Cortical Activation by Yamamoto New Scalp Acupuncture (YNSA) in

Thomas Schockert
R a l p h S c h n i t k e r, B a b a k B o r o o j e r d i , K l a u s V i e t z k e ,
I m Q u a - S m i t h , To s h i k a t s u Ya m a m o t o , F r a n k K a s t r a u
Cortical Activation by
Yamamoto New Scalp Acupuncture
(YNSA) in the Treatment
of Stroke Patients
A Sham-controlled Study aided by
Functional Magnetic Resonance Imaging (fMRI)
Kortikale Aktivierungen durch
Yamamoto Neue Schädelakupunktur
(YNSA) in der Behandlung
von Schlaganfallpatienten
Eine Sham-kontrollierte Studie mit Hilfe
der funktionellen Kernspintomographie (fMRI)
Author
Dr. med. Thomas Schockert
Specialist in General Medicine, Acupuncture, Naturopathy,
Emergency Medicine, Sports Medicine
Lecturer in Yamamoto New Scalp Acupuncture
Witten/Herdecke Private University, Department of Chinese Medicine
Alfred-Herrhausen-Straße 50, 58448 Witten, Gemany
Surgery address:
Am Eisernen Kreuz 2c
D-52385 Nideggen
Tel.: +49 (0) 24 27 / 90 24 24
[email protected]
www.dr-schockert.de
www.ynsa.net
2
Abstract
Zusammenfassung
Background: Yamamoto New Scalp Acupuncture was first
introduced 37 years ago. Today, it is the most often used
microsystem in acupuncture next to auriculotherapy.
Hintergrund: Die Yamamoto Neue Schädelakupunktur
wurde vor 35 Jahren entwickelt. Sie stellt nach der Aurikulotherapie die wichtigste Mikrosystemtherapie in der Akupunktur dar.
Aims: Can the efficacy of YNSA – by means of cortical activation – be visualized in fMRI? The neurological correlates
of YNSA were studied with the aid of fMRI in 17 patients
with ischemic stroke damage in the right hemisphere
suffering from residual paresis of the left hand versus
19 healthy volunteers. A new acupuncture needle for
magnetic resonance imaging developed by Schockert was
used in this study.
Fragestellung: Kann die Wirksamkeit der YNSA über die
kortikale Aktivierung im funktionellen Kernspin sichtbar
gemacht werden? Wir untersuchten die neurologischen
Korrelate der YNSA im funktionellen Kernspin an 17
Schlaganfallpatienten (rechte Hemisphäre mit linksseitigen Paresen) und 19 gesunden Probanden. Durchgeführt
wurde diese Untersuchung mit der Kernspinforschungsnadel nach Schockert.
Methods: The study was performed in a 1.5 tesla Philips
MRI system (TR 3000 ms, TE 50 ms, FA 90°) in a box-car
design. Patients were instructed via video goggles to open
or close their left hand for five seconds. The data were analyzed by the SPM 2 evaluation program. All patients and
volunteers were first subjected to sham acupressure and
then YNSA. The sham acupuncture consisted of a single
application of pressure by a finger nail in the centre of an
imaginary line between SJ 23 and Gb 14. In the verum
YNSA, needles were applied to the yin points of the basal
ganglia, cerebellum and basic point C.
Methodik: Die Untersuchung wurde in einem 1,5 Tesla
Philips MRI-System (TR 3000 MS te 50 ms, fa 90 Grad)
durchgeführt. Für die Datenanalyse wurde das Auswertungsprogramm SPM 2 verwendet. Alle Patienten und
Probanden erhielten einmalig Sham-Akupressur und anschließend YNSA. Als Sham erfolgte eine einmalige Akupressur mit dem Fingernagel in der Mitte einer gedachten
Linie zwischen SJ 23 und Gb 14. In der Verum-YNSA erfolgte die Nadelung der Yin-Punkte Basalganglien, Cerebellum
und Basispunkt C rechts.
Results: Of the 17 patients, only five measurements could
be evaluated due to motion artefacts. It was not possible
to make a group analysis because of the inhomogeneous
lesions. The cortical activations were different in each
patient. In contrast to the sham acupuncture, verum acupuncture displayed significant cortical activation in the
motor, premotor and supplemental motor cortex of the
patients. It was possible to evaluate the measurements of
the volunteers as a group analysis. In contrast to the
patients, the volunteers displayed a decrease in cortical
activation during YNSA.
