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Review

AMPK is mitochondrial medicine for

neuromuscular disorders
Andrew I. Mikhail, 1,* Sean Y. Ng, 1,* Stephanie R. Mattina, 1,* and Vladimir Ljubicic 1,
*

Duchenne muscular dystrophy (DMD), myotonic dystrophy type 1 (DM1), and Highlights
spinal muscular atrophy (SMA) are the most prevalent neuromuscular disorders Mitochondrial stress is a common char-
(NMDs) in children and adults. Central to a healthy neuromuscular system are acteristic of the most prevalent neuro-
muscular disorders (NMDs) in children
the processes that govern mitochondrial turnover and dynamics, which are reg-
and adults, namely Duchenne muscular
ulated by AMP-activated protein kinase (AMPK). Here, we survey mitochondrial dystrophy (DMD), myotonic dystrophy
stresses that are common between, as well as unique to, DMD, DM1, and type 1 (DM1), and spinal muscular atro-
SMA, and which may serve as potential therapeutic targets to mitigate neuro- phy (SMA), which are otherwise distinct
conditions.
muscular disease. We also highlight recent advances that leverage a mutation-
agnostic strategy featuring physiological or pharmacological AMPK activation AMP-activated protein kinase (AMPK)
to enhance mitochondrial health in these conditions, as well as identify outstand- regulates mitochondrial biogenesis,
ing questions and opportunities for future pursuit. while rapidly emerging research also im-
plicates the kinase in organelle dynamics
and mitophagy.

Mitochondrial stress: a common link between the most prevalent NMDs in AMPK stimulation in preclinical models
of DMD, DM1, and SMA, as well as in
children and adults patients, using pharmacological or
NMDs are a group of heterogenous conditions that arise from defects in α-motoneurons (α-MNs), physiological interventions, targets mi-
the neuromuscular junction (NMJ), and/or skeletal muscle [1]. Hundreds of genetic mutations tochondrial stress and results in clini-
have been directly linked to NMDs, including DMD (see Glossary), DM1, and SMA, which are cally meaningful improvements in
neuromuscular function and health.
the most common neuromuscular diseases in children and adults. Loss of skeletal muscle
mass and strength are predominant features of NMDs along with other multisystemic signs,
such as cardiac and respiratory defects, as well as metabolic impairments [1]. At the molecular
level, several NMDs, including DMD, DM1, and SMA, regardless of their causative mutations,
exhibit common and disease-specific alterations in mitochondrial biology. Mitochondria are
regulated by numerous factors, but perhaps none more critical than AMPK [2]. AMPK is also
emerging as a key component of neuromuscular biology [3], which, together with its impact on
mitochondria, strengthens the rationale for manipulating the kinase to mitigate NMD severity
and progression.

The involvement of AMPK in initiating mitochondrial biogenesis is well described but its
role in other processes that regulate organelle quantity and quality, such as mitophagy
and mitochondrial dynamics, is not completely understood, particularly in the context of NMDs
[4,5]. Elucidating these mechanisms may reveal opportunities for the development of novel, effective 1
Department of Kinesiology, Faculty of
therapies. Therefore, the purpose of this review is to: (i) summarize the role of AMPK in regulating Science, McMaster University,
mitochondrial quality control; (ii) survey the evidence of mitochondrial stress within the preclinical Hamilton, Ontario, Canada
and clinical contexts of DMD, DM1, and SMA; and (iii) discuss the therapeutic potential of targeting
AMPK to enhance mitochondrial biology in these conditions.

AMPK regulates the mitochondrial health cycle *Correspondence:

Mitochondrial turnover: biogenesis and mitophagy mikhaiai@mcmaster.ca (A.I. Mikhail),
ngsy@mcmaster.ca (S.Y. Ng),
Mitochondria are highly dynamic and undergo frequent turnover, fundamental processes that are mattis1@mcmaster.ca (S.R. Mattina),
heavily influenced by AMPK (Figure 1, Key figure) [6]. Healthy mitochondrial turnover is and ljubicic@mcmaster.ca (V. Ljubicic).

512 Trends in Molecular Medicine, July 2023, Vol. 29, No. 7 https://doi.org/10.1016/j.molmed.2023.03.008
© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Key figure Glossary

The role of AMP-activated protein kinase (AMPK) in mitochondrial biology AMP-activated protein kinase
(AMPK): a serine/threonine kinase that
regulates mitochondrial biology as one
facet of its ability to maintain and remodel
the neuromuscular system in health and
disease. AMPK consists of three subunits
(α, β, and γ), each of which expresses
several isoforms resulting in different
tissue-specific conformations of the
kinase.
Duchenne muscular dystrophy
(DMD): a progressive X-linked
recessive disorder that arises from out-of-
frame mutations in the gene encoding for
dystrophin protein, the core
component of the dystrophin-associated
protein complex (DAPC).
Dystrophin-associated protein
complex (DAPC): an assembly of
proteins that reside along the
sarcolemma of myofibers to maintain
structural integrity of the cell, as well as a
signaling apparatus between the
extracellular matrix and intracellular
cytoskeleton.
Mitochondrial biogenesis: expansion
of the organelle reticulum through
transcription and translation of
mitochondrial proteins encoded by
nuclear and mitochondrial DNA
Trends in Molecular Medicine (mtDNA).
Mitochondrial dynamics:
homeostatic control between
Figure 1. (A) Mitochondrial synthesis is initiated by AMPK and its downstream effectors histone deacetylase 5 (HDAC5), sirtuin
mitochondrial elongation (i.e., fusion)
1 (SIRT1), and p38 mitogen-activated protein kinase (p38), as well as the master regulator of mitochondrial biogenesis,
and fragmentation (i.e., fission) that
peroxisome proliferator-activated receptor γ coactivator-1⍺ (PGC-1⍺). AMPK is negatively regulated by folliculin-interacting
determines organelle morphology.
protein 1 (FNIP1). These signals converge to upregulate the transcription of nuclear genes encoding mitochondrial proteins
Mitochondrial fusion: the process
(NuGEMs) and mitochondrial transcription factor A (TFAM). NuGEMs are imported and assimilated into the organelle while
that merges separate mitochondria into
TFAM drives mitochondrial DNA (mtDNA) transcription. AMPK-transcription factor EB (TFEB) signaling expands the
a larger reticulum by first anchoring of
mitochondrial reticulum via PGC-1⍺-dependent and -independent pathways. (B) Fusion of the inner and outer mitochondrial
the outer mitochondrial membrane
membranes is coordinated by optic atrophy 1 (OPA1) and mitofusins 1 and 2 (MFN1/2), respectively. A role for AMPK has
(OMM), which is mediated by mitofusins
not been identified in mitochondrial fusion. (C) Organelle splitting is primarily mediated through dynamin-related protein 1
1 and 2, and then subsequently uniting
(DRP1), mitochondrial fission factor (MFF), and mitochondrial fission 1 (FIS1). AMPK regulates mitochondrial fragmentation by
the inner mitochondrial membrane,
altering the function of MFF and mitochondrial fission regulator 1-like (MTFR1L), as well as protein kinase A (PKA)/A-kinase
mainly through optic atrophy 1.
anchor protein (AKAP) signaling. (D) AMPK activates Unc-51-like autophagy kinase 1 (ULK1), which in turn stimulates the
Mitochondrial transcription factor A
PTEN-induced kinase 1 (PINK1)/Parkin system, as well as autophagosome formation. Furthermore, AMPK may directly and
(TFAM): a nuclear DNA-encoded
indirectly (via mammalian target of rapamycin; mTOR) influence TFEB activity to augment the transcription of coordinated
mitochondrial protein that is the primary
lysosomal expression and regulation (CLEAR) genes, the core machinery for autophagosome and lysosomal biogenesis.
transcription factor for mtDNA.
Mitochondrial turnover: the dynamic
relationship between mitochondrial
dependent on the balance between biogenesis and mitophagy. For example, conditions of high biogenesis and mitophagy.
Mitophagy: the process by which
metabolic stress and rapid ATP turnover activate AMPK, which in turn stimulates organelle bio- mitochondria are marked and
genesis and expansion of the mitochondrial pool to meet energetic demands. AMPK plays a dismantled to their core constituents
key role in mitochondrial biogenesis by directly activating peroxisome proliferator-activated through the coordination of
receptor γ coactivator-1⍺ (PGC-1⍺), thereby increasing its nuclear translocation and tran- autophagosomal and lysosomal fusion.
The rate at which mitochondria are
scriptional control [6]. PGC-1⍺ binds to and stimulates the activity of transcription factors such recycled into macromolecules is
as nuclear respiratory factors 1 and 2 (NRF1/2) to promote the expression of nuclear-encoded mitophagic flux.
mitochondrial proteins, including mitochondrial transcription factor A (TFAM) [7]. Folliculin- Myotonic dystrophy type 1 (DM1): an
autosomal dominant condition that is
interacting protein 1 (FNIP1) blunts mitochondrial biogenesis by directly interacting with and
categorized into three types: (i) congenital,
(ii) juvenile, and (iii) adult. The adult-onset
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inhibiting AMPK, which results in the diminished transcriptional actions of PGC-1⍺ [8]. Finally, form is the most common, as well as the
most typical muscular dystrophy in adults,
AMPK modulates transcription factor EB (TFEB) function, which in turn increases the expression and is characterized by cardiorespiratory
of NRF1/2 in a PGC-1⍺-independent manner to further drive organelle biogenesis [9]. It is impor- dysfunction and metabolic disorders,
tant to note that regulation of AMPK activity is complex and is impacted by a confluence of dy- along with skeletal muscle wasting and
namic factors, which is elegantly and comprehensively summarized elsewhere [10,11]. myotonia.
Parkin: an E3 ligase that resides in the
cytosolic compartment when inactive.
AMPK is also a nexus molecule for controlling mitochondrial degradation due to its regulation of Upon mitochondrial depolarization,
autophagy and mitophagy [2]. AMPK drives autophagy via its ability to phosphorylate Unc-51-like Parkin translocates to the OMM to mark
autophagy activating kinase 1 (ULK1) at Ser555 and induce ULK1 activity to upregulate the phos- the organelle for degradation.
Peroxisome proliferator-activated
phorylation of autophagy related 16-like 1 on Ser278 (pATG16L1Ser278), a critical step required for receptor γ coactivator-1⍺ (PGC-1α):
the downstream assembly of the autophagosome [6,12]. Notably, these events are significantly a transcriptional coactivator that regulates
hindered without AMPK also phosphorylating and activating TFEB, an important upstream tran- the expression of many genes in the
neuromuscular system, including, for
scription factor for autophagic and lysosomal genes [13]. Mitophagy initiation is driven by the
example, those driving mitochondrial
PTEN-induced kinase 1 (PINK1)/Parkin pathway. Once mitochondria become depolarized, biogenesis and the maintenance and
for example, due to excess ROS production or mitochondrial Ca2+ influx, cytosolic PINK1 is ac- plasticity of the neuromuscular junction.
tivated, resulting in its stabilization on the outer mitochondrial membrane (OMM) and subsequent PTEN-induced kinase 1 (PINK1): a
serine/threonine kinase that regulates
phosphorylation of ubiquitin on Ser65 (pUbSer65) [14]. Consequently, this enhances the affinity of
Parkin activity, amongst other proteins,
Parkin, an E3 ubiquitin ligase, to the OMM to polyubiquitinate numerous mitochondrial proteins to enhance mitophagy and protect
and triggering mitochondrial removal [14]. Mitophagy is also regulated through the rapid phos- against mitochondria-induced cellular
phorylation of Parkin via AMPK/ULK1 prior to PINK1-mediated Parkin recruitment at the OMM stress.
Spinal muscular atrophy (SMA): an
[2]. Therefore, AMPK controls several critical molecules and cell pathways that regulate mito- autosomal recessive neurogenerative
chondrial turnover. disorder that is caused by mutations in
the survival motor neuron 1 (SMN1)
Mitochondrial dynamics: fusion and fission gene, resulting in deterioration of spinal
cord α-motoneurons, skeletal muscle
In addition to biogenesis and mitophagy, the mitochondrial reticulum is characterized by dynamic atrophy, and other multisystemic
morphology and motility [15]. Discontinuous mitochondria may fuse together to create a more consequences.
complex and expansive network that allows for intermixing of matrix constituents, as well as effi- Survival Motor Neuron 1 (SMN1): a
gene encoding for full-length SMN
cient and rapid synthesis of ATP. Mitofusins 1 and 2 (MFN1/2) and optic atrophy 1 (OPA1) are key
protein, which plays a role in many
molecules responsible for initiating mitochondrial fusion [15]. The involvement of AMPK in this critical cellular events, including
process is largely unknown; however, the available evidence suggests that AMPK activity evokes spliceosome biogenesis and messenger
OPA1 expression [16]. In contrast, a more expansive mitochondrial network can divide via fission ribonucleoprotein transport.
events, which are initiated by the AMPK-mediated phosphorylation of mitochondrial fission factor
(MFF) at Ser155 and Ser172, resulting in the recruitment of dynamin-related protein 1 (DRP1) to mi-
tochondria and binding to its receptors MFF and mitochondrial fission 1 (FIS1) on the OMM [2].
These opposing effects of AMPK appear to occur in a time-dependent manner as acute stimula-
tion of the kinase enhances the phosphorylation and activity of upstream fission regulators, while
long-term AMPK activation results in an overall upregulation of fusion protein levels. Collectively,
the homeostatic orchestration of mitochondrial dynamics and turnover serves to maintain an ef-
fectively functioning organelle reticulum. Alterations to one or more of these processes in DMD,
DM1, and SMA may be contributory to the disease pathology and/or an adaptive stress response
within the compromised neuromuscular system.

