© 2008, Dr. S. Masgutova MASGUTOVA METHOD OF REFLEX INTEGRATION FOR CHILDREN WITH CEREBRAL PALSY Svetlana Masgutova, Ph. D (Russia-Poland) Edited: Susan Wenberg, M.A., D.C. (USA) “All acts of conscious and unconscious life are reflexes by their origin.” I.M. Setchenov. Cerebral Palsy and Primary Motor System Development The “Child Cerebral Palsy” (Z. Freud) – the group of diseases concerned with motor disorders as the result of brain damage or dysfunction of certain brain centers – is usually acquired during the first years of life, at the time when the system of primary movement patterns is developing. Primary movements are genetically programmed for protection and survival, and also for the development of the conscious movement system. Their role is to support: -maturation of the nervous system (synaptogenesis, myelination, and brain plasticity) -brain function (cognitive development, emotional maturation) -sensory-motor integration. Dysfunctions of motor development and sensory-motor integration in the child with CP are a reflection of the type of neurological insult and the developmental stage of the infant/child when the neurological insult occurred. The developmental stages can be divided into prenatal (in utero); natal (during the birth process); or postnatal (after birth but during the first years of life). Each developmental stage is vulnerable to specific neurological insults. Prenatal palsy can be caused by infection, intoxication of the fetus, or compromised health of the pregnant mother. Some primary motor patterns and reflexes develop in utero, such as Trunk Extension, Automatic Gait, Swallowing and Sucking, and Hands Grasp. Prenatal brain damage will cause poor expression of these reflexes and adversely impact the next stage of development. Natal palsy is generally caused by neurological insult during birth: a consequence of premature birth, sudden deliveries, narrow pelvis of the mother, use of forceps during birth, etc. Natal trauma can negatively affect the activation of primary motor patterns and reflexes characteristic of a normal successful birth. In such cases the expression of these genetic programs will be abnormal. The primary movements and reflexes of childbirth, such as Head Righting, Spinal Pereze, Tonic Labyrinthine in Extension, Crawling motor pattern, Sequential side turning and spinning, and sucking may be dysfunctional. Postnatal palsy is often caused by an infection with encephalitic symptoms. Other causes include a childhood cranial injury, a central nervous system injury, and poor systemic health. Infant motor patterns and reflexes will be stressed by postnatal CP, and may develop dysfunctionally or pathologically. Dynamic reflexes (e.g., Grasp, Hands Pulling, Automatic Gait, © 2008, Dr. S. Masgutova 1 © 2008, Dr. S. Masgutova Sequential Side Rotation, Spinning); positional reflexes (e.g., Asymmetrical Tonic Neck, Symmetrical Tonic Neck, Babkin Palm-Mouth, Labyrinthine Tonic in Flexion and Extension); and postural reflexes (e.g., Trunk Extension, Spinal Pereze and Galant) reflexes are most commonly affected. Central nervous system damage causes dysfunction or pathology in these reflex based motor programs and leads to poor motor function, poor physical development, sensory processing disorder, and learning disabilities Motor development is a primary expression of coordinated neurological function in infant and early child development. It will influence future development of all other spheres – physical, emotional, cognitive – and the formation of personality. Motor function can be measured and quantified. Impaired motor function contributes to disorders in development of the child with CP in the spheres of perception, memory, speech and self-organization. Impaired motor function may be due to: -poor sensory perception of stimuli (tactile, visual, auditory, olfactory, vestibular) -inadequate brain processing of the sensory input (dysfunctional or pathological processing of adequate stimuli, such as invalid decoding, poor recognition of stimuli) -inadequate motor response due to abnormal muscle tone that prohibits an appropriate response, or to a musculoskeletal problem such as an orthopedic injury or abnormality. Motor development of the child with CP is impaired on two levels: -at the level of the genetically encoded primary motor patterns -and at the level of consciously learned and controlled movements In our work we focus on the techniques that support primary motor patterns. We define primary motor patterns as genetically programmed reactions that range in complexity from simple reflex responses occurring at the spinal cord level, to more complex “survival based” response patterns involving brain stem activity, to sensory-motor coordination systems (‘handseyes’, ‘hearing-seeing’, etc.), and finally, to application of these fixed patterns to more complex activities (visual tracking of a moving object, articulation for pronouncing sounds, etc). Primary motor patterns serve as the basis for future development, as they are natural resources which support the development of synaptogenesis, myelination, and optimal brain function. Each step of development is based on kinesthetic memory – genetic and individual. Studies show kinesthetic memory is damaged in 40-60% child with CP (N.N. Danilova, A.L. Krilova, 1997). Kinesthetic memory allows us to internalize all types of movements. Poor kinesthetic memory limits the motor and cognitive development of the child with CP; thus, even the simplest motor skills are very difficult for explore and anchor into memory. Our concept of neuro-sensory-motor reflex integration is based on the idea of awakening the latent brainstem genetic motor memory, so that is may serve as a resource for neurodevelopment. Human development, whether normal or abnormal, is continuous. Stages of maturation and the emergence of reflex patterns should not be thought of as static points in development, but as a glimpse of one moment in a dynamic process. We define specific reflexes and specific stages of development because there is diagnostic and therapeutic utility in doing so. In our work we identify traditional, well-known reflexes, such as the Moro and the Babinsky. We also © 2008, Dr. S. Masgutova 2 © 2008, Dr. S. Masgutova choose to identify and name additional reflex patterns which may be unfamiliar to the reader. We encourage the reader to explore the possible merits of these unfamiliar reflex patterns with an open mind, and to think of them in terms of potential applications in the clinical setting. Characteristics of the Early Motor Development of a Healthy Child To understand the uniqueness of the early motor development of a child with CP, it is necessary to compare it to that of a healthy child, with respect to reflex pattern formation. This comparative analysis offers a profound understanding of the dysfunctional features of motor development in the child with CP, and allows us to design a correction using developmental techniques that influence sensory-motor links of the reflex circuit. During the first year of life a healthy child sequentially develops the reflexes and primary movements that include the Antigravity Reaction and Supporting motor patterns (Gravity, Grounding and Stability Reflexes), Automatic Gait Reflex, Crawling, Spinal Galant and Pereze Reflexes, Grasp, Oral Automatisms, etc. During the first 1.5 -2 months of life, a number of reflexes develop in sequence, including the Tonic Reflexes -Labyrinthine Tonic, Symmetrical and Asymmetrical Tonic Neck, Head Righting and Trunk Extension, and Pelvic-Trunk movement patterns. The individual reflexes are difficult to detect as they normally mature into other reflex