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Şimşek Erdem N, Güneş Gencer GY, Alaamel A, Uysal H. Effect of nusinersen treatment on quality of life and motor function in adult patients with spinal muscular atrophy. Neuromuscul Disord 2024; 36:28-32. [PMID: 38310720 DOI: 10.1016/j.nmd.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 02/06/2024]
Abstract
The aim of this study was to assess the effect of 4 loading doses of nusinersen on motor function and quality of life (QoL) in adult patients with spinal muscular atrophy (SMA). Twenty-one adult patients with genetically confirmed SMA who were treated with 4 loading doses of nusinersen were included in this study. All patients were evaluated with the Medical Research Council (MRC) scale, the Hammersmith Functional Motor Scale Expanded (HFMSE), and the Short Form Survey-36 (SF-36) at baseline (V1) and before the first nusinersen maintenance treatment, which was at the 15th month of treatment (V2). The SF-36 score was compared between the patients and 35 age-matched healthy controls. Of the twenty-one patients with a median age of 36 years, 10 were nonambulatory, and 11 were ambulatory. The physical component score and the mental component score of the SF-36 were significantly lower in the SMA patient group at baseline than in the healthy group. The median HFMSE scores significantly improved at V2 in both ambulatory and nonambulatory SMA patients (p < 0.05). The median MRC score significantly increased at V2 in the ambulatory SMA patient group (p = 0.04) but not in the nonambulatory SMA patient group (p = 0.19). There was a significant improvement in physical QoL in all the SMA patients at V2 (p = 0.02), but there was no significant improvement in mental QoL (p = 0.15). The loading nusinersen treatment significantly improved motor function scores, muscle strength, and physical QoL.
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Affiliation(s)
| | | | - Abir Alaamel
- Akdeniz University Hospital Department of Neurology, Türkiye
| | - Hilmi Uysal
- Akdeniz University Hospital Department of Neurology, Türkiye
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Lee YJ, Kim AR, Lee JM, Shim YK, Cho JS, Ryu HW, Kwon S, Chae JH. Impact of nusinersen on the health-related quality of life and caregiver burden of patients with spinal muscular atrophy with symptom onset after age 6 months. Muscle Nerve 2023; 68:404-413. [PMID: 37602664 DOI: 10.1002/mus.27950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION/AIMS Novel disease-modifying approaches for spinal muscular atrophy (SMA) have highlighted the patient's perspective on functional changes over time. In this study, we evaluated the impact of nusinersen on the health-related quality of life (HRQoL) of patients with later-onset SMA and the caregiver burden. METHODS We assessed the changes in HRQoL using the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL GCS) and the Pediatric Quality of Life Inventory 3.0 Neuromuscular Module (PedsQL NMM) during 26 months of treatment. Caregiver burden was assessed using the Assessment of Caregiver Experience with Neuromuscular Disease. We also assessed motor function using the Hammersmith Functional Motor Scale-Expanded (HFMSE) and the Revised Upper Limb Module score. RESULTS Twenty-four patients and their caregivers were included. The median age of patients at treatment onset was 148.8 (6.8 to 269.4) months. A significant improvement was observed in psychosocial health in proxy-reported PedsQL (P = .023). However, the physical health scores of the PedsQL GCS and About my neuromuscular disorder subscores of the PedsQL NMM did not change, although there was a significant increase in HFMSE scores. Regarding the caregiver burden, the financial burden was reduced, whereas time burden increased. A higher HFMSE score was associated with better self-reported PedsQL GCS total scores (P < .001). DISCUSSION Our results provide insights into the multifaceted implications of disease-modifying therapies for SMA through patient-reported outcome measures (PROMs). PROMs should be taken into consideration to assess the clinical significance of the functional changes identified by clinician-reported scales.
