BackgroundNeuromuscular diseases (NMDs) are often progressive conditions that can reduce quality of life and life expectancy and require long-term caregiving. As patients age, caregivers face increasing demands, often resulting in significant caregiver burden. Treatment and care are complex, and a coordinated, family-centered approach is indicated. The current care situation for individuals with NMDs and their families in Switzerland is poorly understood, and there is no standardized NMD care management available. ObjectiveThe proposed study aims to assess the current care practices for individuals with NMDs in Switzerland, identifying unmet needs and challenges faced by patients, families, and health care providers. On the basis of these findings, a care management model will be developed, implemented, and evaluated to enhance support structures, strengthen specialized neuromuscular centers, and improve overall health care outcomes for affected individuals and their families. MethodsWe planned a 3-phase participatory mixed methods study (the Care-NMD-CH study). First, qualitative descriptive data and quantitative survey data were used to assess the current state of care practices. Then, a care management model and training program were codeveloped based on these insights. Finally, the care management service was implemented in pilot specialized neuromuscular centers and evaluated using quantitative, qualitative, and integrated methods. In addition to interview data and patient records, we measured patient-reported outcomes (quality of life and self-efficacy), family-reported outcomes (family functioning and caregiver burden), and stakeholder-reported outcomes (quality of care and interprofessional collaboration). The study population comprises individuals with NMDs and their families living in Switzerland. ResultsEthics approval was obtained in 2020. Baseline data (T0) were collected and analyzed in 2021 (phase A). The NMD care management model (phase B) was developed based on these data and finalized in 2022. Following the start of implementation in 8 centers in 2023, data collection for process and outcome evaluation (T1-T4) commenced and was completed in May 2025. Data analysis is currently ongoing, and results will be published separately. This paper reports only the study protocol. ConclusionsThis study represents an important step toward implementing and evaluating an evidence-based, family-centered care management service for individuals with NMDs and their families in specialized neuromuscular centers. Building on a 3-phase approach, the project identified gaps in current care; developed a structured care management model, including training; and evaluated its impact on patients, family members, and interprofessional care teams. Expected outcomes include possible improvements in the areas of care coordination, quality of life, and self-efficacy and family functioning. In addition, potential alleviation of disease and caregiver burden, as well as reduction in health care costs for those affected and the health system, will be investigated. International Registered Report Identifier (IRRID)DERR1-10.2196/82833

•ENMC organized 270 workshops in the last 30 years. •ENMC established a network of over 4500 participants from more than 65 countries and from 5 continents. •ENMC published 270 lay reports on our website www.enmc.org and over 220 full papers in neuromuscular disorders with a high average mean normalised citation score of 1,24. •ENMC supports the next generation of leaders in the neuromuscular field.

Developmental pharmacology describes the impact of maturation on drug disposition (pharmacokinetics, PK) and drug effects (pharmacodynamics, PD) throughout the paediatric age range. This paper, written by a multidisciplinary group of experts, summarizes current knowledge, and provides suggestions to pharmaceutical companies, regulatory agencies and academicians on how to incorporate the latest knowledge regarding developmental pharmacology and innovative techniques into neonatal and paediatric drug development. Biological aspects of drug absorption, distribution, metabolism and excretion throughout development are summarized. Although this area made enormous progress during the last two decades, remaining knowledge gaps were identified. Minimal risk and burden designs allow for optimally informative but minimally invasive PK sampling, while concomitant profiling of drug metabolites may provide additional insight in the unique PK behaviour in children. Furthermore, developmental PD needs to be considered during drug development, which is illustrated by disease‐ and/or target organ‐specific examples. Identifying and testing PD targets and effects in special populations, and application of age‐ and/or population‐specific assessment tools are discussed. Drug development plans also need to incorporate innovative techniques such as preclinical models to study therapeutic strategies, and shift from sequential enrolment of subgroups, to more rational designs. To stimulate appropriate research plans, illustrations of specific PK/PD‐related as well as drug safety‐related challenges during drug development are provided. The suggestions made in this joint paper of the Innovative Medicines Initiative conect4children Expert group on Developmental Pharmacology and the European Society for Developmental, Perinatal and Paediatric Pharmacology, should facilitate all those involved in drug development.

