Friday, December 17, 2010

Pediatric Optometry Case 1: 2 years 6 m.o./M/F


(NEW CASE)

Hx:
·        - Suspected autism (as not confirmed by HTAA psychiatrist yet).
·        - Birth: Normal delivery.
·        -She was not feeling well during the visit.
·        - Mother reported she can suck well and eat rice as well.
·        -Good development except for speech.
-   - She likes coloring.
-   -Her mother reported she can arrange and match things as well.
·        -From the past few months her father noticed she prefers to sit quite close to television while watching it and tend to have abnormal head posture.  

Test:
·       -Only few tests performed as she not complies.
   -Hirschberg: central.
   -OMT (only manage to do it horizontally): normal
·       - Her father showed us the picture of AHP of her daughter (unfortunately we can’t attach it here).
Let us describe here, the picture showed;
-          Left face turn
-          Right head tilt
-          Chin down

Dx: can’t be diagnosed yet.

Mx: TCA will be determined by call to have further test.

Let’s brainstorm!! 
    1)For this type of case, what would you think the suitable vision testing can be conducted on her?
   
    2) List the possible over-action and under-action muscles.

    3) Discuss the Park-Three-Step test.

prepared by: Group 2 & 3 :)

67 comments:

  1. during the visit, pt has been tested with 100 n 1000's beads but does not comply..
    based on the info reported by her mother regarding normal sucking and eating, it indicates that there is no nerve palsy involved...

    ReplyDelete
  2. @rohaila

    Deadline for this case discussion is this Tuesday 21/12/2010...PLease join this discussion..Case discussion will contribute 40% of total marks.

    ReplyDelete
  3. although Park -3-Step test cannot be done on that day,as the description picture stated above,try to shortlist the possible underaction & overaction muscle.

    ReplyDelete
  4. Please state the plan of the tests to be conducted on the next visit.....

    ReplyDelete
  5. as for vision testing, we tried to use 1000 beads but the patient is uncooperative and not well (have fever) on that day..
    it same goes to do mohindra retinoscope, cannot be performed since noncompliance patient.
    can we perform Autorefractor on next TCA if patient is well and can give good cooperation?

    ReplyDelete
  6. from my opinion, since the patient is uncooporative awake, is it possible to ask the parent to put the baby to sleep while we do mohindra maybe.. if not, try to stimulate the baby to follow different size objects...

    ReplyDelete
  7. good zahirah..but since pt is having a fever on that day, so she is totally uncooperative,even her mother try to make her sleep..myb next visit we can ask the mother to make her sleep first before enter our clinic..we also have tried to get her attention with pentorch, "twinkle star" or other soft dolls, but she just ignore..sometimes angry with us coz disturb her..(means she aware)
    the pt is also very active(in terms of move around)..she loves holding pencil and book.
    the patient also have good eye contact..=)

    ReplyDelete
  8. 1. for this age, we can use Lea Acuity card...if pt can’t respond to this test, we can try lea paddle grating...

    2. not sure...still thinking the aswer...

    3. Park’s 3 Step Test :
    •Use to identify paretic muscle in pts with vertical deviation
    •Only works for paretic and oblique muscle (SR, IR, SO, IO)
    •False reading if more than 1 muscle is weak or if there is restriction

    a.Step 1 : CT is performed in primary position, noting which eye is hyperopic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia

    ReplyDelete
  9. as aida said, this pt love pencil n book, so, we can try to use lea acuity card to assess her vision...instead we ask the pt to matcing the picture, we can ask the pt to draw the object she can see...this test might be interesting to her...

    ReplyDelete
  10. good idea from hanisah n aida..=)

    brainstorming for 2nd question - underaction mucles when:
    1. left face turn - u/a of R LR , L MR
    2. right head tilt - u/a of R SO
    3. chin down - u/a of her depressor muscles

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  11. anyone to add some more? correct me if im wrong...

