Brain Structure and Clinical Endpoints in Myotonic Dystrophy Type 2 (BraCE-DM2)

Brain Structure and Clinical Endpoints in Myotonic Dystrophy Type 2 (BraCE-DM2)

Nearly two-third of patients with myotonic dystrophy type 2 (DM2) report that impaired cognition is among the most disabling symptoms and deeply affects their quality of life. Yet, relatively little is known about how DM2 affects brain structure and cognitive function as brain imaging studies in DM2 are extremely limited. This is a prospective, cross-sectional study of brain structure and function on cognitive and motor performance in patients with DM2 & DM1 compared to healthy controls. All participants will undergo magnetic resonance imaging (MRI) to evaluate brain structure and white matter integrity, a comprehensive battery of cognitive and motor measures, self-reported questionnaires, and blood collection for brain-based biomarker analysis. A subset of participants will undergo lumbar puncture for cerebrospinal fluid (CSF) collection for additional biomarker analysis and validation. This work is critical to inform the development of rigorous clinical trial designs and plan for a longitudinal study to evaluate MRI measures as imaging biomarkers of disease progression and therapeutic response in DM2 & DM1.

Study Overview

• Status: Recruiting
• Conditions: Myotonic Dystrophy Type 2; Myotonic Dystrophy Type 1
• Intervention / Treatment: Other: Non-interventional study

Detailed Description

Myotonic dystrophy type 2 (DM2), autosomal dominant muscular dystrophy, is characterized by late-onset proximal muscle weakness, myotonia, and multisystem features. Although muscle weakness is the key symptom, almost 70% of patients with DM2 report that impaired cognition is among the most disabling symptoms and affects their quality of life. This condition causes severe disability and impaired quality of life similar to those in myotonic dystrophy type 1 (DM1).Small literature describes cognitive deficits and cerebral white matter involvement in those with DM2, compared to controls. However, the mechanisms that lead to cognitive dysfunction are poorly understood.

As the momentum of therapeutic development is outpacing our understanding of the central nervous system (CNS) manifestations in myotonic dystrophy, there is an urgent need to identify measures of brain imaging, cognitive function, and biomarkers of CNS pathology that are disease-specific and clinically relevant, and establish relationships of these measures to inform future clinical trial designs in DM2. This study will carry out a comprehensive baseline characterization of 50 adults with DM2 and 50 age and gender-matched controls identified from clinical populations across the US and through the national myotonic dystrophy registry. A subset of DM1 cohort (n=20), aged over 40 years and without contraindications to MRI, will be invited to participate in the full study protocol similar to the DM2 group. All participants will undergo 3 Tesla (3T)-brain MRI to obtain voxel-based morphometry and diffusion tensor imaging (DTI) sequences, a comprehensive Clinical Assessment Battery (CAB) of cognitive and motor measures, patient-reported outcomes, and blood collection for analysis of CNS biomarkers at their baseline visits. A subset of 20 participants will undergo lumbar punctures to collect cerebrospinal fluid (CSF) specimens for additional biomarker analysis and validation. Measures of MRI, CAB, and fluid biomarkers will be compared between DM2, DM1 and controls.

Relationships between MRI measures, cognitive and motor endpoints, and biofluid (plasma and CSF) biomarkers will be analyzed within the DM2 & DM1 group. Validation of plasma and CSF biomarkers will also be determined.

• Study Type: Observational
• Enrollment (Estimated): 100

Contacts and Locations

• Study Contact: Name: Constance Linville; Phone Number: 336-716-4568; Email: clinvill@wakehealth.edu

Study Locations

• United States
  • North Carolina
    • Winston-Salem, North Carolina, United States, 27157
      • Recruiting
      • Wake Forest University Health Sciences
      • Contact: Constance Linville; Phone Number: 336-716-4568; Email: clinvill@wakehealth.edu
      • Principal Investigator: Araya Puwanant, MD, MS

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

Myotonic dystrophy is a rare disease with an estimated prevalence rate of 12.5/100,000 in both myotonic dystrophy type 1 (DM1) and DM2. There are no expected gender differences. Both men and women will be selected for this study.