Mitochondrial dysfunction in NMDs

Alterations in mitochondrial bioenergetics and morphology in DMD
DMD is the most prevalent congenital NMD affecting ~1 in 5000 to 6000 live male births [17]. Boys
with DMD typically display symptoms by 3–5 years of age and succumb to the disorder by their
third or fourth decade due to the inevitable failure of the cardiac and respiratory systems [17].
Mutations in the DMD gene result in the deficiency of functional dystrophin protein preventing
the formation of its larger, eponymous oligomeric structure, the dystrophin-associated protein
complex (DAPC) [17]. Consequentially, a myriad of cellular and molecular complications arise in

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skeletal muscle that are detailed in other, comprehensive reviews [17–19]. Given the X-linked re-
cessive nature of the diseases, females can be carriers but are often asymptomatic and may exhibit
a mild cardiac phenotype.

Mitochondrial morphological and functional adaptations in dystrophin-deficient human skeletal

muscle are well characterized (Table 1 and Figure 2). There is a consensus that mitochondrial bio-
genesis is impaired in DMD skeletal muscle, as evident by reduced mitochondrial enzyme activity,
lower expression of electron transport chain (ETC) complexes, as well as decreased respiratory
capacity in skeletal muscle fibers from dystrophic animals and DMD patients [20–24]. While the
temporal onset of these mitochondrial consequences is variable and likely dependent on disease
severity, several lines of evidence in preclinical animal models of DMD, such as mdx mice, dem-
onstrate metabolic and mitochondrial functional impairments during early stages of pathogenesis
and, in some cases, prior to the onset of the dystrophic phenotype independent of changes in
mitochondrial protein content [21,22,25]. Similarly, mitochondrial oxygen consumption rates
and enzyme activity are significantly downregulated in asymptomatic adult female carrier mdx
mice [25]. These data suggest that dysregulated mitochondrial content and respiratory capacity
in dystrophin-deficient or partially deficient skeletal muscle presents early in the condition, per-
sists throughout, and may influence disease progression. It is unclear whether this mitochondrial
stress exacerbates the dystrophic pathology or is a compensatory mechanism adapting to the
evolving skeletal muscle environment in DMD.

The overwhelming cytosolic concentration of Ca2+ is perhaps the most well-studied disease hy-
pothesis in DMD [17]. Under healthy conditions, influx of Ca2+ into mitochondria triggers perme-
ability transition pore opening and subsequent mitochondrial depolarization to initiate mitophagy
signaling and degradation of specific organelles targeted for removal and recycling. However, de-
spite high concentrations of cytoplasmic Ca2+ and a lower threshold for Ca2+-induced mitochon-
drial depolarization, dystrophic muscle exhibits an overabundance of damaged mitochondria and
blunted mitophagy [23]. While the mechanism for the diminished capacity to clear dysfunctional
mitochondria is not fully understood, several studies observed lower expression of autophagy
and mitophagy machinery in DMD patient skeletal muscle biopsies [26,27]. In contrast, investiga-
tions in preclinical models of DMD yield inconsistent results, with some showing similar levels of
mitophagic regulators such as Parkin, BCL2-interacting protein 3 (BNIP3), and sequestosome-
1 (p62), in muscles of mdx mice during peak dystrophy as compared with wild-type (WT) animals,
while other studies show diminished, or elevated expression [18,25,26]. This conflicting evidence
is likely due to a large age range at the time of investigation and the examination of different mus-
cle groups of varying fiber types. However, isolated mitochondria from mdx muscle tissue and pri-
mary DMD patient muscle cells express lower amounts of pUbSer65, as well as reduced Parkin
and BNIP3 levels relative to healthy controls, which together suggest impaired mitophagy flux
[27]. Collectively, mitochondrial respiratory distress in DMD may be exacerbated by the presence
of abundant, poor-quality mitochondria due to impaired mitochondrial degradation.

Mitochondrial ultrastructure in DMD patient and mouse skeletal muscle is distorted and contains
fewer cristae [25,28,29]. Processes that dictate mitochondrial dynamics in DMD have only
recently been explored. The simplified organelle reticulum in dystrophic skeletal muscle may be
due to the relative difference between mitochondrial fusion and fission gene expression. For
instance, compared to WT mice, skeletal muscles of mdx mice express greater levels of Dnml1
and Fis1 and lower Mfn1, Mfn2, and Opa1, along with higher DRP1 protein content in mitochon-
drial isolates [25,26]. Moreover, Hardee et al. recently demonstrated that most genes responsible
for organelle fusion and fission are downregulated in skeletal muscle from individuals affected by
DMD [26]. Taken together, these results suggest that mitochondrial dynamics in dystrophic

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Table 1. Skeletal muscle mitochondrial abnormalities in DMD, DM1, and SMA patients
Diagnosis Number of Skeletal muscle Mitochondrial Mitochondrial content Mitochondrial dynamics Mitophagy Refs
(type) patients, age, examined morphology and function gene/protein gene/protein
sex expression expression
Duchenne muscular dystrophy
DMD n = 14 Deltoid biopsy Reduced respiration: [95]
↔ CII state 3 respiration
Not specified ↓ RCI
↔ P:O ratio
DMD n = 11 Gastrocnemius Presence of both Reduced number of [28]
biopsy vacuolated and mitochondria in regenerating
3–17 years dense fibers
(x̄ = 10.2 years) mitochondria in
regenerating fibers
DMD n = 6–12 Gastrocnemius Altered enzyme activity: [96]
biopsy ↑ COX
1–13 years
(x̄ = 6.9 years)
31
DMD n=6 P MRS on the Reduced skeletal muscle [97]
forearm bioenergetics:
9–15 years ↓ PCr/Pi
(x̄ = 12.3 years) ↓ PCr/ATP
DMD n = 23 Vastus lateralis Presence of both [29]
biopsy dilated and dense
Not specified mitochondria in
regenerating fibers
DMD n=5 Biceps brachii N/D in enzyme activity [98]
and quadriceps (muscle-specific results not
2–13 years femoris reported):
(x̄ = 5.8 years) biopsies ↔ CI–III, CII–III, COX
DMD n=6 Quadriceps Increased ROS: [99]
femoris biopsy ↑ Carbonyl
2–10 years
(x̄ = 4.7 years)
DMD n = 2–3 Vastus lateralis Reduced respiration: [20]
biopsy ↓ CI state 3 respiration
Not specified ↓ CII state 3 respiration
↓ RCI

Reduced enzyme activity:

↓ CI, CII–III, COX
↓ CS
↓ PDHC
DMD n=1 Quadriceps Reduced respiration: [100]
femoris biopsy ↓ CI state 3 respiration
2 years ↓ CII state 3 respiration
↑ Redox states of NAD system

