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Thomas Schockert · Florian Beißner

Neurophysiological Correlates
of the Effect of YNSA
for Patients with Chronic Pain
of the Locomotor System
Basic YNSA Research by Means of PET-CT

Neurophyiologische Korrelate
der Wirkung von YNSA bei
Patienten mit chronischen Schmerzen
des Bewegungsapparates
YNSA-Grundlagenforschung mittels PET-CT

Author
Surgery address:
Dr. med. Thomas Schockert Am Eisernen Kreuz 2c
Specialist in General Medicine, Acupuncture, Naturopathy, D-52385 Nideggen
Emergency Medicine, Sports Medicine Tel.: +49 (0) 24 27 / 90 24 24
Lecturer in Yamamoto New Scalp Acupuncture thomas-schockert@gmx.net
Witten/Herdecke Private University, Department of Chinese Medicine www.dr-schockert.de
Alfred-Herrhausen-Straße 50, 58448 Witten, Gemany www.ynsa.net
Abstract Zusammenfassung

Background: The practical and clinical application of Hintergrund: In der praktischen und klinischen Anwen-
YNSA yields rapid and permanently positive results for dung der YNSA zeigen sich rasche und anhaltend positive
patients experiencing pain of the locomotor system. As Behandlungsergebnisse bei Patienten mit Schmerzen des
yet, the areas of the central nervous system influenced by Bewegungsapparats. Die zentralnervösen Angriffspunkte
YNSA for acute and chronic pain have not been identified. der YNSA bei akuten und chronischen Schmerzen sind bis-
The study reported here was motivated by the promising her nicht verstanden. Vielversprechende Ergebnisse in der
results obtained by acupuncture research using imaging Akupunkturforschung mit bildgebenden Verfahren haben
methods. zur Durchführung der hier vorliegenden Untersuchungen
geführt.

Issues: The aim of the study reported here was to investi- Fragestellung: Ziel der vorliegenden Studie war die
gate potential areas of the central nervous system influen- Untersuchung potenzieller zentralnervöser Angriffspunkte
ced by YNSA in the treatment of patients with chronic pain der YNSA bei der Behandlung von Patienten mit chroni-
resulting from diseases of the locomotor system. To this schen Schmerzen aufgrund von Erkrankungen des
end, changes in the cerebral glucose metabolism were Bewegungsapparates. Hierzu wurden Veränderungen des
measured by PET-CT. cerebralen Glukosestoffwechsels im PET-CT gemessen.

Methods: Positron emission tomography (PET) uses wea- Methodik: Die Positronen-Emissions-Tomographie (PET)
kly radioactively labelled glucose to measure the metabo- ermöglicht mittels schwach radioaktiv-markierter Glukose
lic activity in selected regions of the human body. In the eine Messung der Stoffwechselaktivität in beliebigen Tei-
brain, the method has the advantage of permitting the len des menschlichen Körpers. Im Gehirn bietet diese
indirect measurement of brain activity. In the present Methode somit die Möglichkeit einer indirekten Messung
study, two PET-CT measurements were performed on each der Hirnaktivität. In der vorliegenden Studie wurden an
of three patients suffering from chronic pain of the loco- drei Patienten mit chronischen Schmerzen des Bewe-
motor system at intervals of a few days. While the first mea- gungsapparates im Abstand von wenigen Tagen je zwei
surement served as a reference, YNSA treatment was PET-CT-Messungen durchgeführt. Während die erste Mes-
applied shortly before the second measurement. The sung als Referenz diente, wurde kurz vor der zweiten Mes-
results of the two measurements were then compared. In sung eine YNSA-Behandlung durchgeführt. Die Ergebnisse
addition, changes in the pain experienced were measured beider Messungen wurden dann miteinander verglichen.
by a visual analogue scale (VAS). Zusätzlich wurden Veränderungen der Schmerzen mittels
einer visuellen Analogskala (VAS) gemessen.