Description

DM 2 Inclusion Criteria:

• Age 30-65 years old
• Diagnosis of DM1 or DM2 is based on genetic testing and/or clinical criteria. If the diagnosis is based on clinical criteria, positive DM2 genetic testing is required in first-degree relatives
• Symptoms or clinical findings of proximal muscle weakness
• Ambulate independently (a cane or walking stick is permitted)
• Able to provide informed consent for participation in the study

DM1 Inclusion Criteria:

• Only individuals who are 30-65 years old will be eligible to participate for the full study protocol
• Diagnosis of adult-onset DM1 is based on genetic testing or clinical criteria. If the diagnosis is based on clinical criteria, positive DM1 genetic testing is required in first-degree relatives
• The onset of first symptoms must be between the 2nd and 4th decades of life
• Symptoms or clinical findings of distal muscle weakness and myotonia
• Ambulate independently (a cane or walking stick is permitted)
• Able to provide informed consent for participation in the study

DM 1 Exclusion Criteria:

• Congenital or juvenile-onset DM1 (onset of first symptom < 20-year-old)
• Individuals with a prior diagnosis of dementia, seizure, stroke, multiple sclerosis, Parkinson's Disease, or other neurodegenerative diseases
• Individuals with active psychiatric illness or alcohol/substance abuse.
• On medications with substantial sedative or cognitive side effects unless the doses have been stable for at least 3 months before the study visit.
• Inability or unwillingness to give written informed consent.

DM 1 and 2 and Healthy Control (HC) Exclusion Criteria:

• Individuals with a pacemaker, defibrillator, or metal implanted that is contraindicated for MRI
• Individuals who are claustrophobic
• Individuals with a prior diagnosis of dementia, seizure, stroke, multiple sclerosis, Parkinson's Disease, or other neurodegenerative diseases
• Individuals with active psychiatric illness, alcohol or substance abuse, or dependence
• Individuals with a pacemaker, defibrillator, or metal implanted that is contraindicated for MRI
• Individuals who are claustrophobic
• Major medical illness which would prevent safe testing of MRI or motor function.
• On medications with substantial sedative or cognitive side effects unless the doses have been stable over the last 3 months before the study visit
• pregnancy
• Weight > 400 pounds as the participant could not be properly positioned on the MRI table
• Inability or unwillingness to give written informed consent
• For participants who undergo lumbar puncture procedure: Use of anti-platelet medications within 7 days, use of anticoagulants such as warfarin (Coumadin), history of a bleeding disorders, evidence of platelet count < 150,000 within the last 6 months, or have hardware (i.e., pins, screws, rods, etc.) in the lower back area

Healthy Control (HC) Inclusion Criteria:

• Age 30-65 years
• Ambulate independently
• Able to provide informed consent for participation in the study

