Basic YNSA Research by Means of PET-CT - Mit ...

Thomas Schockert · Florian Beißner
Neurophysiological Correlates
of the Effect of YNSA
fo r 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
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
thomas-schockert@gmx.net
www.dr-schockert.de
www.ynsa.net

Abstract
Background: The practical and clinical application of
YNSA yields rapid and permanently positive results for
patients experiencing pain of the locomotor system. As
yet, the areas of the central nervous system influenced by
YNSA for acute and chronic pain have not been identified.
The study re ported here was motivated by the promising
results ob tained by acupuncture research using imaging
methods.
Issues: The aim of the study reported here was to investigate
potential areas of the central nervous system influenced
by YNSA in the treatment of patients with chronic pain
resulting from diseases of the locomotor system. To this
end, changes in the cerebral glucose metabolism were
measured by PET-CT.
Methods: Positron emission tomography (PET) uses weakly
radioactively labelled glucose to measure the metabolic
activity in selected regions of the human body. In the
brain, the method has the advantage of permitting the
indirect measurement of brain activity. In the present
study, two PET-CT measurements were performed on each
of three patients suffering from chronic pain of the locomotor
system at intervals of a few days. While the first measurement
served as a reference, YNSA treatment was
applied shortly before the second measurement. The
results of the two measurements were then compared. In
addition, changes in the pain experienced were measured
by a visual analogue scale (VAS).
Results: On average, YNSA led to a significant increase in
neural activity in cortical and subcortical areas. Activations
were found in the periaqueductal grey, thalamus, insular
cortex, posterior cingulate cortex, lateral frontal and pre -
frontal cortex, as well as in the cerebellum and the basal
ganglia. For all three patients, a comparison of the VAS
values indicated considerable pain relief after YNSA.
Conclusions: All the patients profited perceptibly from the
single application of YNSA and experienced significant
pain relief. The areas identified as displaying a rise in activity
can be assigned to the nociceptive and the motor
system, which represents a possible explanation for the
most frequently observed effects of YNSA.
Keywords
YNSA, PET-CT, pain, locomotor system
Zusammenfassung
Hintergrund: In der praktischen und klinischen Anwendung
der YNSA zeigen sich rasche und anhaltend positive
Be handlungs ergebnisse bei Patienten mit Schmerzen des
Be wegungsapparats. Die zentralnervösen Angriffspunkte
der YNSA bei akuten und chronischen Schmerzen sind bisher
nicht verstanden. Vielversprechende Ergebnisse in der
Akupunkturforschung mit bild gebenden Verfahren haben
zur Durchführung der hier vorliegenden Untersuchungen
ge führt.
Fragestellung: Ziel der vorliegenden Studie war die
Unter suchung potenzieller zentralnervöser Angriffspunkte
der YNSA bei der Behandlung von Patienten mit chronischen
Schmerzen aufgrund von Erkrankungen des
Bewegungs apparates. Hierzu wurden Veränderungen des
cerebralen Glukosestoffwechsels im PET-CT gemessen.
Methodik: Die Positronen-Emissions-Tomographie (PET)
er mög licht mittels schwach radioaktiv-markierter Glukose
eine Messung der Stoffwechselaktivität in beliebigen Teilen
des menschlichen Körpers. Im Gehirn bietet diese
Methode somit die Möglichkeit einer indirekten Messung
der Hirnaktivität. In der vorliegenden Studie wurden an
drei Patienten mit chronischen Schmerzen des Bewegungsapparates
im Ab stand von wenigen Tagen je zwei
PET-CT-Messungen durchgeführt. Während die erste Messung
als Referenz diente, wurde kurz vor der zweiten Messung
eine YNSA-Behandlung durchgeführt. Die Ergebnisse
beider Messungen wurden dann miteinander verglichen.
Zusätzlich wurden Veränderungen der Schmerzen mittels
einer visuellen Analogskala (VAS) gemessen.
Ergebnisse: YNSA führte im Mittel zu einer deutlichen Er -
höhung der neuronalen Aktivität in kortikalen sowie sub -
kortikalen Arealen. Im Einzelnen wurden Aktivierungen im
periaquäduktalen Grau, Thalamus, Insula, posteriorem
Cingulum, lateralem Frontal- und Präfrontalcortex sowie
im Cerebellum und den Basalganglien gefunden. Der Vergleich
der VAS-Werte zeigte bei allen drei Patienten eine
erhebliche Schmerzlinderung nach der YNSA.
Schlussfolgerung: Alle Patienten haben von der einmalig
durchgeführten YNSA gut profitiert und eine deutliche
Schmerz linderung erfahren. Die gefundenen Areale, die
einen Aktivi tätsanstieg zeigten, lassen sich dem nozizeptiven
sowie dem motorischen System zuordnen, was einen
mög lichen Erklärungs ansatz für die am häufigsten beobachteten
Wirkungen der YNSA darstellt.
Schlüsselwörter
YNSA, PET-CT, Schmerzen , Bewegungsapparat
2 Thomas Schockert, Florian Beißner

