Care4BrittleBones aims to improve the quality of life of people with Brittle Bones Disease

Finalised projects

Living with OI


Increasingly people with OI and health care providers realise that living with OI can have an impact well beyond physical. While everyone knows someone with OI who has struggled severely in a certain phase of his/her life, it often is not seen as an area that needs support.

This is why, Care4BrittleBones has funded a 2-year project looking into psychosocial consequences of OI in collaboration with the VOI (Dutch OI Association), the UMC Utrecht (expertise center for children with OI) and the Isala (Expertise Center for adults with OI) in the Netherlands.



Project team: W. Nijhuis, A. Franken, G. Janus, R. Sakkers, M. Verhoef
Expert team: K. Ayers, Ch. Damas, L. Folkestad, A. Forlino, P. Fraschini, C. Hill, R. Kruse, L. Lande-Wekre, L. Michiels, K. Montpetit,  L. Panzeri (S. Paveri), F. Rauch, JP Salles (V. Porquet-Bordes), O. Semler, J. Sun, M. To (Eric Yeung), L. Tosi, L. Zhytnik, C. Zillikens,
Project management: Dagmar Mekking, CEO Care4BrittleBones

Care for the patient with Osteogenesis Imperfecta is complex.

There is a critical need to better define the outcomes particularly those that matter most to patients and their families and to standardize the methods by which these outcomes will be measured.

The underlying research questions for project Key4OI are: “What outcomes should the a multidisciplinary OI team track at each stage of treatment, reflecting what matters most to people with OI throughout their lifetime? How could this data be collected, evaluated and compared taking into account both patient reported outcome measures and clinically reported outcome measures to drive sustainable insights for healthcare improvement and research into OI?”

The primary objective was to reach multidisciplinary and international consensus for a standard set of outcomes in OI care and research. To ensure the outcome set is relevant and reflects the view of people with OI, they were involved in all stages of the process. The standard set had to be comprehensive enough to cover all main aspects of OI relevant for treatment and research, yet practical enough for sustainable implementation. This would allow teams around the world to measure their own performance in a consistent fashion.

In November 2019, the Key4OI Core Outcome set has been agreed. It summarizes the recommendations of an international, multidisciplinary working group, based on input from 16 focus groups held around the world. Each Focus group was based on a detailed script and took several hours.

The Key4OI Set has been presented during the Conference Quality of Life 4 OI

Plans for 2020:

  1. Piloting Key4OI

6 hospitals / countries are setting up to pilot Key4OI in their center(s) and are meeting every 2 weeks to progress critical issues as much as possible together:

(1) Shriners Hospital for children Montreal, Canada,
(2) Alfred I duPont Children’s Hospital, Delaware USA
(3) Norway
(4) China / HongKong
(5) Denmark
(6) NL (Isala, Utrecht MC, others to be discussed)

  1. Engaging with the Key4OI – Affiliate group

11 other countries have expressed interest to work with Key4OI in the future: Brazil, Israel, Russia, Switzerland, India, UK, Italy, Belgium, France, Germany, Estonia. They are forming the Key4OI Affiliates Group and are kept informed in quarterly teleconferences (5 February, 6 May, 9 September, 9 December 2020). If you would like to join this group, please send an e-mail to

  1. Presentation OI Sheffield

We will provide an update on Key4OI during a presentation at OI-Sheffield.

Plans longer term

All funding supporting Key4OI has been generated through the OI community and through the generous work of hundreds of hours of many Key4OI experts and people in the project team (see above). Foundation Care4BrittleBones has been requested to manage the further development of the Key4OI set. The foundation is committed to provide resources to fund future work and provide a platform for learning & development related to Key4OI.

No industry funding has been received. We are currently reviewing the option to use the Key4OI set in the process of clinical trials through the EMA qualification process.

We hope eventually to create a FAIR data environment in which Key4OI data can be aggregated on an anonymous basis to support healthcare improvement and reseach into OI. This is expected to take 3-5 years.

Any questions can be directed to Care4BrittleBones (


Fatigue and sleep disturbances in OI – Prevalence, characteristics, and impact on the quality of life

( D.D.S Heidi Arponen , Department of Oral and maxillofacial diseases, University of Helsinki, Finland. Project end Date: 2019)

Fatigue is a common problem in people with OI and can have multiple physical and mental consequences. Different researches have tried to pin down the cause of fatigue in OI, but no research has yet specifically tried to relate fatigue with sleep disturbance. This innovative project hence tries to answer this important question by investigating the relationship between fatigue and sleep apnea (which a potentially serious sleep disorder) in people with OI. The study includes 151 individuals and used survey questionnaire, clinical examination and sleep study(polysomnography) as a methodology.


