic Neck Reflex) contributes to the hyperextension seen in children with cerebral palsy. Hyperextension means that you extend further back than an upright straight standing posture – you arch your lower back and lean back with your head in extension. Normal functional extension is when you straighten up from leaning over at your hips until you are standing in an upright straight posture. Functional extension is essential for sitting, standing and walking. Most traditional therapies avoid extension activities for a child who uses abnormal hyper-extension to stabilize them self, in fear of making this pattern worse. CME therapy work on normal extension and then balances it with some flexion in functional positions, so that the child can have correct stability and the feeling of correct alignment. CME places the child in various scenarios where they have to find alignment to stay upright against gravity. This correct alignment is a position in which abnormal patterns do not occur. The child’s head is in midline and arms are equally aligned. This position is reinforced with repetition allowing the brain to recognize it and form synapses to make this the automatic position of stability. The correct balance and use of flexor and extension muscles and functional stretches to tight muscles help to modify tone.
Therapy results in changes in speech, eating, and cognitive alertness. Strong core muscles and sensory information contribute to these changes.CME therapy is intensive exercise. A child can work for an hour straight on strong exercises. This develops endurance, strength and attention. Children become more alert and aware. Movement and speech are located side by side in the brain; studies have shown that movement affects speech, especially strong movement like CME that stimulates those areas of the brain. Children use many muscles during the therapy, they develop their core and through some of the harder exercises they may contract neck and facial muscles in effort to complete the task. All of this has a direct effect on the ability to chew food.
No equipment other than the box set, tubes and table are required. i.e. AFO’s, Walkers etc are not used during the therapy session.The aim of CME is for the child to move independently against gravity. For correct and independent reactions to occur at each joint and with each muscle in the body. If a child is wearing AFO’s during therapy they are not able to get a full stretch on a muscle and are not able to strength all the muscles around a joint. Walkers are not used as the child must be hands free to develop full body balance reactions against gravity. CME therapists accept the use of AFO’s and walkers etc. out of the therapy setting and may use them during the therapy session as an adjunct if needed.
Home exercise program is essential for best results. As in all therapies, the more you practice the faster you will improve and the better you will get. In MEDEK therapy we are trying to recreate new pathways in the brain and to do this we need to strengthen these pathways and shut down other pathways by practicing movement in one way and spending less time moving in the other way. It is impossible to do this by seeing your therapists just once or twice a week and then spending the rest of the week using the old pathways. Therefore daily homework is essential, twice daily to get the best results.