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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
- + +
- - +
*