1. Introduction        
      Neuromuscular disease is a very broad term that encompasses      many diseases and aliments that either directly, via      intrinsic muscle pathology, or indirectly, via nerve      pathology, impair the functioning of the muscles.      Neuromuscular diseases affect the muscles and/or their      nervous control and lead to problems with movement. Many are      genetic; sometimes, an immune system disorder can cause them.      As they have no cure, the aim of clinical treatment is to      improve symptoms, increase mobility and lengthen life. Some      of them affect the anterior horn cell, and are classified as      acquired (e.g. poliomyelitis) and hereditary      (e.g. spinal muscular atrophy) diseases. SMA is a      genetic disease that attacks nerve cells, called motor      neurons, in the spinal cord. As a consequence of the lost of      the neurons, muscles weakness becomes to be evident,      affecting walking, crawling, breathing, swallowing and head      and neck control. Neuropathies affect the peripheral nerve      and are divided into demyelinating (e.g.      leucodystrophies) and axonal (e.g. porphyria)      diseases. Charcot-Marie-Tooth (CMT) is the most frequent      hereditary form among the neuropathies and its characterized      by a wide range of symptoms so that CMT-1a is classified as      demyelinating and CMT-2 as axonal (Marchesi & Pareyson,      2010). Defects in neuromuscular junctions cause infantile and      non-infantile Botulism and Myasthenia Gravis (MG). MG is a      antibody-mediated autoimmune disorder of the neuromuscular      junction (NMJ) (Drachman,      1994; Meriggioli &      Sanders, 2009). In most cases, it is caused by pathogenic      autoantibodies directed towards the skeletal muscle      acetylcholine receptor (AChR) (Patrick & Lindstrom, 1973) while in      others, non-AChR components of the postsynaptic muscle      endplate, such as the muscle-specific receptor tyrosine      kinase (MUSK), might serve as targets for the autoimmune      attack (Hoch et al.,      2001). Although the precise origin of the autoimmune      response in MG is not known, genetic predisposition and      abnormalities of the thymus gland such as hyperplasia and      neoplasia could have an important role in the onset of the      disease (Berrih et al.,      1984; Roxanis et al.,      2001).    
      Several diseases affect muscles: they are classified as      acquired (e.g. dermatomyositis and polymyositis) and      hereditary (e.g. myotonic disorders and myopaties)      forms. Among the myopaties, muscular dystrophies are      characterized by the primary wasting of skeletal muscle,      caused by mutations in the proteins that form the link      between the cytoskeleton and the basal lamina (Cossu & Sampaolesi, 2007).      Mutations in the dystrophin gene cause severe form of      hereditary muscular diseases; the most common are Duchenne      Muscular Dystrophy (DMD) and Becker Muscular Dystrophy (BMD).      DMD patients suffer for complete lack of dystrophin that      causes progressive degeneration, muscle wasting and death      into the second/third decade of life. Beside, BMD patients      show a very mild phenotype, often asymptomatic primarily due      to the expression of shorter dystrophin mRNA transcripts that      maintain the coding reading frame. DMD patients muscles show      absence of dystrophin and presence of endomysial fibrosis,      small fibers rounded and muscle fiber      degeneration/regeneration. Untreated, boys with DMD become      progressively weak during their childhood and stop ambulation      at a mean age of 9 years, later with corticosteroid treatment      (12/13 yrs). Proximal weakness affects symmetrically the      lower (such as quadriceps and gluteus) before the upper      extremities, with progression to the point of wheelchair      dependence. Eventually distal lower and then upper limb      weakness occurs. Weakness of neck flexors is often present at      the beginning, and most patients with DMD have never been      able to jump. Wrist and hand muscles are involved later,      allowing the patients to keep their autonomy in transfers      using a joystick to guide their wheelchair. Musculoskeletal      contractures (ankle, knees and hips) and learning      difficulties can complicate the clinical expression of the      disease. Besides this weakness distribution in the same      patient, a deep variability among patients does exist. They      could express a mild phenotype, between Becker and Duchenne      dystrophy, or a really severe form, with the loss of      deambulation at 7-8 years. Confinement to a wheelchair is      followed by the development of scoliosis, respiratory failure      and cardiomyopathy. In 90% of people death is directly      related to chronic respiratory insufficiency (Rideau et al., 1983). The      identification and characterization of dystrophin gene led to      the development of potential treatments for this disorder      (Bertoni, 2008). Even if      only corticosteroids were proven to be effective on DMD      patient (Hyser and Mendell,      1988), different therapeutic approaches were attempted,      as described in detail below (see section 7).    
