Stem Cell Therapy In Neurological Disorders 1

Stem Cell Therapy In

Neurological Disorders
Fourth Edition
Stem Cell Therapy In Neurological Disorders 2
Stem Cell Therapy In Neurological Disorders 3

Stem Cell Therapy

In Neurological Disorders
4th Edition

Author :
Dr. Alok Sharma, M.S., M.Ch.
Professor of Neurosurgery & Head of Department.
LTMG Hospital & LTM Medical College, Sion, Mumbai, India
Director,
NeuroGen Brain & Spine Institute, Navi Mumbai, India
Consultant Neurosurgeon,
Fortis Hospital, Mulund, Mumbai, India

Co-Authors :
Dr. Nandini Gokulchandran, MD
Head- Medical Services & Clinical Research
NeuroGen Brain & Spine Institute, Navi Mumbai, India

Dr. Hemangi Sane, MD (Internal Medicine, USA)

Deputy Director & Head of the Research and Development
Consultant Physician
NeuroGen Brain & Spine Institute, Navi Mumbai, India

Dr. Prerna Badhe, MD

Deputy Director & Consultant Neuropathologist
NeuroGen Brain & Spine Institute, Navi Mumbai, India

Scientic and Research Coordinators :

Ms. Pooja Kulkarni, M.Sc. (Biotechnology)
Chief Research Ofcer
Stem Cell Therapy In Neurological Disorders 4

Stem Cell Therapy in

Neurological Disorders
4th Edition
© 2018 by NeuroGen Brain and Spine Institute

All rights reserved.

This book is protected by copyright. No part of this book may be reproduced

in any form by any means, including photocopying, or utilized by any
information storage and retrieval system without written permission from
the copyright owner, except for the brief quotations embodied in critical
articles and reviews.

This book is basically a compilation of information / literature on the

available on the topic, from various sources (which have been acknowledged
duly). However, this is by no means an exhaustive resource, since the eld is
evolving at a very rapid pace. Every effort is made to ensure accuracy of
material, but the publisher, printer and author will not be held responsible for
any inadvertent error(s).

Published by
NeuroGen Brain & Spine Institute

Cover Page by
Satish Narayan
Pooja Kulkarni

Printed by
Surekha Press,
A-20, Shalimar Industrial Estate,
Matunga Labour Camp, Mumbai 400 019.
Tel. : 2409 3877, 2404 3877
Stem Cell Therapy In Neurological Disorders 5

Grateful Acknowledgments
Dr. V. C. Jacob, Dr. Joji Joseph, Dr. Hema Biju, Mrs. Vibhuti Bhatt, Dr. Monali
Dhanrale, Dr. Hema Sriram, Dr. Khushboo Bhagwanani, Dr. Amruta Paranjape, Dr.
Dhara Mehta, Dr. Shruti Shirke, Dr. Jasbinder Saini, Dr. Vivek Nair, Dr. Rohit Das,
Dr. Jidnyasa Koli, Dr. Sanket Inamdar, Dr. Niranjana Kophrekar, Dr. Sonali Parmar,
Dr. Naushin, Dr. Bhamini Waghela, Mr. Vishal Ganar, Ms. Ridhima Sharma, Ms.
Sukaina Lokhandwala, Ms. Smruthi Murali, Ms. Ashly Joseph, Ms. Sonali
Nalawade, Ms. Zainab Ansari Mr. John Julius, Dr. Snehal Sontate, Dr. Sushil
Kasekar,Dr. Reena Jain, Dr. Kirti Lad, Dr. Abhishek Gupta, Dr. Shailesh Patil, Dr.
Shruti Pasi, Dr. Lata Thakur, Dr. Amol Salagre, Dr. Ajaz Khan, Dr. Ritu Vargese, Mr.
Samson Nivins, Ms. Alitta Jose, Dr. Priyadarshini GR, Ms. Nupur Jha, Ms. Shreya
Madali, Ms. Monica Chugh, Ms. Monica Vacchani, Mrs. Hridhika Rajesh, Ms.
Larissa Monteiro, Ms. Sharon Kinkar, Dr. Arushi Bhaumik, Dr. Ummeammara R
K,Mr. Aditya Nagaraja, Dr. Rajendra, Dr. Anup, Mr. Brain Pinto, Mr. Mandar
Thakur, Ms. Monica Vachhani, Ms. Sucheta, Mrs. Geeta Arora, Mrs. Kanchan Patil,
Mr. Kiran Pawar, Mr. Rajendra Patole, Mrs. Manjula Shete, Mrs. Daisy Devassy,Mr.
Sumedh Kedare, Mrs. Yasmeen Shaikh, Mr. Dinesh Desalae, Mr. Abhishek Patil,
Mrs. Mani Nair, Mrs. Chandra Bhatt , Mr. Udaykant Mishra, Ms. Anjali Avalusa,
Mrs. Amruta Kadam, Mr. Satish Pol, Mr. Roshan Salanki, Mr. Vikram Chikne,Ms.
Bhargavi Mamidi, Ms. Minal Vedante, Ms. Jigyasa Chabbria,Ms. Namrata Katke,
Mr. Roshan Solanki, Mr. Savio Agviour, Mr. Rohit Padale, Mr. Kevin More, Ms.
Sneha Khopkar, Mr. Rohan Awate, Ms. Neeta Thakur, Ms. Prajakta Bhoir, Ms.
Nanda Mane, Ms. Shweta Sathe, Mr. Satyavan More, Mr. Sachin Jamble, John Julius
Chettiar,Vikram Musale, Anup Mallick, Mr. Satish
Stem Cell Therapy In Neurological Disorders 6

This Book is Dedicated to all our Patients

 7

A Prayer

From inability to let well alone; from too much zeal for the
new and contempt for what is old; from putting knowledge
before wisdom, science before art, and cleverness before
common sense, from treating patients as cases, and from
making the cure of the disease more grievous than the
endurance of the same, Good Lord, deliver us.

– Sir Robert Hutchison

(British Medical Journal, 1953; 1: 671.)

 8

“This is the true joy in life, the being used for a purpose recognized
by yourself as a mighty one. The being a force of nature rather
than a selsh feverish little clod of aliments and grievances
complaining that the world will not devote itself to making you
happy. I am of the opinion that my life belongs to the whole
community and as long as I live its my privilege to do for it
whatever I can. I want to be thoroughly used up when I die for the
harder I work the more I live. I rejoice in life for its own sake. Life is
no brief candle to me but a splendid torch that I have got hold of for
the moment and I want to make it burn as brightly as possible
before handing it over to future generations.”

– George Bernard Shaw

Stem Cell Therapy In Neurological Disorders 9

PREFACE
"Stem cell Therapy - An idea whose time has come”
There are times in human history when quantum leaps occur in our thinking and
approach to the various issues that confront us as a race. The discovery of electricity, the
combustion engine, the telephone, the microchip and the internet being amongst a few of
these. In the world of medicine, such landmarks have been the discovery of microbes as
the source of infections, the discovery of x-rays, vaccines and antibiotics etc. The last
decade has seen the evolution of another such landmark. This is the eld of regenerative
medicine where healthy tissues could be used to replace damaged tissues, to help get
relief from various so called incurable conditions.
Whilst this has opened up an entire new world of newer treatments for conditions
for which there was earlier no hope, it has also unfortunately resulted in a storm of ethical
debates that have more to do with religion, politics and personal beliefs than with science.
So whereas on one hand there are millions of suffering patients who could possibly
benet from these treatments, there are also hundreds of people and organizations who
are opposed to these on various grounds, from their not being enough evidence for use of
them as a treatment form, to those that believe that use of cellular therapy is unacceptable
on religious, political and ethical grounds. The unfortunate part of this ethical debate is
that whilst the main objections and problems are regarding the use of embryonic stem
cells, these have resulted in the lack of acceptance and misunderstanding of other non
embryonic stem cells such as adult stem cells that have similar properties but are not of
embryonic origin. Its time that the medical community, activists and patients recognized
that stem cells are not one common entity but that stem cells come from different sources
and the objections to the use of one source need not come in the way of the use of others.
Another important facet of the debate on the use of stem cells is based on the
principles and practice of "evidence based medicine". Whereas there is no denying the
fact that evidence based medicine is the bedrock on which more recent practices are
based, it is also a fact that the principles of evidence based medicine, as we now practice
are a creation and evolution of the past few decades. The notion of evidence based
medicine did not exist from the 1800's to the 1970's, a period in which almost all of the
modern aspects of medicine we now practice were discovered. In fact, it would not be an
exaggeration to say that none of the discoveries and innovations of medicine in the 20th
century would have happened if the present day yardsticks of evidence based medicine
had been in place then. A realization that the systems we created to protect ourselves
from the exploitation of commercial agencies is now hampering the very growth and
development of medicine has led to us now turning to the concept of "practice based
evidence". Clinical trials are expensive. Geron spent US$ 56 million before it could
embark on its historic embryonic stem cell study this year. Outside of the pharmaceutical
and biotechnology companies these sort of resources are almost unavailable. It is time,
therefore, that we relooked at "evidence based medicine" and turned to "practice based
evidence" so that the individual practitioner of medicine could be a part of the newer
developments and evaluation of the systems of medicine. Ninety percent of current
Stem Cell Therapy In Neurological Disorders 10

neurosurgical practice is not supported by prospective randomized double blind clinical

trials. The same is true for many other surgical branches too. Progress in medicine has
come when individual physicians pioneered newer form of therapy that they believed in.
Day to day decisions made in clinical practice specially in intensive care setups and
operating rooms are made empirically based on the treating physicians experiences and
approach and the clinical circumstances at hand. Life is not a randomized trial and all
decisions in medicine cannot be based on randomized clinical trials. Evidence generated
from the individual physicians practice needs to be respected too. Thus "practice based
evidence" needs to looked at in a way similar to "evidence based medicine."
Nowhere is this more applicable than in the eld of stem cell therapy. Despite the
above, caution needs to be exercised in the practise of this therapy since neither the
enthusiasm of the medical practitioner, nor the pressure from the patient community and
emotional aspects of suffering are enough reasons to overlook the safety aspects of any
new medical therapy. However, once safety is established it would further the cause of
medicine as a whole, as well as the well being of the patient community, if more
practitioners participated in these treatments. This would not only make more data
available regarding safety and efcacy, but also by balancing out the supply demand
imbalance, make such treatments more available and affordable.
There is a very thin line that separates "helping someone" and "taking advantage
of someone's helplessness". It is important that we never cross this line. There are two
sides to the ethical debate on basing our treatment options on evidence based medicine.
[1] One side of the debate is " Is it ethical for doctors to offer to patients treatment options
that have not become a standard of care as yet?." [2] The other side of the debate is "Is it
ethical to deny patients suffering from disabling diseases, treatments options that are safe
and available, whilst we wait many years for the results of multicentric international trial
to prove that these treatments work ?" Both these questions are answered differently by
different people depending on what is at stake for them.
Another question that remains unanswered is when does a treatment that is
"unproven or experimental" become a treatment that is "proven or established". How
many publications documenting safety and efcacy will it take to make that shift ? Is a
single publication enough, or are 10, 50 or 100 ok, or are multicentric international trials
the only basis to make any treatment option an excepted form of treatment. Is it necessary
to go on reinventing the wheel just to satisfy our intellectual considerations whilst
millions of patients continue to suffer? Our own belief is, that based on the already
published work and our own clinical experience, this form of treatment is no more
experimental since the safety and efcacy of stem cell treatment in many of the
neurological disorders has been established and documented in several published
articles from several countries. However getting a consensus on these issues is not easy.
The role of regulatory bodies in this eld also needs to be relooked. Whereas there is no
denying the importance of regulation in all aspects of medical care and research, it is also
important for the regulatory bodies all over the world to ensure that regulations do not
hinder or slow down the evolution of newer forms of treatment. They also need to realize
that in this eld that is evolving at a breathtaking speed, regulations made several years
Stem Cell Therapy In Neurological Disorders 11

ago may no longer be valid in the present. That the regulations need to be modied as
more evidence pours in from all over the world. That the regulations need to adapt and
evolve as the research and clinical results are evolving. That individual doctors, medical
institutions and medical associations need to trusted and given the responsibility to both
develop and implement these newer forms of therapy as well as monitor and prevent its
misuse.
Stem cell therapy is a new paradigm in medicine since never before in the history
of modern medicine have we had the capability to repair and replace damaged tissue.
This is an opportunity of epic proportions. As we have a greater aging population
worldwide which is likely to be affected by many of the degenerative processes that stem
cells can help with, the possible benets to humanity as a whole are unprecedented. This
is too important a work to let social activists, politicians, bureaucrats and regulatory
bodies hinder or hijack its progress. This is science and medicine at its very best (and
maybe even its very worst) and decisions regarding its potential uses and benets and
precautions to prevent its misuse must remain in the hands of scientists and medical
doctors. We need to take responsibility for what we are doing and for what is possible
always keeping patient safety and benets in mind. We need to take a stand on what we
believe is the right thing to do. We must respect different points of view and at times agree
to disagree. But we must keep moving ahead. 400 years ago when Galileo rst observed
that the planets including the earth moved around the sun, he was forced to recant or
withdraw his observations under pressure form the church. Will we let history repeat
itself in the 21st century? Will we let religious and political beliefs and various regulators
stop or slow down a science that can possibly help millions of suffering people. The
choice is ours.
This book attempts to put together information to help answer some of these
difcult issues and questions. Whereas there exists a wealth of published information on
the basic science work and animal experimental work to show the efcacy of stem cells in
neurological disorders, in this book we focus on trials and clinical treatments done in
human patients. The book has been created for those medical practitioners, who are keen
to start using stem cell therapy for their patients with incurable neurological disorders, to
understand some of the fundamental principles as well as practical aspects that are
involved in this line of therapy as well as get informed about all the current clinical data
from all over the world that is already published. Our own clinical experiences and
techniques have also been incorporated. We believe that this therapy should be available
conveniently in all the cities and towns at an affordable cost. This will not only make a big
difference to the lives of millions of patients suffering from incurable neurological
disorders, but will also further the cause of medicine and science. This book we hope is
one small step in that direction. Yes we believe that "Stem cell therapy is an idea whose
time has come."
Dr. Alok Sharma
Stem Cell Therapy In Neurological Disorders 12

Preface to the Second Edition

“Two sides of the Coin”
Its 3 years since we wrote the preface to the rst edition of this book. Whilst on one
hand there has been a huge increase in the number of scientic papers published since
then and many patients have safely received stem cell therapy, on the other hand not
much change has happened on the regulatory front in most countries. Exceptions to these
have been Japan and some of the South American countries. We need to ask of ourselves
that had the regulations been more accommodating of stem cell therapy as an accepted
form of treatment then over these last few years :- How many lives could have been
saved? How much patient suffering and disability would have been reduced? How much
pressure would have eased on the hospitals, support services and families?
In no other eld of medicine have regulations so much slowed down the
development of the eld as in Stem Cell Therapy. The genesis of this goes back to the ban
President George Bush placed on the federal funding of embryonic stem cells lines
developed after 2001. (This ban has subsequently been lifted by President Obama).
Whereas regulatory bodies are just doing their job in having stringent standards to
ensure patient safety, we believe there are two sides to this issue. The other side is that
many patients are being deprived of treatments that could potentially save their lives or
help reduce their suffering. In strictly adhering to the letter of the regulations are we
compromising on the spirit of the regulations? Are the regulations now doing more harm
than good by limiting the availability of treatments to patients ? It would not be an
exaggeration to state that there are thousands of patients who are dying today or
suffering from serious disability whose lives could be save or whose suffering could be
reduced from available treatments had the regulations been more accommodating
worldwide. Is sticking to strict regulation worth these lives lost or suffering incurred?
These are difcult and uncomfortable questions to answer but its time regulatory bodies
came to terms with these and then took a more humane approach.
To look at the other side we believe that regulatory bodies need to make the
following distinctions in creating future guidelines. To explain this we quote from the
International Society for Cellular Therapy (ICST) "White paper" published in 2010 in
Cytotherapy [1] Distinction between Experimental therapies and medical innovation:-
The White paper states:- "It is important to recognize the difference between clinical trials
of experimental treatments and medical invocation. Medical innovation in cellular
therapy may be viewed as ethical and legitimate use of non-approved cell therapy by
qualied healthcare professionals in their practice of medicine . Patients not eligible for
controlled clinical trials should be able to choose unproven but scientically validated
cell therapy medical innovations, if the researchers are competent and those
seeking treatment are truthfully and ethically informed. There is a place for both
paradigms in the cell therapy global community. “We wish to emphasize this last
sentence that - there is place for both paradigms in the cell therapy global
community.
Stem Cell Therapy In Neurological Disorders 13

[2] Distinctions Between Different types of centers doing this work:- The
ICST White paper states centers doing this work should be dened and
differentiated as follows:- "[a] approved/standard therapies (e.g hematopoietic
stem cell transplant and other cellular therapies approved for marketing)[b]
Controlled clinical trials [c] Valid compassionate use of unapproved therapies [d]
Treatments not subject to independent scientic and ethical review" We wish to
emphasize that is a need to have centers practicing - valid compassionate use of
unapproved therapies. Therefore regulations should be different for each of these
categories. According to us those falling in category [c] would be those who work in
accordance with the Helsinki declaration of the World Medical Association which
states '"In the treatment of an individual patient, where proven interventions do not
exist or have been ineffective, the physician, after seeking expert advice, with
informed consent from the patient or a legally authorized representative, may use
an unproven intervention if in the physician's judgment it offers hope of saving life,
re-establishing health or alleviating suffering. Where possible, this intervention
should subsequently be made the object of research, designed to evaluate its safety
and efcacy. In all cases, new information should be recorded and, where
appropriate, made publicly available.
“Another Distinction that also needs to be made is between the 3 broadly
different types of stem cells ( embryonic, umbilical cord derived , adult) and
between autologous and allogenic:- If one were to give an example from daily life
then Embryonic stem cells could be compared to Alcohol, Umbilical cord stem cells
to Cold drinks like Pepsi, Coke and Adult autologous stem cells to Homemade Fruit
juice. Whereas alcohol is potentially dangerous and there should denitely be tight
regulations so also embryonic stem cell work should be tightly regulated. Cold
drinks may not be dangerous but can be harmful so there should be quality checks
in place, so also for umbilical cord cells there should be quality checks in place and
these types of cells should be treated like drugs / medicines and the same
regulations and quality control systems should be in place for them. However there
is no need for any strict regulations for home made orange juice and so autologous
adult cells should be freed up from regulations and their availability in fact
encouraged since they are completely safe and have shown clinical benets in many
conditions in various published scientic papers.
We also believe that the centers / practitioners working with the following
principles should be looked upon in a more permissive manner :- [a] Those who
strictly treat patients in accordance with the Helsinki Declaration. That means they
do not treat patients where other more established treatment forms are available
and the patients have not already taken them. [b] The medical practitioners
practicing this are working within the general broad specialty of their qualications
and are dealing with diseases anatomically and physiologically that concern their
broad specialty and that they have received specialized training in cell therapy or
Stem Cell Therapy In Neurological Disorders 14

done some basic research work in their elds.[c] Whilst doing this treatment they
are also making this an object of their research and evaluating its safety and
efcacy.[d] They are publishing the results and outcomes of their clinical work,
including their negative results and complications if any.[e] They are taking special
informed consent [f] There is a honesty and transparency to their work as shown by
the fact that their clinical results are in the public domain and they present their
results in national and international scientic conferences.[g] They have
Institutional Committees that monitor the ethical, scientic and medical aspects of
the work.[h] That quality standards are maintained that is they have GMP facilities,
follow GCP standards &/or have other accreditations such as NABH/JCI/ISO etc.
With the above principles in place we shall be able to simultaneously ensure
that patients with serious illnesses get the benet of available stem cell treatments
and an adequate check is kept on medical practices in this eld to ensure the safety
of patients. In the last Edition of this book we ended the preface with the statement
"Stem cell therapy is an idea whose time has come". Looking at the large number of
scientic publications in this eld and looking at the number of patients opting for
these treatment it looks like for the patients and some parts of the medical
community this is true. However the regulatory authorities need to catch up with
this. Regulations should not be decided by a handful of people sitting in ofces
based on their likes, dislikes , preferences and beliefs. They need to meet up and talk
with patients both those who are suffering from the serious aliments as well as those
who have taken stem cell therapy and benetted from it. They also need to evaluate
read all the available scientic literature available in this eld. They need to see
which direction the wind is blowing. They need to stop being rigid and be more
exible and open to accepting newer concepts. Whilst always ensuring that only
safe and effective treatments are offered to patients there needs to be a human and
caring side to regulations too. This will not only make a difference to the lives of
millions of patients but result in the progress and advancement of the medical
sciences too.
Dr. Alok Sharma
Stem Cell Therapy In Neurological Disorders 15

Preface to the Third Edition

The very fact that we have had to bring out a 3rd edition of this book within 6 years
of writing the rst edition is evidence of the fast moving pace of research and clinical
applications of stem cell therapy. The last two years have seen a quantum increase in the
number of publications highlighting the clinical efcacy of stem cell therapy in various
disorders. The public opinion too is changing in a major way towards making stem cell
therapy more available to the patient population. This has resulted in governments all
over the world making serious efforts to draft new regulations for stem cell therapy. The
lead in this was taken by Japan which has formulated an excellent set of regulations
which simultaneously make the more low risk types of stem cell therapy more easily
available and have stricter regulations for the high risk types of therapies. Korea is
another country which has come up with a progressive set of regulations. In India the
scenario has shifted with the Drug Controller General of India (DGCI) taking over the
regulations from the Indian council of medical research (ICMR). A key change in the
regulatory environment in the country has been the fact that unlike in the past, the
present regulators (DGCI) are far more open to considering the views of stem cell
therapists as well as patients. This progressive approach is likely to result in India coming
out with a set of regulations which might be better than that of Japan and Korea. Thus the
overall change in the public perception, medical opinion as well as regulatory bodies as
well as the large evidence that is now available in published literature has resulted in a
new found acceptance of this new form of therapy. When we wrote the rst edition of this
book we had no publications, when we wrote the 2nd edition of this book we had 28
publications and when we are now publishing our 3rd edition two year after the second
we have 41 publications. This itself tells the whole story of rapid pace at which stem cell
therapy is evolving. We believe that in another 5 years stem cell therapy will become a
standard of care for many incurable neurological conditions.

Dr. Alok Sharma

[email protected]
+919820046663
Stem Cell Therapy In Neurological Disorders 16

Preface to the Fourth Edition

When we rst wrote this book in 2010, little did we realize that within 8 years we
would be printing the 4th Edition. Whereas, lots has happened in the eld since then.
However, the availability of stem cell therapy is still limited. This has to do with the lack
of availability of progressive regulations. When we published the 1st edition we had
done 400 patients, by 4th edition we have treated 6500 patients. Yet, the service providers
in this eld remain very few. But, the last year has seen a major shift in the CDSCO and
DCG(I) playing an aggressive role. Earlier, only ICMR was involved in making stem cell
guidelines.But, since ICMR is all about research, therapy never got the importance it
deserved in the guidelines. However, now that DCG(I) is taking over, they have done
something remarkable. In the new Drugs and Cosmetics Rule, 2018, stem cells have been
divided into processed and non-processed stem cells. Processed stem cells will be
considered as a new drug and will have to undergo the regulatory pathway. While, non
processed stem cells will be free from the same. This important distinction gives freedom
to the doctors working in hospitals to offer minimally manipulated, non -processed cells
as a form of therapy without needing regulatory approval from CDSCO.
Our own clinical experience shows us if children with Autism spectrum disorder
(ASD) are treated early, they can get complete relief from the symptoms and declared free
from ASD. In Cerebral palsy, dramatic improvement is seen in body’s tightness and
functionality. In Intellectual Disability, signicant improvement is seen in cognitive
functions. In Duchenne muscular dystrophy, children who would have otherwise died in
early 20s are surviving beyond that. Patients paralysed due to spinal cord injury, brain
stroke and head injury improve in their muscle strength and movements. We have
published two landmark papers which are rst of its kind.
1. Autologous bone marrow mononuclear cell therapy for autism – an open label proof
of concept study published in Stem cell international in 2013
2. An open label proof of concept study of intrathecal Autologous Bone Marrow
Mononuclear Cells transplantation in Intellectual Disability published in Stem cell
research and therapy in 2017
Apart from these, we have published over 80 publications in peer reviewed journals, 4
chapters in international books and 14 books.
We believe that stem cell therapy for incurable neurological conditions is no more
experimental and should be made available to those who need it the most.

Dr. Alok Sharma

 17

Primum non nocere

(First do no harm)
Stem Cell Therapy In Neurological Disorders 18

The ethical basis of offering stem cell therapy as a treatment option

is based on the Paragraph no. 37 of World Medical Association
Declaration of Helsinki-Ethical Principles for Medical Research
Involving Human Subject.

WORLD MEDICAL ASSOCIATION

DECLARATION OF HELSINKI –
ETHICAL PRINCIPLES FOR
MEDICAL RESEARCH INVOLVING HUMAN
SUBJECTS
"In the treatment of an individual patient, where proven
interventions do not exist or have been ineffective, the
physician, after seeking expert advice, with informed
consent from the patient or a legally authorized
representative, may use an unproven intervention if in the
physician's judgement it offers hope of saving life, re-
establishing health or alleviating suffering. Where possible,
this intervention should subsequently be made the object of
research, designed to evaluate its safety and efcacy. In all
cases, new information should be recorded and, where
appropriate, made publicly available."
Stem Cell Therapy In Neurological Disorders 19

Contents
SECTION A: Basics and Technical Aspects
1. Introduction : Neuroregenerative and Neurorestorative Medicine.... 31-32
2. Historical Review: Evolution of Stem Cell Therapy.............................. 34-46
3. Basics of Stem Cells : Types and Sources................................................ 48-62
4. Mechanism of Action................................................................................. 64-71
5. Laboratory Aspects of Stem Cell Therapy.............................................. 73-80
6. Surgical Aspects of Stem Cell Therapy : Routes of Administration... 82-89
7. Novel Concepts and Technique of Motor Points for
Intra-Muscular Stem Cell Transplantation............................................91-100

SECTION B: Clinical Applications of Stem Cells

8. Role of Stem Cells in Autism...................................................................103-119
9. Role of Stem Cells in Cerebral Palsy.......................................................121-137
10. Role of Stem Cells in Muscular Dystrophy............................................139-158
11. Role of Stem Cells in Spinal Cord Injury................................................160-187
12. Role of Stem Cells in Stroke.................................................................... 189-205
13. Role of Stem Cells in Motor Neuron Disease /
Amyotrophic Lateral Sclerosis.............................................................. 207-225
14. Role of Stem Cells in Traumatic Brain Injury........................................ 227-237
15. Role of Stem Cells in Intellectual Disability.......................................... 239-247
16. Role of Stem Cells in Cerebellar Ataxia................................................. 248-254

SECTION C: Important Related Aspects

17. Radiological Imaging in Stem Cell Therapy......................................... 257-282
18. Importance of Rehabilitation - Concept of NRRT................................ 284-298
19. Complications.......................................................................................... 300-318
20. Regulations of stem cell therapy.............................................................320-339
21. Ethics......................................................................................................... 341-358
Stem Cell Therapy In Neurological Disorders 20

Scientic Publication on Stem Cell Therapy in

Neurological Disorders by the Authors
A) AUTISM:
1. Sharma A, et al., The baseline pattern and age related developmental
metabolic changes in the brain of children with autism as measured on positron
emission tomography/computed tomography scan. World J Nucl Med 2018;17
2. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Sarita
Kalburgi, Ridhima Sharma, Prerna Badhe, Samson Nivins. PET CT Scan Brain
As A Monitoring Tool To Study The Effects Of Autologous Bone Marrow
Mononuclear Cell Transplantation In Autism Spectrum Disorder. International
Journal of Current Advanced Research. Sep 2017
3. Alok Sharma, Nandini Gokulchandran, Pooja Kulkarni, Sarita Kalburgi, Shruti
Kamat, Riddhima Sharma, Samson Nivins, Hemangi Sane, Prerna Badhe.
"Improvements in a case of autism spectrum disorder after cell therapy as noted
on PET CT brain scan" SJSC. May 2017
4. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni,
Suhasini Pai, Vaishali Ganwir, Prerna Badhe. A case of autism showing clinical
improvements after cellular therapy along with PET CT evidence.Journal of
Stem Cell Research & Therapeutics. April 2017
5. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe, Pooja
Kulkarni and Suhasini Pai. Stem Cell Therapy in Autism Spectrum
Disorders.Recent Advances in Autism. SMGroup. 2017
6. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe,
Avantika Patil, Pooja Kulkarni, Amruta Paranjape PET- CT scan shows
decreased severity of Autism after autologous cellular therapy: A case report.
Autism Open Access 2016; 6:169.
7. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Avantika Patil,
Akshata Shetty, Hema Biju, Pooja Kulkarni, Prerna Badhe. Amelioration of
Autism by Autologous Bone Marrow Mononuclear Cells and
Neurorehabilitation: A Case Report. American Journal of Medical Case
Reports, 2015, Vol. 3, No. 10, 304-309
8. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pradnya Bhovad,
Hema Biju, Akshata Shetty, Mrudula Kali and Prerna Badhe. Cell therapy
effects portrayed on positron emission tomography computerized tomography
scan of the brain serve as a new dimension for autism: A case report (2014),
Journal of Paediatric Neurology, 12:3.
Stem Cell Therapy In Neurological Disorders 21

9. Sharma A, Gokulchandran N, Shetty A, Kulkarni P, Sane H, Badhe P.

Neuropsychiatric Disorder Tackled by Innovative Cell Therapy-A Case Report
in Autism. J Stem Cell Res Transplant. 2014;1(1): 4.
10. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Nancy
Thomas, Amruta Paranjape, Prerna Badhe. Intrathecal autologous bone
marrow mononuclear cell transplantation in a case of adult autism. Autism
open access. 2013, 3:2.
11. Alok Sharma, Nandini Gokulchandran, Akshata Shetty, Hemangi Sane, Pooja
Kulkarni and Prerna Badhe. Autologous Bone Marrow Mononuclear Cells may
be Explored as a Novel. Potential Therapeutic Option for Autism. J Clin Case
Rep 2013, 3:7.
12. Alok Sharma, Nandini Gokulchandran, Prerna Badhe, Pooja Kulkarni, Priti
Mishra, Akshata Shetty and Hemangi Sane. An Improved Case of Autism as
Revealed by PET CT Scan in Patient Transplanted with Autologous Bone
Marrow Derived Mononuclear Cells. J Stem Cell Res Ther 2013, 3:2.
13. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Anjana Nagrajan,
Amruta Paranjape, Pooja Kulkarni, Akshata Shetty, Priti Mishra, Mrudula Kali,
Hema Biju, Prerna Badhe. Autologous bone marrow mononuclear cell therapy
for autism – an open label proof of concept study. Stem cell international. 2013
(2013), Article ID 623875, 13 pages.
14. Alok Sharma, Guneet Chopra, Nandini Gokulchandran, Mamta Lohia, Pooja
Kulkarni. Autologous Bone Derived Mononuclear Transplantation in Rett
Syndrome. Asian Journal of Paediatric Practice. 2011; 15 (1): 22-24.
B) CEREBRAL PALSY:
1. Alok Sharma, Pooja Kulkarni, Ritu Varghese, Hemangi Sane, Sanket Inamdar,
Jasbinder Kaur, Samson Nivins, Nandini Gokulchandran, Prerna Badhe.
Clinical translation of the benets of cell transplantation in a case of cerebral
Palsy.International Journal of Biological and Medical Research. Jan 2018.
2. Alok Sharma, Nandini Gokulchandran, Prerna Badhe, Vaibhav Lakhanpal,
Pooja Kulkarni, Suhasini Pai, Khushboo Bhagwanani, Amruta Paranjape and
Hemangi Sane. Multidisciplinary Approach of Cellular Therapy with
Neurorehabilitation in a Case of Mixed Cerebral Palsy. World J. Biol. Med.
Science Volume 4 (3) 70-74, 2017
3. Dr. Alok Sharma, Dr. Nandini Gokulchandran, Mrs. Suhasini Pai, Ms. Pooja
Kulkarni , Dr. Hemangi Sane , Dr. Khushboo Bhagwanani ,Dr. Prerna Badhe.
Diplegic dystonic Cerebral Palsy treated with cellular therapy: a case report.
Journal- International Journal of Case Studies. 2017
Stem Cell Therapy In Neurological Disorders 22

4. Sharma A, Sane H, Kalburgi S, Kulkarni P, Bhagwanani K, et al. Autologous

Bone Marrow Mononuclear Cell Transplantation with Neurorehabilitation for
Cerebral Palsy. J Stem Trans Bio 2017; 2(1): 110
5. Alok Sharma, Hemangi Sane, Suhasini Pai, Pooja Kulkarni, Meenakshi
Raichur , Sarita Kalburgi, Sanket Inamdar, Nandini Gokulchandran, Prerna
Badhe. Intrathecal administration of autologous bone marrow mononuclear
cells in a case of Cerebral Palsy coexisting with autistic features". Phys Med
Rehabil Int. 2017; 4(1): 1110.
6. Alok Sharma, Tongchao Geng, Hemangi Sane, Pooja Kulkarni. Clinical
neurorestorative progresses in cerebral palsy. Journal of Neurorestoratology
2016:4; 1-7
7. Alok Sharma, Hemangi Sane, Pooja Kulkarni, Myola D'sa, Nandini
Gokulchandran, Prerna Badhe. Improved Quality of Life in a Case of Cerebral
Palsy after bone marrow mononuclear cell transplantation. Cell J. 2015; 17(2):
389-394.
8. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Pooja Kulkarni,
Sushant Gandhi, Jyothi Sundaram, Amruta Paranjape, Akshata Shetty,
Khushboo Bhagawanani, Hema Biju and Prerna Badhe. A clinical study of
autologous bone marrow mononuclear cells for cerebral palsy patients: a new
frontier,” Stem Cells International, Volume 2015, Article ID 905874, 11 pages.
9. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe, Pooja
Kulkarni and Amruta Paranjape. Stem Cell Therapy for Cerebral Palsy – A
Novel Option. Cerebral Palsy. Challenges for the future. 2014: 217-242.
10. Alok Sharma, Hemangi Sane, Amruta Paranjape, Nandini Gokulchandran,
Pooja Kulkarni and Anjana Nagrajan, Prerna Badhe. Positron Emission
Tomography – Computer Tomography scan used as a monitoring tool
following cellular therapy in Cerebral Palsy and Mental Retardation – A Case
Report. Case Reports in Neurological Medicine. Volume 2013, Article ID
141983, 6 pages.
11. Dr. Alok Sharma, Ms. Pooja Kulkarni, Dr. Hemangi Sane, Dr. Nandini
Gokulchandran, Dr. Prerna Badhe, Dr. Mamta Lohia, Dr. Priti Mishra. Positron
Emission Tomography- Computed Tomography scan captures the effects of
cellular therapy in a case of cerebral palsy. Journal of clinical case reports. 2012 J
Clin Case Rep 2:195.
B) MUSCULAR DYSTROPHY:
1. Alok Sharma; Hemangi Sane; Ritu Varghese; Amruta Paranjape; Samson
Nivins; Sanket Inamdar;Nandini Gokulchandran; Prerna Badhe.Potential
benets of serial cell transplantation in a case of Duchenne Muscular
Stem Cell Therapy In Neurological Disorders 23

Dystrophy. Open journal of clinical and medical case report, Vol.4, Issue 4,
2018.
2. Alok Sharma, Nandini Gokulchandran, Amruta Paranjape, Hemangi Sane, Dr.
Prerna Badhe. Stem cells as a therapeutic modality in Muscular Dystrophy.
Chapter 2. Muscular Dystrophy. Avid Sciences. India. 2017
3. Alok Sharma, Amruta Paranjape, Hemangi Sane, Nandini Gokulchandran,
Dhanashree Sawant, Shruti Shirke, Vivek Nair, Sanket Inamdar, Prerna Badhe.
Effect of Cellular Therapy in a case of Limb Girdle Muscular Dystrophy.
International Journal Of Current Medical And Pharmaceutical Research, Vol. 3,
Issue, 09, pp.2377-2381, September, 2017
4. Alok S, Amruta P, Ritu V, Hemangi S, Nandini G, et al. Functional
Improvements and Musculoskeletal Magnetic Resonance Imaging with
Spectroscopy Changes following Cell Therapy in a Case of Limb Girdle
Muscular Dystrophy. Int J cell Sci & mol biol. 2017; 2(4) : 555595.
5. Alok Sharma, Hemangi Sane, Vaibhav Lakhanpal, Amruta Paranjape, Pooja
Kulkarni, Nandini Gokulchandran, Prerna Badhe. Stabilization of the disease
progression in a case of Duchenne Muscular Dystrophy with cellular
transplantation. Stem cell: Advanced research and therapy. 2017; 2017(3)
6. Alok Sharma , Dr. Prerna Badhe, Hemangi Sane, Suhasini Pai , Pooja Kulkarni,
Khushboo Bhagwanani, Dr. Nandini Gokulchandran. Halting of functional
decline in a case of Duchenne Muscular Dystrophy after cellular therapy.
International Journal of Recent Advances in Multidisciplinary Research
(IJRAMR), 2017 Jan
7. Sharma, A., Badhe, P., Sane, H., Gokulchandran, N., & Paranjape, A. Role of
Stem Cell Therapy in Treatment of Muscular Dystrophy. Muscular dystrophy.
SMGebooks. July 2016. Dover, USA.
8. Alok Sharma, Hemangi Sane, Jasbinder Kaur, Nandini Gokulchandran,
Amruta Paranjape, Jayanti Yadav, Prerna Badhe Autologous Bone Marrow
Mononuclear Cell Transplantation Improves Function in a Case of Becker's
Muscular Dystrophy. American Based Research Journal. 2016; 5 (2)
9. Sharma A, Sane H, Gokulchandran N, Sharan, R., Paranjape, A., Kulkarni, P.,
Yadav J, Badhe, P. Effect of Cellular Therapy in Progression of Becker's
Muscular Dystrophy: A Case Study. European Journal of Translational
Myology. 2016;26(1):5522.
10. Sharma Alok, Sane Hemangi, Kulkarni Pooja, Mehta Dhara, Kaur Jasbinder,
Gokulchandran Nandini, Bhagwanani Khushboo, Badhe Prerna. Effect Of
Autologous Bone Marrow Mononuclear Cell Transplantation Coupled With
Rehabilitation In Limb Girdle Muscular Dystrophy – A Case Report. Int J Med
Stem Cell Therapy In Neurological Disorders 24

Res Health Sci. 2016, 5(12):1-7

11. Sharma A, Sane H, Gokulchandran N, Gandhi S, Bhovad P, Khopkar D,
Paranjape A, Bhagwanani K, Badhe P. The role of cell therapy in modifying the
course of limb girdle muscular dystrophy- A Longitudinal 5-year study.
Degenerative Neurological and Neuromuscular Disease 2015:5 93–102
12. Alok Sharma, Hemangi Sane, Amruta Paranjape, Khushboo Bhagwanani,
Nandini Gokulchandran, Prerna Badhe.Autologous bone marrow
mononuclear cell transplantation in Duchenne muscular dystrophy – a case
report. American journal of case reports 2014;15: 128-134.
13. Alok Sharma, Hemangi Sane, Prerna Badhe, Nandini Gokulchandran, Pooja
Kulkarni, Mamta Lohiya, Hema Biju, V.C.Jacob. A Clinical Study Shows Safety
and Efcacy of Autologous Bone Marrow Mononuclear Cell Therapy to
Improve Quality Of Life in Muscular Dystrophy Patients. Cell Transplantation.
2013 Vol. 22, Supplement 1, pp. S127–S138.
14. Sharma A., Sane, H., Paranjape, A., Badhe, P., Gokulchandran, N., & Jacob, V.
(2013). Effect of Cellular Therapy seen on Musculoskeletal Magnetic Resonance
Imaging in a Case of Becker's Muscular Dystrophy.Journal of Case Reports,
3(2), 440-447.
15. Sharma, Alok et al. “Cellular Transplantation Alters the Disease Progression in
Becker's Muscular Dystrophy.” Case Reports in Transplantation 2013 (2013):
909328.
16. Dr. Suvarna Badhe, Ms. Pooja Kulkarni, Dr Guneet Chopra, Dr Nandini
Gokulchandran, Dr Alok Sharma Dystrophin Deletion mutation pattern and
Cardiac involvement in 46 cases of Dystrophinopathies. Asian journal of
clinical cardiology. Asian Journal of Clinical Cardiology, Vol. 15, No. 6, October
2012: 211-214.
17. Dr. A. Sharma, Ms. P. Kulkarni, Dr. G. Chopra, Dr. N. Gokulchandran, Dr. M.
Lohia, Dr. P. Badhe. Autologous Bone Marrow Derived Mononuclear Cell
Transplantation In Duchenne Muscular Dystrophy-A Case Report. Indian
journal of Clinical Practice 2012; 23 (3): 169-72.
D) SPINAL CORD INJURY:
1. Alok S, Prerna B, Suhasini, Hemangi S, Samson N, Pooja K, Amruta P, Dhara M,
Nandini G.Functional Recovery and Functional Magnetic Resonance Imaging
changes Following Cellular Therapy in a Case of Chronic Complete Spinal
Cord Injury. Curr Trends Clin Med Imaging. 2017; 1(4): 555566.
2. Alok Sharma, Hemangi Sane, Suhasini Pai, Pooja Kulkarni, Amruta Paranjape,
V C Jacob, Joji Joseph, Sanket Inamdar, Sarita Kalburgi, Nandini
Stem Cell Therapy In Neurological Disorders 25

Gokulchandran, Prerna Badhe, Samson Nivins. Functional and symptomatic

improvement after cellular therapy in a pediatric case of chronic traumatic
incomplete SCI. J Stem Cell Regen Biol 2017; 3(1): 1- 7.
3. Alok Sharma, Hemangi Sane, Dipti Khopkar, Nandini
Gokulchandran,Varghese Chako Jacob, Joji Joseph, Prerna Badhe. Functional
recovery in chronic stage of spinal cord injury by Neurorestorative Approach.
Case Reports in Surgery 2014 Volume 2014, pages 1-4
4. Alok Sharma, Hemangi Sane, Dipti Khopkar, Nandini Gokulchandran, Hema
Biju, V C Jacob, Prerna Badhe. Cellular therapy targeting Functional outcome in
a case of Cervical Spinal Cord Injury. Advances in Stem Cells 2014 (2014)
5. Sharma A, Sane H, Gokulchandran N, Kulkarni P, Thomas N, et al. (2013) Role
of Autologous Bone Marrow Mononuclear Cells in Chronic Cervical Spinal
Cord Injury-A Longterm Follow Up Study. J Neurol Disord 1: 138.
6. Sharma A, Gokulchandran N, Sane H, Badhe P, Kulkarni P, Lohia M, Nagrajan
A, Thomas N. Detailed analysis of the clinical effects of cell therapy for
thoracolumbar spinal cord injury: an original study. Journal of
Neurorestoratology. 2013; 1:13-22.
7. Alok Sharma, Prerna Badhe, Pooja Kulkarni, Nandini Gokulchandran, Guneet
Chopra, Mamta Lohia, V.C.Jacob. Autologous Bone Marrow Derived
mononuclear cells for the treatment of Spinal Cord Injury. The Journal of
Orthopaedics. 2011; 1(1): 33-36.
E) STROKE:
1. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Pooja Kulkarni,
Rishabh Sharan, Amruta Paranjape, Prerna Badhe Effect of Cellular Therapy
Monitored on Positron Emission Tomography - Computer Tomography Scan
in Chronic Hemorrhagic Stroke: A Case Report. Archiv Neurol Neurosurgery,
2016 Volume 1(1): 22-25
2. Alok Sharma, Hemangi Sane , Amruta Paranjape, Nandini Gokulchandran ,
Sushant Gandhi, Prerna Badhe. Benets of Autologous Bone Marrow
Mononuclear Cell Transplantation in Chronic Ischemic Pontine Infarct. Journal
Of Case Reports 2016;6(1):80-85
3. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Dipti Khopkar, Amruta
Paranjape, Jyothi Sundaram, Sushant Gandhi, and Prerna Badhe. Autologous
Bone Marrow Mononuclear Cells Intrathecal Transplantation in Chronic
Stroke Stroke Research and Treatment, Volume 2014, pages 1-9.
4. Alok Sharma, Hemangi Sane, Anjana Nagrajan, et al., “Autologous Bone
Marrow Mononuclear Cells in Ischemic Cerebrovascular Accident Paves Way
Stem Cell Therapy In Neurological Disorders 26

for Neurorestoration: A Case Report,” Case Reports in Medicine, vol. 2014,

Article ID 530239, 5 pages, 2014. doi:10.1155/2014/530239.
5. Dr. Alok Sharma, Dr. Hemangi Sane, Dr. Prerna Badhe, Ms. Pooja Kulkarni, Dr.
Guneet Chopra, Dr. Mamta Lohia, Dr. Nandini Gokulchandran. Autologous
Bone Marrow Stem Cell Therapy shows functional improvement in
hemorrhagic stroke- a case study. Indian Journal of Clinical Practice,
2012:23(2):100-105.
F) ALS/MND
1. Alok Sharma, Hemangi Sane, Sarita Kaliburgi, Amruta Paranjape, Nandini
gokulchandran, Prerna Badhe,“Potential Benets of Cellular Transplantation
in a Patient with Amyotrophic Lateral Sclerosis”. Current Opinions in
Neurological Science 1.2 (2017): 31-43
2. Sharma A, Sane H, Sawant D, Paranjape A, Inamdar S, Kaur J, Gokulchandran
N, Badhe P. Cellular Therapy in Amyotrophic Lateral Sclerosis: A Case Report;
International Journal of Recent Advances in Multidisciplinary Research.
2017;1(4):2605-2609
3. Hemangi Sane, Alok Sharma, Nandini Gokulchandran, Sarita Kalburgi,
Amruta Paranjape, Prerna Badhe Neurorestoration in Amyotrophic Lateral
Sclerosis - A case report. Indian Journal of Stem Cell therapy. 2016; 2(1):29-37
4. Alok K Sharma , Hemangi M Sane , Amruta A Paranjape , Nandini
Gokulchandran , Anjana Nagrajan , Myola D'sa , Prerna B Badhe. The effect of
autologous bone marrow mononuclear cell transplantation on the survival
duration in Amyotrophic Lateral Sclerosis - a retrospective controlled study.
Am J Stem Cells 2015;4(1).
5. Alok Sharma, Prerna Badhe, Omshree Shetty, Pooja Vijaygopal, Nandini
Gokulchandran, V.C. Jacob, Mamta Lohia, Hema Biju, Guneet Chopra.
Autologous bone marrow derived stem cells for motor neuron disease with
anterior horn cell involvement. Bombay hospital journal. 2011; 53(1): 71- 75.
F) MISCELLANEOUS:
1. Efcacy of Autologous Bone Marrow Derived Mononuclear Cells in the
treatment of neurodecits in Down's Syndrome: A case report. British Journal
of BioMedical Research. 2018. (In Press)
2. Alok Sharma, Nandini Gokulchandran,Hemangi Sane,Suhasini Pai , Pooja
Kulkarni, Khushboo Bhagwanani, Nayana Shet, Mr. Samson Nivins, Prerna
Badhe. Functional improvements monitored by Positron Emission
Tomography imaging after cell transplantations in severe chronic Traumatic
Brain Injury. International Journal of Surgery and Medicine. March 2018
Stem Cell Therapy In Neurological Disorders 27

3. Dr. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe, Mrs.
Suhasini Pai, Pooja Kulkarni, Jayanti Yadav, Sanket Inamdar. Cellular Therapy
for Chronic Traumatic Brachial Plexus Injury-A case report. Advanced
Biomedical Research journal. 2018;7:51
4. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Suhasini Pai, Pooja
Kulkarni, Vaishali Ganwir, Maitree Maheshwari, Ridhima Sharma, Meenakshi
Raichur, Samson Nivins, MS; Prerna Badhe. An open label proof of concept
study of intrathecal Autologous Bone Marrow Mononuclear Cells
transplantation in Intellectual Disability. Stem cell research and therapy. 2017
5. Sharma A, Gokulchandran N, Sane H, Pai S, Kulkarni P, et al. Cognitive
Changes after Cellular Therapy in a Case of Intellectual Disability. J Transplant
Stem Cel Biol. 2017;4(1): 4.
6. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe, Pooja
Kulkarni, Suhasini Pai, Ritu Varghese, Amruta Paranjape. Stem cell therapy in
pediatric neurological disabilities In Physical disabilities. Intech 2017
7. Alok Sharma, Hemangi Sane , Sarita Kalburgi , Pooja Kulkarni , Sanket
Inamdar, Khushboo Bhagwanani ,Nandini Gokulchandran , Prerna Badhe.
Autologous Bone Marrow Mononuclear Cell Transplantation for Multiple
System Atrophy type C- A Case Report. American Based Research Journal.
2016.
8. Alok Sharma Hemangi Sane Pooja Kulkarni Nandini Gokulchandran
Dhanashree Sawant Samson Nivins Prerna Badhe. Effect of Cell
Transplantation in a Chronic Case of Traumatic Brain Injury. Transplantation
Open. 2016 Volume 1(1): 22-25
9. Alok Sharma, Ziad M Al Zoubi. Rethinking on ethics and regulations in cell
therapy as part of neurorestoratology. Journal of Neurorestoratology 2016:4
1–14
10. Alok Sharma, Hemangi Sane, Pooja Kulkarni, Nandini Gokulchandran,
Prerna Badhe Cellular therapy in Neurodevelopmental disorders. Indian
Journal of Stem Cell therapy. 2016; 2(1):64-73
11. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Prerna Badhe, Amruta
Paranjape. Current global trends in regulations for stem cell therapy and the
way ahead for India. Indian Journal of Stem Cell therapy. 2016; 2(1):5-16
12. Nandini Gokulchandran, Alok Sharma , Hemangi Sane , Prerna Badhe , Pooja
Kulkarni. Stem Cell Therapy as a Treatment Modality for Neurotrauma. Indian
Journal of Stem Cell therapy. 2015; 1(1):21-26.
13. Dr. Alok K. Sharma, Dr. Hemangi Sane , Dr. Nandini Gokulchandran , Dr.
Stem Cell Therapy In Neurological Disorders 28

Amruta Paranjape , Ms. Pooja Kulkarni , Dr. Prerna Badhe. The need to review
the existing guidelines and proposed regulations for stem cell therapy in India
based on published scientic facts, patient requirements, national priorities
and global trends. Indian Journal of Stem Cell therapy. 2015; 1(1):7-20.
14. Alok Sharma, Prerna Badhe, Nandini Gokulchandran, Pooja Kulkarni,
Hemangi Sane, Mamta Lohia, Vineet Avhad. Autologous bone marrow
derived mononuclear cell therapy for vascular dementia - Case report. Journal
of stem cell research and therapy. J Stem Cell Res Ther 2:129.
15. Sharma A, Sane H, Pooja K, Akshya N, Nandini G, Akshata S. (2015) Cellular
Therapy, a Novel Treatment Option for Intellectual Disability: A Case Report. J
Clin Case Rep 5:483. doi: 10.4172/2165- 7920.1000483.
16. Alok Sharma, Hemangi Sane, Pooja Kulkarni, Jayanti Yadav, Nandini
Gokulchandran, Hema Biju, Prerna Badhe. Cell therapy attempted as a novel
approach for chronic traumatic brain injury - a pilot study. SpringerPlus (2015)
4:26.
17. Sharma A, Sane H, Paranjape A, Gokulchandran N, Takle M, et al. (2014)
Seizures as an Adverse Event of Cellular Therapy in Pediatric Neurological
Disorders and its Prevention. J Neurol Disord 2:164.
18. Alok Sharma, Hemangi Sane, Amruta Paranjape, Nandini Gokulchandran,
Hema Biju, Myola D'sa, Prerna Badhe. Cellular Transplantation May Modulate
Disease Progression In Spino-Cerebellar Ataxia – A Case Report. Indian Journal
Of Medical Research And Pharmaceutical Sciences. August 2014; 1(3).
19. Alok Sharma, Nandini Gokulchandran, Guneet Chopra, Pooja Kulkarni,
Mamta Lohia, Prerna Badhe, V.C. Jacob. Administration of autologous bone
marrow derived mononuclear cells in children with incurable neurological
disorders and injury is safe and improves their quality of life. Cell
Transplantation, 2012; 21 Supp 1: S1 – S12.
20. A. Sharma, P. Badhe, N. Gokulchandran, P. Kulkarni, V.C Jacob, M. Lohia, J.
George Joseph, H. Biju, G. Chopra. Administration of Autologous bone
marrow stem cells intrathecally in Multiple Sclerosis patients is safe and
improves their quality of life. Indian Journal of clinical Practice.
2011:21(11):622-625.
21. Sharma A, Gokulchandran N, Kulkarni P, Chopra G. Application of autologous
bone marrow stem cells in giant axonal neuropathy. Indian J Med Sci
2010;64:41-4.
22. A Sharma, P Kulkarni, N Gokulchandran, P Badhe, VC Jacob, M Lohia, J George
Joseph, H Biju, G Chopra. Adult Stem Cells for Spinal Muscular Atrophy.
Bangladesh Journal Of Neuroscience. 2009; 25(2): 104- 107.
Stem Cell Therapy In Neurological Disorders 29

SECTION A
Basics and Technical Aspects
 30

"I would go anywhere in the world

for a therapy that is safe and that
could accomplish the goal
of recovery”

– Christopher Reeve
Stem Cell Therapy In Neurological Disorders 31

Introduction : Neuroregenerative and

Neurorestorative Medicine
“The regenerative medicine revolution is upon us like iron and steel to the
industrial revolution, like the microchip to the tech revolution. Stem cells will be
the driving force of this next revolution” - Cade Hildreth
Regenerative medicine focuses on restoration, repair and replacement of damaged
tissues by a safe and effective transplantation of living cells in solitude or in
combination with specially designed materials. It has opened up new avenues of
therapeutic strategies for multiple disorders with no denitive treatment or cure
available, such as neurological disorders, diabetes, cardiovascular disorders, bone
disorders, hematopoietic disorders, cancers, hepatic, renal and dermatological
disorders. With its potential to heal and revolutionize health care, regenerative
medicine has been called the “next evolution of medical treatments”, by the US
Department of Health and Human Services.
The most powerful impact of regenerative medicine has been on treatment of
neurological disorders. Since ages it was believed that brain and spinal cord cannot
regenerate, but now the exploding eld of stem cell research has deed this belief.
The basic footprints of regenerative medicine can be traced back to the discovery of
stem cells. Stem cells can be viewed as transformers. They have the ability to create
any type of cell in the body. They are the ones who repair the daily wear and tear in
the body tissues. They have unique potential to multiply manifolds and
differentiate into any specialized tissue cells. The rst origin of embryonic stem cells
was criticized due to ethical issues and side effects of teratomas. However, this
Stem Cell Therapy In Neurological Disorders 32

triggered scientists and researchers to nd numerous other types of stem cells e.g.:
adult stem cells, umbilical cord stem cells and induced pluripotent stem cells
(iPSCs) which evade moral issues. Adult stem cells modied the views of the world
towards stem cell. These cells can be obtained from body tissues such as bone
marrow, adipose tissue, olfactory ensheathing mucosa, endometrium, peripheral
blood etc. They have been studied extensively and have shown relatively better
safety prole.
Neuroregeneration is a modern concept which uses neuroplasticity,
neurorestoration and neurogenesis to develop novel therapeutic strategies.
Neurorestoration is a subdiscipline of neuroscience which studies neural
regeneration, neural structural repair or replacement, neuroplasticity and
neuromodulation. (As dened by International Association of Neurorestoratology) The
four steps of neurorestoratology include restoration of neural structure, signal
transmission, neurorehabilitation and neurofunction. Neuroprotection also plays a
vital role in repair process of damaged nervous system. Stem cell's
neuroregenerative capacity along with endogenous neuroplasticity can make
ground breaking advancements in treatment of neurological disorders. Takahashi
and Yamanaka, Nobel prize winners, reprogrammed adult mature cells back into
pluripotent stem cells. These iPSCs are being projected to be used in personalized
medicine for neurological disorders. Currently, attempts are being made to develop
patient-specic iPSCs which are safe with genomic stability. They are being studied
to be placed into biological scaffoldings which can be transplanted in diseased
patients.
Stem cell therapy does not offer a cure as yet, but has denitely paved new ways to
treat neurological disorders such as autism, cerebral palsy, spinal cord injury, brain
stroke, muscular dystrophy, traumatic brain injury, motor neuron disease, Ataxia
etc. In neurodegenerative disorders, stem cell therapy may positively alter
(slowdown or arrest) the disease progression along with symptomatic
improvements. In neurodevelopmental or traumatic disorders, stem cell therapy
can augment the outcome of currently available standard treatments. The results of
a particular cell therapy needs to be evaluated in the light of various factors like
diagnosis, disease stage, severity, chronicity, age, gender etc. The way forward
would be to study and compare the effects of various cell related aspects for e.g.: cell
type, source, processing, dose, frequency, route of administration, etc
This book is focused on clinical application after stem cell therapy for incurable
neurological and neuromuscular disorders. It has tried to summarize the vast
information on pre clinical and clinical studies of various stem cells for neurological
disorders. It exhibits the journey of stem cells from ambiguity to hope to reality.
“Stem cell research can revolutionize medicine, more than anything since antibiotics” -
Ronald Reagan
Stem Cell Therapy In Neurological Disorders 33

Nobel Prize Winners in Stem Cell Research

2012

John B. Gurdon Shinya Yamanaka

2007 1990

Sir Martin Evans Dr. E. Thomas

Stem Cell Therapy In Neurological Disorders 34

Historical Review:
Evolution of Stem Cell Therapy
“Stem cell research can revolutionize medicine, more than anything since
antibiotics” - Ronald Reagan
The ability of animals to regenerate the lost parts is a dramatic but poorly
understood aspect of biology. The sources of new cells for these regenerative
phenomena have been sought for decades. Although humans cannot replace a
missing nger or limb, we share some of the above abilities since our bodies are
constantly regenerating blood, skin and other tissues.
In this Chapter we trace the history of stem cells from the early history almost a 100
years ago when the term was rst coined to the recent development in the last 10
years where the stem cells are being researched and used for treatment of many
diseases.This discovery raised the hope in the medical potential of regeneration as a
possible treatment for a multitude of diseases that were considered incurable. For
the rst time in human history it became possible to regenerate damaged tissue
with a new supply of healthy cells by drawing upon the unique property of stem
cells to differentiate into specialized cells.
Introduction to the Concept of Stem Cells
The origins of stem cell research lie in a desire to understand how tissues are
maintained in adult life, rather than how different cell types arise in the embryo. It
was appreciated long ago that within a given tissue there is cellular heterogeneity:
in some tissues, such as the blood, skin and intestinal epithelium, the differentiated
Stem Cell Therapy In Neurological Disorders 35

cells have a short lifespan and are unable to self-renew. This led to the concept that
such tissues are maintained by stem cells, dened as cells with extensive renewal
capacity and the ability to generate daughter cells that undergo further
differentiation. Such cells generate only the differentiated lineages appropriate for
the tissue in which they reside and are thus referred to as multi-potent or uni-
potent.
Stem cells are dened as having the capacity to both self renew and give rise to
differentiated cells. Given their proliferation and differentiation capacities, stem
cells have great potential for the development of novel cell-based therapies. In
addition, recent studies suggest that dysregulation of stem cell properties may be
the cause of certain types of cancer.
Historical Review And Evolution of Stem Cell Therapy
Due to these widespread basic and clinical implications, it is of interest to put
modern stem cell research into historical context. This time line takes you through
the roller coaster of ups and downs in the stem cell evolution .
Stem Cell Therapy In Neurological Disorders 36

What is in store for the future?

The eld of stem cell research and therapy has evolved and come a long way since
1868, when the term "stem cells" was coined. The discovery of embryonic stem cells
opened up a new era in the use of stem cells. However stem cell research got
embroiled in a controversy over the use of human embryonic stem cells for
research. This led to scientists and clinicians looking at other sources of stem cells
Stem Cell Therapy In Neurological Disorders 37

such as from the umbilical cord or from the bone as alternative sources of stem cells.
Various different kinds of stem cells are being explored for treating incurable
disorders of organs other than hematopoietic, such as, the brain, muscles, liver,
heart, etc. Much more can be expected in the years to come by.

Stem cells have now entered the era of clinical studies. Numerous clinical studies
using different types of cells and protocols are being conducted worldwide. The
adult stem cells are now at the forefront of clinical studies due to their safety and
feasibility. It is now believed that the future of healthcare and personalized
medicine lies in stem cell therapy.
Interestingly the whole global ethical debate surrounding stem cell research is very
concisely and clearly summed up in the speeches of the two presidents of the United
States of America. These have been reproduced here as a depiction of two opposite
sides of the same coin.
Stem Cell Therapy In Neurological Disorders 38

President George W. Bush's address on stem cell research

August 09, 2001

(Source: White House Press Ofce)

“All of us here today believe in the promise of modern medicine. We're hopeful about where
science may take us. And we're also here because we believe in the principles of ethical
medicine.
As we seek to improve human life, we must always preserve human dignity. And therefore,
we must prevent human cloning by stopping it before it starts.
All of us here today believe in the promise of modern medicine. We're hopeful about where
science may take us. And we're also here because we believe in the principles of ethical
medicine.
As we seek to improve human life, we must always preserve human dignity. And therefore,
we must prevent human cloning by stopping it before it starts.
Science has set before us decisions of immense consequence. We can pursue medical research
with a clear sense of moral purpose or we can travel without an ethical compass into a world
we could live to regret. Science now presses forward the issue of human cloning. How we
answer the question of human cloning will place us on one path or the other.
Human cloning is the laboratory production of individuals who are genetically identical to
another human being. Cloning is achieved by putting the genetic material from a donor into
a woman's egg, which has had its nucleus removed. As a result, the new or cloned embryo is
an identical copy of only the donor. Human cloning has moved from science ction into
science.
One biotech company has already begun producing embryonic human clones for research
purposes. Chinese scientists have derived stem cells from cloned embryos created by
Stem Cell Therapy In Neurological Disorders 39

combining human DNA and rabbit eggs. Others have announced plans to produce cloned
children, despite the fact that laboratory cloning of animals has lead to spontaneous
abortions and terrible, terrible abnormalities.
Human cloning is deeply troubling to me, and to most Americans. Life is a creation, not a
commodity. Our children are gifts to be loved and protected, not products to be designed and
manufactured. Allowing cloning would be taking a signicant step toward a society in
which human beings are grown for spare body parts, and children are engineered to custom
specications; and that's not acceptable.
In the current debate over human cloning, two terms are being used: reproductive cloning
and research cloning. Reproductive cloning involves creating a cloned embryo and
implanting it into a woman with the goal of creating a child. Fortunately, nearly every
American agrees that this practice should be banned. Research cloning, on the other hand,
involves the creation of cloned human embryos, which are then destroyed to derive stem cells.
I believe all human cloning is wrong, and both forms of cloning ought to be banned, for the
following reasons. First, anything other than a total ban on human cloning would be
unethical. Research cloning would contradict the most fundamental principle of medical
ethics, that no human life should be exploited or extinguished for the benet of another.
Yet a law permitting research cloning, while forbidding the birth of a cloned child, would
require the destruction of nascent human life. Secondly, anything other than a total ban on
human cloning would be virtually impossible to enforce. Cloned human embryos created for
research would be widely available in laboratories and embryo farms. Once cloned embryos
were available, implantation would take place. Even the tightest regulations and strict
policing would not prevent or detect the birth of cloned babies.
Third, the benets of research cloning are highly speculative. Advocates of research cloning
argue that stem cells obtained from cloned embryos would be injected into a genetically
identical individual without risk of tissue rejection. But there is evidence, based on animal
studies, that cells derived from cloned embryos may indeed be rejected.
Yet even if research cloning was medically effective, every person who wanted to benet
would need an embryonic clone of his or her own, to provide the designer tissues. This would
create a massive national market for eggs and egg donors, and exploitation of women's bodies
that we cannot and must not allow.
I stand rm in my opposition to human cloning. And at the same time, we will pursue other
promising and ethical ways to relieve suffering through biotechnology. This year for the rst
time, federal dollars will go towards supporting human embryonic stem cell research
consistent with the ethical guidelines I announced last August.
The National Institutes of Health is also funding a broad range of animal and human adult
stem cell research. Adult stem cells which do not require the destruction of human embryos
and which yield tissues which can be transplanted without rejection are more versatile that
originally thought.
Stem Cell Therapy In Neurological Disorders 40

We're making progress. We're learning more about them. And therapies developed from
adult stem cells are already helping suffering people.
I support increasing the research budget of the NIH, and I ask Congress to join me in that
support. And at the same time, I strongly support a comprehensive law against all human
cloning. And I endorse the bill -- wholeheartedly endorse the bill -- sponsored by Senator
Brownback and Senator Mary Landrieu.
This carefully drafted bill would ban all human cloning in the United States, including the
cloning of embryos for research. It is nearly identical to the bipartisan legislation that last
year passed the House of Representatives by more than a 100-vote margin. It has wide
support across the political spectrum, liberals and conservatives support it, religious people
and non-religious people support it. Those who are pro-choice and those who are pro-life
support the bill.
This is a diverse coalition, united by a commitment to prevent the cloning and exploitation of
human beings. It would be a mistake for the United States Senate to allow any kind of human
cloning to come out of that chamber.
I'm an incurable optimist about the future of our country. I know we can achieve great
things. We can make the world more peaceful; we can become a more compassionate nation.
We can push the limits of medical science. I truly believe that we're going to bring hope and
healing to countless lives across the country. And as we do, I will insist that we always
maintain the highest of ethical standards.
Thank you all for coming. God bless."
Stem Cell Therapy In Neurological Disorders 41

President Obama Speech on Stem Cell Policy Change

March 9, 2009

(Source: White House Press Ofce)

"Today, with the Executive Order I am about to sign, we will bring the change that so
manyscientists and researchers; doctors and innovators; patients and loved ones have hoped
for, and fought for, these past eight years: we will lift the ban on federal funding for
promising embryonic stem cell research. We will vigorously support scientists who pursue
this research. And we will aim for America to lead the world in the discoveries it one day may
yield.
At this moment, the full promise of stem cell research remains unknown, and it should not be
overstated. But scientists believe these tiny cells may have the potential to help us
understand, and possibly cure, some of our most devastating diseases and conditions. To
regenerate a severed spinal cord and lift someone from a wheelchair. To spur insulin
production and spare a child from a lifetime of needles. To treat Parkinson's, cancer, heart
disease and others that affect millions of Americans and the people who love them.
But that potential will not reveal itself on its own. Medical miracles do not happen simply by
accident. They result from painstaking and costly research - from years of lonely trial and
error, much of which never bears fruit - and from a government willing to support that work.
From life-saving vaccines, to pioneering cancer treatments, to the sequencing of the human
genome - that is the story of scientic progress in America. When government fails to make
these investments, opportunities are missed. Promising avenues go unexplored. Some of our
best scientists leave for other countries that will sponsor their work. And those countries
may surge ahead of ours in the advances that transform our lives.
But in recent years, when it comes to stem cell research, rather than furthering discovery,
our government has forced what I believe is a false choice between sound science and moral
values. In this case, I believe the two are not inconsistent. As a person of faith, I believe we are
Stem Cell Therapy In Neurological Disorders 42

called to care for each other and work to ease human suffering. I believe we have been given
the capacityand will to pursue this research - and the humanity and conscience to do so
responsibly.
It is a difcult and delicate balance. Many thoughtful and decent people are conicted about,
or strongly oppose, this research. I understand their concerns, and we must respect their
point of view.
But after much discussion, debate and reection, the proper course has become clear. The
majority of Americans - from across the political spectrum, and of all backgrounds and
beliefs - have come to a consensus that we should pursue this research. That the potential it
offers is great, and with proper guidelines and strict oversight, the perils can be avoided.
That is a conclusion with which I agree. That is why I am signing this Executive Order, and
why I hope Congress will act on a bi-partisan basis to provide further support for this
research. We are joined today by many leaders who have reached across the aisle to champion
this cause, and I commend them for that work.
Ultimately, I cannot guarantee that we will nd the treatments and cures we seek. No
President can promise that. But I can promise that we will seek them - actively, responsibly,
and with the urgency required to make up for lost ground. Not just by opening up this new
frontier of research today, but by supporting promising research of all kinds, including
groundbreaking work to convert ordinary human cells into ones that resemble embryonic
stem cells.
I can also promise that we will never undertake this research lightly. We will support it only
when it is both scientically worthy and responsibly conducted. We will develop strict
guidelines, which we will rigorously enforce, because we cannot ever tolerate misuse or
abuse. And we will ensure that our government never opens the door to the use of cloning for
human reproduction. It is dangerous, profoundly wrong, and has no place in our society, or
any society.
This Order is an important step in advancing the cause of science in America. But let's be
clear: promoting science isn't just about providing resources - it is also about protecting free
and open inquiry. It is about letting scientists like those here today do their jobs, free from
manipulation or coercion, and listening to what they tell us, even when it's inconvenient -
especially when it's inconvenient. It is about ensuring that scientic data is never distorted
or concealed to serve a political agenda - and that we make scientic decisions based on facts,
not ideology.
By doing this, we will ensure America's continued global leadership in scientic discoveries
and technological breakthroughs. That is essential not only for our economic prosperity, but
for the progress of all humanity.
That is why today, I am also signing a Presidential Memorandum directing the head of the
White House Ofce of Science and Technology Policy to develop a strategy for restoring
scientic integrity to government decision making. To ensure that in this new
Stem Cell Therapy In Neurological Disorders 43

Administration, we base our public policies on the soundest science; that we appoint
scientic advisors based on their credentials and experience, not their politics or ideology;
and that we are open and honest with the American people about the science behind our
decisions. That is how we will harness the power of science to achieve our goals - to preserve
our environment and protect our national security; to create the jobs of the future, and live
longer, healthier lives.
As we restore our commitment to science, and resume funding for promising stem cell
research, we owe a debt of gratitude to so many tireless advocates, some of whom are with us
today, many of whom are not. Today, we honor all those whose names we don't know, who
organized, and raised awareness, and kept on ghting - even when it was too late for them, or
for the people they love. And we honor those we know, who used their inuence to help others
and bring attention to this cause - people like Christopher and Dana Reeve, who we wish
could be here to see this moment.
One of Christopher's friends recalled that he hung a sign on the wall of the exercise room
where he did his grueling regimen of physical therapy. It read: "For everyone who thought I
couldn't do it. For everyone who thought I shouldn't do it. For everyone who said, 'It's
impossible.' See you at the nish line."
Christopher once told a reporter who was interviewing him: "If you came back here in ten
years, I expect that I'd walk to the door to greet you."
Christopher did not get that chance. But if we pursue this research, maybe one day - maybe
not in our lifetime, or even in our children's lifetime - but maybe one day, others like him
might.
There is no nish line in the work of science. The race is always with us - the urgent work of
giving substance to hope and answering those many bedside prayers, of seeking a day when
words like "terminal" and "incurable" are nally retired from our vocabulary.
Today, using every resource at our disposal, with renewed determination to lead the world in
the discoveries of this new century, we rededicate ourselves to this work.
Thank you, God bless you, and may God bless America."
Stem Cell Therapy In Neurological Disorders 44

A letter written to US President Obama by a young boy suffering from Hodgkins

Lymphoma, thanking him for lifting the ban on stem cell research.
Courtesy: letterstopresidentobama.tumblr.com
Stem Cell Therapy In Neurological Disorders 45

REFERENCES
1. Ramalho-Santos M, Willenbring H. On the origin of the term “stem cell”. Cell
stem cell. 2007;1(1):35-8.
2. Boveri, T. Befruchtung. Sitzungsber. Gesellschaft . Morphologie und
Physiologie. 1892; 8:114–225
3. Martin GR. Teratocarcinomas and mammalian embryogenesis. Science.
1980;209(4458):768-76.
4. Martin GR. Isolation of a pluripotent cell line from early mouse embryos
cultured in medium conditioned by teratocarcinoma stem cells. Proceedings of
the National Academy of Sciences. 1981;78(12):7634-8.
5. Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel JJ, Marshall
VS, Jones JM. Embryonic stem cell lines derived from human blastocysts.
science. 1998;282(5391):1145-7.
6. McDonald JW, Liu XZ, Qu Y, Liu S, Mickey SK, Turetsky D, Gottlieb DI, Choi
DW. Transplanted embryonic stem cells survive, differentiate and promote
recovery in injured rat spinal cord. Nature medicine. 1999 ;5(12):1410-2.
7. Liao L, Li L, Zhao RC. Stem cell research in China. Philosophical Transactions of
the Royal Society of London B: Biological Sciences. 2007;362(1482):1107-12.
8. www.worldstemcellsummit.com/world-stem-cell-report-2010
9. David Audley. History of Stem Cells. 2009
10. www.marrow.org
11. Yamanaka S. Induced pluripotent stem cells: past, present, and future. Cell
stem cell. 2012;10(6):678-84.
12. Stem Cell Timeline. Heart Views : The Ofcial Journal of the Gulf Heart
Association. 2015;16(2):72-73.
13. Backlund EO, Granberg PO, Hamberger B, Knutsson E, Mårtensson A, Sedvall
G, Seiger Å, Olson L. Transplantation of adrenal medullary tissue to striatum in
parkinsonism: rst clinical trials. Journal of neurosurgery. 1985;62(2):169-73.
14. Kondziolka D, Wechsler L, Goldstein S, Meltzer C, Thulborn KR, Gebel J,
Jannetta P, DeCesare S, Elder EM, McGrogan M, Reitman MA. Transplantation
of cultured human neuronal cells for patients with stroke. Neurology. 2000
;55(4):565-9.
15. Huang H, Chen L, Wang H, et al. Inuence of patients' age on functional
recovery after transplantation of olfactory ensheathing cells into injured spinal
cord injury. Chinese medical journal. 2003;116(10):1488-91.
Stem Cell Therapy In Neurological Disorders 46

16. Skuk D, Roy B, Goulet M, et al. Dystrophin expression in myobers of

Duchenne muscular dystrophy patients following intramuscular injections of
normal myogenic cells. Molecular Therapy. 2004;9(3):475-82.
17. Sun L, Lee J, Fine HA. Neuronally expressed stem cell factor induces neural
stem cell migration to areas of brain injury. The Journal of clinical investigation.
2004;113(9):1364-74.
18. Payne AG. Benecial effects of subcutaneously injected human umbilical cord
stem cells on cerebral palsy and traumatic brain injury in children and a posited
mechanism. Med Hypotheses Res. 2005;2:497-501.
19. Xu J, Ji BX, Su L, Dong HQ, Sun XJ, Liu CY. Clinical outcomes after autologous
haematopoietic stem cell transplantation in patients with progressive multiple
sclerosis. Chinese medical journal. 2006;119(22):1851-5.
20. Deda H, Inci MC, Kürekçi AE, et al. Treatment of amyotrophic lateral sclerosis
patients by autologous bone marrow-derived hematopoietic stem cell
transplantation: a 1-year follow-up. Cytotherapy. 2009 ;11(1):18-25.
21. Kemp K, Mallam E, Hares K, Witherick J, Scolding N, Wilkins A. Mesenchymal
stem cells restore frataxin expression and increase hydrogen peroxide
scavenging enzymes in Friedreich ataxia broblasts. PloS one.
2011;6(10):e26098.
22. Sharma A, Gokulchandran N, Sane H, Nagrajan A, Paranjape A, Kulkarni P,
Shetty A, Mishra P, Kali M, Biju H, Badhe P. Autologous bone marrow
mononuclear cell therapy for autism: an open label proof of concept study.
Stem cells international. 2013;2013.
23. Sharma A, Sane H, Pooja K, Akshya N, Nandini G. Cellular Therapy, a Novel
Treatment Option for Intellectual Disability: A Case Report. J Clin Case Rep.
2015;5(483):2.
Stem Cell Therapy In Neurological Disorders 47

"Our enduring hope is invested in Biological research"

M. Gazi Yasargil
(Neurosurgeon of The Millenium)
Stem Cell Therapy In Neurological Disorders 48

Basics of Stem Cells: Types and

Sources
“We are not made of drugs, we are made of cells” – Cade Hildreth
The eld of stem cell therapy has advanced with time to such an extent that it has
percolated in every branch of medicine. The understanding of stem cells has been
increasing exponentially with sophisticated biotechnology and laboratory
experiments. This basic research is now translating into clinical studies in an
attempt to ameliorate various disorders. Thus understanding the basics of these
stem cells has become imperative for the medical community. Here we make an
effort to simplify the complex scientic information regarding stem cells.
The human body is intricate, with respect to its structure and function. It is made up
of diverse cell types, each with a different cytoskeleton, genetic make-up, different
cellular processes and functions. Despite of this intricacy, the origin of each of these
cells is from a pool of stem cells in the early embryo. During early development as
well as later in life, these stem cells give rise to the specialized or differentiated cells
that make up the human body. Over the past 2 decades scientists have been
constantly decoding the processes by which unspecialized stem cells become the
different types of specialized stem cells. Stem cells can regenerate themselves or
produce specialized cell types. This property of differentiation and trans-
differentiation makes them unique for constructing medical treatment that can
replace lost or damaged cells. In this chapter we will look at some of the
fundamental basic properties of Stem cells.
Stem Cell Therapy In Neurological Disorders 49

What Are Stem Cells?