Ergebnisse: Wegen der Bewegungsartefakte konnten von
17 Patienten nur fünf Messungen ausgewertet werden.
Anhand der inhomogenen Läsionen konnte keine Gruppenanalyse durchgeführt werden. Die kortikalen Aktivierungen waren bei jedem einzelnen Patienten unterschiedlich. Im Vergleich zur Sham-Akupunktur zeigte die
Verum-Akupunktur kortikale Aktivierungen im motorischen, prämotorischen und supplementärmotorischen
Kortex der Patienten. Die Messungen der Probanden konnten als Gruppenanalyse ausgewertet werden. Verglichen
mit den Patienten zeigten die Probanden eine Abnahme
der kortikalen Aktivierung während der YNSA-Behandlung.
Conclusions: Eight patients in this study experienced a
perceptible improvement in mobility and a reduction of
spasticity as a result of stroke treatment with YNSA. These
motor improvements positively correlate to cortical activity which can be visualized by functional magnetic resonance imaging. Further more extensive clinical and fMRI
studies are necessary in order to investigate YNSA-induced
cortical activation in stroke patients in deeper detail.
Schlussfolgerung: In dieser Studie erfuhren acht Patienten eine subjektiv spürbare Verbesserung ihrer Mobilität
und eine Abnahme der Spastik durch die Schlaganfallbehandlung mit YNSA. Diese Verbesserungen der Motorik,
die von den Patienten subjektiv erfahren wurden, zeigen
eine korrelierende kortikale Aktivität, die durch Kernspintomographie (fMRI) dargestellt werden kann. Zur detaillierteren Untersuchung der kortikalen Aktivierung durch
YNSA bei Schlaganfallpatienten werden weiterführende
klinische und fMRI-Studien benötigt.
Keywords
Schlüsselwörter
YNSA, fMRT, cortical activation, stroke, boldeffect
YNSA, fMRT, kortikale Aktivierung, Schlaganfall, Boldeffekt
Thomas Schockert
Introduction
Modern acupuncture research uses neuroimaging techniques such as fMRI, PET/CT and SPECT [1–7].
The only published data are using only TCM related data.
No neuroimaging studies on Yamamoto New Scalp Acupuncture (YNSA) have been published to date.
In this study the neurological correlates of the YNSA were
investigated in 17 patients with right ischemic brain lesions
leading to left hand paresis and in 19 normal volunteers
using fMRI. Investigations were performed using Schocker
MRI needle (placement of a plastic needle over a metal wire
which is subsequently removed).
Question
Patient recruitment
Patient and normal volunteers were recruited using a regional daily newspaper.
Inclusion criteria
Patients with ischemic right cerebral lesions and a paresis of
the left hand were recruited. They 70 years or younger and
had no history of acupuncture.
Exclusion criteria
Metallic objects in the body, claustrophobia, recent surgery,
attention deficits and apraxia were exclusion criteria.
Is it possible to visualize the effects of YNSA as cortical
activations? Where are these activations located in patients
with ischemic cerebral lesions?
Fig. 1: YNSA basal points with brain and sensory organ points
Cortical Activation by Yamamoto New Scalp Acupuncture (YNSA) in the Treatment of Stroke Patients
3
Methods
Investigations were performed using a 1.4 Tesla Philips MRI
(TR 3000 MS te 50 ms, fa 90Degrees) in a box-car-design. The
subjects received the instructions over video goggles. To
open and close the left hand for 5 sec. SPM2 was used to
analyze the data. All subjects received a sham acupressure
and YNSA. Sham acupressure was performed using the
fingernails in the middle of points SJ23 and GB14. Directly
after the sham acupressure the plastic part of the acupressure needle was fixed on the head using adhesive tape. As
subjects were wearing the video goggles they were not able
to see the sham stimulation. In the real acupuncture session
points Yin points basal ganglia, cerebellum and basal point
C (right) were stimulated.
