Mobility Group
THE WOLFSON CENTRE FOR INHERITED NEUROMUSCULAR DISEASE (CIND)
The Clinical Research Team:
Prof Tracey Willis, Dr Richa Kulshrestha, Claire Bassie (specialist nurse), James Jones (DMD HUB advanced nurse practitioner), Nick Emery (senior specialist neuromuscular physiotherapist), Jenny Moustoukas (specialist neuromuscular physiotherapist with respiratory interest), Kate Stracham (specialist neuromuscular physiotherapist), Ellen Thompson (DMD HUB neuromuscular physiotherapist), Kerry Jones (care advisor), Yvette Easthope-Mowatt (Clinical Psychologist), Chloe Perry (DMD HUB trials coordinator), Sarah Clamp (Senior study support officer)
The Laboratory Research Team:
Dr. Heidi Fuller, Prof. Glenn Morris, Prof. Caroline Sewry, Dr Ian Holt, Dr Le Thanh Lam, Dr Sharon Owen, Emily Storey. Affiliate member: Dr Melissa Bowerman (Keele)
The clinical research team are actively engaged in several pioneering clinical trials and studies involving patients at RJAH and further afield. The internationally recognised laboratory team, meanwhile, work to find new ways to diagnose and treat inherited neuromuscular diseases. By designing and developing highly specialised research tools and combining these with the use of cutting edge “omics” technology, their research aims to unravel the complexities of disease mechanisms and identify new targets for therapy development.
The laboratory and clinical teams work closely together to promote research and clinical trials as part of clinical practice and access for all. As a group, they are highly committed to training the next generation of scientists and doctors at RJAH and work closely with affiliated Universities at Keele, Manchester and Chester to deliver this.
The Clinical Research Team
The Muscle Team continues to hold “Centre of Clinical Excellence” status for paediatric and adult patients, an award given by the Muscular Dystrophy UK (MDUK) in 2019. This is currently undergoing the standard 3-year review audit, delayed due to COVID. The team were also proud to be awarded Duchenne Muscular Dystrophy (DMD) HUB status in November 2019 for DMD clinical trials.
The Laboratory Research Team have had a productive year working on active research projects funded by UK-based charities. Beyond the impact of the charity-funded work on advancing research into neuromuscular disorders, grant awards benefit the research group enormously by retaining the best scientists; by facilitating new researchers with valuable skills to join the discipline; by training the next generation of researchers; and by facilitating new transnational research collaborations. The team are particularly grateful to the Orthopaedic Institute for their support of pilot studies within CIND which is a vital step towards gaining proof-of-concept evidence for larger grant applications to external funding organisations.
CLINICAL RESEARCH PROJECTS
The Muscle Team continues to participate in multicentre studies of the natural history of Spinal Muscular Atrophy (SMA REACH project) and the genetics of Duchenne muscular dystrophy (DMD). The Muscle Team continues with its successful ITALFARMACO trial, now in the extension phase after a positive interim analysis, a placebo-controlled trial aiming to reduce fibrosis in dystrophic muscle.
It continues with SMA REACH both for paediatrics and adults and Oswestry was acknowledged recently as one of the four top recruiting sites. They have also fully recruited to the rare 12 disease project for DMD and have various studies in set up including antisense therapeutics, Sarepta and hydrotherapy trials (all DMD). They were awarded the status of DMD HUB site in 2019 and with this funding for research physio, advanced nurse practitioner and coordinator and all posts have been filled following COVID.
The team have also successfully completed several studies with patients with Facioscapulohumeral Dystrophy (FSHD) in collaboration with both Keele and Liverpool University, including a pilot study of arm cycling in patients with FSHD, a FSHD ultrasound and biomechanics project and more recently a qualitative study, “Best practice conservative non-pharmacological management for patients with FSHD”. Prof Willis is also one of the founder members of FSHD UK, bringing together six clinical sites, which aims to harmonise FSHD clinical appointments and enable UK trial readiness for FSHD.