A stem cell is dened by two distinct properties of self renewal and differentiation
into various cell types. These cells can divide indenitely, producing a population
of identical cells. Stem cells can, on cue, undergo differentiation by asymmetric
division to produce two different cell lines. One is identical to the parent and
continues to contribute to the original stem cell line. The other cell contains a
different set of genetic instructions and is characterized by a reduced proliferative
capacity and more restricted developmental potential than its parent. Eventually a
stem cell becomes known as a "progenitor" or "precursor" cell, committed to
producing one or a few terminally differentiated cells such as neurons, muscle cells
etc. (1)
Potency of Stem Cells:
There exists a hierarchy in the stem cell compartment, depending on their 'potency'
or fate restriction:
1) Totipotent stem cells give rise to embryonic as well as the extra embryonic
tissue. The physiological totipotent stem cell is a fertilized oocyte (zygote) or
rst blastomere which comprises of the 8 cell stage and the articial counterpart
is a clonote obtained by somatic cell nuclear transfer (SCNT) to an enucleated
oocyte.
2) Pluripotent stem cells have the capacity to give rise to cells of all the three germ
layers of the embryo which is endoderm, mesoderm and the ectoderm.
3) Multipotent stem cells give rise to cells of one of the germ cell layers only,
either ecto-, meso- or endoderm. Sources range from 8 day old embryo to adult
bone marrow.
4) Monopotent/Unipotent stem cells are tissue-committed stem cells that give
rise to cells of one lineage, e.g., hematopoietic stem cells, epidermal stem cells,
intestinal epithelium stem cells, neural stem cells, liver stem cells or skeletal
muscle stem cells. (2)
Classication of Stem Cells
Stem cells are broadly divided into embryonic origin and adult origin. We describe
them into the following groups for the better understanding with respect to clinical
application
A. Embryonic Stem Cells
B. Fetal Stem Cells
C. Umbilical Cord Stem Cells
D. Adult Stem Cells
E. Induced Pluripotent Stem Cells
Stem Cell Therapy In Neurological Disorders 50

A. Embryonic Stem cells:

Embryonic stem cells are pluripotent in nature which are derived from the inner cell
mass (ICM) of 5 to 7 day blastocyst, obtained from IVF clinics. (3) The ICM
ultimately gives rise to the three germ layers and subsequently the whole embryo.
The potential of the embryonic stem cell to form the "germ layers" & its capacity to
self renew indenitely as well as its ability to form any cell type of the body, has led
to opening up of this eld widely but has thrown up debates regarding ethics and
legalities.
Recently, hES cell lines have now been cultivated both on human feeder cells to
avoid xenogenic (8) and in the absence of feeder cells under serum-free conditions
(9) as had been previously done for mES cells. These technological advances
suggest that new hES cell lines free from potential retroviral infections will be
prepared and that these cells, might be suitable for eventual therapeutic
applications in future.

Figure 1: Development of a zygote to a Figure 2 : Mesenchymal stem cells

blastocyst (from where embryonic
stem cells are derived)
Stem Cell Therapy In Neurological Disorders 51

Figure 3 : The umbilical cord and placenta : a rich source of stem cells

B. Fetal Stem Cells:

Fetal Stem Cells (FSCs) are relatively a new addition into the community of
different sources of stem cells, exhibiting unique and fascinating features (15). FSCs
can not only be isolated from the fetal blood and hemopoietic organs in early
pregnancy, but also from a variety of somatic organs as well as amniotic uid and
placenta throughout gestation (16). They can also be extracted from extra-
embryonic sources (17). Fetal blood is a rich source of hemopoetic stem cells
(HSCs). Mesenchymal stem cells, endothelial stem cells, epithelial stem cells and
neural stem cells are other types of stem cells obtained from fetal blood (18).These
cells exhibit rapid proliferative rate as compared to those present in cord blood or
adult bone marrow. As these cells share similar growth kinetics and express
pluripotency markers, it provides us with a strong notion that these cells may be
biologically closer to embryonic stem cells. These cells represent as intermediates
between embryonic stem cells and adult stem cells, with respect to proliferation
rates and plasticity features.
C. Umbilical Cord Stem Cells
Umbilical cord blood stem cells can be obtained from the umbilical cord
immediately after birth. Like bone marrow, umbilical cord blood is another rich
source of hematopoietic stem cells. The blood remaining in the umbilical vein
following birth contains a rich source of hematopoietic stem and progenitor cells,
Stem Cell Therapy In Neurological Disorders 52

has been used successfully as an alternative allogeneic donor source to treat a

variety of genetic, hematologic, immunologic, and oncologic disorders. Fresh cord
blood is also a promising source of non-hematopoietic stem cells. Among others, it
contains endothelial cells, MSCs and unrestricted somatic stem cells (USSC). These
hematopoietic stem cells are less mature than those stem cells found in the bone
marrow of adults or children.
There have been reports that matrix cells (wharton's jelly) from the umbilical cord
also contain potentially useful stem cells. Wharton's jelly has been a source for
isolation of mesenchymal stem cells. These cells express typical stem cell markers
such as c-kit and high telomerase activity and can be induced to differentiate in vitro
into neurons.
The advantages of using cord blood as a source of stem cells are:
1. It is a non-invasive source and can be obtained from the umbilical cord
immediately after birth.
2. Available in vast abundance; thousands of babies are born each day and the
umbilical cord and placenta are discarded as waste.
3. Despite its high content of immune cells, it does not produce strong graft-
versus-host disease
4. Therefore, cord blood grafts do not need to be as rigorously matched to a
recipient as allogenic bone marrow grafts.
5. Higher proliferative capacity
However, there are a few disadvantages (20):
1. Slow engraftment
2. Limited cell dose- small volume of unit, additional cell dose unavailable
3. Autologous donation- limited benet owing to hereditary disorders
4. Storage issues - unknown length of long term storage, Cost related to long term
storage,
5. Quality control
Hence, cord blood has recently emerged as an alternative source of hematopoietic
stem cells for treatment of leukemia and other blood disorders.
All over the world, innumerable cord blood banks have been established for
storage of umbilical cord stem cells. These are generally either pure public banks or
private banks. There are certain banks which offer both types of banking (mixed
type). Umbilical cord stem cells banks also differ in the type of biological material
Stem Cell Therapy In Neurological Disorders 53

that they store. Some banks only store the cord blood (from the umbilical vein)
which predominantly carries the haematopoietic stem cells. Increasingly, banks
have started storing pieces of the placenta and cord, which are a rich source of
mesenchymal stem cells.
D. Adult Stem Cells
Adult stem cells are pluripotent, self renewing and have the ability to differentiate
into the mature cell of it resident environment and also, may have
transdifferentiating abilities. The primary role of these adult stem cells is initiation
of repair process in the organ following an injury/damage. There is practical
difculty to obtain these cells due to the following reasons:
1) Inaccessibility and small numbers (e.g. neural stem cells)
2) Lack of markers for characterization and isolation of the "stem cell population"
from various organs (21).
These cells are a preferred choice of cells as their use does not involve any ethical,
moral or legal issues as compare to the use of embryonic stem cells. However, the
debate over their pluripotency is ongoing and the concept of adult stem cell
plasticity has been extremely dynamic.
Adult stem cells have been identied in many organs and tissues, including bone
marrow, CNS, nose, peripheral blood, blood vessels, skeletal muscle, skin, teeth,
heart, gut, liver, ovarian epithelium, and testis.
Bone Marrow Derived Cells
Bone marrow is the most accessible and most studied source of adult stem cells.
Different types of stem cells have been found to be present in the bone marrow,
which differ in their potential to differentiate and form cells from one or more germ
layers.
Initially, the bone marrow was thought to contain only haematopoietic stem cells.
However, increasing evidence suggests presence of heterogenous population of
cells with varying plasticity.
Potential Pluripotent Stem Cells candidates identied in bone marrow are:
1) Mononuclear Cells:
Bone marrow mononuclear cells are a heterogeneous population that includes
hematopoietic lineage cells such as lymphocytes, monocytes, stem cells and
progenitor cells as well as mesenchymal stromal cells, along with endothelial
progenitor cells (EPCs) and very small embryonic like (VSELs) stem cells.
Mononuclear cells are isolated from human adult bone marrow, peripheral blood
and umbilical cord. This mixture of cells has shown promising therapeutic
Stem Cell Therapy In Neurological Disorders 54

potential in various neurological conditions (53).

2) Mesenchymal Stem Cells (Multipotent Mesenchymal Stromal Cells):
Human mesenchymal stem cells (MSCs) are thought to be multipotent cells that
have the potential to differentiate into multiple lineages including bone, cartilage,
muscle, tendon, ligament fat and a variety of other connective tissues. Bone
marrow-derived cells seem to retain a remarkable plasticity, since they have much
wider differentiation potential than thought previously. Marrow cells have been
reported to contribute to angiogenesis, somatic muscle development, liver
regeneration, and the formation of central nervous system cell types. It is likely that
MSC may be contaminated by other populations of primitive non-hematopoietic
stem cells. This possibility should be considered whenever a
"transdedifferentiation" of MSC into cells from other germ layers is demonstrated.
Because various inconsistencies have come to light in the eld of MSC research, the
International Society for Cellular Therapy recently recommended avoiding the
name of MSC stem cells and changing it to multipotent mesenchymal stromal cells
instead. (22)
3) Multipotent Adult Progenitor Cells (MAPC):
MAPC are isolated from BM as well from various adult organs as a population of
CD45 GPA-A- adherent cells and they display a similar broblastic morphology to
MSC. Interestingly MAPC are the only population of BM derived stem cells that
have been reported to contribute to all three germ layers after injection into a
developing blastocyst, indicating their pluripotency. (23) The contribution of
MAPC to blastocyst development, however, requires conrmation by other,
independent laboratories.
4) Marrow-isolated adult multilineage inducible (MIAMI) cells:
This population of cells were isolated from human adult BM by culturing BM MNC
in low oxygen tension conditions on bronectin. MIAMI cells were isolated from
the BM of people ranging from 3- to 72-years old. Colonies derived from MIAMI
cells expressed several markers for cells from all three germ layers, suggesting that,
at least as determined by in vitro assays, they are endowed with pluripotency.
However, these cells have not been tested so far for their ability to complete
blastocyst development. The potential relationship of these cells to MSC and
MAPC is not clear, although it is possible that these are overlapping populations of
cells identied by slightly different isolation/expansion strategies.
5) Multipotent Adult Stem Cells (MACS):
These cells express pluripotent-state-specic transcription factors (Oct-4, Nanog
and Rex1) and were cloned from human liver, heart and BM-isolated mononuclear
cells. MACS display a high telomerase activity and exhibit a wide range of
Stem Cell Therapy In Neurological Disorders 55

differentiation potential. Again the potential relationship of these cells to

MSC,MAPC and MIAMI described above is not clear, although it is possible that
these are overlapping populations of cells identied by slightly different
isolation/expansion strategies.
6) Very Small Embryonic Like (VSEL) Stem Cells:
Recently, a homogenous population of rare (~0.01% of BM MNC) Sca-1+ lin- CD45-
cells was identied in murine BM. They express (as determined by RQ-PCR and
immunhistochemistry) markers of pluripotent stem cells such as SSEA-1, Oct-4,
Nanog and Rex-1 and Rif-1 telomerase protein (24) Direct electron microscopical
analysis revealed that VSEL (2-4 µm in diameter) display several features typical for
embryonic stem cells such as i) a large nucleus surrounded by a narrow rim of
cytoplasm, and ii) open-type chromatin (euchromatin). Interestingly, these cells
despite their small size possess diploid DNA and contain numerous mitochondria.
VSEL, however, do not express MHC-1 and HLA-DR antigens and are CD90-
CD105- CD29.
2. Central Nervous system (CNS)
Adult CNS is a potential niche for isolation of neural stem cells (NSCs) Adult-
derived neural progenitor and stem cells have been transplanted in animal models,
and shown functional engraftment, supporting their potential use for therapy. (29)
Stem cell niches have now been identied in adult mammalian forebrain, a) in the
subventricular zone (SVZ), subgranular zone (SGZ) and b) dental gyrus of the
hippocampus. The most active NSC compartment is found in SVZ. Two main cell
types are found in the SVZ: migratory, proliferating neuroblasts and astrocytes.
3. Nose:
it contains cells with considerable regeneration potential, including neural cells,
progenitor/ stem cells, and olfactory ensheathing cells. OECs can promote axonal
regeneration by producing insulating myelin sheaths around growing and
damaged axons, secreting growth factors, and generating structural and matrix
macromolecules that lay the tracks for axonal elongation. (33, 34)
4. Skin :
The skin harbors a distinct population of stem cells such as melanoblasts and
epidermal Stem cells. These cells can generate both neural and mesodermal cell
types and that most of the neural cells generated by them have characteristics of
peripheral neurons and Schwann cells (35)
5. Adipose tissue :
The adipose tissue is a highly complex tissue and consists of mature adipocytes,
preadipocytes, broblasts, vascular smooth muscle cells, endothelial cells, resident
Stem Cell Therapy In Neurological Disorders 56

monocytes/macrophages and lymphocytes. Hence, this tissue compartment

provides a rich source of pluripotent adipose tissue-derived stromal cells. It has
been demonstrated that AT contains stem cells similar to BM-MSCs, which are
termed processed lipoaspirate (PLA) cells. Exhibiting a neuronal-like morphology
and expressing several proteins consistent with the neuronal phenotype.(36, 37)
6. Peripheral Nervous system (PNS):
Schwann cells are the supporting cells of the PNS. Like oligodendrocyte, Schwann
cells wrap themselves around nerve axons, but the difference is that a single
Schwann cell makes up a single segment of an axon's myelin sheath. Schwann cells
originating from dorsal and ventral roots are one of the cellular components that
migrate to the site of tissue damage after spinal cord injury. The remyelinating
capability of Schwann cells has been demonstrated in a number of studies and the
functioning status of this myelin in conduction of neural impulses has conrmed.
(38, 39).
7. Eye stem cells
Stem cells have been identied in the adult mouse eye. Single pigmented ciliary
margin cells were shown to clonally proliferate in vitro to form sphere colonies of
cells that can differentiate into retinal-specic cell types, including rod
photoreceptors, bipolar neurons and Muller glia. The adult retinal stem cells were
localized to the pigmentary ciliary margin and not to the central and peripheral
retinal pigmented epithelium. (40)
8. Dental Stem Cells:
Different types of dental stem cells have been isolated from mature and immature
teeth, dental pulp, exfoliated deciduous teeth, periodontal ligament, apical papilla
and dental follicle. Dental stem cells are rich source of mesenchymal stem cells and
neural cells. They are multipotent stem cells which are being widely explored for its
potential in treatment of neurodegenerative and ischemic diseases (54).
9. Muscular Stem Cells:
The progenitor/stem cells are also found in skeletal muscles which are also known
as satellite cells and side progenitor (SP) cells. These stem cells are involved in
repair of regular wear and tear of muscle bers. These cells help to regenerate the
damaged muscles.
E. Induced Pluripotent Stem Cells:
One of the emerging areas in laboratory investigations of stem cells is the attempt to
induce differentiated somatic stem cells into pluripotent stem cells by inducing
certain factors which will initiate cellular reprogramming (48, 49). The induced
pluripotent human stem cells have normal karyotypes, express telomerase activity,
Stem Cell Therapy In Neurological Disorders 57

express cell surface markers and genes that characterize human ES cells, and
maintain the developmental potential to differentiate into advanced derivatives of
all three primary germ layers (50). These IPSCs sidesteps the ethical issues that have
limited the use of embryonic stem cells, as they can be generated without the use of
oocytes or cell from the preimplantation embryo (51). These cells can be autologous,
thereby surmounting the problem of immune reaction. Thus, development of IPS
cell technology can add to the sources of autologous cells for transplantation
therapy (52).

Courtesy: Nsair, Ali, and W. Robb MacLellan. "Induced pluripotent stem cells for regenerative cardiovascular
therapies and biomedical discovery." Advanced drug delivery reviews 63.4 (2011): 324-330.

The progression of Adult Stem Cells to Induced Pluripotent Stem Cells (IPSCs) is
already a dynamic area of research in stem cell therapy. However, recent work has
exhibited strong evidence that the adult somatic cells can be reprogrammed into
mature neurons, without the in-between transition into IPSCs (41-43). There are
recent reports which provide us sufcient evidence that transcription-mediated
reprogramming of human broblasts into subtype specic neurons can be achieved
without undergoing the proliferative progenitor stage (44-46). In one of the studies,
the authors reported that the broblasts were reprogrammed into motor neurons,
by forced expression of select transcription factors (47).
Conclusion
Stem cells have received much attention for their potential use in cell based
therapies for various human diseases. Understanding different types of stem cells
Stem Cell Therapy In Neurological Disorders 58

and their niches is essential for future clinical applications. All the above mentioned
stem cells have distinct differential potentials which need to explored and
manipulated to optimize their therapeutic potential. Until now, adult bone
marrow stem cells have been the most studied type of cells.
REFERENCE:
1. Gerald D. Fischbach and Ruth L. Fischbach. Stem cells: science, policy, and
ethics. J Clin Invest.2004; 114(10): 1364-1370.
2. Mariusz Z. Ratajczak, Ewa K. Zuba-Surma, Marcin Wysoczynski, Wu Wan,
Janina, Ratajczak, and Magda Kucia . Hunt for Pluripotent Stem Cell -
Regenerative Medicine Search for Almighty Cell. J Autoimmun. 2008 ; 30(3):
151-162.
3. Thomson JA, Itskovitz-Eldor J, Shapiro SS et al. Embryonic stem cell line from
human blastocysts. Science 1998; 282: 1145-1147.
4. Evans MJ. The isolation and properties of a clonal tissue culture strain of
pluripotent mouse teratoma cells. J Embryol Exp Morphol 1972;28: 163-176.
5. Richards M, Fong CY, Chan WK, Wong PC, and Bongso A. Human feeders
support prolonged undifferentiated growth of human inner cell masses and
embryonic stem cells. Nat Biotechnol 2002;20: 933-936
6. Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel JJ, Marshall
VS, and Jones JM. Embryonic stem cell lines derived from human blastocysts.
Science 1998;282: 1145-1147
7. Itskovitz-Eldor J, Schuldiner M, Karsenti D, Eden A, Yanuka O, Amit M, Soreq
H, and Benvenisty N. Differentiation of human embryonic stem cells into
embryoid bodies compromising the three embryonic germ layers. Mol Med
2000;6: 88-95.
8. Richards M, Fong CY, Chan WK, Wong PC, and Bongso A. Human feeders
support prolonged undifferentiated growth of human inner cell masses and
embryonic stem cells. Nat Biotechnol 2002;20: 933-936
9. Lee JB, Lee JE, Park JH, Kim SJ, Kim MK, Roh SI, and Yoon HS. Establishment
and maintenance of human embryonic stem cell lines on human feeder cells
derived from uterine endometrium under serum-free condition. Lee JB, Lee JE,
Park JH, Kim SJ, Kim MK, Roh SI, Yoon HS. Biol Reprod. 2005;72(1):42-9
10. Eiges R, Schuldiner M, Drukker M, Yanuka O, Itskovitz-Eldor J, and
Benvenisty N. Establishment of human embryonic stem cell-transfected clones
carrying a marker for undifferentiated cells. Curr Biol 2001;11: 514-518
11. Durick K, Mendlein J, and Xanthopoulos KG. Hunting with traps: genome-
Stem Cell Therapy In Neurological Disorders 59

wide strategies for gene discovery and functional analysis. Genome Res 1999; 9:
1019-1025.
12. Davila JC, Cezar GG, Thiede M, Strom S, Miki T, and Trosko J. Use and
application of stem cells in toxicology. Toxicol Sci 2004; 79: 214-223.
13. Hochedlinger K and Jaenisch R. Nuclear transplantation, embryonic stem cells,
and the potential for cell therapy. N Engl J Med 2003; 349: 275-286.
14. Brustle O, Spiro AC, Karram K, Choudhary K, Okabe S, and McKay RD. In
vitro-generated neural precursors participate in mammalian brain
development. Proc Natl Acad Sci USA 1997; 94: 14809-14814.
15. Kalliopi I Pappa and Nicholas P Anagnou 'Novel sources of fetal stem cells:
where do they t on the development continuum?' Regen. Med. (2009) 4(3) 423-
433.
16. Pascale V. Guillot, Keelin O'Donoghue, Hitoshi Kurata, Nicholas M. Fisk' Fetal
Stem Cells: Betwixt and Between Semin Reprod Med 2006; 24(5): 340-347
17. Akiva J. Marcus, Dale Woodbury 'Fetal stem cells from extra-embryonic
tissues: do not discard' J. Cell. Mol. Med. Vol 12, No 3, 2008 pp. 730-742
18. Keelin O'Donoghue, Nicholas M. Fisk 'Fetal stem cells' Best Practice & Research
Clinical Obstetrics and GynaecologyVol. 18, No. 6, pp. 853-875, 2004
19. Alison MR, Vig P, Russo F, et al. Hepatic stem cells: From inside and outside the
liver? Cell Prolif 2004; 37: 1-21.
20. Kenneth J. Moise Jr Umbilical Cord Stem Cells (Obstet Gynecol 2005;106:1393-
1407
21. Sabine Hombach-Klonisch, Soumya Panigrahi, Iran Rashedi et al. Adult stem
cells and their trans-differentiation potential-perspectives and therapeutic
applications. J Mol Med. 2008 ; 86(12): 1301-1314
22. Cosimo De Bari, Francesco Dell'Accio, Przemyslaw Tylzanowski, and Frank P.
Luyten. Multipotent Mesenchymal Stem Cells From Adult Human Synovial
Membrane. Arthritis & rheumatism. 2001 : 44( 8), 2001, 1928-1942
23. Jiang Y, Jahagirdar BN, Reinhardt RL, Schwartz RE, Keene CD, Ortiz-Gonzalez
XR, et al. Pluripotency of mesenchymal stem cells derived from adult marrow.
Nature 2002;418:41-9.
24. Kucia M, Reca R, Campbell FR, Zuba-Surma E, Majka M, Ratajczak J, et al. A
population of very small embryonic-like (VSEL) CXCR4(+)SSEA-1(+)Oct-4+
stem cells identied in adult bone marrow. Leukemia 2006;20:857-69.
25. Alison MR, Poulsom R, Forbes S, et al. An introduction to stem cells. J Path 2002;
Stem Cell Therapy In Neurological Disorders 60

197:419-423.
26. Metsaranta M, Kujala UM, Pelliniemi L, et al. Evidence for insufcient
chondrocytic differentiation during repair of full thickness defects of
cartilage.Matrix Biol 1996; 15:39-47.
27. Nakajima H, Goto T,Horikawa O, et al. Characterization of cells in the repair
tissue of full thickness articular cartilage defects. Histochem Cell Biol 1998; 109:
331-338.
28. Blanpain C, Lowry WE, Geohegan A, et al. Self-renewal,multipotency, and the
existence of two cell populations within an epithelial stem cell niche. Cell 2004;
118:530-532.
29. Graziadei PP, Monti Graziadei GA. Neurogenesis and neuron regeneration in
the olfactory system of mammals. III. Differentiation and reinnervation of the
olfactory bulb following section of the la olfactoria in rat. J Neurocytol 1980; 9 :
145-62.
30. Lois C, Alvarez-Buylla A. Proliferating subventricular zone cells in the adult
mammalian forebrain can differentiate into neurons and glia. Proc NatlAcad
Sci USA 1993; 90: 2074-2077.
31. Syed Ameer Basha Paspala, Avvari Bhaskara Balaji, Parveen Nyamath,et al.
Neural stem cells & supporting cells - The new therapeutic tools for the
treatment of spinal cord injury. Indian J Med Res 2009; 130, 379-391.
32. Ramón-Cueto A, Nieto-Sampedro M. Regeneration into the spinal cord of
transected dorsal root axons is promoted by ensheathing glia transplants. Exp
Neurol 1994; 127 : 232-44.
33. Ramer LM, Au E, Richter MW, Liu J, Tetzlaff W, Roskams, AJ. Peripheral
olfactory ensheathing cells reduce scar and cavity formation and promote
regeneration after spinal cord injury. J Comp Neurol 2004; 473 : 1-15.
34. Saporta S, Kim JJ, Willing AE, Fu ES, Davis CD, Sanberg PR. Human umbilical
cord blood stem cells infusion in spinal cord injury: engraftment and benecial
inuence on behavior. J Hematother Stem Cell Res 2003; 12 : 271-8.
35. Zhao ZM, Li HJ, Liu HY, Lu SH, Yang RC, Zhang QJ, et al. Intraspinal
transplantation of CD34+ human umbilical cord blood cells after spinal cord
hemisection injury improves functional recovery in adult rats. Cell Transplant
2004; 13 :113-22.
36. Nurse CA , Macintyre L, Diamond J. Reinnervation of the rat touch dome
restores the Merkel cell population reduced afterdenervation. Neuroscience
1984; 13 : 563-71.
Stem Cell Therapy In Neurological Disorders 61

37. Caspar-Bauguil S, Cousin B, Galinier A, Segafredo C, Nibbelink M, André M, et

al. Adipose tissues as an ancestral immune organ: site-specic change in
obesity. FEBS Lett 2005; 579 : 3487-92.
38. Zuk PA, Zhu M, Ashjian P, De Ugarte DA, Huang JI, Mizuno H, et al. Human
adipose tissue is a source of multipotent stem cells. Mol Biol Cell 2002; 13 : 4279-
95.
39. Pennon A, Calancie B, Oudega M, Noga BR. Conduction of impulses by axons
regenerated in a Schwann cell graft in the transected adult rat thoracic spinal
cord. J Neurosci Res 2001; 64 : 533-41.
40. Zulewski H, Abraham EJ, Gerlach MJ, et al. Multipotential nestin positive stem
cells isolated from adult pancreatic islets differentiate ex vivo into pancreatic
endocrine, exocrine and hepatic phenotypes.Diabetes 2001; 50: 521-533
41. Schwarz SC, Schwarz J. Translation of stem cell therapy for neurological
diseases. Transl Res 2010; 156(3): 155-160.
42. Ambasudhan R, Talantova M, Coleman R, Yuan X, Zhu S, Lipton SA, Ding S.
Direct reprogramming of adult human broblasts to functional neurons under
dened conditions. Cell Stem Cell 2011; 9(2): 113-118.
43. Ieda M. Direct reprogramming into desired cell types by dened factors. Keio J
Med 2013; 62(3): 74-82.
44. Kim J, Efe JA, Zhu S, Talantova M, Yuan X, Wang S, Lipton SA, Zhang K, Ding S.
Direct reprogramming of mouse broblasts to neural progenitors. Proc Natl
Acad Sci U S A 2011; 108(19): 7838-7843.
45. Ring KL, Tong LM, Balestra ME, Javier R, Andrews-Zwilling Y, Li G, Walker D,
Zhang WR, Kreitzer AC, Huang Y. Direct reprogramming of mouse and
human broblasts into multipotent neural stem cells with a single factor. Cell
Stem Cell 2012; 11(1): 100-109.
46. Kim HS, Kim J, Jo Y, Jeon D, Cho YS. Direct lineage reprogramming of mouse
broblasts to functional midbrain dopaminergic neuronal progenitors. Stem
Cell Res 2014; 12(1): 60-68.
47. Son EY, Ichida JK, Wainger BJ, Toma JS, Rafuse VF, Woolf CJ, Eggan K.
Conversion of mouse and human broblasts into functional spinal motor
neurons. Cell Stem Cell 2011; 9(3): 205-218
48. Yamanaka S. Induction of pluripotent stem cells from mouse broblasts by four
transcription factors. Cell Prolif 2008; 41 Suppl 1: 51-56.
49. Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse
embryonic and adult broblast cultures by dened factors. Cell 2006; 126(4):
Stem Cell Therapy In Neurological Disorders 62

663-676.
50. Junying Yu et al. Induced Pluripotent Stem Cell Lines Derived from Human
Somatic Cells Science (2007) 318, 1917
51. Hanley J, Rastegarlari G, Nathwani AC. An introduction to induced
pluripotent stem cells. Br J Haematol 2010; 151(1): 16-24.
52. Robbins RD, Prasain N, Maier BF, Yoder MC, Mirmira RG. Inducible
pluripotent stem cells: not quite ready for prime time? Curr Opin Organ
Transplant 2010; 15(1): 61-67.
53. Glover, L., Tajiri, N., Ishikawa, H., Shinozuka, L., Kaneko, Y. et al. (2012) A
Step-up Approach for Cell Therapy in Stroke: Translational Hurdles of Bone
Marrow - Derived Stem Cells. Translational Stroke Research. 3(1), 90-98.
54. Bojic, S., Volarevic, V., Ljujuic, B., Stojkovic, M. Dental Stem Cells-
characteristics and potential. Histol. Histopathol. 2014,
Stem Cell Therapy In Neurological Disorders 63

School yourself to demureness and patience and learn to inure

yourself to drudgery in science. Perfect as the wing is of the bird,
it would never raise the bird up without resting on air. Facts are
the air of the scientist. Without them your theories are vain
efforts. By learning, experimentation and observation try not to
stay on the surface of facts. Do not become an archivists of facts.
Try to penetrate to the secret of their occurrence and persistently
search for the laws that govern them”

– Ivan Pavlov
Stem Cell Therapy In Neurological Disorders 64

Mechanism of Action
“If power is dened as the ability to do anything and create anything, then the
stem cell is the most powerful *known* life source.”
The naturally occur-
ring stem cells in the
organs constantly
repair the daily wear
and tear of tissues
through multitudes of
mechanisms. In vari-
ous disease models, the
mechanism of action of
stem cells has been
studied in great
depths. The pathways
through which they act
have also been studied
in vitro. The micro
cellular environment
plays a crucial role in deciding the fate of stem cells. Stem cells carry out the repair
process by neuromodulation, neuroprotection, axon sprouting, neural circuit
reconstruction, neurogenesis, neuroregeneration, neurorepair, neuroreplacement
and muscle regeneration. Mechanism of stem cells is divided into two categories-
Direct cell replacement and indirect repair via paracrine mechanisms.
Stem Cell Therapy In Neurological Disorders 65

1. Direct Cell Replacement:

Homing of the stem cells
Stem cells are known to migrate to injured/ damaged sites on transplantation. This
property is attributed to the expression of growth factors, chemokine and
extracellular matrix receptors on the surface of cells. Evidence also exists that both
endogenous and exogenous stem cells are able to migrate into the area of injury
from the site of injection or infusion. MSC in the bone marrow can be mobilized,
target the areas of infarction, and differentiate into target tissue type. Granulocyte
colony-stimulating factor (G-CSF) has been studied widely and promotes the
mobilization of bone marrow-derived stem cells in the setting of acute injury. (1)
This homing mechanism may also depend on expression of stromal cell-derived
factor 1 (SDF-1), monocyte chemoattractant protein-3 (MCP-3), stem cell factor
(SCF), and / or IL-8.
SDF-1 represents the major chemokine for initiating stem cell migration.78 The
majority of cytokines that mediate stem cell migration do so via modulation either
of SDF-1 or of its receptor, CXCR4. Thus the SDF-1/CXCR4 axis is central for stem
cell mobilization. Post damage/ injury, injured tissue releases SDF-1 which
stimulates the mobilization and homing of cells. These cells get recruited to the
damaged/injured tissue and carry out further repair. (2)
These cells self renew and differentiate into host cells and replace the damaged or
dead cells. Their ability to differentiate into various other cell types is known as
stem cell plasticity.
Stem Cell Plasticity
Stem cell plasticity refers to the capacity of the tissue derived stem cells to give rise
to cell types, other than that of the resident tissues. One of the mechanisms
explaining stem cell plasticity is "cell fusion". (3) An undifferentiated stem cell fuses
directly with a more differentiated cell resulting in a single cell expressing
properties of either cells. However, many reports have excluded this mechanism
as experimental studies have not shown any evidence of cell fusion. Another
mechanism justifying plasticity of stem cells is "transdifferentiation" or
"dedifferentiation" (4) wherein cells may differentiate from one cell type into
another within the same tissue or develop into a completely different tissue without
acquiring an intermediate recognizable, undifferentiated progenitor state. Also,
there is a possibility of true pluripotent stem cells existing in various tissues of the
body making it the most appealing explanation for the plasticity of stem cells.
Adult stem cells like bone marrow cells have been reported to generate a wide
spectrum of different cell types, including hepatocytes, endothelial, myocardial,
neuronal, and glial cells. In 1998, Ferrari et al. reported that mouse bone-marrow-
Stem Cell Therapy In Neurological Disorders 66

derived cells give rise to skeletal muscle cells when transplanted into damaged
mouse muscle. (5) Hematopoietic cells can differentiate into cardiac myocytes and
endothelial cells, functional hepatocytes and epithelial cells of the liver, gut, lung,
and skin. (6-12) Mesenchymal stromal cells (MSC) of the bone marrow can generate
brain astrocytes . Enriched stem cells from adult mouse skeletal muscle were shown
to produce blood. cells. (13-15) In most of these plasticity studies, genetically
marked cells from one organ of an adult mouse apparently gave rise to cell type
characteristics of other organs following transplantation, which suggest that even
cell types are plastic in their developmental potential.
A critical observation of adult stem cell plasticity is that in order for plasticity to
occur, cell injury is necessary(16), thus micro-environmental exposure to the
products of injured cells may play a key role in determining the differentiated
expression of marrow stem cells. (17)
2. The Paracrine Effect
Stem cells transplanted into injured tissue express paracrine signaling factors
including cytokines and other growth factors, which are involved in orchestrating
the stem cell-driven repair process through neuroprotection, increasing
angiogenesis, decreasing inammation, preventing apoptosis, releasing
chemotactic factors, assisting in extracellular matrix tissue remodeling and
activation of resident/satellite cells which is discussed further in details. (18)
Neuroprotection
Stem cells secrete a vast array of neuroprotective growth factors including BDNF,
nerve growth factor (NGF), neurotrophin-3 (NT-3), glial cell line-derived
neurotrophic factor (GDNF), broblast growth factor-2, and insulin-like growth
factor type 1. These growth factors activate a number of signalling pathways and
help in survival of cells. Brain-derived neurotrophic factor (BDNF) is one of the
most important growth factors. It has shown to enhance differentiation, survival of
neurons and maintain neuronal functions. (19)
Increased Angiogenesis
Stem cells produce local signaling molecules like vascular endothelial growth
factor (VEGF), hepatocyte growth factor (HGF), and basic broblast growth factor
(FGF2) that may improve perfusion and enhance angiogenesis to chronically
ischemic tissue.(20,21)
Chen et al. have recently shown that treatment with bone marrow stromal cells
enhances angiogenesis by increasing endogenous levels of VEGF and VEGFR2.(22)
They previously demonstrated that administration of recombinant human
VEGF165 to rats 48 h after stroke signicantly increased angiogenesis in the
penumbra and improved functional recovery. Hepatic Growth Factor (HGF) exerts
Stem Cell Therapy In Neurological Disorders 67

benecial effects on neovascularization and tissue remodeling, while FGF2 is

involved intimately with endothelial cell proliferation and may be a more potent
angiogenic factor than VEGF. (23)
When exposed to either insult or stress, mesenchymal stem cells (MSC) in cell
culture and in vivo signicantly increase release of VEGF, HGF, and FGF2, which
may improve regional blood ow and promote autocrine self survival. Increased
perfusion due to the production of stem cell angiogenic growth factor has also been
associated with improved end organ function. Thus, VEGF, HGF, and FGF2 may be
important paracrine signaling molecules in stem cell-mediated angiogenesis,
protection and survival. (24)
Immunomodulation
Stem cells appear to attenuate infarct size and injury by modulating local
inammation. When transplanted into injured tissue, the stem cell faces a hostile,
nutrient-decient, inammatory environment and may release substances which
limit local inammation in order to enhance its survival. Modulation of local tissue
levels of pro-inammatory cytokines by anti-inammatory paracrine factors
released by stem cells (such as IL-10 and TGF-β) is important in conferring
improved outcome after stem cell therapy. (25)
Anti-Apoptosis
Stem cells in a third pathway promote salvage of tenuous or malfunctioning cell
types at the infarct border zone. Injection of MSC into a cryo-induced infarct
reduces myocardial scar width 10 weeks later. MSCs appear to activate an anti-
apoptosis signaling system which effectively protects ischemia-threatened cell
types from apoptosis. Furthermore, expression proling of adult progenitor cells
reveals characteristic expression of genes associated with enhanced DNA repair,
upregulated anti-oxidant enzymes, and increased detoxier systems. HGF has
been observed to improve cell growth and to reduce cell apoptosis. (26)
Benecial Remodeling of the Extracellular Matrix
Stem cell transplantation alters extracellular matrix, resulting in post-infarct
remodeling, strengthening of the infarct scar, and prevention of deterioration in
organ function. MSCs improved this function by increasing the cellularity and
decreasing production of extracellular matrix proteins such as collagen type I,
collagen type III, and TIMP-1 which result in positive remodeling and function.
Activation of Neighboring Resident Stem Cells
Recent work demonstrates the existence of endogenous, stem cell-like populations
in adult hearts, liver, brain, and kidney. These resident stem cells may possess
growth factor receptors that can be activated to induce their migration and
Stem Cell Therapy In Neurological Disorders 68

proliferation and promote both the restoration of dead tissue and the improved
function in damaged tissue. Mesenchymal stem cells have also released HGF and
IGF-1 in response to injury which when transplanted into ischemic myocardial
tissue may activate subsequently the resident cardiac stem cells. (27)
To sum up, although the denitive mechanisms for protection via stem cells
remains unclear, stem cells mediate enhanced angiogenesis, suppression of
inammation, and improved function via paracrine actions on injured cells,
neighboring resident stem cells, the extracellular matrix, and the infarct zone.
Improved understanding of these paracrine mechanisms may allow earlier and
more effective clinical therapies
Remyelination
Remyelination is the phenomenon by which new myelin sheaths are generated
around axons in the adult central nervous system. Previous attempts aimed at
regenerating myelin-forming cells have been successful but limited by the
multifocal nature of the lesions and the inability to produce large numbers of
myelin- producing cells in culture. Stem cell-based therapy can overcome these
limitations to some extent and may prove useful in the future treatment of
demyelinating diseases.
Recent studies have shown that remyelination can be accomplished by supplying
demyelinated regions with cells like Schwann cells, oligodendrocyte lineage cells
lines, Olfactory ensheathing cells (OECs), embryonic stem cells and neural stem
cells , Adult bone marrow derived stem cells. The remyelinating effect of these cells
may be via one or more mechanisms, including: the stem cells act as an
immunomodulator by producing soluble factors; they carry out direct cell
replacement by differentiating into neural and glial cells in the lesion; and promote
differentiation of endogenous cells. Interactions with viable axons and supportive
astrocytic responses are required for endogenous immature cells to fulll their
potential remyelinating capacity.(28,29)
Contrary to the general expectations that stem cells would primarily contribute to
formation of tissue cells for repair, other mechanisms such as paracrine effects and
remyelinations appear to be important ways via which stem cells seem to exert their
effect. More Basic research to understand these mechanisms is underway
throughout the world.
REFERENCE
1. Haas R, Murea S. The role of granulocyte colony-stimulating factor in
mobilization and transplantation of peripheral blood progenitor and stem cells.
Cytokines Mol Ther. 1995 Dec;1(4):249-70.
2. Vagima Y, Lapid K, Kollet O, Goichberg P, Alon R, Lapidot T. Pathways
Stem Cell Therapy In Neurological Disorders 69

implicated in stem cell migration: the SDF-1/CXCR4 axis. Methods Mol Biol.
2011;750:277-89
3. Wagers AJ, Weissman IL. Plasticity of adult stem cells. Cell. 2004 Mar
5;116(5):639-48.
4. Arnaldo Rodrigues Santos Jr, Vitor Andrade Nascimento, Selma Candelária
Genari and Christiane Bertachini Lombello (2014). Mechanisms of Cell
Regeneration — From Differentiation to Maintenance of Cell Phenotype, Cells
and Biomaterials in Regenerative Medicine, Dr. Daniel Eberli (Ed.), InTech
5. Ferrari G, Cusella-De Angelis G, Coletta M, Paolucci E, Stornaiuolo A, Cossu G,
Mavilio F. Muscle regeneration by bone marrow-derived myogenic
progenitors. Science 1998;279:1528-1530.
6. Petersen BE, Bowen WC, Patrene KD, Mars WM, Sullivan AK, Murase N, Boggs
SS, Greenberger JS, Goff JP. Bone marrow as a potential source of hepatic oval
cells. Science 1999;284:1168-1170.
7. Lin Y, Weisdorf DJ, Solovey A, Hebbel RP. Origins of circulating endothelial
cells and endothelial outgrowth from blood. J Clin Invest 2000;105:71-77.
8. Orlic D, Kajstura J, Chimenti S, Limana F, Jakoniuk I, Quaini F, Nadal-Ginard B,
Bodine DM, Leri A, Anversa P. Mobilized bone marrow cells repair the
infarcted heart, improving function and survival. Proc Natl Acad Sci USA
2001;98:10344-10349.
9. Brazelton TR, Rossi FM, Keshet GI, Blau HM. From marrow to brain: expression
of neuronal phenotypes in adult mice. Science 2000;290:1775-1779.
10. Jackson KA, Majka SM, Wang H, Pocius J, Hartley CJ, Majesky MW, Entman
ML, Michael LH, Hirschi KK, Goodell MA. Regeneration of ischemic cardiac
muscle and vascular endothelium by adult stem cells. J Clin Invest
2001;107:1395-1402.
11. Lagasse E, Connors H, Al-Dhalimy M, Reitsma M, Dohse M, Osborne L, Wang
X, Finegold M,Weissman IL, Grompe M. Puried hematopoietic stem cells can
differentiate into hepatocytes in vivo. Nat Med 2000;6:1229-1234.
12. Krause DS, Theise ND, Collector MI, Henegariu O, Hwang S, Gardner R,
Neutzel S, Sharkis SJ. Multi-organ, multi-lineage engraftment by a single bone
marrow-derived stem cell. Cell 2001;105:369-377.
13. Kopen GC, Prockop DJ, Phinney DG. Marrow stromal cells migrate throughout
forebrain and cerebellum, and they differentiate into astrocytes after injection
into neonatal mouse brains. Proc Natl Acad Sci USA 1999;96:10711-10716.
14. Gussoni E, Soneoka Y, Strickland CD, Buzney EA, Khan MK, Flint AF, Kunkel
Stem Cell Therapy In Neurological Disorders 70

LM, Mulligan RC. Dystrophin expression in the mdx mouse restored by stem
cell transplantation. Nature 1999;401:390-394.
15. Pang W. Role of muscle-derived cells in hematopoietic reconstitution of
irradiated mice. Blood 2000;95:1106-1108.
16. Abedi M, Greer DA, Colvin GA, Demers DA, Dooner MS, Harpel JA, Pimentel
J, Menon MK, Quesenberry PJ. Tissue injury in marrow transdifferentiation.
Blood Cells Mol Diseases 2004;32:42-46.
17. Quesenberry PJ, Colvin G, Dooner G, Dooner M, Aliotta JM, Johnson K. The
stem cell continuum: cell cycle, injury, and phenotype lability. Ann N Y Acad
Sci 2007;1106:20-29
18. Baraniak PR, McDevitt TC. Stem cell paracrine actions and tissue regeneration.
Regen. Med.2010;5:121–143
19. Hung C-W, Liou Y-J, Lu S-W, et al. Stem Cell-Based Neuroprotective and
Neurorestorative Strategies. International Journal of Molecular Sciences.
2010;11(5):2039-2055
20. Crisostomo PR, Wang M, Herring CM, Markel TA, Meldrum KK, Lillemoe KD,
et al. Gender differences in injury induced mesenchymal stem cell apoptosis
and VEGF, TNF, IL-6 expression: Role of the 55 kDa TNF receptor (TNFR1) J
Mol Cell Cardiol. 2007;42(1):142-149.
21. Vandervelde S, van Luyn MJ, Tio RA, Harmsen MC. Signaling factors in stem
cell mediated repair of infarcted myocardium. J Mol Cell Cardiol.
2005;39(2):363-376.
22. Chen J, Zhang ZG, Li Y, Wang L, Xu YX, Gautam SC, Lu M, Zhu Z, Chopp
M.Intravenous administration of human bone marrow stromal cells induces
angiogenesis in the ischemic boundary zone after stroke in rats. Circ Res.
2003;92(6):692-9.
23. Siqueira Rubens Camargo, Voltarelli Júlio Cesar, Messias André Marcio Vieira,
Jorge Rodrigo. Possible mechanisms of retinal function recovery with the use of
cell therapy with bone marrow-derived stem cells. Arq. Bras. Oftalmol.
[Internet]. 2010 Oct [cited 2016 Dec 05] ; 73( 5 ): 474-479.
24. Gnecchi M, Zhang Z, Ni A, Dzau VJ. Paracrine mechanisms in adult stem cell
signaling and therapy. Circulation research. 2008;103(11):1204-1219.
25. Markel TA, Crisostomo PR, Wang M, Herring CM, Meldrum DR. Activation of
Individual Tumor Necrosis Factor Receptors Differentially Affects Stem Cell
Growth Factor and Cytokine Production. Am J Physiol Gastrointest Liver
Physiol. 2007; 293(4):G657-62.
Stem Cell Therapy In Neurological Disorders 71

26. Crisostomo PR, Markel TA, Wang Y, Meldrum DR. Surgically Relevant
Aspects Of Stem Cell Paracrine Effects. Surgery. 2008;143(5):577-581.
27. Wang M, Crisostomo PR, Herring C, Meldrum KK, Meldrum DR. Human
progenitor cells from bone marrow or adipose tissue produce VEGF, HGF, and
IGF-I in response to TNF by a p38 MAPK-dependent mechanism. Am J Physiol
Regul Integr Comp Physiol. 2006;291(4):R880-884.
28. Jingxian Yang, Abdolmohamad Rostami, Guang-Xian Zhang et al. Cellular
remyelinating therapy in multiple sclerosis. Journal of the Neurological
Sciences.2009 ;Vol 276(1), 1-5
29. Louis N. Manganas and Mirjana Maletic-Savatic . Stem cell therapy for central
nervous system demyelinating disease. Current Neurology and Neuroscience
Reports . 2005; 5 (3), 225-231
Stem Cell Therapy In Neurological Disorders 72

“We are what we repeatedly do.

Excellence is therefore not an act but a habit”

–Aristotle
Stem Cell Therapy In Neurological Disorders 73

Laboratory Aspects of
Stem Cell Therapy
.“This eld [stem cell research] isn’t growing, its EXPLODING.” – Barth Green
Stem cell harvesting is preliminary and important part of the whole process of stem
cell therapy. There are various methods of procuring, culturing, differentiating and
preserving. All these have specic heteregenous protocols which are followed by
different scientists. As these cells are introduced into humans for clinical
application stringent aseptic precautions are mandatory. Safety of the cells has to be
ensured before transplantation. The cells' viability also needs to be ascertained for
correlation to efcacy. The type of stem cells also needs to be conrmed by cell
markers. For all these processes Good Clinical Laboratory Practices should be
followed.
Various sources of stem cells have already been discussed in the previous chapters.
Currently, stem cells are being procured for therapeutic application primarily from
haematopoietic sources such as the bone marrow, peripheral blood and umbilical
cord and other tissues such as adipose tissue, dental pulp, muscles, etc, due to easy
accessibility and absence of ethical issues. Certain aspects of harvesting and
mobilization of these cells is being discussed in this chapter.
Basic methodology
The cells procured from any source are a heterogenous population of various
progenitor cells. The cells of interest for clinical application need to be separated
Stem Cell Therapy In Neurological Disorders 74

from this mixture. Then either they are puried and cultured before use or
introduced without culturing.
Separation of the cells can be performed based on the following properties
1. Density (and size): Density Gradient centrifugation
2. Adhesion: Adhesion to surfaces, Rosette formation
3. Surface markers: Panning, Dynal beads, magnetic activated cell sorting
(MACS), Fluorescence-activated cell sorting (FACS)
4. Lab-on-a-chip methods- Microuidics-New Label free separation methods still
in experimental stage.
However, the choice of cell separation protocol depends upon the cell source, the
characteristics of the desired cell type and its required purity.
There are a multiple methodologies available for both maintaining stem cells in an
undifferentiated state and for differentiating them into different lineages and cell
types. The culture conditions and types of media used for stem cell culture depend
on the type of stem cell to be cultured. This is an extensive subject of discussion
which is out of scope of this chapter. Therefore, we have focused only on separation
of commonly used cells.
Bone marrow derived stem cell separation
Open Method
Bone marrow (100-150 mL) is aspirated from the anterior or posterior superior iliac
spine and is collected in heparin containing tubes/ balanced salt solution such as
Hank's balanced salt solution (HBSS) at a ratio of 1:1. Sample is centrifuged at 400g
for 30 to 40 min at 18ºC to 20°C through a density gradient method using Ficoll-
Paque Premium, 1.073 g/ml; GE Healthcare. The mononuclear cell layer is
recovered from the gradient interface and washed with salt solution. The cells are
centrifuged at 400 to 500 g for 10 to 15 min at 18°C to 20°C and resuspended in 6 to 8
ml balanced salt solution and again centrifuged at 400 to 500 × g (or 60 to 100 × g for
removal of platelets) for 10 min at 18°C to 20°C.
Closed Method
Commercial platforms for harvesting bone marrow concentrates are being
engineered to facilitate harvesting in a closed system. One such system is Harvest's
BMAC™ (Bone Marrow Aspirate Concentrate) System (Harvest Technologies
Corporation, www.harvesttech.com)
A total of 240 mL of marrow aspirate was processed using the point of care
SmartPReP System (Harvest Technologies, Plymouth, MA) to yield 40 mL of
treating volume.
Stem Cell Therapy In Neurological Disorders 75

Figure 1: Aspirated bone

marrow in tubes. Each tube
contains about 20 ml bone
marrow mixed with heparin.

Figure 2: Buffy coat

containing separated fraction
of mononuclear concentrate
(arrow indicating)

Figure 3 : Puried concentrate

of mononuclear cells in
solution (heterogenous
mixture of stem cells - mainly
hematopoietic)
Stem Cell Therapy In Neurological Disorders 76

Stem cell isolation from Peripheral blood

Mobilization and harvesting of peripheral blood stem cells for Autologous
haematopoietic stem cell transplant (AHSCT):
One of the methods of collecting Hematopoietic stem cells (HSCs) is by
mobilization from the peripheral blood. Since negligible HSCs are detectable in the
peripheral blood during the steady state, administration of cytokines such as
granulocyte colony-stimulating factor (G-CSF) with or without chemotherapy is
necessary to mobilize HSCs and subsequently collect HSCs from the blood through
apheresis.
Hematopoietic Stem cell selection
Most mononuclear cells collected by peripheral blood apheresis/ leukaphereses are
immune cells such as lymphocytes and monocytes and not HSCs. Not much is
known about the phenotype or biology of peripheral blood stem cells, however,
CD34 or CD133 are predominant cell markers of hematopoietic stem cells (HSC)
and hematopoietic progenitor cells. The isolation of these cells is carried out either
via positive selection, i.e., isolation according to the marker molecules they express
or negative selection which is depletion of all other cells according to the markers
they express. Positive selection is considered to be superior to negative selection
methodology.
The selection or purication of hematopoietic cells is usually performed using
combination of cell sorting technologies such as MACS, ow cytometry and FACS.
In general, a minimum number of 2x106 CD34 cells per kilogram of recipient weight
with the viability count of 98% will ensure engraftment. (1)
Isolation of Adipocyte cells
Adipose derived stem cells are usually isolated from lipoaspirate waste from
liposuction. They are comprised of three distinct layers: 1) an upper layer of oil due
to the lysis of mature adipocytes, 2) a middle layer of adipose tissue, and 3) a
bottom, liquid infranatant containing saline and blood cells.
Standard protocol involves isolation of the cells from above 2 layers however,
recently, a rapid protocol was developed which isolates ASCs from the saline and
blood cell layer.
Standard Protocol for ASC isolation:
The standard protocol, uses enzymatic digestion and differential centrifugation.(2)
The lipoaspirate is washed using PBS until the adipose layer has a yellow/gold
color. The next step includes enzymatic digestion of the sample using collagenase.
Followed by isolation using control medium (CM), containing DMEM, fetal bovine
Stem Cell Therapy In Neurological Disorders 77

serum and antibiotics. CM is used for collagenase inactivation. The isolated ASCs
are also further cultured in CM.
The standard protocol is time consuming hence, a rapid protocol was established to
obtain viable population of ASCs in a short period of time.
Rapid protocol for ASC isolation
This protocol includes 5 simple steps. (3) First, the blood/saline phase is isolated
and cells pelleted (10 minutes). Second, the resulting pellet is gently re-suspended
in NH4Cl for red blood cell lysis (2–5 minutes). Third, the cells are pelleted again (10
minutes). Fourth, the cell pellet is gently re-suspended in DMEM with 40–50% fetal
bovine serum (FBS), followed by plating the cells (2–5 minutes) and incubation
overnight. Finally, the non-adherent cells and debris are washed away with
phosphate-buffered saline (PBS), and the ASC cultures are grown. This isolation
method not only requires less 30 mins to complete but uses only standard tissue
culture materials and equipment without the need for enzymatic digestion, Percoll
gradients, or extensive washing.
Umbilical Cord blood processing
Currently, cord blood cells are derived using two techniques viz. manual and
automated.
Manual processing involves allowing the blood to sit for a period of time and then
manually extracting cells from the middle of what has "settled" out from the cord
blood. This method was the only method available for a long period of time.
However, there are two potential problems with manual processing. Firstly,
manual methods led to loss of mononuclear cells and could recover only 40%-80%
of cells and secondly, there is increased risk of bacterial contamination. However,
automated processing avoids bacterial contamination by using a completely closed
system and, allows up to 99% recovery of necessary cells for transplantation. In
addition, the possibility of human error is reduced. Unfortunately, these
advancements make automated processing expensive for use. (4)
Endometrial cell processing and expansion
Harvesting
Before the collection procedure a "collection tube" is prepared in a class 100
Biological Safety Cabinet located in a Class 10,000 Clean Room. To prepare the
collection tube, 0.2 ml amphotericin B (Sigma-Aldrich, St Louis,MO), 0.2 ml
penicillin/streptomycin (Sigma) and 0.1 ml EDTA-Na2 (Sigma) are added to a 50
ml conical tube containing 30 ml of GMP-grade phosphate buffered saline (PBS).
Collection of 5 ml of menstrual blood is performed according to a modication of
the published procedure. Collection is performed by the donor. A sterile Diva cup
Stem Cell Therapy In Neurological Disorders 78

inserted into the vagina and left in place for 30-60 minutes. After removal, the
contents of the Diva cup are to be decanted into the collection tube. The collection
tube is then taken to the clean room where it is centrifuged at 600 g for 10 minutes.
The collection tube is then transported to the Biological Safety Cabinet where the
supernatant is removed, and the tube is topped up to 50 ml with PBS in the
Biological Safety Cabinet and cells are washed by centrifugation at 600 g for 10
minutes at room temperature. The cell pellet is to be washed 3 times with 50 ml of
PBS, and mononuclear cells are collected by Ficoll- Paque (Fisher Scientic,
Portsmouth NH) density gradient. Mononuclear cells are washed 3 times in PBS
and resuspended in 5 ml complete DMEM-low glucose medium (GibcoBRL, Grand
Island, NY) supplemented with 10% Fetal Bovine Serum selected lots having
endotoxin level < = 10 EU/ml, and hemoglobin level < = 25 mg/dl clinical grade
ciprooxacin (5 mg/mL, Bayer A.G., Germany) and 4 mM L-glutamine (cDMEM).
The resulting cells are mononuclear cells substantially free of erythrocytes and
polymorphonuclear leukocytes as assessed by visual morphology microscopically.
Viability of the cells is assessed using a Guava EasyCyte Mini ow
cytometer,Viacount reagents, Cytosoft Software version 4.2.1, Guava Technologies,
inc. Hayward, CA (Guava ow cytometer).
Expansion
Cells are plated in a T-75 ask containing 15 ml of cDMEM, cultured for 24 hours at
37°C at 5% CO2 in a fully humidied atmosphere. This allows the ERC precursors to
adhere. Non-adherent cells are washed off using cDMEM by gentle rinsing of the
ask. Adherent cells are subsequently detached by washing the cells with PBS and
addition of 0.05% trypsin containing EDTA (Gibco, Grand Island, NY, USA) for 2
minutes at 37°C at 5% CO2 in a fully humidied atmosphere. Cells are centrifuged,
washed and plated in T-175 ask in 30 ml of cDMEM. This results in approximately
10,000 ERC per initiating T-175 ask. The ask is then cultured for 5 days which
yields approximately 1 million cells in the T-175 ask (Passage 1). Subsequently
cells are passaged at approximately 200,000 cells in a T-175 ask. At passage 3-4,
approximately 100-200 million cells are harvested. (5)
Induced pluripotent cell processing
Induced pluripotent cells (iPSCs) are generated by reprogramming somatic cells to
embryonic-like state cells. The somatic cells are introduced with a dened and
limited set of factors and are cultured under embryonic stem cell like conditions. (6)
For the rst time, Yamanaka et al carried out a retroviral mediated introduction of
four transcription factors - octamer-binding transcription factor-3/4 (OCT3/4),
SRY-related high-mobility-group (HMG)-box protein-2 (SOX2), MYC and
Kruppel-like factor-4 (KLF4) in mouse broblast to produce iPSCs. (6,7) These iPS
cell lines exhibit similar morphology and growth properties as ES cells and express
Stem Cell Therapy In Neurological Disorders 79

ES cell-specic genes. Transplantation of iPS cells into immunodecient mice

resulted in the formation of germ-cell-tumor (teratoma)-containing tissues from all
three germ layers, conrming the pluripotent potential of iPS cells. Since then, the
same protocol has been used for other types of mouse cells and human somatic cells.
Once, the factors are introduced, cells are cultured where they form colonies
resembling pluripotent cells. These cells are then isolated based on the morphology,
surface markers, etc. Generation of iPSCs takes around 1-2 weeks for mouse cells
and 3-4 weeks for human cells. Recently, the iPSCs are being generated virus and
vector free to avoid viral induced tumor formation. The growth factors and
cytokines used for differentiation of iPSCs should be extensively tested to ensure
high biological activity, high purity, freeze-thaw stability, and structural
homogeneity.(8) They should also allow optimal growth, expansion, and storage of
differentiated cells. The major steps in obtaining iPSCs are reprogramming,
culturing, engineering, differentiation and cell analysis. It is essential to validate
their pluripotency and differentiation capacity into the desired cell lineage. (9)
Isolation of Neural Stem Cells
Neural stem cells reside within specic niches of the adult brain. These regions are
located in the subventricular zone (SVZ) of the lateral ventricles and the
subgranular zone (SGZ) in the hippocampus. (10)
Their isolation procedures follow common steps including tissue dissection,
digestion and cell enrichment. The origin of the tissue inuences the type of isolated
cells as well as their proliferation and differentiation capacity. (11) Firstly, brain
tissue is dissected. NSCs are removed from the rest of the tissue by enzymatic
digestion which is a critical step as it inuences the survival rate of the cells. At
times, enzymatic digestion alone is not sufcient hence a mechanical method is
used after of during the enzymatic digestion such as trituration to break up the
digested pieces into a single cell suspension. Lastly, the NSCs are enriched using
different procedures such as methods based on adherent properties of cells,
Differential gradient centrifugation, FACS, immunopanning, etc. These cells are
maintained and propagated either using methods such as free-oating cell clusters
(neurospheres) or as adherent cultures forming a monolayer on the plate surface.
The neurosphere assay has been the most extended method to demonstrate the
presence of NSCs in culture and it is still used with different modications.
However, these cells are yet to be translated for therapeutic use.
REFERENCES:
1. Hyung Chun Park, Yoo Shik Shim,Yoon Ha Seung Hwan Yoon, Et Al.
Treatment of Complete Spinal Cord Injury Patients by Autologous Bone
Marrow Cell Transplantation and Administration of Granulocyte-Macrophage
Colony Stimulating Factor. Tissue Engineering 2005;11(5-6):913-922
Stem Cell Therapy In Neurological Disorders 80

2. https://www.miltenyibiotec.com/~/media/Files/Navigation/Research/
Stem%20Cell/SP_MC_BM_density_gradient.ashx
3. http://www.translationalresearch.ca/documents/SOP%20VI%
20MONONUCLEAR%20CELL%20ISOLATION.pdf
4. http://www.springerprotocols.com/Abstract/doi/10.1007/978-1-60327-169-
1_1)
5. www.harvesttech.com
6. http://www.neocells.com/html/processing.html
7. Zhaohui Zhon, Amit N Patel, Thomas E Ichi et al. Feasibility investigation of
allogeneic endometrial regenerative cells. J Transl Med 2009; 7(1):15.
8. Ye L, Swingen C, Zhang J. Induced pluripotent stem cells and their potential for
basic and clinical sciences. Curr Cardiol Rev. 2013 Feb 1;9(1):63-72.
9. Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse
embryonic and adult broblast cultures by dened factors. Cell. 2006 Aug
25;126(4):663-76.
10. http://www.lifetechnologies.com/in/en/home/references/protocols/cell-
culture/stem-cell-protocols/ipsc-protocols.html
11. http://www.lifetechnologies.com/in/en/home/life-science/stem-cell-
research/ induced-pluripotent-stem-cells.html
Stem Cell Therapy In Neurological Disorders 81

“The best research questions come from the patient’s bedside”

Prof. Harvey Cushing

Neurosurgeon of the Millenium
Stem Cell Therapy In Neurological Disorders 82

Surgical Aspects of Stem Cell

Therapy: Routes of Administration
The stem cell therapy process using autologous bone marrow derived stem cells
consists broadly of 3 stages. (1) Procurement of the stem cells from the Bone
marrowvia a Bone marrow aspiration in the Operating theatre,(2) Separation,
harvesting, enriching &/or expansion and differentiation in the laboratory and
nally (3) Transplantation or delivery of the cells to the desired location. The
laboratory aspects have already been dealt with in the previous chapter therefore in
this chapter the procurement and transplantation aspects will be discussed.
Procurement of Stem cells - Bone marrow aspiration
The choice of site may be dependent on various factors such as age, weight marrow
distribution, physical status of the patient, physicians experience etc. However the
most common site is the pelvis. The aspiration is easily done from either of the iliac
crests (posterior or anterior). The posterior superior iliac spine is easily accessible
and identiable, however to access this, the patient has to be turned in the lateral or
prone position which can be troublesome and cumbersome. The anterior superior
iliac spine can be accessed with the patient lying comfortably in the supine position.
In obese patient, the landmarks may be obliterated due to fat distribution. Sampling
is not normally discordant between the anterior or posterior iliac spines.
The site of the aspiration is palpated. For the posterior superior iliac spine, in thin
individuals, it is usually palpated as the bony prominence superior and three nger
breadth laterals to the intergluteal cleft. The anterior superior iliac spine is can be
Stem Cell Therapy In Neurological Disorders 83

palpated as an anterior prominence on the iliac crest. The overlying skin is prepared
in a manner similar to preparation of any site for surgery. The area is anaesthetized
by intradermally administering a local anesthetic such as lignocaine using a 25G or
26G needle. A 1 cm area is anesthetized.
A standard Bone marrow aspiration needle is inserted through the skin till the bone
is felt. Before using the needle it is ushed with heparin. Some surgeons make a
small incision with a surgical blade and expose the bone before putting in the
needle, however in our experience this is rarely required. The needle which is rmly
xed to the obturator is rmly inserted inside, clockwise and anticlockwise, in a
screwing motion with exertion of downward pressure, until the periosteum is
reached. With similar motion, the needle is inserted till it penetrates the cortex. At
this point initially a sudden giving way of the resistance is felt as the needle enters
the soft trabecular bone and then the needle feels rmly xed in the bone. The angle
of insertion of the needle is important as it has to be in alignment with the curve of
the bone. If this is not done properly the needle will make a through and through
penetration across both the cortical surfaces with the tip now being outside the
marrow. A study of the anatomy of the pelvis with a model and personal experience
over time make this a very simple procedure.
The stylet is now removed and a 10 ml or 20 ml syringe, with some heparin in it, is
attached and the aspiration is done. A total of 100-120 ml is aspirated in adults and
80-100 ml in children. This is collected in heparinized tubes which need to be
appropriately labeled. The bone marrow collected is transported to the laboratory
in a special transporter under sterile conditions.(1)
Transplantation of Stem Cells in neurological disorders
The other surgical aspect in the process of stem cell therapy is the delivery of the
cells which may either be done systemically (through intravenous or intraarterial
routes) or locally (intrathecal or direct implantation into the spinal cord or brain).
Different centers are following different routes to transplant the cells and as of now
there are no comparative studies that could tell us which is the preferred method.
However keeping in mind the existence of the Blood Brain barrier, local delivery
would seem to be a more logical option.
Intrathecal delivery
The patient is positioned in the lateral decubitus position, in the curled up "foetal
ball" position. Occasionally, the patient is made to sit, leaning over a table- top. Both
these maneuvers help open up the spinous processes. The back is painted and
draped and local anaesthetic is injected into the L4-5 or L3-4 space. An 18G Touhy
needle is inserted into the sub-arachnoid space. After ascertaining free ow of CSF,
an epidural catheter is inserted into the space, far enough to keep 8-10 of the catheter
in the space. The stem cells are then injected slowly through the catheter, keeping a
Stem Cell Therapy In Neurological Disorders 84

close watch on the hemodynamics of the patient. The cells are ushed in with CSF.
The catheter is removed and a benzoin seal followed by a tight compressive
dressing is given. This procedure is usually done under local anesthesia. General
anesthesia is given to children.

Figure 1: Bone marrow J needle Figure 2: Bone marrow aspiration

Figure 3: Epidural set (18 G) for intrathecal Inj. Figure 4: Intrathecal Injection step 1

Figure 5: Intrathecal Injection step 2 Figure 6 : Intrathecal Injection step 3

Figure 7: Intrathecal Injection step 4 Figure 8: Intrathecal Injection -

delivery of stem cells
Stem Cell Therapy In Neurological Disorders 85

Figure 9 & 10 : Intraspinal transplantation of stem

cells in a case of thoracic spinal cord injury.

Figure 11: Intra-arterial direct Figure 12: STA-MCA bypass

injection of stem cells
into the carotid artery following
carotid endartrectomy

Figure 13: Leksell Stereotactic Frame for direct stem

cell implantation into the brain.
Stem Cell Therapy In Neurological Disorders 86

A spinal needle instead of a catheter is preferred in patients with cardiac problems,

where excessive intravenous infusion is to be avoided, in patients on anti-coagulant
or anti-platelet drugs so as to avoid bleeding into the sub-arachnoid space, in case
where the spine is scoliotic which happens often in patients with muscular
dystrophy and in some previously operated cases of lumbar spine surgery.
Sometimes in patients with severe spinal deformities such as scoliosis it is very
difcult to get the needle intrathecally and at times assistance has to be taken of the
C arm to exactly locate the point and direction of needle placement.
Callera et al (2007) demonstrated for the rst time that autologous bone marrow CD
34+ cells labelled with magnetic nanoparticles delivered into the spinal cord via
lumbar puncture (LP) technique migrates into the injured site in patients with
spinal cord injury. They conducted the trial on 16 patients with chronic SCI. 10 of
them were injected intrathecally with labelled autologous CD 34+ cells and the
others received an injection containing magnetic beads without stem cells.
Magnetic resonance images were obtained before and 20 and 35 days after the
transplantation. Magnetically labelled CD 34+ cells were visible at the lesion site as
hypointense signals in ve patients, which were not visible in the control group.(2)
Intraspinal transplantation
Direct implantation into the spinal cord may be done in one of many ways :-
a) Through a complete laminectomy from one level above to one level below the
injury site so that there is sufcient access to the transplantation site. The dura is
incised, sparing the arachnoid, which is subsequently opened separately with a
microscissors. The dorsal surface of the contusion site is located under high-
power microscopic magnication. After exposure of sufcient surface in the
contusion site, 300μL aliquots of cell paste (total volume, 1.8 mL) are injected
into six separate points surrounding the margin of the contusion site. To avoid
direct cord injury, 2 × 108 cells are delivered at a rate of 30 μL/min, using a 27-
gauge needle attached to a 1-mL syringe. The depth of the injection site is 5 mm
from the dorsal surface. To prevent cell leakage through the injection track, the
injection needle is left in position for 5 min after completing the injection, after
which the dura and arachnoid are closed. The muscle and skin are closed in
layers. (3)
b) Though a minilaminectomy and exposure of the spinal cord. The dura is opened
and a 27 gauge scalp vein is used by cutting one of the wings. The other wing is
held by a hemostat and inserted at a 45 degree angle into the Dorsal root entry
zone. It is inserted 3mm deep into the spinal cord. Two injections are made on
either side above the injury site and two injections are made below the injury site.
In China, surgeons are injecting 35 μL of stem cells. In his planned trials, Wise
Young is intending to inject an escalating dose of 4 μL, 8 μL and 16 μL.
Stem Cell Therapy In Neurological Disorders 87

c) In their ongoing trials, Geron and Neuralstem are using stereotactic systems
specically designed for intraspinal injections. They have the advantage of
precision as well as being less invasive. Geron is using a stereotactic frame with
a straight needle and injecting 25 μL.
Intra-arterial injection
Following revascularization surgery such as Carotid endartrectomy or Supercial
Temporal artery to Middle Cerebral artery bypass, stem cells could be injected
directly intraarterially immediately after the completion of the revascularization
procedure. The advantage of this approach is that the stem cells would go directly to
the ischemic brain and also that since the artery is already exposed no separate
procedure needs to be done for the stem cell injection. The other method of direct
intra-arterial injection would be via the Endovascular interventional route. This is
done by making a puncture in the femoral artery and negotiating a catheter to the
arteries supplying the brain. The advantage of this is that it is a relatively non
invasive procedure and the limitations of Intravenous injection are avoided.
Stereotactic implantation into the brain
Cell transplantation for neurological conditions started with Stereotactic
implantation of fetal cells for Parkinson's disease.(4) However after a randomized
trial done by Freed et al showed that the clinical outcomes were not signicantly
different from non transplanted patients this has now been given up.(5) There are
many stereo tactic systems available all over the world however the two most
popular ones are the Leksell Stereotactic system and the CRW Stereotactic system.
The Leksell system involves xing the frame on the patients head and then getting a
MRI done with the frame on. The area where the tissue is to be transplanted is
identied on the MRI scan and then using the MRI software the X , Y and Z
coordinates are obtained. The patient is now shifted to the operating room where a
small burr hole is drilled into the skull and then through this the cells to be
transplanted and inserted at the desired location using the X,Y and Z coordinates.
The entire procedure is done under local anesthesia.
Intramuscular injection In certain disorders, especially
Muscular dystrophy, cells are also transplanted into the muscle. The points at
which these have to be injected are termed as the "motor points"(described in detail
in chapter 7).At these motor points, the area is cleaned with povidone iodine.The
cells diluted in CSF are injected with the 26G needle going into the muscle at an
angle(approx. 45 degrees).The piston/plunger of the syringe is slightly withdrawn
to verify the the needle is not inside a blood vessel. The cells are then injected, the
needle removed and the site immediately sealed with a benzoin seal.
Intravenous injection
Stem Cell Therapy In Neurological Disorders 88

Intravenous injectin (IV) is the most widely used route of administration for stem
cells. It is safe, minimally invasive and has no ethical issues involved. Inspite of
these advantages, it is not the most effecient mode of transplantation. Studies have
shown that on IV administration, majority of the cells get trapped in organs other
than the target organ. They are also more susceptible to the host immune system.
Anaesthesia considerations
Muscular Dystrophy
Pre-operative evaluation: Heart is affected to varying degrees, depending on the
stage of the disease and the type of mutation. The myocardium is replaced by
connective tissue or fat, which leads to delated cardiomyopathy. There may also be
tachycardia, T-wave anomalies, ventricular arrythmias etc. This necessitates a good
pre-operative cardiac assessment with an ECG and an echocardiogram, with a 24 hr
Holter monitoring in the presence of arrhythmias. Pulmonary insufciency is
another cause of concern, due to abdominal muscle weakness, scoliosis, and other
factors such as altered chest wall and lung mechanics. Pulmonary function tests are
recommended, though always not feasible. An arterial blood gas study gives a fair
idea of respiratory reserve.
Intra-operative and anaesthetic considerations: increased sensitivity to anaesthetic
agents, with hypersomnolence, increased chances of respiratory problems due to
hypotonia, chronic aspiration, and central and peripheral hypoventilation.
hypotension due to decreased cardiac reserve, difculty in lumbar puncture due to
scoliosis, delayed gastric emptying due to hypomotility of the GI tract,
predisposing to regurgitation and possible aspiration.
Multiple Sclerosis
Cardiac and respiratory systems are generally spared, as this condition primarily
attacks the nervous system.
Anaesthesia considerations: corticosteroid supplementation during the peri-
operative period is advised. Symptoms of MS are known to exacerbate post-
operatively, esp. in the presence of infection and fever. But on the whole, general
anaesthesia is relatively safe.
Cerebral Palsy
Pre-operative Evaluation: these children are usually on anti-convultants and other
drugs to reduce spasticity. They are prone to respiratory tract infections, and also
have increased salivation.
Anaesthesia Considerations: Increased chances of GE reux. Increased chances of
aspiration, both from the regurgitant contents and pooled salivary secretions.
Skeletal and muscle spasticity resulting in contractures and joint deformities, which
Stem Cell Therapy In Neurological Disorders 89

can hamper positioning. increased sensitivity to anaesthetic drugs, resulting in

slow emergence.
Spinal Cord Injury
Intra-operative and anaesthesia considerations: Impaired alveolar ventilation,
especially in cervical cord injury, with impaired ability to cough and clear
secretions, cardiovascular instability manifesting as autonomic hyperreexia,
chronic pulmonary and genitourinary infections, altered thermoregulation,
decubitus ulcers, osteoporosis and skeletal muscle atrophy due to prolonged
immobilization, increased predisposition to deep venous thrombosis, difculty in
positioning, difculty in lumbar puncture if surgery and instrumentation has been
done on the lumbar spine.
Stem Cell Therapy In Neurological Disorders 90

"Whatever you can do or dream you can do, begin it.