Clinical trials for rare neuromuscular diseases imply, among other investments, a high emotional burden for the whole disease community. Translation of data from preclinical studies to justify any clinical trial must be carefully pondered in order to minimize the risk of clinical trial withdrawal or failure. A rigorous distinction between proof-of-concept and preclinical efficacy studies using animal models is key to support the rationale of a clinical trial involving patients. This Review evaluates the experience accumulated by the TREAT-NMD Advisory Committee for Therapeutics, which provides detailed constructive feedback on clinical proposals for neuromuscular diseases submitted by researchers in both academia and industry, and emphasizes that a timely critical review of preclinical efficacy data from animal models, including biomarkers for specific diseases, combined with adherence to existing guidelines and standard protocols, can significantly help to de-risk clinical programs and prevent disappointments and costly engagement.

Muscular dystrophies (MDs) encompass a wide variety of inherited disorders that are characterized by loss of muscle tissue associated with a progressive reduction in muscle function. With a cure lacking for MDs, preclinical developments of therapeutic approaches depend on well-characterized animal models that recapitulate the specific pathology in patients. The mouse is the most widely and extensively used model for MDs, and it has played a key role in our understanding of the molecular mechanisms underlying MD pathogenesis. This has enabled the development of therapeutic strategies. Owing to advancements in genetic engineering, a wide variety of mouse models are available for the majority of MDs. Here, we summarize the characteristics of the most commonly used mouse models for a subset of highly studied MDs, collated into a table. Together with references to key publications describing these models, this brief but detailed overview would be useful for those interested in, or working with, mouse models of MD.

Since 1992, the European Neuromuscular Centre facilitated workshops to bring experts in the field of neuromuscular disorders together. After organising more than 235 workshops, it is time to evaluate what impact these 25 years of ENMC workshops have had on the neuromuscular research field and on people affected by a neuromuscular condition. To measure this, workshop topics were retrospectively evaluated and bibliometric analyses on the citation scores of ENMC-derived publications were performed. In addition, a personalized survey was used to investigate the actual achievement and implementation of workshop deliverables. The evaluation of 25 years' workshop topics revealed a strong representation of muscular dystrophies, congenital and mitochondrial myopathies. The publications derived from ENMC workshops scored "high impact" as illustrated by the Mean Normalized Citation Score of 1.24. Also 16% of the ENMC papers belong to the top 10% best cited articles in the neuromuscular field. The main outcome of the personalised survey was that 90% of all workshop deliverables were started and either ongoing or completed. Of these deliverables, 78% were implemented in the field; bringing state-of-the-art knowledge and new collaborations to researchers and clinicians, improving designs of clinical trials and innovating tools to make accurate diagnoses.

In the era of patient-centered medicine, shared decision-making (SDM) - in which healthcare professionals and patients exchange information and preferences and jointly reach a decision - has emerged as the gold standard model for the provision of formal healthcare. Indeed, in many geographical settings, patients are frequently invited to participate in choices concerning the design and delivery of their medical management. From a clinical perspective, benefits of this type of patient involvement encompass, for example, enhanced treatment satisfaction, improved medical compliance, better health outcomes, and maintained or promoted quality of life. Yet, although the theory and enactment of SDM in healthcare are well-described in the literature [1-3], comparatively less attention has been devoted to contextualizing questions relating to if, when, and how to include patients in decisions within medical research. In this context, patient involvement would be expected to be potentially relevant for and applicable to a wide range of activities and processes, from the identification of research priorities and development of grant applications, to the design of patient information and consent procedures, formulation of interventions, identification and recruitment of study sample populations, feasibility of a clinical trial, identification, selection, and specification of endpoints and outcomes in clinical trials and observational studies, data collection and analysis, and dissemination of results. To this end, 45 clinicians, healthcare professionals, researchers, patients, caregivers, and representatives from regulatory authorities and pharmaceutical companies from 15 different countries met to discuss the level of involvement of patients with neuromuscular diseases, specifically in the following settings of medical research for neuromuscular diseases: i) registries and biobanks; ii) clinical trials; and iii) regulatory processes. In this report, we present summaries of the talks that were given during the workshop, as well as discussion outcomes from the three topic areas listed above.

