The Natural History of Patients With Congenital Muscular Dystrophies Due to Mutations in the SELENON or LAMA2 Genes: Working Towards Trial-readiness in Two Mitochondrial Myopathy Mimics
Conditions: MDC1A, SELENON-related Myopathy
Sponsor: Radboud University Medical Center

NL64269.091.17 
SEPN1 and LAMA2 
THE NATURAL HISTORY OF PATIENTS WITH 
MUTATIONS IN SEPN1 (SELENON) or 
LAMA2: A PILOT STUDY 
Submission to ClinicalTrials.gov: 8 July, 2020 
Approval by ethics committee (CMO Regio Arnhem-Nijmegen): 8 July, 2020 
Submission to ethics committee (CMO Regio Arnhem-Nijmegen): 28 May, 2020 
Unique Protocol ID: NL64269.091.17 
Ethics committee approval number: 2017-3911 
NCT ID: not yet assigned 

NL64269.091.17 
SEPN1 and LAMA2 
 
 
PROTOCOL TITLE The natural history of patients with mutations in SEPN1 (SELENON) or LAMA2: a 
pilot study 
 
Short title 
SEPN-1 and LAMA2 
Version 
3 
Date 
28-05-2020 
Coordinating investigator/project 
leader 
Dr. Nicol Voermans 
Principal investigator(s) (in 
Dutch: hoofdonderzoeker/ 
uitvoerder) 
  
Dr. Nicol Voermans 
Dr. Corrie Erasmus 
Dr. Jan Groothuis 
Prof. dr. Jan Smeitink 
Drs. Karlijn Bouman 
Sponsor (in Dutch: 
verrichter/opdrachtgever) 
Radboudumc 
Subsidising party 
Stofwisselkracht, Spieren voor Spieren, Stichting 
Voor Sara 
Independent expert (s) 
 
Drs. S.C.C. Vincenten 

NL64269.091.17 
SEPN1 and LAMA2 
 
 
PROTOCOL SIGNATURE SHEET 
 
Name 
Signature  
Date  
Head of Department:  
 
 
Prof. dr. Michèl Willemsen 
 
 
 
Coordinating Investigator/Project 
leader/Principal Investigator: 
 
Dr. Nicol Voermans 
 
 
 
18-05-2020 
 
 
 
 
 
 

NL64269.091.17 
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TABLE OF CONTENTS 
 
PROTOCOL SIGNATURE SHEET ......................................................................................................... 3 
LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS .....................................................................5 
1. 
INTRODUCTION AND RATIONALE ....................................................................................................7 
2. 
OBJECTIVES ....................................................................................................................................... 8 
3. 
STUDY DESIGN ............................................................................................................................. 8 
4. 
STUDY POPULATION ........................................................................................................................ 8 
4.1 
Population (base) ........................................................................................................................ 8 
4.2 
Inclusion criteria .......................................................................................................................... 8 
4.3 
Exclusion criteria ......................................................................................................................... 8 
4.4 
Sample size calculation ............................................................................................................... 9 
5. 
METHODS ........................................................................................................................................... 9 
5.1 
Study parameters/endpoints ........................................................................................................ 9 
5.1.1 
Main study parameter/endpoint ................................................................................................ 9 
5.1.2 
Other study parameters .............................................................................................................. 10 
5.2 
Study procedures ...................................................................................................................... 10 
6. 
SAFETY REPORTING ...................................................................................................................... 14 
7. 
STATISTICAL ANALYSIS ................................................................................................................. 14 
7.1 
Primary study parameter(s) ....................................................................................................... 14 
8. 
ETHICAL CONSIDERATIONS ...................................................................................................... 14 
8.1 
Regulation statement ................................................................................................................. 14 
8.2 
Recruitment and consent ........................................................................................................... 14 
8.3 
Objection by minors or incapacitated subjects ............................................................................ 15 
8.4 
Benefits and risks assessment, group relatedness ..................................................................... 15 
8.5 
Compensation for injury ............................................................................................................. 15 
8.6 
Incentives .................................................................................................................................. 15 
9. 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION ............................................... 15 
9.1    Handling and storage of data and documents ............................................................................ 15 
9.2 
Monitoring and Quality Assurance ............................................................................................. 16 
9.3 
Amendments ............................................................................................................................. 16 
9.4 
Annual progress report .............................................................................................................. 16 
9.5 
Temporary halt and (prematurely) end of study report ................................................................ 16 
9.6 
Public disclosure and publication policy ..................................................................................... 16 
10. 
STRUCTURED RISK ANALYSIS .................................................................................................. 16 
11. REFERENCES .................................................................................................................................... 17 
Supplementary table 1 ......................................................................................................................... 18 
 