Boldness has genious, power and magic in it. Begin it now"

– Goethe
Stem Cell Therapy In Neurological Disorders 91

Novel Concepts and Technique of

Motor Points for Intra-Muscular Stem
Cell Transplantation
There's always something new to learn.
Motor point is the point at which the innervating nerve enters the muscle or, in case
of deeply placed muscle, the point where the muscle emerges from the under covers
of the more supercial ones. It also represents the area of the skin above the muscle
where maximal visible contraction is obtained with the lowest possible intensity of
electrical stimulation.
Motor points are usually situated at the junction of the upper & middle one thirds of
the eshy belly of the muscles, although there are exceptions e.g.: The motor point
of vastus medialis, whose nerve enters the lower part of the muscle, is situated a
short distance above the knee joint. Deeply placed muscles may be stimulated most
satisfactorily where they emerge from beneath the more supercial ones, e.g.:
extensor hallucis longus in the lower one third of the lower leg. Motor point is the
point on the skin where an innervated muscle is most accessible to percutaneous
electrical stimulation at the lowest intensity. This point on the skin generally lies
over the neuro vascular hilus of the muscle & the muscles band or zone of
innervations. Muscle bres do not always extend the whole length of a muscle &
myoneural junctions are not uniformly spread out all over the muscle. They are
concentrated in a conned area-the zone or band of innervations where there is
greatest concentration of motor endplates & where the other large diameter nerve
Stem Cell Therapy In Neurological Disorders 92

bres may be reached with less concurrent painful stimulation of the smaller
diameter cutaneous bres.
The exact location of motor point varies slightly from patient to patient but the
relative position follows a fairly xed pattern. Some motor points are supercial &
are easily found, while others belonging to deep muscles are more difcult to locate.
Concept of motor point stimulation

Figure 1: A Neuromuscular Junction

Figure 2 : The Motor Unit

Stem Cell Therapy In Neurological Disorders 93

When a nerve is stimulated at a nerve cell or an end organ, there is only one
direction in which it can travel along the axon, but if it is initiated at some point on
the nerve bre it is transmitted simultaneously in both directions from the point of
stimulation.
When a sensory nerve is stimulated the downward travelling impulse has no effect,
but the upward travelling impulse is appreciated when it reaches conscious levels
of the brain. The sensory stimulation experienced varies with the duration of the
impulse. Impulses of long duration produce an uncomfortable stabbing sensation,
while impulses of 1 ms & less produce only a mild prickling sensation.
When a motor nerve is stimulated, the upward -travelling impulse is unable to pass
the rst synapse, as it is travelling in the wrong direction, but the downward
travelling impulse passes to the muscles supplied by the nerve, causing them to
contract.
When a stimulus is applied to a motor nerve trunk, impulses pass to all the muscles
that the nerve supplies below the point at which it is stimulated, causing them to
contract.
When a current is applied directly over an innervated muscle, the nerve bres in the
muscle are stimulated in the same way. The maximum response is thus obtained
from stimulation at the motor point.
Preparation of the patient
The area to be plotted is exposed & the patient is supported comfortably in good
light. The skin has high electrical resistance as the supercial layers being dry,
contain few ions. The resistance is reduced by washing with soap & water to remove
the natural oils & moistening with saline immediately before the electrodes are
applied. Breaks in the skin cause a marked reduction in resistance which naturally
results in concentration of the current & consequent discomfort to the patient. To
avoid this broken skin is protected by a petroleum jelly covered with a small piece of
non absorbent cotton wool to protect the pad. The indifferent electrode should be
large to reduce the current density under it to a minimum. This prevents excessive
skin stimulation & also reduces the likelihood of unwanted muscle contractions, as
it may not be possible to avoid covering the motor points of some muscles.
Preparation of apparatus
Faradic type of current
A low frequency electronic stimulator with automatic surge is commonly used. A
faradic current is a short -duration interrupted direct current with a pulse duration
of 0.1 - 1 ms & a frequency of 50 - 100 Hz. Strength of contraction depends on the
number of motor units activated which in turn depends on the intensity of the
Stem Cell Therapy In Neurological Disorders 94

current applied & the rate of change of current. To delay fatigue of muscle due to
repeated contractions, current is commonly surged to allow for muscle relaxation.
Stimulation of Motor points
This method has the advantage that each muscle performs its own individual action
& that the optimum contraction of each can be obtained, by stimulating the motor

Figure 3 : Electrical stimulator used for stimulation and plotting of motor points.

Figure 4 : Preparation of the Figure 5 : Plotting of motor

patient for motor point plotting point (strenomastoid muscle)

Figure 6 : Marking of sternomastoid muscle motor point.

Stem Cell Therapy In Neurological Disorders 95

Figure 7 : Plotted motor points of Figure 8 : Injection of stem

tibialis anterior and peronei muscle cells in tibialis anterior
muscle motor point.

Figure 9 : Injection of stem cells in the glutei muscle motor point.

Figure 10 : Injection of stem cell Figure 11 : Injection of stem cells in

injection in the adductor pollicis the lumbrical muscle motor points
muscle motor point.
Stem Cell Therapy In Neurological Disorders 96

point. The indifferent electrode is applied & secured in a suitable area. The
stimulating electrode is placed over the motor point of the muscle to be stimulated.
Firm contact ensures a minimum of discomfort. The operator’s hand may be kept in
contact with the patient’s skin so that she /he can feel the contractions produced.
Selection of the Individual muscles for Stem cell transplant
The physiotherapist selects the weak muscles for stem cell injection on the basis of
manual muscle testing & patient’s complain of weakness & difculty in ADL. Post
stem cell injection these muscles need specic training & individual muscle
strengthening program so that the patient can gain efciency & independency in
ADL. Apart from injecting stem cells intrathecally, injecting them in the motor
points of the muscles facilitates further specic implantation of the stem cells in
isolated individual muscles.
A) Major muscles of UL that are generally considered:
a) Deltoid: Anterior, middle & posterior bres.
b) Biceps brachii.
c) Triceps: long, lateral & medial heads.
d) Thenar muscles: Opponens pollicis, abductor pollicis brevis & exor
pollicis brevis.
e) Hypothenar muscles: abductor, exor & opponens digiti minimi.
B) Major muscles of LL that are generally considered:
a) Quadriceps: vastus medialis, vastus lateralis, rectus femoris.
b) Hamstrings: Biceps femoris, semimembranosus & semitendinosus.
c) Glutei.
d) Dorsiexors: Tibialis anterior, Peronei longus & brevis, EHL.
C) In trunk:
Abdomen & back extensors are considered, & in neck muscles
sternocleidomastoid.
D) Facial Muscles:
In case of facial muscle weakness in conditions like Motor Neuron Disease & a few
muscular dystrophies, facial muscles motor points are also selected for
intramuscular injections e.g.: orbicularis oris, orbicularis oculi, Buccinator,
rhizorius, frontalis, mentalis, etc.
Intramuscular stem cells injection in motor points within the muscle is very specic
Stem Cell Therapy In Neurological Disorders 97

transplantation. Also multiple motor points in chosen muscle group allows for a
graded response. It facilitates increment in muscle strength depending on specic
training & strengthening of individual injected muscles. An injection of stem cell in
the motor end plate, can be identied in the neuromuscular system within few
hours, although the onset of clinical effects is noticed as early as 72 hours post
transplant, which varies from patient to patient.
Stem Cell Therapy In Neurological Disorders 98
Stem Cell Therapy In Neurological Disorders 99
Stem Cell Therapy In Neurological Disorders 100

REFERENCE
1. Clayton’S Electrotherapy, Theory & Practice, Ninth edition 2004.Angela Forstet & Nigel
Palatanga.
2. R.W Reid,M.D, Prof of Anatomy, University of Abeerdeen, Journal Of Anatomy, Vol LIV,
part 4
Stem Cell Therapy In Neurological Disorders 101

SECTION B
Clinical Application of Stem Cells
Stem Cell Therapy In Neurological Disorders 102

“Things don't change.

You change your way of looking at them”

– Carlos Castaneda
Stem Cell Therapy In Neurological Disorders 103

Role of Stem Cells in Autism

Spectrum Disorders
Stem cells have the potential to restore the underlying abnormal neural network
of brain in Autism Spectrum Disorders.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder which begins

in early childhood and is characterized by persistent decits in social interaction
and communication, along with presence of restricted, repetitive patterns of
behavior, interests, or activities. (1)
According to DSM V, ASD is a spectrum of disorders which includes Autism,
Asperger syndrome and pervasive developmental disorder – not otherwise
specied (PDD-NOS). (2) Individuals diagnosed with ASD have a range of
symptoms which are usually showcased in the early developmental period and last
throughout the lifetime. Severity of the disorder depends on the symptoms and
levels of impairment or disability.
The prevalence of ASD has increased radically over few decades for reasons not yet
known. It is seen three to four times more in boys than girls. Autism, similar to other
neurodevelopmental disorders, is incurable and requires lifelong management. It
impacts the health, economic wellbeing, social integration and quality of life of
individuals with the disorder, and also on their families and potentially the rest of
the society. Hence, a great deal of research is being conducted all over the world to
understand the etiology of autism and subsequently nd a cure for it.
Newer treatments like stem cell therapy have shown immense potential as a
Stem Cell Therapy In Neurological Disorders 104

treatment strategy for ASD. This chapter mainly focuses on detailed understanding
of how stem cell therapy works in ASD. It has been supported with adequate
scientic data in the form of worldwide review of clinical studies and their results.
Pathophysiology of Autism

Figure 1: Pathophysiology of ASD

The etiology of ASD is complex and a more denitive understanding of the

pathophysiology is required to develop a cure for ASD. It is likely to be
multifactorial encompassing both genetic predisposition and environmental
factors (3) Research has shown structural and functional abnormalities in the brain
of ASD patients. To understand the brain pathology of autism, we conducted a
study using PET CT scan brain which demonstrated an atypical
neurodevelopmental trajectory of brain maturation in autism. We found that unlike
the healthy controls, as the age increases, there is a linear decrease in brain
metabolism of autism children. Hypometabolism was observed in amygdala,
hippocampus, parahippocampal gyrus, cerebellum, mesial temporal lobe,
thalamus, superior and middle temporal pole, and hypermetabolism in calcarine
ssure and Heschl's gyrus in autism. The trajectory of the brain metabolism in
autism varies across different parts of the brain with the frontal and temporal being
affected more as compared to the parietal and occipital cortices. These
abnormalities explain the developmental, cognitive, and behavioral decits
observed in these children. (4) Autism has also been strongly associated with
underconnectivity of long pathways and increased connectivity in short pathways.
This causes an imbalance in the connectivity of the brain of autism. (5)
Stem Cell Therapy In Neurological Disorders 105

Unmet medical needs

It is difcult to identify autism-specic biomarkers as ASD is considered to be the
nal common pathway of multiple etiological and neuropathological mechanisms.
(6) Hence, the diagnosis relies on the recognition of an array of behavioral symp-
toms that vary from case to case and overlap with other childhood neuropsychiatric
disorders.
Also, due to heterogenous nature, developing a standard cure for ASD is difcult.
Currently, the treatment options available for autism are rehabilitation, behavioral,
nutritional and medical intervention. These do not address the core
pathophysiology of autism but only manage the symptoms and associated medical
conditions. The medicines alleviate the symptoms temporarily but, do not cure
them permanently. Hence, establishing a strategy to target the underlying abnor-
mal neuronal connectivity which will have a longlasting effect is the need of the
hour.
Stem cell therapy in autism
As autism is a complex neurodevelopmental disorder, different studies have tried
understanding its basic pathophysiology. It is assumed that neural hypoperfusion
and immune dysregulation are the two core underlying pathologies associated
with autism. (7) In the past decade stem cell therapy has emerged as one of the most
potential treatment strategies ASD. (7-9) It has the therapeutic potential to repair
the damaged neural tissue at molecular, structural and functional level.
Hypoperfusion results in hypoxia. Reversal of hypoxia may lead to self-repair and
neural proliferation. The angiogenic potential of stem cells facilitates reperfusion
and restores the lost connections. (10) It also regulates the immune system, balances
inammation further exhibiting benecial clinical effects in patients with ASD.
These cells also secrete several biomolecules with anti-inammatory properties
through paracrine effect. This tries to maintain equilibrium in the immune system
alterations and activate endogenous repair mechanisms in autism. (11) Thus, stem
cells are capable of suppressing the pathological immune responses as well as
stimulating neovascularisation. Cell therapy may also prove useful for the treat-
ment of T cell defect associated with autism. (12) Cells may also play a role in stimu-
lating the restoration and/or generation of functional synaptic pathways. (13)
Additional neuroprotection may be offered via molecular mechanisms by inhibit-
ing toxic processes such as neural apoptosis, microglial activation, astrocyte prolif-
eration, and production of oxidative stress molecules.(14) Overall, stem cells carry
out functional restoration of specialized neural systems by neuroprotection, neural
circuit reconstruction, neural plasticity, neurogenesis and immunomodulation.
Stem Cell Therapy In Neurological Disorders 106

Figure 2: Stem Cell Therapy in Autism

Pre-clinical Studies
Some neurodevelopmental disorders like autism are strictly limited to humans.
Autism is usually diagnosed only by the behavioral parameters. Hence, it is difcult
to replicate autism in animal models with all the clinical characteristics. This also
makes it challenging to study the effect of any intervention on these animal models.
BTBR inbred mouse strain is a commonly used animal model for autism as it
demonstrates robust behavioral decits. In a recent study conducted by H
Segal-Gavish et al, transplantation of MSCs in BTBR mice resulted in a reduction of
stereotypical behaviors, a decrease in cognitive rigidity and an improvement in
social behavior. Tissue analysis revealed elevated BDNF protein levels in the
hippocampus accompanied by increased hippocampal neurogenesis in the MSC-
transplanted mice compared with sham treated mice. (15)
Stem Cell Therapy In Neurological Disorders 107

17 studies have been published including 5 clinical studies and 12 case reports
demonstrating the effect of stem cell therapy in ASD. Different types of cells were
used namely autologous bone marrow mononuclear cells, fetal stem cells and
umbilical cord blood cells.
Sharma et al (16) published the rst clinical study which was an open label proof of
concept study in 32 patients of autism. They administered autologous bone marrow
mononuclear cells intrathecally. The results of their trial demonstrated the safety
and efcacy of stem cell therapy for autism. The results of this study have been
described in detail below. The next clinical study was published by Yong-Tao Lv et
al where they studied use of human cord blood MNCs and MSCs in 37 patients. (17)
They used CARS, CGI and ABC scales to assess the therapeutic efcacy in this
study. A positive outcome was obtained in the treatment group. In 2014, Bradstreet
et al published their study using fetal stem cells. (18) The study was carried out on
45 children with autism. On follow up after 6 months and 12 months, there was a
signicant change in Autism Treatment Evaluation Checklist (ATEC) test and
Aberrant Behavior Checklist (ABC) scores. Improvement was also seen in behavior,
eye contact, appetite, etc. In 2017, Dawson et al published their Phase 1 safety and
tolerability study wherein they administered a single intravenous infusion of
autologous cord blood cells in 25 children with ASD. (19)The infusions were safe,
Stem Cell Therapy In Neurological Disorders 108

with no serious adverse events and occasional allergic reactions and irritability
reported. Improvements in ASD symptoms were observed on caregiver-completed
measures (Vineland Adaptive Behavior Scales Second Edition (VABS-II, see gure
1) and Pervasive Developmental Disorder Behavior Inventory (PDDBI)), clinician
assessment (CGI-I, gure 1), and computerized eye tracking assessments. Positive
changes, including increased social communication skills and recep-
tive/expressive language and decreased repetitive behavior and sensory sensitivi-
ties were observed six months post infusion and maintained at 12 months. A Phase
2 randomized study is underway to evaluate the efcacy of autologous or
allogeneic CB therapy versus placebo in children with ASD. In 2017, a case series
from India was published by Shroff G wherein 3 cases of ASD were administered
with embryonic stem cells. (20) The patients showed improvements in eye coordi-
nation, writing, balancing, cognition, and speech and showed reduced hypersensi-
tivity to noises and smells. These patients also showed improvement in SPECT
scans.
Our Published data

Figure 3: Frequency distribution of participants on CGI-II scale

Figure 4: Frequency distribution of participants on CGI-III scale

Stem Cell Therapy In Neurological Disorders 109

An open label proof of concept study (Sharma et al) of autologous bone marrow
mononuclear cells (BMMNCs) intrathecal transplantation in 32 patients with
autism followed by multidisciplinary therapies was performed. All patients were
followed up for 26 months (Mean 12.7) Outcome measures used were ISAA, CGI
and FIM/ Wee-FIM scales. Positron Emission Tomography computed
Tomography (PET-CT) scan recorded objective changes. Out of 32 patients, a total
of 29 (91%) patients improved on total ISAA scores and 20 patients (62%) showed
decreased severity on CGI-I. In the domain of Social relationships and reciprocity 29
out of 32 (90.6%) patients showed improvement. Improved emotional
responsiveness was observed in 18 out of 32 (56%) patients. Under the Speech-
language and communication domain there was an improvement observed in 25
patients out of 32 (78%). Behavior patterns of 21 out of 32 patients (66%) improved.
Hyperactivity or restlessness (71%) and engaging in stereotype and repetitive
motor mannerisms (65%) decreased signicantly. Sensory aspects improved in 14
out of 32 patients (44%). Cognitively they showed improved consistency in
attention and concentration and response time. 71% patients showed better
attention and concentration, 45% patients showed reduction in the delay in
responding. The difference between pre and post scores was statistically signicant
(p <0.001) on Wilcoxon Matched-Pairs Signed Rank Test. On CGI-II 96% of patients
showed global improvement. The efcacy was measured on CGI-III efcacy index.
Functional neuroimaging in the form of PET - CT scan in eight patients,
documented changes in brain metabolism which correlated with clinical
improvements. Few adverse events including seizures in three patients were
controlled with medications. The encouraging results of this leading clinical study
provide future directions for application of cellular therapy in autism.

Table 1: Change in the scores of CGI and ISAA before and after intervention.

Table 2: Change in the ISAA scores of individual domains

measured before and after intervention.
Stem Cell Therapy In Neurological Disorders 110

Eye contact Sensory

develops / improves issues
decrease

Repetitive motor Hyperactivity

mannerisms decrease decrease

Attention span improves

Improved
learning and
concept Cooperation and active
formation participation in therapy
sessions increase

Behavioral
issues
decrease
Command
following
improves
Nonverbal Conveying
communication / needs and
gestures improve expressing
Communication self improve
improves
Verbal
communication
improves

Social interaction Speech and

improves language improve

Global life-skills
development

Figure 5: Schematic representation of clinical improvements after cellular

therapy. This gure shows proposed theoretical outline of observed changes after
cellular therapy.
Stem Cell Therapy In Neurological Disorders 111

Figure 6: Findings in PET-CT scan before and after cellular therapy. (a) PET-CT
scan before intervention showing reduced FDG uptake in the areas of frontal lobe,
cerebellum, amygdala, hippocampus, parahippocampus, and mesial temporal lobe.
(b) PET-CT scan six months after intervention comparison shows increased FDG
uptake in the areas of frontal lobe, cerebellum, amygdala, hippocampus,
parahippocampus, and mesial temporal lobe.
We have also published 12 case reports in various national and international peer
reviewed journals demonstrating the effect of stem cell therapy in autism cases. (21-
32) All these cases were different with respect to age, severity of autism and
symptoms presented. One of the patient also had comorbid ID. These cases
underwent autologous bone marrow mononuclear cell transplantation along with
personalized neurorehabilitation program which included applied behavior
analysis, psychological intervention, speech therapy, occupational therapy, art
based therapy, etc. These patients were followed up regularly to record changes in
clinical symptoms and outcome measures such as CARS, CGI, ISAA and FIM were
used to quantify the changes. On follow up, improvements were observed in
common symptoms such as speech, awareness, logical thinking, attention and
concentration, eye contact, social interaction, emotional responses, command
following, learning abilities, response time, sitting tolerance and ADLs.
Hyperactivity, aggressive behaviour, Stereotypical and self-stimulatory behaviour
were also reduced. They all showed positive changes on outcome measures. The
Stem Cell Therapy In Neurological Disorders 112

scores of the patient categorized as severe autism on CARS improved to no autism.

Which indicates the patient required assistance but was out of the spectrum after
the intervention. There was improvement in IQ as well of the patient with comorbid
ID.
In 9 cases out of 12, PET CT scan was used as a monitoring tool to study the
metabolic changes occurring after stem cell therapy. These scans showed improved
brain metabolism in the areas affected before stem cell therapy. There was a
balancing effect observed in the metabolism. Areas which were hypermetabolic or
hypometabolic before treatment turned normal after treatment.
Unpublished
We have treated 193 cases of autism were treated with autologous BMMNCs
intrathecal administration. The data of these cases was analyzed. Symptoms such as
social interaction, eye contact, hyperactivity, aggressive behaviour, self-
stimulatory behaviour, speech, attention, stereotypical behaviour and
communication were analysed. On follow up we found that, 89.12% of patients
with autism showed improvements while 10.88% did not show any change after
intervention. 25.90% showed mild improvements, 29.53% showed moderate
improvements and 33.67% patients showed signicant improvements. No major
adverse events were recorded. Children showed improvements on objective scales
like CGI – II and III, ISAA and CARS. PET-CT scans also revealed improvements
which correlated well with the clinical improvements.
Improvements in Autism A er Stem Cell Therapy (N=193)
70 33.67%
60 29.53%
25.90%
50
40
30
10.88%
20
10
0
No Mild Moderate Significant
Improvement Improvement Improvement Improvement

Figure 7: Graph representing improvements in Autism a er Stem cell Therapy

PET-CT as a monitoring tool for effects of stem cell therapy in Autism

PET-CT is an imaging technique which utilizes 18-FDG, a dye that is analogous to
glucose. This dye is entrapped in the brain cells, which can then be measured on the
CT scan giving a diagrammatic representation of the function of cells. Uptake of the
FDG is given as standard uptake value (SUV). The SUV of the patient undergoing
Stem Cell Therapy In Neurological Disorders 113

PET-CT evaluation is then compared with the SUV of control population and
standard deviation (SD) is computed. If the SUV value of the patient is beyond 2 SDs
then it is considered as abnormal brain metabolism. Function of the brain cells is
directly proportional to the glucose uptake and metabolism. Thus,
hypofunctioning areas will depict reduced FDG uptake and hypometabolism (SD
values of -2 and below, represented by shades of blue and black); while
hyperfunctioning areas will depict increased FDG uptake and hypermetabolism
(SD values of +2 and above, represented by shades of yellow and red). An increased
FDG uptake in hypofunctioning areas or decreased FDG uptake in
hyperfunctioning areas may be implicated as improvement in brain function
depending upon the correlation with clinical improvement.

Figure 8: Comparative PET CT scans of an autism patient performed before and 6

months after stem cell therapy. Signicant improvement was observed in bilateral
medial temporal cortex, thalamus and cerebellum
Case Report
A 12 years old male child was diagnosed with Autism Spectrum Disorder based on
his clinical presentation. On assessment we observed that his attention and
concentration was affected as he got easily distracted easily. His imitation skills
were poor and inconsistent, he followed basic commands but he required 2 to 3
repetitions. His problem solving and awareness was affected. There was presence
of laughing and crying without any reason. His sitting tolerance was poor i.e. less
than 5 seconds according to the parents, and his social interaction and social norms
were also affected. There was presence of motor mannerisms like hand apping
and rocking behavior. He conveyed most of his basic needs non-verbally. His
Stem Cell Therapy In Neurological Disorders 114

speech was affected and he could make only sounds. He was dependent on his
caretakers for day to day activities. On FIM, he scored 62. On ISAA he scores 123
which indicated moderate autism and on CARS he scored 46.5 which indicated
severe autism. This patient underwent 4 transplantations in a period of 3 years.
Improvements after 1st Transplantation. Follow up period-9 months
Ÿ He could establish eye contact and maintain it for a long time.
Ÿ There was reduced vestibular, proprioceptive seeking. Oral seeking had also
reduced (reduced rocking).
Ÿ Could follow 1 step commands better now as compared to before.
Ÿ Hand apping and spitting has reduced.
Ÿ His sitting tolerance had improved. He could now sit at one place for doing
assignments like colouring.
Ÿ Could perform activities like candle blowing, balloon blowing.
Ÿ There was improvement in day to day activities such as brushing – he does it in a
better way but still requires assistance for cleaning. Dressing speed had
improved. He could eat with spoon which was difcult 6 months ago.
Ÿ He could make his bed with assistance.
Ÿ FIM improved from 62 to 87
Ÿ ISAA improved from 123-108
Improvements after 2nd Transplantation. Follow up period-12 months
Ÿ Attention and concentration had improved
Ÿ Command following had further improved
Ÿ He could copy simple actions e.g. clapping hands
Ÿ Speech had improved
Ÿ He is aware of danger
Ÿ Screaming and hitting had reduced.
Ÿ Hyperactivity has reduced by 50%
Ÿ Spitting behavior had completely stopped
Ÿ He now woke up less frequently in the night
Ÿ He could now match colors and identify fruits like banana
Ÿ He could brush teeth independently with very little help.
Ÿ FIM further improved from 87 to 95
Ÿ ISAA remained same (108)
Improvements after 3rd Transplantation. Follow up period-12 months
Ÿ Eye contact had further improved. He could focus on one object for more than 2
minutes
Ÿ Attention span also improved further, as he could sit for more than 2 hours for
performing tasks
Stem Cell Therapy In Neurological Disorders 115

Ÿ He had now started participating in social activities like playing football with
friends.
Ÿ He had developed awareness with respect to his body
Ÿ He could understand complex commands now
Ÿ He started understanding use of different objects
Ÿ He could now speak 2-3 words
Ÿ His understanding was better as he now opened the door for his dad when he
went for work
Ÿ Aggressive spells had further reduced
Ÿ At school he performed activities of making necklaces, 2 necklaces at a stretch (1.5 hrs)
Ÿ He was able to perform ADL like brushing, bathing, dressing, bed making tasks
faster as compared to before.
Ÿ FIM remained same (95)
Ÿ ISAA improved from 108-104
On comparing the PET CT scans performed before and after stem cell therapy
there was signicant improvement observed in brain metabolism.
Ÿ In 2015, the rst PET scan performed before stem cell therapy revealed reduced
metabolism in bilateral thalamus, cerebellum, and medial temporal cortex
Ÿ In 2016, PET scan performed 9 months after stem cell therapy showed improved
metabolism in thalamus, medial temporal cortex and cerebellum
Ÿ In 2018, the PET scan showed further improved metabolism in medial temporal
cortex and left cerebellum.
Stem Cell Therapy In Neurological Disorders 116

Over three years, this patient had overall improved in behavior, cognition,
communication and attention and concentration. He was more independent than
before and also his quality of life had considerably improved. All these
improvements correlated with improved brain metabolism observed on PET CT
scan.
Adverse Events:
Stem cell therapy for ASD is a safe procedure. However, adverse event monitoring
is important to achieve optimal outcome of the intervention. Adverse events are
categorized into minor and major adverse events. Minor adverse events include
procedure related events such as spinal headache, nausea, diarrhea, vomiting, pain
or bleeding at the site of aspiration /injection, fever amongst others. These are
treated using medications. Anesthetic complications and allergic reactions may
also occur depending on the procedure. Major adverse events include episodes of
seizures occurring after intervention. These can be managed prophylactically. Pre-
existing epileptogenic focus in EEG also predicts the occurrence of seizures.
Evidence suggests that antiepileptic prophylactic regimen decreases the incidence
of seizures along with limiting the onset of new ones. (33)
Conclusion
Based on published literature and our clinical experience we consider that Stem cell
therapy is a safe and effective treatment option for ASD. However, it is not a cure,
but it can be used in combination with current rehabilitation and medical
intervention to augment their clinical outcome. Stem cell therapy can repair the
underlying abnormal neuronal connectivity, improve information processing and
hence, give a long lasting symptomatic relief. It helps in improving the quality of
life of the patients and making them functionally independent which may provide
them mainstream opportunities. To optimize the benets of stem cell therapy, it is
important to explore the most benecial types of cells, route of administration,
quantity of cells to be injected, frequency of injections, etc. Neuroimaging
techniques like PET - CT scan and functional MRI (fMRI) scan give more lucid
information about neural connectivity in the brain of autism and hence need to be
studied in detail and standardized.(34) It is also observed that the earlier the
children undergo stem cell therapy, the better is the outcome. As, younger the age
greater is the brain plasticity, therefore, these children respond better to the
intervention.
REFERENCES
1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, D.C: American Psychiatric Association. (2013)
2. Grzadzinski R, Huerta M, Lord C. DSM-5 and autism spectrum disorders ASDs):
an opportunity for identifying ASD subtypes. Molecular Autism. 2013;4:12.
Stem Cell Therapy In Neurological Disorders 117

3. Watts TJ. The Pathogenesis of Autism. Clinical Medicine Pathology. 2008;1:99-103.

4. Sharma A, et al., The baseline pattern and age-related developmental metabolic
changes in the brain of children with autism as measured on positron emission
tomography/computed tomography scan. World J Nucl Med 2018;17
5. Rudie JD, Brown JA, Beck-Pancer D, Hernandez LM, Dennis EL, Thompson
PM, Bookheimer SY, Dapretto M. Altered functional and structural brain
network organization in autism. Neuroimage Clin. 2012 Nov 16;2:79-94.
6. Bradstreet, J., Smith, S., Baral, M., Rossignol, D. Biomarker-guided
interventions of clinically relevant conditions associated with autism spectrum
disorders and attention decit hyperactivity disorder, Alternative Medicine
Review. 2010; 15(1):15-32.
7. Ichim TE, Solano F, Glenn E, Morales F, Smith L, et al. Stem cell therapy for
autism. J Transl Med. 2007; 5 (1):30.
8. Song M, Mohamad O, Gu X, Wei L, Yu SP. Restoration of Intracortical and
Thalamocortical Circuits after Transplantation of Bone Marrow Mesenchymal
Stem Cells into the Ischemic Brain of Mice. Cell Transplant. 2013;22(11):2001-15
9. Siniscalco D. Stem Cell Research: An Opportunity for Autism Spectrum
Disorders Treatment. Autism.2012; 2:2
10. Siniscalco D, Sapone A, Cirillo A, Giordano C, Maione S, et al. Autism spectrum
disorders: is mesenchymal stem cell personalized therapy the future? J Biomed
Biotechnol. 2012; 2012: 480289.
11. Gesundheit B, Ashwood P, Keating A, Naor D, Melamed M, Rosenzweig JP.
Therapeutic properties of mesenchymal stem cells for autism spectrum
disorders. Med Hypotheses 2015; 84(3): 169-77. 69.
12. Vellasamy S, Tong CK, Azhar NA, et al. Human mesenchymal stromal cells
modulate T-cell immune response via transcriptomic regulation. Cytotherapy
2016;18(10): 1270-83.
13. Koh S, Kim N, Yin HH, Harris IR, Dejneka NS, Eroglu C. Human Umbilical
Tissue-Derived Cells Promote Synapse Formation and Neurite Outgrowth via
Thrombospondin Family Proteins. J Neurosci 2015; 35(47): 15649-65.
14. Sun JM, Kurtzberg J. Cell therapy for diverse central nervous system disorders:
inherited metabolic diseases and autism. Pediatr Res. 2018;83(1-2):364-371.
15. Segal-Gavish H, Karvat G, Barak N, et al. Mesenchymal Stem Cell
Transplantation Promotes Neurogenesis and Ameliorates Autism Related
Behaviors in BTBR Mice. Autism Res. 2016;9(1):17-32
Stem Cell Therapy In Neurological Disorders 118

16. Sharma A, Gokulchandran N, Sane H, et al. Autologous bone marrow

mononuclear cell therapy for autism - an open label proof of concept study.
Stem cell international. 2013 Volume 2013 (2013), Article ID 623875, 13 page
17. Lv YT, Zhang Y, Liu M, et al. Transplantation of human cord blood
mononuclear cells and umbilical cord-derived mesenchymal stem cells in
autism. J Transl Med. 2013;11(1):196.
18. Bradstreet JJ, Sych N, Antonucci N, et al. Efcacy of fetal stem cell
transplantation in autism spectrum disorders: an open-labeled pilot study. Cell
Transplant. 2014;23 Suppl 1:S105-12.
19. Dawson G, Sun JM, Davlantis KS, et al. Autologous Cord Blood Infusions Are
Safe and Feasible in Young Children with Autism Spectrum Disorder: Results
of a Single-Center Phase I Open-Label Trial. Stem cells translational medicine
2017; 6(5): 1332-9
20. Shroff G. Human Embryonic Stem Cells in the Treatment of Autism: A Case
Series. Innovations in Clinical Neuroscience. 2017;14(3-4):12-16.
21. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Sarita
Kalburgi, Ridhima Sharma, Prerna Badhe, Samson Nivins. PET CT Scan Brain
As A Monitoring Tool To Study The Effects Of Autologous Bone Marrow
Mononuclear Cell Transplantation In Autism Spectrum Disorder. International
Journal of Current Advanced Research. Sep 2017 (In Press).
22. Alok Sharma, Nandini Gokulchandran, Pooja Kulkarni, Sarita Kalburgi, Shruti
Kamat, Riddhima Sharma, Samson Nivins, Hemangi Sane, Prerna Badhe.
"Improvements in a case of autism spectrum disorder after cell therapy as noted
on PET CT brain scan" SJSC. May 2017
23. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni,
Suhasini Pai, Vaishali Ganwir, Prerna Badhe. A case of autism showing clinical
improvements after cellular therapy along with PET CT evidence.Journal of
Stem Cell Research & Therapeutics. April 2017
24. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe, Pooja
Kulkarni and Suhasini Pai. Stem Cell Therapy in Autism Spectrum
Disorders.Recent Advances in Autism. SMGroup. 2017
25. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Prerna Badhe,
Avantika Patil, Pooja Kulkarni, Amruta Paranjape PET- CT scan shows
decreased severity of Autism after autologous cellular therapy: A case report.
Autism Open Access 2016; 6:169.
26. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Avantika Patil,
Akshata Shetty, Hema Biju, Pooja Kulkarni, Prerna Badhe. Amelioration of
Stem Cell Therapy In Neurological Disorders 119

Autism by Autologous Bone Marrow Mononuclear Cells and

Neurorehabilitation: A Case Report. American Journal of Medical Case
Reports, 2015, Vol. 3, No. 10, 304-309
27. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pradnya Bhovad,
Hema Biju, Akshata Shetty, Mrudula Kali and Prerna Badhe. Cell therapy
effects portrayed on positron emission tomography computerized tomography
scan of the brain serve as a new dimension for autism: A case report (2014),
Journal of Paediatric Neurology, 12:3.
28. Sharma A, Gokulchandran N, Shetty A, Kulkarni P, Sane H, Badhe P.
Neuropsychiatric Disorder Tackled by Innovative Cell Therapy-A Case Report
in Autism. J Stem Cell Res Transplant. 2014;1(1): 4.
29. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Nancy
Thomas, Amruta Paranjape, Prerna Badhe. Intrathecal autologous bone
marrow mononuclear cell transplantation in a case of adult autism. Autism
open access. 2013, 3:2.
30. Alok Sharma, Nandini Gokulchandran, Akshata Shetty, Hemangi Sane, Pooja
Kulkarni and Prerna Badhe. Autologous Bone Marrow Mononuclear Cells may
be Explored as a Novel. Potential Therapeutic Option for Autism. J Clin Case
Rep 2013, 3:7.
31. Alok Sharma, Nandini Gokulchandran, Prerna Badhe, Pooja Kulkarni, Priti
Mishra, Akshata Shetty and Hemangi Sane. An Improved Case of Autism as
Revealed by PET CT Scan in Patient Transplanted with Autologous Bone
Marrow Derived Mononuclear Cells. J Stem Cell Res Ther 2013, 3:2.
32. Alok Sharma, Guneet Chopra, Nandini Gokulchandran, Mamta Lohia, Pooja
Kulkarni. Autologous Bone Derived Mononuclear Transplantation in Rett
Syndrome. Asian Journal of Paediatric Practice. 2011; 15 (1): 22-24.
33. Sharma A, Sane H, Paranjape A, Gokulchandran N, Takle M, et al. Seizures as
an Adverse Event of Cellular Therapy in Pediatric Neurological Disorders and
its Prevention. J Neurol Disord 2014; 2:164.
34. Schifter T, Hoffman, J., Hatten, H. Jr., Hanson, M., Coleman, R., DeLong G.
Neuroimaging in infantile autism, Journal of child neurology.1994; 9(2), 155-61.
Stem Cell Therapy In Neurological Disorders 120

Security in mostly a superstition. It does not exist in nature nor do

children of men as a whole experience it. Avoiding danger is no safer in the
long run than outright exposure. Life is either a daring adventure or
nothing”

– Hellen Keller
Stem Cell Therapy In Neurological Disorders 121

Stem Cell Transplantation for

Cerebral Palsy
Neurodevelopment in Cerebral Palsy can be accelerated by trophic, paracrine
and neuroregenerative properties of stem cells.

Cerebral Palsy is dened as “a disorder of movement and posture due to a defect or

lesion of the immature brain.” (1) It is known to affect 2/1000 live-born children. CP
may result from a variety of prenatal, perinatal or post natal factors. Evidence
suggests that the cause of CP in 70-80% of cases is prenatal. (2) The symptoms of CP
may vary in terms of severity. The main symptoms include muscle spasticity,
muscle weakness, uncontrolled movements, impaired mobility, speech
impairment and/or challenges in eating, dressing, bathing, etc depending on the
area of the brain affected. Movement dysfunction is often accompanied by visual
impairment, hearing loss, osteoporosis, learning disabilities, cognition impairment,
behavioral issues and seizures. Risk factors for cerebral palsy include prenatal
anemia, improper nutrition, infections, premature delivery, etc.
The conventional treatments available currently for CP are physical and behavioral
therapy, Hyperbaric oxygen therapy (HBOT), (3-5) Botulinum A toxin injection, (6)
surgical treatments, assistive devices, and medical management of associated
conditions play a supportive role. As a variety of symptoms in CP need to be
addressed, a comprehensive multidisciplinary approach needs to be established.
Unmet medical needs
The incidence of CP is increasing at an alarming rate throughout the world. Recent
Stem Cell Therapy In Neurological Disorders 122

medical advances have improved medical care, but still many challenges remain in
the management of these disorders. CP remains an incurable disorder. Hence,
establishing a standard therapeutic approach is the focus of researchers and
clinicians all over the world. Although the available treatment options are helpful in
managing the symptoms to some extent, none of them repair the underlying
damaged brain. There are no denitive treatment options to accelerate the
development of cerebral palsy patients.
Role of stem cell therapy in Cerebral palsy
Hypoxic ischemia is the most common risk factor of CP prenatally and during
delivery. Periventricular leukomalcia (PVL), a diffused damage of cerebral white
matter, could be one of the major underlying neuropathologies of CP. (7) With PVL,
the area of damaged brain tissue can affect the nerve cells that control motor
movements. Along with astrogliosis and microglial inltration, there is loss of pre-
myelinating oligodendrocytes (pre-OLs). (8) A discrepancy in neuronal functions is
triggered, as the loss of pre-OLs lead to disruption in the production of mature OLs
which further leads to disturbance in myelination. (9,10) In CP, microglial
activation also instigates the secretion of tumor necrosis factor alpha (TNF-α),
interferon gamma (INF-γ), Interleukin -1 beta (IL-1β), superoxide radicals, nitrogen
species, glutamates, adenosine which
Stem Cell Therapy in CP

Normal Brain CP Brain Injected Stem Cells in CP

Normal development Birth hypoxia/injury Increased number

of pre-OL
Damage to pre-OL in
Development of the SVZ(seen as PVL) These lead to
pre-OL to mature OL increased mature OL
Decient mature OL
Normal myelination Re-myelination
Myelination
disturbances

Normal brain Abnormal Promotes

development development of brain development of brain

Figure 1: Stem cell therapy in cerebral palsy

exerts a toxic effect on neurons and oligodendrocytes.(11) Stem cell therapy
regulates these cellular mechanisms by migrating and homing to the damaged
areas and initiating the repair process. They reduce the levels TNF- α,IL-1 β, IL-6
and increase levels of IL-10 and exert an anti-inammatory effect (12); therefore,
enhancing the endogenous brain repair. Stem cells also restore the damaged myelin
by replacing lost OLs and pre-OLs.
Stem Cell Therapy In Neurological Disorders 123

OL PROGENITOR PRE OL IMMATURE-OL MATURE-OL

Fig. 2 Phases of Oligodendrocyte development

Animal studies
Various preclinical studies have demonstrated the potential of stem cell therapy in
cerebral palsy. Administration of these cells in animal models have led to survival,
homing and differentiation into neurons, oligodendrocytes, astrocytes, etc. (13-15)
Woodbury et al. demonstrated the differentiation of bone marrow cells into
neurons in adult rats. (16) Similarly, studies have shown that umbilical cord blood
stem cells proliferate into neural cells via Sonic hedgehog (Shh) signaling pathway
and also improve sensorimotor decits along with other neurological functions.
(17-23) Park et al and Titomanlio et al reported differentiation of neural stem cells
(NSCs) into neurons and oligodendrocytes which triggered reduction in lesion size
along with improvement in memory performance. (24,25) Other cells such as
multipotent progenitor cells (MPCs) and oligodendrocyte precursor cells were also
found to be efcacious in rat models. (26)
Human studies
30 studies which include 17 clinical studies and 13 case reports have been published
to demonstrate the effects of various types of stem cells in cerebral palsy. These
studies used different cells such bone marrow derived stem cells, umbilical cord
blood cells, Olfactory Ensheathing cells, embryonic cells and neural cells.
Many studies used bone marrow derived stem cells such as bone marrow
mononuclear cells, mesenchymal cells, enriched bone marrow progenitor cells and
total nucleated cells. (27-36) These cells were administered either intravenously or
intrathecally All the authors reported these cells to be safe and efcacious.
Neurological and functional improvements were observed in all these studies.
Umbilical cord blood cells have also shown a positive outcome after intravenous
and intrathecal route of transplantation. (37-49) No major adverse events were
recorded in any study. Shroff et al, administered human embryonic stem cells
intravenously in 91 patients. 63 patients showed improvement however, seizures
were recorded as a side effect of the intervention. (50) Seledtsov et al carried out a
controlled study injecting a cell suspension from immature nervous and
haematopoietic tissues. Their ndings suggested that cell therapy was an effective,
safe and immunologically justied method of therapy for patients with cerebral
palsy. (51) Chen et al published the results of a randomized controlled study of
Stem Cell Therapy In Neurological Disorders 124

intracranial administration of olfactory ensheathing cells. (52) They reported these

cells to be safe and efcacious. Similarly, Luan et al and Chen et al, administered
neural stem cells and neural stem cell like cells intracranially and intrathecally in a
large number of cases in China and reported it to be an effective treatment for CP.
(53-55) Whereas, Rah et al, demonstrated the neuroregenerative potential of
intravenous G-CSF and autologous peripheral blood stem cells in CP, through a
randomized, double-blind, cross-over study. (56)
Our results
Published data
A study on 40 cases was carried out to evaluate the benets of stem cell therapy in
cerebral palsy. (27) These cases were administered autologous bone marrow
mononuclear cells intrathecally. On follow up after 6 months, overall 95% patients
showed improvements. The total population was further divided into diplegic,
quadriplegic and miscellaneous group of cerebral palsy. On follow up patients
showed improvements in various symptoms. (Figure3-5) On statistical analysis, a
signicant association was established between the symptomatic improvements
and stem cell therapy in diplegic and quadriplegic cerebral palsy. PET-CT scan
done in 6 patients showed metabolic improvements in areas of the brain correlating
to clinical improvements.

Figure 3: Graph demonstrating improvements in

Diplegic CP after stem cell therapy
Stem Cell Therapy In Neurological Disorders 125

Figure 4: Graph demonstrating improvements in

Quadriplegic CP after stem cell therapy

Figure 5: Graph demonstrating improvements in miscellaneous

types of CP after stem cell therapy
Stem Cell Therapy In Neurological Disorders 126

Figure 6: Improvements in PET-CT scan images of (A) pre and (B) Post intervention
showing increased metabolic activity in various areas. Blue areas indicate
hypometabolism, green areas indicate normal metabolism and yellow areas
indicate slightly high metabolism and red areas indicate high metabolism.
Case reports
We have published 8 case reports in various national and international peer
reviewed journals. (57-64) These cases were unique with respect to their age,
severity of CP, type of CP, comorbidities such as autism and ID and their outcomes.
Outcome measures such as GMFCS, GMFM, FIM were used to quantify the
outcome. PET CT scan brain was also used to monitor the metabolic changes
occurring in the brain after intervention. In all these cases, common symptomatic
improvements such as improved trunk strength, limb control, hand functions,
walking stability, balance, posture, spasticity and coordination was observed.
Transfers such as bed, sitting and getting up from the oor had become easier.
Their FIM scores improved indicating improvement in the ability to perform day to
day tasks. The case with comorbid ID showed improved IQ scores suggestive of
improved cognitive functions. These cases improved neurologically as well as
functionally. Their PET CT scans showed improved metabolism of brain areas
which were affected before the intervention. The FDG uptake of previously
hypometabolic areas had increased after stem cell therapy.
Stem Cell Therapy In Neurological Disorders 127

Unpublished data

Improvements in Cerebral Palsy A er Stem Cell Therapy (N=267)

120

41%
100

80 30%

60
20%
40
9%
20

0
No Mild Moderate Significant
Improvement Improvement Improvement Improvement

Figure 7: Graph demonstrating improvements a er

stem cell therapy in cerebral palsy.

We analysed the effect of stem cell therapy in 267 patients diagnosed with cerebral
palsy. Changes in common symptoms like oromotor/speech, balance, trunk
activity, upper limb activity, lower limb activity, muscle tone, ambulation and
Activities of Daily Living were recorded on follow up. The improvements were
graded as no change, mild improvements, moderate improvements and signicant
improvements. Analysis revealed that out of 267 patients, Overall 91.01% patients
showed symptomatic improvements. 8.98% of patients showed no improvements
in any of the symptoms. Mild improvements were observed in 29.96% of patients,
moderate in 41.19% of patients, whereas, 19.85% of patients showed signicant
improvements. We observed that patients who continued regular exercise
program at home under supervision of professional therapists showed signicant
improvements. Patients who did not follow regular rehabilitation showed mild
improvements. Therefore, in our experience stem cell therapy should be followed
by regular rehabilitation under supervision of a therapist.
PET CT Brain in CP
As discussed in previous chapter, PET CT records brain metabolism by using
uorodeoxyglucose uptake. The glucose metabolism in the brain directly correlates
with neuronal activity. Hence, PET CT scan is effectively used to monitor the effects
of stem cell therapy on brain function in CP patients. We have observed that after
stem cell therapy, areas which were hypometabolic before stem cell therapy
showed improved metabolism after intervention. Improvement in these areas
resulted in improved functions.
Stem Cell Therapy In Neurological Disorders 128

Figure 8: Comparative PET CT scan showing improved metabolism in CP. Before

stem cell therapy PET CT showed reduced metabolism in left motor cortex,
bilateral medial temporal cortex, bilateral Basal ganglia, Bilateral cerebellum.
After stem cell therapy, improvement was seen in left motor cortex, signicant
improvement in bilateral basal ganglia, Thalamus and bilateral cerebellum
Case report
A 2 years old boy was diagnosed with CP at the age of 5 months. He had an
emergency low section caesarean section birth. He did not cry immediately after
birth. There was respiratory distress hence, he was intubated and put on ventilator
for 4 days and 6 days in NICU. His MRI brain suggested periventricular
leukomalacia with atrophic corpus callosum. He also had history of seizures at 6
months and since then he has been on medication. On observation, he was
dependent for all ADLs. Responded very poorly to commands. There was no social
smile. Visual tracking was poor. Oromotor functions were affected as there was no
speech, drooling was present and he could only eat semisolid food. There was
presence of macrocephaly. On examination, right upper and lower extremities were
hypertonic while, left upper and lower extremities were normotonic. Reexes were
affected in right biceps, triceps and knee. However, they were normal in left biceps,
triceps and knee. Voluntary Control was poor in left upper extremity and lower
extremity, fair in right upper extremity and lower extremity.
On follow up at 9 months after transplantation following improvements were
observed:
• Higher mental functions were improved, specically cognition and
Stem Cell Therapy In Neurological Disorders 129

orientation. He could understand emotions better and sometimes responded to

name call as well.
• Sitting and standing posture had improved. He sat and stood more erectly.
• Weightbearing on both upper and lower extremities had improved. He had
started doing quadruped and crawling on his own. He could also perform sit to
stand with support on his own and perform weight shifts on legs.
• Reexive development had matured as he had developed equilibrium and
anticipatory postural reactions.
• Voluntary control had improved in both upper and lower extremities. Earlier,
he could not perform crawling and quadruped. Now, he could crawl and even
perform sit to stand, and kneel standing.
• Trunk-pelvis, pelvis femoral, and interlimb dissociations had improved from
poor to fair.
• Reach outs in all postures except quadruped had improved. He tried to grasp
toys in sitting, kneeling, and standing.
• Balance was better. Earlier, he would not crawl and stand. Now, he started to
stand with support. He could stand for 10-15 minutes at a stretch. Also, he
started walking with tripod cycle.
• Transitions were improved. He could perform supine to sit, sit to stand, crawl
and walks with support.
• Left hamstring and TA tightness had reduced and right hamstring and TA
tightness was not there.
• Speech had improved as vocalization had started.
• Awareness and understanding of relationships was better as he could now
recognize his father.
• Social interaction and play behavior had improved. He also developed social
smile
• He had developed visual tracking too.
• ADLs were age appropriate;
• FIM Score had improved from 58 to 61.
• GMFM Score had improved from 6.54 to 32.28.
• GMFCS had improved from level V to level IV.
Stem Cell Therapy In Neurological Disorders 130

Figure 9: Comparitive PET CT scan showing improved brain metabolism. Before

stem cell therapy, PET CT scan showed severely reduced metabolism in the
bilateral thalamus, medial temporal cortex and cerebellum. Post stem cell therapy,
it showed improved metabolism in the bilateral thalamus, medial temporal cortex
and cerebellum
Conclusion-
Various countries all over the world are performing clinical trials to study the
benet of stem cell therapy in cerebral palsy. However, for it to become a standard
treatment it is important to optimize certain factors such as type of cells to be used,
source of cells, number of cells to be administered, time and frequency of
transplantation, etc. Umbilical cord blood cells and bone marrow derived cells are
the most widely studied cells for their therapeutic potential. Use of umbilical cord
blood cells has been approved for hematological conditions; however, protocols for
their intrathecal transplantation in neurological disorders are still being
established. Safety of these cells still needs to be established. Currently, there are
safe and effective protocols available for autologous BMMNCs, which can be used
to repair the underlying neurological damage in CP. PET CT scan brain is being
studied as a monitoring tool to track changes occurring in the brain at a cellular
level. Stem cell therapy may not be a cure for CP. But, it can be used as an adjunctive
treatment modality with the current standardized medical and rehabilitation
intervention to accelerate the development of children with cerebral palsy.
Stem Cell Therapy In Neurological Disorders 131

REFERENCES
1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B,
Jacobsson B. A report: the denition and classication of cerebral palsy April
2006. Dev Med Child Neurol Suppl. 2007 Feb 1;109(suppl 109):8-14.
2. Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res
Clin Obstet Gynaecol. Jun 2004;18(3):425-36
3. Venter A, Leary M, Schoeman J, et al. Hyperbaric oxygen treatment for children
with cerebral palsy. S Afr Med J. 998;88:1362-1363
4. Cronje F. Hyperbaric oxygen therapy for children with cerebral palsy. S fr Med
J. 1999;89:359-361
5. Montgomery D, Goldberg J, Amar M, et al. Effects of hyperbaric oxygentherapy
on children with spastic diplegic cerebral palsy: a pilot project.Undersea
Hyperb Med. 1999;26:235-242
6. Graham HK, Aoki KR, Auii-Rämö I, Boyd RN, Delgado MR, Gaebler- Spira DJ,
Gormley ME, Guyer BM, Heinen F, Holton AF, Matthews D, Molnaers G, Motta
F, Garcia Ruiz PJ, Wissel J. (2000) Recommendations for the use of botulinum
toxin type A in the management of cerebral palsy. Gait Posture 11: 67-79.
7. Folkerth RD. Neuropathologic substrate of cerebral palsy. J Child Neurol.
2005;20(12):940-9.
8. Volpe JJ. Cerebral white matter injury of the premature infant-more common
than you think. Pediatrics. 2003;112:176-9.
9. Miron VE, Kuhlmann T, Antel JP. Cells of the oligodendroglial lineage,
myelination, and remyelination. Biochim Biophys Acta. 2011; 812(2):184-93.
10. Susuki K. Myelin: A Specialized Membrane for Cell Communication. Nature
Education 2010; 3(9):59
11. Hansson E, Ronnback L. Glial neuronal signaling in the central nervous system.
FASEB J 2003; 17:341-348
12. Brenneman M, Sharma S, Harting M, Strong R, Cox CS Jr, Aronowski J,
GrottaJC,Savitz SI. Autologous bone marrow mononuclear cells enhance
recovery after acute ischemic stroke in young and middle-aged rats. J Cereb
Blood Flow Metab. 2010;30(1):140-9.
13. Qu SQ, Luan Z, Yin GC, Guo WL, Hu XH, Wu NH, Yan FQ, Qian YM.
Transplantation of human fetal neural stem cells into cerebral ventricle of the
neonatal rat following hypoxic-ischemic injury: survival, migration and
differentiation. Zhonghua Er Ke Za Zhi. 2005;43(8):576-9.
Stem Cell Therapy In Neurological Disorders 132

14. Zheng T, Rossignol C, Leibovici A, Anderson KJ, Steindler DA, Weiss

MD.Transplantation of multipotent astrocytic stem cells into a rat model of
neonatal hypoxic-ischemic encephalopathy. Brain Res. 2006;1112(1):99-105.
15. Chen G, Wang Y, Xu Z, Fang F, Xu R, Wang Y, Hu X, Fan L, Liu H. Neural stem
cell-like cells derived from autologous bone mesenchymal stem cells for the
treatment of patients with cerebral palsy. J Transl Med. 2013;11:21.
16. Woodbury D, Schwarz EJ, Prockop DJ, Black IB. Adult rat and human bone
marrow stromal cells differentiate into neurons.Journal of Neuroscience
Research. 2000;61:364-370.
17. Wang XL, Zhao YS, Hu MY, Sun YQ, Chen YX, Bi XH. Umbilical cord blood
cells regulate endogenous neural stem cell proliferation via hedgehog signaling
in hypoxic ischemic neonatal rats. Brain Res. 2013;1518:26-35
18. Rosenkranz K, Tenbusch M, May C, Marcus K, Meier C. Changes in
Interleukin-1 alpha serum levels after transplantation of umbilical cord blood
cells in a model of perinatal hypoxic-ischemic brain damage. Ann Anat.
2013;195(2):122-7.
19. Wasielewski B, Jensen A, Roth-Härer A, Dermietzel R, Meier C. Neuroglial
activation and Cx43 expression are reduced upon transplantation of human
umbilical cord blood cells after perinatal hypoxic-ischemic injury. Brain Res.
2012;1487:39-53
20. Meier C, Middelanis J, Wasielewski B, Neuhoff S, Roth-Haerer A, Gantert M,
Dinse HR, Dermietzel R, Jensen A. Spastic paresis after perinatal brain damage
in rats is reduced by human cord blood mononuclear cells. Pediatr Res.
2006;59(2):244-9.
21. Geissler M, Dinse HR, Neuhoff S, Kreikemeier K, Meier C. Human umbilical
cord blood cells restore brain damage induced changes in rat somatosensory
cortex. PLoS One. 2011;6(6):e20194.
22. Pimentel-Coelho PM, Magalhães ES, Lopes LM, deAzevedo LC, Santiago MF,
Mendez-Otero R. Human cord blood transplantation in a neonatal rat model of
hypoxic-ischemic brain damage: functional outcome related to
neuroprotection in the striatum. Stem Cells Dev. 2010;19(3):351-8.
23. Tanaka N, Kamei N, Nakamae T, Yamamoto R, Ishikawa M, Fujiwara H,
Miyoshi H, Asahara T, Ochi M, Kudo Y. CD133+ cells from human umbilical
cord blood reduce cortical damage and promote axonal growth in neonatal rat
organ co-cultures exposed to hypoxia. Int J Dev Neurosci. 2010;28(7):581-7
24. Park KI, Himes BT, Stieg PE, Tessler A, Fischer I, Snyder EY. Neural stem cells
may be uniquely suited for combined gene therapy and cell replacement:
Stem Cell Therapy In Neurological Disorders 133

Evidence from engraftment of Neurotrophin-3-expressing stem cells in

hypoxic-ischemic brain injury. Exp Neurol. 2006;199(1):179-90.
25. Titomanlio L, Bouslama M, Le Verche V, Dalous J, Kaindl AM, Tsenkina Y,
Lacaud A, Peineau S, El Ghouzzi V, Lelièvre V, Gressens P. Implanted
neurosphere-derived precursors promote recovery after neonatal excitotoxic
brain injury. Stem Cells Dev. 2011;20(5):865-79.
26. Yasuhara T, Matsukawa N, Yu G, Xu L, Mays RW, Kovach J, Deans RJ, Hess DC,
Carroll JE, Borlongan CV. Behavioral and histological characterization of
intrahippocampal grafts of human bone marrow-derived multipotent
progenitor cells in neonatal rats with hypoxic-ischemic injury. Cell Transplant.
2006;15(3):231-8.
27. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Pooja Kulkarni,
Sushant Gandhi, Jyothi Sundaram, Amruta Paranjape, Akshata Shetty,
Khushboo Bhagawanani, Hema Biju and Prerna Badhe. A clinical study of
autologous bone marrow mononuclear cells for cerebral palsy patients: a new
frontier," Stem Cells International, Volume 2015, Article ID 905874, 11 pages
28. Purandare C, Shitole DG, Belle V, Kedari A, Bora N, Joshi M. Therapeutic
potential of autologous stem cell transplantation for cerebral palsy. Case Rep
Transplant. 2012;2012:825289
29. Li et al. Treatment of one case of cerebral palsy combined with posterior visual
pathway injury using autologous bone marrow mesenchymal stem cells
Journal of Translational Medicine 2012, 10:100
30. Wang X, Cheng H, Hua R, Yang J, Dai G, Zhang Z, Wang R, Qin C, An Y. Effects
of bone marrow mesenchymal stromal cells on gross motor function measure
scores of children with cerebral palsy: a preliminary clinical study.
Cytotherapy. 2013 Dec;15(12):1549-62.
31. Abi Chahine NH, Wehbe TW, Hilal RA, Zoghbi VV, Melki AE, Bou Habib EB.
Treatment of Cerebral Palsy with Stem Cells: A Report of 17 Cases.
International Journal of Stem Cells. 2016;9(1):90-95.
32. Nguyen LT, Nguyen AT, Vu CD, Ngo DV, Bui AV. Outcomes of autologous
bone marrow mononuclear cells for cerebral palsy: an open label uncontrolled
clinical trial. BMC Pediatr. 2017 Apr 12;17(1):104.
33. Liu X, Fu X, Dai G, Wang X, Zhang Z, Cheng H, Zheng P, An Y. Comparative
analysis of curative effect of bone marrow mesenchymal stem cell and bone
marrow mononuclear cell transplantation for spastic cerebral palsy. J Transl
Med. 2017 Feb 24;15(1):48.
34. Bansal H, Singh L, Verma P, Agrawal A, Leon J, Sundell IB, Koka PS.
Stem Cell Therapy In Neurological Disorders 134

Administration of Autologous Bone Marrow-Derived Stem Cells for Treatment

of Cerebral Palsy Patients: A Proof of Concept. J Stem Cells. 2016;11(1):37-49.
35. Zali A, Arab L, Ashra F, Mardpour S, Niknejhadi M, Hedayati-Asl AA,
Halimi-Asl A, Ommi D, Hosseini SE, Baharvand H, Aghdami N. Intrathecal
injection of CD133-positive enriched bone marrow progenitor cells in children
with cerebral palsy: feasibility and safety. Cytotherapy. 2015 Feb;17(2):232-41.
36. Mancías-Guerra, Consuelo, et al. "Safety and tolerability of intrathecal delivery
of autologous bone marrow nucleated cells in children with cerebral palsy: an
open-label phase I trial." Cytotherapy 16.6 (2014): 810-820.
37. Min K, Song J, Kang JY, Ko J, Ryu JS, Kang MS, Jang SJ, Kim SH, Oh D, Kim MK,
Kim SS, Kim M. Umbilical cord blood therapy potentiated with erythropoietin
for children with cerebral palsy: a double-blind, randomized, placebo-
controlled trial. Stem Cells. 2013 Mar;31(3):581-91
38. Lee et al. Safety and feasibility of countering neurological impairment by
intravenous administration of autologous cord blood in cerebral palsy. Journal
of Translational Medicine 2012, 10:58
39. Fernando Ramirez, David A. Steenblock, Anthony G. Payne And Lyn Darnall.
Umbilical Cord Stem Cell Therapy For Cerebral Palsy. Med Hypotheses Res
2006; 3: 679-686
40. A. G. Payne. Benecial effects of subcutaneously injected human umbilical cord
stem cells on cerebral palsy and traumatic brain injury in children and a posited
mechanism Medical hypotheses and research, 2005; 2(3):497-501
41. Papadopoulos KI, Low SS, Aw TC, Chantarojanasiri T. Safety and feasibility of
autologous umbilical cord blood transfusion in 2 toddlers with cerebral palsy
and the role of low dose granulocyte-colony stimulating factor injections.
Restor Neurol Neurosci. 2011; 29(1): 17-22.
42. Wang L, Ji H, Zhou J, Xie J, Zhong Z, Li M, Bai W, Li N, Zhang Z, Wang X, Zhu
D, Liu Y, Wu M. Therapeutic potential of umbilical cord mesenchymal stromal
cells transplantation for cerebral palsy: a case report. Case Rep Transplant.
2013; 2013: 146347.
43. Jensen A, Hamelmann E. First autologous cell therapy of cerebral palsy caused
by hypoxic-ischemic brain damage in a child after cardiac arrest-individual
treatment with cord blood. Case Rep Transplant. 2013;2013:951827.
44. Romanov, Yury A., et al. "Human allogeneic AB0/Rh-identical umbilical cord
blood cells in the treatment of juvenile patients with cerebral palsy."
Cytotherapy (2015)
Stem Cell Therapy In Neurological Disorders 135

45. Zhang, Che, et al. "Therapy for Cerebral Palsy by Human Umbilical Cord Blood
Mesenchymal Stem Cells Transplantation Combined With Basic Rehabilitation
Treatment A Case Report." Global Pediatric Health 2 (2015): 2333794X15574091.
46. Wang, Xiaodong, et al. "Effect of umbilical cord mesenchymal stromal cells on
motor functions of identical twins with cerebral palsy: pilot study on the
correlation of efcacy and hereditary factors." Cytotherapy 17.2 (2015): 224-231.
47. Yang et al. Effect of Umbilical Cord Mesenchymal Stem Cell Transplantation
Therapy for Cerebral Palsy on Motor Function. Progress in modern
Biomedicine. 2012-02
48. Sun JM, Song AW, Case LE, Mikati MA, Gustafson KE, Simmons R, Goldstein
R, Petry J, McLaughlin C, Waters-Pick B, Chen LW, Wease S, Blackwell B,
Worley G, Troy J, Kurtzberg J. Effect of Autologous Cord Blood Infusion on
Motor Function and Brain Connectivity in Young Children with Cerebral Palsy:
A Randomized, Placebo-Controlled Trial. Stem Cells Transl Med. 2017
Dec;6(12):2071-2078.
49. Dong H, Li G, Shang C, Yin H, Luo Y, Meng H, Li X, Wang Y, Lin L, Zhao M.
Umbilical cord mesenchymal stem cell (UC-MSC) transplantations for cerebral
palsy. Am J Transl Res. 2018 Mar 15;10(3):901-906.
50. Shroff, Geeta, Anupama Gupta, and Jitender Kumar Barthakur. "Therapeutic
potential of human embryonic stem cell transplantation in patients with
cerebral palsy." Journal of translational medicine 12.1 (2014): 1.
51. Seledtsov, V. I.; Kafanova, M. Y.; Rabinovich, S. S.; Poveshchenko, O. V.;
Kashchenko, E. A.; Fel'de, M. A.; Samarin, D. M.; Seledtsova, G. V.; Kozlov, V.
A. Cell therapy of cerebral palsy. Bull. Exp. Biol Med. 139(4): 499–503; 2005
52. Lin Chen, Hongyun Huang, Haitao Xi, et al. Intracranial Transplant of
Olfactory Ensheathing Cells in Children and Adolescents With Cerebral Palsy:
A Randomized Controlled Clinical Trial. Cell Transplantation, Vol. 19, pp.
185–191, 2010
53. Chen G, Wang Y, Xu Z, Fang F, Xu R, Wang Y, Hu X, Fan L, Liu H. Neural stem
cell-like cells derived from autologous bone mesenchymal stem cells for the
treatment of patients with cerebral palsy. J Transl Med. 2013;11:21.
54. Luan Z, Liu W, Qu S, Du K, He S, Wang Z, Yang Y, Wang C, Gong X. Effects of
neural progenitor cell transplantation in children with severe cerebral palsy.
Cell Transplant. 2012; 21 Suppl 1:S91-8.
55. Luan, Zuo, Su-qing Qu, and Wei-peng Liu. "Treatment of heteroptics after
cerebral palsy with transplantation of human neural stem cells into cerebral
ventricle in infants: 7 case report." Chinese Journal of Rehabilitation Theory and
Stem Cell Therapy In Neurological Disorders 136

Practice 13 (2007): 1103-1105.

56. Rah WJ, Lee YH, Moon JH, Jun HJ, Kang HR, Koh H, Eom HJ, Lee JY, Lee YJ,
Kim JY, Choi YY, Park K, Kim MJ, Kim SH. Neuroregenerative potential of
intravenous G-CSF and autologous peripheral blood stem cells in children with
cerebral palsy: a randomized, double-blind, cross-over study. J Transl Med.
2017 Jan 21;15(1):16.
57. Alok Sharma, Pooja Kulkarni, Ritu Varghese, Hemangi Sane, Sanket Inamdar,
Jasbinder Kaur, Samson Nivins, Nandini Gokulchandran, Prerna Badhe.
Clinical translation of the benets of cell transplantation in a case of cerebral
Palsy. International Journal of Biological and Medical Research. Jan 2018.
58. Alok Sharma, Nandini Gokulchandran, Prerna Badhe, Vaibhav Lakhanpal,
Pooja Kulkarni, Suhasini Pai, Khushboo Bhagwanani, Amruta Paranjape and
Hemangi Sane. Multidisciplinary Approach of Cellular Therapy with
Neurorehabilitation in a Case of Mixed Cerebral Palsy. World J. Biol. Med.
Science Volume 4 (3) 70-74, 2017
59. Dr. Alok Sharma, Dr. Nandini Gokulchandran, Mrs. Suhasini Pai, Ms. Pooja
Kulkarni , Dr. Hemangi Sane , Dr. Khushboo Bhagwanani ,Dr. Prerna Badhe.
Diplegic dystonic Cerebral Palsy treated with cellular therapy: a case report.
Journal- International Journal of Case Studies. 2017
60. Sharma A, Sane H, Kalburgi S, Kulkarni P, Bhagwanani K, et al. Autologous
Bone Marrow Mononuclear Cell Transplantation with Neurorehabilitation for
Cerebral Palsy. J Stem Trans Bio 2017; 2(1): 110
61. Alok Sharma, Hemangi Sane, Suhasini Pai, Pooja Kulkarni, Meenakshi
Raichur , Sarita Kalburgi, Sanket Inamdar, Nandini Gokulchandran, Prerna
Badhe. Intrathecal administration of autologous bone marrow mononuclear
cells in a case of Cerebral Palsy coexisting with autistic features". Phys Med
Rehabil Int. 2017; 4(1): 1110.
62. Alok Sharma, Hemangi Sane, Pooja Kulkarni, Myola D'sa, Nandini
Gokulchandran, Prerna Badhe. Improved Quality of Life in a Case of Cerebral
Palsy after bone marrow mononuclear cell transplantation. Cell J. 2015; 17(2):
389-394.
63. Alok Sharma, Hemangi Sane, Amruta Paranjape, Nandini Gokulchandran,
Pooja Kulkarni and Anjana Nagrajan, Prerna Badhe. Positron Emission
Tomography – Computer Tomography scan used as a monitoring tool
following cellular therapy in Cerebral Palsy and Mental Retardation – A Case
Report. Case Reports in Neurological Medicine. Volume 2013, Article ID
141983, 6 pages.
Stem Cell Therapy In Neurological Disorders 137

64. Dr. Alok Sharma, Ms. Pooja Kulkarni, Dr. Hemangi Sane, Dr. Nandini
Gokulchandran, Dr. Prerna Badhe, Dr. Mamta Lohia, Dr. Priti Mishra. Positron
Emission Tomography- Computed Tomography scan captures the effects of
cellular therapy in a case of cerebral palsy. Journal of clinical case reports. 2012 J
Clin Case Rep 2:195.
Stem Cell Therapy In Neurological Disorders 138

"What is at stake, in the present moment, is not the future. What is at stake
now is the stand you and I take for the future - whether our day to day lives
could be lived in the context of a reality which we cannot now even imagine.
Our work has never been about altering things within our realities, within
the realm of possibilities. It is about being able to create the realm of
possibilities itself, to bring forth that which heretofore was unimaginable”

– Werner Erhard
Stem Cell Therapy In Neurological Disorders 139

10

Role of Stem Cells in

Muscular Dystrophy
“If a treatment (for muscular dystrophy) does not replenish the stem cell
compartment, it will be likely fail; it would be like pushing the gas pedal to the
oor when there is no reserve."- Jason Pomerantz, MD

Muscular dystrophy (MD) is a heterogeneous group of genetic disorders that

weaken the muscles of the body. It is characterized by progressive weakness and
wasting of these muscles (1). Each type of muscular dystrophy is associated with a
distinct genetic mutation. Mutation is seen in different components of dystrophin-
glycoprotein complex (DGC) which links the extracellular matrix in muscle to the
intracellular cytoskeleton resulting in destabilization of the muscle membrane,
increased muscle fragility and degeneration, and muscle wasting (2, 3). The nature
of the gene mutation and location of the chromosome determines the characteristics
of the muscular dystrophy and their inheritance. Pre- clinical studies have shown
that muscle weakness in muscular dystrophy is caused not only due to muscle ber
fragility but also due to hampered muscle regeneration caused by intrinsic satellite
cell dysfunction (4). Although the disease progression is due to dystrophin and
other muscle proteins' deciency, it is ultimately a stem cell disease (5).
The types of MD vary according to severity, age of onset, and selective involvement
of muscle groups. The most common types are Duchenne, Becker, limb girdle,
congenital, facioscapulohumeral, myotonic, oculopharyngeal, distal and Emery-
Dreifuss (6). Of these, DMD is the most severe form of muscular dystrophy. All
forms of MD are characterized by a progressive muscle weakness with some types
Stem Cell Therapy In Neurological Disorders 140

affecting cardiac muscle. Abnormal gait (waddling gait) with frequent falls,
difculty in rising from the oor and climbing stairs, pseudohypertrophy of calves,
positive Gowers' sign and scoliosis or kyphosis are a few common symptoms
presented by the affected population of MD (7). With decreasing muscle strength in
those that are affected, function is compromised, interfering with the activities of
daily living and ambulation. Once wheelchair-bound, contractures and spinal
deformities further worsen. On an average, for every 10 degrees of thoracic
scoliosis, there is a 4% decrease in forced vital capacity. This along with cardiac
involvement may result in death (8).

Figure 1: Pathophysiology of the most common muscular dystrophy type;

Duchenne muscular dystrophy (DMD).