patterns, and are naturally integrated into the movement system by three months of life. The Righting reflexes, which mature next, influence the dynamics of body righting and lengthening. These reflexes are complex – they are the result of spontaneous activity of the brainstem, vestibular-cerebellar centers, motor cortex centers, nuclei of the vision centers and the corpus stratium. Coordination of these areas determines the control of muscle tonus, and the control of muscle activity. A primary reflex, the Labyrinthine Head Righting reflex, develops as an antigravity function, allowing the supine infant to raise his head by the age of two months. It triggers him to lift his head when pulled by the hands, or when lying prone. The Labyrinthine Head Righting reflex is mainly controlled by the labyrinthine nuclei and medulla oblongata. In children with CP this reflex is not expressed until the fifth month, or later. Thanks to the development of this reflex pattern, a healthy six month old infant when placed on his stomach is able to support his upper body on his forearms, to lengthen his trunk in an arc, using appropriate muscle contraction, and to flex his legs above ground when he is on his stomach. Later in development the child is able to turn over, to get on all fours, to crawl, and to sit without support. The Head Righting reflex is the basis for all these movements. It is controlled by the vestibular-cerebellum structures in the medula spinal and medulla oblongata, and also in the reticular formation of the brainstem In the second year of life the combination of the Labyrinthine Tonic Reflex and the Symmetrical and Asymmetrical Tonic Neck Reflexes help the child learn control of body position at rest, and how to move through space. © 2008, Dr. S. Masgutova 3 © 2008, Dr. S. Masgutova Characteristics of Early Motor Development in a Child with CP All reflex patterns described above for the healthy infant are dysfunctional or pathological in the child with CP, and the expression of the pattern is delayed – up to eight years or more. In CP with severe brain damage there is minimal development of the Righting reflexes (Child Neurology, 2000); K. Bobath, 1972; L.O. Badalian, 1984; R. Michalowicz, 1993; C.H. Delacato, 1974; G. Doman, 1984; V. Vojta, 1989; K.B. Nelson, J.H. Elleberg, 1979; K.A. Semionova, 1999; D. E. Haines, 2002; L. Sadowska, 1998; S. Masgutova, N. Akhmatova, 2004; S. Masgutova, 2007). Our observation and understanding of reflex patterns in children with CP has allowed us to identify dysfunction or pathology of a number of reflex patterns such as the Labyrinthine Tonic in Flexion and Extension, Robinson Grasp, Babkin Palmomental, Leg Cross Flexion- Extension, Asymmetrical Tonic Neck, Thomas automatic Gate, Bauer crawling, Moro, Hands Supporting, Segmental Rolling Reflexes, Symmetrical Tonic Neck, Spinal Galant and Pereze, Spinning, Pavlov orientation , and “What is this?” The expression of pathological reflexes and movement patterns in children with CP is the result of lack of development, and poor maturation and integration of tonic reflexes at the appropriate time. Tonic reflex patterns, for which the stimulus is head movements or changes of body position, strengthen the functional links between the vestibular system and the musculoskeletal system, thus supporting appropriate muscle tone, proprioception, posture, and motor control. The vestibular end organs are reflexively linked to extra-ocular and spinal muscles. These neurological links are modulated and matured via tonic reflexes. Several important reflexes, and their abnormal expression in children with CP, are noted below: 1. Labyrinthine Tonic reflex (LTR). A prone child with CP, regardless of age, demonstrates abnormally high tension in the upper and lower limbs, flexors, and the abdomen muscles. The child can’t raise his head, straighten his core, or extend his legs and arms – movement that is typical for a 3 -6 month old healthy child. In severe cases the muscles demonstrate spasticity. If the child with CP is supine the extensors tone in the limbs increases. A pathological LTR adversely affects the way the child sits, turns over, and stands up. It also can affect the tongue muscle – blocking articulation and preventing stimulation and development of the functions of the Broca speech center, and subcortical links in the brain. A pathological LTR causes poor head position and abnormal function of the oculo-motor abductors. As a result, the child has a limited view of the objects around him/her, leading to poor development of vision. When sitting or standing, each joint is overly flexed and the child has difficulty extending his limbs. 2. Symmetrical Tonic Neck Reflex. When the child with CP is put into position to test the Symmetrical Tonic Neck Reflex the head is flexed on the chest. The child’s response is increased tonus of the flexors of the arms and of the extensors of the legs. When the head is tilted backwards, the tonus in the limbs reverses – it is increased in the leg flexors and in arms extensors. This abnormal reaction causes problems with development of postural control, inhibits the formation of the links between postural control and binaural vision and also “far-close” vision, and blocks the development of superior and inferior eye muscles. © 2008, Dr. S. Masgutova 4 © 2008, Dr. S. Masgutova 3. Asymmetrical Tonic Neck Reflex. If we turn the head of a healthy newborn lying supine to the side, then the arm and leg on the same side will extend in all joints, and the opposite arm and leg flex. In an abnormal response, the limbs flex on the same side to which the head turns, or there is a global hyperactive response. The abnormal reaction is a protective response that does not support sensory awareness or orientation to the environment. 4. Segmental Rolling Reflexes are of crucial importance for infant development. If such reflexes are not developed and integrated, the child cannot rotate the shoulders independently of the pelvis. This is witnessed in the child with CP who cannot separate movements of different body parts. Abnormalities in the development of the Segmental Rolling Reflexes prevent free balancing of the trunk while walking: the individual will have poor balance and limited ability to subtly shift the center of gravity. Clinical observations include unstable and inappropriate leaning of the body to the side, and poor control of posture and movements. 5. The other reflex that has some link to tone and tonic function is Grasp Reflex. It should mature near the end of the first week, integrate with Hands Pulling Reflex by the second month, and grow to allow for easy expression of manual skills by the end of the first year. However, the Grasping Reflex can become fixed and reactive in the child with CP so that after he/she grasps an object, he cannot relax the palm and open the fingers to release it. For children with CP who have low muscle tone, the Grasp Reflex will not be explored as a possibility for flexing the fingers and palm into a fist for holding, or for the development of manual skills. Manual skills represented in the area of the sensory-motor cortex are strongly correlated with speech centers – Wernicke (auditory center for recognition of human speech) and Broca (phonemes and sounds articulation) and subcortical areas that integrate speech function (W. Penfield, T. Rasmussen, 1950). So poor development of the Grasp Reflex may negatively influences speech formation of the child with CP. In normal infants the tonic reflexes discussed above begin to integrate in the second month of life. In children with CP the adequate reflex responses never occur. The abnormal patterns that occur