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LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS 
 
ABR 
ABR form, General Assessment and Registration form, is the application 
form that is required for submission to the accredited Ethics Committee (In 
Dutch, ABR = Algemene Beoordeling en Registratie) 
CV 
Curriculum Vitae 
IC 
Informed Consent 
 
METC 
Medical research ethics committee (MREC); in Dutch: medisch ethische 
toetsing commissie (METC) 
Sponsor 
The sponsor is the party that commissions the organisation or performance 
of the research, for example a pharmaceutical 
company, academic hospital, scientific organisation or investigator. A party 
that provides funding for a study but does not commission it is not 
regarded as the sponsor, but referred to as a subsidising party. 
Wbp 
Personal Data Protection Act (in Dutch: Wet Bescherming Persoonsgevens) 
WMO 
Medical Research Involving Human Subjects Act (in Dutch: Wet Medisch- 
wetenschappelijk Onderzoek met Mensen 

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SUMMARY 
Rationale: Patients with mutations in the SEPN1 gene (nowadays called SELENON gene) 
suffer from slowly progressive congenital myopathy with early onset rigidity of the spine and 
potentially life-threatening respiratory insufficiency. The protein encoded by SEPN1, 
selenoprotein-1, functions as an endogeneous antioxidant and executes a role in cellular 
redox metabolism. The first results of an intervention study using KH176, currently under 
development for mitochondrial disease, in an animal model (Sepn1 knock out zebrafish) 
showed improved muscular function. Patients with mutations in LAMA2 gene causing 
merosin-deficient congenital muscular dystrophy (MDC1A) have a similar phenotype as 
those with mutations in SEPN1 gene. Key characteristics include congenital hypotonia, 
delayed motor development and contractures. For them no treatment is available either. 
Since not much is known about the clinical progression in these two congenital muscular 
dystrophies, there is an urgent need for natural history-outcome measure studies to reach 
trial-readiness enabling smooth transition towards clinical trials.  
Objective: i) To identify and follow patients withSEPN1- and LAMA2-related congenital 
muscular dystrophies in The Netherlands (and preferably also in Belgium). Ii) To select outcome 
measures based on the natural history data. 
Study design: Observational 1,5-year study with 6-monthly measurements (four 
measurements in total). 
Study population: Patients with the rare muscle condition caused by mutations in SEPN1 or 
LAMA2 aged 0-100 years. 
Main study parameters/endpoints: A wide variety of tests will be performed to get a full 
impression of the patient’s abilities and disabilities (e.g. muscle strength, walking ability, 
muscle endurance, activities, participation, quality of life, fatigue). Full body muscle MRI will 
only be performed in patients who are able to lie still for the full duration of the MRI (~>10 
years) and who are not dependent on respiratory equipment. 
Nature and extent of the burden and risks associated with participation, benefit and 
group relatedness: We aim to study the natural history of these groups of patients. Since 
so few SEPN1 and MDC1A patients are available, we will ask both children and adults to 
participate in this study. This study is a preparation for  clinical trials in these conditions and 
may facilitate the proper conduction of the clinical trials in these conditions. For the patient, 
the conduction of so many tests is without any doubt burdensome. Therefore, we reduced 
the number of test to to-our-opinion the absolute minimum. We have discussed our protocol 
with Spierziekten Nederland and Spieren voor Spieren. We will make a summary of the 
measurements after the first measurement and at the end of the study, when indicated 
answering a question from clinical care. 