Despite extensive studies being carried out in this eld, there is currently no
effective treatment for the same (9). The conventional treatments include medical
intervention such as corticosteroids, physical and occupational therapy, assistive
devices, etc. Corticosteroids help by reducing muscle inammation and
improvements in muscle function (10). Steroids also delay the onset of
cardiomyopathy (11).
Stem Cell Therapy In Neurological Disorders 141

Unmet Medical Needs

The treatments available currently for muscular dystrophy alleviate few symptoms
of the disorder but do not act at the cellular level. They fail to carry out the repair and
regeneration of the damaged muscles. Also, no treatment repairs the underlying
mutation of the genes which cause MD. Gene therapy is being explored and though
appealing as a treatment option in muscular dystrophy. But due to immune
responses and safety issues, it has not been established as a treatment option. No
standard therapeutic modality has been successful to halt the progression of the
disease or increase the survival. Botulinum toxin Type A maybe indicated for
improvement in joint range and minimizing contractures, however these effects are
temporary. Exon skipping which makes use of synthetic antisense oligonucleotide
sequences results in restoration of the reading frame and partial production of
functional dystrophin (12). Recently,
eteplirsen, an antisense oligonucleotide, has
received approval, but is limited to treatment
of patients who have a mutation in the
dystrophin gene that is amenable to exon 51
skipping (13). Also, in the study 6MWT was
used as an outcome measure. While the study
demonstrated improvement in the 6 MWT
distance and a slower rate of loss of
ambulation, two of twelve patients still lost
ambulation. The drug thus does not provide a
cure.
Role of stem cell therapy in MD
Wallace et al postulated the underlying
pathogenic mechanism of muscular
dystrophy to be an imbalance between muscle
damage or degeneration and muscle repair
through stem-cell mediated regeneration (14).
Continuous cycles of degeneration and
regeneration of muscle bers exhausts the
muscle stem cell pool, leading to muscle being
replaced by adipose and brotic tissue. Stem
cell therapy holds promise as a treatment for
muscular dystrophy by providing cells that
can both deliver functional muscle proteins
and replenish the stem cell pool (15).

Figure 2: Normal process of muscle repair.

Stem Cell Therapy In Neurological Disorders 142

The mechanisms by which stem cells may function and reverse the effects of cell
death include differentiation, cell fusion, and secretion of cytokines or paracrine
effects (16-18). These cells have the capacity to mobilize and exert their reparative
effects at the site of injury. They are known to enhance angiogenesis and contribute
to neovascularization by producing signaling molecules such as vascular
endothelial growth factors (VEGF) and broblast growth factors (FGF2) (19). Along
with increase in angiogenesis, they also promote tissue remodeling, prevent
apoptosis, decrease inammation, release growth factors and activate the satellite
cells (20). In animal studies, these cells have shown to produce the decient proteins
and make new muscle cells which fuse with the host bers. Satellite cells, the adult
skeletal muscle progenitor cells, are commonly considered to be the main cell type
involved in skeletal muscle regeneration. Further, stem cell derived exosomes
which are small membrane vesicles and are responsible for inter cellular
communication; promote muscle regeneration by enhancing myogenesis and
angiogenesis.
Although, MD is primarily a muscle disease, dystrophin-glycoprotein complex
(DGC) is also a component of neurons and glia in the brain. Therefore, part of the
cell fraction is injected intrathecally (21). Neuromuscular junction is also impaired
in MD due to synaptic abnormalities. Injecting the cells at the motor points ensures
repair of both, the muscles and the nerves.

Figure 3: Role of stem cells seen in DMD (in other forms of muscular dystrophy,
there is an increase in the decient protein based on the type).
Stem Cell Therapy In Neurological Disorders 143

Precautionary measures before stem cell therapy in MD

Before stem cell therapy, biochemical and hematological blood tests, chest X-ray, 2-
D Echo are performed. Patients with respiratory distress/ respiratory tract
infections, or with acute infections such as, fever, hemoglobin less than 8 g/dl,
bleeding tendencies, left ventricular ejection fraction less than 30% are at high risk
for developing complications after stem cell therapy. High risk precautions should
be taken in these cases before stem cell transplantation. Anaesthesia risk should also
be evaluated for all MD patients before cell therapy.
It is recommended that following stem cell therapy, patients perform voluntary/
assisted active exercises, low-intensity exercises such as swimming avoiding
overexertion. Eccentric exercises such as running or walking downhill should be
avoided (22). Those suffering from MD are at risk of developing osteoporosis with a
consequent susceptibility to fractures. Prolonged exposure to corticosteroids
further negatively impacts bone density. It is therefore important that patients
receive a daily vitamin D supplement. Regular screening of bone density, X-ray
especially of the spine, pelvis and hips should be done. In those patients with
cardiac involvement and in patients with DMD and BMD, complete cardiac
evaluation is recommended. The prophylactic use of ACE inhibitors is
recommended before the establishment of cardiomyopathy (23). Additionally,
evaluation and treatment of respiratory abnormalities should be done.
Musculoskeletal Magnetic Resonance Imaging (MSK MRI) is a useful, non invasive
tool to track disease progression and can serve as an objective measure for assessing
efcacy of a treatment. Diffusion Tensor Imaging (DTI) measures the anisotropy of
water diffusion. DTI may be applied to skeletal muscle as it denes structural
details of a muscle. Since, muscle injury from muscular dystrophy affects the
integrity of muscle microstructure; changes are noted in the DTI parameters. The
fractional anisotropy (FA) is the most commonly used tensor value. The
microstructural changes are thus reected by changes in FA values (24).
Progression of the disease process is marked by an increase in FA values.
Conversely, decrease in FA values is a positive outcome to a treatment measure.
Preclinical studies
Preclinical studies in mouse models of various muscular dystrophies have
demonstrated that myoblasts on transplantation into dystrophic muscle could
repair damaged myobres. However, myoblast transplantation did not show
effective results due to rapid death of most injected myoblasts and the failure of
injected myoblasts to migrate from the injection site (25). Other cells such as adult-
derived stem cells, including bone marrow-derived stem cells, blood and muscle-
derived CD133+ cells, muscle-derived stem cells (MDSC), side population (SP) cells
and mesoangioblasts have been tested in animal models (16,26-32).
Stem Cell Therapy In Neurological Disorders 144

A study that used adult muscle mononuclear cells (AMMCs) in sarcoglycan null
dystrophic mice found that AMMCs were 35 times more efcient at restoring
sarcoglycan compared to cultured myoblasts (33). Similar studies were carried out
using side population (SP) cells (34).
A study carried out to track the fate of bone marrow derived stem cells (BMSC) in
mouse models of muscular dystrophy using green uorescent protein-positive
(GFP+) demonstrated that transplanted BMSC differentiate into muscle cells via
repopulation of the muscle stem cell compartment (35). Similar test was carried out
using 3H-thymidine labeled human bone marrow derived MSCs (36). Embryonic
stem cells (ESC) have also shown its potential in muscle regeneration. On injecting
wild type ESCs into the mdx blastocysts, mice with improved pathology and
function were produced (37-39). However, due to ethical issues and immune
rejection not many studies have been carried out on humans using ESCs.
Experimental studies have also been carried out where human umbilical cord blood
(HUCB) cells have shown to differentiate into muscle cells (40,41).
Clinical studies
Around 20 studies are published demonstrating the effect of stem cell therapy in
different types of muscular dystrophies. Various types of stem cells are being
explored such as autologous bone marrow mononuclear cells, allogenic umbilical
cord stem cells, bone marrow mesenchymal cells, muscle precursor cells, muscle
derived 133+ cells, myogenic cells.
Torrente et al [42] tested the safety of autologous transplantation of muscle derived
CD133+ cells in eight boys with Duchenne muscular dystrophy in a 7-month,
double-blind phase I clinical trial. No local or systemic side effects were observed in
all treated DMD patients. Treated patients had an increased ratio of capillary per
muscle ber with a switch from slow to fast myosin-positive myobers. On the
other hand, donor myoblasts injected into muscles of 12 patients with DMD, did not
show any signicant difference in muscle strength between arms injected with
myoblasts and sham-injected arms [43]. 4 patients however, had low levels of donor
dystrophin. In another study, 3 DMD patients received injections of myogenic cells
[44]. Dystrophin-positive myobers were observed 4 weeks later in all the patients.
In another single case report, donor-derived dystrophin was found in the muscles,
of a patient with DMD, that were injected with allogenic muscle precursor cells [45].
Double transplantations of autologous bone marrow mesenchymal stem cells and
umbilical cord mesenchymal stem cells was tested for safety and efcacy in
progressive muscular dystrophy [46]. Treatment efcacy was observed in 68 of 82
patients (82.9% efcacy) and was found to be safe. In another single-blinded study,
11 DMD patients received umbilical cord mesenchymal stem cells [47]. Stabilisation
or improvement in muscle strength was found in all the treated patients while
Stem Cell Therapy In Neurological Disorders 145

control group showed a decline in muscle strength at 1 year follow up. An 11-year-
old DMD boy underwent umbilical cord blood stem cell transplantation [48].
Serum creatine kinase levels declined from 6000 U/L to 2200 U/L post intervention
together with improvements in walking, turning the body over, and standing up, 6
weeks post intervention. Umbilical cord-derived hematopoietic stem cell
transplantation on the other hand was not found to be efcacious in DMD [49].
Intrathecal and intramuscular transplantation of autologous BMMNCs showed
symptomatic and functional improvements in 130 of 150 patients with MD [50].
Stabilisation or improvement in muscle strength and function was found in all 65
patients with LGMD following intrathecal and intramuscular transplantation of
autologous BMMNCs [51]. Intrathecal and Intramuscular transplantation in 10
separate case reports demonstrated improvement in function and muscle strength
in different MD variants [52-61].
Side Effects
None of the studies encountered any serious side effects. Some minor procedural
side effects were noted, such as pain at the site of injection and bone marrow
aspiration in case of autologous transplantation. These side effects were self
limiting and resolved within a week with medications. Allogenic umbilical cord
derived hematopoietic stem cell transplantation resulted in the graft rejection
during rst transplant which was resolved during subsequent transplants.
Our results
150
Published data 135

A study was carried out 120

105
on 150 patients diagnosed 38.66%
90
w i t h M u s c u l a r
75
Dystrophy. On a mean 28.66%
60
follow up period of 12 45 19.33%
months ± 1 month, 30 13.33%
86.67% cases showed 15
symptomatic and func- 0
No Mild Moderate Significant
tional improvements, Improvement Improvement Improvement Improvement
with 6 patients showing
Figure 4: Graph showing improvements in muscular
muscle regeneration and
dystrophy patients after stem cell therapy.
decrease in fatty inltra-
y-axis = number of patients (n = 150).
tion on Musculoskeletal
Magnetic Resonance Imaging (MSK MRI) and 9 showing improved muscle electri-
cal activity on Electromyography (EMG). 53% cases showed increase in trunk
muscle strength, 48% an increase in upper limb strength, 59 % an increase in lower
limb strength and about 10 % showed an improved gait pattern.
Stem Cell Therapy In Neurological Disorders 146

150
135
120 59.33%
105
90 53.33%
48%
75
40%
60
45
30
10.66%
15
0
Trunk UL LL Gait Started
Strenth Strength Strenght Improved Standing

Figure 5: Graph showing symptomatic improvements in muscular dystrophy

patients after stem cell therapy. Number of patients showing improvements in
trunk strength, upper limb (UL) strength, lower limb (LL) strength, gait pattern,
and standing function are shown. y-axis = number of patients (n = 150).

Figure 6: Figures a & b shows the Musculoskeletal MRI images before and after
stem cell therapy, respectively. Figure b shows regeneration of muscle in vastus
medialis and vastus lateralis.

Figure 7: Figures, A & B show MRI Musculoskeletal images before and after stem
cell therapy. Regeneration of muscles is seen in Fig B.
Stem Cell Therapy In Neurological Disorders 147

Figure 8: The gures A & B show MRI Musculoskeletal images before and after stem
cell therapy, respectively. Regeneration of muscles is seen in Figure B.
An individual study comprising of LGMD patients was also published. This study
included 65 patients diagnosed as LGMD that underwent autologous bone marrow
mononuclear cells intrathecally and intramuscularly. While 59 cases completed the
study, 6 were lost to follow up. These cases were divided into 3 groups depending
on the number of transplantations administered. Group 1 included the cases who
underwent one stem cell therapy (N=31). Group 2 included cases who underwent
two transplantations (N=24). Group 3 included cases who underwent 3
transplantations (N=4). In group 1, 97% of the patients showed improved function.
The total percentage of strength improvement ranged from 84% to 100% in all the
muscles. In group 2, 96% of the patients showed an improved function. The total
percentage of strength improvement ranged from 90% to 100% in all the muscles. In
group 3, of the four patients, one patient deteriorated in his FIM score, whereas two
patients improved, and one maintained functional status. Most of the patients had
maintained muscle strength.
Unpublished data
512 patients diagnosed with muscular dystrophy were analyzed. Symptomatic
analysis was done for the core symptoms of the disease. These included changes in
ambulatory status, hand functions, balance, stamina/fatigue, trunk activation and
standing. They were graded as no change, mild, moderate and signicant change.
On follow up, out of 332 patients, 85.74% of patients showed improvements while
14.25% of patients remained stable without deterioration in any of the symptoms.
Mild improvements were observed in 20.31% of patients, moderate in 35.74% of
patients, whereas, 29.68% of patients showed signicant improvements.
Duchenne Muscular Dystrophy
Total of 139 boys detected with DMD underwent autologous bone marrow
mononuclear cell intrathecal and intramuscular transplantation. Mean age of the
group was 11 years, ranging from 3 to 23 years. 39 boys were below the age of 10
years at admission, 77 were between 10 to 15 years and 23 boys were over the age of
Stem Cell Therapy In Neurological Disorders 148

15 years. 57 boys were ambulatory at assessment and 81 were non-ambulatory.

Genetic testing was available for 64 boys, 38 of which showed distal rod (45-55) exon
deletions, 7 showed proximal rod (3-21) exon deletion, 2 showed both proximal and
distal rod, 4 showed deletion of exons in other regions and 13 patients showed no
deletions but mutations.
Functional status and muscle strength were assessed using, functional
independence measure (FIM) scale, Brooke and Vignos scale and manual muscle
testing. In addition to these outcome measures the time till ambulation was
compared with 35 age matched patients that chose not to undergo stem cell therapy
after initial consultation.
The changes in the scales were analyzed statistically using matched pair Wilcoxon
Sign Rank test (Table 1 and 2). There was no statistically signicant deterioration in
these scales suggesting the delayed progression of the disease. Kaplan-Meier
Survival Analysis was used to compare the age at loss of ambulation (Figure 1,
Table 3). There was a statistically signicant difference in the time till loss of
ambulation for children that underwent stem cell therapy from those that did not.
The average predicted age at the time till loss of ambulation was 142 months f o r
children that did not undergo stem cell therapy; whereas it was signicantly higher,
204 months, in children that underwent stem cell therapy. Percentage analysis was
performed for the symptomatic improvement in these children (Table 4, Figure 2).
This analysis suggested that majority of the patients had shown improvement or
halting of the progression in postural deviations, neck weakness, bed mobility,
trunk activity, gross and ne motor function, functional upper limb activity,
walking and standing. The pre and post therapy measurements were performed at
a median follow up duration of 6 months.

Table1. Matched pair Wilcoxon Sign Rank test analysis of outcome measures pre
and post therapy
Stem Cell Therapy In Neurological Disorders 149

Table2. Matched pair Wilcoxon Sign Rank test analysis of modied manual muscle
testing scale

Table3. Kaplan-Meier analysis of time till loss of ambulation for patients with and
without stem cell therapy
Stem Cell Therapy In Neurological Disorders 150

Survival Functions

1.0
CONORINT
1
2
1-censored
2-censored
0.8
DMD patients that
received cellular therapy
Cum survival

0.6

DMD patients that did not

receive cellular therapy
0.4

0.2

0.0

00 50.00 100.00 150.00 200.00 250.00 300.00

MONTHS TILL LOSS OF AMBULATION

Figure 9: Kaplan-Meier curve analysis of time till loss of ambulation in patients

with and without stem cell therapy

Figure 10: Percentage analysis of symptomatic improvement in the patients with

stem cell therapy
Stem Cell Therapy In Neurological Disorders 151

Table4. Percentage analysis of modied manual muscle testing scale

Stem Cell Therapy In Neurological Disorders 152

All the studies have demonstrated stem cell transplantation to be safe. Since,
muscular dystrophy is a group of genetic disorders; stem cell therapy is not a cure.
However together with neurorehabilitation, it can be effective and may slow down
the disease progression. Though, MD is mainly a disease of the muscle, dystrophin-
glycoprotein complex is also a component of the neurons and glia of the brain. Also
due to synaptic abnormalities, neuromuscular junction is affected. Stem cell
therapy should therefore target the nervous system, the innervating nerves and
muscles. Since, muscular dystrophy maybe accompanied by cardiac involvement,
regular screening and treatment of cardiomyopathy is essential. Along with this
regular evaluation of pulmonary function and care are required. It is important that
stem cell therapy along with multidisciplinary care is done at an early stage before
the disease process has caused much damage.
Although evidence is still limited, stem cell therapy together with multidisciplinary
care improves the quality of life and shows promise as a treatment option in
muscular dystrophies.
Future Directions
In disorders involving muscular damage, the side population (SP) cells are
responsible for production of bro-adipogenic precursors (FAPs), broblasts and
ultimately adipocytes as a response to the injury (58). Hence, brosis and fat
deposition is observed in most chronic muscular dystrophies. This may hinder the
repair and regenerative potential of the transplanted stem cells which may decrease
the efcacy of intervention. Hence, the future research should be focused on
manipulating the cells so as to bypass the fat generation and to stimulate muscle
regeneration. Since, MD is a genetic disorder; leading to low production of
dystrophin or other muscle proteins, genetic correction plus utilization of the
regenerative ability of stem cells to restore the already damaged muscles maybe the
key to treatment of MDs. A combination of gene therapy and cellular therapy may
thus be a powerful tool. Studies should be directed at assessing which cell types are
most benecial and also the route of administering these cells to the target muscles
and innervating nerves. Also, studies carried out so far lack the inclusion of imaging
techniques. MSK MRI maybe a useful, non-invasive tool tool to track disease
progression and can serve as an objective measure for assessing efcacy of a
treatment.
REFERENCES
1. Rahimov F, Kunkel LM. The cell biology of disease: cellular and molecular
mechanisms underlying muscular dystrophy. J Cell Biol. 2013
May13;201(4):499-510.
2. Rando TA. The dystrophin–glycoprotein complex, cellular signaling, and the
regulation of cell survival in the muscular dystrophies. Muscle & nerve. 2001
Stem Cell Therapy In Neurological Disorders 153

Dec 1;24(12):1575-94.
3. Wang Z, Chamberlain JS, Tapscott SJ, Storb R. Gene therapy in large animal
models of muscular dystrophy. ILAR journal. 2009 Jan 1;50(2):187-98.
4. Dumont NA, Wang YX, von Maltzahn J, Pasut A, Bentzinger CF, Brun CE,
Rudnicki MA. Dystrophin expression in muscle stem cells regulates their
polarity and asymmetric division. Nature medicine. 2015 Dec 1;21(12):1455-63.
5. Sacco A, Mourkioti F, Tran R, Choi J, Llewellyn M, Kraft P, Shkreli M, Delp S,
Pomerantz JH, Artandi SE, Blau HM. Short telomeres and stem cell exhaustion
model Duchenne muscular dystrophy in mdx/mTR mice. Cell. 2010 Dec
23;143(7):1059-71.
6. Emery AE. The muscular dystrophies. The Lancet. 2002 Feb 23;359(9307):687-
95.
7. Goyenvalle A, Seto JT, Davies KE, Chamberlain J. Therapeutic approaches to
muscular dystrophy. Human molecular genetics. 2011 Mar 24:ddr105.
8. Kurz LT, Mubarak SJ, Schultz P, Park SM, Leach J. Correlation of scoliosis and
pulmonary function in Duchenne muscular dystrophy. Journal of pediatric
orthopedics. 1983 Jul;3(3):347-53.
9. Emery AE, Muntoni F. Duchenne Muscular DystrophyOxford University
Press.
10. Baschant U, Tuckermann J. The role of the glucocorticoid receptor in
inammation and immunity. The Journal of steroid biochemistry and
molecular biology. 2010 May 31;120(2):69-75.
11. Barber BJ, Andrews JG, Lu Z, West NA, Meaney FJ, Price ET, Gray A, Sheehan
DW, Pandya S, Yang M, Cunniff C. Oral corticosteroids and onset of
cardiomyopathy in Duchenne muscular dystrophy. The Journal of pediatrics.
2013 Oct 31;163(4):1080-4.
12. Mah JK. Current and emerging treatment strategies for Duchenne muscular
dystrophy. Neuropsychiatric Disease and Treatment. 2016;12:1795.
13. Mendell JR, Goemans N, Lowes LP, Alfano LN, Berry K, Shao J, Kaye EM,
Mercuri E. Longitudinal effect of eteplirsen versus historical control on
ambulation in Duchenne muscular dystrophy. Annals of neurology. 2016 Feb
1;79(2):257-71.
14. Wallace GQ, McNally EM. Mechanisms of muscle degeneration, regeneration,
and repair in the muscular dystrophies. Annual review of physiology. 2009 Mar
17;71:37-57.
Stem Cell Therapy In Neurological Disorders 154

15. Meregalli M, Farini A, Colleoni F, Cassinelli L, Torrente Y. The role of stem cells
in muscular dystrophies. Current gene therapy. 2012 Jun 1;12(3):192-205.
16. Orlic D, Kajstura J, Chimenti S, Bodine DM, Leri A, Anversa P. Bone marrow
stem cells regenerate infarcted myocardium. Pediatric transplantation. 2003
Apr 1;7(s3):86-8.
17. Plotnikov EY, Khryapenkova TG, Vasileva AK, Marey MV, Galkina SI, Isaev
NK, Sheval EV, Polyakov VY, Sukhikh GT, Zorov DB. Cell-to-cell cross-talk
between mesenchymal stem cells and cardiomyocytes in co-culture. Journal of
cellular and molecular medicine. 2008 Sep 1;12(5a):1622-31.
18. Cselenyák A, Pankotai E, Horváth EM, Kiss L, Lacza Z. Mesenchymal stem cells
rescue cardiomyoblasts from cell death in an in vitro ischemia model via direct
cell-to-cell connections. BMC Cell Biology. 2010 Apr 20;11(1):1.
19. Dellavalle A, Sampaolesi M, Tonlorenzi R, Tagliaco E, Sacchetti B, Perani L,
Innocenzi A, Galvez BG, Messina G, Morosetti R, Li S. Pericytes of human
skeletal muscle are myogenic precursors distinct from satellite cells. Nature cell
biology. 2007 Mar 1;9(3):255-67.
20. Torrente Y, Belicchi M, Sampaolesi M, Pisati F, Meregalli M, D'Antona G,
Tonlorenzi R, Porretti L, Gavina M, Mamchaoui K, Pellegrino MA. Human
circulating AC133+ stem cells restore dystrophin expression and ameliorate
function in dystrophic skeletal muscle. The Journal of clinical investigation.
2004 Jul 15;114(2):182-95.
21. Waite A, Brown SC, Blake DJ. The dystrophin–glycoprotein complex in brain
development and disease. Trends in neurosciences. 2012 Aug 31;35(8):487-96.
22. Jansen M, de Groot IJ, van Alfen N, Geurts AC. Physical training in boys with
Duchenne Muscular Dystrophy: the protocol of the No Use is Disuse study.
BMC pediatrics. 2010 Aug 6;10(1):1.
23. Duboc D, Meune C, Pierre B, Wahbi K, Eymard B, Toutain A, Berard C,
Vaksmann G, Weber S, Bécane HM. Perindopril preventive treatment on
mortality in Duchenne muscular dystrophy: 10 years' follow-up. American
heart journal. 2007 Sep 30;154(3):596-602.
24. Kim HK, Lindquist DM, Serai SD, Mariappan YK, Wang LL, Merrow AC,
McGee KP, Ehman RL, Laor T. Magnetic resonance imaging of pediatric
muscular disorders: recent advances and clinical applications. Radiologic
Clinics of North America. 2013 Jul 31;51(4):721-42.
25. Fan Y, Maley M, Beilharz M, Grounds M. Rapid death of injected myoblasts in
myoblast transfer therapy. Muscle & nerve. 1996 Jul 1;19(7):853-60.
Stem Cell Therapy In Neurological Disorders 155

26. Gussoni E, Soneoka Y, Strickland CD, Buzney EA, Khan MK, Flint AF, Kunkel
LM, Mulligan RC. Dystrophin expression in the mdx mouse restored by stem
cell transplantation. Nature. 1999 Sep 23;401(6751):390-4.
27. Minasi MG, Riminucci M, De Angelis L, Borello U, Berarducci B, Innocenzi A,
Caprioli A, Sirabella D, Baiocchi M, De Maria R, Boratto R. The meso-
angioblast: a multipotent, self-renewing cell that originates from the dorsal
aorta and differentiates into most mesodermal tissues. Development. 2002 Jun
1;129(11):2773-83.
28. Jiang Y, Jahagirdar BN, Reinhardt RL, Schwartz RE, Keene CD, Ortiz-Gonzalez
XR, Reyes M, Lenvik T, Lund T, Blackstad M, Du J. Pluripotency of
mesenchymal stem cells derived from adult marrow. Nature. 2002 Jul
4;418(6893):41-9.
29. Dezawa M, Ishikawa H, Itokazu Y, Yoshihara T, Hoshino M, Takeda SI, Ide C,
Nabeshima YI. Bone marrow stromal cells generate muscle cells and repair
muscle degeneration. Science. 2005 Jul 8;309(5732):314-7.
30. Collins CA, Olsen I, Zammit PS, Heslop L, Petrie A, Partridge TA, Morgan JE.
Stem cell function, self-renewal, and behavioral heterogeneity of cells from the
adult muscle satellite cell niche. Cell. 2005 Jul 29;122(2):289-301.
31. Dellavalle A, Sampaolesi M, Tonlorenzi R, Tagliaco E, Sacchetti B, Perani L,
Innocenzi A, Galvez BG, Messina G, Morosetti R, Li S. Pericytes of human
skeletal muscle are myogenic precursors distinct from satellite cells. Nature cell
biology. 2007 Mar 1;9(3):255-67.
32. Flix B, Suárez-Calvet X, Díaz-Manera J, Santos-Nogueira E, Mancuso R,
Barquinero J, Navas M, Navarro X, Illa I, Gallardo E. Bone marrow
transplantation in dysferlin-decient mice results in a mild functional
improvement. Stem cells and development. 2013 Jun 18;22(21):2885-94.
33. Wallace GQ, Lapidos KA, Kenik JS, McNally EM. Long-term survival of
transplanted stem cells in immunocompetent mice with muscular dystrophy.
The American journal of pathology. 2008 Sep 30;173(3):792-802.
34. Bachrach E, Li S, Perez AL, Schienda J, Liadaki K, Volinski J, Flint A,
Chamberlain J, Kunkel LM. Systemic delivery of human microdystrophin to
regenerating mouse dystrophic muscle by muscle progenitor cells. Proceedings
of the National Academy of Sciences of the United States of America. 2004 Mar
9;101(10):3581-6.
35. LaBarge MA, Blau HM. Biological progression from adult bone marrow to
mononucleate muscle stem cell to multinucleate muscle ber in response to
injury. Cell. 2002 Nov 15;111(4):589-601.
Stem Cell Therapy In Neurological Disorders 156

36. Liu TY, Li JL, Yao XL, Dong QW, Su QX, Feng SW, Li CM, Zeng Y, Liu ZG,
Zhang C, Liu CZ. [Transplantation of 3H-thymidine-labeled human bone
marrow-derived mesenchymal stem cells in mdx mice]. Di 1 jun yi da xue xue
bao= Academic journal of the rst medical college of PLA. 2005 May;25(5):498-
502.
37. Darabi R, Gehlbach K, Bachoo RM, Kamath S, Osawa M, Kamm KE, Kyba M,
Perlingeiro RC. Functional skeletal muscle regeneration from differentiating
embryonic stem cells. Nature medicine. 2008 Feb 1;14(2):134-43.
38. Darabi R, Baik J, Clee M, Kyba M, Tupler R, Perlingeiro RC. Engraftment of
embryonic stem cell-derived myogenic progenitors in a dominant model of
muscular dystrophy. Experimental neurology. 2009 Nov 30;220(1):212-6.
39. Stillwell E, Vitale J, Zhao Q, Beck A, Schneider J, Khadim F, Elson G, Altaf A,
Yehia G, Dong JH, Liu J. Blastocyst injection of wild type embryonic stem cells
induces global corrections in mdx mice. PLoS One. 2009 Mar 11;4(3):e4759.
40. Erices A, Conget P, Minguell JJ. Mesenchymal progenitor cells in human
umbilical cord blood. British journal of haematology. 2000 Apr 1;109(1):235-42.
41. Zhang C, Chen W, Xiao LL, Tan EX, Luo SK, Zheng D, Ye X, Li Z, Lu XL, Liu Y.
[Allogeneic umbilical cord blood stem cell transplantation in Duchenne
muscular dystrophy]. Zhonghua Yi Xue Za Zhi. 2005 Mar;85(8):522-5.
42. Torrente Y, Belicchi M, Marchesi C, D'Antona G, Cogiamanian F, Pisati F,
Gavina M, Giordano R, Tonlorenzi R, Fagiolari G, Lamperti C. Autologous
transplantation of muscle-derived CD133+ stem cells in Duchenne muscle
patients. Cell transplantation. 2007 Jun 1;16(6):563-77.
43. Mendell JR, Kissel JT, Amato AA, King W, Signore L, Prior TW, Sahenk Z,
Benson S, McAndrew PE, Rice R, Nagaraja H. Myoblast transfer in the
treatment of Duchenne's muscular dystrophy. New England Journal of
Medicine. 1995 Sep 28;333(13):832-8.
44. Skuk D, Roy B, Goulet M, Chapdelaine P, Bouchard JP, Roy R, Dugré FJ,
Lachance JG, Deschênes L, Senay H, Sylvain M. Dystrophin expression in
myobers of Duchenne muscular dystrophy patients following intramuscular
injections of normal myogenic cells. Molecular Therapy. 2004 Mar 1;9(3):475-82.
45. Skuk D, Goulet M, Roy B, Piette V, Côté CH, Chapdelaine P, Hogrel JY, Paradis
M, Bouchard JP, Sylvain M, Lachance JG. First test of a “high-density injection”
protocol for myogenic cell transplantation throughout large volumes of
muscles in a Duchenne muscular dystrophy patient: eighteen months follow-
up. Neuromuscular Disorders. 2007 Jan 31;17(1):38-46.
46. Yang XF, Xu YF, Zhang YB, Wang HM, Lü NW, Wu YX, Lü X, Cui JP, Shan H,
Stem Cell Therapy In Neurological Disorders 157

Yan Y, Zhou JX. [Functional improvement of patients with progressive

muscular dystrophy by bone marrow and umbilical cord blood mesenchymal
stem cell transplantations]. Zhonghua yi xue za zhi. 2009 Sep;89(36):2552-6.
47. Rajput BS, Chakrabarti SK, Dongare VS, Ramirez CM, Deb KD. Human
Umbilical Cord Mesenchymal Stem Cells in the Treatment of Duchenne
Muscular Dystrophy: Safety and Feasibility Study in India. Journal of stem
cells. 2015 Apr 1;10(2):141.
48. Zhang C, Chen W, Xiao LL, Tan EX, Luo SK, Zheng D, Ye X, Li Z, Lu XL, Liu Y.
[Allogeneic umbilical cord blood stem cell transplantation in Duchenne
muscular dystrophy]. Zhonghua Yi Xue Za Zhi. 2005 Mar;85(8):522-5.
49. Kang PB, Lidov HG, White AJ, Mitchell M, Balasubramanian A, Estrella E,
Bennett RR, Darras BT, Shapiro FD, Bambach BJ, Kurtzberg J. Inefcient
dystrophin expression after cord blood transplantation in Duchenne muscular
dystrophy. Muscle & nerve. 2010 Jun 1;41(6):746-50.
50. Sharma A, Sane H, Badhe P, Gokulchandran N, Kulkarni P, Lohiya M, Biju H,
Jacob VC. A clinical study shows safety and efcacy of autologous bone
marrow mononuclear cell therapy to improve quality of life in muscular
dystrophy patients. Cell Transplantation. 2013 Dec 17;22(Supplement 1): S127-
38.
51. Sharma A, Sane H, Gokulchandran N, Gandhi S, Bhovad P, Khopkar D,
Paranjape A, Bhagwanani K, Badhe P. The role of cell transplantation in
modifying the course of limb girdle muscular dystrophy: a longitudinal 5-year
study. Degenerative Neurological and Neuromuscular Disease. 2015; 5:93-102.
52. Sharma A, Sane H, Paranjape A, Badhe P, Gokulchandran N, Jacob V. Effect of
cellular therapy seen on musculoskeletal magnetic resonance imaging in a case
of Becker's muscular dystrophy. Journal of Case Reports. 2013 Dec 5;3(2):440-7.
53. Sharma A, Sane H, Kaur J, Gokulchandran N, Paranjape A, Yadav J, Badhe P.
Autologous bone marrow mononuclear cell transplantation improves function
in a case of Becker's muscular dystrophy. American Based Research Journal.
2016;5(2):1-2.
54. Sharma A, Kulkarni P, Chopra G, Gokulchandran N, Lohia M, Badhe P.
Autologous Bone Marrow-derived Mononuclear Cell Transplantation in
Duchenne Muscular Dystrophy. Indian Journal of Clinical Practice.
2012;23(3):169-72.
55. Sharma A, Paranjape A, Sane H, Bhagawanani K, Gokulchandran N, Badhe P.
Cellular transplantation alters the disease progression in Becker's muscular
dystrophy. Case reports in transplantation. 2013 Jun 6;2013.
Stem Cell Therapy In Neurological Disorders 158

56. Sharma A, Sane H, Paranjape A, Bhagawanani K, Gokulchandran N, Badhe P.

Autologous bone marrow mononuclear cell transplantation in Duchenne
muscular dystrophy–a case report. The American journal of case reports. 2014;
15:128.
57. Alok S, Amruta P, Ritu V, Hemangi S, Nandini G, Jasbinder Kaur, Prerna B.
Functional Improvements and Musculoskeletal Magnetic Resonance Imaging
with Spectroscopy Changes following Cell Therapy in a Case of Limb Girdle
Muscular Dystrophy. International Journal of cell Science & molecular biology.
2017;2(4): 555595.
58. Sharma A, Sane H, Gokulchandra N, Sharan R, Paranjape A, Kulkarni P, Yadav
J, Badhe P. Effect of cellular therapy in progression of Becker's muscular
dystrophy: a case study. European journal of translational myology. 2016 Feb
23;26(1).
59. Sharma A, Gokulchandran N, Sane H, Lakhanpal V, Kulakarni P, Badhe P,
Paranjape A. Stabilization of Disease Progression in a Case of Duchenne
Muscular Dystrophy with Cellular Transplantation. Stem Cell: Advanced
Research and Therapy, 2017;2017(3): J112.
60. Alok S, Hemangi S, Pooja K, Dhara M, Jasbinder K, Nandini G, Khushboo B,
Prerna B. Effect of autologous bone marrow mononuclear cell transplantation
coupled with rehabilitation in limb girdle muscular dystrophy–A case report.
INTERNATIONAL JOURNAL OF MEDICAL RESEARCH & HEALTH
SCIENCES. 2016 Jan 1;5(12):1-7.
61. Sharma A, Badhe P, Sane H, Suhasini P, Kulkarni P, Bhagwanani K,
Gokulchandran N. Halting of functional decline in a case of duchenne
muscular dystrophy after cell therapy. International Journal of Recent
Advances in Multidisciplinary Research. 2017 Feb;4(2):2293- 97.
Stem Cell Therapy In Neurological Disorders 159

"Neurosurgeons would be happy if they could make the spinal cord

regenerate thus helping thousands of paraplegics all over the world.
Sustained efforts in this direction are the Immediate need of the future."

– Dr. B. Ramamurthi
-Founding father of Neurosurgery in India
Stem Cell Therapy In Neurological Disorders 160

11

Role of Stem Cells In

Spinal Cord Injury
Along with neurorehabilitation, stem cells can aid in faster functional recovery
in Spinal Cord Injury.

A spinal cord injury (SCI) is damage to the spinal cord caused due to trauma such as
road trafc accidents (RTAs), fall from height or non-traumatic events such as
infection, loss of blood supply, compression by a cancer or through slow
degeneration of the spinal bones (vertebrae). It often results in a severe neurological
decit. There could be complete disruption or contusion, compression or
penetration of the spinal cord leading to necrosis, demyelination, axonal loss and
glial scarring. (1) The demyelination of axons may lead to a permanent loss of
sensorimotor functions affecting the quality of life of these patients (2). A severe
cervical spinal damage results in quadriplegia, whereas an injury to the thoracic or
lumbar spine leads to paraplegia.
Complete recovery of the damaged spinal cord is very difcult, as it does not have
the ability to regenerate lost or damaged neurons and re-establish the neural
connections. The scar also consists of axonal growth inhibitors which further limit
the repair and regeneration process. (3) As a result, there is no cure for SCI available
presently.
The current treatment for SCI includes surgical interventions, medicines and
rehabilitation. Their main goal is to stabilize the spine and prevent any secondary
complications.
Stem Cell Therapy In Neurological Disorders 161

Unmet Medical Needs

The available treatments for SCI fail to repair the underlying pathology completely,
leaving behind some neurological decits. Presently, all modalities aim at repairing
the vertebral column but no surgery or medication repairs the spinal cord. None of
the treatments help in neuronal or axonal regeneration. Due to loss of functions, the
SCI patients have a high level of dependency on the care taker. Rehabilitation and
assistive devices are used to improve functions like ambulation and hand functions
but while functional improvements are seen in the patients, residual disability
always remains. Affected sensations, loss of bladder bowel control and altered
muscle tone, are some of the major complications observed in SCI. The currently
available treatment modalities fail to improve these complications in cases of severe
injuries.
It is also important to track the cellular changes occurring in the spinal cord over the
period of any intervention. However, there is no potent investigative monitoring
tool available currently to record these changes. Since, there is a global increase in
the incidence of spinal cord injuries, establishing a standard treatment is the need of
the hour.
Stem cell therapy in spinal cord injury
Stem cell therapy is a potential treatment for spinal cord injury (SCI), and a variety
of different stem cell types have been evaluated in animal models and humans with
SCI.
Extensive research has been carried out in the past few decades in order to develop
stem cell transplantation as a therapeutic intervention for SCI. It mainly focuses on
replacing the lost or damaged
cells and promoting axonal
growth and remyelination of
axons. The cells migrate to the
site of injury and initiate the
repair process. They release
trophic factors to stop
neuronal degeneration and
stimulate angiogenesis. These
factors also activate the quies-
cent cells and recruit them to
the injured site. Experimental
models have demonstrated the
formation of functional
neuronal circuits promoting
functional recovery. (4-6)
Stem Cell Therapy In Neurological Disorders 162

Pre-clinical studies
Various animal studies have been conducted in the past to establish role of stem cell
therapy in SCI. A number of different kinds of stem cells have been tested in basic
research to study the safety and efcacy. (7-45) The signaling pathways, protein
interactions, cellular behavior, and the differentiated fates of experimental cells
have been studied extensively in vitro. Moreover, the survival, proliferation,
differentiation, and effects on promoting functional recovery of transplanted cells
have also been examined in different animal SCI models. (46-54) These pre-clinical
studies have helped translate the use of stem cells in humans initiating an array of
human clinical studies.
Clinical Studies
Stem Cell Therapy In Neurological Disorders 163
Stem Cell Therapy In Neurological Disorders 164
Stem Cell Therapy In Neurological Disorders 165
Stem Cell Therapy In Neurological Disorders 166
Stem Cell Therapy In Neurological Disorders 167
Stem Cell Therapy In Neurological Disorders 168

So far 60 studies have been conducted demonstrating a benecial effect of stem cell
therapy in more than 1000 patients. (55-108) Stem cells from different lineages and
sub-types have been used in these studies which include autologous bone marrow
derived mononuclear stem cells, bone marrow derived mesenchymal stem cells,
bone marrow derived stromal cells, adipose derived mesenchymal stem cells,
hematopoietic progenitor cells, peripheral hematopoietic cells, activated Schwann
cells, olfactory ensheathing cells and umbilical cord mesenchymal stem cells.
Improvements have been observed clinically in the form of improved functions and
objectively in the form of improved ASIA scores and MRI changes. Post therapeutic
adverse events were observed in a few patients such as fever, headache, nausea and
vomiting, tingling sensations, spasms, neuropathic sensory symptoms including
burning and pain sensations.
Our Results
Published data:
1. A detailed analysis of chronic thoracolumbar SCI patients who underwent
intrathecal administration of autologous bone marrow mononuclear cells
(BMMNC's) followed by neurorehabilitation was conducted. The study sample
included 110 thoracolumbar SCI patients. The outcome was recorded at a mean
follow up of 2 years ±1 month. The outcome measures were Functional
Independence Measure (FIM) score, American Spinal Injury Association scale
(ASIA) and detailed neurological assessment. Data was statistically analyzed using
McNemar's Test to establish signicance between the change in symptoms and the
intervention.

Figure 1: Symptomatic improvements in patients with spinal cord injury after stem
cell therapy. The x axis denotes symptoms presented in the patient population and
the y axis denotes the number of patients. (ADLs - activities of daily living).
Stem Cell Therapy In Neurological Disorders 169

100 out of 110 (91%) patients showed improvements which are shown in the graph
below. A statistically signicant association of these symptomatic improvements
with the cell therapy intervention was established using McNemar's Test. On
electrophysiological studies, 2 showed improvement and 1 showed change in
functional MRI. (98)

Table 1: Statistical signicance for each symptomatic/functional change using

McNemar's test
Stem Cell Therapy In Neurological Disorders 170

Table 2: Objective improvements evident on electromyography (A) and functional

magnetic resonance imaging (B) after stem cell therapy in selected patients
2. A detailed analysis of chronic cervical SCI patients who underwent intrathecal
administration of autologous bone marrow mononuclear cells followed by
neurorehabilitation was conducted. (99) This study includes 50 patients of chronic
cervical SCI. The outcome was recorded at a mean follow up of 2 years ±1 month.
The outcome measures were Functional Independence Measure (FIM) score,
American Spinal Injury Association scale (ASIA) and detailed neurological
assessment. Data was statistically analyzed using McNemar's Test to establish
signicance between the change in symptoms and the intervention. 37 out of 50
(74%) showed improvements. A statistical analysis using McNemar's test
established a signicant association of these symptoms with the intervention. No
major side effects were noted in the duration of 2 years in both the studies. A better
outcome was observed in thoracolumbar injury as compared to the cervical injury
suggesting that the level of SCI greatly inuences the recovery of the patient. Both
studies demonstrated statistically signicant clinical and functional outcome.
Stem Cell Therapy In Neurological Disorders 171

Figure 2: Graph demonstrating symptomatic improvements in chronic cervical SCI

patients after cell therapy

Table 3: McNemar's test: Table demonstrating the statistical analysis for each
symptomatic improvement in cervical SCI using McNemar's test.
Stem Cell Therapy In Neurological Disorders 172

Table 4: Percentage analysis of improvements: Table demonstrating a detailed

analysis of various factors and the improvements.

Table 5: Comparison between Cervical SCI and Thoracolumbar SCI: Table

comparing the outcome of cell transplantation in cervical SCI and Thoracolumbar
SCI.
Published case reports
We have published 5 case reports of different types of Spinal cord injuries. (109-113)
These cases underwent autologous bone marrow mononuclear cell transplantation
intrathecally. They demonstrated various functional and neurological
improvements in the form of improved symptoms. Improvements were seen in
Stem Cell Therapy In Neurological Disorders 173

bladder and bowel sensations, back and abdominal strength, limb strength, gait,
balance and mobility. They showed improved scores on FIM scale indicating
improved ability to perform daily tasks. It was observed that their quality of life had
improved signicantly.
Unpublished data
Thoracic Spinal Cord Injury:
We analyzed 184 patients with chronic thoracic spinal cord injury to study the effect
of stem cell therapy. Changes were recorded in symptoms like muscle tone, lower
limb activity, sensory changes, bowel/bladder function, trunk activity, balance,
standing, ambulation and activities of daily living. Analysis revealed that out of
184, 96.19% patients showed improvements while 3.80% showed no improvements
in any of the symptoms. Mild improvements were observed in 15.21% of patients,
moderate in 56.52% of patients, whereas, 24.46% of patients showed signicant
improvements

Improvements in Thoracolumbar Spinal Cord Injury A er Stem Cell Therapy

120
56.52%
100

80

60
24.46%
40
15.21%
20
3.80%
0
No Mild Moderate Significant
Improvement Improvement Improvement Improvement

Figure 3: Improvements seen in thoracolumbar SCI after intrathecal

administration of autologous BMMNCs.
Stem Cell Therapy In Neurological Disorders 174

Figure 4:

A. fMRI-T2 weighted image showing the brain activation during the task before the
cell therapy

B. fMRI-T2 weighted image showing the brain activation during the task after the
cell therapy. The brain show increased activation in motor cortex and associated
regions

Cervical Spinal Cord Injury:

104 patients with diagnosis of cervical spinal cord injury were included in the
analysis. Symptomatic analysis was done for the common symptoms observed in
these patients and was graded as no change, mild moderate and signicant
improvements. The symptoms included were muscle tone, upper limb activity,
lower limb activity, sensory changes, bowel/bladder function, trunk activity,
balance, standing, ambulation and activities of daily living. Analysis revealed that
out of 104 patients, 96.19% patients showed improvements while 3.80% did not
show any improvements. Mild improvements were observed in 15.21% of patients,
moderate in 56.52% of patients and 24.46% of patients showed signicant
improvements.
Stem Cell Therapy In Neurological Disorders 175

Figure 5: Improvements seen in cervical SCI after intrathecal administration of

autologous BMMNCs.
Conclusion
It has long been considered that spinal cord injury is an irreversible condition
causing permanent debilitation. However, recent advancements in the eld of
regenerative medicine have disproved that assumption. While stem cell therapy is
not a cure for SCI, the neuro-regenerative and reparative effect of stem cells
enhances the outcome of the currently available rehabilitative and medical
treatments. The safety and efcacy of stem cell therapy has been established in the
clinical studies done so far. Factors that can inuence the outcome of stem cell
therapy in SCI are (A) Level of injury (patients with thoraco-lumbar level of injury
have a better prognosis than those with cervical level of injury) (B) Incomplete SCI
have a better prognosis than complete injury (C) The earlier the treatment initiated
the better the prognosis (D) Rehabilitation is essential for maximizing functional
recovery in patients. Thus the benets of stem cell therapy are clear to see in the
clinical studies conducted so far and the results seen have been very encouraging
and offer much hope for the future.
Future Directions
In SCI, rapid loss of the oligodendrocytes is recorded. The quiescent endogenous
ependymal cells which are activated after the injury are unable to differentiate into
the required cells of oligodendrocyte lineage failing to limit the damage. Also, the
microenvironment of the injured spinal cord prevents neuronal differentiation of
the transplanted cells due to the pro-gliogenic signals. Hence, future research
should focus on manipulating the cells before transplantation or infusing
neurotrophic growth factors in order to stimulate the endogenous cells and
modulate them towards producing more oligodendrocytes. (114) The future of
Stem Cell Therapy In Neurological Disorders 176

regenerative medicine in SCI lies in combining the use of stem cells with nanodrug
delivery systems. (115) Recently, the stem cells are being co-transplanted with
nanospheres improving the cell survival and neurological functions in the animal
models. However, their long term safety needs to be assessed. Cells of varied origin
such as dental pulp, adipose tissue and other induced pluripotent cells are being
studied extensively to test their potency, safety, feasibility and efcacy in SCI. (116-
118) Nanober scaffold formulations have been used successfully for targeted cell
delivery into the body organs. (119) Neuralstem has developed NSI-566 neural stem
cells which it seeks to deliver directly into the spinal cord gray matter in SCI
patients. These cells are expected to integrate with the patient's neural tissue and
potentially form new neural circuits to connect and bridge axons above the site of
injury with neuron segments below. (120)
Many clinical trials are being conducted in the USA, China, India, Switzerland to
optimize the intervention, nd the appropriate time and frequency of injection,
type of cells, route of administration, etc. (121)
REFERENCE
1. Kraus KH. The pathophysiology of spinal cord injury and its clinical
implications. Semin Vet Med Surg (Small Anim). 1996 Nov;11(4):201-7.
2. Deumens R, Koopmans GC, Honig WM, Maquet V, Jérôme R, Steinbusch
HW, Joosten EA. Chronically injured corticospinal axons do not cross large
spinal lesion gaps after a multifactorial transplantation strategy using
olfactory ensheathing cell/olfactory nerve broblast-biomatrix bridges. J
Neurosci Res. 2006 Apr;83(5):811-20.
3. Wanner IB, Deik A, Torres M, Rosendahl A, Neary JT, Lemmon VP, Bixby JL.
A new in vitro model of the glial scar inhibits axon growth. Glia. 2008 Nov
15;56(15):1691-709
4. Wright KT, Masri WE, Osman A, Chowdhury J, Johnson WEB (2011) Concise
Review: Bone Marrow for the Treatment of Spinal Cord Injury: Mechanisms
and Clinical Applications. Stem Cells 29: 169-178.
5. Coutts M, Keirstead HS (2008) Stem cells for the treatment of spinal cord
injury. Exp Neurol 209: 368-377.
6. Reier PJ (2004) Cellular transplantation strategies for spinal cord injury and
translational neurobiology. NeuroRx 1: 424-451
7. John W. Mcdonald, Xiao-Zhong Liu, Yun Qu et al. Transplanted embryonic
stem cells survive, differentiate and promote recovery in injured rat spinal
cord. Nature Medicine. 1999; 5(12).1410-12
8. Bottai D, Cigognini D, Madaschi L, et al. Embryonic stem cells promote motor
recovery and affect inammatory cell inltration in spinal cord injured mice.
Stem Cell Therapy In Neurological Disorders 177

Experimental Neurology. 2010;223(2):452-463. (PubMed)

9. Nicolas Granger, Helen Blamires, Robin J. M. Franklin, and Nick D. Jeffery
Autologous olfactory mucosal cell transplants in clinical spinal cord injury: a
randomized double-blinded trial in a canine translational model Brain (2012)
135 (11): 3227-3237
10. Kumagai G, Okada Y, Yamane J, et al. Roles of ES cell-derived gliogenic neural
stem/progenitor cells in functional recovery after spinal cord injury. PLoS
ONE. 2009;4(11)e7706 (PMC free article) (PubMed)
11. Lowry N, Goderie SK, Adamo M, et al. Multipotent embryonic spinal cord
stem cells expanded by endothelial factors and Shh/RA promote functional
recovery after spinal cord injury. Experimental Neurology. 2008;209(2):510-
522. (PubMed)
12. Fujimoto Y, Abematsu M, Falk A, et al. Treatment of a mouse model of spinal
cord injury by transplantation of human iPS cell-derived long-term self-
renewing neuroepithelial-like. Stem Cells. 2012;30(6):1163-1173. (PubMed)
13. Chen J, Bernreuther C, Dihné M, Schachner M. Cell adhesion molecule L1-
transfected embryonic stem cells with enhanced survival support regrowth of
corticospinal tract axons in mice after spinal cord injury. Journal of
Neurotrauma. 2005;22(8):896-906. (PubMed)
14. Cui YF, Xu JC, Hargus G, Jakovcevski I, Schachner M, Bernreuther C.
Embryonic stem cell-derived L1 overexpressing neural aggregates enhance
recovery after spinal cord injury in mice. PLoS ONE. 2011;6(3)e17126 (PMC
free article) (PubMed)
15. Perrin FE, Boniface G, Serguera C, et al. Grafted human embryonic
progenitors expressing neurogenin-2 stimulate axonal sprouting and
improve motor recovery after severe spinal cord injury. PLoS ONE.
2010;5(12)e15914
16. Hatami M, Mehrjardi NZ, Kiani S, et al. Human embryonic stem cell-derived
neural precursor transplants in collagen scaffolds promote recovery in
injured rat spinal cord. Cytotherapy. 2009;11(5):618-630.
17. Niapour A, Karamali F, Nemati S, et al. Co-transplantation of human
embryonic stem cell-derived neural progenitors and Schwann cells in a rat
spinal cord contusion injury model elicits a distinct neurogenesis and
functional recovery. Cell Transplant. 2012;21(5):827-843.
18. Rossi SL, Nistor G, Wyatt T, et al. Histological and functional benet
following transplantation of motor neuron progenitors to the injured rat
spinal cord. PLoS ONE. 2010;5(7)e11852 (PMC free article)
Stem Cell Therapy In Neurological Disorders 178

19. Kim DS, Jung Jung SE, Nam TS, et al. Transplantation of GABAergic neurons
from ESCs attenuates tactile hypersensitivity following spinal cord injury.
Stem Cells. 2010;28(11):2099-2108.
20. Keirstead HS, Nistor G, Bernal G, et al. Human embryonic stem cell-derived
oligodendrocyte progenitor cell transplants remyelinate and restore
locomotion after spinal cord injury. Journal of Neuroscience.
2005;25(19):4694-4705.
21. Kerr CL, Letzen BS, Hill CM, et al. Efcient differentiation of human
embryonic stem cells into oligodendrocyte progenitors for application in a rat
contusion model of spinal cord injury. International Journal of Neuroscience.
2010;120(4):305-313.
22. Sharp J, Frame J, Siegenthaler M, Nistor G, Keirstead HS. Human embryonic
stem cell-derived oligodendrocyte progenitor cell transplants improve
recovery after cervical spinal cord injury. Stem Cells. 2010;28(1):152-163.
23. Erceg S, Ronaghi M, Oria M, et al. Transplanted oligodendrocytes and
motoneuron progenitors generated from human embryonic stem cells
promote locomotor recovery after spinal cord transection. Stem Cells.
2010;28(9):1541-1549.
24. Salehi M, Pasbakhsh P, Soleimani M, et al. Repair of spinal cord injury by co-
transplantation of embryonic stem cell-derived motor neuron and olfactory
ensheathing cell. Iranian Biomedical Journal. 2009;13(3):125-135.
25. Nakajima H, Uchida K, Guerrero AR, et al. Transplantation of mesenchymal
stem cells promotes an alternative pathway of macrophage activation and
functional recovery after spinal cord injury. Journal of Neurotrauma.
2012;29(8):1614-1625.
26. Karaoz E, Kabatas S, Duruksu G, et al. Reduction of lesion in injured rat spinal
cord and partial functional recovery of motility after bone marrow derived
mesenchymal stem cell transplantation. Turkish Neurosurgery.
2012;22(2):207-217.
27. Park WB, Kim SY, Lee SH, Kim HW, Park JS, Hyun JK. The effect of
mesenchymal stem cell transplantation on the recovery of bladder and
hindlimb function after spinal cord contusion in rats. BMC Neuroscience.
2010;11:p. 119.
28. Abrams MB, Dominguez C, Pernold K, et al. Multipotent mesenchymal
stromal cells attenuate chronic inammation and injury-induced sensitivity
to mechanical stimuli in experimental spinal cord injury. Restorative
Neurology and Neuroscience. 2009;27(4):307-321.
29. Kang ES, Ha KY, Kim YH. Fate of transplanted bone marrow derived
Stem Cell Therapy In Neurological Disorders 179

mesenchymal stem cells following spinal cord injury in rats by

transplantation routes. Journal of Korean Medical Science. 2012;27(6):586-593.
30. Osaka M, Honmou O, Murakami T, et al. Intravenous administration of
mesenchymal stem cells derived from bone marrow after contusive spinal
cord injury improves functional outcome. Brain Research C. 2010;1343:226-
235.
31. Mothe AJ, Bozkurt G, Catapano J, et al. Intrathecal transplantation of stem
cells by lumbar puncture for thoracic Spinal cord injury in the rat. Spinal Cord.
2011;49(9):967-973.
32. Boido M, Garbossa D, Fontanella M, Ducati A, Vercelli A. Mesenchymal stem
cell transplantation reduces glial cyst and improves functional outcome
following spinal cord compression. World Neurosurgery. World Neurosurg.
2014 Jan;81(1):183-190
33. Gu W, Zhang F, Xue Q, Ma Z, Lu P, Yu B. Transplantation of bone marrow
mesenchymal stem cells reduces lesion volume and induces axonal regrowth
of injured spinal cord. Neuropathology. 2010;30(3):205-217.
34. Alexanian AR, Fehlings MG, Zhang Z, Maiman DJ. Transplanted neurally
modied bone marrow-derived mesenchymal stem cells promote tissue
protection and locomotor recovery in spinal cord injured rats.
Neurorehabilitation and Neural Repair. 2011;25(9):873-880.
35. Ban DX, Ning GZ, Feng SQ, et al. Combination of activated Schwann cells
with bone mesenchymal stem cells: the best cell strategy for repair after spinal
cord injury in rats. Regenerative Medicine. 2011;6(6):707-720.
36. Cho SR, Kim YR, Kang HS, et al. Functional recovery after the transplantation
of neurally differentiated mesenchymal stem cells derived from bone barrow
in a rat model of spinal cord injury. Cell Transplantation. 2009;18(12):1359-
1368.
37. Pedram MS, Dehghan MM, Soleimani M, Shari D, Marjanmehr SH, Nasiri Z.
Transplantation of a combination of autologous neural differentiated and
undifferentiated mesenchymal stem cells into injured spinal cord of rats.
Spinal Cord. 2010;48(6):457-463.
38. Liu WG, Wang ZY, Huang ZS. Bone marrow-derived mesenchymal stem cells
expressing the bFGF transgene promote axon regeneration and functional
recovery after spinal cord injury in rats. Neurological Research.
2011;33(7):686-693.
39. Zhang YJ, Zhang W, Lin C-G, et al. Neurotrophin-3 gene modied
mesenchymal stem cells promote remyelination and functional recovery in
the demyelinated spinal cord of rats. Journal of the Neurological Sciences.
Stem Cell Therapy In Neurological Disorders 180

2012;313(1-2):64-74.
40. Zeng X, Zeng YS, Ma YH, et al. Bone marrow mesenchymal stem cells in a
three dimensional gelatin sponge scaffold attenuate inammation, promote
angiogenesis and reduce cavity formation in experimental spinal cord injury.
Cell Transplantation. 2011;20(11-12):1881-1899.
41. Kang KN, Kim da Y, Yoon SM, et al. Tissue engineered regeneration of
completely transected spinal cord using human mesenchymal stem cells.
Biomaterials. 2012;33(19):4828-4835.
42. Park SS, Lee YJ, Lee SH, et al. Functional recovery after spinal cord injury in
dogs treated with a combination of Matrigel and neural-induced adipose-
derived mesenchymal Stem cells. Cytotherapy. 2012;14(5):584-597.
43. Guo YW, Ke YQ, Li M, et al. Human umbilical cord-derived schwann-like cell
transplantation combined with neurotrophin-3 administration in dyskinesia
of rats with spinal cord injury. Neurochemical Research. 2011;36(5):783-792
44. Shang AJ, Hong SQ, Xu Q, et al. NT-3-secreting human umbilical cord
mesenchymal stromal cell transplantation for the treatment of acute spinal
cord injury in rats. Brain Research. 2011;1391:102-113.
45. Lee JH, Chung WH, Kang EH, et al. Schwann cell-like remyelination
following transplantation of human umbilical cord blood (hUCB)-derived
mesenchymal stem cells in dogs with acute spinal cord injury. Journal of the
Neurological Sciences. 2011;300(1-2):86-96.
46. Eglitis MA, Mezey E. Hematopoietic cells differentiate into both microglia
and macroglia in the brains of adult mice. Proc Natl Acad Sci U S A. 1997
Apr15;94(8):4080-5.
47. Kopen GC, Prockop DJ, Phinney DG. Marrow stromal cells migrate
throughout forebrain and cerebellum, and they differentiate into astrocytes
after injection into neonatal mouse brains. Proc Natl Acad Sci U S A. 1999 Sep
14;96(19):10711-6.
48. Brazelton TR, Rossi FM, Keshet GI, Blau HM. From marrow to brain:
expression of neuronal phenotypes in adult mice. Science. 2000 Dec
1;290(5497):1775-9.
49. Mezey E, Chandross KJ, Harta G, Maki RA, McKercher SR. Turning blood into
brain: cells bearing neuronal antigens generated in vivo from bone marrow.
Science. 2000 Dec 1;290(5497):1779-82.
50. Priller J, Flügel A, Wehner T, Boentert M, Haas CA, Prinz M, Fernández-Klett
F, Prass K, Bechmann I, de Boer BA, Frotscher M, Kreutzberg GW, Persons
DA,Dirnagl U. Targeting gene-modied hematopoietic cells to the central
Stem Cell Therapy In Neurological Disorders 181

nervous system: use of green uorescent protein uncovers microglial

engraftment. Nat Med. 2001 Dec;7(12):1356-61.
51. Wichterle H, Lieberam I, Porter JA, Jessell TM. Directed differentiation of
embryonic stem cells into motor neurons. Cell. 2002;110(3):385-397.
52. Hofstetter, C. P., et al. Marrow stromal cells form guiding strands in the
injured spinal cord and promote recovery. Proceedings of the National
Academy of Sciences 99.4 (2002): 2199-2204.
53. Quertainmont R, Cantinieaux D, Botman O, Sid S, Schoenen J, et al. (2012)
Mesenchymal Stem Cell Graft Improves Recovery after Spinal Cord Injury in
Adult Rats through Neurotrophic and Pro-Angiogenic Actions. PLoS ONE
7(6): e39500.
54. Cho SR, Kim YR, Kang HS, Yim SH, Park CI, Min YH, Lee BH, Shin JC, Lim JB.
Functional recovery after the transplantation of neurally differentiated
mesenchymal stem cells derived from bone barrow in a rat model of spinal
cord injury. Cell Transplant. 2009;18(12):1359-68
55. Samuil S. Rabinovich, Victor I. Seledtsov, Olga V. Poveschenko.
Transplantation treatment of spinal cord injury patients. Biomedicine and
Pharmacotherapy. 2003;57(9): 428-433
56. Yoon Ha, Seung Hwan Yoon, So Ra Park. Treatment of Complete Spinal Cord
Injury Patients Receiving Autologous Bone Marrow Cell Transplantation and
Bone Marrow Stimulation with Granulocyte Macrophage-Colony
Stimulating Factor - Report of Three Cases. J Korean Neurosurg Soc 2004; 35:
459-464.
57. Feron F, Perry, C, Cochrane, J, Licina, P, Nowitzke, A, Urquhart, S, Geraghty,
T, Mackay-Sim, A. Autologous olfactory ensheathing cell transplantation in
human spinal cord injury. Brain 2005;128(12):2951-60.
58. Mackay-Sim, F. Féron, J. Cochrane et al. Autologous olfactory ensheathing
cell transplantation in human paraplegia: a 3-year clinical trial. Brain. 2008;
131(9): 2376- 2386.
59. G. P. V. Subbaiah, V. Adavi, L. K. Chelluri, S. Laxman, K. S. Ratnakar, P. B. N.
Gopal and K. Ravindranath. Preliminary report on the safety, efcacy and
functional recovery of spinal cord injury with autologous bone marrow
derived mesenchymal stem cells - a clinical trial. The Internet Journal of Spine
Surgery. 2009;5(1)
60. Jarocha D, Milczarek O, Kawecki Z, Wendrychowicz A, Kwiatkowski S,
Majka M. Preliminary Study of Autologous Bone Marrow Nucleated Cells
Transplantation in Children With Spinal Cord Injury. Stem Cells Transl Med.
2014 Feb 3.
Stem Cell Therapy In Neurological Disorders 182

61. Syková, P. Jendelová, L. Urdzíková, P. Lesný, and A. Hej?l, "Bone marrow

stem cells and polymer hydrogels-two strategies for spinal cord injury repair,"
Cellular and Molecular Neurobiology. 2006; 26(7-8):1113-1129.
62. Eva Syková, Aleš Homola, Radim Mazanec et al. Autologous Bone Marrow
Transplantation in Patients With Subacute and Chronic Spinal Cord Injury.
Cell Transplantation.2006;15:1-100.
63. R. Chernykh, V. V. Stupak, G. M.Muradov et al., Application of autologous
bone marrow stem cells in the therapy of spinal cord injury patients. Bulletin
of Experimental Biology and Medicine 2007;143(4):543-547.
64. H. Saberi, P. Moshayedi, H.-R. Aghayan et al. Treatment of chronic thoracic
spinal cord injury patients with autologous Schwann cell transplantation: an
interim report on safety considerations and possible outcomes. Neuroscience
Letters, 2008;443(1): 46-50.
65. L. F. Geffner, P. Santacruz, M. Izurieta. Administration of Autologous Bone
Marrow Stem Cells Into Spinal Cord Injury Patients Via Multiple Routes Is
Safe and Improves Their Quality of Life: Comprehensive Case Studies. Cell
Transplantation2008;17:1277-1293.
66. Abdelaziz, Osama S. MD. Feasibility, Safety, and Efcacy of Directly
Transplanting Autologous Adult Bone Marrow Stem Cells in Patients With
Chronic Traumatic Dorsal Cord Injury: A Pilot Clinical Study. Neurosurgery
Quarterly: 2010; 20(3):216-226.
67. J. H. Park, D. Y. Kim, I. Y. Sung, et al., "Long-term results of spinal cord injury
therapy using mesenchymal stem cells derived from bone marrow in
humans," Neurosurgery, vol. 70, no. 5, pp. 1238-1247, 2012.
68. Saito F, Nakatani T, Iwase M, et al. Spinal cord injury treatment with
intrathecal autologous bone marrow stromal cell transplantation: the rst
clinical trial case report. J Trauma. 2008;64(1):53-9.
69. R. Pal, N. K. Venkataramana, A. Bansal et al. Ex vivo expanded autologous
bone marrow-derived mesenchymal stromal cells in human spinal cord
injury/ paraplegia: a pilot clinical study. Cytotherapy. 2009;11(7): 897-911.
70. A. Kumar, S. R. Kumar, R. Narayanan, K. Arul, and M. Baskaran. Autologous
bone marrow derived mononuclear cell therapy for spinal cord injury: a phase
I/ II clinical safety and primary efcacy data. Experimental and Clinical
Transplantation 2009; 7(4): 241-248.
71. Zhou Q, Zhang SZ, Xu RX, Xu K. Neural stem cell transplantation and
postoperative management: report of 70 cases. Di Yi Junyi Daxue Xuebao
2004;24(10):1207-9
Stem Cell Therapy In Neurological Disorders 183

72. Moviglia GA, Fernandez Viña R, Brizuela JA.et al. Combined protocol of cell
therapy for chronic spinal cord injury. Report on the electrical and functional
recovery of two patients. Cytotherapy. 2006; 8(3):202-9.
73. Hyung Chun Park, Yoo Shik Shim, Yoon Ha et al. Treatment of Complete
Spinal Cord Injury Patients by Autologous Bone Marrow Cell
Transplantation and Administration of Granulocyte-Macrophage Colony
Stimulating Factor. Tissue Engineering. 2005, 11(5-6): 913-922.
74. Deda H, Inci MC, Kürekçi AE, Kayihan K, Ozgün E, Ustünsoy GE, Kocabay S.
Treatment of chronic spinal cord injured patients with autologous bone
marrow-derived hematopoietic stem cell transplantation: 1-year follow-up.
Cytotherapy. 2008;10(6):565-74.
75. Frolov AA, Bryukhovetskiy AS. Effects of hematopoietic autologous stem cell
transplantation to the chronically injured human spinal cord evaluated by
motor and somatosensory evoked potentials methods. Cell Transplant.
2012;21 Suppl 1:S49-55
76. Dai G, Liu X, Zhang Z, Yang Z, Dai Y, Xu R. Transplantation of autologous
bone marrow mesenchymal stem cells in the treatment of complete and
chronic cervical spinal cord injury. Brain Res. 2013 Oct 2;1533:73-9.
77. Jiang PC, Xiong WP, Wang G, Ma C, Yao WQ, Kendell SF, Mehling BM, Yuan
XH, Wu DC. A clinical trial report of autologous bone marrow-derived
mesenchymal stem cell transplantation in patients with spinal cord injury.
Exp Ther Med. 2013 Jul;6(1):140-146
78. El-Kheir WA, Gabr H, Awad MR, Ghannam O, Barakat Y, Farghali HA, El
Maadawi ZM, Ewes I, Sabaawy HE. Autologous bone marrow-derived cell
therapy combined with physical therapy induces functional improvement in
chronic spinal cord injury patients. Cell Transplant. 2014 Apr;23(6):729-45.
79. Moviglia GA, Fernandez Viña R, Brizuela JA.et al. Combined protocol of cell
therapy for chronic spinal cord injury. Report on the electrical and functional
recovery of two patients. Cytotherapy. 2006; 8(3):202-9.
80. N. Knoller, G. Auerbach, V. Fulga et al., Clinical experience using incubated
autologous macrophages as a treatment for complete spinal cord injury: phase
I study results. Journal of Neurosurgery Spine. 2005; 3(3): 173-181.
81. F. Cristante, T. E. P. Barros-Filho, and T. E. P. Barros-Filho. Stem cells in the
treatment of chronic spinal cord injury: evaluation of somatosensitive evoked
potentials in 39 patients. Spinal Cord. 2009; 47(10):733-738.
82. Thomas E Ichim, Fabio Solano, Fabian Lara et al. Feasibility of combination
allogeneic stem cell therapy for spinal cord injury: a case report. International
Archives of Medicine 2010; 3:30.
Stem Cell Therapy In Neurological Disorders 184

83. Lima, P. Escada, J. Pratas-Vital et al. Olfactory mucosal autografts and

rehabilitation for chronic traumatic spinal cord injury. Neurorehabilitation
and Neural Repair 2010;24(1):10-22.
84. Ra JC, Shin IS, Kim SH, Kang SK, Kang BC, Lee HY, Kim YJ, Jo JY, Yoon EJ,
Choi HJ, Kwon E. Safety of intravenous infusion of human adipose tissue-
derived mesenchymal stem cells in animals and humans.Stem Cells Dev. 2011
Aug;20(8):1297-308.
85. Raisman G. Repair of spinal cord injury by transplantation of olfactory
ensheathing cells. C R Biol. 2007 Jun-Jul;330(6-7):557-60. Epub 2007 May
9.Review.
86. Huang H, Xi H, Chen L, Zhang F, Liu Y. Long-term outcome of olfactory
ensheathing cell therapy for patients with complete chronic spinal cord
injury.Cell Transplant. 2012;21 Suppl 1:S23-31.
87. Saberi H, Firouzi M, Habibi Z, Moshayedi P, Aghayan HR, Arjmand B,
Hosseini K, Razavi HE, Yekaninejad MS. Safety of intramedullary Schwann
cell transplantation for postrehabilitation spinal cord injuries: 2-year follow-
up of 33 cases. J Neurosurg Spine. 2011 Nov;15(5):515-25.
88. Yazdani SO, Hazi M, Zali AR, Atashi A, Ashra F, Seddighi AS, Soleimani
M. Safety and possible outcome assessment of autologous Schwann cell and
bone marrow mesenchymal stromal cell co-transplantation for treatment of
patients with chronic spinal cord injury. Cytotherapy. 2013 Jul;15(7):782-91.
89. Sun T, Ye C, Zhang Z, Wu J, Huang H. Cotransplantation of olfactory
ensheathing cells and Schwann cells combined with treadmill training
promotes functional recovery in rats with contused spinal cords. Cell
Transplant. 2013;22 Suppl 1:S27-38
90. Chen L, Huang H, Xi H, Zhang F, Liu Y, Chen D, Xiao J. A prospective
randomized double-blind clinical trial using a combination of olfactory
ensheathing cells and Schwann cells for the treatment of chronic complete
spinal cord injuries. Cell Transplant. 2014;23 Suppl 1:S35-44.
91. Al-Zoubi A, Jafar E, Jamous M, Al-Twal F, Al-Bakheet S, Zalloum M, Khalifeh
F, Radi SA, El-Khateeb M, Al-Zoubi Z. Transplantation of puried autologous
leukapheresis-derived CD34+ and CD133+ stem cells for patients with
chronic spinal cord injuries: long-term evaluation of safety and efcacy. Cell
Transplant. 2014;23 Suppl 1:S25-34
92. Cheng H, Liu X, Hua R, Dai G, Wang X, Gao J, An Y. Clinical observation of
umbilical cord mesenchymal stem cell transplantation in treatment for
sequelae of thoracolumbar spinal cord injury. J Transl Med. 2014 Sep 12;12:253
93. Callera and R. X. do Nascimento. Delivery of autologous bone marrow
Stem Cell Therapy In Neurological Disorders 185

precursor cells into the spinal cord via lumbar puncture technique in patients
with spinal cord injury: a preliminary safety study. Experimental
Hematology. 2006;34(2): 130-131.
94. Oh SK, Choi KH, Yoo JY, Kim DY, Kim SJ, Jeon SR. A Phase III Clinical
TrialShowing Limited Efcacy of Autologous Mesenchymal Stem Cell
Therapy for SpinalCord Injury. Neurosurgery. 2016 Mar;78(3):436-47;
discussion 447
95. Oraee-Yazdani S, Hazi M, Atashi A, Ashra F, Seddighi AS, Hashemi
SM,Seddighi A, Soleimani M, Zali A. Co-transplantation of autologous bone
marrowmesenchymal stem cells and Schwann cells through cerebral spinal
uid for thetreatment of patients with chronic spinal cord injury: safety and
possibleoutcome. Spinal Cord. 2016 Feb;54(2):102-9
96. Satti HS, Waheed A, Ahmed P, Ahmed K, Akram Z, Aziz T, Satti TM, Shahbaz
N,Khan MA, Malik SA. Autologous mesenchymal stromal cell
transplantation for spinalcord injury: A Phase I pilot study. Cytotherapy. 2016
Apr;18(4):518-22
97. Kakabadze Z, Kipshidze N, Mardaleishvili K, Chutkerashvili G, Chelishvili
I,Harders A, Loladze G, Shatirishvili G, Kipshidze N, Chakhunashvili
D,Chutkerashvili K. Phase 1 Trial of Autologous Bone Marrow Stem Cell
Transplantation in Patients with Spinal Cord Injury. Stem Cells
Int.2016;2016:6768274
98. Sharma A, Gokulchandran N, Sane H, Badhe P, Kulkarni P, Lohia M,
Nagrajan A, Thomas N. Detailed analysis of the clinical effects of cell therapy
for thoracolumbar spinal cord injury: an original study. Journal of
Neurorestoratology. 2013;1:13-22
99. Sharma A, Sane H, Gokulchandran N, Kulkarni P, Thomas N, et al. (2013) Role
of Autologous Bone Marrow Mononuclear Cells in Chronic Cervical Spinal
Cord Injury-A Longterm Follow Up Study. J Neurol Disord 1: 138.
100. Guest J, Herrera LP, Qian T. Rapid recovery of segmental neurological
function in a tetraplegic patient following transplantation of fetal olfactory
bulb-derived cells. Spinal cord. 2006 Mar;44(3):135.
101. Vaquero J, Zurita M, Rico MA, Bonilla C, Aguayo C, Montilla J, Bustamante S,
Carballido J, Marin E, Martinez F, Parajon A, Fernandez C, Reina LD;
Neurological Cell Therapy Group. An approach to personalized cell therapy
in chronic complete paraplegia: The Puerta de Hierro phase I/II clinical trial.
Cytotherapy. 2016 Aug;18(8):1025-36.
102. SHROFF, G., AGARWAL, P., MISHRA, A., SONOWAL, N.. Human
Embryonic Stem Cells in Treatment of Spinal Cord Injury: A Prospective
Stem Cell Therapy In Neurological Disorders 186

Study. Journal of Neurology Research, North America, 2015; Volume 5,

Number 3, June 2015, pages 213-220
103. Thakkar UG, Vanikar AV, Trivedi HL, Shah VR, Dave SD, Dixit SB, Tiwari
BB,Shah HH. Infusion of autologous adipose tissue derived neuronal
differentiated mesenchymal stem cells and hematopoietic stem cells in post-
traumatic paraplegia offers a viable therapeutic approach. Adv Biomed Res.
2016 Mar 16;5:51.
104. Vaquero J, Zurita M, Rico MA, Bonilla C, Aguayo C, Fernández C, Tapiador
N, Sevilla M, Morejón C, Montilla J, Martínez F, Marín E, Bustamante S,
Vázquez D, Carballido J, Rodríguez A, Martínez P, García C, Ovejero M,
Fernández MV; Neurological Cell Therapy Group. Repeated subarachnoid
administrations of autologous mesenchymal stromal cells supported in
autologous plasma improve quality of life in patients suffering incomplete
spinal cord injury. Cytotherapy. 2017 Mar;19(3):349-359.
105. Shroff G. Magnetic resonance imaging tractography as a diagnostic tool in
patients with spinal cord injury treated with human embryonic stem cells.
Neuroradiol J. 2017 Feb;30(1):71-79.
106. Shroff G. Human Embryonic Stem Cell Therapy in Chronic Spinal Cord
Injury: A Retrospective Study. Clinical and Translational Science. 2016;9(3):168-
175. doi:10.1111/cts.12394.
107. Levi AD, Okonkwo DO, Park P, Jenkins AL 3rd, Kurpad SN, Parr AM, Ganju
A, Aarabi B, Kim D, Casha S, Fehlings MG, Harrop JS, Anderson KD, Gage A,
Hsieh J, Huhn S, Curt A, Guzman R. Emerging Safety of Intramedullary
Transplantation of Human Neural Stem Cells in Chronic Cervical and
Thoracic Spinal Cord Injury. Neurosurgery. 2018 Apr 1;82(4):562-575.
108. George M. Ghobrial, Kim D. Anderson, Marine Dididze, Jasmine Martinez-
Barrizonte, Gabriel H. Sunn, Katie L. Gant, Allan D. Levi; Human Neural Stem
Cell Transplantation in Chronic Cervical Spinal Cord Injury: Functional
Outcomes at 12 Months in a Phase II Clinical Trial, Neurosurgery, Volume 64,
Issue CN_suppl_1, 1 September 2017, Pages 87–91,
109. A l o k S h a r m a , H e m a n g i S a n e , D i p t i K h o p k a r , N a n d i n i
Gokulchandran,Varghese Chako Jacob, Joji Joseph, Prerna Badhe. Functional
recovery in chronic stage of spinal cord injury by Neurorestorative Approach.
Case Reports in Surgery Volume 2014, pages 1-4
110. Alok Sharma, Prerna Badhe, Pooja Kulkarni, Nandini Gokulchandran,
Guneet Chopra, Mamta Lohia, V.C.Jacob. Autologous Bone marrow Derived
mononuclear cells for the treatment of Spinal Cord Injury. The Journal of
Orthopaedics. 2011; 1(1): 33-36
Stem Cell Therapy In Neurological Disorders 187

111. Alok Sharma, Hemangi Sane, Dipti Khopkar, Nandini Gokulchandran, Hema
Biju, V C Jacob, Prerna Badhe. Cellular therapy targeting Functional outcome
in a case of Cervical Spinal Cord Injury. Advances in Stem Cells Vol. 2014
(2014)
112. Alok S, Prerna B, Suhasini, Hemangi S, Samson N, Pooja K, Amruta P, Dhara
M, Nandini G.Functional Recovery and Functional Magnetic Resonance
Imaging changes Following Cellular Therapy in a Case of Chronic Complete
Spinal Cord Injury. Curr Trends Clin Med Imaging. 2017; 1(4): 555566.
113. Alok Sharma, Hemangi Sane, Suhasini Pai, Pooja Kulkarni, Amruta
Paranjape, V C Jacob, Joji Joseph, Sanket Inamdar, Sarita Kalburgi, Nandini
Gokulchandran, Prerna Badhe, Samson Nivins. Functional and symptomatic
improvement after cellular therapy in a pediatric case of chronic traumatic
incomplete SCI. J Stem Cell Regen Biol 2017; 3(1): 1- 7.
114. Panayiotou E, Malas S. Adult spinal cord ependymal layer: a promising pool
of quiescent stem cells to treat spinal cord injury. Front Physiol. 2013 Nov
28;4:340. eCollection 2013
115. Sharma HS, Muresanu DF, Sharma A. Novel therapeutic strategies using
nanodrug delivery, stem cells and combination therapy for CNS trauma and
neurodegenerative disorders. Expert Rev Neurother. 2013 Oct;13(10):1085-8
116. Yamamoto A, Sakai K, Matsubara K, Kano F, Ueda M. Multifaceted neuro-
regenerative activities of human dental pulp stem cells for functional recovery
after spinal cord injury. Neurosci Res. 2014 Jan;78:16-20
117. Kokai LE, Marra K, Rubin JP. Adipose stem cells: biology and clinical
applications for tissue repair and regeneration. Transl Res. 2013 Dec 4. pii:
S1931-5244(13) 00426-X.
118. Fu X. The immunogenicity of cells derived from induced pluripotent stem
cells. Cell Mol Immunol. 2014 Jan;11(1):14-6.
119. Garg T, Rath G, Goyal AK. Biomaterials-based nanober scaffold: targeted
and controlled carrier for cell and drug delivery. J Drug Target. 2015
Apr;23(3):202-21.
120. neuralstem.com/cell-therapy-for-sci
121. Clinicaltrials.gov
Stem Cell Therapy In Neurological Disorders 188

Our natural power is sapped by the parasites of the centuries: fear,

superstition, a view of reality that reduces life's wonders tocreaking
machinery. If we starve these parasitic beliefs they will die. But we
rationalize our fatigue, our inertia; we deny that we are haunted.