    ReplyDelete
  12. So,for the next visit, we plan to conduct those tests:-
    a)refraction
    b)OMT
    c)CT
    # seeking opinion from others for any suggested tests dat we've missed...

    ReplyDelete
  13. Maybe for the next visit we would like to try mohindra retinoscopy if not possible, we plan to perform retinoscopy while she sleeping (as mentioned by zahirah).

    ReplyDelete
  14. Salam :)

    Wow..good job guys..hehe

    1)I agree with zahirah since patient is uncooperative and quiet hyperactive. So, doing mohindra retinoscopy while sleeping is good idea.

    2)Just wanna add..if I'm not mistaken, the u/a muscle is RLR and o/a muscle is LMR.. while the vertical muscle are u/a of BE SR and o/a BE IR..how about u guys??

    3)for park's 3 step..credit to Hanisah..but juz for correction, for step 1, not hyperopic but hypertropic ;)

    Next plan..I agree with hidayah and hannan.. for specific refraction..maybe can be specific to objective refraction..mohindra testing..

    ReplyDelete
  15. I agree with zahirah to perform mohindra retinoscopy while patient is sleeping. Besides, we can also perform Lia acuity card test since the mother told that pt. is good at matching.

    As for hannan's question, don't forget to perform PCT to note the degree of deviation. Hopefully for the next visit she becomes more cooperative and interested in test after recover from fever.

    ReplyDelete
  16. Hmmm..
    From what i've been observed frm the visit, the patient is hyperactive (in her own world)...

    I think, the best test for vision testing is Cardiff cards...
    As long as the child can see the optotype (line drawings or picture), the child will show a preference for the picture as compared with the plain grey background.

    ReplyDelete
  17. waahhh...everybody has commented alot.

    when this patient came in she cried a lot and we only manage to do hirschbergh successfully.

    her parents mention that she is able to match things well and thus we tried to test her vision using LEA Test but fail..

    we also tried to test the vision using beads and as expected, we fail..

    On the next visit, what other vision test should we performed on her??

    as we know, she has Left face turn, Right head tilt and Chin down, the possible underaction muscles are RLR, RIO,LIR and both SR..

    correct me if im wrong.

    park's 3 step test is use to identify the paretic muscle in pt with vertical deviation (ayat miss melanie :P)

    the steps are:
    1) do cover test in primary position to note which muscle is palsy in causing hypertropia

    2) do alternate CT on right and left gaze to determine whether hypertropia increase on R@L gaze.

    3)BHTT

    ReplyDelete
  18. @hidayah

    Do you remember about the 2 LAW. Sherrington's Law and Hering's Law....Please explain in the simplest way in this session.

    ReplyDelete
  19. hmmm not much discussion on the faulty muscle i see.
    after waht has been discussed during the session, we came out with conclusion that the faulty muscles were:
    1.RLR
    2.RIO
    3.BE SR
    4.LIR
    but after reading ms melanie's lecture on head tilt, face turn & chin, i was a bit confused especially on the elevator muscle part.
    is it right that a chin depression (chin down)shows elevator palsy?
    please i need some light on this.
    show me the wayyyyyyyyyyy

    ReplyDelete
  20. Hi guys!

    Sorry for the late respond. I just came back from attending programme organised by SLEU last weekend.

    Well our group had experienced such case during last semester clinic. Yes, definately. It's is difficult to do eye examination on autistic patient (if she is autistic pt). Diagnosis may not be achieved without stern consideration on patient condition.

    First of all, we have to really understand the characteristic of autistic patient.Her behavior at home as well as her interests. This are some characteritics of autistic people.



    A person with autism usually has problems interacting with people in the following ways:

    * may avoid or lack eye-contact,
    * may not imitate others,
    * may not point or use other hand gestures,
    * may prefer to be alone, and
    * may not understand social cues.