Treatment of SMA has been greatly advanced by availability of gene therapy for severe SMA since mid-2021. Urgent work is now underway via a national group to establish a Newborn Screening programme within the UK. Prof Willis was appointed by NHS England to a fixed-term role on a national gene therapy multidisciplinary team during the set up in the first year in the UK. Nusinersen, an intrathecal treatment, for patients with severe SMA continues now through a Managed Access Agreement (MAA) for both children and adults with SMA type 1,2 and 3 and as of January 2022, Risdiplam, an oral therapy, also became available for these patients as a MAA.
The Clinical Team has been the main hub in collaboration with University Hospital of North Midlands in the West Midlands region for delivering Nusinersen for children in the West Midlands and through Birmingham (UHB) and Salford for the adults who attend Oswestry.
LABORATORY RESEARCH PROJECTS
Spinal muscular atrophy
Without treatment, SMA is the most common genetic cause of death in infants in the UK, and it is estimated that there are approximately 2,000 – 2,500 children and adults living with the condition in the UK. Although recent research has led to breakthroughs in the treatment of SMA type 1, less attention has been given to understanding the molecular pathways involved in the less severe types of SMA.
With funding from Sparks and Great Ormond Street Hospital (GOSH) Children’s Charity, a study led by Dr Heidi Fuller and Dr Sharon Owen as postdoctoral research associate, examined the quantities of molecules produced by various cells from patients with differing severities of SMA and compared them to the proteins produced by age-matched control cells. The results of the study showed that the molecular biology of different types of SMA are different. This may have implications for future therapy design, optimisation and efficacy monitoring.
Findings from this study were published in the “Cells” journal, where their article was selected as the “Editor’s Choice” and in the “Gene Therapy” journal in collaboration with scientists at Royal Holloway University in London. In addition, their work was shared at national conferences (SMA UK, 2020 and Nerve & Muscle Interest Group, 2022) and internationally (SMA Europe, 2022 – Paris, France; World Muscle Society, 2021 – Online; Neuromuscular Study Group, 2022 – Stresa, Italy) as podium and poster presentations.
Further to the GOSH project, additional financial support was awarded from the Orthopaedic Institute Ltd and Keele University (Faculty Research Fellowship funding, 2022 & 2023) to continue the work and to support the development of additional collaborations both nationally (London, Edinburgh, Salford & Ulster) and internationally (Hannover & Geneva). Current research is examining the possibility of severity[1]specific biomarkers that may prove useful for monitoring current SMA treatment. In addition, the potential of “old drugs” that have proven to be beneficial in the treatment of other diseases will be examined as possible treatments for adult SMA patients with less severe forms of SMA.
Figure 2 – Heat map illustrating the lack of molecular overlap between SMA Type I, II and III
Understanding the effects of glucocorticoids on bone health
Glucocorticoids are prescribed to 1-3% of the UK population for a wide range of conditions but have harmful side effects including glucocorticoid-induced osteoporosis which is the most frequent cause of osteoporosis in adults under 50 years of age. These negative effects on bone can reduce quality of life and influence survival in certain situations. Vamorolone is a new first-in-human investigational glucocorticoid analogue that may be safer for bone health than routinely used glucocorticoids.
Clinical trials of vamorolone for Duchenne Muscular Dystrophy are underway but it is yet to be approved for routine use or trial for other conditions as fundamental evidence regarding its mechanism of action is lacking.
With generous funding from the Michael Davie Research Foundation, Dr Heidi Fuller and Sharon Owen have begun a project evaluating which proteins are altered in expression following vamorolone treatment of a human bone cell line. These results will be compared to protein changes following treatment with routinely prescribed glucocorticoids. This will help to reveal insights into the mechanisms of drug action, particularly those associated with undesired side-effects and may contribute a case for widening studies of valmorolone to other patient groups at risk of glucocorticoid-induced osteoporosis.