Our choice, is between the painful but condence instilling process of

coming to know who and where we are and the immensely appealing but
nally empty alternative of continuing to drift, of acting as if weknow what
we are doing when both the mounting evidence and our most honest fears
indicate that we do not….In government, as in other relationships, we have
the capacity to deceive ourselves, to shape the realities by which we live, so
that our prime focus is on our comfort rather than the truth”

– Marilyn Ferguson
Stem Cell Therapy In Neurological Disorders 189

12

Stem Cell Transplantation In Stroke

Angiogenesis, synaptogenesis and neurogenesis functions of stem cells help in
recovery of Stroke.
Stroke is classically characterized as a neurological decit attributed to an acute
focal injury of the central nervous system (CNS) by a vascular cause, including
cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid
hemorrhage (SAH), and is a major cause of disability and death worldwide. (1) It is
caused by a sudden interruption of the blood supply to the brain leading to reduced
oxygen and nutrient supply in that area. The two major types of stroke are ischemic
and hemorrhagic. In ischemic stroke, decreased or absent circulating blood
deprives neurons of necessary substrates. Intracerebral hemorrhage originates
from deep penetrating vessels and causes injury to brain tissue by disrupting
connecting pathways and causing localized pressure injury. The extent of
neurological involvement may range from mild motor decit to gross involvement
of various function namely sensorimotor, perceptual, emotional, behavioral,
memory intelligence, speech and language function, ultimately affecting the
activities of daily living.
Acute medical management is based on the type of stroke where, ischemic stroke is
treated by thrombolysis or anticoagulation medications. For hemorrhagic stroke,
management is focused at the underlying cause of bleed, that is reduce blood
pressure or treatment of aneurysm etc. Medical and surgical strategies aim at
prevention of recurrence of stroke. Stroke rehabilitation remains the cornerstone for
patients with stroke, and should be initiated as early as possible. Most return of
function is seen in the rst few months, and then improvement falls off with the
Stem Cell Therapy In Neurological Disorders 190

"window" considered ofcially by U.S. state rehabilitation units and others to be

closed after six months, with little chance of further improvement.
Unmet medical needs
With the current treatment approaches, medical, surgical or rehabilitative, the
pathophysiological processes and the resultant damage occurring at the
microcellular level cannot be reversed. This permanent change in the structure of
CNS leads to long lasting physical impairments, seen as residual problems, which
translate gradually into activity limitation and restricts these individuals to
participate in the community. There have been many advances in the medical
management of acute stroke but, little has changed to address the residual decits
of chronic stroke. A treatment approach, which changes the physiology at the
neuronal level, is the need of the hour. Cell therapy offers hope for stroke patients,
especially for those who have missed the "window".
Role of stem cell therapy in chronic stroke:
Stem cells impersonate the natural process of recovery after stroke, which is
mobilization of stem cells, originally present in the bone marrow, to the area of
injury in the brain. This occurs with the release of certain factors. This mobilization
of stem cells to the injured brain initiates the process of neurorestoration. These
stem cells secrete various growth factors like VEGF, bFGF and BDNF which
support and amplify angiogenesis, neurogenesis and synaptic plasticity at the
penumbral region. Along with the above neuroreparative processes, the stem cells
also decrease the glial scar formation and promote glial-axonal remodeling which is
seen in chronic stroke (2-5). The number of stem cells mobilized after acute stroke
starts decreasing as chronic stage approaches. Therefore as time passes by the rate
of recovery also reduces in the chronic stage. This forms the rationale that if more
number of stem cells are supplied to the injured area in the chronic stage, it may
hasten and increase the chances of recovery.

A: Acute phase of stroke B: Chronic phase of stroke

Figure 1: Natural process of mobilization of endogenous bone marrow stem cells

after stroke.
Stem Cell Therapy In Neurological Disorders 191

Courtesy: Borlongan CV, Glover LE, Tajiri N, Kaneko Y, Freeman TB. The Great
Migration of Bone Marrow-Derived Stem Cells Toward the Ischemic Brain:
Therapeutic Implications for Stroke and Other Neurological Disorders. Progress in
neurobiology. 2011;95(2):213-228. doi:10.1016/j.pneurobio.2011.08.005.
Stem cell therapy in Stroke

Figure 2: The transplanted autologous BMMNCs provide large number of stem cells
in the chronic phase which mimic the natural pathway (depicted in gure 1) to
repair the damaged brain areas.
Pre-clinical studies:
There are various studies performed on animals, to assess the effects of stem cell
therapy in improving the outcomes post stroke. The ndings of these studies
included increased angiogenesis at the site of the infarct, increased modulation of
neurotrophic growth factors, and reduction in the infarct volumes. They exhibited
improved functional performance and restore neurological decits (6-14).
A systematic review and meta-analysis of the pre-clinical studies using MSCs for
stroke was conducted by Quynh et al. 2016. They identied 46 relevant studies that
analyzed the effect of MSCs transplantation for Ischemic stroke. Out of these, 44
studies showed a signicant improvement in the neurological severity score and
other motor function tests. There was also a signicant reduction in infarct size of
the treated rats. Greater improvements were noted in rats treated with intracerebral
routes followed by intra-arterial and intra-venous routes. The study did not nd
any signicant change in the outcomes when the cells were delivered within 24
hours of the stroke or after 24 hours of the stroke. The mechanism of action in acute
stage is presumed to be reduction of ongoing injury to neural tissue whereas in
subacute stage stem cells promote neural repair (15).
Stem Cell Therapy In Neurological Disorders 192

Clinical studies
Stem Cell Therapy In Neurological Disorders 193
Stem Cell Therapy In Neurological Disorders 194

Total 33 studies were published demonstrating the benets of stem cell therapy in
stroke. Different cell types studied in these articles were Autologous bone marrow
mononuclear cells (BMMNCs), Autologous and allogenic mesenchymal cells
(MSCs), Fetal porcine cells, Neural stem cells (NSCs), Immature neurons and
hematopoietic cells, Olfactory ensheathing cells (OECs). Different routes of
administration studied in the articles were Intracranial (IC), Intravenous (IV),
Intraarterial (IA), Intrathecal (IT), Subarachnoid.
All these studies unanimously suggested that the transplantation of various types
of stem cells was safe using various routes of administration. Although some
adverse events were noted in these studies none of them were related to cell
transplantation. Many studies showed that there was a statistically signicant
difference in the pre and post measures of Barthel Index, Modied Rankin Scale,
National Institute of Health Stroke Score, Functional Independence Measure and
Frugal Myer scale after stem cell therapy. Along with the functional improvements
Stem Cell Therapy In Neurological Disorders 195

there were improvements in the metabolism as measured on PET-CT scan and

some studies showed reduction in the lesion size on MRI. (16-43)
Our results
Published data
We performed a study to demonstrate the effect of intrathecal administration of
autologous bone marrow mononuclear cells (BMMNCs) on the recovery process of
patients with chronic stroke. (43) 24 patients diagnosed with chronic stroke were
administered cell therapy, followed by multidisciplinary neurorehabilitation. They
were assessed on functional independence measure (FIM) objectively, along with
assessment of standing and walking balance, ambulation, and hand functions. Out
of 24 patients, 12 improved in ambulation, 10 in hand functions, 6 in standing
balance, and 9 in walking balance. Patients with age less than 60 years showed a
higher percentage of improvement in the areas of ambulation, hand functions, and
sitting and standing balance, as compared to the patients with age more than 60
years. They also showed improvement in the FIM scores. Time since the stroke
episode also seemed to have an effect on the recovery of patients. The percentage of
improvement was higher in patients, whose episode of stroke was less than 2 years
old, as compared to those patients whose stroke was older than 2 years. Patients
with ischemic type of stroke had better outcomes in all the mentioned areas, as
compared to thosewith hemorrhagic stroke. Also, patients with right brain
involvement showed higher percentage of improvement in area of ambulation,
standing balance, and walking balance, as compared to the left brain. There was a
statistically signicant difference (□□< 0.05) seen in FIM scores before and after the
cell therapy.

Figure 3: Symptom-wise improvements seen in patients of stroke after intrathecal

administration of autologous BMMNCs.
Stem Cell Therapy In Neurological Disorders 196

Figure 4: Comparison of symptomatic improvements in patients according to

duration since onset of stroke.

Figure 5: Age-wise comparison of symptomatic improvements in patients of stroke.

Stem Cell Therapy In Neurological Disorders 197

Figure 6: Comparison of symptomatic improvements according to the type of

stroke.

Figure 7: Comparison of symptomatic improvements according to side of the brain

involved.
Stem Cell Therapy In Neurological Disorders 198

We published 4 case reports of patients with different types of stroke in various peer
reviewed journals. These cases underwent intrathecal autologous bone marrow
derived mononuclear cell transplantation. All these patients showed functional
and neurological improvements on follow up. Improvements were seen in
symptoms such as walking and standing balance, hand grip, voluntary control,
spasticity, speech, mobility, etc. These patients also showed improved brain
metabolism on PET CT scan brain. (44-47)

Objective improvement on PET-CT scan seen in patients treated with

autologous BMMNCs

Post PET scan following cellular

therapy showed signicant
improvement in Right superior
frontal cortex, sensory motor cortex,
bilateral posterior cingulate, right
temporal cortex

Before
Stem Cell Signicant
improvement in
Therapy
metabolism is
observed in right
thalamus, basal
ganglia and
After cerebellum
Stem Cell
Therapy
Stem Cell Therapy In Neurological Disorders 199

Post PET scan following

cellular therapy showed
signicant improvement in
Left thalamus, bilateral medial
temporal cortex and
cerebellum

Before
Stem Cell
Therapy

After
Stem Cell
Therapy

Signicant improvement in metabolism is observed in bilateral frontal-parietal

cortex, right thalamus, temporal cortex and cerebellum

Future directions
There are many areas which needs to be analyzed in depth, to gain the best
outcomes out of cell therapy. The question of best cell type for transplantation with
stroke needs to be addressed. To optimize cell therapies in stroke, it is also necessary
to elucidate the molecular mechanisms controlling the interaction of the grafted
cells with the ischemic brain, as the post ischemic environment can affect the
function of transplanted stem cells, which in turn can modulate the inammatory
response and the local microenvironment. Timing of transplantation in different
time windows needs to be assessed in detail, as most of the studies takes into
account acute, sub acute and chronic stroke. This is crucial to analyze the effect of
cell therapy at various stages. Appropriate dosage remains unclear. A dose-
Stem Cell Therapy In Neurological Disorders 200

response correlation is an important aspect of cell therapy. Routes of administration

are an important area which decides the intensity of effect of cell therapy. Objective
imaging needs to be introduced into clinical trials, to get an insight into the
physiological processes occurring at the cellular level after cell therapy, to
strengthen the results obtained.
Conclusion:
Autologous bone marrow mononuclear cells facilitate recovery after stroke by
facilitating neuroregeneration and enhancing neural repair through various
paracrine mechanisms like neoangiogenesis, immunomodulation, stimulation of
resident stem cells, secreation of various neurotrophic factors and growth factors. It
mimics the natural recovery process in the body. Autologous bone marrow
mononuclear cells intrathecal transplantation combined with multi-disciplinary
neurorehabilitation can provide signicant clinical benet in acute as well as
chronic stroke patients. It is a safe treatment option and improvements in various
symptoms of stroke as well as activities of daily living can be noted however, it is
not a curative treatment. Various factors may inuence this recovery some of which
are like age, time since stroke and type of stroke may inuence the process of
recovery.
REFERENCES:
1. Sacco, R. L., et al. "on behalf of the American Heart Association Stroke Council,
Council on Cardiovascular Surgery and Anesthesia, Council on
Cardiovascular Radiology and Intervention, Council on Cardiovascular and
Stroke Nursing, Council on Epidemiology and Prevention, Council on
Peripheral Vascular Disease, and Council on Nutrition, Physical Activity and
Metabolism. An updated denition of stroke for the 21st century: a statement
for healthcare professionals from the American Heart Association/American
Stroke Association." Stroke 44 (2013): 2064-2089.
2. Carmeliet P, Storkebaum E. Vascular and neuronal effects of VEGF in the
nervous system: implications for neurological disorders. Semin Cell Dev Biol
2002;13:39 - 53.
3. Jin K, Zhu Y, Sun Y, Mao XO, Xie L, Greenberg DA. Vascular endothelial
growth factor (VEGF) stimulates neurogenesis in vitro and in vivo. Proc Natl
Acad Sci U S A 2002; 99:11946-11950.
4. Chen J, Zhang ZG, Li Y, et al. Intravenous administration of human bone
marrow stromal cells induces angiogenesis in the ischemic boundary zone after
stroke in rats. Circ Res 2003;92: 692-699.
5. Li Y, Chen J, Zhang CL, et al. Gliosis and brain remodeling after treatment of
stroke in rats with marrow stromal cells. GLIA 2005;49:407- 417.
Stem Cell Therapy In Neurological Disorders 201

6. Li-Ru Zhao Wei-Ming Duan Morayma Reyes C. Dirk Keene Catherine M.

Verfaillie Walter C. Low Human Bone Marrow Stem Cells Exhibit Neural
Phenotypes and Ameliorate Neurological Decits after Grafting into the
Ischemic Brain of Rats Experimental Neurology 174, 11-20 (2002)
7. Woei-Cherng Shyu, Shinn-Zong Lin Ming-Fu Chiang Ching-Yuan Su Hung Li
Intracerebral Peripheral Blood Stem Cell (CD34_) Implantation Induces
Neuroplasticity by Enhancing _1 Implantation Induces Neuroplasticity by
Enhancing _1 The Journal of Neuroscience, March 29, 2006 o 26(13):3444 -3453
8. Natalia Pavlichenko, Irina Sokolova, Svetlana Vijde, Evgenia Shvedova,
Georgy Alexandrov, Peter Krouglyakov, Olga Fedotova, Elena G. Gilerovich,
Elena G. Gilerovich, Vladimir A. Otellin Mesenchymal stem cells
transplantation could be benecial for treatment of experimental ischemic
stroke in rats BRAIN Research 1233 ( 2 0 0 8 ) 2 0 3 - 2 1 3
9. Jieli Chen, Zheng Gang Zhang, Yi Li, Lei Wang, Yong Xian Xu, Subhash C.
Gautam, Mei Lu, Zhenping Zhu and Michael Chopp Intravenous
Administration of Human Bone Marrow Stromal Cells Induces Angiogenesis
in the Ischemic Boundary Zone After Stroke in Rats Circ Res. 2003;92:692-699
10. Y. Li, MD; J. Chen, MD; L. Wang, MD; M. Lu, PhD; and M. Chopp, PhD
Treatment of stroke in rat with intracarotid administration of marrow stromal
cells NEUROLOGY 2001;56:1666-1672
11. Sang-Wuk Jeong, Kon Chu, Keun-Hwa Jung, Seung U. Kim, Manho Kim and
Jae- Kyu Roh Human Neural Stem Cell Transplantation Promotes Functional
Recovery in Rats With Experimental Intracerebral Hemorrhage Stroke.
2003;34:2258-2263
12. David C. Hess, William D. Hill, Angeline Martin-Studdard, James Carroll,
Joanna Brailer and Jo Carothers Bone Marrow as a Source of Endothelial Cells
and NeuN-Expressing Cells After Stroke Stroke. 2002;33:1362-1368
13. Boltze J, Schmidt UR, Reich DM, Kranz A, Reymann KG, Strassburger M,
Lobsien D, Wagner DC, Forschler A, Schabitz WR. Determination of the
therapeutic time window for human umbilical cord blood mononuclear cell
transplantation following experimental stroke in rats. Cell Transplant.
2012;21(6):1199–1211.
14. Borlongan CV, Glover LE, Tajiri N, Kaneko Y, Freeman TB. The Great
Migration of Bone Marrow-Derived Stem Cells Toward the Ischemic Brain:
Therapeutic Implications for Stroke and Other Neurological Disorders.
Progress in neurobiology. 2011;95(2):213-228.
15. Vu Q, Xie K, Eckert M, Zhao W, Cramer SC. Meta-analysis of preclinical studies
Stem Cell Therapy In Neurological Disorders 202

of mesenchymal stromal cells for ischemic stroke. Neurology. 2014 Apr

8;82(14):1277-86
16. Hess DC, Wechsler LR, Clark WM, Savitz SI, Ford GA, Chiu D, Yavagal DR,
Uchino K, Liebeskind DS, Auchus AP, Sen S. Safety and efcacy of multipotent
adult progenitor cells in acute ischaemic stroke (MASTERS): a randomised,
double-blind, placebo-controlled, phase 2 trial. The Lancet Neurology. 2017
May 1;16(5):360-8.
17. Bhasin A, Srivastava MP, Mohanty S, Vivekanandhan S, Sharma S, Kumaran S,
Bhatia R. Paracrine mechanisms of intravenous bone marrow-derived
mononuclear stem cells in chronic ischemic stroke. Cerebrovascular diseases
extra. 2016;6(3):107-19.
18. Honmou O, Houkin K, Matsunaga T, Niitsu Y, Ishiai S, Onodera R, Waxman
SG, Kocsis JD. Intravenous administration of auto serum-expanded autologous
mesenchymal stem cells in stroke. Brain. 2011 Apr 14;134(6):1790-807.
19. Taguchi A, Sakai C, Soma T, Kasahara Y, Stern DM, Kajimoto K, Ihara M,
Daimon T, Yamahara K, Doi K, Kohara N. Intravenous autologous bone
marrow mononuclear cell transplantation for stroke: phase1/2a clinical trial in
a homogeneous group of stroke patients. Stem cells and development. 2015 Jul
15;24(19):2207-18.
20. Chen DC, Lin SZ, Fan JR, et al. Intracerebral implantation of autologous
peripheral blood stem cells in stroke patients: a randomized phase ii study. Cell
Transplant 2014; 23: 1599–1612.
21. da Fonseca LM, Gutlen B, de Castro PH, Battistella V, Goldenberg RC, Kasai-
Brunswick T, Chagas CL, Wajnberg E, Maiolino A, Xavier SS, Andre C.
Migration and homing of bone-marrow mononuclear cells in chronic ischemic
stroke after intra-arterial injection. Experimental neurology. 2010 Jan
1;221(1):122-8.
22. Misra V, Ritchie MM, Stone LL, Low WC, Janardhan V. Stem cell therapy in
ischemic stroke Role of IV and intra-arterial therapy. Neurology. 2012 Sep
25;79(13 Supplement 1):S207-12.
23. Taguchi A, Sakai C, Soma T, Kasahara Y, Stern DM, Kajimoto K, Ihara M,
Daimon T, Yamahara K, Doi K, Kohara N. Intravenous autologous bone
marrow mononuclear cell transplantation for stroke: phase1/2a clinical trial in
a homogeneous group of stroke patients. Stem cells and development. 2015 Jul
15;24(19):2207-18.
24. Kalladka D, Sinden J, Pollock K, Haig C, McLean J, Smith W, McConnachie A,
Santosh C, Bath PM, Dunn L, Muir KW. Human neural stem cells in patients
Stem Cell Therapy In Neurological Disorders 203

with chronic ischaemic stroke (PISCES): a phase 1, rst-in-man study. The

Lancet. 2016 Aug 20;388(10046):787-96.
25. Oh Young Bang MD, PhD Jin Soo Lee MD1, Phil Hyu Lee MD, PhD1, Gwang
Lee PhD Autologous mesenchymal stem cell transplantation in stroke patients
Annals of Neurology Volume 57, Issue 6, pages 874-882, June 2005
26. Jin Soo Lee Ji Man Hong Gyeong Joon Moon2 Phil Hyu Lee Young Hwan Ahn4,
Oh Young Bang2 A Long-Term Follow-Up Study of Intravenous Autologous
Mesenchymal Stem Cell Transplantation in Patients With Ischemic Stroke
STEM CELLS Volume 28, Issue 6, pages 1099-1106, June 2010
27. Carlos Suárez-Monteagud1, Porrio Hernández-Ramírez, Lázaro Álvarez-
González et al. Autologous bone marrow stem cell neurotransplantation in
stroke patients. An open study Restorative Neurology and Neuroscience.
2009;27(3):151-161
28. Lee JS, Hong JM, Moon GJ, Lee PH, Ahn YH, Bang OY et al. A long-term follow-
up study of intravenous autologous mesenchymal stem cell transplantation in
patients with ischemic stroke. Stem Cells. 2010;28(6):1099-106.
29. Locatelli F, Bersano A, Ballabio E, Lanfranconi S, Papadimitriou D, Strazzer S,
Bresolin N, Comi GP, Corti S. Stem cell therapy in stroke. Cellular and
Molecular Life Sciences. 2009 Mar 1;66(5):757-72.
30. Parker GC. Stem cell therapy for stroke. Journal of Pediatric Neurology. 2010
Jan 1;8(3):333-41.
31. Suárez-Monteagudo C, Hernández-Ramírez P, Álvarez-González L, García-
Maeso I, de la Cuétara-Bernal K, Castillo-Díaz L, Bringas-Vega ML, Martínez-
Aching G, Morales-Chacón LM, Báez-Martín MM, Sánchez-Catasús C.
Autologous bone marrow stem cell neurotransplantation in stroke patients. An
open study. Restorative neurology and neuroscience. 2009 Jan 1;27(3):151-61.
32. Buchan AM, Warren D, Burnstein R. Transplantation of cultured human
neuronal cells for patients with stroke. Neurology. 2001 Mar 27;56(6):820-3.
33. Kondziolka D, Wechsler L, Goldstein S, Meltzer C, Thulborn K, Gebel J,
Jannetta P, DeCesare S, Elder EM, McGrogan M, Reitman MA. Transplantation
of cultured human neuronal cells for patients with stroke. Neurology. 2000 Aug
22;55(4):565-9.
34. Mendez-Otero R, De Freitas GR, André C, Furtado de Mendonça ML, Friedrich
M, Oliveira-Filho J. Potential roles of bone marrow stem cells in stroke therapy.
35. Prasad K, Mohanty S, Bhatia R, Srivastava MV, Garg A, Srivastava A, Goyal V,
Tripathi M, Kumar A, Bal C, Vij A, Mishra NK. Autologous intravenous bone
Stem Cell Therapy In Neurological Disorders 204

marrow mononuclear cell therapy for patients with subacute ischaemic stroke:
a pilot study. Indian J Med Res. 2012 Aug;136(2):221-8. PubMed PMID:
22960888; PubMed Central PMCID: PMC3461733.
36. Prasad K, Sharma A, Garg A, Mohanty S, Bhatnagar S, Johri S, Singh KK, Nair
V, Sarkar RS, Gorthi SP, Hassan KM. Intravenous autologous bone marrow
mononuclear stem cell therapy for ischemic stroke: a multicentric, randomized
trial. Stroke. 2014 Dec 1;45(12):3618-24.
37. Friedrich MA, Martins MP, Araújo MD, Klamt C, Vedolin L, Garicochea B,
Raupp EF, Sartori El Ammar J, Machado DC, Costa JC, Nogueira RG, Rosado-
de-Castro PH, Mendez-Otero R, Freitas GR. Intra-arterial infusion of
autologous bone marrow mononuclear cells in patients with moderate to
severe middle cerebral artery acute ischemic stroke. Cell Transplant. 2012;21
Suppl 1:S13-21. doi: 10.3727/ 096368912X612512. PubMed PMID: 22507676.
38. Lee JS, Hong JM, Moon GJ, Lee PH, Ahn YH, Bang OY. A long term follow up
study of intravenous autologous mesenchymal stem cell transplantation in
patients with ischemic stroke. Stem cells. 2010 Jun 1;28(6):1099-106
39. Bang OY, Lee JS, Lee PH, Lee G. Autologous mesenchymal stem cell
transplantation in stroke patients. Ann Neurol. 2005 Jun;57(6):874-82
40. Bhasin A, Padma Srivastava MV, Kumaran SS, Bhatia R, Mohanty S.
Neuralinterface of mirror therapy in chronic stroke patients: a functional
magneticresonance imaging study. Neurol India. 2012 Nov-Dec;60(6):570-6.
41. Bhasin A, Kumaran SS, Bhatia R, Mohanty S, Srivastava MVP. Safety
andFeasibility of Autologous Mesenchymal Stem Cell Transplantation in
Chronic Strokein Indian patients. A four-year follow up. J Stem Cells Regen
Med. 2017 May30;13(1):14-19.
42. Bhasin A, Srivastava MV, Kumaran SS, Mohanty S, Bhatia R, Bose S, Gaikwad S,
Garg A, Airan B. Autologous mesenchymal stem cells in chronic stroke.
CerebrovascDis Extra. 2011 Jan-Dec;1(1):93-104.
43. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Dipti Khopkar,
Amruta Paranjape, Jyothi Sundaram, Sushant Gandhi, and Prerna Badhe.
Autologous Bone Marrow Mononuclear Cells Intrathecal Transplantation in
Chronic Stroke Stroke Research and Treatment, Volume 2014, pages 1-9.
44. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Pooja Kulkarni,
Rishabh Sharan, Amruta Paranjape, Prerna Badhe Effect of Cellular Therapy
Monitored on Positron Emission Tomography - Computer Tomography Scan
in Chronic Hemorrhagic Stroke: A Case Report. Archiv Neurol Neurosurgery,
2016 Volume 1(1): 22-25
Stem Cell Therapy In Neurological Disorders 205

45. Alok Sharma, Hemangi Sane , Amruta Paranjape, Nandini Gokulchandran ,

Sushant Gandhi, Prerna Badhe. Benets of Autologous Bone Marrow
Mononuclear Cell Transplantation in Chronic Ischemic Pontine Infarct. Journal
Of Case Reports 2016;6(1):80-85
46. Alok Sharma, Hemangi Sane, Anjana Nagrajan, et al., “Autologous Bone
Marrow Mononuclear Cells in Ischemic Cerebrovascular Accident Paves Way
for Neurorestoration: A Case Report,” Case Reports in Medicine, vol. 2014,
Article ID 530239, 5 pages, 2014. doi:10.1155/2014/530239.
47. Dr. Alok Sharma, Dr. Hemangi Sane, Dr. Prerna Badhe, Ms. Pooja Kulkarni, Dr.
Guneet Chopra, Dr. Mamta Lohia, Dr. Nandini Gokulchandran. Autologous
Bone Marrow Stem Cell Therapy shows functional improvement in
hemorrhagic stroke- a case study. Indian Journal of Clinical Practice,
2012:23(2):100-105
Stem Cell Therapy In Neurological Disorders 206

Do not fear to defend new ideas even the most revolutionary, your own
faith is what counts most. But have the courage also to admit an error as
soon as you have proved it to yourself, that your idea is wrong. Science is
the graveyard of ideas. But some ideas that seem dead and buried away may
at one time or another rise up to life again more vital than ever”

–Louis Pasteur
Stem Cell Therapy In Neurological Disorders 207

13

Role of Stem Cells In Motor Neuron

Disease / Amyotrophic Lateral
Sclerosis
“Stem Cell Research is the KEY to developing cures for degenerative conditions
like Parkinson’s and Motor Neuron Disease from which I and many others
suffer.” – Stephen Hawking
Motor neuron disease [MND]is a progressive disorder characterized by weakness
of muscles and selective degeneration of motor nerves [1]. The disease has poor
prognosis and has poor life expectancy. The disease affects only motor neurons
andsparing the sensory system. There is no conclusive evidence about the causative
or risk factors for the disease [1].Motor neuron disease connotes a group of diseases
that can lead variety of upper and lower motor neuron symptoms like cramps,
fasciculation, dysarthria and dysphagia.
Amyotrophic Lateral Sclerosis [ALS] is a form of MND which is characterized by
fast progression and presence of both UMN and LMN symptoms in the trunk,
extremities and bulbar regions. The life expectancy of patients with ALS is very
poor of up to 3 to 5 years since the onset of the disease [2,3,4,5]. The onset of the
disease may be from weakness in the extremities or bulbar region. As the disease
progresses the weakness spreads to all the regions of the body. The terminal
symptoms of the disease are caused due to weakness of respiratory muscles leading
to respiratory insufciency and eventually respiratory failure [1]. Common
symptoms of the disease are weakness in the distal muscles of the extremities,
Stem Cell Therapy In Neurological Disorders 208

fasciculations and cramps in all the parts of the body, emotional disturbances,
dysarthria, dysphagia, fatigue and spasticity. Reexes may be exaggerated and
Hoffmann's sign may also be positive. ALS signicantly hampers the quality of life
of patients due to increased dependence for performing activities of daily living as
the disease progresses. The presentation of the disease is variable and has different
rates of progression. Some factors have been identied, which may be responsible
for poor prognosis, such as, presence of LMN features, old age, bulbar onset, low
forced vital capacity [FVC] and low scores on revised ALS- functional rating scale
[ALS-FRSr] [6,7]. Various other neurodegenerative disorders also present with
similar UMN and LMN symptoms. The diseases that are categorized as MND, also
present with similar symptoms as observed in ALS [8]. ALS/MND is of two types
familial (10%) i.e. with known genetic involvement, sporadic (90%) with no
underlying genetic abnormality.
However to improve the quality of life and complications developed secondary to
prolonged and progressive muscle weakness, multi-disciplinary care is required.
Commonly the management includes pharmacological intervention,
rehabilitation, nutritional advice, good nursing care, articial ventilator support in
the later stages of the disease and Percutaneous endoscopic gastrotomy[PEG]
preventing dysphagia related complications [9].
Mutations in
Pathophysiology of ALS c9orf72, TDP-43 (TARDBP)
FUS, and SOD-1 (S0D1) genes
TDP-43/FUS

Mutant SOD-1

SOD-1 aggregates
Increased oxidative stress

Neurofilament Mitochondrial
accumulation dysfunction
Pump
Dysfunction of axonal dysfunction
transport systems
Presynaptic
neuron

2K+
3Na+ Glutamate
excitotoxicity
Secretion
Release of of toxic
inflammatory factors Impaired
mediators glutamte
uptake
(EAAT-2
Microglia transporter)
Astrocyte

Figure 1: A diagram depicting various pahtophysiological mechanisms causing

ALS/MND – genetic mutations, glutamate toxicity, inammation and
neurotoxicity due to glial cell response, axonal dysfunction, increased oxidative
stress and mitochondrial dysfunction.
Stem Cell Therapy In Neurological Disorders 209

Unmet medical needs

The progression of the disease is rapid, presentation of the disease is varied and the
causes are not understood. It is therefore challenging to nd a medical cure for the
disease. All the conventional treatments available manage the symptoms and
associated conditions, failing to address the core pathology of ALS. There is a need
to develop a treatment strategy to halt or arrest the progression of the disease and
eventually a treatment that will reverse the symptoms and cure the disease.
Stem cell therapy for ALS
Stem cell transplantation is a promising new therapy for ALS. Different cell types,
routes of administration and different protocols of administration are being studied
widely world over.

Figure 2: Mechanism of action of stem cells in MND/ALS.

Replacement of degenerated motor neurons is the ultimate goal of transplantation
therapy but various factors inuence the outcome of the transplanted cells. Survival
of the cells in the host environment, their neurogenic potential, actual neurogenesis
at the target site and formation of neuronal connections over long distances are
some of the factors [32,33]. As the transplantation science evolves these factors
could be monitored to gain appropriate outcome but currently the aim of
transplantation is to protect the existing motor neurons and attempt to bring out
regeneration and repair in the damaged motor neurons. Although stem cells have
neurogenic potential their fate is dependent on various factors. They have a
neurotrophic inuence on the nervous system and can home onto the site of injury
Stem Cell Therapy In Neurological Disorders 210

[34]. They further demonstrate immomodulatory, anti-inammatory and

cytoprotective properties [35]. The factors secreted by these cells bring about
neoangiogenesis [36]. These paracrine effects lead to neuroprotection and
subsequent alteration in the disease course and progression [37].

Figure 3: Mechanism of Action of cellular therapy in ALS

Animal Studies
Zhou et al. 2013 [10] have shown that intrathecal transplantation of human bone
marrow stromal cells in SOD1 transgenic mice, reduced the inammatory glial
response and facilitates secretion of anti-inammatory cytokines.
Pastor D et al. 2013 [11] suggested that bone marrow injected in the muscles may
have neuroprotective effects and prevent the death of motor neurons.
Chen B K et al. 2015 [12] carried out the study for safety of the intrathecal delivery of
bone marrow mesenchymal stromal cells that showed that stem cell transplantation
was safe in the rabbit model of the disease.
Moura et al. 2016 [13] conducted a review and meta-analysis of 10 preclinical
studies that studied the effect of cell transplantation on disease progression,
survival duration and motor function in mouse model of the disease. Various routes
of administration used were intrathecal, intravenous, intraventricular and
intraspinal. Histopathologically the nervous tissue obtained from the patients
showed better survival of motor neuron and glial cells. It also suggested more
proliferation of the glial cells but with lesser density post transplantation. Gliosis of
neural tissue was also signicantly reduced post transplantation. Clinically the
studies suggested slower rate of disease progression and signicant survival
benet in rats treated with transplantation. These positive effects can be attributed
to the production of neurotrophic factors and the reduction of microgliosis and
macrogliosis.
Stem Cell Therapy In Neurological Disorders 211

Human studies
In a Phase I clinical trial, human spinal cord-derived neural stem cells were
transplanted into the spinal cord of 12 late- to mid-stage ALS patients [14]. There
were no long-term surgical complications and importantly, ALS patients tolerated
the procedure, gave no indications that the stem cells were injurious to the spinal
cord and showed no disease acceleration due to injections. Second part of this
Phase 1 trial determined the safety of injecting cells into the C3–C5 cervical region of
the spinal cord [15]. Three new ALS patients and three patients that had previously
received lumbar injections received human spinal cord-derived neural stem cells.
There were some positive effects including slowing of rate of progression, and one
patient even showed improvement in clinical status. In an expansion of the study,
Mazzini et al. transplanted human fetal brain tissues into the anterior horns of the
spinal cord and additionally used a much higher cell dosage [16]. The authors
concluded that the procedure was well tolerated and safe
In 2003, Mazzini and colleagues injected variable numbers of mesenchymal stem
6
cells (MSCs) (7–152 × 10 cells) into the thoracic spinal cord of seven ALS patients
[17]. Although there was no functional improvement, the transplantation of these
cell suspensions into the human ALS spinal cord was safe and well tolerated. Their
follow-up studies, lasting more than 4 years post-surgery, showed no signs of
toxicity or abnormal cell growth [18,19]. Four patients showed a signicant slowing
down of the linear decline of the forced vital capacity and of the ALS-FRS score. A
phase I/II clinical trial by Karussis and colleagues showed that intrathecal and
intravenous administration of autologous bone-marrow-derived MSCs into ALS
patients is feasible and safe [20]. Although this study was not designed to detect
therapeutic efcacy, encouragingly, it induced immediate immunomodulatory
effects in ALS patient and ALSFRS scores remained stable for up to 6 months
following treatment.
Although allogeneic hematopoietic stem cells (HSCs) transplanted intravenously
in six ALS patients [21] did not provide any clinical benet, donor-derived cells
were found to localize at the sites of pathology, rendering these cells to be
particularly suitable for delivering therapeutic molecules.
Olfactory ensheathing cells extracted from human fetal olfactory bulbs were
injected into the bilateral corona radiata in 15 ALS patients who were compared to
20 untreated controls [22]. Over a 4-month follow-up period, positive and benecial
results were observed as a ve-point difference in the ALSFRS-R. In another study,
327 patients received injection of olfactory ensheathing cells into the spinal cord, the
bilateral corona radiata, or both [23]. They reported improved ALS functioning
rating scale and normalized electromyographical ndings 4 weeks after
transplantation, with no differences between the three groups.
Stem Cell Therapy In Neurological Disorders 212

Studies have demonstrated safety of intraspinal infusion of autologous bone

marrow mononuclear cells [24-26]. Deda et al, demonstrated reinnervation in 7 of
13 patients on electro neuro myography following intraspinal infusion of
autologous bone marrow mononuclear cells, 1-year post treatment [26]. Clinical
improvements were seen in 10 patients. Intrathecal transplantation of autologous
bone marrow mononuclear cells was found to be safe and effective in slowing down
disease progression in 5 studies [27-31].
Our results
Published results
This was a retrospective controlled cohort study of 57 patients [27]. Out of these, 37
patients underwent autologous bone marrow mononuclear cell transplantation in
addition to standard rehabilitation and Riluzole. The survival duration since the
onset of the disease of this group was compared with a control group consisted of 20
patients who did not receive cell transplantation. Survival duration was computed
using a Kaplan-Meier Survival analysis and compared using log-rank test. Effect of
age at onset, type of onset and lithium on survival duration in the intervention
group was analyzed. Mean survival duration of patients in intervention group was
87.76 months which was higher than the control group mean survival duration of
57.38 months (Figure 2) (Table 1). Survival duration was signicantly (p=0.039)
higher in people with the onset of the disease below 50 years of age (Figure 3). Limb
onset and lithium also showed positive inuence on the survival duration (Figure 4
& 5). Mean survival duration of the intervention group was also higher than the
survival duration of ALS patients in previous epidemiological studies (Table 2).
Survival Functions
Age at onset
1.0
Age at onset below 50years of age
Age at onset above 50years of age
Age at onset below 50years of age-censored
0.8
Age at onset above 50years of age-censored
Cum survival

0.6

Figure 4: Kaplan-Meier
0.4 Survival comparison
for the patients in
intervention group
0.2 below and above 50
years of age at the onset
0.0

00 50.00 100.00 150.00 200.00

Survival since the onset of the disease
Stem Cell Therapy In Neurological Disorders 213

Table 2: Survival analysis

Survival Functions
1.0
Group
Intervention
Control
Intervention-censored
Control-censored
0.8
Cum survival

0.6
Figure 5: Kaplan Meier
survival analysis
0.4
comparing the mean
survival duration of the
0.2
intervention and control
group

0.0

00 50.00 100.00 150.00 200.00

Total survival since onset

Survival Functions
Type of Onset
1.0
Bulbar
Limb
Bulbar-censored
0.8 Limb-censored
Cum survival

0.6

0.4
Figure 6: Kaplan-Meier
Survival comparison
0.2 for the patients in
intervention group with
0.0 bulbar onset and limb
onset
00 50.00 100.00 150.00 200.00
Survival since the onset of the disease
Stem Cell Therapy In Neurological Disorders 214

Survival Functions
1.0 Lithium prescription
Lithium
Without lithium
Lithium - censored
0.8 without lithium-censored
Cum survival

0.6

Figure 7: Kaplan-Meier
0.4
Survival comparison
for the patients in
0.2 intervention group with
or without Lithium
prescription.
0.0

00 50.00 100.00 150.00 200.00

Survival since the onset of the disease

Table 3: Mean and median survival duration as observed in previous

epidemiological studies and its comparison with the current ndings
Stem Cell Therapy In Neurological Disorders 215
Stem Cell Therapy In Neurological Disorders 216

Conclusion of the study:

In addition to the standard treatment with Riluzole, early intervention with
combination of BMMNCs transplantation and Lithium may have a positive effect
on the survival duration in ALS. Administration of lithium, younger age and limb
onset patients have better outcome after cell therapy. Prospective randomized
controlled studies with a larger sample size and rigorous methodology are required
for conclusive ndings.
Unpublished Data
The survival duration of the ALS patients treated with intrathecal autologous bone
marrow mononuclear cells transplantation since August 2008 till August 2015 was
analyzed. There was a comparison made between the survival duration of the
patients that underwent stem cell transplantation to those that did not. The
statistical test used for the comparison was Kaplan-Meier survival analysis. There
were total 84 patients in the intervention group and 20 patients in the control group.
Both these groups shared similar baseline demographic characteristics.
Comparison of the survival duration suggested that the mean survival duration of
the patients treated with intrathecal autologous BMMNCs transplantation was
longer than those who were not treated [Table 4][Fig.6]. The mean survival duration
of the patients who received treatment was 90.96(9.27) months and those who did
not was 57.38 (5.31). The difference between the two was statistically signicant
(p=0.051). A clinically signicant difference of 34 months in the survival duration
suggests the potential benet of intrathecal autologous BMMNCs transplantation
in the treatment of ALS.
Table 4: Survival analysis
Stem Cell Therapy In Neurological Disorders 217

Survival Functions
1.0
Group
Intervention
Control
Intervention-censored
Control-censored
0.8
Cum survival

0.6
Figure 8:
Comparitive
0.4 Kaplan-Meier
Analysis of ALS
patients with and
0.2
without stem cell
transplantation
0.0

00 50.00 100.00 150.00 200.00

Total survival since onset

Conclusion of the clinical study:

The study suggested increased survival of patients undergoing autologous
BMMNCs intrathecal transplantation and riluzole as that of control population. In
addition to the standard treatment with Riluzole and neurorehabilitation, there is a
possibility that early intervention with combination of BMMNCs transplantation
has a positive effect on the duration of survival in ALS.
Neuroprotective effects of female reproductive hormones in combination with
cellular therapy

Figure 9: Neuroprotective effects of Estrogen and Progesterone

Stem Cell Therapy In Neurological Disorders 218

It has been shown in various studies that female reproductive hormones i.e.
estrogen and progesterone have several Neuroprotective benets. These
neuroprotective benets are due to various mechanisms as shown in Figure 8. We
analyzed disease progression of the patients that received autologous bone marrow
derived mononuclear cell intrathecal transplantation in various subgroups based
on age and hormonal status. The groups were, pre-menopausal women who still
have the putative neuroprotection of the reproductive hormones, post-menopausal
women who were exposed to the putative neuroprotection of the reproductive
hormones but are not currently exposed to it, men below the age of 50 and men
above the age of 50. Men were divided into 2 groups based on their age because age
is a known prognostic factor and as age advances prognosis of ALS gets worse.
Upon comparing the disease progression and survival percentages we found that,
pre-menopausal women have the slowest disease progression and no mortality in
the 1.5 years of follow up period. This was followed by men below the age of 50
years, post menopausal women and men above the age of 50 years. The disease
progression of the 4 groups is given in Figure 9, Table 5.

Figure 10: Disease progression of the 4 subgroups of ALS patients treated with
cell therapy
Stem Cell Therapy In Neurological Disorders 219

Table 5:Disease progression of the 4 subgroups of ALS patients treated with cell
therapy

There is some evidence to suggest that the male reproductive hormone testosterone
may also provide a Neuroprotective benet in ALS and may have a positive benet
for slowing down the disease progression in younger males.
Future directions
Gene therapy
Suspected genetic causality of ALS and some evidence to support the genetic
alterations in ALS has led to emergence of gene therapy as a future management
strategy for ALS. A clinical trial using Antisense Oligonucleotides to reduce the
toxic protein aggregates in ALS is currently being undertaken [50].
Nur-Own cells transplantation
Recently brain storm cell technologies have developed Nur-Own cells. These are
adult autologous mesenchymal cells harvested from bone marrow which are
differentiated into specialized neuron supporting cells using the technology
developed by Brain Storm Cell Therapeutics. Currently a Phase IIa trial is being
conducted with 12 participants using intramuscular and intrathecal
transplantation of the Nur-Own cells.
In the recently published article the results of the open-label proof-of-concept study
in 26 patients who were administered these mesenchymal stem cells (nur own cells)
intramuscularly or intrathecally or both. The groups were followed for 3 months
before transplantation and 6 months after and it was found out that the rate of
progression of ALS-FRSr and Forced Vital Capacity (FVC) was slower after the
treatment. Responders were identied as the patients who showed progression to
be at least 25% slower than before.
Combination of gene therapy and stem cell therapy
Stem Cell Therapy In Neurological Disorders 220

There have been recent discoveries of various genes involved in the possible
etiology of ALS and therefore trials are targeting combining the two approaches of
gene therapy and stem cell therapy.
Induced pluripotent stem cells (iPSCs)
Progenitors that develop into supporting neurological cells apart from neurons
have been developed and tested to in ALS. A trial has been announced by the
Cedar-Sinai institute in USA that will administer iPSC progenitor of astrocytes
unilaterally and intraspinally in the lumbar cord combined with growth factor
treatment. There will be comparison between the disease progression of the two
extremities of the same patients to nd out the effect of these cells.
Effect of Reproductive hormones
Female and male reproductive hormones provide neuroprotection through
mechanisms similar to that of the paracrine effects of the stem cells. It may therefore
be interesting to explore the benets provided by combination of cellular therapy
with hormonal therapy.
Conclusion:
At present, there is no proven treatment for ALS/MND. The only available
treatment is riluzole which has 3 to 6 months of survival benet. Therefore, there is a
signicant unmet medical need. Stem cell therapy has the potential to slow down or
halt the disease progression of ALS/MND. A combination of stem cell therapy and
Lithium in addition to standard treatment with riluzole and rehabilitation offers a
survival benet of 30 months. In the treated population, premenopausal women
have shown 0% mortality and slowest disease progression. The published results of
Prabhakar, Deda, Martinez and Meamar as well as the recent review by Moura also
shows the benecial effects of cell therapy in ALS.
These results highlight the potential of stem cell therapy in the treatment of
ALS/MND. However, there are many unanswered questions pertaining to stem
cell therapy. Further research needs to be focused on exploring different routes of
administration, types and dosage of cells for better clinical outcome.
It is likely that a denitive treatment and maybe even a cure will come from a
combination of treatments which will include cell therapy, medications like riluzole
and lithium and an aggressive rehabilitation program and may be adjuvant
treatments like hormone replacement therapy.
Based on our own clinical experience we believe that the following patients are
likely to get greater clinical benet with stem cell therapy
1. Younger patients below the age of 50 years
Stem Cell Therapy In Neurological Disorders 221

2. Women, especially premenopausal women

3. Patients in the early stage of the disease
4. Patients who have still not developed swallowing, breathing and speech problems
Cellular therapy provides a promising future in the management of ALS.
Prospective trials with rigorous methodology making use of randomization,
blinding and larger sample size need to be carried out for conclusive evidence. It is
of importance to compare the effects of different cell types. Combination of cellular
transplantation with various other neuroprotective regimens should also be
studied to nd the treatment option that gives best possible results in ALS.
REFERENCES:
1. Gordon PH. Amyotrophic Lateral Sclerosis: An update for 2013 Clinical
Features, Pathophysiology, Management and Therapeutic Trials. Aging Dis.
2013 Oct 1;4(5):295-310.
2. Haverkamp LJ, Appel V, Appel SH. Natural history of amyotrophic lateral
sclerosis in a database population. Validation of a scoring system and a model
for survival prediction. Brain. 1995 Jun;118 ( Pt 3):707-19.
3. Forbes RB, Colville S, Cran GW, Swingler RJ; Scottish Motor Neurone Disease
Register. Unexpected decline in survival from amyotrophic lateral
sclerosis/motor neurone disease. J NeurolNeurosurg Psychiatry. 2004
Dec;75(12):1753-5.
4. Millul A, Beghi E, Logroscino G, Micheli A, Vitelli E, Zardi A. Survival of
patients with amyotrophic lateral sclerosis in a population-based registry.
Neuroepidemiology. 2005;25(3):114-9
5. Norris F, Shepherd R, Denys E, U K, Mukai E, Elias L, Holden D, Norris H.
Onset, natural history and outcome in idiopathic adult motor neuron disease. J
Neurol Sci. 1993 Aug;118(1):48-55.
6. Lee CT, Chiu YW, Wang KC, Hwang CS, Lin KH, Lee IT, Tsai CP. Riluzole and
prognostic factors in amyotrophic lateral sclerosis long-term and short-term
survival: a population-based study of 1149 cases in Taiwan. J Epidemiol.
2013;23(1):35-40
7. Chiò A, Logroscino G, Hardiman O, Swingler R, Mitchell D, Beghi E,
TraynorBG;Eurals Consortium. Prognostic factors in ALS: A critical review.
Amyotroph Lateral Scler. 2009 Oct-Dec;10(5-6):310-23.
8. Brooks BR, Miller RG, Swash M, Munsat TL; World Federation of Neurology
Research Group on Motor Neuron Diseases. El Escorial revisited: revised
criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral
Stem Cell Therapy In Neurological Disorders 222

Scler Other Motor Neuron Disord. 2000 Dec;1(5):293-9

9. Hardiman O.Multidisciplinary care in ALS: expanding the team. Amyotroph
Lateral Scler. 2012 Feb;13(2):165
10. Zhou C, Zhang C, Zhao R, Chi S, Ge P, Zhang C. Human marrow stromal cells
reduce microglial activation to protect motor neurons in a transgenic mouse
model of amyotrophic lateral sclerosis. J Neuroinammation. 2013 Apr 30;10:52
11. Pastor D, Viso-León MC, Botella-López A, Jaramillo-Merchan J,
MoraledaJM,Jones J, Martínez S. Bone marrow transplantation in hindlimb
muscles of motoneuron degenerative mice reduces neuronal death and
improves motor function. Stem Cells Dev. 2013 Jun 1;22(11):1633-44
12. Chen BK, Staff NP, Knight AM, Nesbitt JJ, Butler GW, Padley DJ, Parisi JE, Dietz
AB, Windebank AJ. A safety study on intrathecal delivery of autologous
mesenchymal stromal cells in rabbits directly supporting Phase I human trials.
Transfusion. 2015 May;55(5):1013-20
13. Moura MC, Novaes MR, Zago YS, Eduardo EJ, Casulari LA. Efcacy of Stem
Cell Therapy in Amyotrophic Lateral Sclerosis: A Systematic Review and Meta-
Analysis. J Clin Med Res. 2016 Apr;8(4):317-24
14. Glass JD, Boulis NM, Johe K, Rutkove SB, Federici T, Polak M, Kelly C, Feldman
EL. Lumbar intraspinal injection of neural stem cells in patients with
amyotrophic lateral sclerosis: results of a phase I trial in 12 patients. Stem cells.
2012 Jun 1;30(6):1144-51.
15. Riley J, Glass J, Feldman EL, Polak M, Bordeau J, Federici T, Johe K, Boulis NM.
Intraspinal stem cell transplantation in amyotrophic lateral sclerosis: a phase I
trial, cervical microinjection, and nal surgical safety outcomes. Neurosurgery.
2013 Sep 5;74(1):77-87.
16. Mazzini L, Gelati M, Proco DC, Sgaravizzi G, Pensi MP, Muzi G, Ricciolini C,
Nodari LR, Carletti S, Giorgi C, Spera C. Human neural stem cell
transplantation in ALS: initial results from a phase I trial. Journal of
translational medicine. 2015 Dec;13(1):17.
17. Mazzini L, Fagioli F, Boccaletti R, Mareschi K, Oliveri G, Olivieri C, Pastore I,
Marasso R, Madon E. Stem cell therapy in amyotrophic lateral sclerosis: a
methodological approach in humans. Amyotrophic Lateral Sclerosis and Other
Motor Neuron Disorders. 2003 Sep 1;4(3):158-61.
18. Mazzini L, Mareschi K, Ferrero I, Vassallo E, Oliveri G, Nasuelli N, Oggioni GD,
Testa L, Fagioli F. Stem cell treatment in amyotrophic lateral sclerosis. Journal
of the neurological sciences. 2008 Feb 15;265(1):78-83.
Stem Cell Therapy In Neurological Disorders 223

19. Mazzini L, Mareschi K, Ferrero I, Vassallo E, Oliveri G, Boccaletti R, Testa L,

Livigni S, Fagioli F. Autologous mesenchymal stem cells: clinical applications
in amyotrophic lateral sclerosis. Neurological research. 2006 Jul 1;28(5):523-6.
20. Karussis D, Karageorgiou C, Vaknin-Dembinsky A, Gowda-Kurkalli B,
Gomori JM, Kassis I, Bulte JW, Petrou P, Ben-Hur T, Abramsky O, Slavin S.
Safety and immunological effects of mesenchymal stem cell transplantation in
patients with multiple sclerosis and amyotrophic lateral sclerosis. Archives of
neurology. 2010 Oct 11;67(10):1187-94.
21. Appel SH, Engelhardt JI, Henkel JS, Siklos L, Beers DR, Yen AA, Simpson EP,
Luo Y, Carrum G, Heslop HE, Brenner MK. Hematopoietic stem cell
transplantation in patients with sporadic amyotrophic lateral sclerosis.
Neurology. 2008 Oct 21;71(17):1326-34.
22. Huang H, Chen L, Xi H, Wang H, Zhang J, Zhang F, Liu Y. Fetal olfactory
ensheathing cells transplantation in amyotrophic lateral sclerosis patients: a
controlled pilot study. Clinical transplantation. 2008 Nov 1;22(6):710-8.
23. Chen L, Huang H, Zhang J, Zhang F, Liu Y, Xi H, Wang H, Gu Z, Song Y, Li Y,
Tan K. Short-term outcome of olfactory ensheathing cells transplantation for
treatment of amyotrophic lateral sclerosis. Zhongguo xiu fu chong jian wai ke
za zhi= Zhongguo xiufu chongjian waike zazhi= Chinese journal of reparative
and reconstructive surgery. 2007 Sep;21(9):961-6.
24. Blanquer M, Espejo P, Iniesta F, Meca J, Villaverde R, Izura V, de Mingo P,
Martínez-Lage J, Martínez S, Moraleda JM. Bone marrow stem cell
transplantation in amyotrophic lateral sclerosis: technical aspects and
preliminary results from a clinical trial. Methods and ndings in experimental
and clinical pharmacology. 2010 Dec;32:31-7.
25. Ruiz-López FJ, Guardiola J, Izura V, Gómez-Espuch J, Iniesta F, Blanquer M,
López-San Román J, Saez V, De Mingo P, Martínez S, Moraleda JM. Breathing
pattern in a phase I clinical trial of intraspinal injection of autologous bone
marrow mononuclear cells in patients with amyotrophic lateral sclerosis.
Respiratory physiology & neurobiology. 2016 Jan 15;221:54-8.
26. Deda H, Inci MC, Kürekçi AE, Sav A, Kayıhan K, Özgün E, Üstünsoy G,
Kocabay S. Treatment of amyotrophic lateral sclerosis patients by autologous
bone marrow-derived hematopoietic stem cell transplantation: a 1-year follow-
up. Cytotherapy. 2009 Jan 1;11(1):18-25.
27. Sharma AK, Sane HM, Paranjape AA, Gokulchandran N, Nagrajan A, D'sa M,
Badhe PB. The effect of autologous bone marrow mononuclear cell
transplantation on the survival duration in Amyotrophic Lateral Sclerosis-a
retrospective controlled study. American journal of stem cells. 2015;4(1):50.
Stem Cell Therapy In Neurological Disorders 224

28. Sharma A, Badhe P, Shetty O, Vijaygopal P, Gokuchandran N, Jacob VC, Lohia

M, Biju H, Chopra G. Autologous bone marrow derived stem cells for motor
neuron disease with anterior horn cell involvement. Bombay hospital journal.
2011;53(1):71.
29. Sharma A, Sane H, Paranjape A, Sawant D, Inamdar S, Gokulchandran N, et al.
Cellular therapy in motor neuron disease:a case report. International Journal of
Recent Advances in Multidisciplinary Research. 2017; 4(5):2605-2609.
30. Sharma A, Sane H, Kalburgi S, Paranjape A, Gokulchandran N, Badhe P.
Potential Benets of Cellular Transplantation in a Patient with Amyotrophic
Lateral Sclerosis. Current Opinions in Neurological Science. 2017;1(1):31-43.
31. Sane H, Sharma A, Gokulchandran N, Kalburgi S, Paranjape A, Badhe P.
Neurorestoration in Amyotrophic Lateral Sclerosis -A case report. Indian
Journal of Stem Cell Therapy. 2016: 29-37.
32. Bruijn LI, Miller TM, Cleveland DW. Unraveling the mechanisms involved in
motor neuron degeneration in ALS. Annu Rev Neurosci. 2004;27:723-49
33. Rizzo F, Riboldi G, Salani S, Nizzardo M, Simone C, Corti S, Hedlund E.
Cellular therapy to target neuroinammation in amyotrophic lateral sclerosis.
Cell Mol Life Sci. 2014 Mar;71[6]:999-1015
34. Walczak P, Chen N, Hudson JE, Willing AE, Garbuzova-Davis SN, Song S,
Sanberg PR, Sanchez-Ramos J, Bickford PC, Zigova T. Do hematopoietic cells
exposed to a neurogenic environment mimic properties of endogenous neural
precursors? J Neurosci Res. 2004 Apr 15;76(2):244-54
35. Barker N, Bartfeld S, Clevers H. Tissue-resident adult stem cell populations of
rapidly selfrenewing organs. Cell Stem Cell. 2010; 7[6]:656–670
36. Jiang C, Wang J, Yu L, Ou C, Liu X, Zhao X, Wang J. Comparison of the
therapeutic effects of bone marrow mononuclear cells and microglia for
permanent cerebral ischemia. Behav Brain Res. 2013 Aug 1;250:222-9.
37. Gnecchi, Massimiliano, et al. "Paracrine mechanisms in adult stem cell
signaling and therapy." Circulation research 103.11 (2008): 1204-1219
38. Haverkamp LJ, Appel V, Appel SH. Natural history of amyotrophic lateral
sclerosis in a database population. Validation of a scoring system and a model
for survival prediction. Brain. 1995;118:707–19.
39. Forbes RB, Colville S, Cran GW, Swingler RJ. Scottish Motor Neurone Disease
Register. Unexpected decline in survival from amyotrophic lateral
sclerosis/motor neurone disease. J NeurolNeurosurg Psychiatry.
2004;75:1753–5.
Stem Cell Therapy In Neurological Disorders 225

40. Millul A, Beghi E, Logroscino G, Micheli A, Vitelli E, Zardi A. Survival of

patients with amyotrophic lateral sclerosis in a population-based registry.
Neuroepidemiology.2005;25:114–9.
41. Osuntokun BO, Adeuja AO, Bademosi O. The prognosis of motor neuron
disease in Nigerian africans. A prospective study of 92 patients. Brain.
1974;97:385–94.
42. Radhakrishnan K, Ashok PP, Sridharan R, Mousa ME. Descriptive
epidemiology of motor neuron disease in Benghazi, Libya.
Neuroepidemiology. 1986;5:47–54.
43. Norris F, Shepherd R, Denys E, U K, Mukai E, Elias L, Holden D, Norris H.
Onset, natural history and outcome in idiopathic adult motor neuron disease. J
Neurol Sci.1993;118:48–55.
44. Alcaz S, Jarebinski M, Pekmezović T, Marinković Z, Apostolski S. Survival in
amyotrophic lateral sclerosis. SrpArhCelokLek. 1997;125:19–23.
45. Eisen A, Schulzer M, MacNeil M, Pant B, Mak E. Duration of amyotrophic
lateral sclerosis is age dependent. Muscle Nerve. 1993;16:27–32.
46. Traynor BJ, Codd MB, Forde C, Frost E, Hardiman OM. Clinical features of
amyotrophic lateral sclerosis according to the El Escorial and Airlie House
diagnostic criteria. Arch Neurol. 2000;57:1171–6.
47. Sorenson EJ, Stalker AP, Kurland LT, Windebank AJ. Amyotrophic lateral
sclerosis in Olmsted County, Minnesota, 1925 to 1998. Neurology.
2002;59:280–2.
48. Tysnes OB, Vollset SE, Aarli JA. Epidemiology of amyotrophic lateral sclerosis
in Hordaland county, western Norway. ActaNeurol Scand. 1991;83:280–5.
49. Turner MR, Parton MJ, Shaw CE, Leigh PN, Al-Chalabi A. Prolonged survival
in motor neuron disease: a descriptive study of the King's data base 1990–2002. J
NeurolNeurosurg Psychiatry. 2003;74:995–7.
50. Riboldi G, Zanetta C, Ranieri M, Nizzardo M, Simone C, MagriF, BresolinN,
Comi GP, Corti S. Antisense oligonucleotide therapy for the treatment of
C9ORF72 ALS/FTD diseases. MolNeurobiol. 2014 Dec;50(3):721-32
Stem Cell Therapy In Neurological Disorders 226

To believe that, what has not occurred in history will not occur at all, is to
argue disbelief in the dignity of man.

– Mahatma Gandhi
Stem Cell Therapy In Neurological Disorders 227

14

Role of Stem Cells in Traumatic

Brain Injury
Stem cells can migrate towards the damaged areas of the brain and promote the
repair process in Traumatic Brain Injury .
Traumatic brain injury (TBI) is the most common cause of death and disability in
young people. It is mostly caused by an external physical impact producing an
altered state of consciousness resulting in impairment of physical functions or
cognitive abilities (1) The damage caused to the brain is either focal or diffused
depending on the event causing TBI. The outcome consists of two stages (a) primary
insult, which occurs at the time of impact (b) Secondary insult, which is a cascade of
events after the primary insult with delayed clinical presentation. (2) There are
several signicant pathophysiologic sequelae of TBI responsible for the
neurobehavioural outcome, including the location and severity of the injury,
diffuse effects and secondary mechanisms of injury. Alterations in cerebral blood
ow and oxygenation, edema, excitotoxicity, cell death, disruption of the blood
brain barrier, and generalized atrophy is commonly observed in TBI. (3) The
damage to the brain could result in temporary or permanent behavioral and/or
emotional disturbances leading to functional disability.
Unmet medical needs
The past 2 decades have seen great advancements in understanding the molecular
and cellular mechanisms of TBI. The standard treatment modalities for brain injury
involves medications, physical and behaviour therapy, Hyperbaric Oxygen
Stem Cell Therapy In Neurological Disorders 228

therapy(HBOT), and medical management of associated conditions aims at

improving the functional abilities and restoring the patient's daily life. However,
these strategies have failed to translate into a successful treatment strategy that can
address the core neurological damage. Among the numerous barriers to nding
effective interventions to improve outcomes after TBI is the severity and
heterogeneity of the injury. In chronic TBI, there is high prevalence of residual
neurodecits rendering the patient dependent and many a times bed-ridden. In
case of mild TBI, physical recovery is witnessed with the standard treatments, but
the memory and behavioural issues persist which may affect the quality of life of the
individual. The available pharmacological modalities manage these disabilities,
but their effect wears off gradually.
Stem cell therapy in TBI
Due to the brain's limited capacity to regenerate the damaged neurons, the
intervention should aim at halting the degeneration and replacing the lost and
damaged neurons. (4) In past few years, cell therapy has gained attention as a
prospective therapeutic options for neurological disorders. Stem cells migrate
towards the damaged areas of the brain and initiate the repair process. They
promote angiogenesis, axonal remodeling, neurogenesis and synaptogenesis,
which may help reverse the pathology of TBI. (5) These cells differentiate into
various cells including neural cells, oligodendrocytes, etc. (6) In TBI, there is loss of
myelin which disrupts the signal transduction and damages the axons. The
oligodendrocytes help in remyelination of the damaged axons and repair the
disrupted neural connections. Bone marrow cells also produce various growth
factors and neurotrophic factors such as brain-derived neurotrophic factor (BDNF),
nerve growth factor (NGF), vascular endothelial growth factor (VEGF), basic
broblast growth factor (bFGF), which stimulate the endogenous neuroprotection
and repair. (7,8)

Figure 1: Mechanisms of stem cells for TBI

Stem Cell Therapy In Neurological Disorders 229

Animal studies
Various experiments on animal models have been carried out to test the safety and
feasibility of different types of cells. Reiss et al, transplanted embryonic cells in
experimental rats and recorded dramatic improvements but the safety of
administration could not be established. (9) Series of experiments were conducted
to study the neural stem cells in TBI which reported improved neurological
functions in the injected rat models via various mechanism. (10-15) Bone marrow
stem cells were also found to be efcacious in modulating the inammation-
associated immune cells and cytokines in TBI-induced cerebral inammatory
responses. (16,17) Studies also showed that bone marrow derived mesenchymal
cells (BMMSCs) migrate to the injured areas and increase expression of
neurotrophic factors such as vascular endothelial growth factor (VEGF) and brain
derived neurotrophic factor (BDNF). BMMSCs also upregulate the protein
expression levels of synaptophysin, a synapse protein which is downregulated
after TBI, resulting in neuromotor functional recovery. (18) In an experimental
study, rats injected with BDNF gene-modied umbilical cord mesenchymal stem
cell (UCMSC) led to improvements in behavior and other neurological functions.
(19) In 2016, a study conducted on Wistar rats to investigate the capacity and
sensitivity of diffusion-derived magnetic resonance imaging suggested that cell
intervention executed at 6 hours accelerates the brain remodeling process and
results in an earlier functional recovery.(20)
Few studies were conducted in recently to demonstrate the homing and migration
of transplanted cells in rat models of TBI using uorescence labelling. Dong at al
tracked the distribution of human umbilical cord mesenchymal stem cells (MSCs)
in large blood vessel of traumatic brain injury -rats. They found that intravascular
migration and homing of MSCs in rats which received MSCs transplantation, and
new angiogenesis in MSCs-transplanted blood vessels. (21) Guo et al, demonstrated
the integration of intravenously injected EPCs into the injured brain tissue. These
EPCs enhanced recovery by contributing to neurogenesis. (22.) Lin et al showed
that transplanted human neural precursor cells integrate into the host neural
circuit, which was detected by uorometric Ca2+ imaging and nerve tracing, and
ameliorate neurological decits in a mouse model of traumatic brain injury. (23.)
Clinical Studies
Not many clinical studies have been conducted on human subjects of TBI showing
effects of stem cell therapy. One of the rst studies was published in 2008 by Zhang
et al. They assessed the safety and feasibility of a combined procedure to deliver
autologous mesenchymal stromal cells in 7 patients with traumatic brain injury.
(24) They found that neurological functions improved signicantly at 6 months
after cell therapy. In 2011, Cox et al, performed a phase1 clinical trial to demonstrate
the safety and feasibility of autologous BMMNCs in children with severe traumatic
Stem Cell Therapy In Neurological Disorders 230

brain injury. 10 children were included in the study. Dichotomized Glasgow

Outcome Score at 6 months showed 70% with good outcomes and 30% with
moderate to severe disability. (25) Followed by this, they published the results of
their phase 2 clinical trial in 2017 which included 25 patients; 15 in the intervention
group and 10 in the control group. They recorded positive functional and
neurological outcome and also down regulated Inammatory biomarkers. (26)
Similar studies were published by Sharma et al and Liao et al in 2015 demonstrating
the positive effect of BMMNCs. Wang et al, in 2013 conducted a study on patients
with sequelae of TBI. They administered 40 patients with umbilical cord
mesenchymal stem cells and observed improved neurological functions and self-
care in these patients as compared to the controls. (27) Vaquero et al in 2017,
showed improvement and progressive increase in brain glucose metabolism after
intrathecal administration of autologous mesenchymal stromal cells using 18 FDG
PET CT, in 3 patients. (28) In 2017, Wang Z et al demonstrated the safety and
feasibility of neural stem cell transplantation in patients with severe TBI. They
observed that majority of patients experienced improved neurological function on
follow up along with increased serum levels of nerve growth factor and brain-
derived neurotrophic factor. (29)
Our Published Results
We conducted a study on 14 cases who were administered with autologous bone
marrow mononuclear cells, intrathecally. (30) The follow up was done at 1 week, 3
months and 6 months after the intervention. The Functional Independence Measure
scale, the SF-8 Health Survey Scoring and the disability rating scale were used as
outcome measures.
At the end of six months, a percentage analysis was carried out for improvement in
every symptom as discussed in gure 2. Objective improvements were also
recorded on PET CT scan at the end of 6 months in the form of improved
metabolism of the brain. These changes correlated to the clinical and functional
improvements demonstrated by these patients.
Stem Cell Therapy In Neurological Disorders 231

Symptomwise Improvements in Chronic TBI

After Cell Therapy
14
12
10
8
6
4
2
0
Trunc Upper Lower Volun ADL Psych
Orom Coord Com
al limb Limb Speech Cogni Muscle tary Ambu Postu Balan Indep ologic
otor inatio munic
Activi Activi Activi tion Tone Count lation re ce enden al
Skills n ation
ty ty ty rol ce Status
affected 13 13 11 7 12 8 11 13 11 10 11 12 11 11 10
improved 7 7 6 4 6 3 4 9 6 5 8 4 5 4 5

Figure 2: Symptom-wise improvements in chronic TBI patients seen after

intrathecal administration of autologous BMMNCs

Table 1: SF8 scores before and after intervention suggesting improved quality of
life.
Stem Cell Therapy In Neurological Disorders 232

Table 2: Areas of the brain showing improved metabolism in PET CT scan and
their correlation to the clinical function improvement

Figure 3: PET CT Scan showing improved metabolic activity which is indicated by

decrease in blue areas after stem cell therapy
Stem Cell Therapy In Neurological Disorders 233

Unpublished data
To demonstrate the effect of autologous stem cell therapy in TBI, we analysed the
data of 44 patients. Symptoms such as balance, voluntary control, memory, upper
and lower limb activity , ambulation, posture, muscle tone, speech , cognition and
ADLs were analysed. On follow up we found that 72.73 % of patients showed
improvements while 27.27% showed no change after intervention. No adverse
events were recorded.