YNSA
Prior to each YNSA treatment the appropriate point are
revealed using the neck diagnostic method. Pain is generally
treated ipsilaterally and paresis is treated contralerally. The
neck diagnostic methods ensure an individualized treatment for each patient. Afzet consultation with Prof. Yamamoto no neck diagnostic was performed in this trial and all
patients were treated in the frontal Yin-area at the basal
point C, basal ganglia point, and cebellum.
Paradigm
Five blocks with 120 s duration each: 3 sec closing of the fist,
2 sec opening of the fist
30 sec break
Three runs
No acupuncture
Sham acupuncture (patient is blinded: acupressure and
needle not inserted)
Real acupuncture
Data acquisition and analysis
•
•
•
•
•
•
•
•
•
MRI: Philips Achieva 1.5 T standard head coil
T2*-gradient echo EPR sequence
TR = 3000 ms
TE = 50 ms
Flip angle 90°
27 transversal layers with 4mm (+0.4mm)
250 volume
Voxel size 4×4×4 mm
Analysis in SPM2, random effect analysis, p < .001, corrected, cluster threshold k ≥ 10
YNSA FMRI research needle
Metal cylinder with plastic coating (Fig. 2). Similar to a
venous catheter the needle is placed, the metal needle is
removed and the plastic part is fixed with tape. Its size is
similar to a standard acupuncture needle (.3 × .3 mm).
Fig. 2: YNSA FMRI needle in comparison
to standard metal needle
4
Thomas Schockert
Ethics committee
This study was approved by Ethics committee of Aachen
University (Professor Martin Reim) in Nov 2008.
Data glove
The data glove has a light wave conducting circuit for each
finger. It is bent by the finger movements and based on the
amount of light which is transmitted through it the bending
of the fingers can be measured.
The total bending of the fingers is measured. As no metal
objects are used in the data glove, it can be used inside the
MRI scanner.
At the beginning of each measurement the subjects were
asked to open and close their fist and the data were recorded individually. Data were recorded at 10 Hz, leading to 50
data points for 5 fingers per second [10]. Fig 3.
Results
Data from 5 patients could be evaluated in this study based
on motion artefacts. Subjects had to stay about one hour in
the scanner and this was retrospectively too long. A group
Fig. 3: Data glove
analysis of the data was not possible. Compared to the
placebo acupuncture patients showed an increased cortical
activation in motor, premotor, and supplementary motor
areas (Table 1).
A group analysis was possible for the normal volunteers.
In contrast to the patients, normal volunteers showed a
reduction of cortical activation due to YNSA. The subjects
reported fatigue due to spending 1 hr in the scanner and
Table 1: Zusammenfassung der wesentlichen Aktivierungen
Name (Alter)
Ursache der Hemiparese
Sham-ohne (S-O)
Verum-ohne (V-O)
Verum-sham (V-S)
Sch., G.(57J.), m
hypertensive ICB rechts
Cingulum hinten; Gfm links
Gfs links deutlich; BA 23,
Mittellinie rechts hinten,
Sulcus parietalis transversus
BA 6 links; BA 5 links;
Gts links; Sulcus
parietalis transversus bds.
G., M. (65J., m)
Thalamus-/Stammganglienblutung rechts
Gfs oder Gfm pars superior
links; Gts oder Gyrus
angularis links
Cingulum hinten links;
Gfm links
Cingulum vorn (rechts);
Thalamus oder
Kaudatusschwanz links
S., D. (44 J.), m
Hirnstammischämie
nach Vertebralisdissektion rechts
GFS links; G. angularis links
und Sulcus intraparietalis bds.;
BA 4 rechts etwa Handareal;
Cingulum hinten oben
Sulcus intraparietalis links;
Cingulum rechts vorn;
G. angularis links
Cingulum rechts hinten;
Cingulum rechts oben
vorn; GFI pars orbitalis,
operculum links
Kl., H. (68 J.), w
Mittlerer Mediateilinfarkt rechts
Praecuneus BA31 rechts;
GFI pars orbitalis, operculum
links; Insel BA13
BA 4 rechts (Handareal);
GFM pars superior oder
GFS links; GFM pars superior
und GFS rechts; Cingulum
rechts oben; GFI pars
orbitalis, operculum links;
GTS rechts polar
Rechts Somatosensorik
BA 3 postcentral; GFM
pars superior links;
GFM pars inferior links;
G. angularis oder Slp
links; Cingulum hinten;
Parietotemporaler Übergang rechts direkt postcentral; Temporalpol
rechts
Ka., G. (43J.), m
Stammganglienblutung rechts
G angularis links; Periläsionell
etwa Insel rechts; GTS links
BA 6 rechts (Bein);
Precuneus BA 19 bds.;
GTM occipito-temp.Übergang links
Precuneus rechts BA 19;
Temporalpol rechts
BA = Brodman-Areal; PFC = Präfrontaler Cortex; Gfs = Gyrus frontalis superior; Gfm = Gyrus frontalis medius; Gfi = Gyrus frontalis inferior;
Gts = Gyrus temporalis superior; Gtm = Gyrus temporalis medius; w = weiblich; m = männlich
Cortical Activation by Yamamoto New Scalp Acupuncture (YNSA) in the Treatment of Stroke Patients
5
Table 2: Auflistung der einzelnen kortikalen Aktivierungen
Namen
Verum - ohne
BA
Sham - ohne
BA
Sch.