instead involve muscular hyper-contraction and pathological muscle synergies, which limit joint mobility and morphological development, as well as movement. In summary, the complex process of natural Reflex development in children with CP is impaired. Depending on the locations of the brain damage, different pathological pattern schemes are formed in the cortex, and in the subcortical areas. The expression of these pathological patterns can be vividly seen in the first year of life. In the second year of life, hyperkinesis (unintentional movements) may be diagnosed. Hyperkinesis will involve the tongue, causing the lower lip to protrude. Abnormally high tension of the trunk and limb muscles and poor coordination in the hands may also be noted. Abnormal muscle synergies underlie the pathological motor stereotype of children with CP. As noted above, these abnormal synergies --expressed as abnormal tone, postures, and movements -are linked to abnormal tonic reflex patterns. © 2008, Dr. S. Masgutova 5 © 2008, Dr. S. Masgutova Table 1. Results of Reflex Integration Assessment in children with CP (580 individuals; Age 0,5 – 18 years) MCS DEEPLY DYSFUNCTIONAL and PATHOLOGICAL REFLEX PATTERNS IN CHILDREN WITH CP NUMBER OF CHILDREN (450) Statistic Significance * No % MEDIALLATERAL MCS Robinson Grasp 250 55.6 2 Hands Pulling 142 31.6 7 Babkin Palmomental 248 55.1 3 Babinsky 240 53.3 3 Leg Cross Flexion-Extension 249 55.3 2 Asymmetrical Tonic Neck 252 56.0 2 Abdominal 195 43.3 5 Bonding 147 32.7 7 SUPERIORINFERIOR MCS Thomas Automatic Gait 252 56.0 2 Bauer Crawling 241 53.6 3 Moro 257 57.1 2 Fear Paralysis 271 60.2 1 Hands Supporting 227 50.4 4 Sequential Side Turning 235 52.2 4 Landau 242 73.8 3 Flying and Landing 256 56.9 2 ANTERIORPOSTERIOR Trunk Extension 259 57.6 2 Symmetrical Tonic Neck 242 73.8 3 Galant Spinal 243 54.0 4 Pereze Spinal 240 53.3 3 Tonic Labyrinthine 260 57.8 1 Foot Tendon Guard 237 52.7 4 Spinning 256 56.9 2 Pavlov Orientation “What is this?” 160 35.6 6 * Statistic significance – the frequency of deeply dysfunctional or pathological reflex patterns represented at children with CP. The abnormal synergies and movement patterns discussed above are well known and typical of the child with CP. The clinical question is: are there better options to maximize the motor development of children with CP, to facilitate formation of their motor skills and abilities, and to support higher levels of function? In short, can we improve the lives of children with CP? As an answer to this question we propose our program titled: “Masgutova Neuro-sensorymotor Reflex Integration” (MNRI™) created for children with challenges by Svetlana Masgutova, Ph.D., and her colleagues. © 2008, Dr. S. Masgutova 6 © 2008, Dr. S. Masgutova Children with CP are the largest patient group in our work. Our research of their primary movement patterns has helped us identify specific dysfunctional reflexes, and design a program that restore function and the reflex level. The Masgutova Method of Neurosensorimotor Reflex Integration – MNRI™ The understanding of the importance of motor development for general and cognitive development has been discussed in many works. The works focus on a variety of aspects of human function: bio-mechanics and physiology of movement (N. Bernstein, 1947, 1997); motivation (F. Lesfaft, 1998); psycho-structural and cognitive-motivational (N. Leontiev, 1971, 1977); sensory-motor integration of tactile, vestibular, and proprioceptive systems (J. Ayres, 1975); and neuro-developmental assessment of spontaneous movements, treatment of righting mechanisms, postural reactivity, and neonatal reflexes (V. Vojta, 1989); locomotor function restoration, Dynamic Neuromuscular Stabilization (K. Lewit, 2001; (P Kolar, 2007), motor units correction within NDT rehabilitation (B. Bobath, 1963, 1984); motor rehabilitation treatment within early static-motor development (L. Sadowska, 2001); neurophysiological treatment of motor development based on reflexes (M. Barnes, C. Crutchfield, C. Heriza, 1977); movement centered education, using of the Self through awareness (M. Feldenkries, 1981); (F. Alexander, 1932, 1996), movement based learning for skills of concentration and self-organization (P. Dennison, G. Dennison, 1989); and numerous others. Some of the works noted above are treatment oriented approaches, others are education oriented. In most of them, an early motor development approach is the medium for change. The Masgutova Method of Neuro-sensory-motor Reflex Integration (MNRI™) addresses primary motor system function and its influence on developmental and learning processes (S. Masgutova, 2004, 2005). It is directed toward the restoration of neuro-sensory-motor development and the integration of reflex patterns, motor coordination systems, and skills for optimal motor and cognitive functioning. Our approach involves the activation of reflex patterns to awaken the body’s natural resources, to strengthen the genetic motor memory, and support the coherent functioning of sensory and motor systems. The program applies the concept of the importance of primary movements for the child’s motor and cognitive development, utilizing the child development concepts of L. Vigotsky (1986), J. Piaget (1976), S. Rubinstein (1946), L. Bodzowitch (1972, 1997) and I. Dubrowina, N. Tolstykh (1991). The method is based on the results of long-term research and practical work with children and adults with challenges conducted by Dr. Svetlana Masgutova and her colleagues. The MNRI™ program presents the concept and application of integration on the level of the sensory-motor reflex circuit. The program was developed to use procedures and techniques applied at the level of known neurological patterns to facilitate genetic programs for reflex development. © 2008, Dr. S. Masgutova 7 © 2008, Dr. S. Masgutova This method is based on current knowledge of the norms of neuro-motor development and the evaluation of reflex patterns to assess normal child development. The understanding of this work is supported by the brain integration concepts developed by A. Luria (1969), A. Anokhin (1968), N. Amosov (1978), and by the concepts of neurological reflex function as a response of the “brain-body” system to external and internal stimuli by I. Pavlov (1960), I. Setchenov (1995), V. Simonov (1987). The MNRI™ ™ program includes diagnostic and therapeutic procedures (S. Masgutova, N. Akhmatova, 2004, 2005). Diagnosis The primary diagnostic goal is to assess the level of maturity and integration of motor patterns of dynamic and postural reflexes. Diagnosis includes testing of 24 reflex patterns, including the Asymmetric and Symmetric Tonic, Hand Pulling, Leg Cross Flexion-Extension, Spinal Galant and Pereze, Moro, and Robinson Grasp reflex patterns. Test clusters include from 15 to 25 checks of each reflex. Assessment parameters involve several criteria, assessed with scores from “0” to “20.” Diagnosis procedures focus on the testing of individual reflex patterns: -Does the development of the reflex correspond appropriately to the patient age? -Is the reflex integrated on the sensory-motor level? -Is the basic reflex pattern and its variants appropriately matured and functional? -Is the reflex integrated with motor skills and abilities that are used for conscious learning and movement? The diagnosis reflects the functional strengths and weaknesses of dynamic and postural reflex patterns, and provides the practitioner with the information necessary to design a reflex- based treatment plan. The diagnostic profile allows the practitioner to identify what reflex patterns contribute to the developmental delay. Each reflex has its own developmental dynamics