Patient and public involvement for co-creation is increasingly recognized as a valuable strategy to develop healthcare research targeting patients’ real needs. However, its practical implementation is not as advanced and unanimously accepted as it could be, due to cultural differences and complexities of managing healthcare programs and clinical studies, especially in the rare disease field. The European Neuromuscular Centre, a European foundation of patient organizations, involved its key stakeholders in a special workshop to investigate the position of the neuromuscular patient community with respect to healthcare and medical research to identify and address gaps and bottlenecks. The workshop took place in Milan (Italy) on January 19–20, 2018, involving 45 participants who were mainly representatives of the patient community, but also included experts from clinical centers, industry and regulatory bodies. In order to provide practical examples and constructive suggestions, specific topics were identified upfront. The first set of issues concerned the quality of life at specific phases of a patient’s life, such as at the time of diagnosis or during pediatric to adult transition, and patient involvement in medical research on activities in daily living including patient reported outcome measures. The second set of issues concerned the involvement of patients in the management of clinical research tools, such as registries and biobanks, and their participation in study design or marketing authorization processes. Introductory presentations were followed by parallel working group sessions, to gain constructive contributions from all participants. The concept of shared decision making was used to ensure, in discussions, a partnership-based identification of the wishes and needs of all stakeholders involved, and the “ladder of participation” tool served as a model to evaluate the actual and the desired level of patients’ involvement in all topics addressed. A general consensus on the outcome of the meeting was collected during the final plenary session. This paper reports the outcome of the workshop and the specific suggestions derived from the analysis of the first set of topics, related to quality of life. The outcomes of the second set of topics are reported elsewhere and are only briefly summarized herein for the sake of completeness. The neuromuscular community proved to be very active and engaged at different levels in the healthcare initiatives of interest. The workshop participants critically discussed several topics, providing practical examples where different stakeholders could play a role in making a change and bridging gaps. Overall, they indicated the need for education of all stakeholders for better communication, where everyone should become an ambassador to promote real change. Support should also come from institutions and healthcare bodies both at structural and economic level.

A workshop took place in 2015 to follow up TREAT-NMD activities dedicated to improving quality in the preclinical phase of drug development for neuromuscular diseases. In particular, this workshop adressed necessary future steps regarding common standard experimental protocols and the issue of improving the translatability of preclinical efficacy studies.

A new line of dystrophic mdx mice on the DBA/2J (D2) background has emerged as a candidate to study the efficacy of therapeutic approaches for Duchenne muscular dystrophy (DMD). These mice harbor genetic polymorphisms that appear to increase the severity of the dystropathology, with disease modifiers that also occur in DMD patients, making them attractive for efficacy studies and drug development. This workshop aimed at collecting and consolidating available data on the pathological features and the natural history of these new D2/mdx mice, for comparison with classic mdx mice and controls, and to identify gaps in information and their potential value. The overall aim is to establish guidance on how to best use the D2/mdx mouse model in preclinical studies.

•The issue of translatability of pre-clinical results was discussed with a wide range of stakeholders.•Challenges and pitfalls regarding the planning, funding, reporting and publishing of efficacy studies were discussed.•Future common efforts were planned to improve translatability of pre-clinical research for neuromuscular disorders.

•The issue of translatability of pre-clinical results was discussed with a wide range of stakeholders.•Challenges and pitfalls regarding the planning, funding, reporting and publishing of efficacy studies were discussed.•Future common efforts were planned to improve translatability of pre-clinical research for neuromuscular disorders.

Laminin-α2 related Congenital Muscular Dystrophy (LAMA2-CMD) is a progressive muscle disease caused by partial or complete deficiency of laminin-211, a skeletal muscle extracellular matrix protein. In the last decade, basic science research has queried underlying disease mechanisms in existing LAMA2-CMD murine models and identified possible clinical targets and pharmacological interventions. Experimental rigor in preclinical studies is critical to efficiently and accurately quantify both negative and positive results, degree of efficiency of potential therapeutics and determine whether to move a compound forward for additional preclinical testing. In this review, we compare published available data measured to assess three common parameters in the widely used mouse model DyW, that mimics LAMA2-CMD, we quantify variability and analyse its possible sources. Finally, on the basis of this analysis, we suggest standard set of assessments and the use of available standardized protocols, to reduce variability of outcomes in the future and to improve the value of preclinical research.

•Increasing number of drug development programmes present opportunities and challenges.•Increased focus on rigour and de-risking of both pre-clinical and clinical studies.•Focus on lessening burden on patients and families, reducing cost of development.•Increased patient engagement in design, execution, and regulatory processes key.•TREAT-NMD provides an open discussion for these opportunities and challenges.

Recent years witnessed an exciting increase in the number of clinical trials for neuromuscular disorders, in particular for Duchenne Muscular Dystrophy and Spinal Muscle Atrophy. Given the high emotional impact of such developments for devastating diseases with an urgent medical need, it is particularly important to justify human trials on the basis of robust preclinical studies and to avoid a waste of hopes and of funds.This review focuses the discussion on the quality in the conduct clinically-oriented preclinical assessments in rare neuromuscular disease models and on the importance in reporting of preclinical confirmatory studies. Accordingly, it invites scientists, journal publishers and funding agencies to require quality standards to improve translatability of preclinical findings.