    A person with autism will usually have problems communicating, such as:

    * may not speak at all,
    * may be severely language delayed,
    * may have unusual or odd speech patterns (repeat words and phrases heard by others, i.e. tv or videos,
    * may be unable to initiate or engage in a conversation,
    * may be unable to use their imagination during play i.e. pretending a banana is a telephone).



    An individual with autism may show restricted, repetitive, or ritualistic behaviors, interests, and activities, for example:

    * may be preoccupied with a narrow range of interest (i.e. dinosaurs, astronomy, trains or roller coasters,
    * may insist on sameness (i.e. prefer certain clothing or eating only certain foods,
    * may line up their toys or objects,
    * may flap their hands, or make odd hand and body gestures,
    * may spin or like to spin objects,
    * may rock themselves,
    * may be self-injurious i.e. head banging,
    * may anger easily or show aggression,
    * may be resistance to change,
    * may become angry or upset if their daily routine changes in any way, and
    * may focus on only a small part of a toy or object).


    Do you still remember the research conducted by one of our senior, kak syazana or kak rara. (Don't know which one).

    -most of the autistic pt refracted were having hyperopic astigmatism-

    Perhaps on the next visit, we would have an idea on what kind of refractive error that she have, if any.

    I cannot give any idea yet on the above case coz im using my frens lappy.

    p/s: about vision testing, we do have teller acuity card right? we can use it. But, plz bear in mind that, 'autistic pt would have poor eye contact' - im still thinking on suitable tests which can have pt compliance most.

    see you again later.

    ReplyDelete
  21. Hi guys!

    Sorry for the late respond. I just came back from attending a programme organised by SLEU at PD.

    Em, what im thinking now, if she is an autistic pt, we have to consider a few things before we can come out with the appropriate tests to be done on her. Be sure that we really understand her behaviour, interests, the things that she likes and dislikes most, as well as the refractive characteristics of autistic patient.

    Do you still remember bout a research conducted by one of our senior? (don't know which one, either kak syazana or kak rara).

    -the common refractive error experienced by autistic popullation is hyperopic astigmatism-

    so, this will give us a rough idea on what she is actually experienced.

    these are some characteristics of autistic people:

    A person with autism usually has problems interacting with people in the following ways:

    * may avoid or lack eye-contact,
    * may not imitate others,
    * may not point or use other hand gestures,
    * may prefer to be alone, and
    * may not understand social cues.



    A person with autism will usually have problems communicating, such as:

    * may not speak at all,
    * may be severely language delayed,
    * may have unusual or odd speech patterns (repeat words and phrases heard by others, i.e. tv or videos,
    * may be unable to initiate or engage in a conversation,
    * may be unable to use their imagination during play i.e. pretending a banana is a telephone).



    An individual with autism may show restricted, repetitive, or ritualistic behaviors, interests, and activities, for example:

    * may be preoccupied with a narrow range of interest (i.e. dinosaurs, astronomy, trains or roller coasters,
    * may insist on sameness (i.e. prefer certain clothing or eating only certain foods,
    * may line up their toys or objects,
    * may flap their hands, or make odd hand and body gestures,
    * may spin or like to spin objects,
    * may rock themselves,
    * may be self-injurious i.e. head banging,
    * may anger easily or show aggression,
    * may be resistance to change,
    * may become angry or upset if their daily routine changes in any way, and
    * may focus on only a small part of a toy or object).
    A person with autism usually has problems interacting with people in the following ways:

    * may avoid or lack eye-contact,
    * may not imitate others,
    * may not point or use other hand gestures,
    * may prefer to be alone, and
    * may not understand social cues.



    A person with autism will usually have problems communicating, such as:

    * may not speak at all,
    * may be severely language delayed,
    * may have unusual or odd speech patterns (repeat words and phrases heard by others, i.e. tv or videos,
    * may be unable to initiate or engage in a conversation,
    * may be unable to use their imagination during play i.e. pretending a banana is a telephone).



