Exercise Therapies in Mitochondrial Disease.

CNS Meeting, 2013.

Mark Tarnopolsky, MD, PhD.

Professor of Pediatrics and

Medicine

(Neuromuscular and

Neurometabolic Disorders),

McMaster University,

Hamilton, ON.

Disclosure

Genzyme, Transgenomics – speaker honorarium

2009, 2010, 2011, 2012, 2013.

Amicus Therapeutics, Biomarin - consultant,

2011, 2012.

Wyeth – research funding 2009-2010.

GSK - speaker honoraria 2011.

Genzyme - research funding, 2011.

CEO and founder Exerkine Corp.

Mitochondrial Disease and Exercise intolerance

• Skeletal muscle manifestations:

– Cramps, myalgia, recurrent myoglobinuria, fixed weakness.

• Exercise intolerance:

– Can be a prominent, occasionally

defining feature.

Glycogen

Glucose

Fat

Fat

oxidation ETC / Oxidative

phosphorylation

O2

Physiological Adaptation Pathological Disorders

Atrophy

Mitochondrial

Dysfunction Endurance

Strength

obesity, T2DM,

mitochondrial disease,

immobilization,

neuropathy

sarcopenia/aging,

cancer,

statin myopathy,

corticosteroids

nutrition,

exercise

drugs, nutrition,

exercise

drugs, nutrition,

exercise

0

20

100

# CONTRACTIONS 1 500

E N D U R A N C E

FO

RC

E (

% M

AX

)

RE

SIS

TA

NC

E

60 mins/day, 3/week, 4 months

ENDURANCE EXERCISE

RESISTANCE EXERCISE

10 reps x 3 sets, 3/week, 4 months

A

B Text Text

Text

Contractile Activity Determines Phenotype

Endurance exercise training

Jeppesen T., et al., Brain 129:3402-, 2006

• N = 20 MITO (14 point mutations in mtDNA; N = 16

healthy controls).

• 12 week cycle @ 70 % VO2peak, 4 X/week.

• CS (67 %); VO2peak (67 %); (same in controls).

• No increase in CK or muscle morphology.

Endurance exercise training

Taivassalo, et al., Brain 129:3391-, 2006

0

20

100

# CONTRACTIONS 1 500

E N D U R A N C E

FO

RC

E (

% M

AX

)

RE

SIS

TA

NC

E

60 mins/day, 3/week, 4 months

ENDURANCE EXERCISE

RESISTANCE EXERCISE

10 reps x 3 sets, 3/week, 4 months

A

B Text Text

Text

Contractile Activity Determines Phenotype

Gene Shifting - Satellite Cell Biology

Infants = 20 % of myonuclei

Adults = 3 - 4 % of myonuclei

Older Adults = ? 3 - 4 %, attenuated proliferation (type II).

Activated by trauma, exercise and essential to hypertophy.

Myofiber

Myonuclei

Satellite cell:

from: Bischoff 1994

mtDNA Gene Shifting (Shoubridge et al., 1997)

KSS patient

COX- fibres

KSS patient

COX- Fibers

KSS patient

COX+ Myoblast

KSS patient

COX+ Fibers

3-weeks

Healing

Resistance training in Mitochondrial myopathy • Group of 8 patients: (39+9 y) with single

large-scale deletions.

• Training Protocol

– Bilateral leg extension/flexion, leg press

– 12 weeks, 3 x per week at 80-85% 1RM (3 to

6 sets, 6-8 reps)

Double-leg

press

1 R

M (

pounds)

Pre Post 80

120

160

200

240

280

Pre Post

*

25%

80

100

120

140

160

180

Single-leg extension

15%

*

Taivassalo, Gardner, Haller

and Turnbull, Brain, 2009.

CK pre: 187 + 115 U/L

CK post: 166 + 159 U/L

WT PolG

A B C

Polymerase domain

Asp

III I II N C

Exonuclease domain

Ala Asp

Linker

MTS

D257A - POLG1 - Mutator

Prolla, T., Science, 2005. Larsson, N., Nature, 2004

Lifespan

Body Weight

Alopecia

Kyphosis

Fertility

Cardiomyopathy

Anaemia

Sarcopenia

• Oxidative Stress.

• Inflammation.

• Telomeres.

Safdar, A., et al., 2013.

Kauffman, B., et al., 2013.

Putting an END to AGING…

3 Groups of POLG (3 months > 8 months):

END

SED

Safdar et al., PNAS, 2011.

Exercise attenuates many aging

features.

QuickTime™ and aPhoto - JPEG decompressor

are needed to see this picture.

Endurance Exercise Induces Mediators of

Mitochondrial Biogenesis

* *

Fo

ld-c

ha

ng

e

rela

tive

to

WT

* * * *

Safdar et al., PNAS, 2011 and unpublished.

PG

C-1

a c

onte

nt

rela

tive

to W

T

MITO NUC

Safdar et al., J. Biol.