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Affiliation(s)
- Yun Jeong Lee
- Department of Pediatrics, Kyungpook National University Hospital and School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ae Ryoung Kim
- Department of Rehabilitation Medicine, Kyungpook National University Hospital and School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jong-Mok Lee
- Department of Neurology, Kyungpook National University Hospital and School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Young Kyu Shim
- Department of Pediatrics, Korea University Ansan Hospital, Seoul, South Korea
| | - Jae So Cho
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye Won Ryu
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Soonhak Kwon
- Department of Pediatrics, Kyungpook National University Children's Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jong-Hee Chae
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, South Korea
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Jha NN, Kim JK, Her YR, Monani UR. Muscle: an independent contributor to the neuromuscular spinal muscular atrophy disease phenotype. JCI Insight 2023; 8:e171878. [PMID: 37737261 PMCID: PMC10561723 DOI: 10.1172/jci.insight.171878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a pediatric-onset neuromuscular disorder caused by insufficient survival motor neuron (SMN) protein. SMN restorative therapies are now approved for the treatment of SMA; however, they are not curative, likely due to a combination of imperfect treatment timing, inadequate SMN augmentation, and failure to optimally target relevant organs. Here, we consider the implications of imperfect treatment administration, focusing specifically on outcomes for skeletal muscle. We examine the evidence that muscle plays a contributing role in driving neuromuscular dysfunction in SMA. Next, we discuss how SMN might regulate the health of myofibers and their progenitors. Finally, we speculate on therapeutic outcomes of failing to raise muscle SMN to healthful levels and present strategies to restore function to this tissue to ensure better treatment results.
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Affiliation(s)
- Narendra N. Jha
- Department of Neurology
- Center for Motor Neuron Biology and Disease, and
| | - Jeong-Ki Kim
- Department of Neurology
- Center for Motor Neuron Biology and Disease, and
| | - Yoon-Ra Her
- Department of Neurology
- Center for Motor Neuron Biology and Disease, and
| | - Umrao R. Monani
- Department of Neurology
- Center for Motor Neuron Biology and Disease, and
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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Pera MC, Coratti G, Casiraghi J, Bravetti C, Fedeli A, Strika M, Albamonte E, Antonaci L, Rossi D, Pane M, Sansone VA, Mercuri E. Caregivers' Expectations on Possible Functional Changes following Disease-Modifying Treatment in Type II and III Spinal Muscular Atrophy: A Comparative Study. J Clin Med 2023; 12:4183. [PMID: 37445216 DOI: 10.3390/jcm12134183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Background: The primary aim of this study was to explore current caregivers' expectations on possible functional changes following treatment in comparison to data obtained in the pre-pharmacological era. Methods: A questionnaire, previously used in 2016, was administered to caregivers of type II and III SMA patients of age between 3 and 71 years, and to patients over the age of 13 years. The questionnaire focuses on (1) caregivers and patients expectations, (2) meaningfulness of the changes observed on the functional motor scales, and (3) their willingness to be enrolled in a clinical trial. A comparative study was performed with data obtained using the same questionnaire soon before the advent of disease-modifying therapies. Results: We administered the questionnaire to 150 caregivers. When comparing current caregiver data to those obtained in 2016, the most obvious differences were related to disease perception over the last year (stability: 16.5% in 2016 vs. 43.6% in 2022; deterioration 70.5% vs. 12.8%, and improvement: 12.9% vs. 43.6%) and expectations from clinical trials with higher expectations in 2022 compared to 2016 (p < 0.001). Forty-five of the 150 in the current study were caregivers of patients above the age of 13. In these 45 the questionnaire was also administered to the patient. No difference was found in responses between patients and their caregivers. Conclusions: Both carers and patients reported that even small changes on functional scales, similar to those reported by clinical studies and real-world data, are perceived as meaningful. Comparing the recent responses to those obtained in 2016, before pharmacological treatment was available, we found significant changes in caregivers' perception with increased expectations. These findings will provide a better understanding of the patients' expectations and facilitate discussion with regulators.