Figure 4: Graph showing overall improvement in the TBI patients

after stem cell therapy
PET CT scan as a monitoring tool
18Fluoro-2-deoxyglucose Positron emission tomography (18- FDG PET) is being
considered as monitoring tool, to assess the recovery in the damaged brain after
cellular therapy in many of the studies. It allows non-invasive quantication of
cerebral blood ow, metabolism, and receptor binding. PET CT scan brain is an
imaging tool which aids in measuring the brain glucose metabolism using tracer
(18F) uorodeoxyglucose (FDG). Decreased metabolism is suggestive of decreased
function of the neurons. An increased uptake of FDG in the previously
hypometabolic areas indicate improved function of the neurons.
Stem Cell Therapy In Neurological Disorders 234

Figure 5: PET-CT scan images pre-stem cell therapy and post stem cell therapy. (Colour
code: black- severe hypometabolism, blue-hypometabolism, green-normal metabolism):
The areas marked with the arrows depict the areas of the brain which have improved post
intervention. Improvement recorded in metabolic activity of cerebellum, cingulate regions,
vermis and parietal gyrus.
Conclusion
Cell therapy in combination with neurorehabilitation has a potential to reverse the
damage occurring in the brain after chronic TBI. It addresses the diffused nature of
injury and the neuronal decit to the maximum, which current standard
intervention may not tackle. The outcome of the cell therapy may be dependent on
the age, severity of trauma, time interval between the accident and intervention;
and the rehabilitation regime continued after the procedure. It has been observed
that the mild TBI cases have a better recovery curve than the severe cases. Chronic
TBI patients may require multiple doses of stem cells to accelerate the recovery
process. Functional neuroimaging such as PET CT scan of the brain can help to
objectify the effects of neuroregeneration in TBI.
Future directions
Studies focusing on combining the efcacy of HBOT and stem cell therapy to target
the neurological damage should be established. Future studies should identify the
ideal cells for therapeutic use, along with the ideal route of administration. The
optimum quantity of cells, frequency of doses and the time interval between
consecutive doses should be established to optimize this intervention. The ideal
time of injection of stem cells should also be determined as in the acute phase,
Stem Cell Therapy In Neurological Disorders 235

inammation and pathological metabolic changes make the endogenous

environment inhospitable for the injected cells. In chronic phase the gliotic changes
may affect the efcacy of cell therapy. It is also important to track the changes
occurring in the brain after intervention paving way for more research to be
conducted on the monitoring tools.
References
1. Prins M, Greco T, Alexander D, Giza CC. The pathophysiology of traumatic
brain injury at a glance. Dis Model Mech. 2013; Nov;6(6):1307-15
2. C. Werner and K. Engelhard. Pathophysiology of traumatic brain injury Br. J.
Anaesth. 2007; 99 (1): 4-9
3. Greve MW, Zink BJ. Pathophysiology of traumatic brain injury. Mt Sinai J Med.
2009 Apr;76(2):97-104
4. Horner PJ, Gage FH. Regenerating the damaged central nervous system.
Nature.2000 Oct 26;407(6807):963-70.
5. Longhi L, Zanier ER, Royo N, Stocchetti N, McIntosh TK. Stem cell
transplantation as a therapeutic strategy for traumatic brain injury. Transpl
Immunol. 2005 Dec;15(2):143-8
6. Sanchez-Ramos J, Song S, Cardozo-Pelaez F, Hazzi C, Stedeford T, Willing A,
Freeman TB, Saporta S, Janssen W, Patel N, Cooper DR, Sanberg PR. Adult bone
marrow stromal cells differentiate into neural cells in vitro. Exp Neurol.
2000;164:247-256
7. Zhong C, Qin Z, Zhong CJ, Wang Y, Shen XY. Neuroprotective effects of bone
marrow stromal cells on rat organotypic hippocampal slice culture model of
cerebral ischemia. Neurosci Lett. 2003;342:93-96.
8. Hsu YC, Chen SL, Wang DY, Chiu IM. Stem cell-based therapy in neural
repair.Biomed J. 2013 May-Jun;36(3):98-105
9. Riess P, Molcanyi M, Bentz K, Maegele M, Simanski C, Carlitscheck C,
Schneider A, Hescheler J, Bouillon B, Schäfer U, Neugebauer E. Embryonic
stem cell transplantation after experimental traumatic brain injury
dramatically improves neurological outcome, but may cause tumors. J
Neurotrauma. 2007 Jan;24(1):216-25
10. Zhang H, Zheng X, Yang X, Fang S, Shen G, Zhao C, Tian M. 11C-NMSP/ 18F-
FDG microPET to monitor neural stem cell transplantation in a rat model of
traumatic brain injury. Eur J Nucl Med Mol Imaging. 2008 Sep;35(9):1699-708.
11. Lee DH, Lee JY, Oh BM, Phi JH, Kim SK, Bang MS, Kim SU, Wang KC.
Functional recovery after injury of motor cortex in rats: effects of rehabilitation
Stem Cell Therapy In Neurological Disorders 236

and stem cell transplantation in a traumatic brain injury model of cortical

resection. Childs Nerv Syst. 2013 Mar;29(3):403-11.
12. Wang JY, Liou AK, Ren ZH, Zhang L, Brown BN, Cui XT, Badylak SF, Cai YN,
Guan YQ, Leak RK, Chen J, Ji X, Chen L. Neurorestorative effect of urinary
bladder matrix-mediated neural stem cell transplantation following traumatic
brain injury in rats. CNS Neurol Disord Drug Targets. 2013 May 1;12(3):413-25.
13. Yu B, Ma H, Kong L, Shi Y, Liu Y. Enhanced connexin 43 expression following
neural stem cell transplantation in a rat model of traumatic brain injury. Arch
Med Sci. 2013 Feb 21;9(1):132-8.
14. Pang AL, Xiong LL, Xia QJ, Liu F, Wang YC, Liu F, Zhang P, Meng BL, Tan S,
Wang TH. Neural Stem Cell Transplantation Is Associated with Inhibition of
Apoptosis, Bcl-xL Upregulation, and Recovery of Neurological Function in a
Rat Model of Traumatic Brain Injury. Cell Transplant. 2017 Jul;26(7):1262-1275.
15. Sullivan GM, Armstrong RC. Transplanted Adult Neural Stem Cells Express
Sonic Hedgehog In Vivo and Suppress White Matter Neuroinammation after
Experimental Traumatic Brain Injury. Stem Cells Int. 2017;2017:9342534.
16. Bakhtiary M, Marzban M, Mehdizadeh M, Joghataei MT, Khoei S, Pirhajati
Mahabadi V, Laribi B, Tondar M, Moshkforoush A. Comparison of
transplantation of bone marrow stromal cells (BMSC) and stem cell
mobilization by granulocyte colony stimulating factor after traumatic brain
injury in rat. Iran Biomed J. 2010 Oct;14(4):142-9.
17. Zhang R, Liu Y, Yan K, Chen L, Chen XR, Li P, Chen FF, Jiang XD. Anti-
inammatory and immunomodulatory mechanisms of mesenchymal stem cell
transplantation in experimental traumatic brain injury. J Neuroinammation.
2013 Aug 23;10(1):106
18. Feng Y, Ju Y, Cui J, Wang L. Bone marrow stromal cells promote neuromotor
functional recovery, via upregulation of neurotrophic factors and synapse
proteins following traumatic brain injury in rats. Mol Med Rep. 2017
Jul;16(1):654-660
19. Yuan Y, Pan S, Sun Z, Dan Q, Liu J. Brain-derived neurotrophic factor-modied
umbilical cord mesenchymal stem cell transplantation improves neurological
decits in rats with traumatic brain injury. Int J Neurosci. 2013 Dec 9. [Epub
ahead of print]
20. Li L, Chopp M, Ding G, Qu C, Nejad-Davarani SP, Davoodi-Bojd E, Li Q,
Mahmood A, Jiang Q. Diffusion-Derived Magnetic Resonance Imaging
Measures of Longitudinal Microstructural Remodeling Induced by Marrow
Stromal Cell Therapy after Traumatic Brain Injury. Journal of neurotrauma.
Stem Cell Therapy In Neurological Disorders 237

2016 May 13.

21. Dong HJ, Shang CZ, Li G, Niu Q, Luo YC, Yang Y, Meng HP, Yin HJ, Zhang HX,
Zhao ML, Lin L. The Distribution of Transplanted Umbilical Cord
Mesenchymal Stem Cells in Large Blood Vessel of Experimental Design With
Traumatic Brain Injury. J Craniofac Surg. 2017 Sep;28(6):1615-1619.
22. Guo XB, Deng X, Wei Y. Homing of Cultured Endothelial Progenitor Cells and
Their Effect on Traumatic Brain Injury in Rat Model. Sci Rep. 2017 Jun
23;7(1):4164
23. Lin GQ, He XF, Liang FY, Guo Y, Sunnassee G, Chen J, Cao XM, Chen YY, Pan
GJ, Pei Z, Tan S. Transplanted human neural precursor cells integrate into the
host neural circuit and ameliorate neurological decits in a mouse model of
traumatic brain injury. Neurosci Lett. 2018 May 1;674:11-17
24. Zhang, Z. X., et al. A combined procedure to deliver autologous mesenchymal
stromal cells to patients with traumatic brain injury.Cytotherapy 2008; 134-
139.
25. Cox Jr, Charles S., et al. Autologous bone marrow mononuclear cell therapy for
severe traumatic brain injury in children. Neurosurgery 68.3 2011; 588-600.
26. Cox CS, Hetz RA, Liao GP, et al. Treatment of Severe Adult Traumatic Brain
Injury Using Bone Marrow Mononuclear Cells. Stem cells (Dayton, Ohio).
2017;35(4):1065-1079.
27. Liao GP, Harting MT, Hetz RA, Walker PA, Shah SK, Corkins CJ, Hughes TG,
Jimenez F, Kosmach SC, Day MC, Tsao K. Autologous bone marrow
mononuclear cells reduce therapeutic intensity for severe traumatic brain
injury in children. Pediatric critical care medicine: a journal of the Society of
Critical Care Medicine and the World Federation of Pediatric Intensive and
Critical Care Societies. 2015 Mar;16(3):245.
28. Vaquero J, Zurita M, Bonilla C, Fernández C, Rubio JJ, Mucientes J, Rodriguez
B, Blanco E, Donis L. Progressive increase in brain glucose metabolism after
intrathecal administration of autologous mesenchymal stromal cells in patients
with diffuse axonal injury. Cytotherapy. 2017 Jan;19(1):88-94.
29. Wang Z, Luo Y, Chen L, Liang W. Safety of neural stem cell transplantation in
patients with severe traumatic brain injury. Exp Ther Med. 2017 Jun;13(6):3613-
3618.
30. Sharma A,Sane H, Kulkarni P, Yadav J, Gokulchandran N, Biju H, Badhe P. Cell
therapy attempted as a novel approach for chronic traumatic brain injury - a
pilot study. SpringerPlus 2015; 4:26.
Stem Cell Therapy In Neurological Disorders 238

To believe that, what has not occurred in history will not occur at all, is to
argue disbelief in the dignity of man.

– Mahatma Gandhi
Stem Cell Therapy In Neurological Disorders 239

15

Stem Cell Therapy

for Intellectual Disability
Stem cells have opened new avenues for recovery in cognitive, learning and
behavioral decits of Intellectual Disability.
Intellectual Disability (ID) has been dened as “ a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning
decits in conceptual, social, and practical domains” under DSM V. (1)The
prevalence of ID is approximately 1-3% with a corresponding intelligence quotient
(IQ)< 70. (2) Causes of ID can be heterogeneous which include premature birth,
gene mutation and chromosomal abnormalities ( Trisomy 21 and fragile X), toxins,
prenatal infections and environmental factors (malnutrition, emotional and social
deprivation).(3) The clinical presentations in ID include impairment in adaptive
behaviour and intellectual functioning, delayed developmental milestones,
difculty in various day to day activities like communication, self-care, home
living, social/interpersonal skills, self-direction, academics and safety, inability to
meet up with peers of same age at school, and difculty in solving problems.(4)
Currently, there is no treatment available for ID. The conventional management
strategies involve behavioural therapy, psychological intervention and
occupational therapy which addresses the symptomatic representations in ID. But
these strategies seldom answer the core neurological problems of ID. (5)
Pathophysiology
Recent studies indicate that proper synaptic function, and hence normal intellectual
Stem Cell Therapy In Neurological Disorders 240

function, depends upon two major components: development of the nervous

system, and healthy functioning of the neurons and their network. The underlying
mechanism of ID involves abnormalities in dendritic branching and connectivity of
the neuronal network which limits its ability to process information, especially in
postnatal stage, during which learning and acquisition of intellectual abilities and
emotional behaviour occurs. (Fig 1)Neural dysfunction underlying ID may include
reduction in neuron numbers, disturbed neuronal migration and alterations in
dendritic arborisation and morphology.(6)
Unmet Medical Needs
With increasing awareness, the prevalence of intellectual disability has risen
considerably. The population of patients with ID are intellectually and functionally
dependent on others and are considered socioeconomic burden in the society. The
conventional modalities do not address the residual neuronal decit which
signicantly affects the quality of life of the patients and their families. There is a
critical need to nd new avenues of management of ID which focuses on the
underlying cause of the cognitive decit.
Stem Cell Therapy for Intellectual Disability

Figure 1: Stem Cell Therapy in intellectual disability

Stem Cell Therapy In Neurological Disorders 241

In case of intellectual disability, any damage to the brain is a permanent and

irreversible damage as the neurons of the brain, once damaged, cannot repair
themselves on their own. The underlying neuropathology of intellectual disability
includes neuronal death along with disruption in neuronal networks, cell
migration, cell multiplication, axon growth, brain plasticity, synaptogenesis, etc.
Studies have shown that major defects are recorded in hippocampus and cerebral
cortex areas of the brain which further lead to faulty information processing and
consecutively affect the cognition and adaptive behavior. [7]To reverse the damage
caused to the central nervous system, only a neurorestorative therapy like stem cell
therapy would be benecial.
Stem cells have a unique property of homing and targeting specic damaged areas
on administration that require the right combination of signaling molecules from
the injured tissue and the corresponding receptors on stem cells. They survive,
migrate, proliferate and differentiate into the required cell types. (8) They not only
replace the dead cells but also stimulate the endogenous cells and prevent further
damage. Their paracrine activities such as secretion of growth factors,
angiogenesis, neurogenesis, immunomodulation, decreasing inammation, etc
also help in the repair process. (9) This could help repair the disrupted neuronal
networks in ID and hence improve the information processing.
Not many clinical studies have been carried out to study the effect of stem cell
therapy in ID. But animal studies have shown that administration of stem cells may
support the ability for structural brain repair as well as cognitive improvement
Our Results
Published data
We published the rst case study in the world demonstrating efcacy of intrathecal
autologous bone marrow mononuclear cell transplantation in individuals with ID.
(10) It was an open-label proof-of-concept study which included 58 patients. These
patients were divided into two groups: intervention group (n = 29) and
rehabilitation group (n = 29). The intervention group underwent stem cell therapy
and standard neurorehabilitation while, the rehabilitation group underwent only
standard neurorehabilitation.
The results of the symptomatic outcomes were compared between the two groups.
The outcome measures used were the intelligence quotient (IQ) and the Wee
Functional Independence Measure (Wee-FIM). To compare the pre-intervention
and post-intervention results, statistical analysis was done using Wilcoxon's
matched-pairs test for Wee-FIM scores and McNemar's test for symptomatic
improvements and IQ. The effect of age and severity of the disorder were assessed
for their impact on the outcome of intervention. PET CT brain scan was used as a
monitoring tool to study effects of the intervention. No major adverse events were
Stem Cell Therapy In Neurological Disorders 242

witnessed.
On symptomatic analysis, greater improvements were seen in the intervention
group as compared to the rehabilitation group. In the intervention group, the
symptomatic improvements, IQ and Wee-FIM were statistically signicant.

Figure 2: Graph demonstrating a comparison of overall percentage improvements

in ID between the intervention group and rehabilitation group.

Figure 3: Graph demonstrating a comparison of overall percentage improvements

in the symptoms ID between the intervention group and rehabilitation group.
Stem Cell Therapy In Neurological Disorders 243

Figure 4: Graph demonstrating improvements in the outcome measures (FIM/

WeeFIM and IQ) in patients with ID in the intervention group, six months after
cellular therapy

A signicantly better outcome of the intervention was found in the paediatric age
group (<18 years) and patients with milder severity of ID.

Figure 5: Graph showing the comparison of improvement in patients in the

intervention group with severity of ID.
Stem Cell Therapy In Neurological Disorders 244

Figure 6: Graph showing the comparison of improvement in patients in the

pediatric and adult population of intervention group.
Repeat PET-CT scan in three patients of the intervention group showed improved
metabolism in the frontal, parietal cortex, thalamus, mesial temporal structures and
cerebellum.

Figure 7: The top row indicates the PET CT Scan image before stem cell therapy
showing reduced metabolism in prefrontal, frontal (red arrows), cerebellum (brown
arrow); Below row indicates improved 18F-FDG metabolism after intervention in
the prefrontal, frontal (blue arrows), and cerebellum (pink arrow).
Stem Cell Therapy In Neurological Disorders 245

Figure 8: The top row indicates the PET CT scan brain image before stem cell
therapy showing reduced metabolism in thalamus (red arrow), mesial temporal
structures (white arrow); Below row indicates improved 18F-FDG metabolism
after therapy in thalamus (pink arrow), mesial temporal structures (orange arrow).
Case report
We published 2 case reports of individuals diagnosed with moderate ID. They were
administered with autologous bone marrow mononuclear cells intrathecally. No
major adverse events were recorded in either cases. On follow up they showed
improvements in cognition, attention and concentration, behavior (hyperactivity,
aggression, temper tantrums had reduced), sitting tolerance, speech, eye contact,
etc. These improvements correlated with the improved brain metabolism of the
areas responsible. (11,12)
Conclusion-
The multiple mechanisms of action of stem cells promote a reparative process in the
dysfunctional brain which can be reected by symptomatic and functional
improvement in the patients with ID. Cellular therapy was found to be safe and
effective in repairing the underlying neurological decits in ID. These cells improve
the axon regeneration, brain networking and synaptic arborisation thereby
improving the information processing. The outcome may be inuenced by the
underlying etiology, severity and the time of the intervention. It is well established
that rehabilitation promotes the recovery of neurological decits, and its
multidisciplinary approach along with cellular transplantation and special
schooling may enhance the recovery process further. Early intervention is advised
as the neural circuits, which form the base for learning and behavior, are more
plastic during the initial years of life. Stem cell therapy along with current treatment
can enhance symptomatic improvements which will help the patient to lead a
productive and respectable life in the society.
Stem Cell Therapy In Neurological Disorders 246

Future Directions
Due to the heteregenous nature of the disorder, it is a challenge to nd a denite
cure for intellectual disability. Genetic factors play a major part in intellectual
disability (ID) and gene therapy has provided novel insights in treating the genetic
aberrations underlying ID. But gene therapy cannot replace the lost neurons and
also poses practical difculties that have prevented them from being a clinically
feasible and viable option for the treatment of ID. Stem cell therapy addresses the
core damage occurring in the brain of an individual with ID. The combined
approach of gene therapy and stem cell therapy along with standard rehabilitation
may help in addressing the gene defect as well as the neuronal dysfunction in the
brain. It is also advocated to nd the most effective type of cell, number of cells
required and the frequency of the doses to effectively treat the underlying
neurological decit. Future studies should consider the use of PET-CT scan as
monitoring tool and substantiate the effects of cellular therapy in ID. Large scale,
multicentre, and randomized controlled trials are recommended to further
establish the safety and efcacy of cellular therapy in ID.
References
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. 5th edition. Arlington, VA: American Psychiatric Publishing; 2013.
2. Rey JM. IACAPAP Textbook of Child and Adolescent Mental Health. The
Lancet. 2006 Jan 28.
3. Whitaker S. Causes of Intellectual Disability. Palgrave Macmillan
UK.InIntellectual Disability (pp. 107-121) ;2013 .
4. Harris JC. Intellectual disability: Understanding its development, causes,
classication, evaluation, and treatment. Oxford University Press; 2006.
5. Kottorp A, H, lgren M, Bernspg B, Fisher AG. Client-centred occupational
therapy for persons with mental retardation: Implementation of an
intervention programme in activities of daily living tasks. Scandinavian
Journal of Occupational Therapy. 2003 Jan 1;10(2):51-60.
6. Chelly J, Khelfaoui M, Francis F, Chérif B, Bienvenu T. Genetics and
pathophysiology of mental retardation. European Journal of Human Genetics.
2006 Jun 1;14(6):701-13.
7. Gögel S, Gubernator M, Minger SL. Progress and prospects: stem cells and
neurological diseases. Gene therapy. 2011 Jan 1;18(1):1-6.
8. Chen JR, Cheng GY, Sheu CC, Tseng GF, Wang TJ, Huang YS. Transplanted
bone marrow stromal cells migrate, differentiate and improve motor function
in rats with experimentally induced cerebral stroke. Journal of anatomy. 2008
Stem Cell Therapy In Neurological Disorders 247

Sep 1;213(3):249-58.
9. Gnecchi M, Zhang Z, Ni A, Dzau VJ. Paracrine mechanisms in adult stem cell
signaling and therapy. Circulation research. 2008 Nov 21;103(11):1204-19.
10. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Suhasini Pai, Pooja
Kulkarni, Vaishali Ganwir, Maitree Maheshwari, Ridhima Sharma, Meenakshi
Raichur, Samson Nivins, MS; Prerna Badhe. An open label proof of concept
study of intrathecal Autologous Bone Marrow Mononuclear Cells
transplantation in Intellectual Disability. Stem cell research and therapy. 2017
11. Sharma A, Gokulchandran N, Sane H, Pai S, Kulkarni P, et al. Cognitive
Changes after Cellular Therapy in a Case of Intellectual Disability. J Transplant
Stem Cel Biol. 2017;4(1): 4.
12. Sharma A, Sane H, Pooja K, Akshya N, Nandini G, Akshata S. (2015) Cellular
Therapy, a Novel Treatment Option for Intellectual Disability: A Case Report. J
Clin Case Rep 5:483. doi: 10.4172/2165- 7920.1000483.
Stem Cell Therapy In Neurological Disorders 248

16

Stem Cell Therapy

In Cerebellar Ataxia
With Neuroprotective mechanisms, Stem cells can play a vital role to control
disease progression in Cerebellar Ataxia.
Cerebellar Ataxia is a heterogeneous group of neurodegenerative disorders
characterized by lack of coordination and imbalance. (1) It is distinguished into a
group of hereditary and sporadic ataxias. Hereditary Cerebellar Ataxia can have an
autosomal-dominant, autosomal-recessive, X-linked, or mitochondrial mode of
inheritance. (2) Sporadic can be symptomatic or idiopathic. (3)
The clinical manifestations of cerebellar ataxia consist of irregularities in the rate,
rhythm, amplitude, and force of voluntary movements. Symptoms include gait/
postural abnormalities, balance issues, incoordination and involuntary
movements, poor ne motor skills, visual abnormalities, increased fatigue,
cognitive and mood problems, speech and swallowing difculties. (4) Presently,
there is no effective line of management for treatment of Cerebellar Ataxia. No
treatment is available to halt the disease progression.
Unmet medical needs
All the current treatment options focus on symptomatic management. None of the
treatment approaches address the underlying pathology of the disorder. A
therapeutic strategy is required to stop the degeneration, repair the damaged areas
and protect the unaffected areas.
Stem Cell Therapy In Neurological Disorders 249

Mechanism of action of Stem Cell Therapy:

Stem Cell Therapy has opened new avenues for the treatment of cerebellar ataxia.
Studies have shown that stem cells migrate to the site of injury from the site of
injection. They enhance angiogenesis and contribute to neovascularisation by
producing signalling molecules such as vascular endothelial growth factor (VEGF)
and broblast growth factor (FGF2). They impart immunomodulatory and anti-
inammatory effects. Cvetanovic et al, suggested that, reduction of Vascular
Endothelial Growth Factor (VEGF) levels observed in Spino Cerebellar Ataxia
contribute to its pathology. Stem cells help in regulating the levels of VEGF. (5) The
various mechanisms along with paracrine effects of cellular transplantation may
help reverse the disease pathology.
Animal studies
Jones et al, analyzed the possibility of using bone marrow-derived mesenchymal
stem cells in treating ataxia. They transplanted these cells in animal models and
found, two months after the surgical procedure, the treated mice presented
signicant improvements in the motor behavior tests performed. (6) Zhang et al,
administered umbilical mesenchymal stem cells in ataxic mice and found that these
cells improved the motor skills of the mice and also alleviated cerebellar atrophy. (7)
Chang et al, transplanted mesenchymal cells in mice models of spinocerebellar
ataxic mice intravenously or intracranially. They found that intravenous injection
delays the onset as well as improves the motor function of the affected mice. (8) Diaz
et al and Kemp et al, demonstrated that bone marrow transplantation improves
motor activity and stimulates neural repair in ataxia mice. (9,10) Uhlendorf et al and
Nuryyev et al in 2017, transplanted human neural progenitor cells in Spastic Han-
Wistar Rat models of ataxia. They reported reduced ataxic symptoms and structural
and functional improvements. (11,12)
Human Studies
Stem Cell Therapy In Neurological Disorders 250

Not many clinical studies have been conducted on human subjects until now. Most
of the studies used umbilical cord blood cells (13-16) All of them showed that these
cells result in neurological and functional improvements. Amariglio et al
transplanted human fetal neural stem cells intracerebellarly and intrathecally in 1
patient with Ataxia Telangiectasia. However, the patient developed host derived
brain tumor. (17) Shroff et al transplanted human embryonic stem cells
intravenously and intramuscularly in 3 cases of ataxia and reported it to efcacious.
(18)Tsai et al, recently published the results of their Phase I/IIa Clinical Study
conducted on 6 patients with spinocerebellar ataxia type 3. They transplanted
allogenic adipose tissue derived mesenchymal stem cells intravenously. These cells
were safe as there were no adverse events recorded and also there was minimal
clinical improvement reported. (19)
Published Case report
A 33 year old female with SCA was treated with autologous BMMNCs intrathecal
transplantation followed by standard rehabilitation. (20) She had severe
impairment of dynamic balance, coordination, speech, gross and ne motor
control. Ambulation was dependent; requiring support from two people with an
ataxic gait. Functionally, she scored 86 on Functional independence measure (FIM)
and 62 on Ataxia rating scale. On follow up at six months after the transplantation
there was a signicant improvement in handwriting, ne motor activities, standing
dynamic balance and intelligibility of speech. There was an improvement in the
cerebellar signs and symptoms and outcome measures like Modied International
co-operative Ataxia rating scale (MICARS). The MICARS score reduced from 62 to
58.
Our Experience with Cerebellar Ataxia Patients:
We performed a study to demonstrate the effect of autologous bone marrow
mononuclear cells in 91 cases of cerebellar ataxia. Symptoms such as co-ordination,
ambulation, hand functions, stamina/fatigue, trunk balance and standing were
analysed. On follow up, 93.4% of patients showed improvements while 6.6%
Stem Cell Therapy In Neurological Disorders 251

showed no improvement. 49.45% patients showed mild improvements, 39.5 %

moderate improvements and 4.3% showed signicant improvements.

Improvements in Cerebellar Ataxia A er Stem Cell Therapy (N=91)

45
40
42.85%
35 39.5%
30
25
20
15
10
6.5%
5 4.3%

0
No Mild Moderate Significant
Improvement Improvement Improvement Improvement

Figure 1: Improvements seen in cerebellar ataxia patients after intrathecal

administration of autologous BMMNCs.

Figure 2: PET CT Scan showing improved metabolic activity which is indicated by

increased orange area in the cerebellum after stem cell therapy as indicated by the
circles.
Stem Cell Therapy In Neurological Disorders 252

Figure 3: Comparative PET CT scan showing improvements before and after

cellular therapy. (A) Pre-PET image before cellular therapy shows reduced
metabolism in bilateral sensory motor cortex, parietal cortex, thalamus and
cerebellum
(B) Post-PET image of 12-month interval following cellular therapy show improved
metabolism in bilateral sensory motor cortex, parietal cortex, thalamus and
cerebellum
Conclusion:
Existing literature and our clinical experience highlights the likelihood of stem cell
therapy to be a potential treatment strategy for cerebellar ataxia. It does not cure but
supplements the effect of other conventional treatments. It may help in alleviating
the symptoms and alter disease progression in patients with ataxia making the
patients functionally independent and improving their quality of life. In hereditary
cerebellar ataxias, gene therapy is being developed to repair the underlying genetic
defect. However, stem cell therapy may augment the effect of gene therapy by
repairing the already occurred neural damage via neuroprotection. Hence, they can
be used in combination for enhancing the therapeutic benets. Rehabilitation also
plays an important role in mobilizing the stem cells and enhancing the effect of
transplantation, hence regular rehabilitation is recommended in combination with
stem cell therapy. The efcacy of stem cell therapy depends on various factors. Stem
cell therapy when done at a younger age gives a better outcome. If done at an early
stage of disease, better is the chance of halting the progression and milder the
damage, better are the improvements. PET CT scan brain can effectively showcase
the metabolic changes occurring as a result of stem cell transplantation, at a cellular
level. Hence, it should be further explored as an efcient monitoring tool.
Stem Cell Therapy In Neurological Disorders 253

REFERENCES:
1. Diener, HC., and J. Dichgans. Pathophysiology of cerebellar ataxia. Movement
Disorders, 1992; 7(2): 95-109.
2. Schöls, Ludger, et al. Autosomal dominant cerebellar ataxias: clinical features,
genetics, and pathogenesis. The Lancet Neurology (2004); 3(5): 291-304.
3. Klockgether, T., et al. Idiopathic cerebellar ataxia of late onset: natural history
and MRI morphology. Journal of Neurology, Neurosurgery & Psychiatry
1990;53(4): 297-305.
4. Schmahmann, Jeremy D. Disorders of the cerebellum: ataxia, dysmetria of
thought, and the cerebellar cognitive affective syndrome. The Journal of
neuropsychiatry and clinical neurosciences 2004;16 (3): 367-378.
5. Cvetanovic M, Patel JM, Marti HH, Kini AR, Opal P .Vascular endothelial
growth factor ameliorates the ataxic phenotype in a mouse model of
spinocerebellar ataxia type 1 in Nature Medicine 2011;17(11):1445-7.
6. Jones, Jonathan, et al. Mesenchymal stem cells rescue Purkinje cells and
improve motor functions in a mouse model of cerebellar ataxia." Neurobiology
of disease 2010; 40(2): 415-423.
7. Zhang, Mei-Juan, et al. Human umbilical mesenchymal stem cells enhance the
expression of neurotrophic factors and protect ataxic mice. Brain research 2011;
1402: 122-131.
8. Chang, You-Kang, et al. Mesenchymal stem cell transplantation ameliorates
motor function deterioration of spinocerebellar ataxia by rescuing cerebellar
Purkinje cells. J Biomed Sci 2011; 18(1): 54.
9. Díaz D, Piquer-Gil M, Recio JS, Martínez-Losa MM, Alonso JR, Weruaga E,
Álvarez-Dolado M. Bone marrow transplantation improves motor activity in a
mouse model of ataxia. J Tissue Eng Regen Med. 2017 Dec 8.
10. Kemp KC, Hares K, Redondo J, Cook AJ, Haynes HR, Burton BR, Pook MA,
Rice CM, Scolding NJ, Wilkins A. Bone marrow transplantation stimulates
neural repair in Friedreich's ataxia mice. Ann Neurol. 2018 Mar 13
11. Nuryyev RL, Uhlendorf TL, Tierney W, Zatikyan S, Kopyov O, Kopyov A,
Ochoa J, Trigt WV, Malone CS, Cohen RW. Transplantation of Human Neural
Progenitor Cells Reveals Structural and Functional Improvements in the
Spastic Han-Wistar Rat Model of Ataxia. Cell Transplant. 2017
Nov;26(11):1811-1821.
12. Uhlendorf TL, Nuryyev RL, Kopyov AO, Ochoa J, Younesi S, Cohen RW,
Kopyov OV. Efcacy of Two Delivery Routes for Transplanting Human Neural
Stem Cell Therapy In Neurological Disorders 254

Progenitor Cells (NPCs) Into the Spastic Han-Wistar Rat, a Model of Ataxia.
Cell Transplant. 2017 Feb 16;26(2):259-269.
13. Jin, Jia-Li, et al. Safety and efcacy of umbilical cord mesenchymal stem cell
therapy in hereditary spinocerebellar ataxia. Current neurovascular research
2013;10(1):11-20.
14. Dongmei, Han, et al. Clinical analysis of the treatment of spinocerebellar ataxia
and multiple system atrophy-cerebellar type with umbilical cord mesenchymal
stromal cells. Cytotherapy 2011; 13(8): 913-917.
15. Yang, Wan-Zhang, et al. Human umbilical cord blood-derived mononuclear
cell transplantation: case series of 30 subjects with hereditary ataxia. J Transl
Med. 2011; 9 (1): 1-5.
16. Miao X, Wu X, Shi W. Umbilical cord mesenchymal stem cells in neurological
disorders: A clinical study. Indian J Biochem Biophys. 2015;52(2):140-6.
17. Amariglio N, Hirshberg A, Scheithauer BW, et al. Donor-Derived Brain Tumor
Following Neural Stem Cell Transplantation in an Ataxia Telangiectasia
Patient. Fischer A, ed. PLoS Medicine. 2009;6(2):e1000029.
18. Shroff G. Human Embryonic Stem Cells in the Treatment of Spinocerebellar
Ataxia: A Case Series. J Clin Case Rep 2015; 4:474
19. Tsai YA, Liu RS, Lirng JF, Yang BH, Chang CH, Wang YC, Wu YS, Ho JH, Lee
OK, Soong BW. Treatment of Spinocerebellar Ataxia With Mesenchymal Stem
Cells: A Phase I/IIa Clinical Study. Cell Transplant. 2017 Mar 13;26(3):503-512
20. Sharma A, Sane H, Paranjape A, et al. Cellular Transplantation May Modulate
Disease Progression In Spino-Cerebellar Ataxia – A Case Report. Indian Journal
Of Medical Research And Pharmaceutical Sciences. 2014; 1(3).
Stem Cell Therapy In Neurological Disorders 255

SECTION C
Important Related Aspects
Stem Cell Therapy In Neurological Disorders 256

If you can dream and not make dreams your master, if you can think
but not make thoughts your aim; If you can meet with triumph and
disaster and treat those two imposters just the same...if you can ll
the unforgiving minute with 60 seconds of distant run, yours is the
earth and everything that's in it"

– Rudyard Kipling
Stem Cell Therapy In Neurological Disorders 257

17

Radiological Imaging in Stem Cell

Therapy

Stem cell therapy is the promising novel therapy with a potential to repair the
neurological damage and prevent the rapid progressive neuromuscular
degeneration. It has been widely explored for the treatment of various incurable
neuromuscular disorders. Although there is a large evidence base for the use of
stem cell therapy in neurological disorders, the effects observed are either
functional or on subjective outcome measures. To develop stronger and more
robust evidence base for the effects of stem cell therapy in the treatment of
neurological disorders, more objective outcomes are required. The mechanism of
action of stem cells is through their paracrine effects on surrounding tissues [1-7].
Although the cells have capability for regeneration, with current technology there
are limited structural changes and these may be seen over a long time. The earliest
improvements noted are functional improvements. To study these improvements
and document the effects of stem cell therapy in detail, modern imaging modalities
need to be used. With the use of such sophisticated neuroimaging and
musculoskeletal imaging techniques benecial effects of stem cell therapy have
been documented in some of the published reports [8-20]. Various functional
imaging modalities that can be used are functional magnetic resonance imaging (F-
MRI), Diffusion tensor imaging of the muscles (DTI), Positron emission
tomography - computed tomography (PET-CT) scan and structural imaging
modalities like Musculo skeletal magnetic resonance imaging (MRI-MSK) and
Electromyography.
Stem Cell Therapy In Neurological Disorders 258

Structural imaging modalities

Musculoskeletal MRI:
Radio imaging has advanced and various non-invasive techniques can give
accurate information for diagnosing and monitoring MD [21]. MRI has several
advantages over other imaging techniques used in MD. It is not dependent on the
operator and does not use ionizing radiations. There is no need to administer an
intravenous contrast for image acquisition. Multiplanar acquisition in MRI makes it
easier to be used for the patients with contractures, deformities and severe muscle
weakness as seen in MD. MRI also has an inherently high soft tissue resolution and
discrimination potential for fat, muscles, uids, edema and bones. This makes MRI
the imaging modality of choice for MD. Musuloskeletal MRI helps to differentiate
between the soft tissue and muscles. This allows for grading of the severity of fatty
inltration and muscle atrophy in MD. MRI has been previously used successfully
to assess progression of disease in MD [22,23].
Duchenne's Muscular Dystrophy
In a case report published in American Journal of Case reports, a patient of DMD
was treated with Autologous BMMNCs intrathecal and intramuscular
transplantation and the effects were studied over the period of 3 years using serial
MRI-MSKs [24]. Patient had undergone four subsequent transplantations
performed at 9, 21 and 33 months after 1st transplantation. Clinical improvements
and muscle strength measurements guided the time of subsequent
transplantations. There is a 5% increase in the fatty inltration and 3.9% reduction
in the strength of the muscles every year in DMD as suggested by various studies on
natural progression of the disease [25,26]. However the patient studied showed no
deterioration in the muscle quantity and no increase in the fatty inltration of the
tissues on serial MRI-MSKs (Figure 1A and 1B); which indicated stabilization of the
disease. This was also substantiated by the EMG showing better recruitment of the
muscles and some new normal motor unit potentials. The patient at the end of 33
months showed improved muscle strength, better endurance, improved quality of
the handwriting and was able to walk with the help of push knee splints and
walker.
Stem Cell Therapy In Neurological Disorders 259

Figure 1A: T1 Weighted Axial Figure 1B: T1 Weighted Axial

Musculoskeletal MRI image before Musculoskeletal MRI image 24 months
cellular transplantation after cellular transplantation showing
no reduction in muscle mass and no
increase in fatty inltration suggestive
of halting of disease progression in
Duchenne Muscular Dystrophy

Becker's Muscular Dystrophy

We studied the therapeutic effect of cellular therapy on BMD using an MRI-MSK
over a period of 8 months, as published in the Journal of case reports [27]. There was
an increase in the muscle bers of peronei, gastro-soleus and long, medial and
lateral head of triceps with decreased fatty inltration as observed on the MRI-MSK
post 6 months of cellular transplantation (Figure 2A, 2B, 3A, 3B, 4A & 4B). Clinically
there was improved standing balance, ability to walk with the help of push knee
splints and unilateral human support. There was reduction in calf pain while
standing and upper extremity pain while maintaining the quadruped position. All
these activities involve the above mentioned muscles. The improved quality of
movement may suggest better recruitment of the existing muscle bers. Post
cellular therapy increase in the muscle bres and reduced fatty inltration was an
improvement that also corelated with the clinical improvements.

Figure 2A : T1 weighted axial musculoskeletal MRI images of Peroneous Longus

and Brevis before Autologous BMMNCs transplantation
Stem Cell Therapy In Neurological Disorders 260

Figure 2B: T1 weighted axial musculoskeletal MRI images of Peroneous Longus

and Brevis 6 months after Autologous BMMNCs transplantation, arrows showing
muscle regeneration and reduced fatty inltration

Figure 3B: T1 weighted axial musculoskeletal MRI images of Gastrocnemius and

Soleus 6 months after Autologous BMMNCs transplantation; arrows showing
muscle regeneration and reduced fatty inltration

Figure 4A: T1 weighted axial musculoskeletal MRI images of Left and Right Long,
Medial and Lateral head of Triceps before Autologous BMMNCs transplantation
Stem Cell Therapy In Neurological Disorders 261

Figure 4B: T1 weighted axial musculoskeletal MRI images of Left and Right Long,
Medial and Lateral head of Triceps 6 months after Autologous BMMNCs
transplantation; arrows showing muscle regeneration and reduced fatty
inltration

Functional imaging modalities

The underlying principle of functional neuroimaging using PET-CT scan is that the
changes in blood ow and energy consumption in the form of glucose are
associated with brain metabolism and tissue function [28,29]. F-MRI is another
modality that is used for functional neuroimaging. F-MRI measures the blood
oxygenation level dependent effects (BOLD) in the brain and spinal cord and
provides a diagrammatic representation for the function of the brain and spinal
cord [30].
Functional MRI
Spinal Cord Injury
A patient of traumatic paraplegia due to a complete spinal cord injury at the level of
10th thoracic vertebra, underwent autologous BMMNCs intrathecal
transplantation one month after his injury. He had complete motor and sensory loss
below the level of injury. Bladder and bowel sensory and motor control was absent.
He was completely dependent for daily activities. After two serial transplantations
6 months apart and rigorous rehabilitation, he showed some motor recovery in
adductors of hip showing strength of grade 1 on manual muscle testing. He also had
minimal sensory recovery. Bladder and bowel sensations had improved. This
improvement reected in the functional MRI showing more number of nerve cells
being recruited during a particular activity. He also showed improvement in the
conduction velocity of motor nerves when tested using EMG.
Stem Cell Therapy In Neurological Disorders 262

Figure 5: FMRI showing changes after stem cell therapy

Positron Emission Tomography - Computed Tomography Scan

PET-CT scan is a functional imaging technique that represents physiological
activity of brain as three dimensional images and reects the functional processes in
the body. The physiological activity of brain is measured using, the FDG
(uorodeoxyglucose) uptake by the brain cells. FDG is an analogue of Glucose.
Glucose transporter proteins transport FDG to the brain cell where it undergoes the
metabolic processes. Once it has been converted to Glucose 6 phosphate it cannot be
metabolized further and is trapped in the cells as the cell membrane is impermeable
to this molecule [31]. Metabolism of FDG is due to glycolysis and therefore the
trapped glucose 6 phosphate molecules correlate with the metabolic activity of the
brain cells. Increased retention of FDG therefore indicates increased metabolic
activity of the tissue [32]. PET measures the retention of FDG in terms of standard
uptake value (SUV), which is the ratio of the actual concentration of glucose in brain
tissue and the hypothetical concentration of the glucose in brain tissue if it was
distributed evenly in all the areas of brain. Increased SUV indicates better metabolic
activity of the tissue [33]. The following are the PET-CT scan ndings that correlated
with the functional recovery of the patients with different diagnoses like Autism,
Cerebral Palsy, Stroke, Traumatic brain injury, Dementia and Ataxia.
Autism
1. A 6 year old boy diagnosed of Autism was treated with autologous bone marrow
mononuclear cell transplantation. He exhibited poor eye contact, hyperactivity,
poor communication, poor attention and concentration, repetitive motor behaviour
like hand apping, aggressive behaviours like biting and hitting as well as very
poor social interaction. He scored 123 on Indian scale for assessment of autism
(ISAA). His PET-CT scan showed hypometabolism in the regions of superior
temporal gyrus, amygdale and fusiform gyrus (social brain) as well as bilateral
basal ganglia, hippocampus, parahippocampus and cerebellum. 6 months post
transplantation metabolism in all the above areas had improved signicantly
Stem Cell Therapy In Neurological Disorders 263

(Figure 6A, B and C). He showed improvement in non verbal communication, eye
contact, social interaction, attention and concentration. Aggressive and repetitive
motor behaviour had reduced signicantly. His ISAA score also showed
improvement, intensity of all symptoms reduced and therefore the score reduced
from 123 to 103. In view of these improvements he underwent second stem cell
transplantation. 6 months following the stem cell transplantation the ISAA score
was maintained and he showed further improvement in speech, communication,
hyperactivity, command following and eye contact.

Figure 6A: PET-CT scan before cellular transplantation showing

hypometabolism highlighted in blue and black colour in the regions of mesial
temporal lobes, amygdala, hypocampus, cingulate regions and cerebellum

Figure 6B: PET-CT scan 6 months after cellular transplantation showing

increased metabolism in the regions of superios temporal gyrus, mesial
temporal lobes, amygdala, hypocampus, cingulate regions and cerebellum;
indicated by reduction in the blue and black areas

Figure 6C: PET-CT scan 8 months after second cellular transplantation

showing maintained increase in the metabolism of superios temporal
gyrus, mesial temporal lobes, amygdala, hypocampus, cingulate regions
and cerebellum and reduction in the metabolism cortical regions showing
the balancing effect
Stem Cell Therapy In Neurological Disorders 264

2. A 13 year old male and a known case of Autism was treated with autologous bone
marrow mononuclear cells intrathecal transplantation. He was born full term by
normal delivery, with history of delayed cry and no neonatal complications. His
motor milestones were normal but his speech development was delayed. When he
was 2 years old, he was diagnosed to have Autistic features. He presented with
symptoms like hyperactivity, restlessness, poor social interaction, poor sitting
tolerance, poor command following, temper tantrums, hypersensitivity to touch
and eeting eye contact. After 6 months of the transplantation he showed
improvement in sitting tolerance in class, reduction in hyperactivity, reduction in
aggressive behaviour, improved eating habits and preference, improved clarity of
speech and improved command following. These clinical improvements were
reected on PET-CT scan as increased metabolism in the region of bilateral occipital
lobes and mesial temporal structures.

Figure 7A: PET - CT Scan before stem cell transplantation suggestive of

reduction in the metabolism of occipital lobes and mesial
temporal structures bilaterally

Figure 7B: PET-CT scan after stem cell transplantation showing improved
metabolism in bilateral occipital lobes mesial temporal structures
3. A 9 year old girl with Autism underwent autologous BMMNCs intrathecal
transplantation. Her main symptoms were poor attention and concentration, social
interaction, difculty in adapting to changed environment, presence of repetitive
and strange movements, poor eye contact, irrelevant speech and complete
dependence for ADL's. 6 months after the rst transplantation, she showed
improvements in eye contact, non- verbal communication, and learning, reduction
in laughing without reason, improvement in command following, understanding
relationships, reduced hyperactivity and started picking up well in ADL training.
Stem Cell Therapy In Neurological Disorders 265

These changes also correlated with the PET-CT scan showing improvement in the
metabolism of mesial temporal lobes, amygdala, hypocampus, and cerebellum
bilaterally (Figure 8B).

Figure 8A: PET-CT scan before cellular transplantation showing

hypometabolism highlighted in blue and black colour in the regions of mesial
temporal lobes, amygdala, hypocampus, cingulate regions and cerebellum

Figure 8B: PET-CT scan 6 months after cellular transplantation showing

increased metabolism in the regions of mesial temporal lobes, amygdala,
hypocampus, and cerebellum bilaterally; indicated by reduction in the blue
and black areas
4. 11 year old boy with poor attention and concentration, increased hyperactivity,
poor social interaction, with abnormal presence of stereotypical behaviour, poor
eye contact, monosyllable speech was treated with cellular therapy. The PETCT
scan before stem cell therapy was suggestive reduced metabolism in Temporal
lobes, Mesial temporal lobes, Cingulate and paracingulate regions, Cerebellum,
Amygdala, Hippocampus and Parahippocampus. Six months after cellular therapy
he showed reduction in hyperactivity, he could sit at one place for ½ hour at a
stretch. His cognition had improved, he started following written instructions, his
sitting posture had improved, his imitation skills had improved, he started
following commands and his eye contact also had improved. The PET-CT scan after
cellular transplantation also showed increased metabolism in the regions of
Temporal lobes, Mesial temporal lobes, Cingulate and paracingulate regions,
Cerebellum, Amygdala, Hippocampus and Parahippocampus.
Stem Cell Therapy In Neurological Disorders 266

Figure 9A: PET-CT scan before cellular transplantation showing

hypometabolism highlighted in blue and black colour in the regions of mesial
temporal lobes, amygdala, hypocampus, cingulate regions and cerebellum

Figure 9B: PET-CT scan after cellular transplantation showing increased

metabolism in the regions of mesial temporal lobes, amygdala, hypocampus
& cerebellum bilaterally; indicated by reduction in the blue & black areas
5. A 4 year boy with a diagnosis of Autism underwent bone marrow mononuclear
cells intrathecal transplantation. He presented with symptoms like poor eye
contact, inability to speak, poor cognition, hyperactivity, poor attention
concentration and poor social interaction. 14 months after transplantation he
showed improvement in eye contact, he could indicate bladder and bowel, he
started imitating and repeating words, he was able to write the alphabets, social
interaction, attention and concentration improved. These clinical improvements
also co related with the changes observed in PET-CT scan ndings.

Figure 10A: PET-CT scan before cellular transplantation showing hypometabolism

highlighted in blue and black colour in the regions of bilateral cerebellum
Stem Cell Therapy In Neurological Disorders 267

Figure 10B: PET-CT scan after cellular transplantation showing increased

metabolism in the regions of cerebellum bilaterally; indicated by reduction in
the blue and black areas

6. A case of autism presented with symptoms like poor attention and concentration,
eeting eye contact, poor sitting tolerance, hyperactivity, poor social interaction
and impaired speech underwent autologous BMMNCs intrathecal transplantation.
The PET-CT scan ndings suggested reduced metabolism in mesial temporal lobes,
basal ganglia and cerebellar lobes bilaterally. After cellular therapy he showed
improment in attention and concentration, sitting tolerance, command following,
improved social engagement, improved vocalisation and speech and reduction in
hyperactivity and stereotypical behaviours. PET-CT scan correspondingly showed
improved metabolism in basal ganglia, mesial temporal structures and cerebellar
lobes bilaterally.

Figure 11A: PET-CT scan before cellular transplantation showing

hypometabolism highlighted in blue and black colour and as outlined by the
circles in the regions of basal ganglia, mesial temporal structures and
cerebellum
Stem Cell Therapy In Neurological Disorders 268

Figure 11B: PET-CT scan after cellular transplantation showing increased

metabolism as outlined by the circles in the regions of basal ganglia, mesial
temporal structures and cerebellum

7. A 7 year old boy diagnosed with Autism underwent autologous BMMNCs

intrathecal transplantation. His main symptoms were poor social interaction,
crying spella, hyperactivity, poor eye contact, temper tantrums, poor command
following and complete dependence for daily activities. His PET-CT scan (Figure 12
A) suggested diffuse increase in the metabolic activity of the cortical lobes and
reduced metabolic activity in bilateral cerebellar lobes. 6 months after the rst
transplantation he showed improvements in command following, eye contact,
attention and concentration, understanding of the relationships, social interaction
and reduction in stereotypical behaviour, hyperactivity, temper tantrums and
aggressive behavior. These improvements correlated with the PETCT scan chages
of balancing of the brain metabolism as shown in the Figure 12B.

Figure 12A: PET-CT scan before stem cell therapy showing diffuse increase
in the metabolic activity of the cortical lobes and reduced metabolic
activity in bilateral cerebellar lobes
Stem Cell Therapy In Neurological Disorders 269

Figure 12B: PET-CT scan after stem cell therapy showing reduction in the
metabolic activity of the cortical lobes and increased metabolic activity in
bilateral cerebellar lobes hence highlighting the balancing effect of
cellular therapy

8. A 4 year old boy with Dopamine Responsive Dystonia underwent Adult

Autologous BMMNC's intrathecal transplantation. His main symptoms were
severe dystonia and poor trunk control and hand functions ,absence of speech,
presence of drooling, presence of rigidity. 6 months after rst transplantation, he
showed improvements in his neck and trunk control, reduction in drooling,
improvements in sitting balance improvement in gross motor skills and tendency
for extensor posture has reduced. A comparison PET-CT scan showed increased
metabolic activity in bilateral cerebellar lobes and thalami.

Figure 13A: PET-CT scan before stem cell therapy showing reduction in the
metabolic activity of the cerebellar lobes and thalami bilaterally

Figure 13B: PET-CT scan after stem cell therapy showing increased
metabolic activity in bilateral cerebellar lobes and thalami bilaterally
Stem Cell Therapy In Neurological Disorders 270

Cerebral Palsy
1. A 12 year old boy suffering from spastic diaplegic cerebral palsy was treated with
cellular therapy. He was hypertonic and hyperreexic. He had poor hand writing,
poor balance in sitting and standing and walked with a crouch gait and was
moderately dependent for activities of daily living. There was no sensory or
cognitive involvement. The PET-CT scan showed reduced FDG uptake in the
cerebellar lobes and mesial temporal structures (Figure 14A). 6 months post cellular
therapy he showed signicant improvement in ne motor activities, gait and
balance. He required only a minimal help for his activities of daily living. PET-CT
showed improved metabolism in all the areas of reduced FDG uptake (Figure 14B).

Figure 14A: PET-CT scan before cellular transplantation showing

hypometabolism highlighted in blue and black colour in the regions of
cerebellar lobes and mesial temporal structures

Figure 14B: PET-CT scan 6 months after cellular transplantation

showing increased metabolism in the regions of cerebellar lobes and
mesial temporal structures seen as reduced blue and black areas

2. An 8 year old child born of consanguineous marriage, delivered by caesarean

section presented with a history of brain hypoxia due to delayed cry after birth and
also had a seizure 5 hours after birth. He was diagnosed with CP and the main
symptoms were presence of abnormal reexes, uctuating tone, poor voluntary
control and poor cognition. His PET-CT scan ndings suggested reduced
Stem Cell Therapy In Neurological Disorders 271

metabolism in the regions of hippocampus, basal ganglia and cerebellum

bilaterally (Figure 15A). He underwent autologous BMMNCs intrathecal
transplantation. There were improvements noted after stem cell therapy in the
oromotor skills, voluntary control of upper extremity, reduction of spasticity,
improved bed mobility, improved awareness and other cognitive skills, improved
eye contact and improved trunk control. These changes also correlated with the
improvements in the PET-CT scan suggestive of increased metabolism in the
regions of hippocampus, basal ganglia and cerebellum bilaterally (Figure 15B).

Figure 15A: PET-CT scan before cellular transplantation showing

reduced metabolism in the regions of hippocampus, basal ganglia and
cerebellum bilaterally as indicated by the circles

Figure 15B: PET-CT scan 9 months after cellular transplantation

showing increased metabolism in the regions of hippocampus, basal
ganglia and cerebellum bilaterally as indicated by the circles

3. A 12 year old boy diagnosed with cerebral palsy was treated with autologous
BMMNCs intrathecal transplantation. He presented with symptoms like increased
muscles tone, poor voluntary control of bilateral lower extremity and fair ne motor
activity of upper extremity. He could walk with elbow crutches in crouch Gait. Post
cellular therapy improvements were noted in balance while standing and
Stem Cell Therapy In Neurological Disorders 272

performing exercise related activities. Voluntary control of both upper and lower
limbs had improved, he could perform all the daily activities independently and his
handwriting speed improved. These clinical improvements correlated with PET-
CT ndings of improved metabolism in the regions of hippocampus, basal ganglia,
thalami, mesial temporal structures and cerebellar lobes (Figure 16 A&B).

Figure 16A: PET-CT scan before Figure 16B: PET-CT scan after cellular
cellular transplantation showing transplantation showing improved
reduced metabolism in the regions of metabolism in the regions of
hippocampus, basal ganglia, thalami, hippocampus, basal ganglia, thalami,
mesial temporal structures and mesial temporal tructures and
cerebellar lobes bilaterally as cerebellar lobes bilaterally as
indicated by the circles indicated by the circles

Mental Retardation
1. A 20 year old male suffering from CP and Mental Retardation (MR) was treated
with cellular therapy at our center. He had diplegic gait and Intelligence Quotient
(IQ) score of 44 with affected ne motor activities, balance, speech and higher
functions. PET-CT scan identied frontal, temporal, parietal, occipital, left
cerebellar lobes, amygdala, hippocampus, and parahippocampus as the affected
areas (Figure 17A). He was treated with cellular therapy of Autologous BMMNCs
intrathecal transplantation followed by multidisciplinary rehabilitation. Six
months following therapy, he showed improvement in social behavior, speech,
balance, daily functioning and IQ score increased to 55. PET-CT scan showed
signicant increase in metabolic activity in all four lobes, mesial temporal
structures and left cerebellar hemisphere. The clinical improvements correlated
with the changes observed in the PET CT scan (Figure 17B).
Stem Cell Therapy In Neurological Disorders 273

Figure 17A: PET-CT scan before Figure 17B: PET-CT scan 6 months
cellular transplantation showing after cellular transplantation
hypometabolism highlighted showing increased metabolism in the
in blue and black colour in the regions regions of frontal, temporal, parietal,
of frontal, temporal, parietal, occipital, left cerebellar lobes,
occipital, left cerebellar lobes, amygdala, hippocampus, and
amygdala, hippocampus, and parahippocampus; indicated by
parahippocampus reduction in the blue and black areas

Ischemic Stroke
1. In a case of chronic stroke caused by ischemia in the territory of right middle
cerebral artery Autologous BMMNCs intrathecal transplantation was performed 3
years after the stroke. Upon performing the serial PET-CT scans before and 1 year
after transplantation, there was a signicant increase in the metabolism of brain in
the regions of Parietal lobes. The standard uptake of FDG in parietal lobe increased
from 7.01 to 9.51. Clinically he showed improvement in balance, gait and functional
independence as well as reduction in spasticity.

Figure 18A. PET-CT scan before Autologous BMMNCs transplantation suggestive

of stroke in the region right MCA territory with black areas suggestive of gliosis
where as the blue regions suggestive of penumbra
Stem Cell Therapy In Neurological Disorders 274

Figure 18B. PET-CT scan 1 year after Autologous BMMNCs transplantation

showing improved metabolism in the parietal lobe penumbral regions seen as
reduction in the blue coloured areas

2. A 58 year old man with ischemic stroke presented with poor control of right
upper and lower extremity, slurred speech, impaired cognition and behavior,
increased spasticity in the muscles of upper limb, poor balance while walking and
hemiplegic gait pattern. He was treated with autologous BMMNCs intrathecal
transplantation 3 years after stroke. 7 months post transplantation he showed
improvement in various physical tasks like upper limb overhead activity and ne
motor activity, improved gait pattern, improved walking balance, orientation to
date, time and place and reduced confusion and emotional outbursts. These
changes correlated with the PET-CT scan ndings of improved brain metabolism in
the region of left frontal lobe, occipital lobe and basal ganglia.

Figure 19A: PET-CT scan before Autologous BMMNCs transplantation

suggestive of reduced metabolism in the regions of left frontal lobe, occipital
lobe and basal ganglia
Stem Cell Therapy In Neurological Disorders 275

Figure 19B: PET-CT scan after Autologous BMMNCs transplantation

suggestive of increased metabolism in the regions of left frontal lobe,
occipital lobe and basal ganglia

Hemorrhagic Stroke
Cellular transplantation in the case of chronic hemorraghic stroke involving frontal,
parietal lobes and cerebellum and brainstem was performed 1 year after the
transplantation. There was increase in the metabolism of the brain in PET-CT scans.
The increase in the metabolism was noted in the regions of Frontal lobe, Parietal
lobe and Cerebellum. Clinically this increased metabolism was correlated with
improved cognition, balance, motor function, functional independence and speech
intelligibility as well as reduction in spasticity.

Figure 20A: PET-CT scan before Autologous BMMNCs transplantation

suggestive of hemorrhagic stroke in the region left parietal lobe with black areas
suggestive of gliotic areas where as the blue regions suggestive of penumbra

Figure 20B: PET-CT scan 6 months after Autologous BMMNCs transplantation

shows reduced blue areas signifying improved metabolism of the penumbral
regions
Stem Cell Therapy In Neurological Disorders 276

Traumatic Brain Injury

1. 15 yrs old girl presented to us with a history of RTA at age of 8 yrs due to which
she suffered a Severe Head Injury and transtentorial herniation with
decompressive craniotomy and diffuse axonal injury. Her PET showed Gliotic
areas with reduced uptake in bilateral parieto-occipital and right anterior inferior
temporal region. She underwent autologous bone marrow mononuclear cell
transplantation, with intensive multidisciplinary rehabilitation. Post SCT
improvements were seen throughout, with maximum changes occurring by 6
months. Improvements were seen in her in her short term memory, behavior,
improved new learning skills, improved understanding and her overall cognition,
she also had an improvement in her vision with better perception for moving
objects, there was also an improvement seen in her Rt sided gross motor and ne
motor co-ordination and reduced neglect on Rt side with an overall improvement in
her bilateral co-ordination. There was also signicant change seen in her PET scan,
there was an increase in the FDG uptake seen in the anterior cingulate gyrus, the
middle cingulate gyrus and in the posterior cingulate gyrus. The para hippocampal
gyrus uptake has increased. Increased FDG uptake is also seen in the amygdala.
There was also increased FDG uptake seen in both frontal lobes, and in the right
temporal lobe.

Figure 21A: PET-CT scan before Figure 21B: PET-CT scan after
Autologous BMMNCs Autologous BMMNCs showing
transplantation showing gliotic improved metabolism in the regions
areas in black with areas of reduced of anterior, middle and posterior
metabolism in blue seen in bilateral cingulate gyrus, amygdale,
parieto-occipital&right anterior hypocampus and parahypocampus
inferior temporal region

2. A 34 year old patient with traumatic head injury was treated with autologous
BMMNCs intrathecal transplantation. Due to the traumatic injury he had
developed right hemiplegia, increased muscle tone in right upper and lower
extremity, dysrthria, poor sitting and standing blance, inability to walk without
Stem Cell Therapy In Neurological Disorders 277

support and subnormal coginition. His PET-CT scan showed reduced metabolism
in the region of right cerebellum. After the stem cell therapy he showed
improvements in sitting and standing posture, gait pattern, spasticity, oromotor
control, speech and higher cognitive functions. This clinical
improvementcorrelated with improved metabolism in cerebellum.

Figure 22: PET CT Scan showing improved metabolic activity which is indicated
by decrease in blue areas after stem cell therapy

Dementia
1. A 61 year old, right handed female, presented with a medical history of
hypertension and vascular dementia. On the Functional Independence Measure
(FIM), she scored 75/126. And on the objective neuropsychological assessment
using Mini Mental Status examination, she got a score of 10/30 indicating severe
dementia. PET scan showed global hypo metabolism in the brain. Bilateral parietal
lobe showed moderately reduced FDG uptake and bilateral frontal and temporal
showed mild reduction. She underwent autologous bone marrow derived
mononuclear cell transplantation. At follow up assessment, improvements were
noted in terms of her Cognition, behavior and physical activities. On MMSE, her
scores improved from 13/30 to 16/30 at 6 months follow up and nally to 20/30 at
the end of 2 years. Her FIM score improved from 75 to 80 in 2 years. On PET-CT scan
there was increase FDG uptake noted in the regions of bilateral parietal, frontal and
temporal lobes (Figure 23A and 23B).
Stem Cell Therapy In Neurological Disorders 278

Fig 23A: Pre stem cell. There is overall hypometabolism seen in the brain, with
purple areas depicting areasof hypometabolism and orange areas as areas of
normal metabolism

Fig 23B. Post stem cell. As compared to Fig A, there is increase in the orange
area, which is the area of normal metabolism and reduction in the purple area.
This suggests that after stem cell therapy, there is increased metabolic activity
in the brain, thus improved neural activity.

Cerebellar Ataxia
1. An 18 year old girl with progressive cererbellar ataxia was treated with
autologous BMMNCs intrathecal transplantation. The symptoms were progressive
beginning at the age of 3 years of age. Although initially it started only with minor
loss of balance while walking the symptoms progressed rapidly with inability to
speak clearly, severe tremors in the arms, legs and trunk, continuous uncontrolled
movement of head and visual focusing decits. She slowly regressed in her physical
abilities and was wheel chair bound since the age of 15. 6 months after 1st stem cell
transplantation there was improvement seen in her symptoms and the progression
of the disease had completely halted. She could walk with the help of a walker, her
speech was much louder and clearer, the shivering of hands had reduced and
Stem Cell Therapy In Neurological Disorders 279

uncontrolled head movement had reduced. She was moderately dependent for
daily activities but could initiate most of those activities. Her PET-CT scan
evaluation had shown severely reduced metabolism in bilateral cerebellar lobes. 6
months after transplantation the metabolism in the bilateral cerebellar lobes had
increased as depicted in Figure 24 A & B.

Fig 24A: Pre stem cell therapy there Fig 24B: Post stem cell therapy there
is hypometabolism seen in bilateral is increased metabolism seen in
cerebellar lobes bilateral cerebellar lobes

REFERENCES:
1. N. Payne, C. Siatskas, A. Barnard, and C. C. A. Bernard, "The prospect of stem
cells as multi-faceted purveyors of immune modulation, repair and
regeneration in multiple sclerosis," Current Stem Cell Research and therapy,
vol. 6, no. 1, pp. 50-62, 2011.
2. P. M. Chen, M. L. Yen, K. J. Liu, H. K. Sytwu, and B. L. Yen, "Immuno-
modulatory properties of human adult and fetal multipotent mesenchymal
stem cells," Journal of Biomedical Sciences, vol. 18, article 49, 2011.
3. P. R. Crisostomo, M. Wang, C. M. Herring et al., "Gender differences in injury
induced mesenchymal stem cell apoptosis and VEGF, TNF, IL-6 expression:
role of the 55 kDa TNF receptor (TNFR1)," Journal of Molecular and Cellular
Cardiology, vol. 42, no. 1, pp. 142-149, 2007.
4. Burlacu, G. Grigorescu, A. M. Rosca, M. B. Preda, and M. Simionescu, "Factors
secreted by mesenchymal stem cells and endothelial progenitor cells have
complementary effects on angiogenesis in vitro," Stem Cells Development. In
press.
5. M. X. Xiang, A. N. He, J. A. Wang, and C. Gui, "Protective paracrine effect of
mesenchymal stem cells on cardiomyocytes," Journal of Zhejiang University B,
vol. 10, no. 8, pp. 619-624, 2009.
Stem Cell Therapy In Neurological Disorders 280

6. P. R. Crisostomo, M. Wang, T. A. Markel et al., "Stem cell mechanisms and

paracrine effects: potential in cardiac surgery," Shock, vol. 28, no. 4, pp. 375-383,
2007.
7. M. Gnecchi, Z. Zhang, A. Ni, and V. J. Dzau, "Paracrine mechanisms in adult
stem cell signaling and therapy," Circulation Research, vol. 103, no. 11, pp.
1204-1219, 2008.
8. Alok Sharma, Prerna Badhe, Nandini Gokulchandran, Pooja Kulkarni,
Hemangi Sane, Mamta Lohia, Vineet Avhad. Autologous bone marrow
derived mononuclear cell therapy for vascular dementia - Case report. Journal
of stem cell research and therapy. J Stem Cell Res Ther 2:129. doi:10.4172/2157-
7633.1000129
9. Alok Sharma, Hemangi Sane, Amruta Paranjape, Nandini Gokulchandran,
Pooja Kulkarni and Anjana Nagrajan, Prerna Badhe. Positron Emission
Tomography - Computer Tomography scan used as a monitoring tool
following cellular therapy in Cerebral Palsy and Mental Retardation - A Case
Report. Case Reports in Neurological Medicine. Volume 2013, Article ID
141983, 6 pages
10. Alok Sharma, Nandini Gokulchandran, Prerna Badhe, Pooja Kulkarni, Priti
Mishra, Akshata Shetty and Hemangi Sane. An Improved Case of Autism as
Revealed by PET CT Scan in Patient Transplanted with Autologous Bone
Marrow Derived Mononuclear Cells. J Stem Cell Res Ther 2013, 3:2
11. Alok Sharma, Nandini Gokulchandran, Akshata Shetty, Hemangi Sane, Pooja
Kulkarni and Prerna Badhe. Autologous Bone Marrow Mononuclear Cells may
be Explored as a Novel. Potential Therapeutic Option for Autism. J Clin Case
Rep 2013, 3:7
12. Sharma A., Sane, H., Paranjape, A., Badhe, P., Gokulchandran, N., & Jacob, V.
(2013). Effect of Cellular Therapy seen on Musculoskeletal Magnetic Resonance
Imaging in a Case of Becker's Muscular Dystrophy.Journal of Case Reports,
3(2), 440-447
13. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Nancy
Thomas, Amruta Paranjape, Prerna Badhe. Intrathecal autologous bone
marrow mononuclear cell transplantation in a case of adult autism. Autism
open access. 2013, 3:2
14. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pradnya Bhovad,
Hema Biju, Akshata Shetty, Mrudula Kali and Prerna Badhe, Cell therapy
effects portrayed on positron emission tomography computerized tomography
scan of the brain serve as a new dimension for autism: A case report (2014),
Journal of Paediatric Neurology, 12:3
Stem Cell Therapy In Neurological Disorders 281

15. Sharma A , Gokulchandran N , Shetty A , Kulkarni P, Sane H , Badhe P.

Neuropsychiatric Disorder Tackled by Innovative Cell Therapy-A Case Report
in Autism. J Stem Cell Res Transplant. 2014;1(1): 4.
16. Alok Sharma, Hemangi Sane, Pooja Kulkarni, Myola D'sa, Nandini
Gokulchandran, Prerna Badhe. Improved Quality of Life in a Case of Cerebral
Palsy after bone marrow mononuclear cell transplantation. Cell J. 2015; 17(2):
389-394.
17. Dr. Alok Sharma, Ms. Pooja Kulkarni, Dr. Hemangi Sane, Dr. Nandini
Gokulchandran, Dr. Prerna Badhe, Dr. Mamta Lohia, Dr. Priti Mishra. Positron
Emission Tomography- Computed Tomography scan captures the effects of
cellular therapy in a case of cerebral palsy. Journal of clinical case reports. 2012 J
Clin Case Rep 2:195. doi:10.4172/2165-7920.1000195
18. Dr. A. Sharma, Ms. P. Kulkarni, Dr. G. Chopra, Dr. N. Gokulchandran, Dr. M.
Lohia, Dr. P. Badhe. Autologous Bone Marrow Derived Mononuclear Cell
Transplantation In Duchenne Muscular Dystrophy-A Case Report. Indian
journal of Clinical Practice 2012; 23 (3): 169-72
19. Sharma A, Sane H, Pooja K, Akshya N, Nandini G, Akshata S. (2015)
CellularTherapy, a Novel Treatment Option for Intellectual Disability: A Case
Report. J Clin Case Rep 5:483. doi: 10.4172/2165-7920.1000483
20. Nandini Gokulchandran, Alok Sharma , Hemangi Sane , Prerna Badhe , Pooja
Kulkarni. Stem Cell Therapy as a Treatment Modality for Neurotrauma. Indian
Journal of Stem Cell therapy. 2015; 1(1):21-26
21. Kinali M, Arechavala-Gomeza V, Cirak S, Glover A, Guglieri M, FengL,
Hollingsworth K, Hunt D, Jungbluth H, Roper H, Quinlivan R,
GosalakkalJA,Jayawant S, Nadeau A, Hughes-Carre L, Manzur A, Mercuri E,
Morgan J, Straub V,Bushby K, Sewry C, Rutherford M, Muntoni F (2011)
Muscle histology vs. MRI in Duchenne muscular dystrophy. Neurol 76 (4):346-
53.
22. Noseworthy M, Davis A, Elzibak A. Advanced MR imaging techniques for
skeletal muscle evaluation. Semin Musculoskelet Radiol. 2010; 14(2):257-268.
23. Tasca G, Iannaccone E, Monforte M, Masciullo M, Bianco F, Laschena F, et al.
Muscle MRI in Becker muscular dystrophy. Neuromuscul Disord. 2012;22
Suppl 2:S100-106.
24. Sharma, A., Sane, H., Paranjape, A., Bhagawanani, K., Gokulchandran, N., &
Badhe, P. (2014). Autologous bone marrow mononuclear cell transplantation in
Duchenne muscular dystrophy-a case report. The American journal of case
reports, 15, 128.
Stem Cell Therapy In Neurological Disorders 282

25. Serial manual muscle testing in Duchenne muscular dystrophy.Kilmer DD,

Abresch RT, Fowler WM Jr Arch Phys Med Rehabil. 1993 Nov; 74(11):1168-71.
26. The strength and functional performance of patients with Duchenne muscular
dystrophy based on natural history].Lue YJ, Jong YJ, Lin YT, Chen SSGaoxiong
Yi Xue Ke Xue Za Zhi. 1992 Nov; 8(11):597-604.
27. Sharma, A., Sane, H., Paranjape, A., Badhe, P., Gokulchandran, N., & Jacob, V.
(2013). Effect of Cellular Therapy seen on Musculoskeletal Magnetic Resonance
Imaging in a Case of Becker's Muscular Dystrophy. Journal of Case Reports,
3(2), 440-447
28. Villringer A, Dirnagl U. Coupling of brain activity and cerebral blood ow:
basis of functional neuroimaging. Cerebrovasc Brain Metab Rev. 1995
Fall;7(3):240-76
29. Aubert A, Costalat R. A model of the coupling between brain electrical activity,
metabolism, and hemodynamics: application to the interpretation of functional
neuroimaging. Neuroimage. 2002 Nov;17(3):1162-81. 30. Toma K, Nakai T.
Functional MRI in human motor control studies and clinical applications.
Magn Reson Med Sci. 2002 Jul 1;1(2):109-20
31. E. K. J. Pauwels (1998) FDG Accumulation and Tumor Biology Nuclear
Medicine and Biology Volume 25, Issue 4, May 1998, Pages 317-322.
32. S Ahmad Sarji (2006) Physiological uptake in FDG PET simulating disease.
Biomed Imaging Interv J 2006; 2(4):e59
33. 5. Siemens-CTI, Knoxville, Tenn., Imaging Life: The Magazine for Molecular
Imaging Innovation, Issue Number 02/June 2011 SNM-Edition | June 4-8, 2011
USA
34. A. Varrone, S. Asenbaum, T. Vander Borght et al., "EANM procedure
guidelines for PET brain imaging using [18F]FDG, version 2," European Journal
of Nuclear Medicine and Molecular Imaging, vol. 36, no. 12, pp. 2103-2110,
2009.
35. J. A. Thie, "Understanding the standardized uptake value, its methods, and
implications for usage," Journal of Nuclear Medicine, vol. 45, no. 9, pp. 1431-
1434, 2004.
36. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Anjana Nagrajan,
Amruta Paranjape, Pooja Kulkarni, Akshata Shetty, PritiMishra, Mrudula Kali,
Hema Biju, and Prerna Badhe: (2013) Autologous Bone Marrow Mononuclear
Cell Therapy for Autism: An Open Label Proof of Concept Study, Stem Cells
International, Volume 2013, Article ID 623875, 13 pages
Stem Cell Therapy In Neurological Disorders 283

“You can do anything if you have enthusiasm. Enthusiasm is the

yeast that makes your hopes rise to the stars. Enthusiasm is the
sparkle in the eyes, the swing in your gait, the grip of your hand, the
irresistable surge of will and energy to execute your ideas.
Enthusiasts are ghters. They have fortitude. They have staying
qualities. Enthusiasm is the bottom of all progress. With it, there is
accomplishment. Without it, there are only alibis."