    An individual with autism may show restricted, repetitive, or ritualistic behaviors, interests, and activities, for example:

    * may be preoccupied with a narrow range of interest (i.e. dinosaurs, astronomy, trains or roller coasters,
    * may insist on sameness (i.e. prefer certain clothing or eating only certain foods,
    * may line up their toys or objects,
    * may flap their hands, or make odd hand and body gestures,
    * may spin or like to spin objects,
    * may rock themselves,
    * may be self-injurious i.e. head banging,
    * may anger easily or show aggression,
    * may be resistance to change,
    * may become angry or upset if their daily routine changes in any way, and
    * may focus on only a small part of a toy or object).


    It is easier now right?
    To do the vision testing we can use these as the guideline, perhaps.

    Im using other the clinic pc now,hehe... cannot go further into discussion. I'll be here back later.

    p/s: we do have teller acuity card in our clinic. it can be used for the vision testing.

    ReplyDelete
  22. sorry guys. I've just 'pasted' the autism characteristics twice. please ignore one.

    ReplyDelete
  23. Q1) Suitable vision testing.

    - Forced choice preferential looking (Grating
    paddle, LEA symbols test, teller acuity card,
    Cardiff cards)
    - OKN drum
    - Visually Evoked Potential (but we don't have
    it in our clinic)

    At 6 months child VA should be around 6/36-6/60

    Q2) Involved muscles.

    Face turn indicate horizontal muscle involvement, while head tilt and chin down indicate oblique and vertical muscle involvement.

    For this care child is likely to have:
    Fixating with RE.
    u/a RLR
    u/a IR in BE(depressor muscle)
    u/a RSO

    Q3)Park 3 Step test:

    1) CT at primary position. Identify hypertropic
    eye & measure deviation using prism bar.
    2) Alternating CT on R & L gaze. Measure &
    identify greatest vertical deviation.
    3) BHTT. Head tilt to either shoulder & note
    degree of hypertropia. Sometimes need to
    becareful, if involved head tilt is not
    associated with strabismus, patient may have
    head tilt as a result of weak neck muscle.
    Important to rule this out. Patient need to
    see pediatician.

    Other suggestions:
    - Perform Bruckner test
    - Perform Krimsky test
    - Important also to do slit lamp and fundus
    examination.
    - Since patient it still 6 months, if basic
    visual function such as ability to track and
    seeing things is normal, my suggestion is to
    have patient come back when she's 12 months
    old. In the means time patient must be
    referred to see a pediatrician.

    (Enlighten me if im wrong)

    ReplyDelete
  24. wow everyone has discuss a lot already..i think most of the the things are already being discussed, however i'll add some more..to give feedback from bro muziman regarding sherrington and hering's laws..

    The Sherrington's law of reciprocal innervation, also called Sherrington's law II explains how a muscle will relax when its opposite muscle is activated. in other words, when a muscle contracts, it's direct antagonist relaxes to an equal extent allowing smooth movement..for example, when the muscle of lateral rectus in the right eye is contract, it will relax the reciprocal muscle (medial rectus)of the same eye...and the same time it will also contract the medial rectus of the other eye...

    meanwhile,Hering's law of equal innervation is used to explain the conjugacy of saccadic eye movement in stereoptic animals. The law proposes that conjugacy of saccades is due to innate connections in which the eye muscles responsible for each eye's movements are innervated equally..

    p/s: i think my explanation is not that complete or accurate..anybody can add some more??

    ReplyDelete
  25. i think atikah got it right for the appropriate vision tests which can be done on her..

    tq to azuwan for the info.. :)
    it helps alot...however, for this patient she is not diagnosed yet as autism..even if it is existed, the severity is only mild..

    atikah,sorry if im wrong..this patient had chin down because she cant elevate her eyes..thus, the u/a muccle is elevator mucles which are SR of BE..

    okay guys, correct me if im wrong!! :D

    ReplyDelete
  26. Good info azuwan..

    hmm..i agree with nazaryna about that..
    we still not sure which oblique musle is affected until we done the park's 3 step..