A stable human Schwann cell model of Charcot-Marie-Tooth disease type 1A
Dr Ian Holt and colleagues have been working on a project funded by the Orthopaedic Institute Ltd to make and utilise a human Schwann cell model of Charcot-Marie-Tooth disease type 1A (CMT1A). CMT1A is a hereditary condition affecting the insulating myelin sheath surrounding peripheral nerves which results in muscle weakness and wasting, and loss of sensation. Schwann cells surround the axons in peripheral nerves and produce the myelin sheath. In CMT1A, duplication of the PMP22 gene causes overexpression of peripheral myelin protein 22 (PMP22) in Schwann cells, leading to myelin sheath defects and nerve damage and loss. Therapy development is hindered by limited insights into the molecular pathways involved in PMP22 accumulation and clearance, and by limitations of current disease models, including high cost, time, and variability.
To overcome the limitations of current disease models, human immortalised Schwann cells were engineered with plasmid vectors, to overexpress PMP22. The overexpressed fusion proteins contained a Green Fluorescent Protein (GFP) tag for visual identification and a promiscuous biotin ligase (BioID2) tag for proximity-dependent biotinylation. Control cells, expressing the two tags without PMP22 were also produced. Schwann cells were selected and cloned and the resultant cell lines validated to confirm that they were expressing the appropriate recombinant proteins. Control cells often had a smooth and regular appearance (as seen with non-transfected Schwann cells), whereas those cells overexpressing PMP22 had a spiky irregular appearance. Overexpressed PMP22 exhibited a punctate appearance and asymmetric localisation within the cytoplasm, suggestive of a role in Schwann cell polarity Figure 3.
This work was presented at the Neuromuscular Study Group conference, Italy (2022), for which travel funding was awarded for the work being ranked among the top 15% of all submissions.
The BioID2 tag was used to label and enrich any proteins within close proximity that were interacting with the overexpressed PMP22, including low affinity and transient interactions. The identity of these interacting partners was revealed by proteomic analysis.
Several hundred proteins were identified in proximity of PMP22. Some of the proteins and pathways represent potential therapeutic targets for CMT1A by promoting degradation and enhanced trafficking of PMP22. The proteins were associated with several enriched molecular pathways including paxillin signalling which is responsible for regulating cell shape, motility and spreading and neuregulin signalling which promotes Schwann cell expansion, survival and myelination. One of the PMP22-interacting proteins was Extended Synaptotagmin-like Protein 1 (ESYT1), which is a component of the endoplasmic reticulum membrane. Microscopic analysis revealed close association between ESYT1 and overexpressed PMP22 Figure 4.
This new cell model of CMT1A will be used to generate insights into the pathological mechanisms associated with CMT1A, to identify targets for therapy design and to screen compounds to evaluate their therapeutic potential, with the aim of reducing the aberrant accumulation of PMP22 in CMT1A.
Figure 3 – Control Schwann cells (left) were smooth and regular whereas those overexpressing PMP22 (right) were spiky and irregular with aggregations within the cytoplasm
Figure 4 – Close association between ESYT1 (red), which is a component of the endoplasmic reticulum membrane and overexpressed PMP22 (green). Low power (left) and high power (right) images
Lamin-A related congenital muscular dystrophy
LMNA-related congenital muscular dystrophy (L-CMD) is a rare disorder predominantly causing muscle weakness and wasting, which over time, leads to development of dysphagia and life-threating respiratory insufficiency and sometimes cardiac arrhythmias. There are no pharmacological therapies for L-CMD and treatment focuses on managing symptoms of the condition. L-CMD is caused by mutations in LMNA, a gene encoding the nuclear lamina component lamin A/C. Many mechanisms downstream of LMNA mutations in L-CMD remain elusive, making the identification of non-genetic therapeutic targets difficult. During her PhD studies supported by Keele University and the Orthopaedic Institute, Emily Storey has focused on identifying conserved cellular and molecular defects across muscle cells from L-CMD patients, each harbouring different genetic mutations in the LMNA gene. The research has so far identified numerous defects that are common to each of the cell lines. It has also offered insight into mechanisms which may underlie the pathophysiology of L-CMD and has highlighted potential targets for future therapy design studies.
This work has been published in the journal “Cells” and was presented at a range of conferences including Cure CMD, Tennessee (2022) and The World Muscle Society, Canada (2022), where it was selected as a poster highlight from having scored among the top 4% of submissions.