– Henry Ford
Stem Cell Therapy In Neurological Disorders 284

18

Importance of Neurorehabilitation –
Concept of NRRT
Introduction
Neurorehabilitation is the clinical subspecialty that is devoted to the restoration
and maximization of functions that have been lost due to impairments caused by
injury or disease of nervous system. The goal being to make patients functionally
independent, neurorehabilitation requires a team of rehabilitation specialists such
as nurses, physical therapists, occupational therapists, speech therapists,
psychologists and others (1).
Importance of Neurorehabilitation:
Neuroplasticity is dened as brain's ability to adapt or use cellular adaptations to
learn or relearn functions which are previously lost as result of cellular death by
trauma or disease at any age. Neuronal sprouting is thought to be primary
mechanism, allowing injured neurons, to reconnect in new ways and allowing
intact undamaged neurons to form new connection and enhance function. Motor
learning will continue throughout life as long as environment asks for change and
CNS has pliability and desire to learn. The rehabilitation team promotes this
learning and facilitates neural plasticity (2). The philosophic foundation of
rehabilitation team is to promote purposeful activity thereby preventing
dysfunction and eliciting maximum adaptation. These goal-oriented activities are
meant to be culturally meaningful and important to the needs of patient and their
families. Activities include daily life and work skills, exercise, recreation and crafts.
Stem Cell Therapy In Neurological Disorders 285

Exercise tasks in animal models; have shown that specically skilled type of
exercises lead to increased angiogenesis in damaged cortical areas whereas
unskilled activities did not show this positive change. It is believed that in humans
too rehabilitation techniques would enhance neuroplastic changes.
Various studies have suggested that regular physical activity and exercise leads to
neoangiogenesis [1], anti-inammatory effect on the local [2] as well as global
systemic environment [3], anti apoptotic effects [3,4] and effects modulating the
immune system [4,5]. But the most important advantage of exercises is the
mobilization of the local stem cells for repair and regeneration of the tissue [6].
Exercise also secretes various growth factors that stimulate the resident stem cells to
grow into the tissue cells. It is therefore of utmost importance that stem cell therapy
should be followed by the rigorous rehabilitation (3).
Concept of Neuro Regenerative Rehabilitation Therapy (NRRT):
The concept of Neuro Regenerative Rehabilitation Therapy (NRRT) at NeuroGen
promotes a multidisciplinary and holistic approach to bring about recovery of
neural function with a close integration of Neuro regenerative (including stem cell
therapy), Neuro protective (medications) and neurorehabilitative therapies
(physical / occupational / speech). Thus, it combines the best neurobiological
repair technologies and neurorestorative techniques. The rehabilitation protocol is
then individualized to the specic requirements of each patient emphasizing on
functional recovery and independence in ADL.
Studies have shown that exercise enhances the effect of injected stem cells by
inducing mobility in the injected stem cells, by activation and proliferation of the
local stem cells, muscle angiogenesis and release of cytokines and nerve growth
factors, thereby enhancing the achievable outcomes. Hence, neurorehabilitation
appears to work complimentarily with stem cells therapy (3,4).
Multidisciplinary rehabilitation in Various Neurological Conditions
1. Autism
Autism is one of the most common conditions which remain undiagnosed until late
into the developmental or formative years of a child. Diagnosing a child with
autism becomes very difcult as they do not display any obvious physical problems
and hence they require multiple evaluators like developmental pediatrician, child
psychiatrist, clinical psychologist, speech and language pathologist, etc.
Management and treatment for a child with autism would call for a multi-
disciplinary holistic approach.
• Psychological Intervention: A clinical psychologist/ child psychologist plays
an important role as they may look at what effect a behavior has on the child and
Stem Cell Therapy In Neurological Disorders 286

may introduce a behavior management plan accordingly.

• Applied Behaviour Analysis: An ABA analyst may use different strategies of
ABA like discrete trial teaching, pivotal response therapy, etc to reduce the
maladaptive behaviours and increase the appropriate ones.
• Occupational Therapy: This therapy focuses on teaching activities of daily
living (ADL) like eating, bathing, grooming, etc and more specically sensory/
motor integration training, would work on optimizing sensory processes and
training for developing gross and ne motor skills.
• Speech Therapy: The speech therapist works with the child and his/her family
to facilitate effective communication among them such that it benets the
overall development of the child. The therapist would conduct oro-motor
exercises, deep breathing exercises or may teach the child to communicate
through Picture Exchange Communication System (PECS).
• Physiotherapy: A Physiotherapist can help in optimal development of motor
skills and addressing any underlying weakness in both sensory and muscular
systems in children with autism.
• Aquatic therapy: An aquatic therapist makes use of properties of water and
hydrodynamic principles to address the motor and sensory problems observed
in these children. Aquatic therapy helps to reduce hyperactivity, improve
attention and concentration, improved sleep patterns, improved tone and
improved strength of the muscles.
There are many more effective therapies for children with autism like art therapy,
play therapy, special education, dance therapy, aquatic therapy, etc
2. Spinal cord Injury
Regardless of the level of the lesion, the goal of rehabilitation for patients with SCI,
include the following:
• Prevention of all secondary complications as a result of being bed ridden.
• Restoration of functional independence to the maximum possible.
• Psychological counseling
• Social and Vocational Rehabilitation
• Family Education and Home adaptation (5)
1. Education:
Patient and caregiver education plays an integral part of rehabilitation. This
includes preventive skin care, bladder-bowel training, and safe ways to perform
Stem Cell Therapy In Neurological Disorders 287

ADL tasks, nutritional guidelines, thermoregulation precautions, pulmonary

management, cardiopulmonary resuscitation, equipment management and
maintenance, transfer techniques, wheelchair mobility and transfer techniques,
and leisure skills.
2. Home programs to increase strength, endurance, ROM and function are taught.
Components of an exercise program include exibility, muscular strength and
cardiovascular endurance.
Frequency ranges from 2-5 times per week with atleast 1 day of rest between
strengthening sessions. Duration of an exercise program could be as little as 20
minutes or as much as 90- 120 minutes.
Intensity should range between 40% and 85% of maximal heart rate or within 13 -15
on Borg Rate of Perceived Exertion Scale.
Injuries can be prevented or slowed if clients perform a proper warm up with
stretching/exibility exercises, wear protective equipment (i.e helmet and padded
gloves), and get proper rest between exercises sessions.
3. Preventing and Managing Pressure Ulcers and Skin compromise:
- Turning the positions at regular intervals, every 2-3 hrs.
- Pillows and rectangular foam pads to cover bony prominence should be used.
- Treatment like hydrotherapy, electromodalities and thermomodalities to
increase circulation can be given.
- Surgical intervention with skin aps or muscle aps can be used to close the
wound if not healed.
- Patient should be educated to maintain skin integrity.
4. Prevention and Management of Joint Contracture:
- Daily ROM exercises and proper positioning will prevent contractures.
- Use of splints for proper joint alignment techniques like wt bearing, ADLS and
functional exercises prevents contracture.
- Splinting to prevent Joint Deformity:
- Education regarding splint wearing schedule, skin checks and splint care
should be emphasized. (6).
5. Sexual Issues:
- Altered sexual function result in impairment of erection, ejaculation, orgasm,
male fertility and vaginal lubrication.
Stem Cell Therapy In Neurological Disorders 288

- Formal sexual counseling and education programs like group sessions to

addresses general issues and individual sexual function evaluations should be
addressed in areas of sexual dysfunction, alternative behaviours, precautions
and other related areas.
- Coordinated effort between client, signicant other, psychologist and urologist
can help with treatment of sexual dysfunction.
- Options like surgical implantation of a penile prosthesis, vacuum erection
devices, intracorporeal injection therapy and use of lubricants can be used to
treat sexual dysfunction (7).
Psychological Aspect in Spinal Cord Injury
Spinal Cord Injury (SCI) leaves a major impression on the person's body and mind.
A person who had been leading an independent satisfying life becomes
immobilized, bowel and bladder incontinence, loss of sexual functioning and
becomes dependent on others for every small necessity. The patient not only faces
loss of body control but also experience changes in self worth, sense of
independence, condence, attractiveness, sexuality, and relationship with family
and friends.
There are various stages that one goes through post spinal cord injury: 1) shock and
denial 2) grieving followed by depression or vice versa 3) anxiety / frustration 4)
anger /aggression 5) trying to adapt to the situation.
Psychological treatment of SCI often includes group psychotherapy, which is an
excellent method to both maximize patient learning and efciently use therapist
time.
Patient groups can provide emotional support, peer role models; teach new coping
skills, and decrease social discomfort. Likewise, multiple-family group
psychotherapy is a powerful and effective tool for facilitating family adjustment to
SCI. Family members experience similar emotional responses to the patient and
similarly benet from psychological intervention.
Role of Aquatic therapy is Spinal Cord injury
Aquatic therapy uses physical properties of water and hydrodynamic principles to
facilitate movement and muscle contraction. In spinal cord injury it provides great
advantage as it negates the effect of gravity and therefore the patients can
experience higher degree of freedom of movement. Aquatic therapy helps to reduce
spasticity, improve strength, improve standing and walking balance and promotes
faster progression of Ambulation in Spinal Cord Injury.
3. Cerebral palsy:
Stem Cell Therapy In Neurological Disorders 289

Aims of Rehabilitation:
a. Improve performance components (postural management and hand functions)
e.g. improve accuracy when reaching for a toy.
b. Enhance performance of functional activities (performance areas), e.g. eating a
wafer biscuit independently.
c. Support the overall motor program through complementing therapy aims
using the appropriate selection of equipment solutions, e.g. apply active
seating principles to selection of toilet seat and transfer/facilitation techniques.
d. Minimize restriction on participation and social role function.
e. Increase self-esteem and self - actualization.
f. Promote positive interactions and relationships.
Principles of Treatment:
1. Repetition and reinforcement are essential for learning and establishing of
modied motor pattern.
2. Maximize sensory motor experiences.
3. Adequate consideration for developmental training and facilitation of
purposeful activities: Therapist incorporates the principles of the neuro-
developmental concept
Integrated approach for CP:
1. Developing rapport with parents and patients:
2. Normalising tone of muscles
3. Stretching and Mobilty
4. Developing Postural Reaction: Postural reactions consist of righting reactions,
protective extension and equilibrium reactions. These reactions are best
developed by various exercises on vestibular ball and tilt board.
5. Sensory integration Therapy:
This therapy helps to overcome problems experienced by many young children in
absorbing and processing sensory information. Encouraging these abilities
ultimately improves balance and steady movement. Therapies include stimulating
touch sensations and pressures on different parts of the body. This therapy can also
motivate children to learn sequences of movements.
6. Oromotor control training (depends on good head control):
Stem Cell Therapy In Neurological Disorders 290

Common oromotor problems are drooling, problems in sucking, swallowing,

inadequate tongue movements and speech. Hence, therapy consists of good neck
control, use of brush to decrease drooling and speech therapy.
Psychotherapy
Mental Retardation: Because cerebral palsy and mental retardation can exist at the
same time in an individual, they can contribute to emotional stresses as well.
Learning disabilities may be present, depending on the area of the brain that was
damaged (8).
Behavioral Problems seen in Cerebral Palsy: Behavioral problems and cerebral
palsy usually correlate, depending on the degree of mental retardation. The child
may have behavioral problems or emotional issues that in turn, may affect
psychological development and their ability to have social interaction (9).
1. Frustration:
2. Communication difculties:
3. Attention Decit Disorder:
Treatment: Education and vocational preparation come into the foreground by
school age. Neuro-cognitive therapy: A new approach to treating cerebral palsy
from Snowdrop. It is based upon two proven principles. (1) Neural Plasticity. (2)
Learning can lead to development.
Counseling and behaviour therapy, for emotional and psychological challenges
may be needed at any age, but is often most critical during adolescence. Behaviour
therapy is often used to increase a child's ability and discourage destructive
behaviors. Aversion therapy i.e. to reward rather than punish on negative
consequences can help enhance self-esteem. Expressive therapies are usually used
with people who have difculty verbalizing their feelings such as art, music, poetry,
etc which could help freeing and empowering oneself.
Role of Aquatic therapy is Cerebral Palsy
Cerebral palsy is primarily a movement disorder. Children with CP develop
abnormal movement patterns due to cortical damage, spasticity, dystonia, muscle
weakness and inability to ght the effect of gravity. Water provides them a unique
environment to explore, experience and retrain the movement patterns. Aquatic
therapy uses the hydrodynamic principles of water and physical properties of
water to achieve these goals. Aquatic therapy can reduce spasticity, improve
voluntary control, improve breathing, improve oromotor control, improve posture,
improve strength of the muscles and facilitate faster ambulation.
4. Muscular Dystrophy:
Stem Cell Therapy In Neurological Disorders 291

In Muscular Dystrophy patients, due to lack of mature dystrophin, the muscle

membrane is very fragile, so some forms of exercises are more likely to cause muscle
bre damage by breaking the muscle membrane integrity, especially activities
involving high load eccentric exercise.
Eg: lot of running, walking on stairs etc.
Conversely, concentric activities where muscle bre shorten when they re, stress
on muscles is reduced signicantly and are thus advised.
Eg: water exercises, where gravity is eliminated. (10)
Aims of Physical Rehabilitation
1. Maintain / Improve muscle strength.
2. Prevent Deformity from Contractures.
3. Maintain Function and Mobility for as long as possible.
4. Prevent Respiratory Complications.
5. Prevent Pressure sores.
Aims of Functional Rehabilitation
1. Self-Care activities such as
i) Eating
ii) Grooming
iii) Bathing
iv) Dressing
2. Mobility training:
Transfers in and out of bed/ chairs/ car transfers etc.
Use of aquatic therapy is also advised as many experts agree that water exercises
and swimming help to tone and strengthen muscles and joints without putting
stress on those parts of the body that are already weakened or weakening. Hot baths
during hydrotherapy sessions also help to keep tendon and joints loose and exible,
thereby avoiding contractures.
Role of Aquatic therapy in Muscular Dystrophy
MD is a neuromuscular disorder with progressive muscle weakness due to
contractile damage to the exoskeleton of myocytes. Therefore day to day activities
can also damage the muscle cells. There are different types of muscles contractions,
out of which, eccentric contraction is the most detrimental to the muscles. Patients
with muscular dystrophy need to use these harmful contractions several times a
day to ght the gravity and maintain upright posture. In water because of increased
buoyancy and reduced gravity these contractions are reduced, which means the
Stem Cell Therapy In Neurological Disorders 292

same movement on land causes more harm to the muscles than in water. Therefore
aquatic therapy can provide greater benets to these patients, immersion in water is
responsible for secreting neuroprotective and anti-inammatory cytokines which
help to maintain the muscle strength further. Aquatic therapy can improve strength
of the muscles, provides higher degree of freedom of movement, helps to reduce
contractures and brosis, promotes sitting and standing balance, facilitates
ambulation even after they are unable to walk on land, improves respiratory muscle
strength and cardiovascular endurance.
5. Stroke:
Specic Measures for Stroke:
Rehabilitation approaches for stroke patients include Neuro-developmental
Treatment (NDT), Movement Therapy in Hemiplegia. - Brunnstorm Approach,
Proprioceptive Neuromuscular Facilitation (PNF) and Sensory stimulation
techniques. Currently, there is increased emphasis on functional/task specic
training using intense practice on functional tasks along with behavioral shaping
and environmental enrichment e.g. Constraint-induced movement therapy (CIMT)
for paretic UE or locomotor training using body weight support and treadmill
training (BWSTT). Compensatory training strategies are also used to restore
resumption of function using the less involved extremities. These are indicated for
patients who demonstrate severe motor impairment and limited recovery. Early
emphasis on improving functional independence provides an important source of
motivation for patient and family.
Thus the strategies used are as follows:
1. Strategies to improve Sensory function:
Sensory stimulation is important for recovery by focusing on restoring sensitivity of
more affected extremities, with sufcient intensity to engage the system.
2. Strategies to improve Motor Function:
i) Strategies to improve Flexibility and Joint Integrity
ii) Strategies to improve Strength
iii) Strategies to manage Spasticity
iv) Strategies to improve Initial Movement Control
v) Strategies to improve Motor Learning
vi) Strategies to improve Postural Control and Functional Mobility
vii) Strategies to improve Upper Extremity Function
viii) Strategies to improve Lower Extremity Function
ix) Strategies to improve Balance
x) Strategies to improve Locomotion
Stem Cell Therapy In Neurological Disorders 293

3. Strategies to improve Aerobic Function

Endurance training has shown to yield signicant improvements in physical
tness, functional status, psychological outlook and self-esteem.
4. Strategies to Improve Feeding and Swallowing:
Positioning of head, Oral exercises, Food preparation and verbal cues helps to
improve feeding and swallowing.
Psychological Rehabilitation:
The psychological reaction to having a stroke can cause feelings of frustration,
anxiety, apathy, anger or depression. Depression can seriously hinder an
individual's willingness and ability to participate in rehabilitation. Social isolation,
or lack of access to social contact or resources, can be a consequence of difculties in
cognitive and emotional functions that inuence interpersonal relationships,
changes in social roles, communication difculties, and challenges in
transportation and employment. Social stigma and marginalization also contribute
to isolation.
Attention training helped people with acquired brain injury and seemed to work
best with younger patients less than a year after injury. Visuo-spatial training
helped stroke patients with visuo-spatial neglect, the inability to respond or orient
to something shown on the side opposite to the site of the injury. Visuo-spatial
training also tended to improve performance in other cognitive domains .Family
counseling is a major factor for psychological rehabilitation in stroke.
Role of Aquatic therapy in Stroke
Aquatic therapy helps to reduce tone, improve posture, improve voluntary control,
retrain movement to break synergy patterns in stroke. It is a tool for faster recovery
of the patients. Immersion in water also releases certain neurotrophic factors and
anti-inammatory cytokines that can help aid the neural recovery.
6. Motor neuron disease:
Specic Measures for MND:
The efcacy of therapeutic interventions is related to:
1. Timing of interventions,
2. Motivation and persistence of patient in carrying out the program.
3. Support from family members.
Rehabilitation intervention plan depends on the following:
1. The rate of progression of the disease.
Stem Cell Therapy In Neurological Disorders 294

2. Presence of spasticity, bulbar involvement, respiratory involvement causing

hypoxia and fatigue.
3. Phase of Disease. Exercises are to be prescribed according to level of
impairment, functional limitation and level of disability (11).
Phase I (Independent)
Stage 1: In case of mild weakness advice is to continue normal activities. In case of
clumsiness, stretching exercises like Yoga. In case of ambulatory patients, gentle
resisted exercises without fatigue.
Stage 2: In case of moderate selective weakness, stretching exercises to avoid
contractures.

Figure 1: Exercises to improve grip strength Figure2: Gait Training

Figure 3: Over head activity while Figure 4: Standing on standing board with
standing with walker. bilateral push knee splints and high boots
Stem Cell Therapy In Neurological Disorders 295

Figure 5: Quadruped for trunk balance Figure 6: Strengthening of scapular muscles

Figure 7: Strengthening of back extensors Figure 8: Strengthening of lower abdominals

Figure 9: Strengthening of neck muscles Figure 10: Strengthening of upper abdominals

Stem Cell Therapy In Neurological Disorders 296

Figure 11: Stretching of dorso lumbar fascia Figure 12: Trunk Strengthening act.

In case of difculty in ADLs like climbing, overhead activities and difculty in

buttoning etc, strengthening exercises should be prescribed avoiding fatigue. In
case of difculty in ambulation, orthotic devices like AFO, hand splints should be
considered.
Stage 3: In case of fatigability in long distance ambulation, deep breathing exercises
should be added.
In case of non-ambulatory cases, consider wheelchair; standard or motorized.
Phase 2 - (Partially Independent)
Stage 4: In case of pain and edema in hand and feet, consider modalities like
massage, elevation and active exercises. In case of severe weakness in extremities,
caution is to be taken to support the joints while doing rotations. In case of
fatigability in ADLS, encourage isometric exercises to the level of tolerance and to
consider slings or arm support, motorized chairs etc.
Stage 5: In case of severe lower extremity weakness, teach family members proper
techniques of transfer and positioning of patients limbs and modications at home.
Phase 3 (Dependent)
Stage 6: In case of totally bedridden patients with dysphagia, consider suction, soft
diet, tube feeding, PEG feeding etc.
In case of severe breathing difculty, frequent clearing of airways, tracheostomy
and respiratory support if needed.
Studies with other neuromuscular diseases (NMD) such as poliomyelitis,
Duchene's muscular dystrophy, myotonic dystrophy, hereditary motor and
sensory neuropathy, spinal muscular atrophy and limb-girdle, Becker and
fascioscapulohumeral dystrophy have found that exercises programs are benecial
and do not produce overuse weakness.
Stem Cell Therapy In Neurological Disorders 297

Role of Aquatic therapy in Motor Neuron Disease

Aquatic therapy benets the patients of Motor neuron disease in multiple ways. It
provides higher degree of freedom of movement. It helps to reduce spasticity,
improves posture, improves balance, improves voluntary control and improves
respiratory as well as cardiovascular endurance.
Process of neurorehabilitation is to reintegrate the patient in community. Therefore,
the most important aim of the neurorehabilitation is to facilitate maximum
neurological recovery and functional independence. However, some of the other
important aspects of neurorehabilitation are to prevent secondary complications,
deformity prevention and crisis management. The process of neurorehabilitation
educates the patient about the prognosis of the condition, makes them aware of the
possible complications and helps them to manage the complications in the most
effective way. Neurorehabilitation process also includes compassionate therapies
and palliative care provided at the terminal stages of the progressive disease.
Rehabilitation process is essential after stem cell therapy to exploit maximum
benets of stem cell therapy.
REFERENCES
1. Zorowitz R.D. Textbook of neural repair and rehabilitation.Vol 2. Cambridge
University Press; 2006.32, The organization of neurorehabilitation services: the
rehabilitation team and the economics of neurorehabilitation; p.515-26.
2. Wang X, Zhang M, Feng R, Li WB, Ren SQ, Zhang J, Zhang F. Physical exercise
training and neurovascular unit in ischemic stroke. Neuroscience. 2014 Jun
20;271:99-107.
3. Markert CD, Ambrosio F, Call JA, et al. Exercise and duchenne muscular
dystrophy: Toward evidence-based exercise prescription. Muscle & nerve. 2011
Apr 1;43(4):464-78.
4. Wahl P, Brixius K, Bloch W. Exercise-induced stem cell activation and its
implication for cardiovascular and skeletal muscle regeneration. Minimally
Invasive Therapy & Allied Technologies. 2008 Jan 1;17(2):91-9.
5. Anonymous. Spinal Cord Injuries. Rehabilitation Council of India. Available
from www.rehabcouncil.nic.in/writereaddata/spinal.pdf/; Accessed on 27
February, 2015.
6. Peranich L, Reynolds KB, O'Brien S, Bosch J, Cranll T. The roles of
occupational therapy, physical therapy, and speech/language pathology in
primary care. The journal for nurse practitioners. 2010 Jan 31;6(1):36-43.
7. Benevento BT, Sipski ML. Neurogenic bladder, neurogenic bowel, and sexual
dysfunction in people with spinal cord injury. Physical Therapy. 2002 Jun
Stem Cell Therapy In Neurological Disorders 298

1;82(6):601-12.
8. Krigger KW. Cerebral palsy: an overview. Am Fam Physician. 2006 Jan
1;73(1):91-100.
9. Wallander JL, Varni JW. Effects of pediatric chronic physical disorders on child
and family adjustment. Journal of child psychology and psychiatry.
1998;39(01):29-46.
10. Jansen M, de Groot IJ, van Alfen N, Geurts AC. Physical training in boys with
Duchenne Muscular Dystrophy: the protocol of the No Use is Disuse study.
BMC pediatrics. 2010 Aug 6;10(1):1.
11. Oliveira AS, Pereira RD. Amyotrophic lateral sclerosis (ALS): three letters that
change the people's life. For ever. Arquivos de neuro-psiquiatria. 2009
Sep;67(3A):750-82.
Stem Cell Therapy In Neurological Disorders 299

Every error is an opportunity to learn, just don't commit the same

mistake again. That is stupidity. But commit as many new mistakes
as you are capable of. Don't be afraid, because its the only way
nature allows you to learn."

–Albert Einstein
Stem Cell Therapy In Neurological Disorders 300

19

Complications

Cell replacement therapy is an exciting research area and it offers potential

treatment for several developmental, traumatic and degenerative neurological
diseases for which there is currently no cure. The eld was rst brought alive by
blooming of the differentiation potential of the embryonic stem cells (McDonald et
al). A lot was expected from this research and very intensive work has gone behind
elucidating the pathways of neuronal development and differentiation. But, like
any therapeutic modality, cellular therapy is also associated with some minor and
major complications. The occurrence of these complications depends upon the type
of cells used and the route of administration. Therefore, we describe the
complications as cell related adverse events and procedure related adverse events.
Cell related adverse events:
Cell related adverse events depend on the type of cell, potency of cell, source or
origin of cell, cultured or uncultured and cell processing. Here we describe the most
studied stem cell types.
i) Embryonic and Fetal Stem Cells
ii) Adult Stem Cells
iii) Umbilical Cord Stem Cells
iv) Induced Pluripotent Stem Cells
Below are the major cell related adverse events reported with different cell types. It
is important to note that not all the complications are associated with all cell types.
There are some adverse events like teratomas which have been reported only with
the use of embryonic and fetal stem cells.
Stem Cell Therapy In Neurological Disorders 301

(1) Tumorogenecity/ Teratomas

Embryonic and Fetal Stem Cells
Apart from ethical problems related to human embryonic stem cell derivations,
nude mice experiments for various disorders, including brain injury, brought out
the problem of teratoma formation after embryonic stem cell transplantation. To
achieve human embryonic stem (ES) cell-based transplantation therapies,
allogeneic transplantation models of nonhuman primates have been useful. A
model based on cynomolgus ES cells genetically marked with the green uorescent
protein has been described by researchers from Jichi Medical Centre, Japan.
Primates provide a close mammalian representation to the humans. The cells were
transplanted into the allogeneic fetus because the fetus is supposed to be
immunologically premature and does not induce immune responses to
transplanted cells. In addition, fetal tissue compartments are rapidly expanding,
presumably providing space for engraftment. However, the researchers found that
3 months after transplantation, a uorescent teratoma, which was obviously
derived from transplanted ES cells, was found in the fetus. Hence, it was
understood that, though the transplanted cynomolgus ES cells can engraft in
allogenic fetuses, the cells may, however, form a tumor if they "leak" into an
improper space (1).
In 2007, Amariglio et al reported the rst case of a human brain tumor complication
in human fetal neural stem cell therapy (2). Their ndings suggest that fetal
neuronal stem/progenitor cells may be involved in formation of gliomas. This
provides the rst example of a donor-derived brain tumor. Further work is urgently
required to assess the safety of fetal stem cell therapies.
Hence, it has been established in many mammalian models that although ES cells
may provide treatment for degenerative disease in the future, their unlimited self
renewal and high differentiation potential poses the risk of tumor induction after
engraftment.
Thus, a lot of caution and diligent research will be required before using various
human ES cell lines for cell transplantation as a therapeutic option for patients with
degenerative disease. In the literature review.
Ablating the immune cell niche with immunosuppressive drugs to prevent
immune rejection following allogenic transplantation, has the potential to create a
tumorigenic microenvironment. A recent paper demonstrated tumor formation
from the donated cells following transplantation of donor derived fetal neural
tissue into an ataxia telangiectasia patient [3].
So far, we have not come across any reported complication, such as
tumorogenecity, for treatment of neurological diseases using autologous adult
stem cells.
(2) Seizures
Seizure is one of the possible adverse events of stem cell therapy. This side effect can
Stem Cell Therapy In Neurological Disorders 302

be seen with any type of stem cell transplantation. Earlier bone marrow
transplantation in children with leukemia has exhibited epilepsy as an adverse
event post transplantation [1]. A case series of autologous BMMNCs
transplantation in stroke also reported one patient who developed seizures post
transplantation [5]. Seizure is considered to be an adverse event in case of
development of new seizures post transplantation and increase in the intensity or
frequency of pre-existing seizures. In our experience we observed that children
with neurological disorders like cerebral palsy and autism developed seizures as an
adverse event post autologous BMMNCs transplantation [6].
Seizures could be hypothesized to arise post transplantation due to increased
production of Brain derived Neurotrophic factor (BDNF), Vascular endothelial
growth factor (VEGF) and Nerve growth factor (NGF) by BMMNCs. However the
exact mechanism remains unknown [7-9]. Also these disorders present with
seizures as a co-morbidity [10,11]. The percentage of children that developed
seizures as an adverse event was very small (Table 1). However, this adverse event
is preventable by using an antiepileptic prophylactic regimen (Table 1). After the
use of antiepileptic prophylactic regimen (Table 1) the percentage of seizures as an
adverse event reduced signicantly.

Table 1. Incidence of Seizures as an adverse event of cell therapy and

its prevention by anti-epileptic prophylactic regimen

Published data
We analyzed the incidence of seizures as an adverse event in 131 children (Mean age
9 years) with incurable neurological diseases, treated with autologous bone
marrow mononuclear cell (BMMNCs) intrathecal transplantation. Seizures
occurred as an adverse event in 8 (6.10%) of the children. There was correlation
between the electroencephalograph (EEG) examination and the occurrence of
seizures with seven children showing a pre-existing epileptogenic. The history of
seizures was not so strongly correlates ad only four children had history of seizures
and 3 children did not have any history of seizures. Seizures was considered as an
adverse event in an event of new onset of the seizures or increased intensity or
Stem Cell Therapy In Neurological Disorders 303

frequency of preexisting seizures.

A prophylactic antiepileptic regimen was designed based on these ndings and 67
patients were analyzed for the incidence of seizures. The antiepileptic regimen was
implemented based on following factors, EEG examination ndings, the history of
seizures and the current medical treatment for the seizures. The antiepileptic
regimen in given in detail in Table 2.

Table 2: Prophylactic antiepileptic regimen

Out of the 67 patients only 2 patients showed seizures as an adverse event after
implementation of the antiepileptic regimen. The percentage of patients with
seizures was therefore reduced signicantly from 6% to 2.98%. Both these patients
showed increase in the frequency and severity of the pre-existing seizures.
Therefore, the percentage of new onset seizures reduced to 0% from 2.29%.
(3) Immunogenicity:
Stem Cell Therapy In Neurological Disorders 304

a) Autologous:
Autologous adult stem cells, which are not modied or cultured, have not been
associated with any cell related adverse events. Also, there is minimal risk of
immunological reactions.
b) Allogenic:
These may be associated with immunological reactions [12,13]. When allogenic
stem cells are used there is a risk of stem cell-tissue rejection which may be partially
overcome by donor-patient matching, by immunological sequestration or using
immune suppressants, all of which have their own drawbacks [14]. Use of
histocompatibility leukocyte antigen (HLA) matching of the donor to the recipient
to prevent immune rejection is often not readily achievable [14]. Immune
suppression may put the patient at risk of infection. The risk of donor-to-recipient
transmission of bacterial, viral, fungal or prion pathogens may lead to life-
threatening and even fatal reactions. Disease transmission has been reported after
allograft transplantation [15,16].
Hence, as of date, autologous adult stem cells appear to be a relatively safe and
reasonably efcacious option for therapeutic use in neurological disorders.
Procedure related adverse events:
Procedure related adverse events depend on the route of administration of stem
cells. Here are some minor adverse events related to intrathecal administration, as
our team is most experienced with this route of administration.
(1) Local Infection either at the bone marrow aspiration site or the CSF injection site
or a more severe meningitis is always a possibility after stem cell implantation.
However, at the NeuroGen Brain and Spine Institute where over 400 stem cell
implants have been done there has not been any case of local or meningeal infection.
None of the other papers reviewed have reported any very serious infection leading
to any morbidly or mortality.
(2) Spinal Headache: This is a frequent post treatment symptom which occurs in
almost one fourth of all patients (low pressure post spinal headache). Once it comes
on, this headache is very severe, but is self limiting and resolves in 3 days. The
headache is worse on sitting up. The methods to prevent this are making the
patients lie in bed (preferably, head low position) for at least a day after the
implantation, drinking lots of uid, the application of a lumbosacral belt (to act as a
binder to raise the intracranial pressure) and the use of analgesics. It is our
observation that by keeping the lumbar dressing at the lumbar puncture site on for
about 5-6 days the incidence of the spinal headache is reduced.
(3) Giddiness, vomiting and neck pain are some other occasionally occurring
Stem Cell Therapy In Neurological Disorders 305

adverse events. But these are usually always self limiting and respond to medical
management and rest. Similarly, other surgical methods, such as intraspinous,
intracerebral, intrarterial and intravenous injections have possibilities of side
effects or complications, specic to the respective procedures. It is beyond the
scope of this book to describe the adverse events associated with all other types of
stem cells, though umbilical cord stem cells may be associated with immunological
reactions and infections. Induced Pluripotent Stem Cells (IPSCs) have not reached
clinical applications due to associated complications of genomic instability, viral
vector infections and mutagenesis.
Unpublished data for regarding adverse events associated with Autologous bone
marrow mononuclear cells
We analyzes 1001 patients oven an average follow up period of 18 months. All the
patients were diagnosed with an incurable neurological disorder and underwent,
autologous BMMNCs intrathecal transplantation followed by rigorous
rehabilitation. Figure 1 shows the percentage of minor and major adverse effects
noted after transplantation.

Figure 1. Percentage of adverse events observed post transplantation

Minor adverse events:

Fever was noted in 0.90% of the patients which resolved during the hospital stay by
administration of antipyretic medication.
Stem Cell Therapy In Neurological Disorders 306

Spinal headache was observed in 8.39% of the patients during hospitalization.

Patients with mild headache were advised to lay at in supine position for as long as
possible and to increase the oral uid intake to 4 to 5 liters. In patients where the
pain did not resolve or the patients who had severe headache or the patients who
had headache along with nausea or vomiting or patients who had poor command
following and cognition, I.V uids were given. It was noted that the spinal subsided
within 72 hours of administration of I.V uids.
Nausea was observed in 2. 4% and vomiting was observed in 7.09% patients and
subsided within 48 hours of administration of antiemetic medication.
Diarrhea was observed in 3.10% of the patients which resolved with antidiarrheal
medical management.
Pain at the site of injection was noted in 3% of the patients. Pain at the site of
aspiration was noted in 0.7%. Analgesic medication was given to all the patients
prophylactically immediately after the procedure. Dosage of the same was altered
in case pain persisted.
Transient increase in hyperactivity was noted in 0.8% which subsided with
rehabilitative therapies without any medical intervention during the hospital stay.
Minor allergic reactions were noted in 1% of the patients and presented as mild
generalized itching and localized rashes which resolved with antiallergic medical
management
Major adverse events:
None of the patients exhibited major adverse events like persistent increase in
hyperactivity till six months , neurological decits, nerve root damage, parasthesia
in lower limb, loss of sensation in lower limb, loss of motor function in the lower
limbs, hematoma at the site of injection, hematoma at the site of aspiration, bleeding
at the site of injection or aspiration, local infection at the site of injection or
aspiration, meningismus or meningitis, brain infection, bowel or bladder
incontinence, respiratory distress, cardiac failure, major allergic reaction and
tumors.
Seizures as an adverse event, was noted in 2.34% of the patients. All of these patients
had either history of seizures or abnormal EEG. Another cell transplantation related
adverse event was persistent increase in hyperactivity over 6 months post
transplantation which was noted in 0.30% of the patients which subsided upon
rehabilitative management with occupational therapy in combination with medical
management.

Literature Review:
Stem Cell Therapy In Neurological Disorders 307

7 studies [16-23] were published including a total of 175 patients with ataxia that
were treated with stem cell therapy. In one single case report in 2007, Amariglio et al
reported the rst case of a human brain tumor complication in human fetal neural
stem cell therapy [24]. Their ndings suggest that fetal neuronal stem/progenitor
cells may be involved in formation of gliomas. This provides the rst example of a
donor-derived brain tumor. Further work is urgently required to assess the safety of
fetal stem cell therapies. One study [25] reported minor adverse effects with 4
patients developing dizziness, 2 patients developing back pain and 1 patient
developing headache all of which were self-limiting and resolved within 3 days.
16 studies [16-39] have been published (160 patients) that studied efcacy and
safety of stem cell therapy in patients diagnosed with autism. Headache, nausea,
vomiting, pain at injection site and pain at aspiration site were the encountered
minor procedure related adverse events which resolved within a week in a study
[24]. In another study involving 23 patients, 12 events of allergic reaction
manifested as urticaria and/or cough were related to the procedure with 2
requiring an additional dose of IV Benadryl.
In the 5 studies [40-44], involving 220 patients with cerebral palsy, two studies
[41,43] reported vomiting and headaches, in the participants, which were self-
limiting.
28 studies including 426 patients with MD were published [45-75]. A study
involving 12 DMD patients, reported transient soreness in injected muscles which
self-resolved in 3-4 days. 1 patient developed cellulitis which was treated with
antibiotics and drainage [37]. In another study including 10 DMD patients, fever
and cough in 1 patient, diarrhea, nausea, vomiting and abdominal pain in another,
hirsutism in 1, and perioral rash in 1 patient were reported [38]. Mild graft versus
host disease was reported in another study [42]. Minor procedure related events
including nausea, headache and backache was reported in a study [45] and; pain at
aspiration site, pain at the injection site, fatigue, pain in upper and lower limbs, neck
pain which were self-limiting and resolved in a week, were reported in another
study [50].
Park and his colleagues, investigated on the role of autologous bone marrow cell
transplantation (BMC) for six complete spinal cord injury (SCI) patients. During six
to eighteen months follow up, fever and myalgia were noted [76]. No other
complications were reported. Samuil et al 2003, injected stem cells from fetal
nervous and hemopoietic tissues in 15 patients. During 1 month to 6 years, no
serious complications were noted [77]. Olfactory mucosa autografts were injected
into seven SCI patients, and noticed decrease in the sensory in one patient
suggestive of difculty in locating lesion. Moreover, transient pain was notice in
patients, and was relieved by medication [78].
Stem Cell Therapy In Neurological Disorders 308

Four studies used autologous BMC for 195 SCI patients and found no adverse
effects in all the patients during follow-up [79-82]. Moreover, autologous
mesenchymal stem cells were transplanted into 10 SCI patients. No adverse effects
were noted during the long-term follow-up [8].
Adipose tissue-derived mesenchymal stem cells were administered intravenously
in 8 patients with SCI and showed no severe adverse events during the three-month
follow-up [9]. Hematopoietic stem cells (HSCs) and progenitor cells (PCs) were
administered in 202 cases of SCI patients, and have shown no adverse events [83].
Thirty-nine patients with complete cervical and thoracic SCI were injected with
autogenous peripheral blood stem cells. During the two and half year follow-up no
complications were reported [84].
Six patients with SCI were selected for the grafting autologous activated Schwann
cells, and during follow-up of ve years no complications were noted [85]. Saberi
and his team investigated on intramedullary Schwann cell transplantation on 356
patients with SCI, and during 2 years of follow-up found no infection, or worsening
or tumor formation [86].
Transplantation of peripheral nerve tissue were grafted into 12 SCI patients. During
2-year follow-up patients were noted with certain complications which includes 1
case of transient increased spasm, one case of transient cystitis, 3 patients with
transient increased neuropathic pain and 1 case with transient episode of
autonomic dysreexia. Moreover, no donor site infections were observed. The
authors, support that the above complications were transient as they responded to
temporary medical treatment [87].
Olfactory unsheathing cells, were transplanted into 108 patients with complete
chronic SCI patients. During the follow-up of 3 years, none of the patients had
complication involving neoplasm, bleeding, swelling, cysts, neural tissue
destruction or infection (abscess) or any other pathological changes in or around
OEC transplant sites [88]. Autologous bone marrow cells were injected into 4
patients with SCI. During 1 year of follow-up, no adverse events were recorded in
patients [89]. Moreover, Bone marrow (BM) mesenchymal stromal cells (MSC) were
injected into 30 patients, with complete SCI patients. During 1 year of follow-up,
none of the patients have reported any adverse events associated with BM MSC
transplantation [17]. Further, autologous bone marrow stem cell was injected in 20
patients with transversal spinal cord injury (SCI). No adverse events were noted
[90-94].
REFERENCES:
1. Antonini G, Ceschin V, Morino S, Fiorelli M, Gragnani F, Mengarelli A, Iori
AP,Arcese W. Early neurologic complications following allogeneic bone
marrow transplant for leukemia: a prospective study. Neurology 1998,
Stem Cell Therapy In Neurological Disorders 309

50(Suppl 5):1441- 1445.

2. Amariglio N, Hirshberg A, Scheithauer BW, Cohen Y, Loewenthal R,
Trakhtenbrot L, Paz N, Koren-Michowitz M, Waldman D, Leider-Trejo L, et al.:
Donor-derived brain tumor following neural stem cell transplantation in an
ataxia telangiectasia patient.PLoS Medicine 2009, 6:0221-0231.
3. Amariglio N, Hirshberg A, Scheithauer BW, Cohen Y, Loewenthal R,
Trakhtenbrot L, Paz N, Koren-Michowitz M, Waldman D, Leider-Trejo L,
Toren A. Donor-derived brain tumor following neural stem cell transplantation
in an ataxia telangiectasia patient. PLoS medicine. 2009 Feb 17;6(2): e1000029.
4. Moniche F, Gonzalez A, Gonzalez-Marcos JR, Carmona M, Piñero
P,EspigadoI,Garcia-Solis D, Cayuela A, Montaner J, Boada C, Rosell A, Jimenez
MD,MayolA,Gil-Peralta A. Intra-arterial bone mzarrow mononuclear cells in
ischemic stroke: a pilot clinical trial. Stroke 2012, 43(Suppl 8):2242-2244.
5. Sharma A, Gokulchandran N, Sane H, Nagrajan A, Paranjape A, Kulkarni P,
Shetty A, Mishra P, Kali M, Biju H, Badhe P. Autologous bone marrow
mononuclear cell therapy for autism: an open label proof of concept study.
Stem Cells Int 2013,2013:623875.
6. Sharma A, Gokulchandran N, Sane H, Nagrajan A, Paranjape A, Kulkarni P,
Shetty A, Mishra P, Kali M, Biju H, Badhe P. Autologous bone marrow
mononuclear cell therapy for autism: an open label proof of concept study.
Stem Cells Int 2013,2013:623875.
7. Simonato M, Tongiorgi E, Kokaia M. Angels and demons: neurotrophic factors
and epilepsy. Trends Pharmacol Sci 2006, 27(Suppl 12):631- 8.
8. Bregola G, Frigati L, Zucchini S, Simonato M. Different patterns of induction of
broblast growth factor-2 and brain-derived neurotrophic factor messenger
RNAs during kindling epileptogenesis, and development of a herpes simplex
vector for broblast growth factor-2 gene transfer in vivo. Epilepsia 2000,
41(Suppl 6): S122-S126.
9. Viscid EW, Triche EW, Pescosolido MF, McLean RL, Joseph RM, Spence SJ,
Morrow EM. Clinical characteristics of children with autism spectrum disorder
and co-occurring epilepsy. PLoS On. 2013, 8(Suppl 7): e67797.
10. Knezevi-Pogancev M. [Cerebral palsy and epilepsy]. Med Pregl. 2010 Jul-
Aug;63(7-8):527-30. Review.
11. Viscidi EW, Triche EW, Pescosolido MF, McLean RL, Joseph RM, Spence
SJ,Morrow EM. Clinical characteristics of children with autism spectrum
disorder and co-occurring epilepsy. PLoS One. 2013 Jul 4;8(7): e67797
Stem Cell Therapy In Neurological Disorders 310

12. Tremblay JP, Malouin F, Roy R, Huard J, Bouchard JP, Satoh A, Richards CL.
Results of a triple blind clinical study of myoblast transplantations without
immunosuppressive treatment in young boys with Duchenne muscular
dystrophy. Cell transplantation. 1993 Mar 1;2(2):99-112.
13. Zhang C, Chen W, Xiao LL, Tan EX, Luo SK, Zheng D, Ye X, Li Z, Lu XL, Liu Y.
Allogeneic umbilical cord blood stem cell transplantation in Duchenne
muscular dystrophy. Zhonghua Yi Xue Za Zhi. 2005 Mar;85(8):522-5.
14. Schwartz PH. The potential of stem cell therapies for neurological diseases.
Expert review of neurotherapeutics. 2006 Feb 1;6(2):153-61.
15. Kainer MA, Linden JV, Whaley DN, Holmes HT, Jarvis WR, Jernigan DB,
Archibald LK. Clostridium infections associated with musculoskeletal-tissue
allografts. New England Journal of Medicine. 2004 Jun 17;350(25):2564-71.
16. Mendell JR, Kissel JT, Amato AA, King W, Signore L, Prior TW, Sahenk Z,
Benson S, McAndrew PE, Rice R, Nagaraja H. Myoblast transfer in the
treatment of Duchenne's muscular dystrophy. New England Journal of
Medicine. 1995 Sep 28;333(13):832-8.
17. Jin JL, Liu Z, Lu ZJ, Guan DN, Wang C, Chen ZB, Zhang J, Zhang WY, Wu JY, Xu
Y. Safety and efcacy of umbilical cord mesenchymal stem cell therapy in
hereditary spinocerebellar ataxia. Current neurovascular research. 2013 Feb
1;10(1):11-20.
18. Shroff G. A novel approach of human embryonic stem cells therapy in
treatment of Friedreich's ataxia. International Journal of Case Reports and
Images (IJCRI). 2015 Apr 4;6(5):261-6.
19. Amariglio N, Hirshberg A, Scheithauer BW, Cohen Y, Loewenthal R,
Trakhtenbrot L, Paz N, Koren-Michowitz M, Waldman D, Leider-Trejo L,
Toren A. Donor-derived brain tumor following neural stem cell transplantation
in an ataxia telangiectasia patient. PLoS medicine. 2009 Feb 17;6(2): e1000029.
20. Dongmei H, Jing L, Mei X, Ling Z, Hongmin Y, Zhidong W, Li D, Zikuan G,
Hengxiang W. Clinical analysis of the treatment of spinocerebellar ataxia and
multiple system atrophy-cerebellar type with umbilical cord mesenchymal
stromal cells. Cytotherapy. 2011 Sep 1;13(8):913-7.
21. Yang WZ, Zhang Y, Wu F, Zhang M, Cho SC, Li CZ, Li SH, Shu GJ, Sheng YX,
Zhao N, Tang Y. Human umbilical cord blood-derived mononuclear cell
transplantation: case series of 30 subjects with hereditary ataxia. Journal of
translational medicine. 2011 Dec;9(1):65.
22. Sharma A, Paranjape A, D'sa M, Badhe P. cellular transplantation may
modulate disease progression in spino-cerebellar ataxia–a case report. Indian
Stem Cell Therapy In Neurological Disorders 311

Journal of Medical Research and Pharmaceutical Sciences. 2014;1(3).

23. Miao X, Wu X, Shi W. Umbilical cord mesenchymal stem cells in neurological
disorders: a clinical study.
24. Sharma A, Gokulchandran N, Sane H, Nagrajan A, Paranjape A, Kulkarni P,
Shetty A, Mishra P, Kali M, Biju H, Badhe P. Autologous bone marrow
mononuclear cell therapy for autism: an open label proof of concept study.
Stem cells international. 2013;2013.
25. Lv YT, Zhang Y, Liu M, Ashwood P, Cho SC, Huan Y, Ge RC, Chen XW, Wang
ZJ, Kim BJ, Hu X. Transplantation of human cord blood mononuclear cells and
umbilical cord-derived mesenchymal stem cells in autism. Journal of
translational medicine. 2013 Dec;11(1):196.
26. Bradstreet JJ, Sych N, Antonucci N, Klunnik M, Ivankova O, Matyashchuk I,
Demchuk M, Siniscalco D. Efcacy of fetal stem cell transplantation in autism
spectrum disorders: an open-labeled pilot study. Cell transplantation. 2014
Jan;23(1_suppl):105-12.
27. Sharma A, Badhe P, Gokulchandran N, Kulkarni P, Mishra P, Shetty A, Sane H.
An improved case of autism as revealed by PET CT scan in patient transplanted
with autologous bone marrow derived mononuclear cells. J Stem Cell Res Ther.
2013 May;3(139):2.
28. Sharma A, Gokulchandran N, Shetty A, Sane H, Kulkarni P, Badhe P.
Autologous bone marrow mononuclear cells may be explored as a novel
potential therapeutic option for autism. J Clin Case Rep. 2013 May;3(282):2.
29. Sharma A, Gokulchandran N, Sane H, Kulkarni P, Thomas N, Paranjape A,
Badhe P. Intrathecal autologous bone marrow mononuclear cell
transplantation in a case of adult autism. Autism. 2013 Sep;3(2):113.
30. Sharma A, Gokulchandran N, Sane H, Bhovad P, Biju H, Shetty A, Kali M,
Badhe P. Cell therapy effects portrayed on positron emission tomography of
the brain serve as a new dimension for autism. Journal of Pediatric Neurology.
2014 Jan 1;12(3):151-6.
31. Sharma A, Gokulchandran N, Shetty A, Kulkarni P, Sane H, Badhe P.
Neuropsychiatric Disorder Tackled by Innovative Cell Therapy-A Case Report
in Autism. J Stem Cell Res Transplant. 2014 Aug;1(1):4.
32. Sharma A, Chopra G, Gokulchandran N, Lohia M, Kulkarni P. Autologous
Bone Marrow-derived Mononuclear Transplantation in Rett Syndrome. Asian
Journal of Paediatric Practice. 2011;15(1).
33. Sharma A, Gokulchandran N, Sane H, Patil A, Shetty A, Biju H, Kulkarni P,
Stem Cell Therapy In Neurological Disorders 312

Badhe P. Amelioration of autism by autologous bone marrow mononuclear

cells and neurorehabilitation: a case report. American Journal of Medical Case
Reports. 2015;3(10):304-9.
34. Sharma A, Sane H, Gokulchandran N, Badhe P, Patil A, Kulkarni P, Paranjape
A. PET-CT scan shows decreased severity of autism after autologous cellular
therapy: a case report. Autism Open Access. 2016;6(2).
35. Sharma A, Gokulchandran N, Sane H, Kulkarni P, Pai S. A Case of Autism
Showing Clinical Improvements after Cellular Therapy along with PET CT
Evidence. J Stem Cell Res Ther. 2017;2(4):00070.
36. Kalburgi AS, Sharma PK, Badhe SN. Improvements in a Case of Autism
Spectrum Disorder after Cell Therapy As Noted On PET CT Brain Scan.
37. Alok Sharma, Nandini Gokulchandran, Hemangi Sane, Pooja Kulkarni, Sarita
Kalburgi, Ridhima, Sharma, Prerna Badhe, Samson Nivins. PET CT Scan Brain
as a Monitoring Tool To Study The Effects of Autologous Bone Marrow
Mononuclear Cell Transplantation in Autism Spectrum Disorder. International
Journal of Current Advanced Research. Sep 2017.
38. Dawson G, Sun JM, Davlantis KS, Murias M, Franz L, Troy J, Simmons R,
Sabatos DeVito M, Durham R, Kurtzberg J. Autologous cord blood infusions
are safe and feasible in young children with autism spectrum disorder: Results
of a single center phase I open label trial. Stem cells translational medicine.
2017 May 1;6(5):1332-9.
39. Bansal H, Verma P, Agrawal A, Leon J, Sundell IB, Koka PS. A Short Study
Report on Bone Marrow Aspirate Concentrate Cell Therapy in Ten South Asian
Indian Patients with Autism. Journal of stem cells. 2016 Jan 1;11(1):25.
40. Nguyen LT, Nguyen AT, Vu CD, Ngo DV, Bui AV. Outcomes of autologous
bone marrow mononuclear cells for cerebral palsy: an open label uncontrolled
clinical trial. BMC pediatrics. 2017 Dec;17(1):104.
41. Chahine NH, Wehbe TW, Hilal RA, Zoghbi VV, Melki AE, Habib EB. Treatment
of cerebral palsy with stem cells: a report of 17 cases. International journal of
stem cells. 2016 May;9(1):90.
42. Rah WJ, Lee YH, Moon JH, Jun HJ, Kang HR, Koh H, Eom HJ, Lee JY, Lee YJ,
Kim JY, Choi YY. Neuroregenerative potential of intravenous G-CSF and
autologous peripheral blood stem cells in children with cerebral palsy: a
randomized, double-blind, cross-over study. Journal of translational medicine.
2017 Dec;15(1):16.
43. Liu X, Fu X, Dai G, Wang X, Zhang Z, Cheng H, Zheng P, An Y. Comparative
analysis of curative effect of bone marrow mesenchymal stem cell and bone
Stem Cell Therapy In Neurological Disorders 313

marrow mononuclear cell transplantation for spastic cerebral palsy. Journal of

translational medicine. 2017 Dec;15(1):48.
44. Sharma A, Sane H, Kalburgi S, Kulkarni P, Bhagwanani K, Gokulchandr N.
Autologous Bone Marrow Mononuclear Cell Transplantation with
Neurorehabilitation for Cerebral Palsy. Journal of Stem Cell and
Transplantation Biology. 2017;2(01).
45. Law P, Bertorini T, Goodwin T, Chen M, Fang Q, Li HJ, Kirby D, Florendo JA,
Herrod H, Golden G. Dystrophin production induced by myoblast transfer
therapy in Duchenne muscular dystrophy. The Lancet. 1990 Jul
14;336(8707):114-5.
46. Law PK, Goodwin TG, Fang Q, Chen M, Li HJ, Florendo JA, Dana S, Kirby BS.
Myoblast transfer therapy for Duchenne muscular dystrophy. Pediatrics
International. 1991 Apr;33(2):206-15.
47. Huard J, Bouchard JP, Roy R, Malouin F, Dansereau G, Labrecque C, Albert N,
Richards CL, Lemieux B, Tremblay J1. Human myoblast transplantation:
preliminary results of 4 cases. Muscle & Nerve: Ofcial Journal of the American
Association of Electrodiagnostic Medicine. 1992 May;15(5):550-60.
48. Law PK, Goodwin TG, Fang Q, Duggirala V, Larkin C, Florendo J, Kirby DS,
Deering MB, Li HJ, Chen M, Yoo TJ. Feasibility, safety, and efcacy of myoblast
transfer therapy on Duchenne muscular dystrophy boys. Cell transplantation.
1992 Jan 1;1(2-3):235-44.
49. Gussoni E, Pavlath GK, Lanctot AM, Sharma KR, Miller RG, Steinman L, Blau
HM. Normal dystrophin transcripts detected in Duchenne muscular dystrophy
patients after myoblast transplantation. Nature. 1992 Apr;356(6368):435.
50. Karpati G, Ajdukovic D, Arnold D, Gledhill RB, Guttmann R, Holland P, Koch
PA, Shoubridge E, Spence D, Vanasse M, Watters GV. Myoblast transfer in
Duchenne muscular dystrophy. Annals of neurology. 1993 Jul 1;34(1):8-17.
51. Tremblay JP, Malouin F, Roy R, Huard J, Bouchard JP, Satoh A, Richards CL.
Results of a triple blind clinical study of myoblast transplantations without
immunosuppressive treatment in young boys with Duchenne muscular
dystrophy. Cell transplantation. 1993 Mar 1;2(2):99-112.
52. Morandi L, Bernasconi P, Gebbia M, Mora M, Crosti F, Mantegazza R, Cornelio
F. Lack of mRNA and dystrophin expression in DMD patients three months
after myoblast transfer. Neuromuscular Disorders. 1995 Jul 1;5(4):291-5.
53. Mendell JR, Kissel JT, Amato AA, King W, Signore L, Prior TW, Sahenk Z,
Benson S, McAndrew PE, Rice R, Nagaraja H. Myoblast transfer in the
treatment of Duchenne's muscular dystrophy. New England Journal of
Stem Cell Therapy In Neurological Disorders 314

Medicine. 1995 Sep 28;333(13):832-8.

54. Miller RG, Sharma KR, Pavlath G, Gussoni E, Mynhier M, Yu P, Lanctot AM,
Greco CM, Steinman L, Blau HM. Myoblast implantation in Duchenne
muscular dystrophy: the San Francisco study. Muscle & Nerve: Ofcial Journal
of the American Association of Electrodiagnostic Medicine. 1997 Apr;20(4):469-
78.
55. Neumeyer AM, Cross D, McKenna-Yasek D, Zawadzka A, Hoffman EP,
Pegoraro E, Hunter RG, Munsat TL, Brown RH. Pilot study of myoblast transfer
in the treatment of Becker muscular dystrophy. Neurology. 1998 Aug
1;51(2):589-92.
56. Skuk D, Roy B, Goulet M, Chapdelaine P, Bouchard JP, Roy R, Dugré FJ,
Lachance JG, Deschênes L, Senay H, Sylvain M. Dystrophin expression in
myobers of Duchenne muscular dystrophy patients following intramuscular
injections of normal myogenic cells. Molecular Therapy. 2004 Mar 1;9(3):475-82.
57. Torrente Y, Belicchi M, Marchesi C, D'antona G, Cogiamanian F, Pisati F,
Gavina M, Giordano R, Tonlorenzi R, Fagiolari G, Lamperti C. Autologous
transplantation of muscle-derived CD133+ stem cells in Duchenne muscle
patients. Cell transplantation. 2007 Jun 1;16(6):563-77.
58. Zhang C, Chen W, Xiao LL, Tan EX, Luo SK, Zheng D, Ye X, Li Z, Lu XL, Liu Y.
Allogeneic umbilical cord blood stem cell transplantation in Duchenne
muscular dystrophy. Zhonghua Yi Xue Za Zhi. 2005 Mar;85(8):522-5.
59. Skuk D, Goulet M, Roy B, Piette V, Coˆté CH, Chapdelaine P, Hogrel JY, Paradis
M, Bouchard JP, Sylvain M, Lachance JG. First test of a “high-density injection”
protocol for myogenic cell transplantation throughout large volumes of
muscles in a Duchenne muscular dystrophy patient: eighteen months follow-
up. Neuromuscular Disorders. 2007 Jan 1;17(1):38-46.
60. Sharma A, Gokulchandran N, Chopra G, Kulkarni P, Lohia M, Badhe P, Jacob
VC. Administration of autologous bone marrow-derived mononuclear cells in
children with incurable neurological disorders and injury is safe and improves
their quality of life. Cell transplantation. 2012 Jan;21(1_suppl):79-90.
61. Sharma A, Sane H, Badhe P, Gokulchandran N, Kulkarni P, Lohiya M, Biju H,
Jacob VC. A clinical study shows safety and efcacy of autologous bone
marrow mononuclear cell therapy to improve quality of life in muscular
dystrophy patients. Cell transplantation. 2013 Jan;22(1_suppl):127-38.
62. Sharma A, Kulkarni P, Chopra G, Gokulchandran N, Lohia M, Badhe P.
Autologous Bone Marrow-derived Mononuclear Cell Transplantation in
Duchenne Muscular Dystrophy.
Stem Cell Therapy In Neurological Disorders 315

63. Sharma A, Paranjape A, Sane H, Bhagawanani K, Gokulchandran N, Badhe P.

Cellular transplantation alters the disease progression in Becker's muscular
dystrophy. Case reports in transplantation. 2013;2013.
64. Sharma A, Sane H, Paranjape A, Badhe P, Gokulchandran N, Jacob V. Effect of
cellular therapy seen on musculoskeletal magnetic resonance imaging in a case
of Becker's muscular dystrophy. Journal of Case Reports. 2013 Dec 5;3(2):440-7.
65. Sharma A, Sane H, Paranjape A, Bhagawanani K, Gokulchandran N, Badhe P.
Autologous bone marrow mononuclear cell transplantation in Duchenne
muscular dystrophy–a case report. The American journal of case reports.
2014;15:128.
66. Sharma A, Sane H, Gokulchandran N, Gandhi S, Bhovad P, Khopkar D,
Paranjape A, Bhagwanani K, Badhe P. The role of cell transplantation in
modifying the course of limb girdle muscular dystrophy: a longitudinal 5-year
study. Degenerative Neurological and Neuromuscular Disease. 2015 Sep 14;
5:93-102.
67. Sharma A, Sane H, Gokulchandra N, Sharan R, Paranjape A, Kulkarni P, Yadav
J, Badhe P. Effect of cellular therapy in progression of Becker's muscular
dystrophy: a case study. European journal of translational myology. 2016 Feb
23;26(1).
68. Sharma A, Sane H, Kaur J, Gokulchandran N, Paranjape A, Yadav J, Badhe P.
Autologous bone marrow mononuclear cell transplantation improves function
in a case of Becker's muscular dystrophy. American Based Research Journal.
2016;5(2):1-2.
69. Sharma A, Badhe P, Sane H, Pai S, Kulkarni P, Bhagwanani K, et al. Halting Of
Functional Decline In A Case Of Duchenne Muscular Dystrophy After
Cellular Therapy. International Journal of Recent Advances in
Multidiscipilinary Research. 2018;5(3).
70. Sharma A, Gokulchandran N, Sane H, Lakhanpal V, Kulakarni P. Stabilization
Of Disease Progression In A Case Of Duchenne Muscular Dystrophy With
Cellular Transplantation. Stem Cell Adv Res Ther. 2017;2017:J112.
71. Alok S, Hemangi S, Pooja K, Dhara M, Jasbinder K, Nandini G, Khushboo B,
Prerna B. Effect of autologous bone marrow mononuclear cell transplantation
coupled with rehabilitation in limb girdle muscular dystrophy–A case report.
Health Sciences. 2016 Jan 1;5(12):1-7.
72. Sharma A, Paranjape A, Varghese R, Sane H, Gokulchandran N, Kaur J, Badhe
P. Functional Improvements and Musculoskeletal Magnetic Resonance
Imaging with Spectroscopy Changes following Cell Therapy in a Case of Limb
Stem Cell Therapy In Neurological Disorders 316

Girdle Muscular Dystrophy.

73. Sharma A, Sane H, Gokulchandran N, Pai S, Kulkarni P, Ganwir V,
Maheshwari M, Sharma R, Raichur M, Nivins S, Badhe P. An open-label proof-
of- concept study of intrathecal autologous bone marrow mononuclear cell
transplantation in intellectual disability. Stem cell research therapy. 2018
Dec;9(1):19.
74. Sharma A, Gokulchandran N, Sane H, Pai S, Kulkarni P, et al. Cognitive
Changes after Cellular Therapy in a Case of Intellectual Disability. J Transplant
Stem Cel Biol. 2017;4(1): 4.
75. Sharma A, Sane H, Pooja K, Akshya N, Nandini G, Akshata S. (2015) Cellular
Therapy, a Novel Treatment Option for Intellectual Disability: A Case Report. J
Clin Case Rep 5:483.
76. Park HC, Shim YS, Ha Y, Yoon SH, Park SR, Choi BH, Park HS. Treatment of
complete spinal cord injury patients by autologous bone marrow cell
transplantation and administration of granulocyte-macrophage colony
stimulating factor. Tissue Engineering. 2005 May 1;11(5-6):913-22.
77. Rabinovich SS, Seledtsov VI, Poveschenko OV, Senuykov VV, Taraban VY,
Yarochno VI, Kolosov NG, Savchenko SA, Kozlov VA. Transplantation
treatment of spinal cord injury patients. Biomedicine & pharmacotherapy. 2003
Nov 1;57(9):428-33.
78. Lima C, Pratas-Vital J, Escada P, Hasse-Ferreira A, Capucho C, Peduzzi JD.
Olfactory mucosa autografts in human spinal cord injury: a pilot clinical study.
The journal of spinal cord medicine. 2006 Jan 1;29(3):191-203.
79. Yoon SH, Shim YS, Park YH, Chung JK, Nam JH, Kim MO, Park HC, Park SR,
Min BH, Kim EY, Choi BH. Complete spinal cord injury treatment using
autologous bone marrow cell transplantation and bone marrow stimulation
with granulocyte macrophage colony stimulating factor: phase I/II clinical
trial. Stem cells. 2007 Aug 1;25(8):2066-73.
80. Geffner LF, Santacruz P, Izurieta M, Flor L, Maldonado B, Auad AH,
Montenegro X, Gonzalez R, Silva F. Administration of autologous bone
marrow stem cells into spinal cord injury patients via multiple routes is safe
and improves their quality of life: comprehensive case studies. Cell
transplantation. 2008 Dec 1;17(12):1277-93.
81. Deda H, Inci MC, Kürekçi AE, Kayıhan K, Özgün E, Üstünsoy G, Kocabay S.
Treatment of chronic spinal cord injured patients with autologous bone
marrow-derived hematopoietic stem cell transplantation: 1-year follow-up.
Cytotherapy. 2008 Jan 1;10(6):565-74.
Stem Cell Therapy In Neurological Disorders 317

82. Ravikumar R, Narayanan S, Baskar S, Abraham S. Autologous stem cell

injection for spinal cord injury-a clinical study from India. Journal of Stem Cells
and Regenerative Medicine. 2007 Jan 1;3(1):24-5.
83. Park JH, Kim DY, Sung IY, Choi GH, Jeon MH, Kim KK, Jeon SR. Long-term
results of spinal cord injury therapy using mesenchymal stem cells derived
from bone marrow in humans. Neurosurgery. 2011 Nov 29;70(5):1238-47.
84. Ra JC, Shin IS, Kim SH, Kang SK, Kang BC, Lee HY, Kim YJ, Jo JY, Yoon EJ, Choi
HJ, Kwon E. Safety of intravenous infusion of human adipose tissue-derived
mesenchymal stem cells in animals and humans. Stem cells and development.
2011 Feb 8;20(8):1297-308.
85. Bryukhovetskiy AS, Bryukhovetskiy IS. Effectiveness of repeated
transplantations of hematopoietic stem cells in spinal cord injury. World
journal of transplantation. 2015 Sep 24;5(3):110.
86. Cristante AF, Barros-Filho TE, Tatsui N, Mendrone A, Caldas JG, Camargo A,
Alexandre A, Teixeira WG, Oliveira RP, Marcon RM. Stem cells in the treatment
of chronic spinal cord injury: evaluation of somatosensitive evoked potentials
in 39 patients. Spinal Cord. 2009 Oct;47(10):733.
87. Zhou XH, Ning GZ, Feng SQ, Kong XH, Chen JT, Zheng YF, Ban DX, Liu T, Li H,
Wang P. Transplantation of autologous activated Schwann cells in the
treatment of spinal cord injury: six cases, more than ve years of follow-up. Cell
transplantation. 2012 Jan;21(1_suppl):39-47.
88. Saberi H, Firouzi M, Habibi Z, Moshayedi P, Aghayan HR, Arjmand B,
Hosseini K, Razavi HE, Yekaninejad MS. Safety of intramedullary Schwann cell
transplantation for postrehabilitation spinal cord injuries: 2-year follow-up of
33 cases. Journal of Neurosurgery: Spine. 2011 Nov;15(5):515-25.
89. Derakhshanrad N, Saberi H, Shaee S, Yekaninejad MS, Hadian MR,
Sheikhrezai A, Khan ZH, Javidan AN, Kohan AH. Safety of Intramedullary
Autologous Peripheral Nerve Grafts for Post-Rehabilitated Complete Motor
Spinal Cord Injuries: A Phase I Study. Acta Medica Iranica. 2013 Dec
1;51(12):842.
90. Huang H, Xi H, Chen L, Zhang F, Liu Y. Long-term outcome of olfactory
ensheathing cell therapy for patients with complete chronic spinal cord injury.
Cell transplantation. 2012 Jan;21(1_suppl):23-31.
91. Attar A, Ayten M, Ozdemir M, Ozgencil E, Bozkurt M, Kaptanoglu E, Beksac M,
Kanpolat Y. An attempt to treat patients who have injured spinal cords with
intralesional implantation of concentrated autologous bone marrow cells.
Cytotherapy. 2011 Jan 1;13(1):54-60.
Stem Cell Therapy In Neurological Disorders 318

92. Pal R, Venkataramana NK, Bansal A, Balaraju S, Jan M, Chandra R, Dixit A,

Rauthan A, Murgod U, Totey S. Ex vivo-expanded autologous bone marrow-
derived mesenchymal stromal cells in human spinal cord injury/paraplegia: a
pilot clinical study. Cytotherapy. 2009 Jan 1;11(7):897-911.
93. Syková E, Homola A, Mazanec R, Lachmann H, Langkramer Konrádová Š,
Kobylka P, Pádr R, Neuwirth J, Komrska V, Vávra V, Štulík J. Autologous bone
marrow transplantation in patients with subacute and chronic spinal cord
injury. Cell transplantation. 2006 Aug 1;15(8-9):675-87.
94. Jarocha D, Milczarek O, Wedrychowicz A, Kwiatkowski S, Majka M.
Continuous improvement after multiple mesenchymal stem cell
transplantations in a patient with complete spinal cord injury. Cell
transplantation. 2015 Apr;24(4):661-72.
Stem Cell Therapy In Neurological Disorders 319

“Stem cell research, with appropriate oversight, should be directed

by scientists, not politicians."