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1. INTRODUCTION AND RATIONALE
Patients with mutations in the SEPN1 gene suffer from slowly progressive congenital 
myopathy with early onset rigidity of the spine and potentially life-threatening respiratory 
insufficiency. The prevalence of this condition, above the age of 5 years, based on a 
Danish study, is estimated around 0.5:1000,0001. The estimated number of patients in 
the Netherlands is therefore around 10-20, which limits the clinical experience that is 
available for this condition. A relatively recent retrospective cross-sectional study in 41 
subjects by our colleagues at the Dubowitz Neuromuscular Centre in London showed that 
the spectrum of the disease is wider than previously reported2,3, ranging from patients 
who lose ambulation to patients with a very stable and mild disease course. This is in line 
with our limited clinical experience. Since this was a retrospective study, neuromuscular 
function was not quantified using a standardized set of instruments. 
Patients with mutations in LAMA2-gene causing merosin-deficient congenital muscular 
dystrophy (MDC1A) have a similar phenotype as those with mutations in SEPN1 gene. 
Key characteristics include congenital hypotonia, delayed motor development and 
contractures. The clinical manifestations of LAMA2-related muscular dystrophy range 
from severe, early-onset congenital muscular dystrophy (complete laminin α2 deficiency) 
to mild, later childhood-onset limb-girdle type muscular dystrophy (partial laminin  
deficiency)4.The prevalence of LAMA2-related muscular dystrophy is estimated at 4 in 
500.0005,  
For both SEPN1 and LAMA2-related congenital muscular dystrophies no (curative) 
treatment is available. Experience with quantifying neuromuscular function in these 
conditions should be obtained before scientifically sound clinical trials can be performed 
in these conditions. 
The protein encoded by SEPN1, selenoprotein-1, functions as an endogeneous 
antioxidant and executes a role in cellular redox metabolism6. Consequently, 
selenoprotein deficiency causes oxidative stress in muscle cells. Patients with SEPN1 
deficiency therefore not only show striking similarities to patients with classical 
mitochondrial diseases on certain clinical aspects, but also on the cellular level. We 
recently confirmed that the cells of patients with SEPN1-related congenital myopathy 
indeed showed increased ROS production and abnormal redox status. Both cellular 
abnormalities could be counteracted by KH176, a new chemical entity developed for 
mitochondrial oxidative phosphorylation disturbances. Interestingly, the first results of the 
experiments in an animal model (Sepn1 knock out zebrafish) showed improved muscular 
function. We hypothesize that KH176 is also beneficial for SEPN1-mutated patients. 
LAMA2-related muscular dystrophy is caused by mutations in the LAMA2 gene that 
result in a deficiency or absence of the alpa-2 subunit of laminin 2 and 4. This results in 
a decrease of the strength and stability of muscle tissue, leading to the signs and 
symptoms of LAMA2-related muscular dystrophy5. Currently, Maastricht UMC+ is taking 
preparations to start a phase I/II clinical trial involving mesoangioblast cultures for 
therapy in the near future.  
In conclusion, both SEPN1-and LAMA2-related congenital muscular dystrophy patients 
are rare and no Dutch registry exists. The future clinical trials emphasize the urgent 
need to identify and follow up these patients and to select optimal outcome measures.

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2. OBJECTIVES
Primary Objective:
To identify and follow patients with SEPN1 and LAMA2  mutations.
Secondary Objective(s): 
To assess the natural history and to select outcome measures based on the natural 
history data. 
3. STUDY DESIGN
This is an observational study.
In both SEPN1- and LAMA2-related muscular dystrophy, we will assess disease
severity in 10 patients using different outcome measures every 6 months, during 18
months (one-and-a-half-year study with four measurements). First inclusions will take
place in 2020. We expect that within 2 years inclusion will be completed. If more than 10
patients are willing to participate, we will select per muscle disease 10 patients that are
representative of the patient population (based on age, gender, disease severity etc.).
The remaining patients will be retrospectively analyzed through medical records and will
receive questionnaires, which can be completed at home.
4. STUDY POPULATION
4.1 Population (base)
SEPN1 patients  (prevalence 0.5:1000,000) and MDC1A patients (4 in 500,000) are 
rare and no Dutch registry exists. Therefore, we can only estimate the number of 
patients in the Netherlands and Belgium (n ≈ 20 in each disease group). All patients 
with SEPN1 and LAMA2 mutations within the Netherlands and Belgium will be 
identified through contact with genetic diagnostic services, rehabilitation centers, and 
muscle disease experts. A previous pathology study confirmed that 20 patient have 
been diagnosed with SEPN1 in the past years in the Netherlands and Belgium. The 
Stichting Voor Sara welcomed 17 MDC1A patients at their first held patient information 
day. We expect that more patients will be referred once we start these natural history 
studies.
4.2 Inclusion criteria 
In order to be eligible to participate in this study, a subject must meet all of the following 
criteria: 
- 
0-100 years of age 
- 
Willing and able to complete (part of the) measurement protocol 
- 
Willing and able to travel to Nijmegen 
- 
Dutch-speaking 
-  Genetically-confirmed muscle disease caused by mutations in SEPN1: congenital muscular 
dystrophy with early spine rigidity or congenital myopathy (multicore/minicore disease, congenital 
fiber type size disproportion) 
-  Genetically confirmed muscular dystrophy caused by mutations in LAMA2: merosin-deficient 
muscular dystrophy 1A (early-onset LAMA2-related muscular dystrophy) or childhood-onset limb-
girdle type muscular dystrophy (late-onset LAMA2-related muscular dystrophy) 
4.3 Exclusion criteria 
This study doesn’t have any exclusion criteria. 