In the last few years, several publications, editorials and commentaries have addressed the issue of transparency and reproducibility in research. When research is conducted on animal models with the aim of assessing the potential efficacy of a treatment for patients, the robustness of results becomes even more important, as data may serve as the scientific rationale for large, expensive and ultimately unsuccessful clinical trials. Surely, the response of animal models to drugs and treatments may not precisely reflect the response observed in patients. However, there is overwhelming evidence that animal models are very valuable for the understanding of disease pathogenesis, and for developing therapeutic interventions, provided that experiments are carefully designed, interpreted and reported. Therefore, the transparency, reproducibility and finally also the predictive power of preclinical experiments can be significantly improved by adopting general standards in experimental design. The TREAT-NMD Network recognized this need in the scientific community years ago and initiated the implementation of standard operating protocols for the most common animal models of neuromuscular diseases. With the collaboration of several key scientists, a number of protocols was drafted and made available to the community. Today, the Swiss Foundation for Research on Muscle Diseases, a member of the TREAT-NMD Alliance, took over the regular reviewing of the protocols and the expansion to other disease areas. In the last two years, with the support of CureCMD and AFM, several protocols for mouse models of merosin-deficient muscular dystrophy were finalized and published online. Besides common experimental protocols, however, a discussion with main stakeholders will be needed as to which guidelines in reporting preclinical efficacy data need to be implemented to significantly improve the predictive power of preclinical research for patient trials. In the last few years, several publications, editorials and commentaries have addressed the issue of transparency and reproducibility in research. When research is conducted on animal models with the aim of assessing the potential efficacy of a treatment for patients, the robustness of results becomes even more important, as data may serve as the scientific rationale for large, expensive and ultimately unsuccessful clinical trials. Surely, the response of animal models to drugs and treatments may not precisely reflect the response observed in patients. However, there is overwhelming evidence that animal models are very valuable for the understanding of disease pathogenesis, and for developing therapeutic interventions, provided that experiments are carefully designed, interpreted and reported. Therefore, the transparency, reproducibility and finally also the predictive power of preclinical experiments can be significantly improved by adopting general standards in experimental design. The TREAT-NMD Network recognized this need in the scientific community years ago and initiated the implementation of standard operating protocols for the most common animal models of neuromuscular diseases. With the collaboration of several key scientists, a number of protocols was drafted and made available to the community. Today, the Swiss Foundation for Research on Muscle Diseases, a member of the TREAT-NMD Alliance, took over the regular reviewing of the protocols and the expansion to other disease areas. In the last two years, with the support of CureCMD and AFM, several protocols for mouse models of merosin-deficient muscular dystrophy were finalized and published online. Besides common experimental protocols, however, a discussion with main stakeholders will be needed as to which guidelines in reporting preclinical efficacy data need to be implemented to significantly improve the predictive power of preclinical research for patient trials.

Duchenne Muscular Dystrophy is an X-linked disorder that affects boys and leads to muscle wasting and death due to cardiac involvement and respiratory complications. The cause is the absence of dystrophin, a large structural protein indispensable for muscle cell function and viability. The mdx mouse has become the standard animal model for pre-clinical evaluation of potential therapeutic treatments. Recent years have seen a rapid increase in the number of experimental compounds being evaluated in the mdx mouse. There is, however, much variability in the design of these pre-clinical experimental studies. This has made it difficult to interpret and compare published data from different laboratories and to evaluate the potential of a treatment for application to patients. The authors therefore propose the introduction of a standard study design for the mdx mouse model. Several aspects, including animal care, sampling times and choice of tissues, as well as recommended endpoints and methodologies are addressed and, for each aspect, a standard procedure is proposed. Testing of all new molecules/drugs using a widely accepted and agreed upon standard experimental protocol would greatly improve the power of pre-clinical experimentations and help identifying promising therapies for the translation into clinical trials for boys with Duchenne Muscular Dystrophy.