    In my opinion, if we review back and try to imagine about elevator palsy, yes.. actually it will cause chin elevation in order to obtain fusion. so, if the pt has chin depression(chin down), the probably affected muscles might be depressor (IR)... anyone??

    ReplyDelete
  27. @azuwanmusa

    We don't have Teller Acuity Chart.TAC is PL VA testing.. Since we don't have it, we can use other PL VA testing...

    ReplyDelete
  28. Reason for having a chin down is because patient can't look down meaning the eye is somehow hypertropic and patient have problem to repress the eye, chindown help to maintan BSV at primary position. If patient can't elevate the eyes, means that she's hypotropic (eye position down), in this case she would have chin up. I'm confused? HELP me out!

    ReplyDelete
  29. I think i'm on the same road as che nur's...

    ReplyDelete
  30. @azuwanmusa

    Please someone from G2 and G3 give extra info about this girl..eye contact ability and etc (autism symptoms and sign..

    Wif the info..we are able to predict either she has autism or not, or maybe mild autism

    ReplyDelete
  31. @azuwanmusa

    Azuwan..you have posted a nice photo, but, I prefer if you can insert a clearer photo which I can easily your handsome face

    ReplyDelete
  32. To all guys and gurls,

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    ReplyDelete
  33. To correct tiqah, this patient is 30 mo( 2 years, 6 months)not 6 mo...

    ReplyDelete
  34. Tq to ayu on discussing about the laws..

    In simpler words, Hering’s Law states that equal innervations to the contralateral synergists of the mucles. For example; if there is underaction of R LR, there is also underaction of L MR according to this law.

    Secondly, Sherington’s law states that there is reciprocal innervation occurs in the ipsilateral antagonist of the muscle. For example; if there is underaction of R LR, so, there is overaction in R MR.

    Thus possible muscle problem are - R LR, L MR, R SO , L IO, and both depressor muscles…(according to miss melanie’s notes – chin depression have problem with depressor muscle)

    Thus, this pt should be tested for her vision, refractive error, and the muscle problem (depending on what technique most suitable for her that had been discussed above)

    Correct me if there is lacking anywhere or wrong informations..=)

    ReplyDelete
  35. Im agrred on the step-by-step procedures of park-3-step test posted by hanisah.

    im still confused on which faulty muscles are actually involved. If we look at the horizontal OMT test done during the visit, the finding was normal. Meaning to say, she was supposed to have normal action of both medial and lateral rectus muscle. Im I right guys?

    This was contrary to the photo presented by pt's parent, showing that pt was having face turn.

    Do we need more photos to prove that pt really has face/head turn? I think we need them.

    I have one suggestion to look either pt actually has face turn, head tild, chin down or not. PLay a movie or cartoon which pt likes most. We can observe her then.

    i Need to read more on this.

    ReplyDelete
  36. errmmm...I think we should hv a group discussion about abnormal head posture..

    im a bit confuse now..i want to request a special lecture from sir on this topic..

    shall we sir?

    ReplyDelete
  37. @nurlizzz

    Of course can my gurl..But maybe not tommorrow because I've other interesting topic to be shared with all of you dude and gurls.

    ReplyDelete
  38. You still have time to join this case discussion before 12pm..Hurry up

    ReplyDelete
  39. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    ReplyDelete
  40. From what azuwan listed about sign & symp. of autistic, not all characteristics the pt has. For example:
    -eye-contact: pt do have eye contact
    -not imitate others- maybe yes
    -may not point or use other hand gestures: not sure
    -may prefer to be alone: mybe yes (angry if disturb her)
    -may not understand social cues: not sure coz pt still young
    -may not speak at all: pt speak in her ‘language’.. sometimes just pointed or show the things when she wants something..for example; when she wants milk, she just show her bottle. She can say mama, ayah.
    -may be severely language delayed; not sure (she got fever on that day)
    -may have unusual or odd speech patterns (repeat words and phrases heard by others, i.e. tv or videos: not sure, cz she just 2yo.
    -may be unable to initiate or engage in a conversation; mostly, she avoid to communicate or respond to us.
    -may be unable to use their imagination during play i.e. pretending a banana is a telephone; not sure but according to her mother she seems can recognize things.
    -may be self-injurious i.e. head banging: not sure but according to her parents, if she bump onto something, maybe other children will cry, but she not.
    -may anger easily or show aggression: yes, from what we observed.
    -may become angry or upset if their daily routine changes in any way: no, from what br.muzi asked the parents; if the furniture in the house is being reorganized/change, the pt still can recognize her home and familiar with it.