Results: On average, YNSA led to a significant increase in Ergebnisse: YNSA führte im Mittel zu einer deutlichen Er-
neural activity in cortical and subcortical areas. Activations höhung der neuronalen Aktivität in kortikalen sowie sub-
were found in the periaqueductal grey, thalamus, insular kortikalen Arealen. Im Einzelnen wurden Aktivierungen im
cortex, posterior cingulate cortex, lateral frontal and pre- periaquäduktalen Grau, Thalamus, Insula, posteriorem
frontal cortex, as well as in the cerebellum and the basal Cingulum, lateralem Frontal- und Präfrontalcortex sowie
ganglia. For all three patients, a comparison of the VAS im Cerebellum und den Basalganglien gefunden. Der Ver-
values indicated considerable pain relief after YNSA. gleich der VAS-Werte zeigte bei allen drei Patienten eine
erhebliche Schmerzlinderung nach der YNSA.

Conclusions: All the patients profited perceptibly from the Schlussfolgerung: Alle Patienten haben von der einmalig
single application of YNSA and experienced significant durchgeführten YNSA gut profitiert und eine deutliche
pain relief. The areas identified as displaying a rise in activi- Schmerzlinderung erfahren. Die gefundenen Areale, die
ty can be assigned to the nociceptive and the motor einen Aktivitätsanstieg zeigten, lassen sich dem nozizepti-
system, which represents a possible explanation for the ven sowie dem motorischen System zuordnen, was einen
most frequently observed effects of YNSA. möglichen Erklärungsansatz für die am häufigsten beob-
achteten Wirkungen der YNSA darstellt.

Keywords Schlüsselwörter

YNSA, PET-CT, pain, locomotor system YNSA, PET-CT, Schmerzen, Bewegungsapparat

2 Thomas Schockert, Florian Beißner


Introduction The patients’ subjective perception of pain was measured
immediately before and after YNSA treatment and after
Disorders of the locomotor system are one of the most conclusion of the PET-CT examination by a visual analogue
frequent reasons for the long-term administration of anti- scale (VAS).
inflammatory drugs and analgesics. Both nonsteroidal and
also steroidal pharmaceuticals involve the risk of significant
Inclusion criteria
side effects, which often represent a considerable burden
for the patients affected. Criteria for inclusion in the study were severe pain in the
Chronic disorders of the locomotor system are an im- region of the lower extremities, age over 18, readiness not to
portant field of indications for Yamamoto New Scalp eat or drink for 12 hours before the examination, and the
Acupuncture (YNSA) [1]. This is an acupuncture method ability to lie still for 30 minutes so that the PET images would
which provides rapid long-term relief for pain of the loco- not be spoilt by movement artefacts.
motor system. Special neck diagnostics performed before
each treatment provides the basis for individualized therapy
Exclusion criteria
[2]. With respect to the effectiveness of YNSA for stroke
patients, one of the authors was able to demonstrate Patients with pain not emanating from the locomotor
changes in the central nervous system in an fMRT study system were excluded from the study as were diabetics and
involving 36 patients [3]. In contrast, as yet no study has patients undergoing Marcumar treatment.
been made of the areas stimulated by YNSA for patients
with chronic pain due to disorders of the locomotor system.
Yamamoto New Scalp Acupuncture (YNSA)
In the study reported here, three patients were treated by
YNSA for chronic pain arising from disorders of the locomo- According to the currently applicable official rules of YNSA
tor system. The indication for positron-emission computer [1], before treatment can begin an examination must be
tomography (PET-CT) was given by an evident component made of the lateral neck triangle by YNSA neck diagnostics.
of the disorder that was either neurological or related to the In the case of disorders affecting regions below the
central nervous system for each patient and also to rule out diaphragm, an inspection of the palms of both hands and
the possibility of neoplastic origin. Since chronic pain is palpitation according to Hegu (Di 4) can be dispensed with.
manifested by the activation of distinct cortical networks, Neck diagnostics always starts with palpitation of the two
the aim of the present study was to identify the potential kidney points. The diagnostics provides basic information
areas influenced by YNSA during the treatment of chronic about the side on which treatment should begin and,
pain on the level of the cortex or subcortical regions. depending on the subjective perception of the person be-
ing treated, about whether needles should be applied to the
frontal yin or dorsal yang treatment area. If the person being
Patients, Materials and Methods treated experiences sensitivity to pressure during palpita-
tion of the kidney point then treatment will be applied in
Investigation sequence
the front yin area. Either the parietally located Y points can
Informed consent was obtained from the patients by means be used or exclusively the cranial nerve points located in the
of a public lecture on the day before the examination and yin area. At the moment, there are no hard and fast rules
also on the day of the examination using the form for concerning when cranial nerve points or Y points are to be
informed consent employed by the Medizin Center Bonn, used. The choice is up to the therapist. Cranial nerve points
headed by Prof. Dr. Dr. Jürgen Ruhlmann. Before the exami- and Y points can also be combined. If, for example, a treat-
nation, the weakly radioactive glucose tracer was administe- ment area has been destroyed by trauma or an operation,
red intravenously. After waiting for 30 minutes, the cranial especially in treatment for apoplectic insult due to cerebral
PET-CT measurement was then performed, which took about haemorrhage, or if the treatment is made more difficult due
20 minutes. to the lack of a cranial vault or restricted by extensive scar-
The second measurement was performed a week later. ring, then, depending on anatomical conditions, the points
Before this measurement, individualized YNSA treatment may be freely selected from both somatotopes.
was applied after neck diagnostics. The procedure was the The basic treatment points A for the cervical spine, E for
same as on the first day of the study: injection, waiting the thoracic spine and D for the lumbar spine were identi-
period, PET-CT measurements. fied with the aid of the neck diagnostics.