The MDA Monoclonal Antibody Resource
CIND continues to house and run the “Monoclonal Antibody Resource”, originally established with over one million dollars of support from the Muscular Dystrophy Association (USA). Among its successes are collaborations with Sarepta Therapeutics USA and REGENEXBIO Inc USA in the development of novel, FDA-approved treatments for DMD and contributions to the US “SMA Project” which has resulted in new and effective treatments for severe SMA in the UK.
This Resource has produced over 500 new monoclonal antibodies, supplying them around the world (including to the USA, Europe and Japan) for muscle disease research and is also a source of external income. The antibodies are made available to researchers either directly from CIND, from the Iowa Hybridoma Bank (DSHB) and from companies such as Sigma, Millipore and Santa Cruz.
Over the last year, the Resource has sent out a total of 291 units of antibodies across the world to 24 separate researchers. Whilst the majority of these were charged for, some were supplied without cost on a collaborative basis. Direct antibody sales during this period generated £18,600 income, alongside £25,000 income from royalties received from companies that have licensed some of the antibodies, all of which was returned to the Orthopaedic Institute Ltd to support the continued development of the Resource and aligned research.
ORLAU – ORTHOTIC RESEARCH AND LOCOMOTOR ASSESSMENT UNIT
Clinical & Eduational Activity
ORLAU’s clinical services are as busy as ever, with a wide range of patients coming through the doors. Our movement analysis service provides detailed assessment of patients’ movement problems, whilst our rehabilitation engineering and orthotic teams prescribe and manufacture medical devices to help them move more easily. Many patients come to ORLAU after having exhausted options elsewhere. Our specialist facilities and expert staff allow us to come up with new and innovative solutions to many complex mobility problems, whether that be for a child with cerebral palsy or an adult who has had a stroke.
During the pandemic years we continued to provide training for clinical scientists specialising in rehabilitation engineering and for physiotherapy students on placement. Other training on site was, however, put on hold to reduce the risk of infection. We are delighted to say that face to face teaching is back, with ORLAU staff contributing to the Orthopaedic Institute’s popular Basic Science Course in May 2023 and also running our own Gait Analysis course the following month.
Locomotor assessment sensors
Research is vital to the team
Movement Analysis
During the pandemic many research projects were paused. As life has returned to normal, we are pleased to report that research is flourishing once again. We have run four large, funded projects, two of which are on-going, and we continue to support students in their research endeavours.
We have previously reported progress on our EPSRC funded project ‘Personalised approach to restoration of arm function in people with high-level tetraplegia’. This project aims to use functional electrical stimulation, in combination with an arm support, to help patients who have had a spinal injury to use their arms for functional tasks. The team have successfully configured a stimulator to be activated by EMG signals from the muscles a patient can still use to control stimulation to muscles that are paralysed. The aim is for the system to be adapted to suit the requirements for each individual patient and has now been tested on two patients with further testing planned.
In late 2019 we were awarded funding from the charity Action Medical Research for a project entitled ‘Exploration of the role of subtalar joint morphology in the development of foot deformity in cerebral palsy’. The subtalar joint allows the foot to move from side to side and abnormal postures are thought to contribute to the problems children with cerebral palsy experience with their feet. Walking is made more challenging for these children due to deformity and pain. Researcher Dr Erik Meilak has been collecting data in the gait laboratory, along with MRI and CT images of children’s feet to build and analyse computer models. The work is leading to exciting new insights into why children’s feet deform and Dr Meilak’s methods are suitable for application to many different foot and ankle pathologies. He will present his work to date at the conference of the European Society for Movement Analysis in Adults and Children (ESMAC) in Athens in September.
Dr Fraser Philp (from Liverpool University) will also be presenting the results of his research in Athens. He holds two grants, one from the Private Physiotherapy Educational Foundation and the other from the Orthopaedic Institute. Dr Philp is interested in the biomechanics of shoulder instability and he has been measuring subjects with and without instability in the ORLAU gait laboratory. His patient groups include children whose shoulders tend to dislocate or sublux and adults with Facioscapulohumeral Muscular Dystrophy (FSHD), a condition also associated with shoulder problems. Dr Philp has conducted a biomechanical analysis of shoulder motion, with Martin Seyes, a PhD student from Keele University, providing musculoskeletal modelling.