      The identification and characterization of the genes whose      mutations caused the most common neuromuscular diseases led      to the development of potential treatments for those      disorders. Gene therapy for neuromuscular disorders embraced      several concepts, including replacing and repairing a      defective gene or modifying or enhancing cellular      performance, using gene that is not directly related to the      underlying defect (Shavlakadze et al., 2004). As an example, the      finding that DMD pathology was caused by mutations in the      dystrophin gene allowed the rising of different therapeutic      approaches including growth-modulating agents that increase      muscle regeneration and delay muscle fibrosis (Tinsley et al., 1998), powerful      antisense oligonucleotides with exon-skipping capacity      (Mc Clorey et al.,      2006), anti-inflammatory or second-messenger      signal-modulating agents that affect immune responses      (Biggar et al., 2006),      agents designed to suppress stop codon mutations (Hamed, 2006). Viral and      non-viral vectors were used to deliver the full-length - or      restricted versions - of the dystrophin gene into stem cells;      alternatively, specific antisense oligonucleotides were      designed to mask the putative splicing sites of exons in the      mutated region of the primary RNA transcript whose removal      would re-establish a correct reading frame. In parallel, the      biology of stem cells and their role in regeneration were the      subject of intensive and extensive research in many      laboratories around the world because of the promise of stem      cells as therapeutic agents to regenerate tissues damaged by      disease or injury (Fuchs and      Segre, 2000; Weissman,      2000). This research constituted a significant part of      the rapidly developing field of regenerative biology and      medicine, and the combination of gene and cell therapy arose      as one of the most suitable possibility to treat degenerative      disorders. Several works were published in which stem cell      were genetically modified by ex vivo introduction of      corrective genes and then transplanted in donor dystrophic      animal models.    
      Stem cells received much attention because of their potential      use in cell-based therapies for human disease such as      leukaemia (Owonikoko et al.,      2007), Parkinsons disease (Singh et al., 2007), and neuromuscular      disorders (Endo, 2007;      Nowak and Davies, 2004).      The main advantage of stem cells rather than the other cells      of the body is that they can replenish their numbers for long      periods through cell division and, they can produce a progeny      that can differentiate into multiple cell lineages with      specific functions (Bertoni,      2008). The candidate stem cell had to be easy to extract,      maintaining the capacity of myogenic conversion when      transplanted into the host muscle and also the survival and      the subsequent migration from the site of injection to the      compromise muscles of the body (Price et al., 2007). With the advent of more      sensitive markers, stem cell populations suitable for      clinical experiments were found to derive from multiple      region of the body at various stage of development. Numerous      studies showed that the regenerative capacity of stem cells      resided in the environmental microniche and its regulation.      This way, it could be important to better elucidate the      molecular composition  cytokines, growth factors, cell      adhesion molecules and extracellular matrix molecules - and      interactions of the different microniches that regulate stem      cell development (Stocum,      2001).    
      Several groups published different works concerning adult      stem cells such as muscle-derived stem cells (Qu-Petersen et al., 2002),      mesoangioblasts (Cossu and      Bianco, 2003), blood- (Gavina et al., 2006) and muscle (Benchaouir et al., 2007)-derived      CD133+ stem cells. Although some of them are able to migrate      through the vasculature (Benchaouir et al., 2007; Galvez et al., 2006; Gavina et al., 2006) and efforts were      done to increase their migratory ability (Lafreniere et al., 2006; Torrente et al., 2003a), poor      results were obtained.    
      Embryonic and adult stem cells differ significantly in regard      to their differentiation potential and in vitro expansion      capability. While adult stem cells constitute a reservoir for      tissue regeneration throughout the adult life, they are      tissue-specific and possess limited capacity to be expanded      ex vivo. Embryonic Stem (ES) cells are derived from the inner      cell mass of blastocyst embryos and, by definition, are      capable of unlimited in vitro self-renewal and have the      ability to differentiate into any cell type of the body      (Darabi et al., 2008b).      ES cells, together with recently identified iPS cells, are      now broadly and extensively studied for their applications in      clinical studies.    
      Embryonic stem cells are pluripotent cells derived from the      early embryo that are characterized by the ability to      proliferate over prolonged periods of culture remaining      undifferentiated and maintaining a stable karyotype (Amit and Itskovitz-Eldor, 2002;      Carpenter et al., 2003;      Hoffman and Carpenter,      2005). They are capable of differentiating into cells      present in all 3 embryonic germ layers, namely ectoderm,      mesoderm, and endoderm, and are characterized by      self-renewal, immortality, and pluripotency (Strulovici et al., 2007).    
        hESCs are derived by microsurgical removal of cells from        the inner cell mass of a blastocyst stage embryo (Fig. 1). The ES cells can be also        obtained from single blastomeres. This technique creates ES        cells from a single blastomere directly removed from the        embryo bypassing the ethical issue of embryo destruction        (Klimanskaya et al.,        2006). Although maintaining the viability of the        embryo, it has to be determined whether embryonic stem cell        lines derived from a single blastomere that does not        compromise the embryo can be considered for clinical        studies. Cell Nuclear Transfer (SCNT): Nuclear transfer,        also referred to as nuclear cloning, denotes the        introduction of a nucleus from an adult donor cell into an        enucleated oocyte to generate a cloned embryo (Wilmut et al., 2002).      
            ESCs differentiation. Differentiation potentiality of            human embryonic stem cell lines. Human embryonic stem            cell pluripotency is evaluated by the ability of the            cells to differentiate into different cell types.          
See more here:
Stem Cell Therapy for Neuromuscular Diseases | InTechOpen