– Dr. E Thomas,
Winner of the Nobel prize in Medicine, 1990
Stem Cell Therapy In Neurological Disorders 320

20

Regulations of Stem Cell Therapy

Regenerative medicine is a rapidly evolving eld of medicine, possibly the most

promising and most challenging to regulate. There has been a colossal increase in
the information regarding regenerative medicine in the past decade. Stem cell
science has moved from laboratory to clinic with published evidence, exploring
possible treatment and cure of numerous incurable diseases. Unlike
pharmacological science the science of stem cell therapy is very complex due to
availability of multiple types of cells, multiple routes of administration and
multiple possibilities for dosage and unlimited combinations of these. This is what
makes it very challenging to regulate on the basis of current evidence based medical
system. If the same regulations as that of drugs are used for cellular therapy and
cellular products it will be another decade before we can use cellular therapy as a
treatment modality. Therefore various regulatory medical bodies have felt an
urgent need to monitor and regulate the research in the eld of stem cell therapy. An
overview of the regulatoryprocedures in the global players shows that these vary
from nonexistent to extremelystiing. Both ends of the spectrum are not conducive
for the healthy progress of thishighly promising area and we feel there needs to be a
discussion so that a middleground can be reached.
Global trends in the regulation of stem cell therapy
Majority of the countries have very cautious and skeptical approach towards
regulating stem cell therapy and have very stringent regulations but there are some
countries like Japan, Korea and USA that have quiet progressive approach of
regulating stem cell therapy. Some of the other countries like Australia, Canada,
Stem Cell Therapy In Neurological Disorders 321

European countries have strict regulations but have provisions for clinical usefor
terminally ill patients suffering from incurable diseases to protect patients’ rights
for using unproven treatments. However, the regulations in India are restrictive
without any provision for clinical use even for terminally ill patients suffering from
incurable diseases.
Permissive regulations in other countries
Korea [5]
Korean guidelines make a clear distinction between the levels of manipulation of
the cells very clear. The guidelines state, ‘Cell therapy product" means a medicinal
product manufactured through physical, chemical, and/or biological
manipulation, such as in vitro culture of autologous, allogeneic, or xenogeneic cells.
However, this denition does not apply to the case where a medical doctor
performs minimal manipulation which does not cause safety problems of
autologous or allogeneic cells in the course of surgical operation or treatment at a
medical center (simple separation, washing, freezing, thawing, and other
manipulations, while maintaining biological properties).’
Regulations should be more permissive for cells that are autologous, of adult origin
and minimally manipulated than the cells that are allogenic, of embryonic origin or
are signicantly manipulated.
Korean Food and Drug Association (FKDA) Regulation on review and
authorization of biological products, Article 41not onlyexcludes the minimally
manipulated cells from the denition of cell therapy product, but has a fast track
review process for the use of cell therapy in life threatening, serious diseases and
conditions for which treatment is not possible with existing therapy [5].
The article 41 states, “(Fast Track Review Process) For the following medicinal
products, the Commissioner of the KFDA may allow post-marketing submission of
some documents required under this Regulation or apply the fast track review
process. Medicinal products that may have therapeutic effects against AIDS,
cancers, or other life-threatening or serious diseases. 2. Medicinal products of which
fast introduction is deemed necessary because treatment is not possible with
existing therapies (due to development of resistance or other reasons) 3. Medicinal
products that may have preventive or therapeutic effects against bioterror diseases
and other pandemic infections.”
The Korean setup is much more permissive for stem cell research. The government
allows and funds work on human embryonic stem cells. The Bioethics and Safety
act lays down the legal boundaries for permissible area for stem cell research. The
early guidelines made by the Ethics Committee of the Stem Cell Research Center in
2003 permitted the use of only spare embryos for hES cell line derivation. They
Stem Cell Therapy In Neurological Disorders 322

prohibited cloning, inter-species transplantation of reproductive cells that might

lead to chimeras, production of embryos for research purposes, and somatic cell
nuclear transfer to prevent attempts to engage in reproductive cloning. A further
advanced version of the Bioethics and Safety Act enacted in January 2004, and
enforced since 2005 as a penal law identies criminal offenses pertaining to stem cell
research. It prohibits human reproductive cloning. The transfer of embryos
between two different species, embryo production other than for the purpose of
pregnancy and also disallows research on spare embryos that have the
embryological primitive streaks appearing in their developmental process. It only
allows research on spare embryos for research aimed at curing rare or incurable
diseases. The though on surface it appears prohibitive, but in practicality provides a
legal platform to allow legitimate researchers to conduct research on human
embryonic stem cells, including somatic cell nuclear transfer for the purpose of
conducting research aimed at curing currently incurable diseases., if they adhere to
the procedures laid down by the act.
In 2006, Dr. Hwang Woo-suk scandal, raised not only ethical issues regarding
procurement of the eggs, but also questions regarding scientic ethics & falsifying
results brought disrepute to the stem cell " hub" which was to be lead by him. This
also, lead to enactments of stricter rules regarding embryo donor for research,
which came in the form of Bioethics and safety act 2008. Nevertheless, South Korea
continues to pursue research for the purposes of therapeutic cloning, with complete
nancial and legal backing from the government [6].
The Korean guidelines have taken into consideration the need for different
regulations for minimally manipulated cells and the need for more efcient
pathways for the approval of the same. Other regulatory bodies need to keep these
two important points in consideration whilst framing their regulations.
Japan [7,8,9]
Evolution of regulatory framework in Japan
Till 2014 Japan had no statutory body for regulating regenerative medicine
separately. All the drugs and regenerative medicine products were regulated under
same regulations. In 2014 Japanese Health authorities realized the need for separate
regulations for regenerative medicine and implemented the changes in their
current regulatory system. Japanese Diet passed ‘Regenerative medicine
promotion act’ which made it necessary to amend existing laws to promote growth
and safe implementation of generative medicine. In view of this Pharmaceuticals
Affairs Law (PAL) was amended Pharmaceuticals and Medical Devices Act (PMD
Act). This amendment made a provision for separate regulation of regenerative
medicine products by companies and set standards and regulatory criteria for the
manufacturing and sell of the same. It was very progressive of Japanese regulatory
Stem Cell Therapy In Neurological Disorders 323

evolution to recognize difference between drugs and regenerative medicine as well

as difference between regenerative medicine product and therapies for treatment of
diseases. While PMD Act regulated the products, Act on Safety of Regenerative
Medicine (ASRM) was designed to promote safe regenerative medicine
therapies.ASRM safeguarded the patients from unsafe cellular therapies.
In these two laws they have made a clear distinction between the companies that
make stem cell products, institutes that offer medical services and medical research.
The laws introduce the concept of conditional marketing for medical products,
separate approval systems based on the risk stratication for the medical services,
presumed efcacy of the treatments and post hoc efcacy analysis.
Highlights of the Japanese regulations
(A) Regulations for the product
(B) Regulations for the medical services and research (stem cell services)
(A) Regulations for the product:
Pharmaceuticals, Medical Devices, and Other Therapeutic Products Act (PMD
Act)
The partial amendment in this law created a separate approval channel for the cell
based therapies and products. This amendment recommended that the cell based
products may not need to use the phased clinical trials to establish efcacy for
marketing approval. The provision was made for a conditional approval for the
marketing of these products once the safety and presumed efcacy was established.
Investigators could demonstrate efcacy in pilot studies of as few as 10 patients in
one study if the change was dramatic enough or a few hundred when the
improvement was marginal. At the provisional approval stage the treatment could
be approved for commercial use as well as national insurance coverage.
(B) Regulations for the medical services and research (stem cell services): (Figure 1)
Act on safety of regenerative medicine (ASRM)
While PMD act regulated the products, ASRM regulated the therapies to make sure
the safety of the treatments provided and to ensure that the efcacy was established
in the due course. Regenerative medicine treatments were categorized as
regenerative medicine I (High risk), Regenerative medicine II (Medium risk) and
Regenerative medicine III (Low risk) (Figure 1). Each of these classes had a separate
approval channel and different approval procedure.
Low risk regenerative medicine therapies (Class III):
The approval process is by a committee within the institute and by submitting the
provisional plans to the department of health and welfare.
Stem Cell Therapy In Neurological Disorders 324

The institutional committee is called as, “Certied Committee for Regenerative

Medicine” includes experts in the regenerative medicine technologies as well as
legal experts and is approved by the ministry of health, labor and welfare.
Medium risk regenerative medicine therapies (Class II):
The approval process is by a committee outside of the institute and by submitting
the provisional plans to the department of health, labour and welfare.
The institutional committee is called as, “Certied Special Committee for
Regenerative Medicine” approved by the ministry of health, labor and welfare;
which includes experts in the regenerative medicine technologies as well as legal
experts with capabilities for specialized investigation and objectivity.
The Japanese guidelines have made a provision for a middle level regulatory body
for faster approval process. This committee has an authority to conditionally
approve the treatment and marketing using the cell based products; but the
provisional plans are required to be submitted to department of health, Labour and
welfare. Once the conditional approval is granted the institute must conduct.
High risk regenerative medicine therapies (Class I):
The approval is through the “Certied Special Committee for Regenerative
Medicine” which is from outside of the institute as that in Class II but the Ministry of
health, labor and welfare (MHLW) will impose a certain period of restricted
implementation.

Figure 1: Categorization of regenerative medicine

Stem Cell Therapy In Neurological Disorders 325

*Diagram available online at h p://www.mhlw.go.jp/english/policy/health-

medical/medical-care/dl/150407-01.pdf

During this period the MHLW will conrm the safety by hearing opinions of the
Health Science Council. The Ministry can order change of the plan if there is
nonconformity to the standards of safety and the institute will have to adhere to
these changes for the conditional market approval.
Thus the Japanese government has been very permissive in promoting the
regenerative medicine. The classications that are made are based on the safety of
the cell products and not the efcacy. The approval is granted with proven safety
and presumed efcacy, imposing further testing to establish safety satisfying the
standards of evidence based medicine. Regulatory bodies from other countries
should consider following the Japanese model of regulations for regenerative
therapies.
USA
Evolution of regulatory framework in USA
The original guidance regarding use of tissue products was drafted and approved
in 1996. In the subsequent year (1997) a separate code of federal regulation (CFR)
1271 was drafted to regulate these products. (3) These were classied under Human
cells and tissue and cellular and tissue based products HCT/Ps in this CFR which
made a clear distinction between a ‘drug’ which is a chemical molecule from these
biological products. The products were further classied as biological products or
medical devices based on difference criteria and a separated set of regulations was
drafted for both.These guidelines took into consideration the differences not only
between the type of cells but also between the procurement procedures and routes
of administration that may signicantly alter the safety and efcacy prole of the
cells. Although the classication was primitive and inadequate, it was based on the
available body of evidence and existing trends and concepts for monitoring
development of new therapeutic drugs. The products were classied into;
minimally manipulated cells, dened as, cells that do not alter their relevant
biological characteristics (due to the technique and/or chemicals used to procure
them) and more than minimally manipulated cells. The regulations also
differentiated between the route of administration as homologous and non-
homologous use. Homologous use was dened as the repair, reconstruction,
replacement, or supplementation of a recipient's cells or tissues with an HCT/P that
performs the same basic function or functions in the recipient as in the donor.
These products were regulated by 2 governing laws, rst, Public health services act
(PHS) which mandated that any new biological product for licensing will be
required to produce the data from clinical study or studies that demonstrate the
safety, purity and potency of the cells. (4) However, the guidelines did not dene
Stem Cell Therapy In Neurological Disorders 326

what type of studies or number of patients will be considered appropriate for

demonstrating this.
The 21CFR 1271.15 clearly stated that minimally manipulated cells used for non-
homologous use will be exempted from the regulatory requirements of FDA for
marketing approval if the cells and procured and transplanted in the same surgical
procedure. Another provision in the 21CFR 601.40 allowed for the accelerated
approval for serious or life threatening illness. This was applicable to certain
biological products that had been studied for safety, efcacy and provided
meaningful therapeutic benet to the patients over existing treatment. In
accordance with these guidelines various autologous regenerative medicine
products that were used for homologous use were approved and licensed in USA
between1997 to 2011.
Between the years 2011 and 2015 in the view of growing clinical evidence for stem
cell therapy, Right to try act was designed. Although the regulations prevented
generalized marketing of regenerative medicine products up till 2015, after the
introduction of Right to try act marketing of experimental drugs for the terminally
ill patients was allowed on a case by case review basis.(5)
The act quoted, “Notwithstanding the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 301 et seq.), the Controlled Substances Act (21 U.S.C. 801 et seq.), and any
other provision of Federal law, the Federal Government shall not take any action to
prohibit or restrict the production, manufacture, distribution, prescribing,
dispensing, possession, or use of an experimental drug, biological product, or
device that (1) is intended to treat a patient who has been diagnosed with a terminal
illness; and (2) is authorized by, and in accordance with, State law.”
Recently based on the growing clinical evidence for the use of cellular therapy for
the treatment of various incurable disorders, Senator Mark Kirk introduced a bill to
amend the Federal food, drug and cosmetic act; in front of committee on Health,
Education, Labor and Pensions, in 114th congress of the American senate. The
amendment was named Reliable and Effective Growth for Regenerative Health
Options that Improve Wellness act, REGROW Act.
Highlights of the US regulatory system
REGROW act alters the current regulatory framework to provide conditional
marketing approval to minimally manipulated cells for non-homologous use and
more than minimally manipulated cells without going through the formal
procedure of approval as per section 351 (A) of part F of Title III of PHS law.
Subsequently it is required that the licensing application be led in the next 5 years,
based on the post marketing research, as per section 351 (A) of part F of Title III of
PHS law. The cells and products exempted under these conditions are described in
detail in the REGROW act as, “
Stem Cell Therapy In Neurological Disorders 327

(1) Such cells or tissues are adult human cells or tissues.

(2) Such cells or tissues have been evaluated to examine immunogenicity and do
not provoke a signicant unintended immune response in the recipient.
(3) Such cells or tissues are –
a. minimally manipulated for a non-homologous use; or
b. more-than-minimally manipulated for a homologous or non-homologous
use, but are not genetically modied.
(4) Such cells or tissues are produced for a specic indication.
(5) Such cells or tissues are produced exclusively for a use that performs, or helps
achieve or re-store, the same, or similar, function in the recipient as in the donor.
(6) Within 5 years of the safety and effectiveness determination described in his
section, the sponsor of the conditionally approved new product prepares and
submits an application for approval of a biological product under section
351(a), demonstrating potency, purity, safety, and efcacy of the use. The
Secretary may permit continued use of such product until the Secretary
completes the review of the application and makes a determination. Upon a
determination by the Secretary not to approve the application, use of the
cellular therapeutic shall not be permitted.
(7) During the conditional approval period and before approval of an application
under section 351(a), the sponsor shall prepare and submit annual reports and
adverse event reports to the Secretary containing all the information required
for approved biological products.
(8) The sponsor has submitted an application under section 505(I) of the Federal
Food, Drug, and Cosmetic Act for the treatment of the patients during the 5-
year conditional use period.
(9) The sponsor has not previously received conditional approval for such product
for the same indication.”
Although REGROW Act is uniformly applicable to stem cell products as well as
stem cell therapies the highlight of this act is A] Conditional marketing approval
and B] Provision for post-hoc efcacy analysis. (2) This relieves the burden of the
evidence from newer upcoming cellular therapies and products. It allows medical
innovators and practitioners to develop promising therapies without having to go
through phased approval process as before. The proposed law has created criteria
to protect patients from unsafe therapies. This ensures easy and faster availability of
promising cell therapies to patients that can benet from them without any risk of
adverse effects.
Stem Cell Therapy In Neurological Disorders 328

Once this law is implemented the principles of Conditional marketing approval

and Provision for post-hoc efcacy analysis will become part of the regulations.
Another law passed by the state of Texas in USA named as Charlie’s Law. Charlie’s
law legalizes provision of investigational (unproven, but safe medical therapies)
stem cell treatment in certain patients with chronic diseases or terminal illness.
The law categorically denes investigational stem cell treatment as adult stem cell
treatment, that is being used in clinical trials but is unavailable for use in general.
This is a very progressive step by the state of Texas which has denitely brought
back hope for patients suffering from incurable illnesses. USA as well as other
countries should follow in these directions to bring hope to the patients who can’t
wait for the conventional evidence based medicine to provide answers and who are
suffering from years in absence of any cure or treatment to alleviate their symptoms
provided by modern medicine.
Although president George bush had banned the federal funding for the research
on embryonic stem cells and by using embryonic cell lines in 2001, President Barack
Obama subsequently lifted this ban. Currently embryonic stem cell research is
eligible for federal funding. To obtain federal funding to conduct research using
stem cells, a sponsor must submit its application to the NIH. Guidelines for
applying to the NIH can be found on the Federal Register (Vol 65, No 166/Friday,
August 25, 2000/Notices). Under the auspices of the Obama administration, the
National Institutes of Health plans to expand federal funding for stem cell lines that
meet following ethical requirements: the embryo used is discarded after IVF;
informed consent is obtained from the donors; the couple must not receive
compensation (neither nancial nor medical benets) or be coerced or threatened.
Older stem cell lines created in the spirit of the new regulations will be considered
for federal funding, whereas embryos created solely for research purposes will be
excluded [12].
Regulatory framework in Europe:
European medical agency (EMA) has drafted a separate legislation for regenerative
medicine products which is known as act on advanced therapy medicinal product
(ATMP).(9) Various regenerative medicine products are put into this newly
designed category for such products. This legislation recognizes the difference
between the drugs and stem cell products. Another law formulated by EMA, called
Hospital Exemptions act (HE) allows a practitioner or an institute to offer stem cell
therapy as a form of treatment for terminally ill patients. (10) The law states that,
“Advanced therapy medicinal products which are prepared on a non-routine basis
according to specic quality standards, and used within the same Member State in a
hospital under the exclusive professional responsibility of a medical practitioner, in
Stem Cell Therapy In Neurological Disorders 329

order to comply with an individual medical prescription for a custom-made

product for an individual patient, should be excluded from the scope of this
Regulation whilst at the same time ensuring that relevant Community rules related
to quality and safety are not undermined.”
Recently in the year 2016 EMA also formulated a PRIority Medicines (PRIME)
program to support development of medicines for unmet medical needs. (11)
Under this scheme promising therapies and medicines that are important for public
health will be given additional support and accelerated regulatory approval. The
products that are in the stage before Phase II as well as Phase III trials can be a part of
this scheme.
These schemes highlight patient’s right to seek treatment for a disease that has no
cure. If there is no treatment available, then regulatory bodies should not prevent
patients from taking benet of safe but unproven therapies. This concept was
known as compassionate use in Europe earlier which has now evolved in the
legislation explained above. In Australia and Canada as well such laws exists which
allow marketing and provision of safe but unproven therapies and drugs to patients
that suffer from incurable disorders after taking their informed consent and by
reporting any possible adverse events noted. In Australia this is known as Special
access scheme and in Canada it is known as special access program. (12,13)
Some common themes and concepts emerge from these new and more permissive
regulations. It is important to implement these in the guidelines and regulations of
countries that have less permissive regulations.
New concepts that have emerged from the recent regulations (Figure. 2)
1. Conditional marketing approval
2. Risk Stratication
3. Post-Hoc efcacy analysis
4. Presumed efcacy
5. Patients right to seek treatment
6. Distinction between cellular therapies
7. Distinction between a stem cell product and medical service
8. Non-homologous use
Conditional approval
Conditional approval rst introduced by Japan and later also implemented by USA
is revolutionary concept that allows for faster marketing of promising stem cell
therapy products. In the last century the most promising medical research was done
Stem Cell Therapy In Neurological Disorders 330

Figure 2: New concepts emerging from the recent regulations

by individual doctors in their eld of practice who kept patient care at the center of
their research. But industrialization of pharmaceutical sciences and stricter
regulations implemented for getting marketing approval made it impossible for
individual practitioners to develop promising therapies and medicines.
Conditional approval allows for promising therapies to be marketed for a
stipulated time at an earlier stage of Phase I or pilot trials which are sufcient to
prove the safety of the therapy and suggest efcacy of the same.
The concept of conditional approval has shifted the control of medical innovation
back in the hands of individual doctors practicing and researching to provide better
patient care.
Risk Stratication
Risk stratication means grouping the stem cell therapies and products based on
their risk to human life and health. Such stratication helps to differentiate between
less harmful and more harmful cellular therapy products.
A] Using this principle Korea has excluded the safer forms of therapies from their
regulatory framework.
B] Japanese guidelines have based their regulatory requirements on risk
Stem Cell Therapy In Neurological Disorders 331

stratication. With low risk needing only institutional clearance, medium risk
needing outside institutional clearenace and high risk requiring clearance from
MHLW.
C] The new proposed American law REGROW Act, using this principle has
proposed more permissive regulatory pathway for safe cell therapies such as cells
or tissues that are minimally manipulated for a non-homologous use; or more-than-
minimally manipulated for a homologous or non-homologous use, but are not
genetically modied.
Post-Hoc efcacy analysis
Concept of Post-Hoc efcacy analysis means that true efcacy of the product or
therapy can be determined post marketing. This is the most dramatic shift in the
current medical regulations that do not permit marketing of unproven drugs and
therapies. However based on this principle therapy or product can be permitted
for marketing based on studies showing denite safety but preliminary efcacy
analysis. The roots of this concept are in the basic principle of compassionate use,
facilitating early availability of potentially lifesaving experimental medication
which are safe but unproven.
This is a revolutionary concept that has already been implemented in Japan since
November 2014 and 2 products have already received approval under this
legislation. Recently, based on this concept REGROW Act has also been put forth in
the USA.
The basis of post – hoc efcacy analysis lies in the concept of Practice based evidence
which allows for gathering information regarding efcacy of a particular therapy
after using it clinically as a form of treatment and recording the clinical outcomes in
the patients treated. Unlike evidence based medicine, the concept of practice based
evidence gives the exibility to offer a treatment after the safety is established and
offer it as a treatment while simultaneously studying the effects on clinical outcome.
Presumed efcacy
It has been debated earlier that the modern standards for efcacy testing are too
idealistic and may in turn slow down the progress of medical science. Although the
regulations are for safe guarding the patients they fail to determine when a therapy
will be considered as proven. The current regulations ask for Phased clinical trials
that take up to 6 to 8 years before a new product can come in the market and have a
cost estimate of about 5 million dollars. Current research and statistical methods are
more suited for a drug or a molecule that has nite chemical reactions in the body,
however in biological products there are innite possibilities for interactions and
therefore it may take decades before a conclusive efcacy analysis can be done.
Japan in their regenerative medicine regulations for the rst time proposed a
Stem Cell Therapy In Neurological Disorders 332

concept of ‘Presumed efcacy’. This means that the preliminary trials that lack
statistical rigor but are suggestive of benecial clinical outcome can be considered
as the evidence for efcacy of the treatment. Simply put, it means that it can be
reasonably assumed that therapy will be effective in larger population based on a
nding with a smaller population.
It was earlier considered unethical to charge for therapies that have shown efcacy
in smaller populations. Japan in their recent regulations allowed for marketing of
such therapies under a conditional approval and these therapies were also covered
under Japan’s national health insurance schemes. In the recently proposed
REGROW act, USA; similar suggestions have been made for allowing safe therapies
to be marketed based on their presumed efcacy.
Patient’s right to seek treatment
Up till the last century availability of the clinical treatments was solely based on
decisions of regulatory bodies. If a treatment did not t the criteria laid out in the
regulations then it was not allowed in the market, thereby denied to the patients.
Although this was to safeguard patients from adverse effects of under investigated
therapies, terminally ill patients were losing out on promising therapies due to
strict demands for proving efcacy.
Most of the patients with progressive fatal disorders do not have enough time for an
experimental drug which has proven safety and has shown efcacy in smaller trials
to be tested in the statistical rigor of bigger trials. These drugs could be potentially
lifesaving for these patients. There were many efforts lead by patients and non-
prot organizations, which demanded access to such experimental drugs for
patients with terminal illnesses.
The origin of compassionate use is in the World Medical Association’s Declaration
of Helsinki on ethical principles for medical research involving human subjects.
The declaration in their clause on unproven intervention in clinical practice states
that, ‘In the treatment of an individual patient, where proven interventions do not
exist or other known interventions have been ineffective, the physician, after
seeking expert advice, with informed consent from the patient or a legally
authorised representative, may use an unproven intervention if in the physician's
judgement it offers hope of saving life, re-establishing health or alleviating
suffering. This intervention should subsequently be made the object of research,
designed to evaluate its safety and efcacy. In all cases, new information must be
recorded and, where appropriate, made publicly available’. (14)
The concept of patient’s right to seek treatment is highlighted in the White paper
published by the International society of Cellular Therapy which states that
“Patients seeking medical treatment for cellular therapies have the following rights
that must be respected by healthcare providers and all associated with their care.
Stem Cell Therapy In Neurological Disorders 333

The right to seek treatment: patients and their families/partners have the right to
seek treatments for their diseases. No entity should withhold this fundamental
right unless there is a high probability of harm to the patients.”(15)
Efforts made by the patients in accordance with this ethical principle led to changes
in the legislation for USA, Europe and several other countries in the world. In USA
this was implemented as Treatment/Emergency IND initially and later as Right to
try Act in 2015. (5) In Europe this was implemented as Compassionate use Act and
recently a program was launched to support to development of priority medicines
for unmet medical needs, PRIME. In addition other Acts like Hospital Exemption
Act in Europe (10), Special access program in Australia (12) and special access
scheme in Canada (13) are based on this principle.
These compassionate use programs highlight patient’s right for seeking unproven
but safe experimental drugs and allows access to such medicines and therapies at
the personal recommendation and responsibility of the treating physician. Such use
is deemed ethical and can be charged for after receiving an informed consent from
the patient, explaining the possible adverse effects if any and informing the patient
about the experimental nature of the therapy.
Unfortunately, in India there are no laws or regulations for compassionate use.
Indian regulators and guideline formulators have not taken into consideration the
right’s of these patients to seek treatments that may potentially save their lives.
Distinction between different types of cellular therapies
Earlier the guidelines did not make distinction between different types of cells,
processes of procurement and routes of administration. However the recent
guidelines have made various distinctions and have made separate regulations and
guidelines accordingly.
In USA the REGROW Act makes distinction between minimally manipulated cells
and more than minimally manipulated cells.(2) Minimally manipulated cells are
dened as, “cells procured using technologies when there is no intended alteration
in the biological characteristics of the cell population relevant to its claimed utility,
performed by a medical doctor at a medical center during the same surgical
procedure without compromising the safety of the cells; this may include
separation of mononuclear cells, washing, centrifugation and suspension in
acceptable medium.” All the other cell types are characterized as more than
minimally manipulated cells.
In Japan, there is a separate law designed only for the classication of the
regenerative medicine products based on their safety prole.(7) These products are
divided into 3 separate classes as, class I – High risk, Class II – Medium risk and
Class III – Low risk products (Figure).
Stem Cell Therapy In Neurological Disorders 334

In European guidelines, the products are divided into minimally and more than
manipulated as well. Minimal manipulation is dened as cells procured through
simple technologies like cutting, grinding, shaping, centrifugation, soaking in
antibiotics of antibiotic solutions, sterilization, irradiation, cell separation,
concentration or purication, ltering, lyophilization, freezing, cryopreservation
and vitrication. However there are no separate guidelines for the use of these
products as allowed in Japanese and USA laws.
Distinction between a cellular therapy product and cellular therapy medical service
Advent of cellular therapy has given rise to a huge dilemma for regulators whether
to regulate these as a product or a medical service. Therefore most of the guidelines
are too restrictive where it is considered as a product or too liberal where it is
considered a therapy. Although burden of evidence lies on both therapy and
product; the criteria for marketing approval have been traditionally very different
for both. Every new product is regulated separately and the evidence for one is
usually not applicable to the other therefore companies designing different
products need to seek different approvals. The guidelines for these are also very
strict. However a therapy once proven safe and effective can be used by multiple
practitioners and they individually do not need to seek approval for the same. This
is a basic distinction in the product and therapy which most of the guidelines in the
world including Indian guidelines fail to understand.
Japanese guidelines however have been very progressive and they have designed 2
separate laws for products and therapies. These two laws have also been very
progressive in their eld of application allowing fast track conditional approval for
products and mandatory approval from MHLW only for high risk therapies. USA
has taken a step ahead in not only allowing a fast track conditional approval for
products but also allowing different companies to get faster marketing approval
based on exhibited biosimilarity with an already existing approved product.
Non-homologous use
The proposed REGROW Act 2016 has for the rst time made a provision for
conditional approval of therapies and products using minimally and more than
minimally manipulated cells for non-homologous use i.e. not in the same body
system as that of the source of the cells. (2)
Current regulatory system in India [1,2,3,4]
The present situation in India with regards to guidelines for stem cell therapy
1) The National guidelines for stem cell research have been formulated by the
Indian Council of Medical Research and the Department of Biotechnology in
2013 [1]. These guidelines have retained the 2007 classication of stem cell
research into 3 categories namely Permissive, Restrictive and Prohibitive
Stem Cell Therapy In Neurological Disorders 335

research. Human embryonic stem cell derivation and differentiation falls in

"restrictive" category, whereby, these cells can only be used for research
purposes. "The prohibitive research" includes any research related to germ line
genetic engineering or reproductive cloning of any in vitro culture of the intact
human embryo, regardless of the method of its derivation, beyond fourteen 14
days or the formation of the primitive streak, whichever is earlier; transfer of
human blastocysts generated by SCNT; or the breeding of
parthenogeneticanimals,in which human stem cells have been introduced at
any stage of development. Adult and umbilical cord blood cells are clubbed
under the "permissive" group [2]. It has introduced an additional layer of
oversight besides the institutional ethics committee (IEC) in the form of
Institutional Committee for Stem Cell Research (IC-SCR) and the National
Apex Committee for Stem Cell Research and Therapy (NAC-SCRT). A major
recommendation has been to omit the word therapy from the title of the
guidelines as compared to the guidelines in 2007. As per National guidelines,
every organization (academic or otherwise) interested in working on stem cells,
must formulate an Institutional Committee for Stem Cell Research and Therapy
(IC-SCR). Members of the Committee must include people with appropriate
expertise (representatives of the public and persons with expertise in clinical
medicine, developmental biology, stem cell research, molecular biology,
assisted reproduction technology, and ethical and legal issues in stem cell
research) and this Committee must function at the institutional level. Projects
will be approved on the basis of scientic evaluation and ethical conduct. The
IC-SCR must also be registered with an NAC-SCRT. The NAC-SCRT is
constituted by the Government of India. NAC would be comprised of experts
from various elds, who would be responsible for examining the scientic,
technical, ethical, legal and social issues in the area of stem cell based research
and therapy. It will have around 10 members. A chairman, a deputy chairman,
member secretary and nominees from DBT, DST, CSIR, ICMR, DCGI, DAE, and
biomedical experts from pharmacology, immunology, cell biology,
hematology, genetics, developmental biology, clinical medicine and nursing.
Legal expert, social scientist, and a women's representative will also be part of
NAC. NAC could also consult outside experts on a case to case basis.
Institutions involved in stem cell research and therapy will have to be
registered with the NAC through Institutional Committee for Stem Cell
Research and Therapy (IC-SCR).
2) The Ministry of Health and Family Welfare, Government of India, established a
High Powered Committee in June 2013 to suggest a road map for regulation of
stem cells and other cell based therapies being practiced in India. Under the
chairmanship of Professor Lalji Singh it submitted a Guidance Document for
Regulatory Approvals of Stem Cell and Cell Based Products (SCCPs) in
Stem Cell Therapy In Neurological Disorders 336

December 2013. This Guidance Document is based on the recommendations of

that committee and it is subsidiary to the amendments made in 2013 to the
Drugs and Cosmetics Act (DCA), 1940 and the new rules proscribed there
under. As per these amendments it has been decided that Government of India,
through the DCG (I) and CDSCO, shall regulate all practices related to the use of
stem cells, and other cells, for therapeutic purposes in India. The amendment in
DCA also mandates that all stem cells and cell based products that can be used
for therapeutic purposes shall be referred as Stem Cell and Cell Based Products
(SCCPs) and all activities related to their usage i.e. manufacture/isolation/
collection, storage and transplantation into patients must be done only under a
license or permission that would be granted by the DCG(I)/CDSCO [3].
3) Another important and major development has been the proposal of the Drug
Controller General of India DCG(I) to include "stem cells" in the denition of
new drugs in the proposed bill titled "Drugs and Cosmetics (Amendment) Bill
2015" [4]. The revision in this was proposed earlier in this year which exclude
autologous and minimally manipulated type of cells from this law.
The Gazette of India published in April 2018 states that,
In sharp contrast to the regulatory developments in the world, the latest Indian
guidelines made by Indian council of Medical Research (ICMR) in 2013 are moving
backward and are in the process of trying to implement policies that will completely
destroy the stem cell therapy eld in India.Indian regulators fail to understand the
1] distinction between drug and stem cell therapy 2] distinction between stem cell
therapy product and stem cell therapy. The current Indian guidelines do not
incorporate any of the new concepts that have emerged in the recent progressive
guidelines of other countries.
Our recommendations for designing the guidelines
Based on various international guidelines, white papers and declarations from
world medical association we would like to recommend some guiding principles
while designing the guidelines in our country for approval and monitoring of stem
cell based research as well as therapy.
The recommendations are based on the following documents
1) The regulatory guidelines from different countries like Japan, Korea and
United States of America [5-12]
2) Opinions from white paper of the International society of cellular therapy
(ISCT)[13]
3) Helsinki declaration of World Medical Association that guides the ethical
principles of human research [14]
Stem Cell Therapy In Neurological Disorders 337

and
4) Beijing declaration of the International Association of the Neurorestoratology
[15]
Recommendations
1. Acceptance of unproven cellular therapies for the treatment of incurable
conditions, based on the World Medical Association’ declaration of Helsinki.
2. Distinction between legitimate cell therapy medical services and fraudulent
services, based on the ISCT White paper.
3. Distinction between clinical trials and medical innovation, based on the ISCT
white paper.
4. The basic right of a patient to seek treatment should be respected, based on the
ISCT white paper.
5. Distinguishing various centers offering cellular therapy, based on the
recommendation of the ISCT white paper.
6. Recognition of the importance of cellular therapy as part of neurorestorative
therapies, based on Beijing declaration of the International Association of the
Neurorestoratology (IANR).
7. Giving importance to Practice Based Evidence
8. Regulations need to make a distinction between different types of cellular
therapies, based on the regulations in countries like Korea, Japan and USA
9. Adapting regulations from countries that have been progressive and more
permissive of cellular therapies like Korea, Japan and USA.
Proposed changes in the Indian regulations:
We would like to propose a road map for regulating stem cell work in India in such a
manner that the safer forms of therapies are easily available to patients with
incurable diseases whereas less safer forms of therapies are regulated more strictly.
{A} For this we propose that there should be 3 different sets of guidelines for,
1) Researchers – Those who are doing basic laboratory research and clinical trials
in patients.
2) Corporate Manufacturers – companies that are manufacturing stem cells and
stem cell related products on a large scale
3) Clinical stem cell therapists – doctors and institutes that offer cellular therapy as
a treatment.
Stem Cell Therapy In Neurological Disorders 338

Separate rules and regulations should be formulated for these. The researchers
should follow ICMR guidelines. Corporate manufacturers should follow CDSCO /
DCG(I) guidelines.
Clinical stem cell therapies should further be categorized into
Low risk: Therapies using autologous and minimally manipulated stem cells.
These therapies could be permitted under the oversight from the IEC.
Medium risk: Therapies using more than minimally manipulated allogeneic cells
of non-embryonic origin. These therapies would need oversight of IEC and
approval from CDSCO/DCG(I).
High risk: Embryonic/ Fetal stem cells and iPSCs. Therapies using these cells
would require oversight of IEC and approval from CDSCO and ICMR.
A key aspect of debate between clinicians and regulatory bodies is what new
clinical indications should be considered as approved to offer stem cell therapy. We
believe that if there are publications, that document safety and presumed efcacy of
stem cell therapy in a particular indication from any part of the world, then this
should be considered as an accepted indication.
{B} The membership of NAC-SCRT should be expanded to include more members
from the clinical side having experience and expertise in Stem cell therapy so that a
more balanced view is taken. The Chairmanship of NAC-SCRT should be changed
by rotation every year so that fresh insights are available to the committee.
REFERENCES
1. Guidelines for stem cell research and therapy,ICMR-DBT,2007
2. Guidelines for stem cell research and therapy,ICMR-DBT,2013
3. Central Drug Standard Control Organization (CDSCO), Guidance Document
for Regulatory Approvals of Stem Cell and Cell Based Products (SCCPs),
Document No. STEM CELL AND CELL BASED PRODUCTS
(SCCPs)/SPS/2013-001 Version: 004. Available online at
http://cdsco.nic.in/writereaddata/DRAFT 20GUIDANCE 20STEM
20CELLS-FINAL.pdf, last accessed on 29th May 2015.
4. Central Drug Standard Control Organization (CDSCO), The drugs and
cosmetics amendment bill 2015, available online on
http:/www.cdsco.nic.in/writereaddata/D& 20C 20AMMEND-MENT
20BILL(1).pdf, last accessed on 29th May 2015.
5. Regulations on review and authorization of biological products 2010.10, Korea
food and drug administration; available online at
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&
Stem Cell Therapy In Neurological Disorders 339

cad=rja&uact=8&ved=0CB4QFjAAahUKEwjYlN2itabHAhWVj44KHTnDBN
E&url=https%3A%2F%2Fptop.only.wip.la%3A443%2Fhttp%2Fwww.mfds.go.kr%2Fjsp%2Fcommon%2Fdownle.j
sp%3Fleinfo%3D%2Fles%2Fupload%2F1%2FTB_F_INFODATA%2F9218%
2F71d5a5a567f74eaa4586e4b8144a5824.pdf&ei=W73MVZj7BZWfugS5hpOID
Q&usg=AFQjCNHZ4zFWcRlH0IV-mxSUJtnY1Er35Q&sig2=1jJTSpxuqquz
KdFv539xNA&bvm=bv.99804247,d.c2E
6. Ock-Joo Kim Stem Cell Research in Korea: Ethical and Legal Perspectives,
World Stem Cell Report,2010
7. Amendment of the pharmaceuticals affairs law, available online at
http://www.mhlw.go.jp/english/policy/health-medical/pharmaceuticals
/dl/150407-01.pdf, last accessed on 10th August 2015.
8. Cyranoski D. Japan to offer fast-track approval path for stem cell therapies.
Nature medicine. 2013;19(5), 510-510.
9. Institutional framework for promoting implementation of regenerative
medicine, ministry of health and welfare Japan, available online at
http://www.mhlw.go.jp/english/policy/health-medical/medical-
care/dl/150407-01.pdf, list accessed on 10th of August 2015.
10. Kazuto Kato and Masahiro Kawakami. Stem Cell Research in Japan: Policy
Changes in "The Era of iPS Cells",, World Stem Cell Report,2010
11. The United States of America, department of health and human services, Code
of federal regulations, food and drug administration, Part 1271: Regulations for
Human cells, Tissues, and Cellular and Tissue based products; available online
at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/
cfrsearch.cfm?cfrpart=1271&showfr=1. Last accessed online on 14/2/2015
12. 'Bernard Siegel - The US stem cell dilemma', Pharmaceutical Technology
Europe, 27 March 2009
13. Gunter KC, Caplan AL, Mason C et al. Cell therapy medical tourism: time for
action. Cytotherapy. 2010;12(8), 965-968
14. World Medical Association. World Medical Association Declaration of
Helsinki: ethical principles for medical research involving human subjects.
JAMA: The journal of the American Medical Association. 2013;310(20), 2191.
15. Huang H, Raisman G, Masri WS et al. International Association of
Neurorestoratology. Beijing Declaration of International Association of
Neurorestoratology (IANR). Cell Transplantation. 2009;18(4):487
Stem Cell Therapy In Neurological Disorders 340

Difculty of Being Good:

“In order to preserve dharma in this imperfect world of Kali Yuga, he had to
commit 'smaller wrongs' for the sake of a 'bigger right'.”

From the book "The Difculty of being Good. On the subtle art of Dharma”
in the chapter "Krishna's Guile" by Gurcharan Das (Penguin Allen Lane)
Stem Cell Therapy In Neurological Disorders 341

21

Ethics

Consensus on the potential of stem cell therapy to address various incurable,

debilitating disorders is unanimous. Stem Cell research and therapy is the front line
of the biomedical eld. However, no other area of biomedical research has faced the
quantum of ethical, moral and political controversies that surrounds stem cell
research. Adult stem cells as an alternative source, other than embryos, have been
spared of controversies and have been generally welcomed and encouraged for
research and therapy.

Embryonic stem cell, on the other hand, has been hounded by objections and
restrictions due to the source of its procurement, by various religious bodies of the
world.

Ethical Issues Associated With Embryonic Stem Cell Research

Religion and embryonic stem cell:

The major dictum common to all religions is : 1) Human life is sacred and has to be
guarded 2) Alleviation of human suffering should be strived for. Though, there is
consensus among all religions regarding the potential of stem cell research being a
means towards addressing the second dictum, the opinion on what construes a
human life differs vastly.

Should the 5-7 day embryo be given the status of a person and hence have the right
to life or is this stage too early to confer this right?
Stem Cell Therapy In Neurological Disorders 342

For some religions, ensoulment of the embryo would make it a person. But,then
when does ensoulment take place?
These are just a few issues surrounding the embryonic stem cell eld.
Contrastingopinions among various religions and even within the religion
exist.The following is a sample of this diversity among different faiths.
Greek Orthodox and Roman Catholic Churches
The ofcial position of these churches is that a human person begins at
conceptionand the human embryo has the same moral status as human persons.
Consequently,research on human embryos, including hES derivation and
subsequent use is unethical,and if it involves the willful destruction of embryos, it is
homicide.The argument that the cell lines are derived from excess embryos, after
thefertility needs are dealt with, is of no consequence, since the production of
excessembryos itself is unacceptable to the church. The fact that these embryos and
theirproducts would be used for the alleviation of human suffering, does not justify
thedestruction of the embryos.
Since the underlying belief is in the embryo's right to life, any use of the embryothat
is not for its own good is immoral and therefore, impermissible. There is
noconsequentialist or utilitarian approach that would make this act acceptable.The
belief in the personhood of human embryos also means that it is not possibleto use
hES lines previously derived from human embryos or to use therapies derivedfrom
hES research. The idea is that these cell lines and therapies are tainted by
theimmoral act of killing the embryo. To use them would be to become complicit in
theimmoral act.
However, this rigid stance, especially of the Roman Church, is somewhat dilutedby
certain other catholic groups, who do not believe that the embryo is a humanperson,
but believe that its ensoulment is the morally relevant time with regard
topersonhood.
Protestant Churches
Most protestant churches do not believe that embryos have personhood and
areopen to embryo research but consider that the goals of the research are of
paramountimportance. In addition, considerable emphasis is placed on the need
for both publicdiscussion and for oversight of the research rather than leaving it as
an unregulatedprivate enterprise. They believe that the benets from this and other
medical researchbe distributed evenly and justly to all those in need, regardless of
resources orgeography.
Ofcial positions vary from country to country on the moral status of the
embryoand therefore, on the morality of embryo research in general. These
divisions showjust how personal an issue stem cell research can be. For these
Stem Cell Therapy In Neurological Disorders 343

churches like for thelay public, weighing the moral status of the embryo and the
need to help ailing andsuffering people is not a simple arithmetic. (1)
Judaism
Orthodox Jews believe that embryos do not have the same moral status as
humanpersons. In fact, gametes and embryos outside a human body do not have
any legalstatus under Jewish law. The result therefore, is that embryos created by
IVF haveno special moral or legal status. Under Jewish law (Halcha) the fetus does
not becomea person (nefesh) until the head emerges from the womb.
They believe that when the embryo is implanted it is "as water" up to the
fortiethday. After that time and before the fetus emerges from the woman's body it
is apotential life and has great value. Ensoulment is generally thought to occur
sometimeafter the fortieth day. It gains full human status, however, only once it
emerges fromthe woman's body. Since embryos used in hES research are outside
the body, accordingto the Jewish faith it is possible to use excess IVF embryos in
research.
In addition to the Jewish views on the moral status of the human embryo,
thisreligion places emphasis on preventing and alleviating suffering. This leads to a
deepbelief in the morality of and value in pursing medical research. The
commitment topreserving one's body and health is joined by a commitment to
helping others andalleviating suffering. So there is a moral imperative to help those
who are sufferingfrom diseases and to explore the potential of all types of stem cell
research. Thisbelief leads Jews to have a generally favorable view of stem cell
research includinghES research. (2)
Islam
In Iran, Turkey, Singapore (with a majority of Muslims) and other Islamic
countries,embryo research policies are inuenced by the religious belief that full
human lifewith its attendant rights begins only after the ensoulment of the fetus.
This is generallybelieved by Muslim scholars to take place at 120 days after
conception (although aminority belief indicates ensoulment takes place 40 days
after conception). This fact,in conjunction with the importance articulated in the
Qur'an of preventing humansuffering and illness, means that the use of surplus IVF
embryos for stem cell researchis relatively uncontroversial. What remains
controversial in the Muslim world iscreating embryos for the purpose of
research.As with other religions, Islam and its followers have differing point of
views onthese issues. For example, in Egypt, a conservative religious country, the
Muslimhead of the Egyptian Medical Syndicate stated that embryos are early
human life andshould never be used in research.
Hinduism and Buddhism
Stem Cell Therapy In Neurological Disorders 344

In traditional Hindu belief, conception is the beginning of a soul's rebirth from a

previous life. Some Hindu traditions place the beginning of personhood between
three and ve months of gestation, while few believe that the soul's rebirth can
occuras late as the seventh month. Most Buddhists have adopted the classical
Hindu teaching that person hood begins at conception. Though Buddhist teachings
do not directly address the issue, like Hinduism there are two main tenets - the
prohibition against harming ordestroying others (ahimsa), and the pursuit of
knowledge (prajña) and compassion(karua) - that divide Buddhists. Some
Buddhists argue that embryonic stem cell research is in accordance with the
Buddhist tenet of seeking knowledge and ending human suffering, while others
argue that it is a violation of the notion of not harming others.
A central belief of Hinduism and Buddhism is that an individual's soul or self
iseternal. In Hinduism the soul is believed to be passed from one living being to
another in a process called reincarnation. In Buddhism reincarnation is described
differentlyas the rebirth of the self. These beliefs, that the soul or the self are reborn
lead to agreater acceptance of cloning technology. Although the use of embryos in
stem cellresearch remains a divisive issue in these religions, the use of cloning
technology instem cell research is less controversial.(3-5)
Medical And Other Ethical Issues And ES Cell Research:
Proponents of embryonic stem cell research advocate that obtaining human
EScellsfrom the embryos left over after successful pregnancy in the course of
IVFtreatmentfor the goal of treating diseases and saving lives justies the symbolic
lossthatarises from destroying embryos in the process. They emphasize on the
signicanceofsaving life of many patients who need cell replacement therapy, as an
essentialreasonfor permission of research on embryos and obtaining ES-cells from
them.A different set of ethical issues arises once researchers have learnt safe
andeffective ways to direct human ES-cell to differentiate into specied cell or
tissue types, and to transplant them for therapeutic effects in patients.An important
clinical issue at this point will be whether ES-cell not derivedfrom the patient, will
be rejected by the patient's immune system. The strategy fordealing with this
problem, would then be to use a patient's nuclear DNA to create anembryo from
which ES-cells compatible with that patient could then be derived. Thisprocess,
known as somatic cell nuclear transfer could prove to be a safe and effectiveuse of
ES-cell derived replacement therapies.However, this would raise more ethical
issues beyond the destruction of leftoverembryos to obtain human ES-cells. One
issue would be ethical concerns aboutcreatinghuman embryos for the sole purpose
of destroying them to obtain replacementcellsfor the patient who provided the
nuclear DNA. Ethical debates about creatinghumanembryos solely for research
have existed since the inception of debates over embryoresearch. One can question;
however, whether those concerns are evenrelevant to generating human ES-cells by
Stem Cell Therapy In Neurological Disorders 345

somatic cell nuclear transfer, for the haplogenomes of gametes are not combined
through sexual fertilization to form the blastocyst that provides the ES-cells. In
addition, there is no intention of culturing the embryo beyond the blastocysts stage,
nor of implanting that blastocyst in a uterus for reproduction. Given the asexual
means of creating the embryo and the lack of intent of implanting it in the uterus, the
embryonic entity produced in these circumstances lacks the reproductive
signicance that some have argued is the moral basis for valuing early embryos.
The other issue is of egg donation for therapeutic cloning and effective cell
replacement therapy. The ability to meet the therapeutic demand for oocytes would
present an important problem. The ability of live, unrelated donors to meet such a
demand is highly unlikely for several reasons: the hormone treatments that
stimulate the production of many oocytes impose a considerable burden on
women; surgery is required to retrieve the oocytes; and ethical problems now
surround such donations.
Fetal Stem Cells And Ethics:
Pluripotent stem cells can be derived from fetal tissue after abortion. However, use
of fetal tissue is ethically controversial because it is associated with abortion, which
many people object to. Under American federal regulations, research with fetal
tissue is permitted provided that the donation of tissue for research is considered
only after the decision to terminate pregnancy has been made. This requirement
minimizes the possibility that a woman's decision to terminate pregnancy might be
inuenced by the prospect of contributing tissue to research. Currently there is a
phase 1 clinical trial in Batten's disease, a lethal degenerative disease affecting
children, using neural stem cells derived from fetal tissue . (6,7)
Induced Pluripotent Stem Cells (iPS Cells)- a safe and ethical alternative?
Somatic cells can be reprogrammed to form pluripotent stem cells, called induced
pluripotential stem cells (iPS cells).These would match the donor cells. This was
initially tried using viral vectors, followed by plasmids. Currently, the aim is to be
able to induce pluripotency without genetic manipulation. Because of unresolved
problems with iPS cells, which currently preclude their use for cell-based therapies,
most scientists urge continued research with hESC. (8 )iPS cells avoid the heated
debates over the ethics of embryonic stem cell research because embryos or oocytes
are not used. Furthermore, because a skin biopsy to obtain somatic cells is relatively
noninvasive, there are fewer concerns about risks to donors compared with oocyte
donation. The President's Council (USA) on Bioethics called iPS cells "ethically
unproblematic and acceptable for use in humans" Neitherthe donation of materials
to derive iPS cells nor their derivation raises special ethicalissues.
Evolution Of Policies On The hES Cell Research In The US:
The most keenly followed and studied policy change regarding the human EScell
Stem Cell Therapy In Neurological Disorders 346

research has been that of the United States. This has been mainly attributed to
beinuenced by the ethical, moral & religious stand of the catholic church. In 1973 a
moratorium was placed on government funding for human embryo research. In
1988 a NIH panel voted 19 to 2 in favor of government funding. In 1990,Congress
voted to override the moratorium on government funding of embryonic stem cell
research, which was vetoed by President George Bush. President Clintonlifted the
ban, but changed his mind the following year after public outcry. Congress banned
federal funding in 1995. In 1998 DHHS Secretary Sullivan extended the
moratorium. In 2000, President Bill Clinton allowed funding of research on
cellsderived from aborted human fetuses, but not from embryonic cells. On August
9,2001, President George W. Bush announced his decision to allow Federal funding
of research only on existing human embryonic stem cell lines created prior to his
announcement. His concern was to not foster the continued destruction of living
human embryos. In 2004, both houses of Congress asked President George W. Bush
to review his policy on embryonic stem cell research. President George W. Bush
released a statement reiterating his moral qualms about creating human embryos to
destroy them, and refused to reverse the federal policy banning government
funding of ESC research (other than for ESC lines established before the funding
ban).In the November 2004 election, California had a Stem Cell Research Funding
authorization initiative on the ballot that won by a 60% to 40% margin. It established
the "California Institute for Regenerative Medicine" to regulate stem cell research
and research facilities. It authorizes issuance of general obligation bonds to nance
institute activities up to $3 billion dollars subject to an annual limit of $350 million.
Under President Obama, it is expected that federal funding will be made available
to carry out research with hESC lines not on the NIH list and to derive new
hESClines from frozen embryos donated for research after a woman or couple using
invitro fertilization (IVF) has determined they are no longer needed for
reproductive purposes. However, federal funding may not be permitted for
creation of embryosexpressly for research or for derivation of stem cell lines using
somatic cell nuclear transfer (SCNT)
The Korean Stem Cell Controversy
The meteoric rise and equally sudden fall of Korean scientist Woo-Suk Hwang
depicts all that can possibly go awry, ethically and scientically, in the world of
stem cell research. What would have been regarded as a seminal paper in SCNT
technology and human ES therapeutics turned out to complete fraud and hogwash.
Not only were the results fabricated, but also, unethical practices were employed to
procure oocytes for the research.
At the end of 2005, the scientic community was shocked by one of the greatest
cases of misconduct in the history of science. Two breakthrough articles about stem
cell technology from a Korean laboratory headed by Woo-Suk Hwang, published in
Stem Cell Therapy In Neurological Disorders 347

Science, appeared to be almost completely fabricated and were therefore retracted.

The two fraudulent papers concentrated on the concept of therapeutic cloning in
humans. In this somatic cell nuclear transfer (SCNT) technology, a nucleus from a
patient's somatic cell is transplanted into an enucleated donor oocyte. The resulting
blastocyst embryo is used for the isolation of embryonic stem cell (ESC) lines that
possess virtually all the patient's characteristics and thus will minimize immune
rejection upon transplantation. Until the publication of the fraudulent papers,
therapeutic cloning was a cumbersome and inefcient technique and successful
therapeutic cloning in humans had not been reported before. In their 2004 paper,
Hwang and his associates claimed to have isolated the rst human ESC line derived
from SCNT and in their second paper they reported to have improved the
efciencyto such an extent that clinical application became within reach. Two
months following the rst paper, criticism arose on the ethics of obtaining the
human oocytes used in the study. After initial denial it became clear that egg donors
had been paid and two lab members had provided oocytes. This forced Hwang to
admit these unethical practices. Subsequently, the scientic content itself raised
questions. Duplications off our microscopic photographs in different panels, and
designated as different ESClines, in the publication of 2005 were uncovered, but
these were parried as an accidentalmistake by Hwang and the Science editorial
board. Furthermore, DNA nger print comparison of presumed donor and derived
ESC lines showed no inter-experimentalvariety and were in fact performed on the
same ngerprint prole. Hwang agreed to an independent investigation by Seoul
National University. His three most important recent works were investigated: the
retracted 2004 and 2005 Science papers and a publication in Nature about a cloned
dog. The conclusions were clear. The claim of being the rst laboratory to create a
pluripotent human ESC line through SCNT was reported to be false. Verication of
the DNA ngerprints of cell lines, teratomas and donors showed that the NT-1 cell
line was not derived from the designated donor. Second, no evidence was found to
verify the conclusions of there port of the 11 ESC lines in the paper of 2005. The
claims were based on material obtained from two ESC cell lines derived by IVF
rather than SCNT. Displayed results of DNA ngerprinting, karyotyping, data of
MHC-HLA is otyping and photographs of teratoma and embryoid bodies were all
fabricated. (9)
Ethical Issues For Cord Blood Banking
The ethical implications of cord blood banking in the case of donated samples for
the purposes of allogeneic transplantation or research are the same as for any tissue
bank. This issue has been addressed in the European group on Ethics in Science and
New technologies (EGE) Opinion no. 11 on the ethical aspects of tissue banking(21
July 2001). The ethical values underlined in this opinion are the following: body
integrity, respect of privacy and condentiality of data, promotion of solidarity,
fairness of access to healthcare and information and consent of the donors.
Stem Cell Therapy In Neurological Disorders 348

(10)Umbilical cord blood banking process should comprise of a detailed consent

explained clearly to the woman or to the couple of the prospective new treatments,
but stress that they are still very much at the experimental stage. Principally, tissue
bank activities should be reserved to public health institutions or non-prot making
organizations. All public and private banks tissue banks should be monitored for
quality measures and standards. These guidelines are based on the principle of
respect for human dignity and integrity which asserts the principle of non
commercialization of the human body; principle of autonomy or the right to self-
determination on the basis of full and correct information; principles of justice and
solidarity, as regards to fair access to healthcare services; principle of benecence,
or the obligation to do good, especially in the area of health care; principle of non-
malecence, or the obligation not to harm, including the obligation to protect
vulnerable groups and individuals, to respect privacy and condentiality; and
principle of proportionality which implies a balance between means and objectives.
(11)
There are also some value conicts regarding the Umbilical cord blood banking.
The values of freedom and free enterprise can conict with the principles of
solidarity and justice, according to which access to healthcare should be on an
equitable basisand based on realistic needs, as well as with the principle of
protection of vulnerable groups.
Informed Consent:
Informed consent is a vital step to any research project. It is the process in which a
patient/participant consents to participate in a research project after being
informed of its procedures, risks, and benets (12) After fully comprehending the
information about the project, the patient/participant gives full and conscious
consent for the physician/scientist to continue with the procedure. The consent is
obtained after giving all the information to the patient in comprehensible non-
medical terms, preferably in the local language about the diagnosis; nature of
treatment; risks involved, prospectus of success, prognosis if the procedure is not
performed and alternative treatment. The three main aspects of the informed
consent are information, voluntariness and capacity. In keeping the observations of
the Supreme Court, the National Commission of India stated that all information
would imply adequate information to enable the patient to make a balanced
judgement to whether or not to be a part of the trial or treatment.
Ethics in medical practice
Greek word Ethos, meaning character, is the origin of the word ethics. Ethics is part
of philosophy in modern world and explores the rights, wrongs and morality of
human behavior. Ethical principles related to medical practices form bioethics.
Bioethical principles guide the current regulatory systems and are the foundation of
Stem Cell Therapy In Neurological Disorders 349

modern research practices [13].

Four core principles of bioethics are Autonomy, Nonmalecence, Benecence and
Justice.
Autonomy:
Principle of autonomy states that the patient should be considered capable of taking
an informed decision about the treatment after understanding the benets and
adverse events of the treatment should be given the right to exercise his/her choice
of the treatment without any external inuence preventing voluntary action.
Nonmalecence:
The second principle of Nonmalecence suggests that there should be no harm
caused to the patient by providing or denying a treatment.
Benecence:
The third principle of Benecence is self explanatory and suggests that the
physician has a duty to benet the patients and also to prevent them from any harm
that may be caused by a medical treatment.
Justice:
The fourth and nal of the basic principles, is the principle of Justice; meaning a
physician should be fair in offering his services and there should not be any
preferential attribution of services.
The principles have been intentionally or unintentionally violated in past while
offering medical treatments and performing medical research. Medical
experiments conducted on the prisoners of war in Germany were intentional
examples and occurrence of phocomelic infants after thalidomide consumption
was an unintentional example of this violation. Because of these the need to enforce
strict adherence to the biomedical principle in medical research and practice was
necessitated. In modern world the ethical principles are implemented through
various regulatory bodies to protect the patients from being taken advantage of and
to protect them from any harm caused by the treatment or medical incompetence.
The guidelines formed by these regulatory bodies are based on Evidence Based
Medicine (EBM).
Principles of Evidence based medicine
Evidence based medicine (EBM) is dened as, “The conscientious and judicious use
of current best evidence from clinical care research in the management of individual
patients.” [14] To cope with the growing medical information and to determine the
true efcacy of medical treatments, EBM was used. EBM helps to form most
informed conclusions about the efcacy of existing treatment options [14]. Various
Stem Cell Therapy In Neurological Disorders 350

steps involved in coming to this conclusion are forming a relevant clinical question,
searching for the evidence to answer that question, appraising the evidence,
integrating that evidence into the clinical practice keeping in mind patient
preferences, evaluating the outcome of such integration using standardized
scientic tools and then documenting and disseminating these ndings for others
to appraise [15]. This makes the whole process combustive.
Information gathered clinical experience, expert opinions, individual cases or series
of cases and research trials using cohort studies or randomized can be considered as
evidence but there is a hierarchy. While the clinical experience and collective expert
opinions are considered to have least generalizability, randomized controlled trials
and systematic reviews of such trials are considered to be the most applicable
evidence.The quality of the evidence is based mainly on the epidemiological
principles [16].
The primary aim of using EBM model is to provide synthesis of the available
information to empower the doctors to take most informed clinical decisions. Using
this system has prevented the consumption of unsafe drugs, serious adverse effects
and use of ineffective medical practices. However, most of the revolutionary
concepts of modern medicine were developed in the late 19th and early and mid
20th century when the notion of EBM was not there. This period has witnessed
some of the most extra-ordinary medical inventions and they happened in the
absence of regulatory bodies.
Although EBM is the most scientic approach towards concluding the information
gathered, the process of EBM is very time consuming and has its limitations in
assessing the effectiveness. It is difcult to apply the evidence gathered collectively
from patients to an individual patient with dissimilar characteristics [16]. EMB
relies on the empirical evidence for informed conclusions and is unable to formulate
clinically relevant conclusions in absence of such evidence. Therefore most
common fallacy of EBM is that lack of evidence of efcacy is considered as lack of
efcacy itself. [16]. Empiricism of EBM undermines the philosophical origin of the
medical innovations that are based on the clinical expertise and pathophysiological
knowledge of the disease [16].
With the advent of evidence based medical practices, the development of new
therapies and drugs has become very time consuming and the burden of evidence
also increases the economical burden. Current process of developing new drugs
includes preclinical laboratory & animal testing as well as multiple phases of
human testing to rst establish its safety and then efcacy rst in a small group and
then in larger groups[17]. It takes approximately 6 to 8 years and $5,000,000,000 to
develop a new marketable drug [18]. It is almost impossible for a single medical
practitioner to spend the time and money required for this process. It can only be
done collectively or by corporate. It is based on commercial interest and demand
Stem Cell Therapy In Neurological Disorders 351

from the consumers rather than medical expertise. Therefore the rare disease get
neglected and development of drugs for rare diseases is limited.
So the debate is:
1. Are current medical practices for developing new treatments adhering to the
principle of Justice?
2. Are we then really observing the principle of benecence?[c] Is the system of
EBM which was developed for making efcient, scientic and evidence
informed clinical decisions, now perhaps slowing the pace of medical
evolution. Therefore although very essential, practice of EBM needs to be
relooked especially with reference to cell therapy.
Ethical Dilemmas of cellular therapy
The last decade has seen the evolution of cellular therapy. This is the eld of
regenerative medicine where healthy tissues could be used to replace or repair
damaged tissues. Cell therapy holds a special place in the development of
Neurorestorative treatments for otherwise incurable neurological
conditions.Development of cellular therapy has also sprouted debates on various
ethical grounds based on religious, social, political and capitalistic beliefs. It has
been unanimously accepted that the science of regenerative medicine is vast and
holds a tremendous potential of nding cure to various untreatable diseases. But in
the past there has been a strong opposition to research associated with embryonic
stem cell therapy. The genesis of this was the ban put by President George W Bush
on the federal funding of embryology stem cell lines developed after 2001. This ban
still remains in public memory with the result that subsequent clinical
developments in the eld have not received the recognition these should have. In
any case, this ban was subsequently lifted by President Barak Obama. Cellular
therapy consists of various other types of cells which are not of embryonic origin.
The ethical dilemmas associated with embryonic stem cells need not be applied to
the cells of non embryonic origin like umbilical cord stromal cells and adult stromal
cells. The medical community, patients and regulatory authorities need to make
this distinction and the objections for the use of one type of cells should not be
applied to the other types.
Another facet of the ethical considerations is using cellular therapy as a form of
treatment. Clinical practitioners in the eld of cellular therapy face a moral and an
ethical dilemma every single day of whether it is ethical to offer a treatment that has
not yet been approved as a standard of care for that disease? But if they deny a safe
and available treatment to the patients who have incurable diseases, just because
there efcacy has not been established by the modern medical standards and wait
for it to be established while the patients wither away, then Is that ethical? The basis
of this dilemma lies in the conict of the two fundamental principles of bio ethics,
Stem Cell Therapy In Neurological Disorders 352

Benecence and Non-maleence. On one hand one is expected to always benet the
patient on the other one may not offer the treatments to the patients unless those are
approved as per the modern medical standards. By not offering such treatments
one is actually violating the principle of non-maleence through omission. EBM in
modern medicine has become synonymous with ethical medical practice. But the
unique challenges put forth by evolution of cellular therapies demands us to
rethink about this. Cellular therapies are far more dynamic and diverse than drug
therapies and therefore it may take decades or more to generate empirical evidence
validating use of cellular therapy as a treatment form. The generation of such
evidence will also be dependent on various socio-politico-economic variables and
not on the need for medical innovation alone.Is it fair then, that on one hand we
claim to protect patients from adverse effects and ineffectiveness of the therapy
using EBM whereas on the other hand we let them die or suffer waiting for the
treatment? It is time to revisit the concept of 'Practice Based Evidence' (PBE) and not
rely solely on 'Evidence Based Medicine'. Whereas EBM may perhaps jeopardize
the autonomy of the patients in choosing an unproven treatment for the lack of any
other proven treatment, PBE protects such autonomy. PBE respects the evidence
generated from a single practitioner whereas EBM will disregard it as the lowest
form of the evidence. But this lowest form of the evidence is what has given
medicine its most brilliant inventions. Medical eld progressed when the
individual clinical practitioners pioneered newer forms of therapy based on their
clinical experience and expertise. Most of the surgical practice comes from
individual surgical expertise and cannot be tested using multicenter randomized
controlled trials. Day to day decisions made in an intensive care setups and
operating rooms are primarily inuenced by the clinical circumstances at hand and
the clinicians own experiences in dealing with such situations. Not everything in
the medicine can be measured on the yardsticks of EBM; neither can it all be tested
using EBM. Further the question remains when can a particular form of treatment
be considered to have conclusive evidence? How many clinical trials will it take for
us to get that evidence? The more daunting question is whether we have the funds,
the resources and the time to conduct multitude of trials. Should we accept to slow
the pace of medical advancements for lack of funds and resources for formal clinical
trials? PBE could therefore be a key to faster progress in medicine. Both the
paradigms of evidence based medicine and practice based evidence need to co-
exist. The science of cellular therapies provides a unique opportunity for this co-
existence. This does not mean that the treatments should not be tested scientically.
Novel treatments must be very stringently monitored for its safety. However once
the safety has been established, the use of such treatments may be permitted in case
of the diseases where there are no other treatments available. Not only these
treatments should be permitted but also more and more number of practitioners
should be involved in providing these treatments so that a large body of evidence
can be generated. Greater availability would also make such treatments easily
Stem Cell Therapy In Neurological Disorders 353

available and less expensive. Rather than relying on the corporates to generate
evidence, individual practitioners and institutions should also be empowered and
entrusted.
An ethical dilemma that often confronts practitioners of cellular therapy is whether
it is appropriate to charge for treatments that are yet unproven. The answers to
questions like this are complex however in general it could be said that what is
important is whether a treatment method should or should not be offered to a
patient. If it is ethical to offer a treatment to a patient that will benet the patient then
it there should not be any ethical issues about charging for the same.
Ethical Basis Of Stem Cell Therapy:
Ethical principles like autonomy, benecence, non-malecence and justice are
expected to be adhered to in the medical research and treatment according to the
modern regulatory practices. The primary intention of these is to safeguard the
patients who are the consumers of medical services from any risk and exploitation
during research and therapy. The evolution of cellular therapy as a new form of
treatment has opened up a new debate about ethics of the stem cell practice.
American society of gene and cell therapy denes cell therapy as the,
'Administration of live whole cells or maturation of a specic cell population in a patient for
the treatment of a disease by American society of gene and cell therapy.' The primary aim of
cellular therapy is to repair the damaged tissue by replacement or regeneration of
new cells. Therefore cellular therapy is different from the drug therapies where a
single molecule is investigated for a putative benecial effect.
When considering whether stem cells can be offered as a form of treatment or not,
there are two extreme views. There are those that strongly oppose the offering of
cellular therapy as a treatment form till there is denitive evidence of its
effectiveness. On the other hand there are the practitioners of these treatments who
believe that patients suffering from many of the untreatable conditions should not
be denied these treatments just because they are still unproven. Both sides are
correct in their own ways and both these views are like two sides of a coin. The
existence of one does not negate the other. Together they make a whole. It is
therefore time to relook at the ethics, regulations and principles of evidence based
medicine in a new light in connection with cellular therapy.
The ethical basis of offering stem cell therapy as a treatment option is based onthe
Paragraph no. 32, World Medical Association Declaration of Helsinki-
EthicalPrinciples for Medical Research Involving Human Subject. It states that "In
thetreatment of a patient, where proven prophylactic, diagnostic and therapeutic
methodsdo not exist or have been ineffective, the physician, with informed consent
from thepatient, must be free to use unproven or new prophylactic, diagnostic and
therapeuticmeasures, if in the physicians judgment if offers hope of saving life,
Stem Cell Therapy In Neurological Disorders 354

reestablishinghealth or alleviating suffering. Where possible, these measures

should be made theobject of research, designed to evaluate their safety and efcacy.
In all cases, newinformation should be recorded and, where appropriate,
published."In accordance to theInternational policies as stated in the Helsinki
Declaration,our centre NeuroGen Brain & Spine Institute follows the
guidelines.There are in addition some other aspects of the Stem cell therapy debate
thatneed further discussion.
These are:
(1) That there is a need to make a clear cut distinction between embryonic
stemcells and adult stem cells whilst strict regulations for embryonic stem
cell workare completely justied the same are not needed for adult stem cell
work.
(2) That there is a need to look at the whole issue from the patients point of
viewrespecting the fact that even small functional improvements can mean a
lot to aparticular patient.
(3) That there is a ethical ground for offering stem cell therapy as a treatment
optionbased on the Helsinki declaration.
(4) That there is enough published clinical evidence about the safety and
efcacy ofadult stem cells in neurological disorders and based on this
evidence there is noneed to keep on doing trials.
To elaborate on the above points:
(1) That there is a need to make a clear cut distinction between embryonic stem cells
and adultstem cells whilst strict regulations for embryonic stem cell work are
completely justiedthesame are not need for adult stem cell work:-
It is clear from all the above that the entire ethical debate regarding stem celltherapy
revolves around the use if embryonic stem cell and cloning. There areno ethical
issues with the use of autologous stem cells derived from bone marrow,Yet there
are various restrictions in place for the use of any types of stem cells indifferent
countries. Until everyone concerned starts looking at stem cells of nonembryonic
origin differently from embryonic stem cells we will continue to
involved in debating the issue and the price for these delays are paid for by
thepatients for no fault of theirs. Herein lies the tragedy. There is available a formof
cellular replacement therapy that can give relief to millions of patients, forwhich
there is enough published clinical evidence of safety and a satisfactorypublished
evidence of efcacy yet this treatment cannot be freely used by oneand all. It is our
belief that by letting patient suffer and at time side when there
are treatment option with stem cells that could possibly benet them is unethical.
Stem Cell Therapy In Neurological Disorders 355

(2) That there is a need to look at the whole issue from the patients point of view
respecting the
fact that even small functional improvements can mean a lot to a particular
patient:We tend to judge improvements from normal peoples point of view. We
don'trealize that even small improvements, seemingly unimportant to us, can make
aquantum difference in the lives of patients paralyzed with neurological
problems.The Beijing Declaration of the International Association of
Neurorestoratology(IANR) says it "recognizes the importance of small functional
gains that havesignicant effects on quality of life". We need to stop being arm chair
professors and talking only about evidence based medicine. We have to look at this
fromthe point of view of the patients. To highlight this we highlight a case
whichshow us how improvements that may mean nothing to us can mean the
world tosuffering patients. This was one of the rst cases of multiple sclerosis
treatedwith stem cells. Patient had a lot of improvements including signicant
improvements in her speech, ability to use her hand to hold a cup and her
mobile,ability to sit without support, ability to stand with support. All of these
werenot possible before the stem cell therapy treatment. Yet the improvement
thatmattered to her more than all of these was something very small. Earlier
whenlying in the prone position she could not turn in bed by herself. After the
stemcell therapy she could do so. Prior to the treatment every night she would
haveto wake up her grandmother 3-4 times a night to help her turn her position
inbed. This used to upset the patient since it used to emotionally hurt and pain
herthat she had to wake up her grandmother multiple times in the night just to
turnher. And she needed to turn since sleeping in one position would make her
veryuncomfortable. So despite all her otherimprovements with her speech and
handswhat made her most happy and the improvements that mattered to her
themost was after the treatment she could turn in bed by herself and did not haveto
wake up her grandmother every night. This has been highlighted just tomake one
very simple point. That we must look at this entire issue from the patients point of
view. We musts recognize that small improvements that do notmean anything to us
can mean a lot to a patient with severe physical limitations.That at the end of the day
all ethics, moral, values principles, laws and regulationshave just one purpose. The
well being of the common man.
What has unfortunately happened in the eld of stem cell therapy is that
theregulations we have made to protect ourselves are now limiting us and tying
usup. These regulatory chains need to be unshackled. Physicians need to be free
touse whatever modality of treatment they believe is in the patients best
interests.However the other side of the argument is that these are helpless patients
andthey are likely to be exploited by physicians offering stem cell therapy. We
musthowever note that there are black sheep in every profession. That those
whodon't have values and principles are doing all manner of unprincipled
Stem Cell Therapy In Neurological Disorders 356

andunethical practices with conventional treatments also. On the other had

thereare researchers who have been working in this eld for many years both in
thelaboratory as well as clinically. They should be permitted to offer treatmentsthey
believe are safe and will benet patients. Unless more physicians offer
these treatments there will always be a supply demand gap with the result thaty
by night operators will enter the eld to make money. Therefore freeing upthe eld
will bring more transparency and accountability to this aspect of medicaltreatment.
That there is a ethical ground for offering stem cell therapy as a treatment option
based on the Helsinki declaration:-
The Helsinki Declaration that has been discussed earlier in this chapter makesone
thing very clear that for diseases for which there are no cures or the cureshave been
ineffective the physician is justied in using an unproven treatment ifthe physician
believes that it will benet the patient. This is the ethical bedrockon which we offer
stem cell therapy as a form of treatment for neurologicaldisorders for which there
are no other treatments.
That there is enough published clinical evidence about the safety and efcacy of
adult stemcells in neurological disorders and based on this evidence there is no
need to keep on doing trials. In the section on clinical aspects we have mentioned in
this book numerous studies that have clearly shown the safety and efcacy of adult
stem cells invarious neurological disorders. A question that remains unanswered is
whendoes a treatment that is "unproven or experimental" become a treatment that
is"proven or established". How many publications documenting safety and
efcacywill it take to make that shift ? Is a single publication enough, or are 10, 50 or
100ok, or are multicentric international trials the only basis to make any
treatmentoption an excepted form of treatment. Is it necessary to go on reinventing
thewheel just to satisfy our intellectual considerations whilst millions of
patientscontinue to suffer?
Ethical issues surrounding the stem cell research and practice are complicated.
There is growing published evidence about safety and efcacy of stem cell therapy
explains the ethics of offering it to patients with incurable disorders who otherwise
have no other option than to endure the suffering.
REFERENCES
1. Testimony of Ronald Cole-Turner, Ethical Issues in Human Stem Cell Research,
Commissioned Papers, Volume III Religious Perspectives,2000: A1.http://
www.bioethics.gov/reports/past_commissions/ nbac_stemcell3.pdf
2. Testimony of Rabbi Elliot N. Dorff, Ethical Issues in Human Stem Cell
Research, Commissioned Papers, Volume III Religious Perspectives, 2000: A-1.
http:// www.bioethics.gov/reports/past_commissions/ nbac_stemcell3.pdf.
Stem Cell Therapy In Neurological Disorders 357

3. Ethical Issues in Human Stem Cell Research, Commissioned Papers, Volume III
Religious Perspectives, 2000; http://www.bioethics.gov/reports/
past_commissions/nbac_stemcell3.pdf
4. Holland, S., Lebacqz, Karen., and Zoloth, L., eds. The Human Embryonic Stem
Cell Debate: Science, Ethics, and Public Policy. (Cambridge: MIT Press, 2001).
5. The Pew Forum on Religion and Public Life, Religious Groups' Ofcial
Positions on Stem Cell Research, July 17, 2008,
http://pewforum.org/docs/?DocID=319
6. Clinical trial overview: neuronal ceroid lipofuscinosis (NCL, often called
Batten disease).Available at: http://www.stemcellsinc.com/clinicaltrials/
clinicaltrials.html. Accessed March 4,2009.
7. 18 December 2008 StemCells, Inc. receives FDA approval to initiate clinical trial
of HuCNS-SC cells in a myelin disease. Available at: http://
www.stemcellsinc.com/news/081218.html. Accessed March 3, 2009.
8. International Society for Stem Cell Research 2008 Endorse the open letter.
Support all forms of stem cell research. Available at: http://www.isscr.org/
Science StatementEndorsers.cfm. Accessed January 7, 2009.
9. Fraud and misconduct in science: the stem cell seduction. Implications for the
peer-review process. M.A.G. van der Heyden, T. van de Ven and T. Opthof.
Neth Heart J. 2009 January; 17(1): 25-29.
10. Ethical aspects of umbilical cord blood banking. Opinion Of The European
Group On Ethics In Science And New Technologies To The European
Commission. No.19
11. Ethical aspects of umbilical cord blood banking. Ofcial Journal L 281, 1995;
0031 - 0050. 12. Bulger, R.E. (2002). Research with Human Beings. In Bulger,
R.E., Heitman, I., & Reiser, J. (Ed.), The Ethical Dimensions of the Biological and
Health Sciences (pp 117-125). New York: Cambridge University Press.
13. Lawrence, D. J. (2007). The four principles of biomedical ethics: a foundation for
current bioethical debate. Journal of Chiropractic Humanities, 14, 34-40.
14. Sackett, D. L., Rosenberg, W., Gray, J. A., Haynes, R. B., & Richardson, W. S.
(1996). Evidence based medicine: what it is and what it isn't. British Medical
Journal, 312(7023), 71-72.
15. Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010).
Evidence-based practice: step by step: the seven steps of evidence-based
practice. AJN The American Journal of Nursing, 110(1), 51-53.
16. Cohen, A. M., Stavri, P. Z., &Hersh, W. R. (2004). A categorization and analysis
Stem Cell Therapy In Neurological Disorders 358

of the criticisms of evidence-based medicine. International journal of medical

informatics, 73(1), 35-43.
17. Klees, J. E., &Joines, R. (1996). Occupational health issues in the pharmaceutical
research and development process. Occupational medicine (Philadelphia, Pa.),
12(1), 5-27.