Neurophysiological Correlates of the Effect of YNSA for Patients with Chronic Pain of the Locomotor System 3
YNSA is not “ready-made” acupuncture but rather a treat- Results
ment tailored to the individual patient [2].

Individual patients
PET-CT
Patient: G.J. (born 1985)
At the start of the PET examination, a radiopharmaceutical Symptoms: Gonalgia in the right knee after an accident at
(glucose tracer) is administered to the patient intravenously. work on 27.02.2007. Putting too much weight on the joint
The tracer decays in the patient’s body (β+ decay) leading to led to increasing pain in the region of the right knee joint.
the emission of positrons. The interaction of a positron with Subjectively, the pain was perceived as a nail being driven
an electron in the body leads to the emission of two high- upwards from the lower outer region into the joint.
energy photons in precisely opposite directions, i.e. at an Measurements: 1st PET-CT: 16.11.07, 2nd PET-CT: 20.11.07.
angle of 180° relative to each other. The PET scanner con- YNSA treatment points: Cranial nerve points (CNP) kidney,
sists of a number of detectors arranged in a ring around the pericardium, heart, gall bladder, liver, right G2, basic point D
patient which record the photons emitted during the reac- ipsilaterally and extra point knee right (8 needles).
tion described above. The fundamental principle of PET VAS values (0–100):
measurement is the recording of coincidences between two − before treatment: 26
detectors positioned directly opposite each other. The spa- − after treatment: 10
tial distribution of the tracer inside the patient’s body can be − after PET-CT: 0
reconstructed from the spatial and temporal distribution of Telephone follow-up on 09.03.2010:
these recorded decays. The result can be depicted in a series After acupuncture treatment, pain did not reoccur in the
of cross sections. knee in the same form as previously subjectively perceived
The radionuclide most frequently used for PET examina- before YNSA treatment. Only in the case of extreme strain,
tions is the radioactive isotope of fluorine (18F). It can be e. g. protracted jogging, does the pain occur in isolated
produced with the aid of a cyclotron and due to its relatively cases during the activity.
long half-life of about 110 minutes it can be transported
over considerable distances. Patient: K.S. (born 1964)
The radiation burden of a whole-body PET-CT examinati- Symptoms: Condition after herniated vertebral disc 14 years
on corresponds roughly to nine months’ natural exposure to ago, muscular tension in the region of the lumbar spine and
cosmic radiation. The safety of this method has been amply the iliosacral joint, weakness in dorsal flexion of the foot and
demonstrated [4–6]. toes on the left-hand side with muscular atrophy of the left
leg, severe pain in the entire left leg and knee.
Measurements: 1st PET-CT: 22.11.07, 2nd PET-CT: 27.11.07.
Processing the image data
YNSA treatment points: CNP kidney, bladder, lung, stomach,
The data from the two measurements were co-recorded spleen, gall bladder, basic point D ipsilateral, master key
spatially in order to compensate for differences in the positi- points lower extremities on both sides, basal ganglia
on of the head between the two measurements. The data In J somatotope: lumbar spine (11 needles).
were subsequently transformed to a standard brain for bet- VAS values:
ter comparability and then spatially smoothed with a half- − before treatment: 68
life width of 12 mm in order to compensate for anatomical − after treatment: 20
differences between the patients. Finally, a mean normaliza- − after PET-CT: 5
tion was performed to compensate for any global signal Remarks: After acupuncture K.S. experienced a feeling of
fluctuations in the PET scanner. All the steps described warmth in the left foot. The second toe in the region of the
above were performed with the software packages SPM 8 left foot had previously been completely numb. This
(Wellcome Trust Centre for Neuroimaging, London, UK) or numbness disappeared completely after acupuncture.
FSL 4.1 (FMRIB, Oxford, UK). After these preprocessing steps, Telephone follow-up on 08.03.2010:
it was possible to directly compare the results of the two K.S. said she had experienced no pain at all for a week but
examination days. An increase in the cerebral glucose meta- due to her peroneal palsy she had twisted her foot and
bolism of more than ten percent was regarded as significant. fallen over; due to this she had had to take painkillers and