Reduced enzyme activity:

↓ COX
↔ CI–III, CII–III,
↔ CS
DMD n=6 Biopsied Reduced enzyme activity: [24]
muscle not ↓ CIII, CI–III, CII–III
x̄ = 9 years specified ↔ CI, CII, CIV, CV, CS
DMD n=5 Vastus lateralis Reduced protein expression: [42]
biopsy ↓ CII, CIII, CIV, CV
7–10 years
(x̄ = 7.9 years) Increased ROS:
↑ Carbonyl

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Table 1. (continued)
Diagnosis Number of Skeletal muscle Mitochondrial Mitochondrial content Mitochondrial dynamics Mitophagy Refs
(type) patients, age, examined morphology and function gene/protein gene/protein
sex expression expression
DMD n=3 Vastus lateralis Reduced protein expression: [101]
biopsy e.g., ↓ NDUFA4
9 months–8 ↓ UQCRC2
years ↓ CYC1
(x̄ = 3.6 years) ↓ SLC25A4
DMD n=6 Biopsied Reduced biogenesis Reduced fusion Reduced [26]
muscle not transcript expression: transcript expression: transcript
11 months–8 specified e.g., ↓ PGC-1⍺ e.g., ↓ MFN1 expression:
years ↓ ESRRA ↓ MFN2 e.g., ↓ BCL2
(x̄ = 5 years) ↓ SIRT1 ↓ OPA1 ↓ BECN1
↓ BNIP3
Reduced fission tran- ↓ SQSTM1
script expression:
e.g., ↓ DNM1L
↓ FIS1
DMD n = 10 Biopsied Reduced biogenesis Reduced fission Reduced [27]
muscle not transcript expression: transcript expression: transcript
5–9 years specified e.g., ↓ PGC-1⍺ e.g., ↓ FIS1 expression:
(x̄ = 7.3 years) e.g., ↓ BECN1
↓ BNIP3
↓ PINK1
↓ PARK2
↓ SQSTM1
Myotonic dystrophy (MD)
MD n = 5–25 Biceps brachii Type I RRFs [54]
(type not and quadriceps containing enlarged
specified) 11–57 years femoris SS mitochondria
(x̄ = 37 years) biopsies with dense granular
matrix,
M and F paracrystalline
inclusions and
irregular cristae in
biceps brachii

N/D in quadriceps
femoris
MD n=1 Biceps brachii Type I RRFs in Reduced enzyme activity in [55]
(type not and superior both muscles both muscles examined:
specified) 53 years rectus biopsies examined ↓ CI, CII, COX
↔ CI–III, CII–III
M Aggregates of ↓ CS
enlarged
mitochondria with
proliferated inner
membranes,
vacuolated
matrices,
paracrystalline
inclusions and
irregular cristae in
both muscles
examined
MD n = 13 Biceps brachii, RRFs with ↓ COX Increased mtDNA deletions in [56]
(type not gastrocnemius, expression in all muscles examined
specified) 26–53 years and vastus biceps brachii and
(x̄ = 39.6 years) lateralis vastus lateralis
biopsies
M and F
(continued on next page)

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Table 1. (continued)
Diagnosis Number of Skeletal muscle Mitochondrial Mitochondrial content Mitochondrial dynamics Mitophagy Refs
(type) patients, age, examined morphology and function gene/protein gene/protein
sex expression expression
MD n = 32 Biceps brachii, No accumulation N/D in mtDNA in all muscles [102]
(type not deltoid, of RRFs in all examined
specified) 15–58 years gastrocnemius, muscles examined
(x̄ = 37 years) and vastus
lateralis
M and F biopsies
31
n = 31 P MRS on the Altered skeletal muscle [103]
MD calf and flexor bioenergetics in both muscles
(type not x̄ = 34 years digitorum examined:
specified) (calf), x̄ = 39 superficialis e.g., ↓ PCr/(PCr + Pi)
years (FDS) ↓ PCr/ATP
↑ Pi/ATP
Not specified ↑ [ADP]
31
DM1 n = 16 P MRS on the Altered skeletal muscle [57]
calf bioenergetics:
22–71 years e.g., ↑ [Pi]
(x̄ = 39 years) ↓ PCr/Pi
↔ [PCr]
M and F ↔ [ADP]
DM1 n = 9–11 Vastus lateralis Reduced respiration: Reduced fusion Altered [52]
biopsy ↓ CI submaximal and maximal protein expression: protein
26–53 years respiration ↓ OPA1 expression:
(x̄ = 42.6 ↔ CI state 2 respiration ↔ MFN1 ↓ BNIP3
years) ↓ CI state 3 respiration ↓ MFN2 (P = 0.062) ↔ PINK1
↓ CI–II state 3 respiration ↑ Parkin
M and F ↔ CII state 3 respiration (P = 0.07)
Altered fission protein
Reduced respiratory chain expression:
transcript expression: ↔ FIS1
e.g., ↓ NDUFA1 ↓
↓ SDHA p-DRP1Ser637/t-DRP1
↓ UQCRC2 (inhibition)
↓ CYC1 ↑
↓ COX1 p-DRP1Ser616/t-DRP1
↓ ATP6 (activation) (P = 0.10)

Reduced protein expression:

↓ CI, CIII, CIV, CV
↔ CII
↓ AMPKThr172
↔ t-AMPK, PGC-1α
Spinal muscular atrophy
Chronic n=7 Quadriceps, Altered respiration in all [104]
SMA gastrocnemius, muscles examined:
8–62 years and peroneus ↓ CI state 3 respiration
(x̄ = 32 years) biopsies ↓ CII state 3 respiration
↑ CI state 4 respiration
M and F ↑ CII state 4 respiration
↓ RCI
↓ ADP:O ratio
SMA n=5 Biceps brachii N/D in enzyme activity [98]
(type not and quadriceps (muscle-specific results not
specified) 27 days–6 femoris reported):
years biopsies ↔ CI–III, CII–III
(x̄ = 1.8 years) ↓ COX (in one patient)

M and F

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Table 1. (continued)
Diagnosis Number of Skeletal muscle Mitochondrial Mitochondrial content Mitochondrial dynamics Mitophagy Refs
(type) patients, age, examined morphology and function gene/protein gene/protein
sex expression expression
SMA n=6 Vastus lateralis Reduced respiration: [20]
(type not biopsy ↓ CI state 3 respiration
specified) Not specified ↓ CII state 3 respiration
↑ RCI
Not specified
Reduced enzyme activity:
↓ CI, CII–III, COX
↓ CS
↓ PDHC
SMA n=6 Vastus lateralis N/D in enzyme activity: [105]
(type not biopsy ↔ CI–III, CII–III, COX
specified) 6–62 years ↔ CS

M and F
SMA n = 7–20 Biopsied Reduced mtDNA [73]
(types muscle not
1-3) 2 months–16 specified Reduced enzyme activity:
years ↓ CII, COX
(x̄ = 2 years) ↓ CS

Not specified Reduced protein expression:

↓ MT-COX1, COX4
SMA n=2 Biopsied Reduced enzyme activity: [24]
(type not muscle not ↓ CIII, CI–III
specified) x̄ = 3.1 years specified ↔ CI, CII, CII–III, CIV, CV, CS

Not specified
SMA n=9 Quadriceps Reduced respiratory chain [106]
(types 1 femoris biopsy transcript expression (type 1):
and 3) 2 months–11 e.g., ↓ NDUFB1
years ↓ CYC1
↓ SLC25A4
M and F
SMA n = 4–24 Quadriceps Reduced mtDNA (inversely [74]
(types 1–3) femoris and related to disease severity)
2 months–14 paraspinal
years biopsies Reduced biogenesis
transcript expression
M and F examined in the quadriceps
femoris (types 1 and 2):
↓ PGC-1⍺
↓ NRF1
↓ NRF2
↓ PTEN
↓ TFAM

Reduced respiratory chain

transcript expression
examined in the quadriceps
femoris (types 1–3):
↓ ND1
↓ SDHA
↓ COX1, COX2, COX4I1
↓ ATP6

Reduced enzyme activity in both

muscles examined (types 1 and
2):
↓ CI, CII, CII–III, CIV
(continued on next page)

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Table 1. (continued)
Diagnosis Number of Skeletal muscle Mitochondrial Mitochondrial content Mitochondrial dynamics Mitophagy Refs
(type) patients, age, examined morphology and function gene/protein gene/protein
sex expression expression
↓ CS
Reduced protein expression
examined in the quadriceps
femoris (measured in type 1):
↓ MT-COX1, MT-COX2, COX4
↓ SDHA

Abbreviations: ADP, adenosine diphosphate; BCL2, B cell lymphoma 2; BECN1, beclin-1; CI–V, complex I–V; COX, cytochrome c oxidase; CS, citrate synthase; CYC1, cytochrome
c1; ESRRA, estrogen related receptor ⍺; F, female; FDS, flexor digitorum superficialis; M, male; NAD, nicotinamide adenine dinucleotide; N/D, no difference; ND1, NADH-ubiquinone
oxidoreductase chain 1; NDUFA1, NADH dehydrogenase 1 ⍺ subcomplex subunit 1; 31P MRS, phosphorus magnetic resonance spectroscopy; PCr, phosphocreatine; PDHC,
pyruvate dehydrogenase complex activity; Pi, inorganic phosphate; PTEN, phosphatase and tensin homolog; RCI, respiratory control index; ROS, reactive oxygen species;
RRFs, ragged reg fibers; SDHA, succinate dehydrogenase; SLC25A4, solute carrier family 25 member 4; SS, subsarcolemmal; UQCRC2, cytochrome b-c1 complex subunit 2.