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4.4 Sample size calculation 
We think that we will be able to identify 20 SEPN1 and 20 MDC1A patients in the 
Netherlands and Dutch- speaking Belgium. Based on our experience in rare diseases, 
we estimate that ~50% of the patients will participate in the study.. 
5. METHODS
5.1 Study parameters/endpoints
5.1.1 Main study parameter/endpoint 
The following outcome measures will be used in both children and adults: 
Degree and extent of muscle weakness: maximal voluntary isometric contraction 
(measured by MRC scores and handheld dynamometry) 
Motor Function Measure 
30 seconds sit to stand test 
Graded and timed function tests  
10 meter walk test 
6-minute walking test 
Accelerometry for 7 days  at home 
Hammersmith Functional Motor Scale (HFMS) 
Pedriatric balance scale or miniBEST 
Vignos and Brooke scale 
Range of motion of ankle (contracture Achilles tendon) and elbow 
Muscle ultrasound 
Whole-body muscle MRI (yearly; above the age of 10 years; no respiratory equipment) 
Respiratory function test (above 5 years): forced vital capacity FVC upright and 
supine, forced expiratory volume in 1 second FEV1, (measured by spirometry), peak 
cough flow, sniff nasal inspiratory pressure (SNIP), maximal inspiratory pressure 
(MIP) and maximal expiratory pressure (MEP); muscle ultrasound measurement of 
the diaphragm 
ECG (yearly) 
Cardio-echography (yearly) 
X-ray of the spine (yearly) 
DEXA scan (yearly) 
Neurological phenotype (e.g. facial appearance, ophthalmoplegia) – only at start of 
study by experienced (paediatric) neurologist (yearly) 
The following questionnaires will be included:  
Activlim questionnaire 
Borg Rating Scale of Perceived Exertion 
Checklist individual strength questionnaire  
Egen Klassifikation scale version 2 (EK2) 
Functional Ambulation Category (FAC) 
Wong-Baker Faces Pain Scale 
McGill pain questionnaire 
PedsQL generic quality of life, neuromuscular module and Multidimensional Fatigue 
Scale 
SF36 quality of life scale  
Individualised Neuromuscular Quality of Life (INQoL) 
IPA 

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5.1.2 Other study parameters 
Weight 
Height 
Demographic parameters (age, sex, age at diagnosis) 
Genetic information (mutation) 
Medical history, including the 10 most burdensome complaints 
Level of education; work 
 
5.2 Study procedures 
Ranked alphabetically 
See also Supplementary Table 1 
 
10 meter walk testThe time in which a patient is able to walk safely (!) for 10 meter is noted. 
 
30 seconds sit to stand test -> video+ 
The patient is asked to stand up from full squatting position as many times as 
possible within 30 seconds. 
 
6 minute walking test (6MWT) 
In the six minute walk test, children are asked to walk (not run, skip, or gallop) as 
fast as possible, with or without devices and with the opportunity to rest, but not to 
sit or lay down (timing continues during resting). 
 
Accelerometer 
Patients are asked to wear an accelerometer for 7 days, the recommended period. 
 
Activlim questionnaire - above 6 years only 
Questionnaire to assess the ability to perform 22 activities of daily life on a 3-point 
scale from impossible to easy. 
 