ORLAU’s gait laboratory team are active members of the Clinical Movement Analysis Society of the UK and Ireland (CMAS). A small grant from the society has enabled researchers Dr Jo Reeves (Exeter University) and Dr Hannah Shepherd (Liverpool Hope University), along with Dr Caroline Stewart from ORLAU to explore how laboratories across the UK measure muscle activity during gait analysis and how this information is used. This work will also be presented at ESMAC, along with the MSc research of clinical scientist trainee Tim Arthur who has designed a new method for improving the measurement of the walking patterns of amputees.
In February 2023, PhD student Mohammad Alshehab successfully defended his PhD entitled ‘The potential for compression garments to influence upper limb’, work carried out with the upper limb team in ORLAU, including Mr Rob Freeman, Dr Neil Postans and Mrs Sarah Jarvis. We hope that Martin Seyres and Shallum Sardar will submit their theses later this year. Shallum has been studying toe walking in cerebral palsy and the effects of treatment with botulinum toxin and plaster casts. Alice Faux-Nightingale successfully defended her MPhil in 2021. Her research was impacted by the pandemic leading to her changing her project and researching the experience of staff in the hospital living and working through the early stages of the pandemic. This research was published in the prestigious Sociology of Health and Illness journal in 2022 and a further paper is being prepared which will focus on the famous hospital corridor.
CAD Model of a Flexible Pad for 3D Printing
3D Printed Flexible Pad, highlighting how a thumb or finger can be depressed into it
ORLAU Ankle Contracture Correction Device (CCD)
Rehabilitation Engineering
ORLAU’s rehabilitation engineering team has received substantial capital funding this year, allowing us to replace our aging lathe and pillar drill with new machines. These acquisitions will result in increased capacity and precision in manufacturing, and they will significantly improve staff safety. Furthermore, we have acquired a second fused deposition modelling 3D printer to explore and test prototype ideas, leading to patient-centred solutions. This advanced printer operates at higher temperatures, enabling the use of alternative materials in our manufacturing processes.
To complement the printer’s capabilities, we have also purchased a handheld 3D scanner. This scanner will enable us to capture highly accurate measurements of complex individual patients, particularly those in need of orthotic extensions to existing devices, where conventional measurement techniques can be challenging.
These scanned measurements can be directly imported into our CAD software, facilitating the development of precise and efficient solutions based on a 3D model of the patient and device.
Our Rehab Engineering team remains committed to offering tailored, engineered solutions to a diverse range of patients. We have successfully undertaken unique adaptations to existing patient devices and have developed innovative solutions that comply with current medical device regulations.
We have purchased a new 3D printer this year, one that can print a wider range of materials. One of those materials is TPU (thermoplastic polyurethane), which exhibits flexible, rubber like properties that we hope to incorporate into some patient-based developments. The images below show a CAD model of a flexible pad and the corresponding 3D printed component, highlighting how a thumb or finger can be depressed into it. This material has the potential to be used for custom cushioning or in devices where flexible parts would be an advantage.
As we navigate the uncertainties posed by the UK’s post[1]Brexit medical device regulations, our department’s continued accreditation against ISO 9001 & ISO 13485 places us in a favourable position to adapt to future challenges.
The team is currently working on an exciting redevelopment of the ORLAU Standing Frame. The aim is to replace the existing device in the next few years. The new frame is expected to offer significant benefits, such as improved postural management, easier adjustments to reduce clinic time and enhanced features for convenient device transportation and storage.
Additionally, the team is in talks with a trusted partner about commercialising the mechanical components of the ORLAU ankle Contracture Correction Device. If all goes well, it should be available throughout the UK by the end of 2023.
In conclusion ORLAU continues to be a busy clinical centre, with lots of complex patients coming through the doors every day. Our education and research projects are fundamental to our specialist services. We need to develop innovative new treatments and assessment tools. We are also keen to disseminate our knowledge to others in the field. In both of these areas support from the Orthopaedic Institute is invaluable.