Chem. Jan, 2011

Endurance Exercise Reduces Accumulation of

Random Point Muations

P < 0.05 Safdar et al., 2013 under review

Fre

qu

ency

of

mtD

NA

ran

do

m p

oin

t

mu

tati

on

s (%

) *

Endurance Exercise Promotes Systemic

Mitochondrial COX Activity

P < 0.05

* *

CO

X a

ctiv

ity

rel

ati

ve

to W

T

* *

Safdar et al., PNAS, 2011.

Endurance Exercise Prevents

Skin Histological Alterations

WT PolG-SED PolG-END

P < 0.05

Safdar et al., PNAS, 2011.

“Myokines” (Petersen and Febbraio)

Endurance Exercise Lowers Inflammation and

Restores Growth Factors/cytokines (EXERKINES) V

EG

F c

onte

nt

rela

tive t

o W

T

P < 0.05

*

P < 0.05 Safdar et al., 2013 in preparation

IL-6

(vs c

ontr

ols

= 1

.00) *

Eota

xin

rela

tive t

o W

T *

IL-1

5 r

ela

tive t

o W

T

*

“Exerkines”/”Mitokines” Identify time-point post- exercise where mito. biogenesis is stimulated in various

tissues - humans and mice (pre/imm/+1/+2/+3/+24h).

Cross reference skeletal muscle mRNA array data in humans and mice post-

exercise overlap with muscle specific PGC-1α overexpression data - confirm in

young and old pre/post endurance and resistance exercise.

Used Signal P 4.1 (http://www.cbs.dtu.dk/services/SignalP/) to ID predicted

secretory proteins with P > 0.9 (1.0 = 100 % likely to be secreted).

Add serum from (Y vs O, pre/post exercise) to 4 tissue cell types (epithelial,

connective, muscle, nerve) and evaluate mito. function.

Proteomics (targetted bead assays + LC/MS/MS).

Muscle specific gene manipulation in exercising mice (AMPK knock-out, PGC-1α

muscle specific over-expression).

in vitro and in vivo (mice) application of suspected exerkines +/- blocking Abs. Justin Crane, PhD, 2012/13; Adeel Safdar, PhD, 2013.

Endurance Athlete/Sedentary Study.

Sedentary = < 1 h/week.

Athlete = > 3 h/week.

Crane, J., et al, J. Gerontol,

Dec, 2012

EXERKINE -

Tissue stimulation studies.

10 % serum added to

culture media (post-Ex vs

resting, Y vs O):

Human - fibroblasts.

Murine - all 4 tissues.

IL-15 - A known myokine

with new systemic effects.

Dermal fibroblasts Plasma [x] Multiplex TNF and IL-15 Ab

IL-15 - A known myokine with new

systemic effects.

Vs.

7 days/week for 33 days

IL-15 - A known myokine with new

systemic effects.

OGTT

ITT

A Novel Exerkine -

METRNL.

METRNL - glial cell differentiation regulator-like.

311 aa - 4 transcript variants - full length = 34 Kd -

processed to 30 Kd (released) and 26/10 Kd.

Predicted to be secreted and documented in blood

proteome.

Seen on our microarray data after exercise in men.

VERY robustly induced by both endurance and

resistance exercise in young and older adults and mice

after endurance exercise.

A Novel Exerkine -

METRNL.

• Exercise mice (7d/wk X 30 days)

+/- blocking Abs.

• rmMETRNL (0.4 ng/kg/d) X 30

days.

• Sub-cutaneous white adipose tissue

(? browning)

A Novel Exerkine -

METRNL.

METRNL + IL-15?

High-Fat Fed

Diet

(T2DM/obesity).

METRNL, IL-15,

M+ IL-15, EX

(one and two

months).

Thanks The lab:

Dr. A. Safdar

Dr. J. Crane

Dr. L. McNeil

Dr. A. Saleem

Dr. A. Gomez

Dr. M. Akhtar

Mr. A. Green

Dr. D. Ogborn

Mr. B. Hettinga

Local Collaborators:

Dr. G. Parise

Dr. J. Bourgeois

Dr. M. Gibala

Dr. S. Phillips

Dr. G. Steinberg

Dr. J. Schertzer

• Dan Wright and family.

• MitoCanada

• Warren Lammert and Family

• CIHR – Institute of aging.

• NSERC/CHRP.

• McMaster Children’s Hospital

and Hamilton Health Sciences

Foundation.

National/International Collaborators:

Dr. S. Melov

Dr. J. Thompson

Dr. M. Falk

Dr. D. Simon

Dr. A. Hubbard

Dr. B. Kaufmann

Dr. K. Khrapko

Endurance Athlete/

Sedentary Study.

Crane, J., et al, 2013 McNeil, L., et al, 2013

• N = 32 men and women > 65 y.

• Skin biopsy pre/post 3 months:

• Endurance exercise

Endurance Exercise Reduces

Mitochondrial H2O2 Production

Muscle

Mitoch

ondrial H

2O

2

(pm

ol/m

in/m

g o

f pro

tein

)

P < 0.05

*

P < 0.05 Safdar et al., 2012 in preparation

P/M

ROT

- + +

- - +

*