    p/s; correct me or add some more if i/m wrong..=)

    ReplyDelete
  41. need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  42. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  43. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  44. ignore the previous comment.sory not organized well.difficult to edit.(sir, u can delete the previous comment. tqvm.

    From what azuwan listed about sign & symp. of autistic, not all characteristics the pt has. For example:

    1)eye-contact: pt do have eye contact
    2)not imitate others- maybe yes
    3)may not point or use other hand gestures: not sure
    4)may prefer to be alone: mybe yes (angry if disturb her)

    5)may not understand social cues: not sure coz pt still young
    6)may not speak at all: pt speak in her ‘language’..sometimes just pointed or show the things when she wants something.for example; when she wants milk, she just show her bottle. She can say 'mama n ayah'.
    7)may be severely language delayed: not sure (she got fever on that day)
    8)may be unable to initiate or engage in a conversation: mostly she avoid to communicate or respond to us.

    9)may be unable to use their imagination during play i.e. pretending a banana is a telephone: not sure but according to her mother she seems can recognize things.
    10)may be self-injurious i.e. head banging: according to her parents, if she bump onto something, maybe other children will cry, but she not.
    11)may anger easily or show aggression: yes, from what we observed.
    12)may become angry or upset if their daily routine changes in any way: no. From what br.muzi asked the parents; if the furniture in the house is being reorganized/change, the pt still can recognize her home and familiar with it.

    p/s: correct me or add some more if i'm wrong..=)

    ReplyDelete
  45. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  46. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  47. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  48. i've tried to post this comment since 11pm. always failed..stress betul..

    ------------------------------

    it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  49. it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    ReplyDelete
  50. need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  51. tq aida for adding some information!

    ReplyDelete
  52. i've been trying to post this comment since 11pm. bout 20 trials already. always failed!

    -------------------------------------------

    it's not yet 12 o'clock. need to write sometin..hehe

    I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?

    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)

    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.

    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.

    Credit to hanisah(i get it from the same source)

    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic

    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation

    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia


    ----such a long comment, haha-------

    need to add some more.

    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles

    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)


    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  53. I’ve been trying to post this comment since 11pm. Bout 20 trials already. Always failed.
    ---------------------------------------
    it's not yet 12 o'clock. need to write sometin..hehe.....I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?
    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)
    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.
    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.
    Credit to hanisah(i get it from the same source)
    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia
    ----such a long comment, haha-------

    need to add some more.
    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles
    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)
    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  54. I’ve been trying to post this comment since 11pm. Bout 20 trials already. Always failed.

    ---------------------------------------------------------------------------------------------------------------------
    it's not yet 12 o'clock. need to write sometin..hehe…I would like to give my comment n respond on this case.
    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?
    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)
    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.
    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.
    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----
    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.
    Credit to hanisah(i get it from the same source)
    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia
    ----such a long comment, haha-------
    need to add some more.
    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles
    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)
    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  55. I’ve been trying to post this comment since 11pm. Bout 20 trials already. Always failed.
    it's not yet 12 o'clock. need to write sometin..hehe…I would like to give my comment n respond on this case.
    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?
    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)
    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.
    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.
    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----
    3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.
    Credit to hanisah(i get it from the same source)
    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia
    ----such a long comment, haha-------
    need to add some more.
    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles
    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)
    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  56. i've been trying to post a comment since 11pm. 20 trials already. but always failed! stress nyerr...