G. fusiformis
links
37
Gfm
links
47
G. parahippocampalis
GFd
rechts 30
G. parahippo- rechts
auditorisch und
visuelle Assoziation campalis
multimodales Are- GFs
links
al, veget., musikalische Funktionen ,
Sprache
limbisches System
rechts 10
GFs
Cingulum
anterior
GFm
0,001/12 Cingulum
posterior
Ga.
links
10
PFC
Cingulum
posterior
rechts
31
limbisches System
GTs
links
39
PFC
Praecuneus/
Cuneus
bds
links 10
rechts 24
PFC
prä-SMA
G.präcentralis links
G.postcentralis links
auditorisches Assoziationsfeld
18 + parietale Kortex
31 komplex; Hypnose,
episodisches Gedächtnis, aufmerksamkeit
6
Motorik
5
Sensomotorik
links
links
9
31
PFC
limbisches System
G. fusiformis
links
37
GFd
bds
10
PFC
links
30
24
prä-SMA
links
13
Prämotorik ?
Cingulum
anterior
Thalamus
bds
0,01/10
G. parahippocampalis
GFm
Cingulum
auditorisch und
visuelle Assoziation posterior
limbisches System GFd
Kl.
GTs polar
rechts 38
hören
rechts
38
hören
GTm
rechts 21
bds
23
limbisches System
links
19
rechts
links
40
9
sehr parietal, Interkonnektion
Assoziationsfelder
Prämotorik
9
2
Prämotorik
Sensomotorik
rechts
17
sehen
rechts
38
hören
Gfi
links
47
PFC
Cingulum
posterior
rechts
30
limbisches System
GFm
rechts
6
Prämotorik
links
30
links
9
links
47
recht
23
GFm
Cingulum
anterior
G.präcentralis
G.postcentralis
GFs
rechts 10
rechts 24
Cingulum
posterior
multimodales Areal, veget., musikalische Funktionen, Sprache
PFC
prä-SMA
rechts 6
rechts 2
links 6
Prämotorik
Sensomotorik
Prämotorik
Praecuneus
bds
23
links
19
GOm
links
19
rechts
13
links
39
0,003/10 GFm
Ka.
10
links
47
hören
rechts 6
S.
GOi
links
visuelle Integration G. lingualis
bds
18
GFi
rechts 47
PFC
links
19
GOm
links
19
links
39
GTm/G.angularis
links
39
Interconnektion
GTm/G.anguvisuelles System
laris
Sensomotorik
parietale Assoziati- Cuneus
onsfelder
rechts
19
bds
23
rechts
4
GOm
Cingulum
posterior
G.präcentralis
6
multimoGTs polar
dales Areal,
veget., musikalische
Funktionen,
Sprache
limbisches Cingulum
System
posterior
GTm
links
GFd
links
G.postcentralis rechts
0,001/20 G.präcentralis
0,01/10
limbisches
System
PFC
Gpi
GFm
parietale Kortex
GOm
komplex; Hypnose,
episodisches Gedächtnis, aufmerksamkeit,
Insel
Interconnektion
visuelles System
Sensomotorik
Prämotorik
GTs
18
limbisches
System
PFC
BA
Gfd
GFm
30
Verum - Sham
InterconCuneus
nektion
visuelles
System Sensomotorik
sehr vielfäl- GTs polar
tiges Assoziationsareal
Assoziationsfeld
visuelles
Integration
Interconnektion
visuelles
System Sensomotorik
parietale
Assoziationsfelder
visuelle
Interkonnektion
limbisches
System
Motorik
Thomas Schockert
Fig. 4
they became sleepy. The activity pattern of a 68 year old
patient is reported in Fig 4 as an example.