The results show that fatigue was reported by 96%, and daily pain by 87% of individuals with OI. Notably, the level of daily fatigue reported was similar between OI population and healthy control group.

However, various sleep disturbances are significantly high among individuals with OI than the control group. Eight OI- respondents of the survey study had a diagnosis of sleep apnea whereas 96% of those without sleep apnea diagnosis reported one or more of the following sleep disturbance related symptoms like snoring, pauses of breathing during sleep, restless sleep, grinding of teeth during sleep, recurrent nightmares, daytime sleepiness, likelihood of dozing, dysphagia (swallowing disorder), difficulties of concentration, nocturia (multiple waking up to urinate) and restless legs.

The research recommends that unravelling undiagnosed sleep apnea as underlying cause of tiredness and receiving appropriate treatment for it can make a huge positive long-term difference in an individual’s life.

↓ Research Summary

Transplantation of mesenchymal stem cells to treat Osteogenesis Imperfecta

(Goetherstroem C, Karolinska University Hospital, Stockholm/Sweden. Project end date: 2015)

Researchers from Karolinska University have used stem cells to treat severe OI before and multiple times after birth. One of them is a boy called Adam King, who received significant media attention in 2016 en 2017 here.

The goal of the project was to localize the transplanted stem cells in the bone. Care4BrittleBones supported a part of the research project by enabling a highly specialized technique to be performed on bone material from one of the individuals treated with stem-cells using laser micro dissection.


The project confirmed that the transplanted stem cells have actually reached the bone of the receiving patient and been built in. These results contributed to the principal researcher receiving a 1,6 Mio Research Grant from the European Union (Horizon 2020), which is seen as an area of potential future break through for OI. The name of this multicenter research project is BoostB4. The BOOSTB4 project is focused on translating fetal-derived mesenchymal stem cell (MSC) transplantation into the clinic as a therapy for Osteogenesis Imperfecta. During the project Karolinska and partnering hospital centers (eg University of Cologne/D and University Hospital of Utrecht/WKZ/ Netherlands) will investigate the safety and efficacy of this innovation in regenerative medicine in the treatment of OI. Successful clinical demonstration of the BOOSTB4 therapy in OIwould pave the way for the treatment of many developmental fetal disorders. Curing or decreasing the severity of these congenital diseases would result in life-long benefits for the affected individuals and their families from birth onwards. The scientific proof for the efficacy of stemcell treatment is still outstanding at this stage, but enough evidence is there to continue the research in this area at full speed.

As Care4BrittleBones we keep following the development in this area with great interest.

More information is available here.

Denosumab as an alternative for Bisphosphonates?

(Semler O, University of Cologne/Germany. Project end date: 2016)

Currently children with a moderate or severe type of OI are treated with intravenous bisphosphonates. Due to unknown long-term side effects and the “hassle” with the intravenous application, research is performed to develop alternative approaches to the medical treatment of children with OI. During this study, a special antibody (Denosumab) was used on 10 children to inhibit bone resorption and to stabilize the bones. The aim of the pilot trial, which is co-funded by Care4BrittleBones and is performed at the children´s hospital at the university Cologne, is to assess the efficacy of a therapy with Denosumab in children 5-10 years of age with OI types III or IV.


  • The trial has confirmed the effectiveness of Denosumab for the small cohort of the trial.
  • On average Denosumab leads to significant changes in areal bone mineral density at the lumbar spine.
  • Children under Denosumab treatment show an increase in absolute height.
  • Denosumab appears to suppress bone resorption in children over 10-12 weeks.
  • Denosumab seems to be safe in a one-year treatment course if a sufficient calcium and vitamin D substitution is provided.

More information is available here. (

Based on these first results the pharmaceutical company AMGEN has now started a 3-year formal clinical trial on a broader cohort of patients around the globe, possibly enabling an alternative option to Bisphosphonate treatment.

Osteogenesis Imperfecta and Fatigue

(Harsevoort A, Isala Clinics/NL. Project end date: 2017)

It seems that people with OI experience more fatigue than the regular population. Therefore the Expertise Centre for OI has investigated if there is a demonstrable link between OI and fatigue, involving 99 adult patients with OI. These insights may help to develop new treatment protocols and thus improve the quality of life for this group of people.


Results from the study confirm the hypothesis that the severity and impact of fatigue in people with OI is greater than in the general healthy population. Interestingly, the score was not very variable between people with different OI types or between people from different gender and age groups.

As people often raise fatigue with OI as a factor that significantly decreases their quality of life, this outcome could be an important indicator that reflects quality of care for OI patients. More information is available here.