Disease-specific animal models offer the possibility to test the efficacy of potential therapeutic interventions for neuromuscular diseases. Much data is generated every year reporting important effects and strategies. However, the lack of a consensus on the appropriate animal models and efficacy readouts and the lack of standardized protocols present a major hurdle to compare data from different laboratories. Given the restricted patient population available for clinical trials and the need to avoid duplicating efforts, it is important to create standards that help reducing the risk of false results and accelerate the translation of promising treatments to clinical development. TREAT-NMD aims at overcoming these hurdles by developing standard procedures and guidelines to conduct adequately planned efficacy studies in selected animal models. With the support of patient organizations and research institutes, experts were involved in workshops to reach a consensus on appropriate animal models and readouts. So far, recommendations for preclinical efficacy studies have been developed for Duchenne Muscular Dystrophy (DMD), Spinal Muscular Atrophy and Congenital Muscular Dystrophy. A total of 30 protocols, compiled and approved by several laboratories, are available online under www.treat-nmd.eu, meant to support researchers in assessing a range of histological, physiological, behavioral, biochemical and electrophysiological readouts. Also, a consensus paper on the choice of appropriate animal models for DMD was published 2009 and another one is underway that proposes guidelines for efficacy studies in the mdx mouse model. In summary, the current effort to develop standardized procedures is an important step to overcome limitations of preclinical assessment of possible interventions for neuromuscular diseases. The use of available protocols will certainly facilitate comparison of data and prioritization of emerging therapy strategies in preparation for clinical trials.