Subjectively reported changes in patients:
“my left hand is more relaxed”
“my left leg is more mobile and somehow more stable”
“my had is surprisingly relaxed”
“I feel pins and needles in my left side and left leg”
“my fingers are open now”.
Data analysis of the subjects
Without: Cortical activation was shown in motor cortex, cingulated gyrus and occipital lobe.
Sham: Identical to without
Real acupuncture: No activation in cingulated gyrus. It is
part of the limbic system a multimodal area with important
afferent and efferent connections which is involved in
planning of complex and difficult movements. Data from
13 subjects could be analysed without artefacts. Theoretically a lack of activation in cingulated gyrus could be a training
effect or a selective inhibition of this area by YNSA. Without
acupuncture or with sham acupuncture cortical activation
could be observed close to DU20. This activation is not seen
after real acupuncture. So it is conceivable that this is a
specific YNSA effect.
Discussion
In the western world stroke is still the leading cause of
disability in adults, often in form of hemiparesis [11].
According to the guidelines of the Neurological German
society YNSA can be a valuable addition in the motor rehabilitation after stroke [12].
Because no effect of the medical primary prevention of
stroke has been shown to date, activities are focused on
reduction of cardiovascular risk factors and treatment of
cardiac arrhythmia and atrial fibrillation. The secondary prevention strategies are based on drugs [13]. Rehabilitation
uses several methods and can be enriched using YNSA and
reduction of hematocrit via hemodilution (Allport et al.,
[14]).
Because of the huge economic burden of stroke YNSA
can be an alternative method in the routine therapy of
stroke.
Mechanisms of action and activation patterns
The voluntary motor act is based on several brain areas.
Beside motor cortex, other areas such as supplementary
motor 8SMA and pre-SMA) and cingular motor cortex are
involved. By building complex contrasts (V-O, S-O) in the
fMRI data the repetitive uniform effects of Brodman Area 4
are masked and the initiation of the hand movement under
the effects of YNSA are visible. Because of the small sensory
input of the professional acupuncture, no BOLD effect is
seen in thalamus or primary sensory areas after sham or real
acupuncture. Such effects are seen after stimulation of
mechanoreceptors. Most subjects show parietal activations
of the association fields which are involved in the integration of somatosensory information. This is often seen in the
complex contrast of V-S which shows the real acupuncture
effect.
Clear differences could be seen between the activation
patterns under real and sham acupuncture. During sham
acupuncture no areas were activated which were involved
in planning and coding of the movements. During the real
acupuncture sessions such areas were active on the ipsilateral side (affected by stroke). This main effect could be seen
after building a contrast between two conditions. Activation
of multimodal areas such as prefrontal cortex is a common
finding in both conditions. The limbic system is active in
Cortical Activation by Yamamoto New Scalp Acupuncture (YNSA) in the Treatment of Stroke Patients
7
several patients. A modulating effect has been shown
previously with the fMRI [16].
Activations in visual and auditory areas are inhomogeneous and are possibly related to the video goggles and noise
in the scanner.
It is conceivable that a reduction of the interhemispheric
inhibition is the basis for the effects of acupuncture on preand supplementary motor areas [17]. Most studies in this
field were performed using transcranial magnetic stimulation as fMRI is not able to show the interhemispheric connections yet.
Practical problems of the investigations
Retrospectively the following problems could be observed
in the practical conduct of this study: Patients had to stand
still in the scanner for about one hour. This was very tiresome and difficult for the patients. In addition, it is conceivable that patients had major concentration problems during
the third block (real acupuncture).