Pain Less – OI Youngsters take control

(Barros L, University of Lisbon/Portugal. Project end date: 2016)

Fracture and non-fracture pain can pose a significant burden in the lives of young people with Osteogenesis Imperfecta (OI) and it has been identified as one of the central issues related to their quality of lifeTherefore adequate pain management is essential. Persistent pain in young people is often associated with physical limitations, increased risk of adjustment problems and internalizing symptoms (e.g. anxiety, depression social withdrawal), leading to restricted social interactions and school/work absenteeism. Although medical treatment plays a major role in the management of OI, psychological strategies are critical components of this plan. Even though there is currently no research about the effectiveness of psychological treatment of pain within the OI population, evidence of the positive impact of psychological interventions in young people with chronic health conditions, where pain is a major symptom, is robust. This proposal aimed to develop an online programme to raise awareness and control for OI youngsters pain issues.


The project developed self-management IT-tool based on Moodle – technology. It was applied to a group of Portuguese youngsters with OI. Adherence to the programme has been a challenge. More work would be required to make the tool more interactive and user-friendly for the target group before using it for a larger group of people. The results of the study are being used in other, larger studies looking at pain and OI. This area offers plenty of room for more research in all age groups.

Gene/cellular therapyapproach to treat dominant form of Osteogenesis Imperfecta

(Forlino A, University of Pavia, Italy. Project end date: 2017).

The project will focus on the development of a novel gene-cellular therapy approach for the treatment of the most common dominant forms of the heritable brittle bone disease OI. A validated murine model for classical OI, carrying a single glycine substitution in 1 chain of collagen type I, has been used. A silencing approach has been optimized to stably target the mutant collagen transcript in fibroblast cells that will be dedifferentiated to multipotent iPS cells and then transplanted in utero. Their ability to become osteoblasts in vivo have been stimulated using a specific drug. A success of this therapy in vivo would pave the way for its use in clinical trials using as source of treatment the patients’ fibroblast cells.


The Principal Researcher successfully introduced in a safe genomic murine locus, a single copy of a specific silencing RNA molecule using the innovative genomic scissors CRISPR/cas9. This genetic tool allowed to cut the DNA in a specific location and to insert another DNA sequence, working as drug against the mutation. The silencing RNA (siRNA) introduced was already tested by the researcher as being able to stop the synthesis of the mutated collagen type I chain in the Brtl cells. The effect of this intervention is that the siRNA molecule turns off the mutant allele allowing only the synthesis of normal protein.

Although the success of this approach will need further studies mainly in order to improve the amount of siRNA able to be expressed by the cells, the results will open the possibility to move from the bench to the bedside for the treatment of OI. The design of various silencing molecules specific for the mutations known to cause OI can be easily tested in in vitro systems first, such as in patients cells in a laboratory setting. The ultimate goal is to correct the defect in patient’s cells and to dedifferentiate them to multipotent iPS cells that will then be suitable for transplantation.

Physical rehabilitation for children and adolescents with OI

(Semler O, University of Cologne, and Müller B, Unireha, Center of Prevention and Rehabilitation, Cologne, Germany, in collaboration with an international team of Experts. Follow up lead by Foundation Care4BrittleBones. Project end date: August 2018).This project has been enabled by a grant from AGIS Innovatie Fonds.

The purpose of the project was to collect expert knowledge as well as evidence in the literature regarding physical rehabilitation in children and adolescents with Osteogenesis Imperfecta (OI) in order to develop evidence based recommendations. These consensus statements serve as guidelines for the individual therapist, who needs to adapt them to the needs of each patient. Particular attention must be paid to the severity of the disease in the individual child, as this will influence the therapeutic options and goals. The paper was developed by O. Semler and B. Mueller in collaboration with an expert-group which included 16 representatives (12 physiotherapists, two occupational therapist and two medical doctors) from 14 countries.


The project has resulted in 17 statements ranging across all areas of physical rehabilitation for children and adolescents: Musculoskeletal, spine, self-care and role of upper extremity, infant & development, mobility, post surgery as well as general aspects. The article has been published in open source modus and can be found HERE. The projects results have been overwhelmingly positively received:

  • A webcast was held with physiotherapists, occupational therapists and rehabilitationdoctors from all over the world
  • The guideline is being translated into several different languages including Chinese and Portuguese.
  • Semler has received the Germany Child protection award for his role in this project.

This important topic will continue to receive attention and support. Care4BrittleBones is currently working with the expert team to enable access to various tools and techniques that people with OI can use by themselves or together with their physiotherapist or occupational therapist to achieve the best possible outcomes for their lives through physical rehabilitation.