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Controls; Healthy individuals who meet all inclusion and exclusion criteria for healthy controls. To be assessed at the baseline visit: Medical history and a focused neurological examination, brain MRI, a comprehensive Clinical Assessment Battery (CAB) of cognitive and motor measures, self-reported questionnaires, strength and motor function evaluation, and blood drawn for biomarker analysis. A subset of the participants who agree to have cerebrospinal fluid (CSF) collection for additional biomarker analysis will undergo lumbar puncture procedure.	Other: Non-interventional study; No intervention will be administered as part of this study.
Myotonic dystrophy types 1 and 2; Adults with myotonic dystrophy types 1 and 2 who meet all inclusion and exclusion criteria for the study. To be assessed at the baseline visit: Medical history and a focused neurological examination, brain MRI, a comprehensive Clinical Assessment Battery (CAB) of cognitive and motor measures, self-reported questionnaires, strength and motor function evaluation, and blood drawn for biomarker analysis. A subset of the participants who agree to have cerebrospinal fluid (CSF) collection for additional biomarker analysis will undergo lumbar puncture procedure.	Other: Non-interventional study; No intervention will be administered as part of this study.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Measures of voxel-based brain morphometry	Measures of brain volume will be expressed as a ratio (0 to 1) to intracranial volume to create proportional values of brain volume.	Baseline
Fractional Anisotropy (FA)	FA is an index of non-uniform movement of water molecules ranging from 0 to 1. Higher values of FA indicate healthy, dense, and well-organized white matter fibers. Lower values of FA indicate less healthy white matter track.	Baseline
Radial Diffusivity (RD)	The value of apparent water diffusion coefficient in the direction perpendicular to the axonal fibers. The higher RD value indicates high dispersion of water and poorly-organized white matter fibers.	Baseline
Axial Diffusivity (AD)	The value of apparent water diffusion coefficient in the direction lying along with the axonal fibers. The higher AD value indicates greater extracellular water content consecutively to the impaired white-matter fibers health, and to alterations of axonal water content	Baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
NIH-Toolbox (TB) Cognitive Measures: Executive Function Domain Scores	Raw scores of Dimensional Card Sorting will be compared between groups. The higher score, the better executive function.	Baseline
NIH-TB: Executive Function/Attention Domain Scores	Raw scores of Flanker Inhibitory Control and Attention will be compared between groups. The higher score, the better attention and executive function.	Baseline
NIH-TB: Processing Speed Domain Scores	Raw scores of Pattern Comparison Processing Speed Test will be compared between groups. The higher score, the better processing speed.	Baseline
NIH-TB: Language Domain Scores	Raw scores of Oral Reading Recognition Test will be compared between groups. The higher score, the better language domain.	Baseline
NIH-TB: Working Memory Domain Scores	Raw scores of List Sorting Test will be compared between groups. The higher score, the better working memory.	Baseline
NIH-TB: Episodic Memory Domain Scores	Raw scores of Picture Sequence Memory Test will be compared between groups. The higher score, the better working memory.	Baseline
Trail Making Test Part B (TMT-B) for executive function domain	Scores of TMT - Part B is based on time to complete the test (seconds). The lower scores of TMT-B, the better executive function. For TMT-B, an average score is 75 seconds and a deficient score is greater than 273 seconds. Maximum score is 300 seconds (5 minutes).	Baseline
Digit Span Scores for attention domain	The Digit Span score is the length of the longest correctly repeated number sequence. Digit Span Score is an indication of intelligence among other tests. The average digit span for normal adults without error is seven plus or minus two (a span of 5 to 9 digits).	Baseline
Trail Making Test Part A (TMT-A) for processing speed.	Scores of TMT-Part A is based on time taken to complete the test (seconds). An average score for TMT-A is 29 seconds and a deficient score is greater than 78 seconds.	Baseline
Memory Domain Scores	Rey Auditory Verbal Learning Test (RAVLT) scores will be compared between groups - Scoring: Different summary scores are derived from raw RAVLT scores. These include RAVLT Immediate (the sum of scores from 5 first trials, i.e., Trials 1 to 5), Learning (the score of Trial 5 minus the score of Trial 1), and Forgetting (the score of Trial 5 minus score of the delayed recall).	Baseline
Controlled Oral Word Association (COWA)	Scores of COWA will count up the total number of words that the individual is able to produce within 60 seconds. A score of under 17 indicates concern, although some practitioners use 14 as a cutoff for abnormal.	Baseline
Verbal Fluency Animal Category	Scores of verbal fluency will count up the total number of animals that the individual is able to produce within 60 seconds. A score of under 17 indicates concern, although some practitioners use 14 as a cutoff for abnormal.	Baseline
Beck Depression Inventory (BDI-II) Scores	The BDI is a widely used 21-item standardized self-report questionnaire measuring depression on a 4-point scale ranging from 0 to 3. Scores are interpreted as follows: 1-9, minimal depression; 10-16, mild depression; 17-29, moderate depression; 30-63, severe depression. BDI-II scores will be compared between groups.	Baseline
Beck Anxiety Inventory (BAI) Scores	The BAI is a 21-item self-report scale typically surveys features of anxiety. In using the BAI, patients rate the severity of each symptom on a 4-point scale ranging from 0 (not at all) to 3 (severely - I could barely stand it). A total score ranging from 0 to 63 is calculated by summing the severity ratings for all 21 items. BAI scores will be compared between groups.	Baseline
Apathy Evaluation Scales (AES)	AES was built based on the definition of apathy: syndrome of loss of motivation as reflected by acquired changes in affect (mood), behavior, and cognition. The AES is a four-point Likert-Scale response measure (0 = not at all true/characteristic to 3 = very much true/characteristic), composed of 18 items that assess and quantify emotional, behavioral, and cognitive aspects of apathy. We will evaluate AES in both participants and informants.	Baseline
Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10	The possible score ranges from 0 to 20 points in each case. 0 points represent the patient's most severe physical and/or mental impairment, while 20 points represent the best possible state of health.	Baseline
Short-Form Health Survey (SF-36) Scores	The SF-36 was used to assess the generic quality of life (QoL). It is a self-report measure with established reliability and validity across a wide range of clinical populations. Scores of SF-36 in each sub-scale will be compared between groups - SF-36 scores range from 0 (worst) to 100 (best)	Baseline
Brief Pain Inventory (BPI) - Short Form Scores	The short-form BPI is designed to measure the interference pain has on the patient's daily activities. These scales were selected based on their validity, simplicity, ability to detect the change in pain with treatment, patient relevance, reliability, test-retest scores, and their previous use in pain studies of the myotonic dystrophy population. BDI scores will be compared between groups - Worst Pain Score: 1 - 4 = Mild Pain. Worst Pain Score: 5 - 6 = Moderate Pain. Worst Pain Score: 7 - 10 = Severe Pain.	Baseline
Pittsburgh Sleep Quality Index (PSQI) Scores	PSQI is a self-reported questionnaire that measures seven components of sleep over a 1-month time interval: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. PSQI scores will be collected and compared between groups - The sleep component scores are summed to yield a total score ranging from 0 to 21 with the higher total score (referred to as global score) indicating worse sleep quality.	Baseline
Checklist Individual Strength (CIS) - Fatigue Scores	The CIS-fatigue severity sub-scale contains eight items scored on a 7-point Likert scale. Scores can range between 8 and 56 with higher scores indicating higher levels of fatigue and scores of 35 or more are considered to indicate severe fatigue. Fatigue scores will be compared between groups.	Baseline
Plasma Neurology 4-Plex E (N4PE)	The N4PE assay simultaneously measures four biomarkers in plasma. The targets are Abeta 40 (Aβ40), Abeta 42 (Aβ42), Glial Fibrillary Acidic Protein (GFAP™), and Neurofilament light (Nf-L).	Baseline
Cerebrospinal Fluid (CSF) Neurology 4-Plex E (N4PE)	The N4PE assay simultaneously measures four biomarkers in CSF. The targets are Abeta 40 (Aβ40), Abeta 42 (Aβ42), Glial Fibrillary Acidic Protein (GFAP™), and Neurofilament light (Nf-L).	Baseline
Plasma phosphorylated tau (P-tau) 181	Plasma P-tau 181 will be measured in DM2 and control groups. Relationships between plasma and CSF biomarkers will also be determined within the DM2 group. Plasma p-tau181 is categorized into three categories: low < 12.03 pg/ml, medium 12.04-19.63 pg/ml, and high > 19.65 pg/ml. High level of plasma P-tau 181 is correlated with neurodegenerative diseases.	Baseline
CSF P-tau 181	The P-tau-181 assay will be measured in CSF samples. A maximum concentration of CSF P-tau of 60 pg/ml or lower is considered normal.	Baseline
6-minute walk test (6MWT) Times (minutes)	Among the tools that assess walking ability in muscular dystrophies, the 6MWT offers a good combination of reliability, sensitivity, clinical significance, and feasibility for multi-center trials. We will compared 6MWT between groups.	Baseline
10-meter walk test times (seconds)	Subjects will be instructed to walk at maximum speed in a long corridor with an even surface over 10 meters with a still-standing start and a "flying" finish. Time to complete 10-meter will be measured between groups.	Baseline
Short Physical Performance Battery (SPPB) Scores	The SPPB measures physical function using three components: usual gait speed over 4-meters time to complete five chair rises, and standing balance with a progressively narrow base of support. Each component is scored on a 0-4 scale and summed for an overall score range of 0-12. SPPB scores will be compared between groups.	Baseline
Step Test - Number of Steps	Participants will be instructed to make as many "full steps" as possible in 15 seconds. Both legs will be tested, one foot at the time. The number of the step will be compared between groups.	Baseline
Grip and Pinch Strength (kg)	Handgrip dynamometer will be used to test grip strength. The subject will also perform quantitative pinch strength testing with a pinch gauge. Average grip and pinch strength (kg) will be measured and compared between groups.	Baseline
Nine-Hole Peg Test Times (9HPT)	The test will evaluate upper extremity function, specifically fine dexterity, and coordination. We will test each subject twice, starting with a dominant hand first, then a non-dominant hand. One practice trial (per hand) should be provided before timing the test. Average time to complete the 9HPT will be compared between groups.	Baseline