We were not able to show the motor improvement using
the data glove. Tiresome repetitive movements are possibly
not appropriate to assess dynamic changes because attention problems are possibly working against such improvements. We don’t think that improvements in force or acceleration of movement lead to the observed fMRI changes but
that improved central motor planning and coordination
have enabled the subjects to use their remaining resources
more effectively. Data gloves are not able to assess such
changes. Topometric measurements as performed in the
YNSA study I Bonn [18] are possibly a better choice to
measure this phenomenon but this method cannot be used
in combination with the fMRI.
An objective assessment of the motor improvements and
a possible correlation with the cortical activation results has
not been performed in this study.
Only 5 out of 17 data sets in patients can be analyzed
completely. Movement artefacts could often not be compensated. It was not possible to pool the data, as in different
patients different sensory-motor areas and pathways were
affected by the stroke. In addition, different significance
levels had to be set for individual patients. Thus, a group
statistical analysis of the data was not possible.
Despite these problems general assessments of the
activation patterns based on functional systems could be
performed (Table 1).
In normal volunteers we could show an activation of the
cingulated gyrus in conditions without acupuncture and
with sham acupuncture. There is no activation of the cingulated gyrus under real acupuncture. It is possible that this
8
effect is based on YNSA. We cannot say why this activation
could not be seen under YNSA but it is conceivable that
YNSA induces activation and inhibition patterns individually
in different patients and different treatment sessions. Because activation of the cingulated gyrus was seen both in
the sham condition and in the condition without acupuncture, we believe that patients were not able to distinguish between these 2 sessions.
Another retrospective caveat of the data is based on the
order effect. It is theoretically possible that the effects in the
motor system are based on the order of the performed
manipulations. This could have been solved with a crossover design.
Stroke rehabilitation has changed in recent years based
on new therapies such as task oriented and repetitive exercises, therapy with forced use of a limb, bilateral training,
treadmill training and electrical stimulation [15]. Mirror
therapy is another interesting supportive method [21, 22].
For stroke patients the effects of the acupuncture of the
brain points and the anti-spasticity point at basal joint of the
second toe [9] should be investigated in the future.
Lee and co-workers have shown in a SPECT study that
acupuncture in the stroke rehabilitation can induce activations close to the lesioned areas and can induce reorganisation in the brain [4].
Kong and co-workers could show that stimulation of the
point Hegu (colon 4) with needles and electrical stimulation
over the needle can induce different cortical activations [3].
Acupuncture and sham acupuncture
The effects of the sham and real acupuncture in this study
are individual reactions which are related to the lesion,
disease duration and the intensity of the neurological
deficits. Differences between sham and real acupuncture
could be seen in this study. Whereas sham acupuncture did
not lead to premotor and motor activations, sham acupuncture led to changes in areas responsible for planning of
actions and movements. This seems to be the main specific
effect of YNSA.
In this study 8 patients experienced a subjective improvement in their movements and a reduction of spasticity. Such
improvements could also be shown objectively using realtime ultrasound topometry in another pilot study with
23 patients [29].
The good results of this study should encourage the use
of YNSA as a supportive measure in stroke rehabilitation as
8 out of 17 patients had a subjective improvement after this
treatment.
Thomas Schockert
Further larger clinical and fMRI studies are needed to
investigate the cortical activation induced by YNSA in stroke
patients in more detail.
Future prospects
We hope that this study will help neurologists and rehabilitation specialists to use YNSA as a supportive therapy of stroke.
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Information on the author (Stricta requirements)
Thomas Schockert (born 1966) studied medicine at RWTH Aachen University from 1987 to 1994. He received clinical
training in anaesthetics, surgery, internal medicine and naturopathy. He has undertaken several courses of training in
acupuncture abroad, including China and Japan with Dr. Yamamoto. He received his diploma from the German Medical
Association for Acupuncture (DÄGfA) in 2003. He completed his qualification as a specialist in general medicine in 1999.
Additional specializations: acupuncture, naturopathy, emergency medicine, sports medicine.
Since 2003 authorized to provide further training in YNSA, and since 2006 authorized to hold courses in naturopathy by
the North Rhine General Medical Council. Since 2007 lecturer in YNSA at Witten/Herdecke Private University. Set up his
own practice for integrative medicine nine years ago. Other areas of interest are YNSA research, emergency medicine and
organization of YNSA seminars.
Cortical Activation by Yamamoto New Scalp Acupuncture (YNSA) in the Treatment of Stroke Patients
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