Quantitative manual testing - Dystrophie Myotonique · QUANTITATIVE MUSCLE TESTING OF ANKLE DORSI FLEXION AND FEET EVERSORS USING A CHATILLON TYPE DYNAMOMETER: PROTOCOL Investigator

QUANTITATIVE MUSCLE TESTING OF ANKLE DORSI FLEXION AND FEET EVERSORS

USING A CHATILLON TYPE DYNAMOMETER: PROTOCOL

Investigator for this part of the project: Dr. Luc J. Hébert

May 8 2006

Steinert study / evaluation of maximal isometric muscle strength by QMT and MMT

Luc J. Hébert, May 8 2006

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Instructions for evaluators: GENERALITIES: To ensure precision and constancy for each evaluation, it is important to:

Know the standard evaluation procedure. It is essential to specifically follow the positions and stabilizations mentioned in the protocol and to use only the recommended accessories. If modifications are necessary, they must be duly noted in the commentary section.

Make sure that you understand the instructions to be given to the subjects and take time to become familiar with the procedure by practicing before you begin the tests. Ideally, you should only keep the measurements with high validity. When in doubt, make a note in the commentary space (ex: Difficulty with cooperation or comprehension, compensation, difficulty to stabilize, presence of spasms, etc.).

If possible, always proceed with the evaluations at the same time of the day for each and every session, so that fatigue does not affect the measurements and verify that the subject is in his usual physical condition (no presence of cold or flu, no unusual physical activity in the last 48 hours before the evaluation, etc.). Always follow the same order for muscular testing from one session to the next.

Make sure that the subject presents no contraindication to undergo the muscular strength

evaluation tests (pain or unusual fatigue). In order to ensure that fatigue is not a significant variable, the order of Quantitative

Muscular Testing (QMT) and Manual Muscular Testing (MMT) will be alternated from one subject to another. For example, subject 1 will first be evaluated by starting with QMT followed by MMT, subject 2 will first be evaluated with MMT followed by QMT, and subject 3 will first be evaluated with QMT followed by MMT, and so on.

Specifically for MMT: During the evaluation of a muscle group, if there is a difference of more than 3 in the

ratings for 2 successive trials, you must do a third test. For analysis, the highest rating (2 tests leading to 2 adjacent ratings) or the median rating between 2 extreme ratings (when 3 tests must be done) will be used.

Specifically for the QMT with the Chatillon Type Manual Dynamometer: Master all aspects of the Chatillon type dynamometer before you begin the evaluation. Make sure that the dynamometer’s surface is always perpendicular to the limb segment and

that it is always applied to the exact same area on the limb segment for every test and session.



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Make sure that the evaluator’s and the subject’s positions remain completely stable. Since these tests are “make tests”, you must always wait until you feel the subject’s resistance and not “push” on the limb segment.

During the evaluation of a muscle group, if there is more than a 10% difference between 2

successive tests, you must do a 3rd test. If, after a 3rd test there is still a difference of more than 10% between compared tests, you must then do a fourth and final test.

Feedback:

It is extremely important to encourage the subject in a constant and uniform manner. Use a tone of voice that varies progressively from normal, to strong, to very strong. Use a number of words that will encourage the subject for the entire duration of the test, i.e. 6 to 10 seconds. Suggestions: “Go on, go on, go on, push, push” or “Push hard, push hard, harder, harder” or “Go, go, go, keep going, keep going” …

Use the starting instructions: “1, 2, 3, GO”. It is very important to make sure that the contraction begins at the word “GO” and stops when you say “Relax” and have ceased all verbal encouragement.

*Please note that the masculine form is used only to simplify the text.



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1. QUANTIFIED MUSCULAR TESTING (QMT) DORSAL ANKLE FLEXORS SUBJECT’S POSITION: Supine position (lying on his back), legs stretched out, ankles over the edge of the table. Place a

raised half-roll under the knees and a non-slip pad under the subject’s posterior. Ankle tested at 90° dorsi flexion, toes slightly extended. The subject will remain stable by holding the sides of the table with his hands. Place a mirror so that you can observe the patient during the test.

EVALUATOR’S AND DYNAMOMETER’S POSITIONS: The evaluator must be on the same side as the ankle to be tested, with the inferior member adjacent

to the bed at an open angle and facing the front. This enables the evaluator to be as close to the patient as possible and to offer optimal resistance to dorsi flexion.