Trends in Molecular Medicine

Figure 2. AMPK-mediated mechanisms that target mitochondrial stress in Duchenne muscular dystrophy
(DMD). (A) DMD is caused by mutations in the DMD gene that result in the lack of dystrophin protein production and,
consequently, the dissolution of the dystrophin-associated protein complex (DAPC). Contracting muscles are therefore more
susceptible to sarcolemmal tears, which leads to a pathological influx of Ca2+. Mitochondrial stress in DMD is characterized
by reduced mitochondrial biogenesis and content, as well as impaired oxidative phosphorylation (OxPhos) of substrates that
are specifically linked to complex I (CI) respiration. There is also an imbalance in the expression of mitochondrial fusion
(MFN1/2, OPA1) and fission (DRP1) molecules, as well as an increase in fragmented and damaged mitochondria.
Accumulation of these dysmorphic organelles is exacerbated by reduced mitophagy flux despite the elevated sensitivity to
Ca2+-mediated opening of the mitochondrial permeability transition pore (mPTP). (B) Stimulating AMPK with small molecule
compounds such as AICAR, resveratrol (RESV), metformin (MET), or MK-8722, as well as with exercise, augments
mitochondrial biogenesis and content. AMPK-activating interventions may also target other sources of mitochondrial stress,
including mitochondrial dynamics and mitophagy. In addition, mitochondrial adaptations are observed with Urolithin A (UA)
treatment, which may or may not be AMPK-dependent in the DMD context. Abbreviations: AMPK, AMP-activated protein
kinase; DRP1, dynamin-related protein 1; MFN1/2, mitofusins 1 and 2; OPA1, optic atrophy 1.

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skeletal muscle skews toward a fragmented phenotype. However, mechanisms responsible for
dysregulated fission signaling in DMD skeletal muscle have not been examined but likely involve
AMPK along with other upstream modifiers of organelle fission. To further expand our under-
standing of mitochondria in dystrophic muscle and identify therapeutic strategies targeting mito-
chondrial stress, future research should focus on assessing the morphological and gene
expression adaptations of the organelle throughout DMD progression.

AMPK activation and mitochondrial remodeling in DMD

Evidence regarding resting AMPK activity in dystrophin-deficient skeletal muscle is inconsistent.
However, preclinical studies using genetically modified DMD mice with altered expression of pro-
teins in the AMPK pathway, such as increased PGC-1⍺, or decreased FNIP1, demonstrated an
amelioration of the dystrophic phenotype underpinned by more high-quality mitochondria, as re-
vealed by improved organelle Ca2+ buffering capacity and augmented respiratory function
[8,30–34]. This line of evidence provides a direct link between AMPK activation and enhanced mi-
tochondrial biology in DMD (Figure 2). Similarly, the chronic use of AICAR, a synthetic AMP analog
that potently activates AMPK, in DMD mice promoted the nuclear localization of PGC-1⍺, which
in turn initiated organelle biogenesis and augmented mitochondrial content [35–37]. Furthermore,
AICAR administration increased the expression of autophagic and mitophagic markers, including
ULK1, microtubule-associated proteins 1A/1B light chain 3 (LC3) II and BNIP3, resulting in the
clearance of previously swollen and grossly distorted mitochondria observed in untreated dystro-
phic mice [38]. While the use of AICAR in mdx mice can augment skeletal muscle force produc-
tion and provides valuable mechanistic insight into the role of AMPK, its administration is
associated with several detrimental effects and lacks clinical translatability. Metformin (MET) is a
widely prescribed drug and potent, indirect activator of AMPK. In skeletal muscle of mdx mice,
long-term MET treatment upregulated AMPK activity as well as downstream AMPK targets but
failed to alter metrics of mitochondrial abundance or health [39–41]. Nevertheless, MET-
mediated AMPK activation resulted in remarkable improvements in skeletal muscle function
and strength in dystrophic mice [40,41]. In five DMD patients, 16 weeks of concurrent treatment
with MET and L-arginine (NCT02516085)i increased expression of skeletal muscle ETC proteins
[42]. Given that both MET and L-arginine expand the mitochondrial pool [42], the extent to which
MET (i.e., AMPK activation) contributed to this mitochondrial response is unclear. Other indirect
AMPK activators such as resveratrol (RESV) can successfully stimulate PGC-1⍺ activity and cy-
tochrome c oxidase mRNA expression in skeletal muscle of mdx mice [43]. There is exciting, re-
cent evidence supporting AMPK-stimulated mitophagy using small molecules that have high
clinical significance. MK-8722 is a novel, direct AMPK agonist [11] that demonstrates effective ac-
tivation of the kinase and several of its downstream targets in dystrophic muscle, including the au-
tophagy master switch ULK1 [44]. A single, oral dose of the compound sparked TFEB-mediated
transcription of Sqstm1 and Bnip3, as well as increased the expression of p62 and LC3 II in mdx
mice [44]. Alternatively, Urolithin A (UA) is emerging as a modifier of skeletal muscle health by aug-
menting PINK1/Parkin signaling partially through an AMPK-dependent mechanism [45]. UA-
treated mdx mice display improved mitochondrial function due to evoked mitophagic flux, as ev-
ident by enhanced expression of mitochondria-specific pUbSer65, Parkin, and BNIP3, which was
also concomitant with better skeletal muscle strength and function. Whether these effects of UA
in dystrophic mice were mediated by AMPK is unknown [27]. A well-known and remarkably effec-
tive nonpharmacological modality to stimulate AMPK in the neuromuscular system is exercise
[3,7]. Indeed, informed exercise prescription is a clinically translatable AMPK-activating interven-
tion that impacts mitochondrial biology in DMD and other NMDs (Box 1). Altogether, AMPK is a
key player in mitochondrial biogenesis and mitophagy in dystrophic skeletal muscle, which may
have clinical implications in DMD patients. Augmented biogenesis can also enhance mitochon-
dria–endoplasmic reticulum crosstalk and improve the unfolded protein response, both of

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Box 1. Exercise-induced AMPK activation is mitochondrial medicine in NMDs

Chronic aerobic exercise training preserves, and in some cases augments, skeletal muscle mass and function, as well as
enhances cardiorespiratory fitness in DMD, DM1, and SMA patients [52,86–88]. Recent evidence indicates that these
adaptations are due, at least in part, to improvements in muscle mitochondrial health driven by exercise-induced AMPK
activation. In the DMD context, for example, running elicits canonical exercise signaling pathways, including rapid AMPK
phosphorylation and Pgc-1⍺ transcription in skeletal muscle of mdx animals. Accordingly, DMD mice that perform low
intensity endurance training, or other AMPK-enhancing modes of chronic contractile activity such as low-frequency elec-
trical stimulation (LFS), present with greater mitochondrial content and respiration in some [89,90] but not all studies [91].
Additionally, LFS in dystrophin-deficient mice can promote the formation of ETC supercomplexes, which is indicative of a
fused and elongated reticulum [90]. In DM1 patients, 12 weeks of cycling upregulated resting amounts of total and acti-
vated AMPK, mitochondrial protein expression, and functional capacity in skeletal muscle [52]. Also observed were dra-
matically increased fusion protein levels, which restored the balance between fusion- and fission-related markers, as
well as normalized the expression of mitophagy-specific proteins [52]. Chronically exercised DM1 animals experience sim-
ilar organelle remodeling and increased mitochondrial enzyme activity [92,93]. In fact, a single dose of exercise in DM1
mice strongly stimulated the AMPK/PGC-1⍺ pathway in skeletal muscle, which was followed by enhanced short-term mi-
tochondrial dynamics signaling as indicated by a time-dependent increase in fission and fusion proteins and genes along
with greater autophagosome formation, enhanced mitochondrial tagging for degradation, and blunted expression of au-
tophagosome- and lysosome-associated proteins [61]. Finally, in SMA mice, acute exercise elicits AMPK phosphorylation
and subsequent upregulation of Pgc-1⍺, as well as other mitochondrial biogenesis transcripts [79]. Running-induced
AMPK activation also augmented the phosphorylation of ULK1 and normalized the expression of mitophagy-related genes
to similar levels as healthy controls [79]. Altogether, although the available evidence is still emerging, exercise-evoked
AMPK simulation in skeletal muscle translates to mitochondrial medicine in DMD, DM1, and SMA. It is noteworthy that
while AMPK stimulation may account for several exercise-induced mitochondrial adaptions, numerous other signaling
molecules are activated in response to physical activity that may also contribute to improving mitochondrial biology in
an AMPK-independent manner [94]. Thus, which other exercise-sensitive molecules should be targeted to enhance mito-
chondrial biology and neuromuscular health in NMDs?

which are known to be dysregulated in DMD skeletal muscle [46,47]. Therefore, it is plausible that
chronic AMPK activation may mitigate these pathways to improve overall muscle health in dystro-
phic patients.

DM1-specific changes in mitochondrial biology

DM1 is the most common muscular dystrophy in adults with a prevalence of ~ 1 in 2100 persons
[48]. Hallmark characteristics of DM1 include skeletal muscle wasting and weakness, as well as
myotonia, which are thought to progress in a similar fashion in males and females. However,
emerging evidence suggest that some symptoms are more pronounced in a sex-specific manner
and require further attention [49]. A microsatellite mutation of greater than 50 ‘CTG’ DNA repeat
expansions in the 3′ untranslated region of the Dystrophia Myotonica Protein Kinase (DMPK)
gene is responsible for DM1 pathophysiology [48]. The repetitive ‘CUG’ mRNA sequences aggre-
gate in nuclei to form double-stranded hairpin structures that trigger abnormal localization and
activity of RNA-binding proteins vital for healthy mRNA splicing [48]. Several hundred abnormally
spliced transcripts [50–52], some of which are involved in the regulation of mitochondrial turnover
and dynamics, among other molecular perturbations in DM1 skeletal muscle [53], are thought to
contribute to the complex and variable DM1 phenotype. While the functional role for the vast ma-
jority of these mitochondria-specific exons remains in question, some have been linked to im-
paired mitochondrial biology such as OPA1 exon 4b, which is discussed later in further detail.

Pathogenesis of DM1 involves disease-specific mitochondrial adaptations, including diminished

respiration and altered morphology (Table 1 and Figure 3). The initial studies demonstrating
mitochondrial stress in patients were performed prior to the discovery of the DM1 mutation or
the use of genetic testing as routine diagnostic practice [54–56], thus these investigations may
have included DM1 and/or DM2 patients, as well as potentially other participants with myotonias.
More recent work revealed an impairment in oxidative phosphorylation and lower abundance
of mitochondrial proteins in skeletal muscle of DM1 patients relative to healthy controls
[52,57,58]. Diminished mitochondrial content and function in DM1 may, in part, be a

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Clinician’s corner
DMD, DM1, and SMA are the most
common NMDs in children and adults,
with a prevalence of ~1 in 2100 to 1 in
10 000 individuals. These conditions
may vary in age of onset and severity,
but they typically result in reduced
healthspan and lifespan. In recent
years, remarkable advances in thera-
peutic strategies have emerged for
several NMDs, including DMD and
SMA. However, there are currently no
cures for DMD, DM1, or SMA.