A workshop was held in Zürich (Switzerland) to develop standard procedures and protocols for pre-clinical efficacy studies in mouse models of spinal muscular atrophy (SMA). The workshop was organized by the Network of Excellence TREAT-NMD (Translational Research in Europe – Assessment and Treatment of Neuromuscular Disorders), launched 2007, that addresses the fragmentation currently existing in the evaluation, diagnosis and care of neuromuscular diseases on one side, and in the procedures of drug development from research to the design of clinical trials on the other side. Within this frame, one aspect that needs particular care is the design and performance of pre-clinical animal studies that should predict the efficacy of a new treatment in patients. In the absence of commonly accepted guidelines and standardized protocols, data from different laboratories are often not comparable and the result is a duplication of efforts. The workshop was attended by 30 key researchers from Europe and North America, as well as industry representatives (Santhera Pharmaceuticals, Psychogenics, Genyzme, Trophos) and patient organisations (SMA Foundation, AFM-Association Française contre les Myopathies). The goals of the workshop were (1) to select endpoints that best assess drug efficacy in mouse models and/or that best reflect human outcome measures and (2) for each endpoint, to form a working group of experts (consisting of a main author and contributing members), who were assigned the responsibility of preparing a selected SOP. The workshop was opened by Stefanie Possekel, who, following an introductory round of all participants, described the structure and aims of the Network of Excellence TREAT-NMD in general and of Activity 7 in particular. She pointed out some of the key problems in animal research which included the large variability in animal species and strains, the difficulty in comparing different dose regimen used, the choice of appropriate controls, methods of animal randomization, group size (usually small) and the inadequate power of some experiments. She then summarized the success achieved in the harmonization of pre-clinical research for Duchenne Muscular Dystrophy [[1]Nagaraju K. Willmann R. Developing standard procedures for murine and canine efficacy studies of DMD therapeutics: report of two expert workshops on “Pre-clinical testing for Duchenne dystrophy”: Washington, DC, October 27th–28th 2007 and Zurich, June 30th–July 1st 2008.Neuromuscul Disord. 2009; 19: 502-506Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] and presented an example of an existing SOP. Stefanie pointed out the efforts previously made in standardizing procedures in SMA pre-clinical research [[2]El-Khodor B.F. Edgar N. Chen A. et al.Identification of a battery of tests for drug candidate evaluation in the SMNDelta7 neonate model of spinal muscular atrophy.Exp Neurol. 2008; 212: 29-43Crossref PubMed Scopus (75) Google Scholar], to which Meg Winberg added that, as several mouse models are actually available and in use, it is particularly important to agree on common endpoints and methodologies to improve comparability across laboratories. The session was opened by Charlotte Sumner who addressed some of the key issues to be considered when planning experiments with SMA mice. The variation of phenotype encountered in SMA mouse colonies may depend on several extrinsic factors that can be controlled: background strain, litter size, temperature, frequency of handling, maternal diet and nutritional support for pups to name but a few. She also pointed out that it would be useful to reach a consensus on the definition of ‘survival’, which at the moment is quite variable between laboratories, since mice may have to be sacrificed due to institutional regulations versus being “found dead”. However, discussions showed that this may be difficult as local animal protection laws dictate to some extent how death is defined. It is therefore a clear wish of this audience that in future, when survival data is presented, the appropriate definition is always supplied. Arthur Burghes presented some recent results in his SMA mice (SMN2+/+; Smn−/−; SMNΔ7 [[3]Le T.T. Pham L.T. Butchbach M.E. et al.SMNDelta7, the major product of the centromeric survival motor neuron (SMN2) gene, extends survival in mice with spinal muscular atrophy and associates with full-length SMN.Hum Mol Genet. 2005; 14: 845-857Crossref PubMed Scopus (486) Google Scholar]) mouse model which also contained a doxycycline inducible SMN transgene. Survival was considered the best end point. The mice could be rescued by switching on the inducible SMN gene, with postnatal induction giving a very significant extension in survival. He addressed the optimal time point of initiation of drug therapy (the later SMN is ‘switched on’, the lower the responder rate) with induction at 5–6 days postnatally giving minimal survival extension. In addition, the Burghes lab has found that when dosing animals with drug compounds, mice from the same litter should all receive the same treatment, as cross contamination of neonatal mice is a major issue if two treatments are administered to the same litter. Danilo Tiziano reviewed the biomarkers currently used in patients (compound motor action potential, motor unit number estimation, dual-energy X-ray absorptiometry, dosage of the SMN protein and transcript with several methods). He pointed out strengths and weaknesses of these measurements and compared their effectiveness and feasibility with biomarkers used in mice. He finally concluded that none of these measurements can be considered as a ‘golden standard’ and that pre-clinical studies are indispensable to establish which should be tested in clinical trials. Some observations were made regarding the possible bias introduced in hSMN2 full length transcript quantification by absolute real-time PCR, due to the presence of mSmn gene in heterozygous mice and likely related to the competition of primers for murine and human transcripts. However, no data are available and further studies are necessary to elucidate this aspect. Finally, it was pointed out that is crucial to gain comparative data on protein and transcript levels. Regarding this aspect, Karen Chen informed the audience that a new test kit (ELISA) optimized for detection of SMN protein in human peripheral blood mononuclear cells (but which probably cross-reacts with mouse SMN and could therefore be used also to detect mouse protein) is now available at the SMA Foundation. The SMA Foundation biomarker discovery study, the BforSMA study, was