The surface of the dynamometer is placed on the dorsal surface of the foot as distally as possible to the head of the metatarsus. The dynamometer must be perfectly perpendicular to the foot and situated opposite the dorsi flexion of the ankle.

The evaluator’s elbows must be “locked” into his hips or against his thighs. The forearm adjacent to the member to be evaluated should rest on the table, in contact with the

lateral surface of the leg. Important: When doing this test it is often difficult to keep the dynamometer perpendicular to the surface of the foot. Make sure that the starting position is maintained during the entire test. PROCEDURE: 1. MEASURING THE LENGTH OF THE LIMB SEGMENT: The limb segment must be measured while in the test position, i.e. 90° dorsi flexion (or ˗10 if complete dorsi flexion is impossible). Make a pencil mark on the foot at the point where the dynamometer touches it, on the dorsal surface as distally as possible to the head of the metatarsus. Measure the length of the lever, i.e. the perpendicular distance between the distal extension from the middle of the external malleolus of the ankle and the extension from your mark indicating the upper edge of the part of the dynamometer that touches the foot. Take note of the length of the lever in cm. This distance will be used for all other successive measurements of dorsi flexion strength. Measure the length of both the right and left segments before starting the strength tests. 2. TAKING MEASUREMENTS: a. Always start with the ankle that is the strongest (side that is considered the least affected). b. Check the total possible amplitude of the dorsi flexion movement by manipulating the ankle. If the subject does not have more than 90° of dorsi flexion (neutral position), the evaluation must be done at ˗10 dorsi flexion (take note of this in the commentary section of the evaluation file). c. Ask the subject to perform at least 2 consecutive active pure dorsi flexion movements (guide him if necessary) while in the evaluation position. d. Ask the subject to execute a dorsi flexion effort equivalent to approximately 50% of his maximum capacity. This will enable you to verify the quality of the contraction and the stability of the evaluation position.



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e. Take note of any pain with the help of the PPI scale before starting the test. f. Calibrate the Chatillon machine by setting it to zero. g. Ask the subject to execute a progressive voluntary maximal isometric contraction. Encourage the subject throughout the effort by following the above-mentioned instructions. Take note of the Newton force registered for this first test. Immediately rate the presence of pain during effort by using the PPI scale and enter the rating (0 to 5) in the file for the first test. h. Wait 60 seconds and ask for a second maximal isometric contraction. Take note of the result obtained for this second test as well as of the pain intensity for this second effort (PPI 0 to 5). If there is more than a 10% difference between the 2 tests, you must do a 3rd test. As mentioned in the general instructions, you must do a fourth test if needed. i. Repeat steps a to h for the other ankle.



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FOOT EVERSORS

SUBJECT’S POSITION: Supine position (lying on his back), legs stretched out, ankles over the edge of the table. Place a

raised half-roll under the knees and a non-slip pad under the subject’s posterior. Ankle tested at 90° dorsi flexion, toes slightly extended. The subject will remain stable by holding the sides of the table with his hands. Place a mirror so that you can observe the patient during the test. To increase the subject’s stability, the knee of the inferior member that is not being tested must

remain flexed with the foot flat on the table. EVALUATOR’S AND DYNAMOMETER’S POSITIONS: The evaluator must be at the end of the table on the side being tested. A strap is attached to the most distal part of the tested leg and to the evaluator’s hip. This strap

ensures a counter resistance which permits to stabilize the inferior member being tested and free both of the evaluator’s hands for a better grip.

The surface of the dynamometer must be right under the fifth metatarsus, perpendicular to the axis of the foot.

The evaluator’s elbows are “blocked” and resting on the thighs or EIAS. PROCEDURE: 1. MEASURING THE LENGTH OF THE LIMB SEGMENT: Make a pencil mark on the foot at the point where the upper edge of the dynamometer touches the foot surface, i.e. on the lateral surface right under the head of the fifth metatarsus. Measure the length of the