Mitochondrial stress is a common

characteristic of these otherwise
relatively disparate NMDs. In patients,
this is apparent in vivo when using
31
P-NMR spectroscopy of skeletal
muscle, as well as ex vivo in patient
samples using several complementary
molecular and biochemical tech-
niques. This mitochondrial stress also
presents more generally as muscle
frailty and cardiorespiratory fatigue,
which are recapitulated well in preclini-
Trends in Molecular Medicine cal animal models of DMD, DM1, and
SMA.
Figure 3. Mitochondrial stress and AMPK in myotonic dystrophy type 1 (DM1). (A) DM1 is caused by a ‘CTG’ DNA
repeat mutation in the noncoding region of the Dystrophia Myotonica Protein Kinase (DMPK) gene. The resultant ‘CUG’
AMPK is an endogenously expressed
transcripts are trapped within myonuclei in hairpin-like structures that dysregulate the localization and function of RNA-
protein that regulates several critical
binding proteins (RNA-BP) that regulate mRNA splicing and causing the spliceopathy that defines DM1. Skeletal muscle of
processes in the neuromuscular
DM1 patients and mice express lower levels of AMPK and PGC-1⍺, resulting in diminished mitochondrial content and
system, including mechanisms
function. Mis-splicing of OPA1 transcripts to exclude exon 4b affects fusion-independent roles of the protein and further
specific to mitochondrial biology, such
exacerbates the diminished mitochondrial pool by curbing mtDNA replication and transcription. Furthermore, altered
as organelle turnover and dynamics.
organelle dynamics favors fission processes that result in punctate and simplified mitochondrial networks. While there is
Administration of AMPK-stimulating
evidence of mitophagic processes in DM1, the extent to which mitophagy is impacted remains unclear. (B) Exercise or
compounds to mice with DMD, DM1,
pharmacological activation of AMPK improves muscle function and health in preclinical models of DM1, as well as DM1
or SMA evoked mitochondrial biogen-
patients. These AMPK-induced adaptations have been attributed, in part, to mitochondrial biology, including increased
esis, augmented fusion and fission sig-
organelle content and oxygen consumption rates. Additionally, AMPK activation impacts the regulatory profile and
naling, and enhanced the removal of
molecular machinery of mitochondrial fusion, fission, and mitophagy in skeletal muscle. Notably, exercise-induced AMPK
damaged mitochondria, all of which re-
activation corrects the mis-splicing of several transcripts in DM1 mice, including Opa1. Abbreviations: AMPK, AMP-
sulted in an overall amelioration of dis-
activated protein kinase; PGC-1⍺, peroxisome proliferator-activated receptor γ coactivator-1⍺.
ease outcomes.

consequence of the lower expression of PGC-1⍺ and hypophosphorylation of its upstream ac- In DMD and DM1 patients, metformin
tivator AMPK, both of which have been documented in DM1 mice and patients [52,59,60]. and exercise, which are potent activa-
tors of AMPK, were able to restore
the expression of mitochondrial pro-
Processes that control mitochondrial dynamics are largely unknown in DM1 and direct evidence teins and enhance organelle function.
of organelle morphology and motility is also scarce. Electron microscopy images of skeletal mus- Additionally, exercise-induced upregu-
cle from DM patients (not specified DM1 or DM2) display enlarged mitochondria with abnormal lation of AMPK in skeletal muscle of
DM1 patients stimulated molecules in-
granular matrix, as well as disorganized and simplified cristae [54,55]. Our laboratory has recently volved in mitochondrial dynamics and
extended these findings by reporting dysregulated expression of mitochondrial dynamics genes mitophagy pathways that have yet to
in DM1 patient muscle biopsies along with a protein profile that favors a fragmented mitochondrial be investigated in DMD, DM1, and
phenotype, as evident by lower expression of fusion proteins such as OPA1 and MFN2 [52,61]. SMA with any pharmacological-based
intervention. These exercise-based mi-
Similarly, skeletal muscle from DM1 mice display an overabundance of fission proteins relative to tochondrial adaptations translated into
WT animals, but no difference in the machinery that regulates organelle fusion [61]. A previous in- significant improvements in functional
vestigation of splicing defects in skeletal muscle of DM1 patients and mice detected increased ex- capacity, lean mass, and whole-body
clusion of exon 4b in OPA1 mRNA transcripts [50]. The presence of this specific exon in OPA1 is oxygen consumption. Following these
earlier, seminal studies in patients,
critical to its organelle fusion-independent role of mediating mtDNA replication and transcription

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[62]. Increased exclusion of exon 4b in OPA1 had a strong positive correlation with muscle weak- several larger clinical trials are currently
testing the efficacy of pharmacological
ness in patients, which suggests an important role of full length OPA1 in DM1 skeletal muscle [50]. (EudraCT 2018-000692-32ii,
Collectively, these data strongly suggest that lower expression of key components of mitochon- NCT05532813iii) and physiological
drial dynamics leads to an aberrant organelle architecture in DM1. Notably, skeletal muscles from (NCT04322357iv, NCT04173234v,
NCT03319030vi, NCT04782440vii,
DM1 mice express a greater amount of autophagic and mitophagic proteins such as LC3 and
NCT05072288viii, NCT05715749ix,
Parkin relative to WT animals [61], which is associated with perturbations in autophagic flux NCT05544994x) AMPK activation in
[60]. However, we observed conflicting evidence regarding mitophagy proteins with some individuals with DMD, DM1, and SMA.
markers increased, decreased, or unchanged in DM1 muscle biopsies compared with muscle
samples from a healthy, age- and sex-matched control cohort, which is due, at least in part, to
the small number of patients examined and the variable phenotypes presented [52]. Thus,
more work is needed to increase our understanding of the contribution of mitophagy to organelle
turnover in DM1 skeletal muscle, as well as mitochondrial turnover and dynamics in other cell
types of the peripheral neuromuscular system.

Targeting AMPK to enhance mitochondrial biology in DM1

A growing body of literature supports stimulating AMPK to target mitochondrial stress in DM1 as
AMPK signaling is known to be downregulated in skeletal muscle of DM1 patients and mice
(Figure 3) [3,63]. For example, daily AICAR injections in DM1 mice augmented markers of skeletal
muscle mitochondrial biogenesis such as PGC-1⍺ and ETC complex expression [59]. Interest-
ingly, these effects were more pronounced in female DM1 mice as compared with their male coun-
terparts, which indicates a sexually dimorphic mechanism involving AMPK [63]. In the clinic, the
antidiabetic drug MET significantly improved walking capacity during a 6-minute walk test in
DM1 patients without altering the spliceopathy [64]. That study did not report a sex-based analysis.
Furthermore, in vitro experiments with patient-derived fibroblasts demonstrated that MET treat-
ment enhanced mitochondrial oxygen consumption rates, as well as augmented the expression
of dynamics genes such as Opa1 and Mfn2 [65]. Phase 3 clinical trials examining the effect of 12
months (EudraCT 2018-000692-32)ii and 24 months (NCT05532813)iii of MET administration in
a large cohort of DM1 patients are currently underway, the results of which may provide important
therapeutic insight to AMPK-mediated regulation of mitochondrial turnover and dynamics in DM1.

Mitochondrial health in SMA skeletal muscle and ⍺-MNs

With a prevalence of 1 in 10 000 births, SMA is the leading genetic cause of infant mortality [66]. In
its most severe form, disease onset takes place prenatally with life-limiting respiratory defects and
subsequent death occurring prior to 6 months of age [66]. A homozygous mutation of the Survival
Motor Neuron 1 (SMN1) gene, which results in the lack of functional SMN protein, is responsible
for the progressive denervation of myofibers and skeletal muscle wasting and weakness that typ-
ically defines SMA [66].

Mitochondrial stress in SMA has recently been surveyed in a comprehensive and eloquent review
[5]. As such, this section will focus on SMA-specific changes in mitochondrial turnover and dy-
namics within ⍺-MNs and skeletal muscle, as well as present novel evidence of mitochondrial al-
terations in SMA models not discussed by Zilio and colleagues [5]. SMN is necessary for
mitochondrial homeostasis as cultured SMN null ⍺-MNs display aberrant organelle bioenergetics
and ATP synthesis, prior to any apparent dysregulation in axonogenesis or soma morphology
[67–69]. Furthermore, isolated ⍺-MNs innervating skeletal muscles that are vulnerable to SMA
progression are deficient in mitochondrial transcripts compared with those that are more resistant
to denervation [70,71]. This leads to an interesting hypothesis, whereby mitochondrial abun-
dance, and therefore metabolic supply, determines the onset and progression of ⍺-MN degen-
eration. ATP availability within ⍺-MNs is also dictated by mitochondrial transport along the
axon. In vitro culture of ⍺-MNs from type I SMA patient skin biopsies [67] and SMA mice [72]

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display impaired organelle migration from the cell body to the axon terminal. It is unclear if defective Outstanding questions
axonal transport of mitochondria in SMA is due to low metabolic demand at the deteriorating NMJ Is mitochondrial stress in DMD, DM1,
or an inherent component of SMA pathology. This impaired ATP homeostasis in SMA ⍺-MNs is and SMA a resilient compensatory
mechanism adapting to the microenvi-
likely further exacerbated by abnormal mitochondrial morphology and degradation. For instance,
ronment or is it an indication of truly
⍺-MN mitochondria from SMA mice are shorter in length, display lower cristae density, and have dysfunctional organelles? Further-
an increased prevalence of vacuoles [67,70,72]. Altogether, several sites of mitochondrial stress more, is this stress a downstream con-
are present within the SMA motor unit, including lower abundance of mitochondrial genes and sequence of the causative mutations
or due primarily to the sedentary be-
proteins, impaired ATP synthesizing capacity, aberrant degradation, and reduced motility. havior and inactivity observed in these
populations?
Like DMD and DM1, skeletal muscle from SMA patients is characterized by deficits in oxidative
How are autophagic and mitophagy
phosphorylation and mitochondrial content as compared with healthy individuals (Table 1 and
flux impacted in DMD, DM1, and
Figure 4) [20,24,73–75]. Interestingly, lower mtDNA is present in all types of SMA but is exagger- SMA? Elucidating this may assist in
ated in more severe type 1 SMA patients, a phenomenon that requires further understanding. the development of novel therapies to
Similarly, reduced mitochondrial size and density are observed in preferentially affected muscles clear damaged and dysfunctional or-
ganelles.