Borg Rating Scale of Perceived Exertion 
Borg Rating Scale of Perceived Exertion is a way of measuring physical activity 
intensity level. Perceived exertion is based on the physical sensations a person 
experiences during physical activity. We will ask patients to score the intensity 
level at the end of the 6MWT.  
 
Cardiac ultrasound 
The usual cardiac ultrasound will be performed using a standardized protocol to 
obtain images which can be analyzed for cardiac contractility using the 2D strain 
technology, a detailed software analysis of the images. 
The test can be performed in all children. 
 
Checklist individual strength (CIS) 
The CIS is a questionnaire rating four subscales: subjective tiredness, 
concentration, motivation and physical activity. It consists of 20 items on a 7-point 
scale. 
 
 

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The Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders 
(CHOP INTEND) – children < 2 years only 
CHOP INTEND has been shown to be valid for the assessment of motor skills of 
children below 2 years of age.  
 
DEXA scan 
The bone density of the spine and hip will be measured by a DEXA scan 
 
Egen klassifikation version 2 (EK2) 
The EK2 is a questionnaire that was designed to measure functional ability of activities in 
daily living in non-ambulant Duchenne muscular dystrophy patients. This questionnaire is 
only available in English. Therefore, only patients older than 16 years who have a sufficient 
understanding of the English language will be asked to complete this questionnaire.  
 
Functional Ambulation Category (FAC) 
The FAC assesses functional ambulation in patients. 
 
Graded and timed function tests-> video+ 
The time it takes to complete functions of the lower extremity will be assessed with 
the time it takes to climb 5 stairs,  to rise from the floor and the ‘Timed up and Go’. 
 
Individualized Neuromuscular Quality of Life (INQoL) 
The INQoL is a validated muscle disease specific measure of quality of life, which can be used 
for individuals or large samples. 
 
Hammersmith Infant Neurological Examination (HINE) 
HINE is designed to be a simple and scorable method for evaluating infants from 2 months to 
2 years of age. It includes 3 sections that assess different aspects of neurologic function, 
including neurological examination, developmental milestones and behavioral assessment. 
 
Hammersmith Functional Motor Scale (HFMS) 
The HFMS was originally developed to assess the physical abilities of children with non-
ambulant Spinal Muscular Atrophy (SMA). It consists of 20 items that were considered as 
important to measure the physical functioning of those patients.  
 
Impact of Participatie en Autonomie (IPA) – adults only 
Questionnaire about participation and autonomy in daily life. 
 
Full body muscle MRI 
A full body muscle MRI (quantitative and qualitative) will be performed in patients 
who are able to lie supine and still for 60 minutes (~> 10 years old) and who are 
not dependent on respiratory equipment.  
 
Maximal voluntary isometric contraction -> video+ 
Both hands will be tested for maximal voluntary isometric contraction using a hand 
held dynamometer. Also strength of the m. quadriceps and m. biceps brachii are 
measured using dynamometry. Three attempts will be noted bilaterally.  
McGill pain questionnaire 
Questionnaire in which the location, level and characteristics of pain are assessed. 
 
Mini Balance Evaluation System Test (miniBEST) 

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The miniBEST evaluates balance control by scoring of exercises that belong to one of the 
following categories: anticipatory postural changes, reactive postural control, sensory 
orientation and walking.  
 
Motor Function Measure (MFM) 
Motor function in patients (aged 2-62 years) with neuromuscular diseases (ambulant 
or non-ambulant) can be measured with the Motor Function Measure. The MFM is a 
scale which consists of 32 items in three dimensions: standing position and  
transfers, axial and proximal motor function, distal motor function. 
 
Muscle ultrasound 
Ultrasound quantification of the leg, arm, back and abdominal muscles, as well as 
the diaphragm, will be performed. 
 
Neurological examination 
The promovendus (MD) and/or an experienced (paediatric) neurologist will do a full 
neurological examination at the start of the study, including muscle power 
measurements and hand-held dynamometry. A shortened version of the 
neurological examination will be performed every subsequent visit. 
 
PedsQL generic quality of life – children only 
The PedsQL generic quality of life questionnaire consists of 23 questions in four 
domains: Physical, Emotional, Social, and School Functioning. It has been 
translated and subsequently validated into many languages, including Dutch. 
 