4 Thomas Schockert, Florian Beißner


have physiotherapy so that she was only able to give an by acupuncture. As an aid to orientation, the PET data were
objective evaluation of the first week after treatment. superimposed on a standard brain (MRT image). The data on
the coordinates refer to the stereotaxic atlas of Talairach and
Patient: R.R. (born 1960) Tournaux [7]. Only signal changes greater than ten percent
Symptoms: Gonalgia more extreme in the right knee than are shown.
the left, diffuse lumbar spine pain for three years. The pain During YNSA, we found a network of cortical and sub-
was subjectively perceived as being most severe behind the cortical activations including activations of the brainstem
kneecap, pain was also experienced in the front and central and cerebellum (Fig. 1). Bilateral activations occurred in the
region of the knee joint. Pain only occurred when weight thalamus, cerebellum, lateral frontal and dorsolateral
was placed on the joint. prefrontal cortex (DLPFC), in the insula and also the medial
Measurements: 1st PET-CT: 16.11.07, 2nd PET-CT: 20.11.07. prefrontal cortex. Furthermore, activations were identified
YNSA treatment points: CNP kidney left, extra point knee medianly in the posterior cingulum (PCC, transition to the
right, G2 at the mastoid left, basal ganglia (4 needles). precuneus), the ventromedial prefrontal cortex (VMPFC)
VAS values: and in the periaqueductal grey (PAG) of the brainstem.
− before treatment: 87 Moreover, a significant focal cluster in the region of the left
− after treatment: 18 basal ganglia was manifested in the form of an unpaired
− after PET-CT: 18 activation outlier of the medial line.
Telephone follow-up on 09.03.2010:
R.R. said he had not experienced any pain for two months.

Results of the PET-CT measurements Discussion


On the basis of the similar syndromes (pain of the lower
extremities, gonalgia) and combinations of points, we The good efficacy of YNSA for the most varied syndromes
decided to perform the evaluation on a group level. In the has been described in numerous publications [8–18]. Objec-
following, we shall therefore not present any individual tive demonstrations of the efficacy of YNSA have so far only
results but rather only group results contrasting “YNSA been provided with the aid of real-time ultrasonic topo-
minus control measurement” (see Fig. 1). The figure thus metry after Schumpe [15]. Of the almost 100 imaging
shows those areas where the neural activity was increased acupuncture studies performed using fMRT [19–23] or PET

Fig. 1: Results of the PET measurements


shortly after YNSA. The figure shows the
contrast “YNSA minus control measurement”
and thus all areas in which a rise in neural
activity resulting from YNSA is identified.
Only percentage increases of 10 % and over
were regarded as significant.