Patients with more severe types of

SMA also exhibit greater mitochondrial
stress. Similarly, in DM1 is there an as-
sociation between ‘CTG’ mutational
load and the mitochondrial pheno-
type? Along these lines, what is the re-
lationship between dystrophin levels
and mitochondrial stress in individuals
with DMD gene mutations?

How does restoration of full-length

SMN protein levels, for example, with
Spinraza or Evrysdi, affect mitochon-
drial stress and does this uncover op-
portunities for understanding new
mechanisms of regulating mitochon-
drial biology?

Are there mitochondrial-targeted mol-

ecules that can delay the onset and/
or mitigate the progression of disease
in DMD, DM1, and SMA and do their
salutary effects require AMPK?

In addition to the crucial role of SMN in

spliceosome biogenesis and mRNA
transport, what is the function of skele-
Trends in Molecular Medicine tal muscle SMN protein in mitochon-
Figure 4. Mitochondrial stress in spinal muscular atrophy (SMA) and the effects of AMPK. (A) Mutations in the drial fusion and fission?
Survival Motor Neuron 1 (SMN1) gene result in lower expression of full-length (FL) SMN protein and the pathogenesis of
SMA. The SMN2 gene is highly homologous to SMN1 but only produces ~10% of transcripts that are FL SMN while the Do NMD-specific therapies
remainder are the fruitless SMNΔ7. SMN deficiency leads to ⍺-motoneuron (⍺MN) degeneration, as well as the downstream (i.e., Exondys 51, Zolgensma) stimu-
weakness and wasting of its innervating skeletal muscle fibers. Mitochondrial stress in SMN-deficient ⍺MNs is characterized late AMPK and its downstream signal-
by impaired bioenergetics, aberrant cristae pattern, as well as declines in overall content. Reduced mitochondrial motility ing network? Moreover, does
along the microtubule (MT) tract has also been reported in ⍺MNs of SMA animals. In SMA skeletal muscle, there is lower administration of these drugs com-
PGC-1⍺ and NRF1/2 protein expression, indicating impairments in organelle biogenesis and declines in mitochondrial bined with AMPK agonist treatment or
content and function. This mitochondrial stress is partially linked to reduced expression of regulatory miRNAs that are under exercise provide additional or synergis-
the transcriptional control of functional SMN protein. Relatively limited evidence is currently available regarding mitochondrial tic benefits to mitochondrial health and
dynamics and mitophagy in SMA. (B) It is hypothesized that AMPK may enhance mitochondrial shuttling to the synaptic disease pathology?
terminal via p21-activated kinase (PAK)/Myosin VI (Myo6) phosphorylation in SMA ⍺MNs. Furthermore, activation of AMPK
via exercise and AICAR elicits adaptive signaling to increase the expression of PGC-1⍺ and other mitochondrial biogenesis Chronic physiological activation of
transcripts in SMA skeletal muscle. While the roles of the kinase in mediating organelle fusion, fission, and mitophagy in SMA AMPK in the neuromuscular system
are unclear, AMPK stimulation may target mitochondrial stress at these loci. Abbreviations: AMPK, AMP-activated protein via aerobic-type exercise can elicit a
kinase; NRF1/2, nuclear respiratory factors 1 and 2; PGC-1⍺, peroxisome proliferator-activated receptor γ coactivator-1⍺.

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of SMA mice and are often circular shaped (i.e., fragmented) and contain vacuoles [76,77]. Mito- myriad of benefits in ambulatory DMD
and SMA patients, as well as in individ-
chondrial biogenesis deficiency in SMA muscle tissue can partly be attributed to lower levels of uals affected by adult-onset DM1.
PGC-1⍺, TFAM, NRF1, and NRF2 [74,78,79]. Alternatively, recent work demonstrates that What are the optimum parameters of
SMN depletion in muscle cells leads to reduced mtDNA copy number, protein content, and res- exercise prescription (i.e., frequency,
intensity, duration, and mode) that
piration due to lower expression of specific miRNAs that are crucial for skeletal muscle develop-
safely elicit positive mitochondrial and
ment and mitochondrial homeostasis [80]. These findings are in line with observations in physiological adaptions in DMD, DM1,
presymptomatic SMA mice displaying less mitochondrial content and size prior to any NMJ de- and SMA patients?
generation. To date, a single study has aimed to investigate the role of SMN on mitochondrial
clearance. Using mice with a muscle-specific Smn1 knockout, Chemello and colleagues demon-
strated that the absence of functional SMN results in the accumulation of abnormal mitochondria
and greater expression of mitophagy proteins Parkin and PINK1, which was due to lower autoph-
agic flux relative to WT animals [81]. Whether organelle fusion and fission are impacted by the ab-
sence of SMN is unclear.

Targeting AMPK to mitigate mitochondrial stress in SMA

Remarkable advances in genetic technologies designed to increase functional SMN levels have
resulted in the recent approval of several treatments for SMA [82]. In addition, other investigations
have focused on ostensibly SMN-independent interventions targeting AMPK that may attenuate
mitochondrial stress in ⍺-MNs and skeletal muscle (Figure 4) [3]. For example, SMA mice chron-
ically treated with AICAR experience a milder skeletal muscle phenotype and improved NMJ mor-
phology [83]. Of note, in this study SMA mice demonstrated hyperphosphorylation of AMPK in
skeletal muscle prior to AICAR treatment, which suggests that further activating the kinase can
be beneficial. Recent evidence indicates that AMPK regulates mitochondrial shuttling within neu-
rons, a process that is dysregulated in SMA, via its downstream effector p21-activated kinase, as
well as cytoskeletal proteins myosin VI and syntaphilin [84]. Furthermore, AMPK activation decel-
erates retrograde axonal transport of mitochondria to augment ATP supply at the nerve terminal
[85]. Therefore, it is reasonable to speculate that pharmacological or physiological AMPK activa-
tion may stimulate mitochondrial biogenesis and function at the synapse to meet metabolic de-
mand. Collectively, these data provide evidence for targeting AMPK to improve mitochondrial
health in the neuromuscular system and mitigate SMA.

Concluding remarks
In summary, aberrant mitochondrial biogenesis and function are common to DMD, DM1, and SMA,
the most prevalent NMDs in children and adults. Direct evidence of organelle fusion, fission, and
mitophagy, as well as the molecular regulation of these critical processes, are relatively less abun-
dant in these neuromuscular diseases and therefore require further investigation (see Outstanding
questions). We propose that pharmacological and physiological AMPK activation can be safe, ef-
fective, and practical therapeutic approaches to target mitochondrial stress in DMD, DM1, and
SMA (see Clinician’s corner). Continued development of AMPK-stimulating modalities may be lev-
eraged as mutation-agnostic therapies applicable to other NMDs and conditions broadly affecting
the neuromuscular system. Other rapidly emerging mitochondria-targeting agents, some working
via AMPK-independent mechanisms, may also benefit NMD patients and should be examined.

Acknowledgments
This work was supported by the Canadian Institutes of Health Research (CIHR), Muscular Dystrophy Canada, Canada Re-
search Chairs program, and the Ontario Ministry of Economic Development, Job Creation and Trade (MEDJCT). A.I.M. is
a recipient of an Ontario Graduate Scholarship. S.Y.N. and S.R.M. are Natural Sciences and Engineering Research Council
of Canada postgraduate scholars. V.L. is the Canada Research Chair (Tier 2) in Neuromuscular Plasticity in Health and Dis-
ease and a MEDJCT Early Research Award Scholar. The authors would like to extend their appreciation to the Exercise Me-
tabolism Research Group. All figures were created with BioRender.com.