Collaborators and Investigators

• Sponsor: Wake Forest University Health Sciences
• Collaborators: National Institute of Neurological Disorders and Stroke (NINDS)
• Investigators: Principal Investigator: Araya Puwanant, MD, MS, Wake Forest University Health Sciences

Study record dates

Study Major Dates

• Study Start (Actual): April 26, 2023
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): June 1, 2027

Study Registration Dates

• First Submitted: April 21, 2023
• First Submitted That Met QC Criteria: May 2, 2023
• First Posted (Actual): May 11, 2023

Study Record Updates

• Last Update Posted (Actual): February 2, 2026
• Last Update Submitted That Met QC Criteria: January 29, 2026
• Last Verified: January 1, 2026

More Information

Terms related to this study

• Keywords: MRI; memory; biomarkers; brain; central nervous system; cognitive dysfunction; white matter; myotonic dystrophy; muscular dystrophy; neurodegenerative diseases
• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Nervous System Diseases; Muscular Diseases; Mental Disorders; Neuromuscular Diseases; Genetic Diseases, Inborn; Neurocognitive Disorders; Cognition Disorders; Heredodegenerative Disorders, Nervous System; Muscular Disorders, Atrophic; Myotonic Disorders; Congenital, Hereditary, and Neonatal Diseases and Abnormalities; Cognitive Dysfunction; Muscular Dystrophies; Myotonic Dystrophy; Neurodegenerative Diseases
• Other Study ID Numbers: IRB00065459; K23NS125110-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No