Neurophysiological Correlates of the Effect of YNSA for Patients with Chronic Pain of the Locomotor System 5
[24–26], only two fMRT studies have so far been concerned data. Moreover, none of them regarded the acupuncture
with scalp acupuncture [3, 21], whereas all the others have treatment as unpleasant. This observation would suggest a
applied body acupuncture as used in traditional Chinese different interpretation, which would regard the activations
medicine. observed as the activation of the body’s own analgesic
The study presented here used PET-CT for the first time to system. This is particularly supported by the activation of
investigate changes in the cerebral glucose metabolism – as the PAG, which, amongst other functions, is responsible for
an indirect measure of neural activity – during YNSA for opioidergic descending pain suppression [33]. The activa-
patients with pain of the lower extremities. tions observed may therefore be evaluated as a direct effect
With respect to their pain symptoms, all three test sub- of acupuncture stimulation.
jects benefited significantly from a single application of Although the study was concerned with the treatment of
YNSA. This was clearly demonstrated by the reduction of chronic pain of the lower extremities, the occurrence of
their subjective perception of pain measured by VAS. motor activations (cerebellum and basal ganglia) during
The brain activations found can be roughly assigned to YNSA is probably the most interesting result. Since in both
three basic systems. The PAG, thalamus, insula and DLPFC cases the patients were lying motionless in the PET scanner
are typical areas of the nociceptive system [27]. The cerebel- this cannot be an unspecific effect. Although it is known
lum and basal ganglia can be assigned to the motor system from imaging pain research studies that both areas are
and, in particular, to movement control [28, 29]. The most activated by strong pain stimuli [27], in this case we are
striking and most extensive activations are located in the dealing with the motor response to pain, which usually
PCC and the lateral frontal cortices. These regions of the occurs immediately after the stimulus. Since the YNSA
brain play an important part in attention processes. All three needles had already been positioned before the start of PET
systems will be discussed in more detail in the following. measurements, this possibility can be ruled out here. Conse-
With respect to the attention system, the most striking quently, the observed rise in activity in the cerebellum and
aspect is the PCC with an activity rise of more than 15 %. the basal ganglia must be an actual effect of acupuncture.
In functional terms, it is an important part of the so-called It is interesting to note that for two of the three patients
default mode network (DMN) [30]. As part of the so-called the acupuncture needles were applied to the “basal ganglia”
resting state networks [31], in recent years this network has point. This point was determined by neck diagnostics. It can
become known for displaying considerable activity even in be combined with all other points from the most varied
the absence of cognitive tasks. As various other studies with somatotopes or be employed as an independent point.
fMRT have already shown, this default mode of the brain can According to the ideas of Dr. Toshikatsu Yamamoto, the
be influenced by (body) acupuncture [32]. This is a possible acupuncture point of the “basal ganglia” corresponds to the
explanation for the appearance of such areas in our study. equivalent neuroanatomical region. The fact that in the
This statement has to be qualified by saying that we cannot present study a rise in activation was actually found in this
rule out actual differences in the degree of attention be- region of the brain during the application of acupuncture is
tween the two PET measurements. Particularly due to the a clear indication of the correctness of this hypothesis.
unaccustomed situation during the first acupuncture treat-
ment one should tend to assume such a difference, as also
evidenced by the activation of the lateral frontal cortices,
which include, amongst others, the frontal eye fields. In our Conclusions
further interpretation, we shall therefore exclude attention-
relevant areas. In the present study, clear indications were found of a
The nociceptive activations found can be interpreted in specific effect of YNSA on the activity of cortical and sub-
two ways. On the one hand, it is possible that acupuncture cortical areas correlating to the observed therapeutic
itself is perceived as pain and consequently the correspon- effects. Whereas attention-related activations probably do
ding areas are activated. In this case, the observed activa- not represent a direct effect of acupuncture, in the authors’
tions would merely be the body’s expected reaction to a opinion the rise in activity in the nociceptive and motor
pain stimulus. It would therefore not be possible to speak of areas indicates a specific effect of YNSA on pain processing
a specific acupuncture effect. On the other hand, this inter- and the motor system.
pretation is contradicted by the fact that during the applica- Due to the limited number of patients, the findings
tion of YNSA all three patients experienced a significant reported here can only be regarded as provisional. In order
reduction of their chronic pain, as demonstrated by the VAS to verify the conclusions drawn here, the authors consider it