526 Trends in Molecular Medicine, July 2023, Vol. 29, No. 7

Trends in Molecular Medicine
Declaration of interests
No interests are declared.
Resources
i
https://clinicaltrials.gov/ct2/show/NCT02516085
ii
www.clinicaltrialsregister.eu/ctr-search/trial/2018-000692-32/IT
iii
https://clinicaltrials.gov/ct2/show/NCT05532813
iv
https://clinicaltrials.gov/ct2/show/NCT04322357
v
https://clinicaltrials.gov/ct2/show/NCT04173234
vi
https://clinicaltrials.gov/ct2/show/NCT03319030
vii
https://clinicaltrials.gov/ct2/show/NCT04782440
viii
https://clinicaltrials.gov/ct2/show/NCT05072288
ix
https://clinicaltrials.gov/ct2/show/NCT05715749
x
https://clinicaltrials.gov/ct2/show/NCT05544994
References
1. Mcdonald, C.M. (2012) Clinical approach to the diagnostic eval-
uation of hereditary and acquired neuromuscular diseases.
Phys. Med. Rehabil. Clin. N. Am. 23, 495–563
2. Trefts, E. and Shaw, R.J. (2021) AMPK: restoring metabolic ho-
meostasis over space and time. Mol. Cell 81, 3677–3690
3. Dial, A.G. et al. (2018) The role of AMPK in neuromuscular biol-
ogy and disease. Trends Endocrinol. Metab. 29, 300–312
4. Timpani, C.A. et al. (2015) Revisiting the dystrophin-ATP con-
nection: how half a century of research still implicates mitochon-
drial dysfunction in Duchenne muscular dystrophy aetiology.
Med. Hypotheses 85, 1021–1033
5. Zilio, E. et al. (2022) Mitochondrial dysfunction in spinal muscu-
lar atrophy. Int. J. Mol. Sci. 23, 10878
6. Spaulding, H.R. and Yan, Z. (2022) AMPK and the adaptation
to exercise. Annu. Rev. Physiol. 84, 209–227
7. Hood, D.A. et al. (2019) Maintenance of skeletal muscle mito-
chondria in health, exercise, and aging. Annu. Rev. Physiol.
81, 19–41
8. Liu, J. et al. (2016) Coupling of mitochondrial function and skel-
etal muscle fiber type by a miR-499/Fnip1/ AMPK circuit.
EMBO Mol. Med. 8, 1212–1228
9. Mansueto, G. et al. (2017) Transcription factor EB controls met-
abolic flexibility during exercise. Cell Metab. 25, 182–196
10. Steinberg, G.R. and Hardie, D.G. (2022) New insights into acti-
vation and function of the AMPK. Nat. Rev. Mol. Cell Biol. 24,
255–272
11. Steinberg, G.R. and Carling, D. (2019) AMP-activated protein
kinase: the current landscape for drug development. Nat. Rev.
Drug Discov. 18, 527–551
12. Tian, W. et al. (2020) An antibody for analysis of autophagy in-
duction. Nat. Methods 17, 232–239
13. Paquette, M. et al. (2021) AMPK-dependent phosphorylation is re-
quired for transcriptional activation of TFEB and TFE3. Autophagy
17, 3957–3975
14. Triolo, M. and Hood, D.A. (2021) Manifestations of age on au-
tophagy, mitophagy and lysosomes in skeletal muscle. Cells
10, 1054
15. Tilokani, L. et al. (2018) Mitochondrial dynamics: overview of
molecular mechanisms. Essays Biochem. 62, 341–360
16. Zhang, Y. et al. (2019) Melatonin attenuates myocardial
ischemia-reperfusion injury via improving mitochondrial fusion/
mitophagy and activating the AMPK-OPA1 signaling pathways.
J. Pineal Res. 66, e12542
17. Duan, D. et al. (2021) Duchenne muscular dystrophy. Nat. Rev.
Dis. Primers 7, 13
18. de Palma, C. et al. (2012) Autophagy as a new therapeutic tar-
get in Duchenne muscular dystrophy. Cell Death Dis. 3, e418
19. Ng, S.Y. and Ljubicic, V. (2020) Recent insights into neuromus-
cular junction biology in Duchenne muscular dystrophy: im-
pacts, challenges, and opportunities. eBioMedicine 61, 103032
OPEN ACCESS
20. Sperl, W. et al. (1997) High resolution respirometry of perme-
abilized skeletal muscle fibers in the diagnosis of neuromuscular
disorders. Mol. Cell. Biochem. 174, 71–78
21. Hughes, M.C. et al. (2019) Early myopathy in Duchenne muscu-
lar dystrophy is associated with elevated mitochondrial H2O2
emission during impaired oxidative phosphorylation.
J. Cachexia. Sarcopenia Muscle 10, 643–661
22. Ramos, S.V. et al. (2020) Mitochondrial bioenergetic dysfunc-
tion in the D2.mdx model of Duchenne muscular dystrophy is
associated with microtubule disorganization in skeletal muscle.
PLoS One 15, e0237138
23. Dubinin, M.V. et al. (2020) Duchenne muscular dystrophy is as-
sociated with the inhibition of calcium uniport in mitochondria
and an increased sensitivity of the organelles to the calcium-
induced permeability transition. Biochim. Biophys. Acta Mol.
basis Dis. 1866, 165674
24. Jongpiputvanich, S. et al. (2005) Mitochondrial respiratory chain dys-
function in various neuromuscular diseases. J. Clin. Neurosci. 12,
426–428
25. Moore, T.M. et al. (2020) Mitochondrial dysfunction is an early
consequence of partial or complete dystrophin loss in mdx
mice. Front. Physiol. 11, 690
26. Hardee, J.P. et al. (2021) Dystrophin deficiency disrupts muscle
clock expression and mitochondrial quality control in mdx mice.
Am. J. Physiol. Cell Physiol. 321, C288–C296
27. Luan, P. et al. (2021) Urolithin A improves muscle function by in-
ducing mitophagy in muscular dystrophy. Sci. Transl. Med. 13,
319
28. Mastaglia, F.L. et al. (1970) Regeneration of muscle in
Duchenne muscular dystrophy: an electron microscope study.
J. Neurol. Sci. 11, 425–444
29. Watkins, S.C. and Cuuen, M.J. (1987) A qualitative and quanti-
tative study of the ultrastructure of regenerating muscle fibres in
Duchenne muscular dystrophy and polymyositis. J. Neurol. Sci.
82, 81–192
30. Selsby, J.T. et al. (2012) Rescue of Dystrophic skeletal muscle
by PGC-1α involves a fast to slow fiber type shift in the mdx
mouse. PLoS One 7, e30063
31. Godin, R. et al. (2012) Peroxisome proliferator-activated recep-
tor γ coactivator 1-α gene transfer restores mitochondrial bio-
mass and improves mitochondrial calcium handling in post-
necrotic mdx mouse skeletal muscle. J. Physiol. 590,
5487–5502
32. Matsakas, A. et al. (2013) Muscle ERRγ mitigates Duchenne
muscular dystrophy via metabolic and angiogenic reprogramming.
FASEB J. 27, 4004–4016
33. Chalkiadaki, A. et al. (2014) Muscle-specific SIRT1 gain-of-
function increases slow-twitch fibers and ameliorates patho-
physiology in a mouse model of Duchenne muscular dystrophy.
PLoS Genet. 10, e1004490
Trends in Molecular Medicine, July 2023, Vol. 29, No. 7 527