PedsQL neuromuscular module (PedsQL NMM) – children only 
The PedsQL NMM questionnaire consists of 25 questions in three domains: 
Neuromuscular disease, communication and family resources. 
 
PedsQL Multidimensional Fatigue Scale (PedsQL MFS) – children only 
A questionnaire assessing subjective fatigue in three domains, namely General 
Fatigue Scale, Sleep/Rest Fatigue Scale, and Cognitive Fatigue Scale. 
 
Pediatric balance scale – children only 
The Pediatric Balance Scale is a modified version of the Berg Balance Scale 
that is used to assess functional balance skills in school-aged children with 
mild to moderate motor impairments.  
 
Pulmonary function 
In those patients able to follow commands, pulmonary function (forced vital capacity 
(FVC), forced expiratory volume in the first second (FEV1) , maximal inspiratory 
pressure (MIP) and maximal expiratory pressure (MEP)) will be assessed. The FVC 
will be assessed in lying and in sitting position to assess the contribution of the 
diaphragm. 
 
Range of motion ankle and elbow 
The range of motion of the ankles and elbows is noted bilaterally. 
 
 
SF36 quality of life scale – adults only 
Measure for quality of life with 36 items. 

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Vignos and Brooke scale 
The Brooke and Vignos scales provide ordinal ordinal-level data to assess the upper and lower 
extremity functions.  
 
Wong-Baker Faces Pain Scale 
The Wong-Baker Faces Pain Scale was originally created for children to help them 
communicate about their pain.  
 
X-ray of the spine 
A full spine X-ray will be made in a lateral and anteroposterior direction in a sitting position. 
While lying on the side, a flexion-extension X-ray will be made. 
 

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6. SAFETY REPORTING
We don’t expect any adverse events. 
7. STATISTICAL ANALYSIS
The data will be presented per patient per test. Missing data will not be replaced. 
0 months 
6 months 
12 months 
18 months 
SEPN001 
SEPN002 
MDCA001 
MDCA002 
7.1 Primary study parameter(s) 
Primary Objective: 
To identify and follow patients with SEPN1 or LAMA2 mutations. 
Secondary Objective(s): 
To select outcome measures based on the natural history data. 
Since the numbers in this study will probably be very low, data will be analyzed based 
on a) the correspondence of test results to our clinical observation of the patient (face 
validity, will be assessed at each occasion), b) the fluctuation of the results in 
combination with the patient-reported disease progression, c) floor and ceiling effects, d) 
variation and variability of the data and e) the opinion of the patient about which test 
reflects his/her disease severity. 
We will use descriptive statistics (mean, median, SD, 95%-CI) in order to summarize 
the features of SEPN1 and MDC1A patients.  
We will perform (Spearman’s) correlation analysis and non-parameterical testing to test 
e.g. correlation between age and difference between ambulatory and non-ambulatory 
patients. In order to assess disease progression between subsequent measuring 
moments, we will perform the Wilcoxon signed-rank test (nonparametric continuous 
paired data) and the McNemar’s test (categorial paired data). 
To visualize the correlation between several parameters, we will show our results in 
Scatter Plots. Spaghetti Plots will be used to show disease progression. 
The low number of included patients will be kept in mind while we will interpret our 
results.  
8. ETHICAL CONSIDERATIONS
8.1 Regulation statement
The study will be conducted according to the principles of the Declaration of Helsinki
(version, date, see for the most recent version: www.wma.net) and in accordance with the
Medical Research Involving Human Subjects Act (WMO).
8.2 Recruitment and consent
We will contact the patients known at our centre via their treating physicians with a letter
in which we ask them to participate in this study. They will be asked to return the

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answering form by mail. 
We will contact colleagues at other neuromuscular and rehabilitation centres to identify 
patients. Patients will be contacted by their treating physician. 
We will also recruit through patient organizations. An advertisement is placed on the 
website and/or social media of these organizations, or a patient information letter is sent 
to the patients known to have this condition. 
We will also recruit via our own social media. 
 
8.3 Objection by minors or incapacitated subjects 
If children object to participate in this study (defined as: the promovendus (MD)  is not 
able to motivate the child to perform the measurements, also not after a 30-minute break 
in which the child was able to play and have a snack), the study will be ended for that 
participant. 
 