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Affiliation(s)
- Maria Carmela Pera
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giorgia Coratti
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Jacopo Casiraghi
- The NEMO Center in Milan, Neurorehabilitation Unit, University of Milan, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Chiara Bravetti
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Fedeli
- The NEMO Center in Milan, Neurorehabilitation Unit, University of Milan, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Milija Strika
- The NEMO Center in Milan, Neurorehabilitation Unit, University of Milan, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Emilio Albamonte
- The NEMO Center in Milan, Neurorehabilitation Unit, University of Milan, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Laura Antonaci
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Diletta Rossi
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Marika Pane
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valeria Ada Sansone
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Eugenio Mercuri
- Department of Life Science and Public Health, Pediatric Neurology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- The NEMO Center in Rome, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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Wohnrade C, Velling AK, Mix L, Wurster CD, Cordts I, Stolte B, Zeller D, Uzelac Z, Platen S, Hagenacker T, Deschauer M, Lingor P, Ludolph AC, Lulé D, Petri S, Osmanovic A, Schreiber-Katz O. Health-Related Quality of Life in Spinal Muscular Atrophy Patients and Their Caregivers-A Prospective, Cross-Sectional, Multi-Center Analysis. Brain Sci 2023; 13:brainsci13010110. [PMID: 36672091 PMCID: PMC9857112 DOI: 10.3390/brainsci13010110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a disabling disease that affects not only the patient’s health-related quality of life (HRQoL), but also causes a high caregiver burden (CGB). The aim of this study was to evaluate HRQoL, CGB, and their predictors in SMA. In two prospective, cross-sectional, and multi-center studies, SMA patients (n = 39) and SMA patient/caregiver couples (n = 49) filled in the EuroQoL Five Dimension Five Level Scale (EQ-5D-5L) and the Short Form Health Survey 36 (SF-36). Caregivers (CGs) additionally answered the Zarit Burden Interview (ZBI) and the Hospital Anxiety and Depression Scale (HADS). Patients were clustered into two groups with either low or high HRQoL (EQ-5D-5L index value <0.259 or >0.679). The latter group was mostly composed of ambulatory type III patients with higher motor/functional scores. More severely affected patients reported low physical functioning but good mental health and vitality. The CGB (mean ZBI = 22/88) correlated negatively with patients’ motor/functional scores and age. Higher CGB was associated with a lower HRQoL, higher depression and anxiety, and more health impairments of the CGs. We conclude that patient and CG well-being levels interact closely, which highlights the need to consider the health of both parties while evaluating novel treatments.
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Affiliation(s)
- Camilla Wohnrade
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany
| | | | - Lucas Mix
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
| | | | - Isabell Cordts
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Benjamin Stolte
- Department of Neurology and Center for Translational Neuro- and Behavioral Science, University Medicine Essen, 45147 Essen, Germany
| | - Daniel Zeller
- Department of Neurology, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Zeljko Uzelac
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
| | - Sophia Platen
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Science, University Medicine Essen, 45147 Essen, Germany
| | - Marcus Deschauer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Paul Lingor
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Albert C. Ludolph
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
- German Center for Neurodegenerative Diseases, 89081 Ulm, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany
| | - Alma Osmanovic
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany
- Essen Center for Rare Diseases (EZSE), University Hospital Essen, 45147 Essen, Germany
| | - Olivia Schreiber-Katz
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany
- Correspondence:
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Day JW, Howell K, Place A, Long K, Rossello J, Kertesz N, Nomikos G. Advances and limitations for the treatment of spinal muscular atrophy. BMC Pediatr 2022; 22:632. [PMID: 36329412 PMCID: PMC9632131 DOI: 10.1186/s12887-022-03671-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 10/16/2022] [Indexed: 11/06/2022] Open
Abstract
Spinal muscular atrophy (5q-SMA; SMA), a genetic neuromuscular condition affecting spinal motor neurons, is caused by defects in both copies of the SMN1 gene that produces survival motor neuron (SMN) protein. The highly homologous SMN2 gene primarily expresses a rapidly degraded isoform of SMN protein that causes anterior horn cell degeneration, progressive motor neuron loss, skeletal muscle atrophy and weakness. Severe cases result in limited mobility and ventilatory insufficiency. Untreated SMA is the leading genetic cause of death in young children. Recently, three therapeutics that increase SMN protein levels in patients with SMA have provided incremental improvements in motor function and developmental milestones and prevented the worsening of SMA symptoms. While the therapeutic approaches with Spinraza®, Zolgensma®, and Evrysdi® have a clinically significant impact, they are not curative. For many patients, there remains a significant disease burden. A potential combination therapy under development for SMA targets myostatin, a negative regulator of muscle mass and strength. Myostatin inhibition in animal models increases muscle mass and function. Apitegromab is an investigational, fully human, monoclonal antibody that specifically binds to proforms of myostatin, promyostatin and latent myostatin, thereby inhibiting myostatin activation. A recently completed phase 2 trial demonstrated the potential clinical benefit of apitegromab by improving or stabilizing motor function in patients with Type 2 and Type 3 SMA and providing positive proof-of-concept for myostatin inhibition as a target for managing SMA. The primary goal of this manuscript is to orient physicians to the evolving landscape of SMA treatment.