OPEN ACCESS
34. Reyes, N.L. et al. (2015) Fnip1 regulates skeletal muscle fiber
type specification, fatigue resistance, and susceptibility to mus-
cular dystrophy. Proc. Natl. Acad. Sci. U. S. A. 112, 424–429
35. Ljubicic, V. et al. (2011) Chronic AMPK activation evokes the
slow, oxidative myogenic program and triggers beneficial adap-
tations in mdx mouse skeletal muscle. Hum. Mol. Genet. 20,
3478–3493
36. Al-Rewashdy, H. et al. (2015) Utrophin A is essential in mediat-
ing the functional adaptations of mdx mouse muscle following
chronic AMPK activation. Hum. Mol. Genet. 24, 1243–1255
37. Jahnke, V.E. et al. (2012) Metabolic remodeling agents show
beneficial effects in the dystrophin-deficient mdx mouse
model. Skelet. Muscle 2, 1–11
38. Pauly, M. et al. (2012) AMPK activation stimulates autophagy
and ameliorates muscular dystrophy in the mdx mouse dia-
phragm. Am. J. Pathol. 181, 583–592
39. Ljubicic, V. and Jasmin, B.J. (2015) Metformin increases perox-
isome proliferator-activated receptor γ Co-activator-1α and utrophin
a expression in dystrophic skeletal muscle. Muscle Nerve 52,
139–142
40. Dong, X. et al. (2021) Metformin increases sarcolemma integrity
and ameliorates neuromuscular deficits in a murine model of
Duchenne muscular dystrophy. Front. Physiol. 12, 642908
41. Mantuano, P. et al. (2018) Effect of a long-term treatment with
metformin in dystrophic mdx mice: a reconsideration of its po-
tential clinical interest in Duchenne muscular dystrophy.
Biochem. Pharmacol. 154, 89–103
42. Hafner, P. et al. (2016) Improved muscle function in Duchenne
muscular dystrophy through L-arginine and metformin: an
investigator-initiated, open-label, single-center, proof-of-
concept-study. PLoS One 11, e0147634
43. Ljubicic, V. et al. (2014) Resveratrol induces expression of the
slow, oxidative phenotype in Mdx mouse muscle together
with enhanced activity of the SIRT1-PGC-1α axis. Am.
J. Physiol. Cell Physiol. 307, C66–C82
44. Ng, S.Y. et al. (2023) Acute, next-generation AMPK activation
initiates a disease-resistant gene expression program in dystro-
phic skeletal muscle. FASEB J. 37, e22863
45. D’Amico, D. et al. (2021) Impact of the natural compound
urolithin A on health, disease, and aging. Trends Mol. Med.
27, 687–699
46. Pauly, M. et al. (2017) ER stress disturbs SR/ER-mitochondria
Ca2+ transfer: implications in Duchenne muscular dystrophy.
Biochim. Biophys. Acta Mol. Basis Dis. 1863, 2229–2239
47. Slavin, M.B. et al. (2022) Regulatory networks coordinating mi-
tochondrial quality control in skeletal muscle. Am. J. Physiol.
Cell Physiol. 322, C913–C926
48. Hamel, J.I. (2022) Myotonic dystrophy. Continuum (Minneap
Minn) 28, 1715–1734
49. Perna, A. et al. (2020) High prevalence and gender-related dif-
ferences of gastrointestinal manifestations in a cohort of DM1
patients: a perspective, cross-sectional study. Front. Neurol.
11, 394
50. Nakamori, M. et al. (2013) Splicing biomarkers of disease sever-
ity in myotonic dystrophy. Ann. Neurol. 74, 862–872
51. Wang, E.T. et al. (2019) Transcriptome alterations in myotonic
dystrophy skeletal muscle and heart. Hum. Mol. Genet. 28,
1312–1321
52. Mikhail, A.I. et al. (2022) Aerobic exercise elicits clinical adapta-
tions in myotonic dystrophy type 1 patients independent of
pathophysiological changes. J. Clin. Invest. 132, e156125
53. Ozimski, L.L. et al. (2021) The hallmarks of myotonic dystrophy
type 1 muscle dysfunction. Biol. Rev. Camb. Philos. Soc. 96,
716–730
54. Ono, S. et al. (1986) “Ragged-red” fibres in myotonic dystro-
phy. J. Neurol. Sci. 74, 247–255
55. Isashiki, Y. et al. (1989) Mitochondrial abnormalities in
extraocular muscles in myotonic dystrophy. Neuro-
Opthalmology. 9, 115–122
56. Sahashi, K. et al. (1992) Increased mitochondrial DNA deletions
in the skeletal muscle of myotonic dystrophy. Gerontology 38,
18–29
57. Gramegna, L.L. et al. (2018) Mitochondrial dysfunction in myo-
tonic dystrophy type 1. Neuromuscul. Disord. 28, 144–149
528 Trends in Molecular Medicine, July 2023, Vol. 29, No. 7
Trends in Molecular Medicine
58. Leo, V. di et al. (2023) Strength training rescues mitochondrial
dysfunction in skeletal muscle of patients with myotonic dystro-
phy type 1. medRxiv Published online January 23, 2023.
https://doi.org/10.1101/2023.01.20.23284552
59. Ravel-Chapuis, A. et al. (2018) Pharmacological and physiolog-
ical activation of AMPK improves the spliceopathy in DM1
mouse muscles. Hum. Mol. Genet. 27, 3361–3376
60. Brockhoff, M. et al. (2017) Targeting deregulated AMPK/
mTORC1 pathways improves muscle function in myotonic dys-
trophy type I. J. Clin. Invest. 127, 549–563
61. Mikhail, A.I. et al. (2023) A single dose of exercise stimulates
skeletal muscle mitochondrial plasticity in myotonic dystrophy
type 1. Acta Physiol. (Oxf). 237, e13943
62. Yang, L. et al. (2020) OPA1-exon4b binds to mtDNA D-loop for
transcriptional and metabolic modulation, independent of mito-
chondrial fusion. Front. Cell Dev. Biol. 8, 180
63. Misquitta, N.S. et al. (2022) Combinatorial treatment with exer-
cise and AICAR potentiates the rescue of myotonic dystrophy type 1
mouse muscles in a sex-specific manner. Hum. Mol. Genet. 32,
551–566
64. Bassez, G. et al. (2018) Improved mobility with metformin in patients
with myotonic dystrophy type 1: a randomized controlled trial. Brain
141, 2855–2865
65. García-puga, M. et al. (2020) Myotonic dystrophy type 1 cells
display impaired metabolism and mitochondrial dysfunction
that are reversed by metformin. Aging (Albany NY) 12,
6260–6275
66. Mercuri, E. et al. (2022) Spinal muscular atrophy. Nat. Rev. Dis.
Primers 8, 52
67. Xu, C.C. et al. (2016) Abnormal mitochondrial transport and
morphology as early pathological changes in human models
of spinal muscular atrophy. Dis. Model. Mech. 9, 39–49
68. Wang, Z.B. et al. (2013) Recapitulation of spinal motor neuron-
specific disease phenotypes in a human cell model of spinal
muscular atrophy. Cell Res. 23, 378–393
69. Acsadi, G. et al. (2009) Mitochondrial dysfunction in a neural cell
model of spinal muscular atrophy. J. Neurosci. Res. 87,
2748–2756
70. Boyd, P.J. et al. (2017) Bioenergetic status modulates motor
neuron vulnerability and pathogenesis in a zebrafish model of
spinal muscular atrophy. PLoS Genet. 13, e10006744
71. Murray, L.M. et al. (2015) Transcriptional profiling of differentially
vulnerable motor neurons at pre-symptomatic stage in the
Smn2b/- mouse model of spinal muscular atrophy. Acta
Neuropathol. Commun. 3, 55
72. Miller, N. et al. (2016) Motor neuron mitochondrial dysfunction in
spinal muscular atrophy. Hum. Mol. Genet. 25, 3395–3406
73. Berger, A. et al. (2003) Severe depletion of mitochondrial DNA
in spinal muscular atrophy. Acta Neuropathol. 105, 245–251
74. Ripolone, M. et al. (2015) Impaired muscle mitochondrial biogenesis
and myogenesis in spinal muscular atrophy. JAMA Neurol. 72,
666–675
75. Habets, L.E. et al. (2022) Magnetic resonance reveals mitochondrial
dysfunction and muscle remodelling in spinal muscular atrophy.
Brain 145, 1422–1435
76. Voigt, T. et al. (2010) Ultrastructural changes in diaphragm neu-
romuscular junctions in a severe mouse model for spinal mus-
cular atrophy and their prevention by bifunctional U7 snRNA
correcting SMN2 splicing. Neuromuscul. Disord. 20, 744–752
77. Fulceri, F. et al. (2021) Ultrastructural characterization of peripheral
denervation in a mouse model of type III spinal muscular atrophy.
J. Neural Transm. (Vienna) 128, 771–791
78. Meijboom, K.E. et al. (2022) Dysregulation of Tweak and Fn14 in
skeletal muscle of spinal muscular atrophy mice. Skelet. Muscle
12, 18
79. Ng, S.Y. et al. (2019) Mechanisms of exercise-induced survival
motor neuron expression in the skeletal muscle of spinal muscular
atrophy-like mice. J. Physiol. 587, 4757–4778
80. Ikenaka, A. et al. (2023) SMN promotes mitochondrial metabolic
maturation during myogenesis by regulating the MYOD-miRNA
axis. Life Sci. Alliance 6, e202201457
81. Chemello, F. et al. (2023) Dysfunctional mitochondria accumu-
late in a skeletal muscle knockout model of Smn1, the causal
gene of spinal muscular atrophy. Cell Death Dis. 14, 162
Trends in Molecular Medicine
82. Chaytow, H. et al. (2021) Spinal muscular atrophy: from ap-
proved therapies to future therapeutic targets for personalized
medicine. Cell Rep. Med. 2, 100346
83. Cerveró, C. et al. (2016) Chronic treatment with the AMPK ag-
onist AICAR prevents skeletal muscle pathology but fails to im-
prove clinical outcome in a mouse model of severe spinal
muscular atrophy. Neurotherapeutics 13, 198–216
84. Li, S. et al. (2020) The cross-talk of energy sensing and mito-
chondrial anchoring sustains synaptic efficacy by maintaining
presynaptic metabolism. Nat. Metab. 2, 1077–1095
85. Watters, O. et al. (2020) AMPK preferentially depresses retro-
grade transport of axonal mitochondria during localized nutrient
deprivation. J. Neurosci. 40, 4798–4812
86. Ng, S.Y. et al. (2018) Exercise biology of neuromuscular disor-
ders. Appl. Physiol. Nutr. Metab. 43, 1194–1206
87. Kostek, M.C. and Gordon, B. (2018) Exercise is an adjuvant to con-
temporary dystrophy treatments. Exerc. Sport Sci. Rev. 46, 34–41
88. Madsen, K.L. et al. (2015) Training improves oxidative capacity, but
not function, in spinal muscular atrophy type III. Muscle Nerve 52,
240–244
89. Hyzewicz, J. et al. (2015) Low intensity training of mdx mice re-
duces carbonylation and increases expression levels of proteins
involved in energy metabolism and muscle contraction. Free
Radic. Biol. Med. 82, 122–136
90. Hardee, J.P. et al. (2021) Metabolic remodeling of dystrophic
skeletal muscle reveals biological roles for dystrophin and
utrophin in adaptation and plasticity. Mol. Metab. 45, 101157
91. Camerino, G.M. et al. (2014) Gene expression in mdx mouse muscle
in relation to age and exercise: aberrant mechanical–metabolic cou-
pling and implications for pre-clinical studies in Duchenne muscular
dystrophy. Hum. Mol. Genet. 23, 5720–5732
92. Manta, A. et al. (2019) Chronic exercise mitigates disease
mechanisms and improves muscle function in myotonic dystro-
phy type 1 mice. J. Physiol. 597, 1361–1381
93. Sharp, L. et al. (2019) Endurance exercise leads to beneficial
molecular and physiological effects in a mouse model of myo-
tonic dystrophy type 1. Muscle Nerve 60, 779–789
94. Furrer, R. et al. (2023) The molecular athlete: exercise physiology from
mechanisms to medals. Physiol. Rev. 103, 1693–1787
OPEN ACCESS
95. Ion şescu, V. et al. (1967) Respiratory control and oxidative phos-
phorylation in the dystrophic muscle. Acta Neurol. Scand. 43,
564–572
96. Scholte, H.R. and Busch, H.F.M. (1980) Early changes of
muscle mitochondria in Duchenne dystrophy: partition and
activity of mitochondrial enzymes in fractionated muscle of
unaffected boys and adults and patients. J. Neurol. Sci.
45, 217–234
97. Newman, R.J. et al. (1982) Nuclear magnetic resonance studies of
forearm muscle in Duchenne dystrophy. Br. Med. J. (Clin. Res. Ed.)
284, 1072–1074
98. Ohtaki, E. (1990) Secondarily reduced cytochrome c oxidase activity
in various neuromuscular disorders. Brain and Development 12,
326–333
99. Haycock, J.W. et al. (1996) Oxidative damage to muscle
protein in Duchenne muscular dystrophy. Neuroreport 8,
357–361
100. Kuznetsov, A.V. et al. (1998) Impaired mitochondrial oxidative
phosphorylation in skeletal muscle of the dystrophin-deficient
mdx mouse. Mol. Cell. Biochem. 183, 87–96
101. Capitanio, D. et al. (2020) Comparative proteomic analyses of
Duchenne muscular dystrophy and Becker muscular dystrophy
muscles: changes contributing to preserve muscle function in
Becker muscular dystrophy patients. J. Cachexia. Sarcopenia
Muscle 11, 547–563
102. Vita, G. et al. (1993) Muscle mitochondria investigation in myo-
tonic dystrophy abstract. Eur. Neurol. 33, 423–427
103. Barnes, P.R.J. et al. (1997) Skeletal muscle metabolism in myo-
tonic dystrophy. A 31P magnetic resonance spectroscopy
study. Brain 120, 1699–1711
104. Gobernado, J.M. et al. (1980) Mitochondrial functions in chronic
spinal muscular atrophy. J. Neurol. Neurosurg. Psychiatry 43,
546–549
105. Vielhaber, S. et al. (1999) Visualization of defective mitochon-
drial function in skeletal muscle fibers of patients with sporadic
amyotrophic lateral sclerosis. J. Neurol. Sci. 169, 133–139
106. Millino, C. et al. (2009) Different atrophy-hypertrophy transcrip-
tion pathways in muscles affected by severe and mild spinal
muscular atrophy. BMC Med. 7, 14
Trends in Molecular Medicine, July 2023, Vol. 29, No. 7 529