Muscle Imaging
Muscle MRI and UltrasoundTable SEQ Table \* ARABIC 1 Muscle MRI and Ultrasound Date and LocationTestDate Performed (YYYY-MM)Where PerformedMuscle MRIData to be filled in by siteData to be filled in by siteUltrasoundData to be filled in by siteData to be filled in by siteIs a pattern seen? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is this pattern consistent with one described in a CMD subtype? FORMCHECKBOX Yes FORMCHECKBOX No, specify:Thigh MusclesTable SEQ Table \* ARABIC 2 Thigh Muscles MRI and Ultrasound ResultsMuscleLevel of Involvement on MRILevel of Involvement on UltrasoundPattern on UltrasoundVastus lateralis FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeVastus intermedius FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeRectus femoris FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeVastus medialis FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeAdductor longus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeSartorius FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeAdductor magnus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeGracilis FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeBiceps femoris FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeSemitendinosus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeSemimembranosus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeCalf MusclesTable SEQ Table \* ARABIC 3 Calf Muscles MRI and Ultrasound ResultsMuscleLevel of Involvement on MRILevel of Involvement on UltrasoundPattern on UltrasoundGastrocnemius: medial FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeGastrocnemius: lateral FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeSoleus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeTibialis anterior FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeTibialis posterior FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeExtensor digitorum longus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeExtensor digitorum brevis FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likePeroneus longus FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Yes – severe FORMCHECKBOX Yes – mild/moderate FORMCHECKBOX No FORMCHECKBOX Granular FORMCHECKBOX Mixed FORMCHECKBOX Streak-likeGeneral InstructionsThis form contains data elements that are collected from muscle imaging to assess progression of disease.Responses to categories are obtained from health professionals performing the procedure and laboratory tests results.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.MRI and Ultrasound date performed - The preferred format for recording date is YYYY-MM. 9999-99 can be used to indicate an unknown date. ................
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