6 Thomas Schockert, Florian Beißner


desirable that YNSA should be investigated in further 10. Marek M. Vertebrobasiläre Insuffizienz als häufige Ursache eines zentralvestibu-
lären Schwindels – Vertigo-Behandlung mit YNSA, Falldarstellung. ZTCM 2009;
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We would like to take this opportunity of thanking the patients Locomotor System – An Open Prospective Study. Poster, ICMART Congress Buda-
who volunteered to take part in this study. We are especially grateful to pest 2008
Prof. Dr. Dr. Jürgen Ruhlmann, Medizin Center Bonn for performing the PET- 13. Schockert T, Schneider B. YNSA und Spiegeltherapie in der Schlaganfallbehand-
lung – Falldarstellung. ZTCM. 2008;3:72
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We gratefully acknowledge Mr Andreas Mang from the Institute
punktur (YNSA) bei Schmerzen am Bewegungsapparat – eine offene, prospektive,
of Medical Engineering at the University of Lübeck (chair: Prof. Dr. Thorsten topometrisch kontrollierte Studie, Dt Ztschr f Akup. 2002;2:93–100
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Conflict of interests 2007;1,14–18
None. 18. Yamamoto T, Schockert T, Boroojerdi B. Treatment of juvenile stroke using Yama-
moto New Scalp Acupuncture (YNSA) – a case report. Acupuncture in Medicine
2007;25,4:200–202
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Authors brainstem and higher structures in response to acupuncture. Neuroimage 2009;
47(1): 289–301
TS: original idea, organization of the study, project management, imple- 20. Chae Y, Lee H, Kim H. The neural substrates of verum acupuncture compared to
mentation of the acupuncture, funding, writing the paper non-penetrating placebo needle: an fMRI study. Neurosci Lett. 2009;450,2:80–84
FB: evaluation of the PET data, writing the paper 21. Park SU, Shin AS, Jahng GH, Moon SK, Park JM. Effects of scalp acupuncture versus
upper and lower limb acupuncture on signal activation of blood oxygen level
dependent (BOLD) fMRI of the brain and somatosensory cortex. J Altern Comple-
ment Med. 2009;15,11:1193–2000
Financial support 22. Dhond RP, Kettner N, Napadow V. Neuroimaging acupuncture effects in the
human brain. J Altern Complement Med. 2007; 13(6): 603–16
Florian Beißner wishes to thank the Horst Görtz Foundation for financial
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support. Critical Review With Special Emphasis on Visual and Auditory Cortex Activations.
Evid Based Complement Alternat Med. 2009; doi:10.1093/ecam/nep154
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Information on the authors (Stricta requirements)


Thomas Schockert (born 1966) studied medicine at RWTH Aachen University from 1987 to 1994. He received clinical training in anaes-
thetics, 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.
Florian Beißner (born 1979) studied physics at Munich University of Technology from 1998 to 2005. In his dissertation at the Brain
Imaging Center in Frankfurt, he investigated the fMRT measurement of neurophysiological correlates of acupuncture treatment. At the
same time, he completed a master’s course in traditional Chinese medicine at the University of Porto.
Apart from methodological developments in functional imaging, his research interests concern the autonomic nervous system and
the human brainstem.

Neurophysiological Correlates of the Effect of YNSA for Patients with Chronic Pain of the Locomotor System 7