and role. Delayed maturation and integration of the reflex can disrupt the next level of motor development and cognitive function. For example, poor formation of the Hands Grasp Reflex can negatively affect the development of manual skills and handwriting (S. Masgutova, 2005, 2007). Delay of the Asymmetrical Tonic Neck Reflex may affect spatial orientation, hearing, and auditory processing. This may lead to language and auditory processing disorders (S. Masgutova, 2005, 2007). Our clinical experience also suggests that delays in maturation and integration of reflexes patterns is a primary factor in dysfunctions such as impulsive reactions and behavior disorders; delays in the formation of more highly organized and consciously controlled movements and skills; and regression in self-management, communication development, and learning. For ease of diagnosis we have divided the reflex patterns into three groups which highlight the interrelationship of motor coordination, brain anatomy, and brain function (Table 2). © 2008, Dr. S. Masgutova 8 © 2008, Dr. S. Masgutova Table 2. Motor Coordination Systems, Brain Levels and Infant Reflexes Medial-lateral Motor Coordination Anatomy symmetry Movements of left and right sides of the body. Superior-Inferior Motor Coordination Dynamic Symmetry Movements of upper and lower sections of the body Anterior-Posterior Motor Coordination Postural Symmetry Movements of front and back of the body Cerebral cortex (cerebrum- Consciousness): Left and right hemispheres Diencephalon (Consciousness and subconscious: Thalamus, hypothalamus. Epithalamus, subthalamus, basal ganglia (caudate nucleus, globus pallidus, putamen, Claustrum, amygdala) Connects cerebral cortex and brain stem Brain stem system (Unconsciousness): Medula spinalis, Medulla oblongata, pons, midbrain (connection with cerebellum) Functions: Functions: Functions: Rational thinking, cause and effect, sequence, whole perception, intuition as the result of experience Emotions, affects, and feelings, experience Unconditioned reflexes, automatic – routine actions, habitual behavior, instincts Reflexes: • Robinson Hands Grasp • Hands Pulling • Babkin Palmomental • Babinsky Foot • Leg Cross Flexion-Extension • Asymmetrical Tonic Neck • Abdominal • Sequential Side Turning • Spinning • Bonding Reflexes: • Thomas Automatic Gait • Bauer Crawling • Moro Embracing • Hands Supporting • Leg Cross Flexion-Extension • Landau • Masgutova Flying and Landing • Foot grasp • Sequential Side Turning • Amphibian • Pavlov Orientation “What is this?” Reflexes: • Trunk Extension • Symmetrical Tonic Neck • Spinal Pereze • Spinal Galant • Tonic Labyrinthine • Foot Tendon Guard • Landau • Sequential Side Turning • Spinning • Pavlov Orientation “What is this?” The first subset of reflex patterns, which we termed the “Medial-Lateral” Motor Coordination System (MCS), supports the development of Right/Left symmetry, and Right/Left side movements, postures, and skills. For example, MCS patterns are included in homologous movements (two hand do the same mirroring symmetrical motion, like catching a ball with two hands), homolateral movements (one sided motion –catching of a ball with one hand), and cross lateral (limbs of different sides are reciprocally active – such as in dance, running, and most sports). The second subset of reflex patterns, termed the “Superior-Inferior” MCS, supports the interrelationship between gross and precise motor coordination (like: crawling on all fours while © 2008, Dr. S. Masgutova 9 © 2008, Dr. S. Masgutova looking at a specific object, maintaining posture while writing; running on the football field while focusing visually on the ball in motion). The third subset, the “Anterior-Posterior” MCS, provides a basis for postural development This includes static postures and movement that balance core flexion and extension, providing postural control in response to gravity. The correlation between Motor Coordination Systems and reflex patterns allows for a deeper understanding of more global developmental patterns. Assessment of individual reflexes allows us to determine which Motor Coordination System is most compromised. Therapeutic Approach Our MNRI™ therapeutic approach is a neuro-sensory-motor correction of dysfunctional reflex patterns. The approach is based on “re-patterning” movement exercises and techniques (re-education, re-coding schemes). It focuses on repetition of dynamic and postural reflex patterns to “revive traces of genetic motor memory,” and to activate “defensive mechanisms of the body-brain system.” The exercises stimulate the expression of genetically encoded resources, such as programs of self-regulation and stress release. “Re-patterning” is based on stimulation of “defense” functions of lower brain areas (I.M. Setchenov, 1895, A.A. Ukhtomsky, 1950-1952), stimulating synaptic growth and myelination (L. Lundy-Ekman, 2002). The approach uses eight specific protocols developed by Dr. S. Masgutova. These include “Neuro- Structural Reflex Integration” (2003), “Tactile Therapy” (2005), “Reflexes Re-patterning” (2004), and “Visual and Auditory Reflexes Integration” (2007). MNRI™ programs have been used for the last 7 -9 years by practitioners of sensory-motor integration, somatic oriented psychology, occupational therapy and physiotherapy in over 40 countries including the USA, Canada, Australia, Germany, France, and Belgium. The Method shows statistically significant and favorable results. The goal of the following study was to determine the important clinical parameters in the assessment of children with developmental delays and to assess the effectiveness of the Neurosensory- motor Reflex Integration (MNRI™) Program. Children and adults involved in our study participated in a therapeutic clinic for 14 days at the International Dr. S. Masgutova Institute of Movement Development and Reflex Integration in Warsaw (Poland) and/or for 10 days at the Svetlana Masgutova Educational Institute for Neuro-Sensory-Motor and Reflex Integration (USA). Each clinic consisted of 6 -7 hours per day of treatment that included active structural motor therapy and directed relaxation procedures. © 2008, Dr. S. Masgutova 10 © 2008, Dr. S. Masgutova The Concept of Sensory-Motor Integration of a Reflex Circuit Neurophysiology dictates that each reflex must integrate on the sensory-motor level. A specific sensory stimulation will trigger a corresponding motor/gland response. The neural link between the sensory and motor aspects of a reflex is genetically based, having evolved over thousands of years. Fig. 1. Three aspects of sensory-motor integration of a reflex circuit. Sensory stimulation: Tactile end organ Visual end organ Auditory end organ Vestibular end organ Brain processing: (of genetic program) Normal Dysfunctional Pathological Motor response: Normal (matured) Dysfunctional (hyperactive, hypoactive) Pathological (opposite, reversed, a-reflexive) Fig. 2. Sensory information is received by the brain, which determines the character of the motor/gland response. If a stimulus is not recognized by the peripheral sensory apparatus, it will be misinterpreted by the brain. If the central nervous system response is abnormal, then the expression and development of the reflex pattern will be inappropriate. The integration of the reflex with controlled movements and skills will be delayed and will be unreliable. The dysfunction will be most obvious in situations of new learning or stress. © 2008, Dr. S. Masgutova 11 © 2008, Dr. S. Masgutova Concept of the Dynamic of a Reflex Integration Fig. 3. Reflex development dynamic Each reflex emerges at a specific time. It develops its own basic pattern, expressed in three