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lever i.e. the perpendicular distance between the inferior prolongation of the external malleolus of the ankle and your pencil mark indicating the upper edge of the part of the dynamometer that touches the foot. Take note of the length of the lever in cm in the file. This distance will be used for all other successive measurements of dorsi flexion strength. Measure the length of both the right and left segments before starting the strength tests. 2. TAKING MEASUREMENTS: a. Always start with the ankle that is the strongest (side that is considered the least affected). b. Check the total possible amplitude of the dorsi flexion movement by manipulating the ankle. If the subject does not have more than 90° of dorsi flexion (neutral position), the evaluation must be done at ˗10 dorsi flexion (take note of this in the commentary section of the evaluation file). c. Check the total possible amplitude of the eversion movement by manipulating the ankle. Explain to the subject that this is the proper direction for the movement that needs to be done. d. Ask the subject to execute at least 2 consecutive pure active eversion movements (guide him if necessary). e. Ask the subject to make an eversion effort equivalent to approximately 50% of his maximum capacity, which will enable you to verify the quality of the contraction and the stability of the evaluation position. f. Take note of any pain with the help of the PPI scale before starting the test. g. Calibrate the Chatillon machine by setting it to zero. h. Ask the subject to execute a progressive voluntary maximal isometric contraction. Encourage the subject throughout the effort by following the above-mentioned instructions. Take note of the Newton force registered for this first test. Immediately rate the presence of pain during effort by using the PPI scale and enter the rating (0 to 5) in the file for the first test. i. Wait 60 seconds and ask for a second maximal isometric contraction. Take note of the result obtained for this second test as well as of the pain intensity for this second effort (PPI 0 to 5). If there is more than a 10% difference between the 2 tests, you must do a 3rd test. As mentioned in the general instructions, you must do a fourth test if needed. j. Repeat steps a to i for the other ankle.



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2. MANUAL MUSCULAR TESTING (MMT) 2.1 DORSAL ANKLE FLEXORS A. FOR MUSCULAR STRENGTH RATINGS 2+ TO 5 SUBJECT’S POSITION: Seated on the edge of the table, legs hanging and a rolled towel placed under the knees. The subject must keep the upper body straight and remain stable by holding the edge of the table. EVALUATOR’S POSITION: Seated on a fixed bench, facing the subject or slightly to the side. PROCEDURE: TAKING MEASUREMENTS: a. Always start with the strongest and less affected side. b. Take note of any pain with the help of the PPI scale before starting the test. c. Ask the subject to execute a maximal active dorsi flexion movement and to maintain resistance at the end of the movement. d. Apply resistance to the dorsal surface of the foot with one hand while holding the posterior distal part of the tibia with the other hand. The evaluator must do a “break test”, thus trying to break resistance. Take note of the registered strength according to the muscular testing ratings from 3+ to 5. e. If the subject is unable to resist to any opposing force when in complete amplitude of movement, ask the subject to execute the movement to his maximal capacity and take note of the registered strength according to the muscular testing ratings from 2+ to 3. f. Rate the presence of pain during effort with the help of the PPI scale and take note of the rating (0 to 5) for this first test in the file. g. Wait 60 seconds and do a second test. Take note of the obtained results for this second test and of the pain intensity during this second effort (PPI 0 to 5). If the difference between the 2 tests is more than 3 ratings (Appendix 1) you must do a 3rd test. h. Repeat steps a to g for the other ankle. B. FOR MUSCULAR STRENGTH RATINGS FROM 0 TO 2 (When the subject is unable to execute a movement against gravity (weight)) SUBJECT’S POSITION: Lying down on his side, the leg that is not being tested is bent and in contact with the table, and the

leg being tested is stretched out, parallel to the floor and resting on a bench placed on the table and aligned with the upper body.

The subject’s head is resting on a pillow, upper body and head must be aligned and the subject can stabilize himself by holding onto the edge of the table with his hands.



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EVALUATOR’S POSITION: Standing up facing the subject or slightly to the side. The evaluator must be positioned in order to be

able to see the movement. PROCEDURE: TAKING THE MEASUREMENTS: a. Always start with the strongest and less affected side. b. Take note of any pain with the help of the PPI scale before starting the test. c. Ask the subject to execute an active dorsi flexion movement. Stabilize the leg above the ankle in to avoid compensation. Take note of the registered strength according to the muscular testing values and ratings from 2- to 2. d. Rate the presence of pain during effort with the help of the PPI scale and take note of the rating (0 to 5) for this first test in the file. e. Wait 60 seconds and do a second test. Take note of the result obtained for this second test and the intensity of pain during this second effort (PPI 0 to 5). f. If there is no dorsi flexion movement at step c, the evaluator must determine whether there is a contraction of the anterior leg muscle or not. g. The evaluator must ask the subject to execute a dorsi flexion movement while feeling the anterior tendon of the leg. Take note of the muscular rating between 0 and 1. h. Rate the presence of pain during effort with the help of the PPI scale and take note of the rating (0 to 5) for this first test in the file. i. Wait for 60 seconds and do a second test. Take note of the results obtained for this second test and of the pain intensity during this second effort (PPI 0 to 5). j. Repeat steps a to i for the other ankle. 2.2 FOOT EVERSORS A. FOR MUSCULAR STRENGTH RATINGS FROM 2+ TO 5 SUBJECT’S POSITION: Seated on the edge of the table, legs hanging and a rolled towel placed under the knees. The subject must keep the upper body straight and remain stable by holding the edge of the table.