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Affiliation(s)
- John W Day
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Kelly Howell
- Spinal Muscular Atrophy Foundation, New York, NY, USA
| | | | | | - Jose Rossello
- Scholar Rock, Inc, 301 Binney St, Cambridge, MA, USA
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Duan C, Ai D, Xu Q, Sui B, Zhao K. Assessment of health-related quality of life in patients with spina muscular atrophy in China. Intractable Rare Dis Res 2022; 11:189-195. [PMID: 36457580 PMCID: PMC9709625 DOI: 10.5582/irdr.2022.01094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 11/28/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a rare disease that has attracted considerable interest in China due to its severity and hefty treatment costs. Few studies have been conducted on Chinese patients. The objective of this study was to assess the quality of life of SMA patients in China and to investigate the real impact of new treatments. We used the Pediatric Quality of Life Inventory (PedsQL) to analyze the Health-related quality of life (HRQoL) of patients with SMA in China. Information on demographics, disease-specific characteristics, and treatment were collected using a child-reported or proxy-reported questionnaire. The mean scores of HRQoL for the Nusinersen treatment group and conventional treatment groups are 55.6 and 48.4, respectively. Patients with SMA type I have the lowest scores, while those with type III have the highest scores. A higher proportion of the medication group showed improvement in the condition in the past six months (56.9% vs. 17.1%). Our results show that the clinical type, motor function and treatment strategy have a significant influence on HRQoL. The findings imply that Nusinersen benefits patients by slowing the progression of the disease and increasing their quality of life in the real world.
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Affiliation(s)
- Chengaxin Duan
- China National Health Development Research Center; National Center for Drug and Technology Assessment, Beijing, China
| | - Dandan Ai
- China National Health Development Research Center; National Center for Drug and Technology Assessment, Beijing, China
| | - Qian Xu
- China National Health Development Research Center; National Center for Drug and Technology Assessment, Beijing, China
| | - Binyan Sui
- China National Health Development Research Center; National Center for Drug and Technology Assessment, Beijing, China
- Address correspondence to:Binyan Sui, China National Health Development Research Center; National Center for Drug and Technology Assessment, No.9 Courtyard Chegongzhuang Street, Beijing 100044, China. E-mail:
| | - Kun Zhao
- Vanke School of Public Health, Tsinghua University; Institute for Healthy China, Tsinghua University, Beijing, China
- Address correspondence to:Binyan Sui, China National Health Development Research Center; National Center for Drug and Technology Assessment, No.9 Courtyard Chegongzhuang Street, Beijing 100044, China. E-mail:
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Thimm A, Brakemeier S, Kizina K, Munoz Rosales J, Stolte B, Totzeck A, Deuschl C, Kleinschnitz C, Hagenacker T. Assessment of Health-Related Quality of Life in Adult Spinal Muscular Atrophy Under Nusinersen Treatment—A Pilot Study. Front Neurol 2022; 12:812063. [PMID: 35140677 PMCID: PMC8818760 DOI: 10.3389/fneur.2021.812063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/27/2021] [Indexed: 01/16/2023] Open
Abstract
5q-Spinal muscular atrophy (SMA) is a severely disabling inherited neuromuscular disease that progressively reduces the motor abilities of affected individuals. The approval of the antisense oligonucleotide nusinersen, which has been shown to improve motor function in adult SMA patients, changed the treatment landscape. However, little is known about its impact on patients' quality of life (QoL), and there is still a need for adequate patient-reported outcome measures. In this study, we used the short form of the Neuro-QoL (Quality of Life in Neurological Disorders) for upper/lower extremity function to prospectively assess the health-related QoL of 17 adult SMA patients prior to initiation of nusinersen treatment and 2, 6, 10, and 14 months afterwards. At baseline, Neuro-QoL scores strongly correlated with motor function scores (Hammersmith Functional Motor Scale Expanded, HFMSE; Revised Upper Limb Module, RULM), but QoL did not increase significantly during the 14-month treatment period despite significant motor improvement as measured by HFMSE. Our results underline the need for novel, disease-specific assessments of QoL in SMA.
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Affiliation(s)
- Andreas Thimm
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
- *Correspondence: Andreas Thimm
| | - Svenja Brakemeier
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Kathrin Kizina
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Juan Munoz Rosales
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Benjamin Stolte
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
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