phases. It then goes through a transition time (the fourth phase) before developing variants during the fifth, sixth, and seventh phases. Each phase has its own role. For example, a basic pattern is responsible for coding the sensory- motor circuit. It creates the nerve network for specific stimuli, in order to establish appropriate physiological functioning and protection. The transition phase is important for the maturation of the basic pattern. The reflex variants, developed during the last phases, are characterized by a highly developed neural network. The reflex pattern now evolves from the level of reflex protection to the higher level of intentional response. Maturation of the nervous system involves the inter-connection of reflex circuits. The role of these latter phases is to expand the development of a reflex in order to create the groundwork for reflex integration with motor skills and abilities. This supports the development of academic skills such as elementary reading, drawing, writing, and calculating. Delayed reflex development, or the omission of any phase, adversely affects the formation of future skills. The result is evident in the next level of development; the reflex will not develop an appropriately matured neural network. Thus there will be dysfunctions or compensations rather than ideal patterns. The altered patterns are less reliable in situations of stress or unexpected transition. It is critical for a reflex to evolve through each phase for full development, maturation, and integration. This concept is unique, and should be distinguished from the traditional understanding based on “inhibition” of a reflex. © 2008, Dr. S. Masgutova 12 © 2008, Dr. S. Masgutova Reflex Characteristic Components The five main characteristics we evaluate are: pattern, timing and dynamics, motor direction, strength of the reaction, and symmetry. These characteristics are evaluated solely through the recognition of the motor response. Direct measurement of brain processing and the level of sensory sensitivity are not possible at this time. Pattern of a reflex. Pattern is the co-ordination of a set of reactions and movements organizing the response to the stimulus. Direction of motion in a reflex response. Each reflex represents a certain sequence of reactive movements which finish in a specific posture or continue as a motion in a specific direction. Our neuromusculoskeletal system serves to organize these postures and movements. Fig. 4. Correct Grasp Reflex: basic pattern and variant (phase-4). Fig. 5. Incorrect Grasp Reflex: basic pattern and variant (phase-4). Response time. The reflex circuit involves sensory input, brain processing, and the motor response. The 7 motor response should take approximately 10 bit/seconds from the moment the sensory stimulations starts. The reaction must happen within a very short time; it must be quick because the primary function of a reflex is for protection. A temporal delay will delay the protective response needed at any moment, and may result in injury. The temporal delay in a reflex will be perpetuated in later patterns and conscious movements developed on the foundation of that reflex. Strength of the reaction. This characteristic of a reflex reaction includes the physical strength supplied by the tone and status of the musculoskeletal system. The strength of the muscles serving the functioning of a reflex pattern must reflect the intensity of the stimuli. Hyperactive or hypoactive reactions, or no reaction, are inadequate responses. Symmetry. Motor reaction in a reflex circuit can be evaluated by comparison of the bilateral organization of the body. Symmetry should be seen in the body structure, direction of the motion of a reflex response, and in the timing and strength of the reaction. Fig. 6. Direction of motion in Hands Supporting Reflex pattern: a) correct and b) asymmetrical/inappropriate © 2008, Dr. S. Masgutova 13 © 2008, Dr. S. Masgutova Fig.7. Asymmetry in Babinsky: reaction in left foot is correct, and in right foot is incorrect. Program workshops have revealed correlations of the following reflex patterns to health and development: -“Red and Green Light” Tendon Guard and Labyrinthine Tonic Neck – for the self-regulating processes of well being; -Asymmetrical Tonic Neck – for hearing, memorization, and development of the proprioceptive system; -Symmetrical Tonic Neck, Truck Extension – for body posture control, binocular vision, and binaural hearing; -Spinal Pereze and Galant – for cross motor coordination; -Eyes: Horizontal and vertical tracking, staring – for visual function, reading, and writing; -Grasp and Hands Pulling -for supporting writing skills and drawing; -Sequential Fingers Opening -for calculation and other mathematic skills. Our program is designed to facilitate the growth and potential of children and adults with challenges: CP (cerebral palsy), autism and the autistic spectrum, ADD and ADHD (attention deficit disorder, attention deficit and hyperactive disorder), dyslexia and hyperlexia, genetic conditions, developmental delays, and FAS (Fetal Alcohol Syndrome). Our work with individuals with challenges supports the importance and effectiveness of facilitation approaches directed to the level of primary movements and reflexes. It clearly supports the understanding that reflexes are the units of sensory-motor development, thus influencing all neuro-development. Our program is commenced by the professionals who are trained and certified in the Masgutova Neuro-sensory-motor Reflex Integration (MNRI™) program (see www.masgutovamethod.com). Reflex Pattern Assessment and Interpretations Assessment of each reflex is based on five parameters, each scored from 0 to 4, allowing for a total score of 20 for each reflex. This simplified procedure allows us to measure the level of reflex development/integration or dysfunction. A final score of “20” represents complete reflex pattern integration and “0” represents an overt pathological response. Table 2 shows an example of an evaluation form for a reflex. © 2008, Dr. S. Masgutova 14 © 2008, Dr. S. Masgutova Main Parameters of the Basic Reflex Pattern Evaluation Key description: 4 = Correct response 3 = Correct in all basic features 2 = Elements of correct pattern, but incorrect response for stimuli to some of the features of the pattern 1 = Dysfunctional response 0 = Pathological response Table 3 demonstrates the characteristic description of the reflex pattern evaluation. Table 3. Short Description of a Reflex Pattern Evaluation Score for a Pattern Direction of Strength of a Response Symmetry Notes reflex constuc-tion motion in a reflex time of the reflex response (compensapattern reflex response reaction tions, response symmetry distortions) 4 Completely Completely Completely Completely Completely Completely right right direction appropriate/ appropriate symmetrical right/ adequate and timing appropriate stable 3 Right in Right Appropriate in Appropriate Motor response in Right and whole direction in whole and timing in reflex reaction is appropriate in whole almost stable whole approximately whole symmetrical 2 Several/ many Not Not Motor response in Several Several components appropriate, appropriate in reflex reaction is components components are incorrect and instable timing symmetrical in some Are incorrect are incorrect (postponed or elements and not too fast symmetrical in other reaction) elements 1 Dysfunc- Dysfunctional (wrong) Wrong direction Not adequate (too strong or Wrong timing (postponed/ Motor response in reflex reaction is not tional too weak) late response symmetrical/wrong or too fast/ hyperactive reaction) 0 Wrong Completely Completely Motor response in