also briefly described by Karen. Bassem El-Khodor presented some of the issues involved in performing neuromuscular tests in SMA mice. Ideally, the test used to assess the efficacy of a drug should be reflex-based, be able to differentiate between knock-out and wild type mice, be valid as early as postnatal day 2 (and for at least until 2 weeks of life) and resistant to side-effects. Care should be taken not to induce hypothermia (avoid separating the pups from their mothers for too long) and always perform the test at the same time of day (am or pm). The geotaxis test is considered a useful tool to evaluate neuromuscular function in neonatal mice in an easy, non-invasive, sensitive and quick way. It was remarked, however, that for this test it is key to define the surface material of the inclined plane. This test has its limitations as it is not entirely specific and may show up a drug’s side-effects (for instance drugs that increase alertness but not muscle function will have a positive effect on geotaxis), and cannot be performed before postnatal day 4. Therefore this test should be used as complementary to other assessments. In the next presentation Jean-Marc Raymackers discussed the practical details of the running wheel method, which can be used for adult mouse models to assess muscle function. The use of inclined wheels, the critical point of wheel resistance, the number of mice needed to account for the individual variability and the number of wheels necessary to test mice in parallel were discussed. The rotarod test and the pen test (also known as the balance beam test), that assess coordination and balance, were presented by Rashmi Kothary. The value of the rotarod test in the pre-clinical assessment of drugs in SMA was questioned as animals require training so can only be applied to mouse strains with a longer survival. It was agreed that the pen test was more suitable due to its simplicity and speed of performance and because no training was required. Therefore an SOP for the pen test would be prepared rather than for the rotarod test. Stefania Corti presented three different methods for grip strength measurements: the mesh grip test, the wire test and the automated grip strength test. Also here, the high variability and the degree of animal collaboration (motivation) represent the main disadvantages of this assay. For SMA, hind-limb strength may be more relevant than forelimb strength but this is the more difficult parameter to measure reliably. Therefore a measure of all four limbs would be preferable as an alternative. In the final presentation of this session Brian Kaspar discussed the open field test for the recording of spontaneous locomotor activity. As for the geotaxis test, drugs that improve awareness and/or motivation could produce false positive results. From a practical point of view it was noted that the beam height of commercially available equipment may need to be adjusted (lowered) to suit the size of the young SMA mice and that the general well-being of the animals taking part in an assessment should be visually inspected for necrosis of the hind-limbs as this would also affect their ability to complete a task. The afternoon session was kicked off by Christine DiDonato, who presented the righting reflex as a simple and quick test which is particularly useful to assess the efficacy of a drug in severe SMA mouse models. This test can only be used for neonatal mice. Repetition of the assay during the day can cause fatigue and it would be important for across-lab comparisons to clearly define what is a valid ‘righting’ (i.e. how does one evaluate an animal that rights itself but then falls over again). Bassem El-Khodor then presented the tube test, a method developed to evaluate the neuromuscular function that considers three parameters: latency to fall from the edge of the tube, number of pulls and the hind-limb score. Together these parameters give an overall impression of performance (scores 1–5). The correlation of this test with others and some technical issues such as number of test repeats, effect of fatigue and influence of rate of growth on the tube test outcome were discussed. Brunhilde Wirth confirmed the usefulness and reliability of the test. Ke Ning proposed a protocol for cell body counts in the ventral horn regions of the spinal cord, as this reflects the motor neuron loss observed in patients and represents a useful readout for gene therapy. It was observed that cell body loss is typically a late phenomenon which occurs shortly before death. However, it can also start earlier (e.g. from 3 to 5 days postnatal) or may not occur at all. Also, several technical hurdles have to be taken into account that may lead to false positives, for instance the specificity of common markers like choline-O-acetyltransferase in SMA-affected neurons. George Mentis presented techniques to evaluate the motor neuron loss that occurs as early as postnatal day 4 and can be traced precisely if certain experimental conditions are followed. This technique is, however, highly sophisticated and not a method with widespread use. The following talk, by Thierry Bordet, focused on axon counts and showed the correlation with other endpoints such as the number of spinal motor neurons and muscle fibre area in the new SMA mouse line N11/N46 [[4]Michaud M. Arnoux T. Bielli S. et al.Neuromuscular defects and breathing disorders in a new mouse model of spinal muscular atrophy.Neurobiol Dis. 2010; 38: 125-135Crossref PubMed Scopus (61) Google Scholar]. Despite the relevance to the disease and the ease of automation, this method has only limited value for assessing drug effects due to the lack of historical data, very small difference between knock-outs and wild types and the fact that axon loss is most often a late event. Therefore, this method is considered as probably not appropriate as a primary outcome in pre-clinical testing for SMA. Thomas Gillingwater presented methods for neuromuscular junction imaging with optical microscopy and electron microscopy, showed the pathological signs of neuromuscular junctions in SMA mice and addressed key points to achieve high imaging quality. Simon Parson presented several techniques for ex-vivo nerve-muscle preparations that can be used for targeted application of compounds to test efficacy and also to test for differential vulnerability of individual muscle phenotypes. These techniques should be more widely considered. The issue of SMN quantification at protein and RNA level was addressed by Giorgio Battaglia, who showed a collection of published data