8.4 Benefits and risks assessment, group relatedness 
We aim to study the natural history of these groups of patients to prepare the groups of 
these disorders for  clinical trials which are in preparation. Since so little patients are 
available, we will ask both children and adults to participate in this study. This study is a 
preparation for  clinical trials in these conditions and may facilitate the proper conduction 
of the clinical trials in these conditions. For the patient, the conduction of so many tests is 
without any doubt burdensome. Therefore, we reduced the number of test to to-our-
opinion the absolute minimum. In addition, we will call every patient two weeks after each visit to 
the hospital to discuss and evaluate the burdensomeness of the research day(s). We have 
discussed our protocol with Spierziekten Nederland and Spieren voor Spieren. We will 
make a summary of the measurements after the first measurement and at the end of the 
study, when indicated answering a question from clinical care. 
 
8.5 Compensation for injury 
The sponsor has an insurance which is in accordance with the legal requirements in the 
Netherlands (Article 7 WMO). This insurance provides cover for damage to research 
subjects through injury or death caused by the study. 
The insurance applies to the damage that becomes apparent during the study or within 4 
years after the end of the study. 
 
8.6 Incentives 
No incentives, we will try to arrange a nice present for when the study is complete (e.g. a trip to the 
zoo). Travel costs and lunch are reimbursed. If patients are expected to be at the hospital for two 
subsequent days in order to complete all measurements, they will be offered a free overnight stay at 
the Radboud hotel or another (nearby) accommodation that fits their requirements. 
  
9. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 
9.1 Handling and storage of data and documents 
All records identifying the patients will be kept confidential and, to the extent permitted by 
the applicable laws and/or regulations (Dutch Personal Data Protection Act), will not be 
made publicly available. 
Patient data is coded using codes not reducible to the patient, on patient initials or birth- 
date, e.g. SEPN001, SEPN002, or MDCA001, MDCA002 etc. 
The Coordinating and Principal Investigators and their designee will have access to the 
source data and to the key of the code during the study. After publication of the study, the 

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key will be in an encrypted document only on the Coordinating Investigators hospital hard 
drive (which is regularly backed up). 
 
9.2 Monitoring and Quality Assurance 
Monitoring will take place 
 
9.3 Amendments 
Amendments are changes made to the research after a favourable opinion by the 
accredited METC has been given. All amendments will be notified to the METC that gave 
a favourable opinion. 
 
9.4 Annual progress report 
The sponsor/investigator will submit a summary of the progress of the trial to the 
accredited METC once a year. Information will be provided on the date of inclusion of the 
first subject, numbers of subjects included and numbers of subjects that have completed 
the trial, serious adverse events/ serious adverse reactions, other problems, and 
amendments. 
 
9.5 Temporary halt and (prematurely) end of study report 
The investigator/sponsor will notify the accredited METC of the end of the study within a 
period of 8 weeks. The end of the study is defined as the last patient’s last visit. 
 
The sponsor will notify the METC immediately of a temporary halt of the study, including 
the reason of such an action. 
 
In case the study is ended prematurely, the sponsor will notify the accredited METC 
within 15 days, including the reasons for the premature termination. 
 
Within one year after the end of the study, the investigator/sponsor will submit a final  
study report with the results of the study, including any publications/abstracts of the study, 
to the accredited METC. 
 
9.6 Public disclosure and publication policy 
We will publish our data, independent on the outcome. 
 
 
10. STRUCTURED RISK ANALYSIS 
This study does not concern any product: medicinal product, food product, or medical 
device. There is a small risk for minor injury, e.g. when a patient falls. However, since we 
use all functional test using movements to which most patients are familiar (i.e. walking, 
transfers, etc), the patient will be able to estimate his/her own risk. We don’t include tests 
in which we push patient to their physical limits. We conclude that this study has a 
negligible risk. 