Pathological Pathological direction, opposite inappropriate strength wrong in timing reflex pattern is pathologically direction /pathological (delayed or no asymmetrical (hyperactive or response, (functions against hypoactive or other…) reflex patterns no response) damaging its development) Reflex patterns are evaluated before and after the integration procedures (Reflex Pattern activation/Re-patterning Exercises). © 2008, Dr. S. Masgutova 15 © 2008, Dr. S. Masgutova Table 4 shows details of the basic Grasp Reflex pattern evaluation, illustrating the description of the Grasp Reflex in a child with delays in motor development and sensory processing. Table 4. Example of a Grasp Reflex – Basic Pattern Evaluation Before and After Re-patterning Procedure Grasp Reflex Basic pattern Pattern Direction of movement Strength Response time Symmetry Before After Before After Before After Before After Before After 1 3 1 2 1 2 3 3 1 3 Dysfun ctional (wrong) Basically Correct Wrong direction Small positive change in direction Inadequate (too weak) Small positive change in strength Appropri ate timing in whole Appropri ate timing in whole Motor response in reflex reaction is not symmetrical/ wrong pattern Motor response in reflex reaction is approximately symmetrical The score before the re-patterning procedure is: 6 (Incorrect pattern. Average of dysfunction). The score after the re-patterning procedure is: 13 (Pattern is functional, but still at a low level of development). The interpretation of the score is presented in Table 5. Table 5. Criteria for Evaluation of Reflex Patterns Integration/Dysfunction NORMAL FUNCTION DYSFUNCTION/PATHOLOGY POINTS LEVEL OF DEVELOPMENT / INTEGRATION POINTS LEVEL OF DYSFUNCTION 19-20 High level of integration 10 The pattern is on boundary of normal function and dysfunction. Elements of right pattern. 17-18 Matured level, integration is higher than average 8-9 Incorrect pattern. Light dysfunction 15-16 Development and integration is average level = NORM 6-7 Incorrect pattern. Average dysfunction 13-14 Pattern is functional, but at a low level of development 4-5 Incorrect pattern. Deep dysfunction 11-12 Pattern is functional, but at a very low level of development 2-3 Incorrect pattern. Pathology 10 The pattern is on the boundary of normal function and dysfunction. Elements of right pattern. 0-1 Incorrect pattern. Severe pathology © 2008, Dr. S. Masgutova 16 © 2008, Dr. S. Masgutova The evaluation process for Reflex Pattern Integration requires thorough knowledge in the arena of Neuro-Sensory-Motor Reflex Development, special professional education, and extensive clinical experience. We teach practitioners of our Method at special courses, workshops and clinics. Our evaluation provides us with a deeper understanding of the etiology of poor motor-cognitive development, allowing us to create individualized programs to support motor-cognitive development, by facilitating the primary movement system. The goal of each individualized program is to support positive protection, and to support physical, emotional, and cognitive development. Reflex pattern evaluation is not intended to be the basis for labeling any child or adult because of neurological symptoms, physical or mental disability, age, or other factors. It serves only to support, through genetic motor programs, further development of motor-cognitive function. We suggest it is possible to change dysfunctional or pathological expression of a reflex pattern to support better function. The information from reflex pattern evaluations serves to give direction for attaining the highest potential of any individual, allowing them to realize their inherent possibilities. Results and Discussion of Application of the MNRI™ Program to Children with CP The MNRI™ program supports optimal function of the motor, tactile, visual, and auditory systems. The MNRI™ concept differs from other concepts in that it proposes neurosensory- motor integration of reflex patterns instead of inhibition. The program demonstrates the possibility of integration of reflexes (natural genetic motor programs) with consciously learned and controlled movements, skills, and abilities. MNRI™ integrating techniques and exercises are directed to facilitation and maturation of “neurological pathways” (I.P. Pavlov, 1960; I.M. Setchenov, 1960) corresponding to specific reflex patterns. The program proposes non–invasive gentle movements and playful exercises, which can be learned by parents of challenged children, adults, and professionals who work with challenged individuals. These techniques require few external resources, and can be in conjunction with other therapies. Results of the assessment procedure of integration/dysfunction of the reflex patterns in children with CP were analyzed based on the function z = f(x) by Prof. Anna Krefft Method (“Diagnostic Function of the Non-observable Phenomena.” (Oficyna Wydawnicza Politechniki Wroclawskiej. 2007. Wroclaw. Poland). This function allows us to estimate the level of the changes in expression (z) of the reflex patterns as the result of the synthesis of information of the chosen diagnosis qualities (x) within 3 groups of Motor Coordination Systems (MCS): “Medial- Lateral,” “Superior-Inferior,” and “Anterior-Posterior.” © 2008, Dr. S. Masgutova 17 © 2008, Dr. S. Masgutova In Table 6 we present examples of results of statistically important validation of the synthesized function z = f(x). Each parameter (x) shows the level of development of the specific reflex pattern; this function allows us to measure each parameter (x) for each individual child. The data was taken before and after the use of the MNRI™ program for children with CP who attended the 10 or 14 day clinic at the Rehabilitation Camps for Children with Challenges, part of the Dr. S. Masgutova Institute. Results demonstrate the effectiveness of the MNRI™ Program with children having severe CP. The study group consisted of 42 children ranging in age from 2 to 8 years. They attended either a 14 day clinic (in Poland; 31 children) or a 10 day clinic (in the USA; 11 children). Table 6. Example Fragment of the Analysis of Reflex Patterns Change within the Group Anterior-Posterior MSC Function z = f(x) is the synthesized function of changes in reflex patterns development (z) and presents synthesized information of chosen diagnosis parameters (x). Nr of Child NR of Assessment X1 X2 X3 X4 X5 X6 X7 X8 Z (Coefficient of the change) Child 1 1 (Before) 5 5 7 5 4 5 4 8 0,351 2 (After) 8 8 9 7 7 7 5 9 0,472 Child 2 1 (Before) 14 11 5 3 6 3 6 5 0,382 2 (After) 15 13 8 4 15 5 9 13 0,611 Reflex patterns: X1 – trunk extension reflex; X2 – symmetrical tonic neck reflex; X3 – Galant spinal reflex; X4 – Pereze spinal reflex; X5 – labyrinthine tonic reflex in flexion and extension; X6 – foot tendon guard reflex; X7 – spinning reflex; and X8 – Pavlov cognitive orientation reflex. The parameters (x) were estimated according to the criteria of reflex pattern assessment noted in Table 5. © 2008, Dr. S. Masgutova 18 © 2008, Dr. S. Masgutova Fig. 8. Dynamic of the changes in development of reflex patterns in children with CP within Motor Coordination System Superior-Inferior. Dynamic of the Change in the Reflex Patterns Development Fig. 9. Dynamic of the changes in development of reflex patterns in children with CP within Motor Coordination System Superior-Inferior. Cofficient of Changes in the Reflex Patterns Development 0,6 0,351 0,472 0,1 0,2 0,4 After 0,3 Level of Reflex Integration 0,5 8 7 4 3 2 1 Level of Reflex Integration Before Program After Program Before Program Program 0 X4 X5 Reflex patterns In Figure 8 we see a fragmentary example of the dynamic of changes in development