EVALUATOR’S POSITION: Seated on a fixed bench, facing the subject or slightly to the side. PROCEDURE: TAKING MEASUREMENTS:



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a. Always start with the strongest and less affected side. b. Take note of any pain with the help of the PPI scale before starting the test. c. Ask the subject to execute an active eversion movement at 90° dorsi flexion and maximal amplitude and to maintain the position. d. Apply resistance to the head of the fifth metatarsus with one hand while the other hand holds the medial distal part of the tibia in place. The evaluator must do a break test and thus try to break resistance. Take note of the registered strength according to the muscular testing ratings and values between 3+ and 5. e. If the subject is unable to resist to any opposing force when in complete amplitude of movement, ask the subject to execute the movement in the possible amplitude and take note of the registered strength according to the muscular testing ratings from 2+ to 3. f. Rate the presence of pain during effort with the help of the PPI scale and enter the rating (0 to 5) for this first test in the file. g. Wait for 60 seconds and do a second test. Take note of the result obtained for this second test as well as the intensity of pain during this second effort (PPI from 0 to 5). If the difference between both tests is greater than 3 ratings (Appendix 1), you must do a 3rd test. h. Repeat steps a to g for the other ankle. B. FOR MUSCULAR STRENGTH RATINGS FROM 0 TO 2 (When the subject is unable to execute a movement against gravity (weight)) SUBJECT’S POSITION: Supine position (lying on his back), legs extended, a roll placed under the knees, ankles over the

edge of the table. The subject will remain stable by holding the sides of the table with his hands.

EVALUATOR’S POSITION: Seated on a fixed bench, facing the subject or slightly to the side. The evaluator must be positioned

in order to be able to see the movement. PROCEDURE: TAKING THE MEASUREMENTS: a. Always start with the strongest and less affected side. b. Take note of any pain with the help of the PPI scale before starting the test. c. Ask the subject to executive an active eversion movement at 90° dorsi flexion. Stabilize the leg above the ankle to avoid compensation. Take note of the registered strength according to the muscular testing values and ratings between 2- and 2. d. Rate the presence of pain during effort with the help of the PPI scale and note the rating (0 to 5) for this first test in the file.



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e. Wait for 60 seconds and do a second test. Take note of the obtained results for this second test as well as the intensity of pain during this second effort (PPI 0 to 5). f. If there is no eversion movement at step 3, the evaluator must determine whether the fibular muscles are contracting or not. g. The evaluator will ask the subject to execute an eversion movement while feeling the fibular tendon. Take note of the muscular rating between 0 and 1. h. Rate the presence of pain during effort with the help of the PPI scale and note the rating (0 to 5) for this first test in the file. i. Wait for 60 seconds and do a second test. Take note of the obtained results for this second test as well as the intensity of pain during this second effort (PPI 0 to 5). j. Repeat steps a to i for the other ankle.



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APPENDIX 1. Modified Quebec MRC Scale for manual muscular test ratings (adapted from the modified Quebec scale by LJ Hébert – April 2006)

Rating Modified-Modified Medical Research Council Scale Score

5 Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added a maximal opposing resistance (it must be impossible for the evaluator to break resistance).

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5- Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added a maximal opposing resistance from which the subject tends to slightly weaken.

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4+ Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added a maximal opposing resistance.

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4 Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added a moderate opposing resistance.

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4- Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added a minimal opposing resistance.

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3+ Sufficient muscular strength to resist gravity (weight) with limb segment in full amplitude to which is added an opposing resistance that the person cannot hold and must abruptly release.

5

3 Sufficient muscular strength to fight gravity (weight) with limb segment in full evaluation amplitude.

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3- Sufficient muscular strength to fight gravity (weight) with limb segment in ¾ of amplitude movement.