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11.REFERENCES 
1. 
Witting N, Werlauff U, Duno M, Vissing J. Phenotypes, genotypes, and prevalence of congenital 
myopathies older than 5 years in Denmark. Neurol Genet. 2017;3(2):e140. 
2. 
Scoto M, Cirak S, Mein R, et al. SEPN1-related myopathies: clinical course in a large cohort of 
patients. Neurology. 2011;76(24):2073-2078. 
3. 
Schara U, Kress W, Bönnemann CG, et al. The phenotype and long-term follow-up in 11 
patients with juvenile selenoprotein N1-related myopathy. Eur J Paediatr Neurol. 
2008;12(3):224-230. 
4. 
Oliveira J, Gruber A, Cardoso M, et al. LAMA2 gene mutation update: Toward a more 
comprehensive picture of the laminin-α2 variome and its related phenotypes. Hum Mutat. 
2018;39(10):1314-1337. 
5. 
Nguyen Q, Lim KRQ, Yokota T. Current understanding and treatment of cardiac and skeletal 
muscle pathology in laminin-α2 chain-deficient congenital muscular dystrophy. Appl Clin Genet. 
2019;12:113-130. 
6. 
Moulin M, Ferreiro A. Muscle redox disturbances and oxidative stress as pathomechanisms and 
therapeutic targets in early-onset myopathies. Semin Cell Dev Biol. 2017;64:213-223. 
 

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Supplementary table 1 
 
Ambulant 
patients 
Non-
ambulant 
patients 
Time (min) 
Every 
assessment 
Yearly 
                                       Functional outcome measures 
CHOP INTEND (< 2 years old) 
x 
x 
‘short period 
of time’ 
x 
Hammersmith Infant Neurological Examination (HINE) (< 
2 years old) 
x 
x 
‘quick’ 
x 
Muscle power measurements (≥ 2 years old) 
Hand-held dynamometry (≥ 5 years old) 
x 
x 
5 
x 
Motor Function Measure-20 (2-7 years old) 
Motor Function Measure-32 (> 7 years old) 
x 
x 
x 
x 
30 
40 
x 
30 seconds sit to stand test (≥ 2 y/o) 
x 
x 
1 
x 
Graded and timed function tests (≥ 2 years old) 
x 
 
15 
x 
10 meter walk test (≥5 years old) 
x 
 
1 
x 
6-minute walking test (≥5 years old) 
x 
 
7 
x 
Functional Ambulation Category (≥5 y/o) 
x 
x 
1 
x 
Hammersmith Functional Motor Scale (HFMS) (≥2 years 
old) 
 
x 
12 
x 
Vignos and Brooke scale (≥ 2 years old) 
X 
X 
2 
x 
Pediatric balance scale (2 – 17 years old) 
x 
 
15 
x 
Mini Balance Evaluation System Test (≥18 years old) 
x 
 
15 
x 
Range of motion of ankle (contracture Achilles tendon) 
and elbow 
x 
x 
4 
x 
Accelerometry for 7 days  at home (non-dominant hand, 
≥2 years old) 
 
x 
x 
- 
x 

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                       Clinical endpoint/questionnaires 
Checklist individual strength questionnaire (≥18 y/o) 
x 
x 
10 
x 
Individualized Neuromuscular Quality of Life 
Questionnaire (INQoL) (≥18 y/o) 
x 
x 
20 
x 
Activlim questionnaire (≥6 years old) 
x 
x 
3 
x 
PedsQL generic quality of life, neuromuscular module 
and Multidimensional Fatigue Scale (2-17 years old) 
x 
x 
15 
x 
Egen Klassifikation scale version 2 (EK2) (≥ 16 years 
old and good understanding of the English language) 
 
x 
10 
x 
Wong-Baker Faces Pain Scale (≥2 y/o) 
x 
x 
1 
x 
McGill pain questionnaire (≥12 years old) 
x 
x 
15 
x 
Impact on Participation and Autonomy (IPA) (≥18 years 
old) 
x 
x 
20 
x 
SF36 quality of life scale (adults only) 
x 
x 
5-10 
 
Borg Rating Scale of Perceived Exertion 
x 
x 
1 
x 
Neurological examination and medical history 
x 
x 
30 
x 
Surrogate endpoints 
Respiratory function test (≥ 5 years old) 
x 
x 
30 
x 
ECG (≥ 2 years old) 
x 
x 
5 
 
x 
Cardio-echography (≥ 2 years old) 
x 
x 
30 
 
x 
X-ray of the spine (≥ 2 years old) 
x 
x 
15 
 
x 
Muscle ultrasound (including ultrasound of diaphragm) 
x 
x 
90 
x 
 
Muscle MRI (≥ 10 years old) 
x 
x 
60 
 
x 
DEXA scan (≥ 2 years old) 
x 
x 
20 
 
x