of reflex patterns within Anterior-Posterior MCS. Mathematical statistical analysis demonstrates the statistical importance and validity of changes within each reflex pattern and also for the whole group of reflex patterns referring to Anterior-Posterior MCS (Fig. 9). This type of analysis was used for all diagnostic parameters of reflex patterns for each child, with comparison of results before and after the MNRI™ Program, for all three MCSs: Medial-Lateral, Superior- Inferior, and Anterior-Posterior. In Figure 9 we see the fragmentary example of the coefficient (z) by Prof. A. Krefft (2007), which demonstrates the statistical validity of the changes in expression of reflex patterns in children with CP within the Anterior-Posterior MCS. Figures 10, 11, and 12 show examples of dynamic changes in the expression of reflex patterns in children with severe CP after 14 or 10 days of utilizing the MNRI™ Program. X1 X2 X3 X6 X7 Cofficient of changes before and after Program © 2008, Dr. S. Masgutova 19 © 2008, Dr. S. Masgutova Dynamic of the Change in Reflex Pattern Development within "Medial-Lateral" Motor Coordination in Children with CP (42 individuals) 0 2 4 6 8 10 12 14 Reflex Integration Level of Reflex Inntegration Przed korekcja6,8 6,9 5,1 5,8 4,3 5,7 4,9 10,5 Po korekcji 8,1 8,2 6,6 7,3 6,9 7,4 6,6 11,7 1 2 3 4 5 6 7 8 Dynamic of the Change in Reflex Pattern Development within "Superior-Inferior" Motor Coordination in Children with CP (42 individuals) 12 0 2 4 6 8 10 Level of ReflexInntegration 1 2 3 4 5 6 7 Before Program 5 5 5 7 3,5 3 8,6 After Program 6,4 7 7 8,6 5,1 4 10 Reflex Integration © 2008, Dr. S. Masgutova 20 © 2008, Dr. S. Masgutova Dynamic of the Change in Reflex Pattern Development within "Anterior-Posterior" Motor Coordination in Children with CP (42 individuals) 0 2 4 6 8 10 12 Reflex Integration Level of Reflex Inntegration Before Program 5 5 5 7 3,5 3 8,6 After Program 6,4 7 7 8,6 5,1 4 10 1 2 3 4 5 6 7 Coefficient of Change in Reflex Patterns Development for three Motor Coordination Systems: "Medial- Lateral", "Superior-Inferior", "Anterior-Posterior" in Children with CP (42 individuals) 0 0,1 0,2 0,3 0,4 0,5 0,6 Before and After Program Coefficient of ChangeBefore Program After Programi Mathematical statistical analysis shows high validity of our results: improved reflex pattern expression in children with CP after attending the MNRI™ program. This validity reflects the whole group of children with CP. The coefficient of change is 0.43 before the MNRI™ Program and 0.56 after which supports a valid and significant change. (Fig. 13). The lineal error in projection of changes is not more than 1.87 – 2,82 %, again supporting the conclusion that the MNRI™ Program results in statistically significant changes in reflex pattern expression © 2008, Dr. S. Masgutova 21 © 2008, Dr. S. Masgutova Summary Our program is designed to facilitate the growth and potential of children and adults with challenges: CP (cerebral palsy), autism and the autistic spectrum, ADD and ADHD (attention deficit disorder, attention deficit, and hyperactive disorder), dyslexia and hyperlexia, genetic conditions, developmental delays, and FAS (Fetal Alcohol Syndrome). The results of our work with individuals with challenges strongly supports the importance of appropriate corrective procedures directed at the level of primary movements: reflexes. Our program reveals potential for the use of these natural self-regulating patterns for functional health correction. Our method is offered as a strong support for creation of new developmental possibilities and programs for children and adults. It involves natural, non-invasive movements that can be easily learned by parents of challenged children, adults, and professionals who work with challenged individuals. The techniques require few external resources. They can be applied in conjunction with other therapies. This method is put into practice by a group of trained professionals certified in the Masgutova Method of Neuro-sensory-motor Reflex Integration (www.masgutovamethod.com). The Masgutova Method (MNRI™) is taught in a series of courses, with clinical experience gained in Rehabilitation Camps/Clinics. Our work using the MNRI™ Method with children with CP demonstrates measurable results in reflex pattern expression, with these implications for primary motor system function: improved postural control, stability, and sense of equilibrium. This provides a sufficient and stable basis for effective sensory motor function, thus supporting the neurophysiological basis for development and learning. The MNRI™ Method demonstrates the primary importance of addressing reflex patterns to support the development and function of motor and cognitive systems. Statistical analysis has supported the effectiveness of the MNRI™ diagnostic protocol and validates the results of the therapeutic part of the program. MNRI™ utilizes natural motor genetic resources to facilitate development, using concepts of reflex pattern integration. The coordination of neurological, sensory, and motor components provides the foundation on which reflex movements are integrated with intentional movements, learned motor skills, and consciously controlled motor abilities in children with CP, and in all human beings. © 2008, Dr. S. Masgutova 22 © 2008, Dr. S. Masgutova LITERATURE Alexander F.M. (1932). The Use of Self, 1985 Edition, London: Orion Books Limited. Amosov N. M. (1978).Thinking about the Health. Moscow. Russia. p. 16-29. Andre A., Thomas H., Chesni Y., Disgassies A. (1962). The Neurological Examination of the Infant. National Spastic Society. London, U.K. Anokhin P.K. (1968). Biology and Neurophysiology of a Conditioned Reflex. Medicina. (Russ.) Moscow. Russia. Ayres J. (1975). Sensory Integration and The Child. Western Psychological Services, Los Angeles, C.A. U.S.A. Aylward E., Reiss A., Reader M., Singer H., Brown J, Denckla M. (1996). Basal Ganglia Volumes in Children with Attention-Deficit Disorder. Journal of Child Neurology 11 (2) -March, 112-115. U.S.A. Ayres J. (1971). Characteristics of Types of Sensory Integrative Functions. The American Journal of Occupational Therapy, 25(27), 329-334. U.S.A. Badalian L.O. (1984). Child neurology. Medicina. Moscow. (Russ.). Russia. Barashniev J.I. (2001). Prenatal neurology. Triada-X, Moscow. (Russ.). Russia. -640. Barnes M. R , Crutchfield C.A., Heriza C.B. (1977). The Neurophysiological Basis of Patient Treatment. Volume II. Reflexes in Motor Development. Stokeville Publishing Company. Atlanta, CA. USA. Bernstein N.A. (1947). The construction of the Movement. Moscow. (Russ.). Russia. Bernstein N. (1997). Bio-Mechanics and Physiology of the Movement. Moscow-Voroniez. (Russ.) Russia. Bobath K. (1972). The normal postural reflex mechanism and this deviation in children with cerebral palsy. Physiotherapy, 57, 515. Bobath B. (1963) Treatment principles and planning in cerebral palsy./Physiotherapy April: 1–3. Bobath K, Bobath B. (1984) The neurodevelopmental treatment. In: Scrutton D, editor. Management of the Motor Disorders of Children with Cerebral Palsy. Oxford: Blackwell Scientific Publications Ltd. p 6–18. Bodzovitch L.I. (1972). The Problems of Child’s Motivation Sphere Development In book: Studies of Motivation of Behavior in Children and Teenagers. Moscow. Russia. Bodzovitch L.I. (1997). Basis of Personality Formation. Selected Psychological Works. Moscow. Russia. Campbell St. (2004). Watch Me Grow! A Unique, 3-Dimensional, Week Look at Baby’s Behavior and Development Inside the Womb. Carroll and Brown Publishers Limited. Caesar P., Dubovittz V. (1985). Neonatal Clinical Neurological Assessment. In Harel S. Anastasion N.J. (eds): The