and concluded that very little data are available on subcellular localization of SMN protein and transcript and no data are known on SMN protein fate and post-translational modifications. A discussion followed regarding the efficiency of N-terminal or C-terminal targeted antibodies. Michael Sendtner showed how isolated motor neurons in cell culture can be used to study drug candidates and how accurate measurements of calcium fluxes in motorneurons can predict dysfunction in the neuromuscular junction. He concluded that these methods are suitable for drug screening but less for efficacy tests. An overview of electrophysiological properties of the neuromuscular junction (synaptic transmission) was given by Lucia Tabares, who described spontaneous and evoked responses in wild type mice and SMA mice. Veronica Setola illustrated the measurement of compound muscle activated potentials as a sensitive method to evaluate functionality of motor units and showed data obtained in SMA mice as compared to wild type. And finally, Chien-Ping Ko concluded the session by presenting the use of in vitro muscle tension measurements, achieved by stimulating either the nerve or the muscle, as a functional readout that estimates neuromuscular junction transmission as well as motor unit numbers and sizes. The first session of the second day was opened by Rudolf Korinthenberg, who gave an overview of SMA Type I, II and III pathology in human patients and of the clinical outcome measures used to assess impairment and performance. The authorities require a clinical benefit to be shown by a potential new drug and not just, for example, an increase in strength. The issue of motivation and investigator’s training was addressed, and some questions were raised regarding the testing procedures used in the 6-min-walk test. This presentation was followed by a lively discussion, conducted by Thomas Gillingwater, which aimed at finding a consensus as to which endpoints in mouse models should be regarded as primary to evaluate efficacy of drugs and/or should be standardized with SOPs. Everyone agreed on the need to include measurement of body weight daily and survival analysis in every study. One main point that required consensus was the handling of spontaneous deaths that occur within the first 1–2 days of birth (i.e. are these animals included or excluded from the survival curves). Charlotte Sumner pointed out that exclusion criteria should be defined for mice as they are defined for patients in clinical trials. Arthur Burghes volunteered to prepare a proposal on this issue together with other points to consider when planning an experiment to test a new therapy (such as dosing schedule, times of testing and diet, as well as procedures to plot survival and body weight curves as endpoints). A second document on general SMA mouse housing and handling considerations will be authored by Charlotte Sumner, which would include maternal diet and nutritional support for pups. Among the behavioural tests, there was agreement to write SOPs for the tube test/clasping response, geotaxis, open field testing, righting reflex, grip strength, running wheel and pen test. Several biochemical and histological SOPs were regarded as relevant for testing drug efficacy in mice: cell body/motor neuron counts, axon counts, neuromuscular junction imaging, SMN levels on western blot and ELISA, SMN immunocytochemistry, real-time PCR, small nuclear ribonucleoproteins (snRNP) assay, genotyping. Finally, the electrophysiological assays for synaptic transmission, compound muscle activated potential and electromyography, and muscle tension were considered worth being standardized through SOPs. Judith Dubach opened the last session illustrating the advantages of implementing SOPs to optimize reproducibility both within a single institution over time and across institutions. She described key aspects of SOP writing and mentioned guidance documents (http://www.epa.gov/QUALITY/qs-docs/g6-final.pdf). She underlined the need of creating working groups that collaborate with authors with regards to the SOPs content, and of implementing an approval procedure (by the author and a named reviewer). An updating procedure for each SOP and a wide distribution to the appropriate work areas would increase acceptance and the overall use of the SOPs. Finally, she introduced a template for SOP writing and proposed deadlines for draft and final SOPs. In the plenary discussion that followed, the list of desired SOPs was circulated and workshop participants signed up in the working groups of interest. For SOPs not addressed during the workshop, authors were proposed and it was agreed to also contact other researchers for authorship and/or taking part in working groups according to their expertise. The SOP-template was distributed to the SOP authors shortly after the workshop. Once finalized, SOPs will be uploaded on the TREAT-NMD website on a web link that allows download of the documents as well as contact with the author should any questions or comments arise (www.treat-nmd.eu/SOPSMA). •Giorgio Battaglia (Istituto Neurologico C. Besta, Milan, Italy).•Thierry Bordet (Trophos, France).•Arthur Burghes (The Ohio State University, USA).•Karen Chen (SMA Foundation, USA).•Stefania Corti (University of Milan, Italy).•Christine DiDonato (Northwestern University, USA).•Judith Dubach-Powell (Santhera Pharmaceuticals Ltd., Switzerland).•Bassem El-Khodor (Psychogenics Inc., USA).•Thomas Gillingwater (University of Edinburgh, UK).•Natalie Kayadjanian (AFM, France).•Brian Kaspar (The Ohio State University, USA).•Chien-Ping Ko (University of Southern California, USA).•Rudolf Korinthenberg (Pediatric University Hospital Freiburg, Germany).•Rashmi Kothary (Ottawa Hospital Research Institute, Canada).•George Mentis (Columbia University, USA).•Ke Ning (University of Sheffield, UK).•Simon Parson (University of Edinburgh, UK).•Marco Passini (Genzyme, USA).•Stefanie Possekel (Santhera Pharmaceuticals, Switzerland).•Jean-Marc Raymackers (Université Catholique de Louvain, Belgium).•Daniel Schümperli (University of Bern, Switzerland).•Michael Sendtner (Institute for Clinical Neurobiology, Würzburg, Germany).•Veronica Setola (EPFL Lausanne, Switzerland).•Charlotte Sumner (Johns Hopkins School of Medicine, USA).•Lucia Tabares (University of Seville, Spain).•Danilo Tiziano (Catholic University, Rome, Italy).•Raffaella Willmann (University of Basel, Switzerland).•Meg Winberg (SMA Foundation, USA).•Brunhilde Wirth (University Hospital of Cologne, Germany).•Rafael Yáñez-Muñoz (Royal Holloway–University of London, UK).