    ReplyDelete
  57. I would like to give my comment n respond on this case.

    1) the suitable test can any forced preferential looking vision testing, we do have lea gratings paddle in our clinic. If pt able yo recognise the lea symbols, it can be used as well. This is more appropriate to her age right?
    2) this is what come to my mind:
    Left face turn: o/a LMR, o/a RLR, u/a LLR, u/a RMR - eg: in case of pt with ET due to o/a of LMR, pt tent to have left face turn no avoid diplopia (least deviation)
    Right head tilt: o/a of levator muscle on RE causing hypertropia , RSR / RIO. it also can be due to hypotropia on the LE becoz of o/a of LSO n LIR.
    Chin down: this happened if pt has hypertropia. (o/c of any levator muscles SR,IO). Chin down to the less deviating position.

    ----these are merely on what sir muziman has written in the above case----- the actualy causes of AHP may vary----need to do more test on pt in order to get correct diagnosis, and to look for faulty muscles-----

    ReplyDelete
  58. 3) park's 3 step
    - this is to identify the paretic muscle in an incommitant deviation with a vertical ocmponent.
    Credit to hanisah(i get it from the same source)
    a.Step 1 : CT is performed in primary position, noting which eye is hypertropic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia

    ReplyDelete
  59. need to add some more.
    1) hering's law of equal innervation (yoke).
    - contra lateral synergists are equally innervated.
    - synergist = same action
    - yoked muscles
    2) Sherrington's law of reciprocal innervation (antagonist)
    - contraction of a muscle is accompanied with a simultaneous & proportion relaxation of its antagonist.
    - antagonist = opposing action.
    - same eye, ipsi-lateral eye (primary antagonist)
    During the next visit, we need to consider this tests:
    - bruckner test
    - CT
    - OMT
    - Ret (for sure la)

    ReplyDelete
  60. selepas sejam lebih berhempas pulas, akhirnya dpt jugaak post. tu pun sy dah split kpd 3 komen....kegigihan.

    sorry for that guys!

    aida, that one is just a general classification of autistic pt.

    - always bomp into things can be an indication of vision problem. can be either VF problem or uncorrected ref error. Can also be caused by others factors.

    -did the pt have frequent blinking or eye rubbing?

    ReplyDelete
  61. assalamualaikum,

    sorry for the very late comment on this discussion. i was on medical leave because of diarrhea..pity me..huhuhu

    for the above case,
    1. i would suggest to use lea chart and mohindra for this patient.this is based on her age and response.

    2. i would agree with atikah for the the possible u/a and o/a which are
    Fixating with RE.
    u/a RLR
    u/a IR in BE(depressor muscle)
    u/a RSO

    o/a LLR
    o/a LIO

    3.
    Park’s 3 Step Test :
    •Use to identify paretic muscle in pts with vertical deviation
    •Only works for paretic and oblique muscle (SR, IR, SO, IO)
    •False reading if more than 1 muscle is weak or if there is restriction

    a.Step 1 : CT is performed in primary position, noting which eye is hyperopic
    b.Step 2 : Alternate CT is performed on R n L gaze to assess the direction of greater vertical deviation
    c.Step 3 : The Bielschowsky Head Tilt Test (BHTT) is performed, tilting the head to either shoulder and note the difference in the degree of hypertropia

    ReplyDelete
  62. sorry sir x follow2 lg.sbb sy nak follow by twitter tp xdpt2..huu

    ReplyDelete
  63. Hering Law= Contralateral Synergist

    Sherrington Law= Ipsilateral Antagonist

    E.g

    Look at right;

    Contraction of RLR & LMR.

    Relaxation of RMR.

    ReplyDelete
  64. MS

    O/A Contralateral synergist
    O/A Ipsilateral antagonist
    U/A Contralateral antagonist

    ReplyDelete

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