At-Risk Infant. Psycho/Social/Medical Aspects. Paul H. Brookes Baltimore. N.J. USA. 197-229. Child Neurology. (2000). Medical Publishing -Urban & Partner. Wroclaw. Poland. Cohen B. B. (1993). Sensing, Feeling, and Action. The Experiential Anatomy of Body-Mind Centering. Northampton, M.A. Contact Edition, U.S.A. Cook A., Woollacott M. (1997). Motor Control, Theory and Practical Applications. Baltimore,Williams and Wilkins. U.S.A. Danilova N.N., Krilova A.L. (1997). Physiology of the High Nerve System Activity. Uchebnaja literatura. (Russ.), Moscow Russia. Delacato C.H. (1974). The Diagnosis and Treatment of Speech and Reading Problems. Garden City, New York, Doubleday. U.S.A. Doman G. (1984). How to Multiply Your Baby’s Intelligence. Garden City. New York, Doubleday. U.S.A. Dubrovina I.V. (1991). School Psychology Service. Theoretical and practical Aspects. Scientific Research Institute of General and Educational Psychology. Moscow. (Russ.). Russia. Feldenkrais M. (1981). The Elusive Obvious. Cupertino, Calif.: Meta Publications, p. 7-9. ISBN 0-916990 Galant S. (1917). Der Ruckgratreflex. Diss. Basel. Galperin P.J. (1976). The Development of the Researches on Formation of Intellectual Operations. (Russ.) Moscow, Russia. Gross D.R. (1987). Psychology. The Science of Mind and Behavior. Hodder and Stoughton,. London. U.K. Gordejeva N.D., Zinczenko V.P. (1982). Functional Structure of the Action. Moscow State University. Moscow. Russia. Haines D.E. (2002). Fundamental Neuroscience, Second Edition. N.Y. Edinburgh, London, Philadelphia. UK. © 2008, Dr. S. Masgutova 23 © 2008, Dr. S. Masgutova Humphrey T. (1964). Some Correlations Between the Appearance of Human Fetal Reflexes and the Development of the Nervous System. Progress in Brain Research. Amsterdam, Elsevier. 4. Khomskaja E.D. (1987). Neuropsychology. Moscow University. (Russ.) Moscow. Russia. Konorski J. (1969). Integrating Activity of the Brain, PZWL, Warsaw. Kolár P. (1996). Importance of Developmental Kinesiology for Manual Medicine, Czech Journal of Rehabilitation and Physical Therapy. Krefft A. (2007). Funkcje diagnostyczne zjawisk nieobserwowalnych. Oficyna Wydawnicza Politechniki Wroclawskiej. Wroclaw. Landau A., Mikschiczek D., Peiper A., Spath L., Hansischer Verlagskontor, Lubeck, Hooker D. (1952). The prenatal origin of behavior. University of Kansas Press, Laurence. U.S.A. Leontiev A.A. (1971). The Psychological Structure of the Meaning. Semantic Structure of the Word. (Russ.) Moscow. Russia. Leontiev A. N. (1977). The Activity, Consciousness, Personality. (Russ.) Moscow. Russia. Lesgaft P.F. (1998). Psychology of the Moral and Physical Training. Voroniez. (Russ.). Russia. Lewit K. (2001). Manual Therapy in Rehabilitation of Motor Diseases. Ed. by: Jerzy Stodolny ZL Natura, Kielce 2001, wyd. 3. – Polish version Lundy-Ekman L. (2002). Neuroscience. Fundamentals for Rehabilitation. 2-nd Edition. Pacific University. Forest Grove, Oregon. U.S.A. Luria A.R. (1969). High Cerebrum Functions of the Human and their disorders in cases of local damages. Moscow State University. Moscow. Russia. Masgutova S. (1999). Effect of the Edu-K Exercises on the Work of Dynamic and Postural Reflexes / Freiburger Kinesiologietage: Institute fur Angewandte Kinesiologie. Kinesiologie Kongress Deutschland. Freiburger. Masgutova S., Akhmatova N. (1998, 2004). Integration of Dynamic and Postural Reflexes into the Whole Body Movement System. Moscow. Russia. Masgutova S., Akhmatova N. (2004, 2005). Children with Challenges: Integration of Dynamic and Postural Reflexes. MINK, Warsaw. Masgutova S. (2005). Reflexes as the Basis of the Nerve System Development and Formation of the Motor Patterns in Infancy. / Materials of International Conference: Modern Methods of Stimulation of Motor and Language Development. International Kinesio-Rehabilitation Camp for Children with Challenges of Dr. S. Masgutova Institute, MINK. Warsaw. P. 14-36. Masgutova S., Sadowska L. (2006). The Use of the Edu-K for Children with Learning Difficulties: Early Developmental Dynamic / In materials of: Polish National Conference: “NeuroKinesiology as the Method of Facilitation of Development and Learning for Children and Youth with Dyslexia, ADHD, Autism and Asperger”. 08.04.2006. Warsaw. p. 39-50. Masgutova S. (2007). Integration of Infant Dynamic and Postural Reflex Patterns: Masgutova Neuro- Sensory-Motor and Reflex Integration – MNRI™ Method for Children and Adults. Third ed. Revised,. Illustrated. 250 p. Masgutova S. (2007). Reflex integration and the implication on learning, development and health. / International Conference Materials. International Applied Kinesiology Conference. Salt-Lake-City, USA. 13 p. Masgutova S. (2007). Neuro-structural Reflex Integration Therapy. MISM. Revised Edition. 120 p. Warsaw. Masgutova S. with Kowal J., Mazur G., Masgutov D, (2005). NeuroKinesiology Tactile Therapy™ by Dr S. Masgutova, Scientific Edition: Dr. A. Regner, J. Szymczak. MINK, 133 p. Warszawa. ISBN 83-89370-38-7. Masgutova S., Akhmatova N. (2004). Reflexes Re-patterning Exercises. In: Integration of Dynamic and Postural Reflexes into the Whole Body Movement System. Scientific edition: Prof. N. Akhmatova. MINK, Warsaw. Poland. Masgutova S. (2007). Neuro-Sensory-Motor Development: Visual and Auditory Reflexes Integration. Facilitation Program of Development and Learning for Children and Adults. Scientific Edition: Prof. N. Akhmatova. 86 p. MISM. Warsaw. ISBN 978-83-60761-05-2. Michalowicz R. (1993). Cerebral Palsy in Child. PZWL. Warsaw, Poland. Nelson K.B., Elleberg J.H. (1979). Neonatal Signs as Predictors of Cerebral Palsy. Pediatrics, 64-68, 225- 231. Neurokinezjologiczna diagnostyka i terapia dzieci z zaburzeniami rozwoju psychoruchowego. (2001). Pod redakcja L. Sadowiskej. AWF-Wroclaw. Wroclaw. Penfield W., Rasmussen T. (1950). The Cerebral Cortex of Man: A Clinical Study of localization of Function. Macmillian, New York. © 2008, Dr. S. Masgutova 24 © 2008, Dr. S. Masgutova Pavlov I.P. (1960). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. (Anrep G.V., D. Sc. Trans., 1960). New York. Dover Publications Inc. U.S.A. Piaget, J. (1976). The Grasp of Consciousness: Action and Concept in the Young Child. Cambridge. M.A. Harvard. U.S.A. Pierce J. F. (May 1997). Freedom to Change; The Development and Science of the Alexander Technique. London: Mouritz. Rubinstein C.L. (1946). The General Psychology Basis. (Rus.) Moscow. Sadowska L. (1998). Neurological Basis of the Early Kinesiology Diagnosis and Rehabilitation using Vojta Method. Medycyna Manualna, 2. Wroclaw, Poland. Sadowska L. (2001). Nuerokinesiological Diagnosis and Therapy of Children with Motor Developmental Disorders. AWF. Wroclaw, Poland. Saint-Anne Dargasses. (1986). The neuro-motor and psycho-affective development of the infant. Amsterdam, N.Y., U.S.A. Setchenov I.M. (1995). Physiology of Behavior. Scientific Works/ Edd.: M.G. Jaroshevsky Moscow. (Russ.). Russia. Semionova K.A. (1999). Rehabilitation Treatment of the CP Patients in Residual State. Moscow. (Russ.). Russia. Simonov V.P. (1987). Motivated Brain. oscow, Russia. Tolstych N.N (1991). School Psychology Service. Theoretical and practical Aspects. Scientific Research Institute of General and Educational Psychology. Moscow. (Russ.). Russia. Ukhtomsky A.A. (1950-1952). The Study of Dominance // Collected works in 6 books. Book 6. Leningrad, Russia. Vojta V. (1989). Die Posturale Ontogenese als Basis der Entwicklungsstorungen. Monatsschr. Kinderheilkd., 141, 639-642. Vigotsky L.S. (1986). The Child Psychology. The Problems of Child Development. In 6 Books. Book – 4. Pedagogika. Moscow. (Russ.). Russian. Article written: April, 15, 2008. © 2008, Dr. S. Masgutova 25