3

2+ Sufficient muscular strength to fight gravity (weight) with limb segment in 1/3 of amplitude movement.

3

2 Sufficient muscular strength to mobilize a joint in full amplitude when no weight is applied.

2

2- Sufficient muscular strength to mobilize a joint in half (1/2) the amplitude when no weight is applied.

2

1 Minimal contraction without perceptible movement

1

0

No detectable contraction 0



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APPENDIX 2. Present Pain Index Scale (PPI) developed by Melzack and adapted by Hébert et al. (2001).

Present Pain Index (PPI)

0 None

1 Low

2 Uncomfortable

3 High

4 Severe

5 Intolerable



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APPENDIX 3. Data form for maximal isometric muscle strength.

MUSCULAR STRENGTH EVALUATION FILE (front) Patient’s name: Evaluator: Date of birth: Date: File number: Time: Sex: male female Session : D0 D0+21 M18 M18+21D M36 M36+21D

QUANTIFIED MUSCULAR TESTING (QMT)

Executed: first second

Newton force

(PPI: /5) Muscles R L

Variations/Comments

PPI resting :

PPI resting :

Dorsal ankle flexors

length of segment (m): R : - 0.8 cm* = L : - 0.8 cm =

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

4.

(PPI: )

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

4.

(PPI: )

Feet eversors

length of segment (m) :

R : - 0.8 cm = L : - 0.8 cm =

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

4.

(PPI: )

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

4.

(PPI: )

* this 0.8 cm value represents half the width of the support surface that must be used for this test.



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MUSCULAR STRENGTH EVALUATION FILE (back) Patient’s name: Evaluator: Date of birth: Date: File number: Time: Sex: male female Session : D0 D0+21 M18 M18+21D M36 M36+21D

MANUAL MUSCULAR TESTING (MMT)

Executed: first second

Strength - Rating

(PPI: /5) Muscles R L

Variations/Comments

Dorsal ankle flexors

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

Feet eversors

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )

1.

(PPI: )

2.

(PPI: )

3.

(PPI: )



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APPENDIX 4. Balanced evaluation sequence to collect data on the measurement of isometric muscle strength of dorsal flexors (DF) and feet eversors (EV) for Quantified Muscular Testing (QMT) and Manual Muscular Testing (MMT) for the 24 subjects in the study. Each sequence will be repeated simultaneously for the data collected at the France site and at the Quebec site on Day 0 (D0), on Day 0 + 21 days (D0+21D), at Month 18 (18M), at Month 18 + 21 days (18M+21D), at Month 36 (36M) and at Month 36 (36M) + 21 days (36M+21D). Subject 1 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT FD 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 2 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M+21D : QMT EV 2. QMT DF 3. MMT EV 4. MMT DF Subject 3 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF Subject 4 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF J0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV Subject 5 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV



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Subject 6 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 7 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF Subject 8 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF D0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV Subject 9 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 10 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M+21D : QMT EV 2. QMT DF 3. MMT EV 4. MMT DF Subject 11 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF



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Subject 12 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF D0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV Subject 13 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 14 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M+21D : QMT EV 2. QMT DF 3. MMT EV 4. MMT DF Subject 15 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF Subject 16 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF D0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV



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Subject 17 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 18 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M+21D : QMT EV 2. QMT DF 3. MMT EV 4. MMT DF Subject 19 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF Subject 20 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF D0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV Subject 21 D0: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV D0+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M+21D : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV Subject 22 D0: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV D0+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 18M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M+21D: QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 36M : MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M+21D : QMT EV 2. QMT DF 3. MMT EV 4. MMT DF



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Subject 23 D0: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF D0+21D: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 18M : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M+21D: 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 36M : 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M+21D : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF Subject 24 D0: 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF D0+21D: 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV 18M : 1. MMT DF 2. MMT EV 3. QMT DF 4. QMT EV 18M+21D: 1. QMT EV 2. QMT DF 3. MMT EV 4. MMT DF 36M : 1. MMT EV 2. MMT DF 3. QMT EV 4. QMT DF 36M+21D : 1. QMT DF 2. QMT EV 3. MMT DF 4. MMT EV

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Quantitative manual testing - Dystrophie Myotonique · QUANTITATIVE MUSCLE TESTING OF ANKLE DORSI FLEXION AND FEET EVERSORS USING A CHATILLON TYPE DYNAMOMETER: PROTOCOL Investigator