Introduction
Disorders of the locomotor system are one of the most
frequent reasons for the long-term administration of antiinflammatory
drugs and analgesics. Both nonsteroidal and
also steroidal pharmaceuticals involve the risk of significant
side effects, which often represent a considerable burden
for the patients affected.
Chronic disorders of the locomotor system are an im -
portant field of indications for Yamamoto New Scalp
Acupunc ture (YNSA) [1]. This is an acupuncture method
which provides rapid long-term relief for pain of the locomotor
system. Special neck diagnostics performed before
each treatment provides the basis for individualized therapy
[2]. With respect to the effectiveness of YNSA for stroke
patients, one of the authors was able to demonstrate
changes in the central nervous system in an fMRT study
involving 36 patients [3]. In contrast, as yet no study has
been made of the areas stimulated by YNSA for patients
with chronic pain due to disorders of the locomotor system.
In the study reported here, three patients were treated by
YNSA for chronic pain arising from disorders of the locomotor
system. The indication for positron-emission computer
tomography (PET-CT) was given by an evident component
of the disorder that was either neurological or related to the
central nervous system for each patient and also to rule out
the pos sibility of neoplastic origin. Since chronic pain is
manifested by the activation of distinct cortical networks,
the aim of the present study was to identify the potential
areas influenced by YNSA during the treatment of chronic
pain on the level of the cortex or subcortical regions.
Patients, Materials and Methods
Investigation sequence
Informed consent was obtained from the patients by means
of a public lecture on the day before the examination and
also on the day of the examination using the form for
informed consent employed by the Medizin Center Bonn,
headed by Prof. Dr. Dr. Jürgen Ruhlmann. Before the examination,
the weakly radioactive glucose tracer was administered
intra venously. After waiting for 30 minutes, the cranial
PET-CT measurement was then performed, which took about
20 minutes.
The second measurement was performed a week later.
Be fore this measurement, individualized YNSA treatment
was applied after neck diagnostics. The procedure was the
same as on the first day of the study: injection, waiting
period, PET-CT measurements.
The patients’ subjective perception of pain was measured
immediately before and after YNSA treatment and after
conclusion of the PET-CT examination by a visual analogue
scale (VAS).
Inclusion criteria
Criteria for inclusion in the study were severe pain in the
region of the lower extremities, age over 18, readiness not to
eat or drink for 12 hours before the examination, and the
ability to lie still for 30 minutes so that the PET images would
not be spoilt by movement artefacts.
Exclusion criteria
Patients with pain not emanating from the locomotor
system were excluded from the study as were diabetics and
patients undergoing Marcumar treatment.
Yamamoto New Scalp Acupuncture (YNSA)
According to the currently applicable official rules of YNSA
[1], before treatment can begin an examination must be
made of the lateral neck triangle by YNSA neck diagnostics.
In the case of disorders affecting regions below the
diaphragm, an inspection of the palms of both hands and
palpitation according to Hegu (Di 4) can be dispensed with.
Neck diagnostics always starts with palpitation of the two
kidney points. The diagnostics provides basic information
about the side on which treatment should begin and,
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
treated experiences sensitivity to pressure during palpi ta -
tion of the kidney point then treatment will be applied in
the front yin area. Either the parietally located Y points can
be used or exclusively the cranial nerve points located in the
yin area. At the moment, there are no hard and fast rules
concerning when cranial nerve points or Y points are to be
used. The choice is up to the therapist. Cranial nerve points
and Y points can also be combined. If, for example, a treatment
area has been destroyed by trauma or an operation,
especially in treatment for apo plectic insult due to cerebral
haemorrhage, or if the treatment is made more difficult due
to the lack of a cranial vault or restricted by extensive scarring,
then, depending on anatomical conditions, the points
may be freely selected from both somato topes.
The basic treatment points A for the cervical spine, E for
the thoracic spine and D for the lumbar spine were identified
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 treatment
tailored to the individual patient [2].
PET-CT
At the start of the PET examination, a radiopharmaceutical
(glucose tracer) is administered to the patient intravenously.
The tracer decays in the patient’s body (β + decay) leading to
the emission of positrons. The interaction of a positron with
an electron in the body leads to the emission of two highenergy
photons in precisely opposite directions, i.e. at an
angle of 180° relative to each other. The PET scanner consists
of a number of detectors arranged in a ring around the
patient which record the photons emitted during the reac -
tion described above. The fundamental principle of PET
measurement is the recording of coincidences between two
detectors positioned directly opposite each other. The spatial
distribution of the tracer inside the patient’s body can be
reconstructed from the spatial and temporal distribution of
these recorded decays. The result can be depicted in a series
of cross sections.
The radionuclide most frequently used for PET examina -
tions is the radioactive isotope of fluorine (18F). It can be
produced with the aid of a cyclotron and due to its relatively
long half-life of about 110 minutes it can be transported
over considerable distances.
The radiation burden of a whole-body PET-CT examination
corresponds roughly to nine months’ natural exposure to
cosmic radiation. The safety of this method has been amply
demonstrated [4–6].
Processing the image data
The data from the two measurements were co-recorded
spatially in order to compensate for differences in the position
of the head between the two measurements. The data
were subsequently transformed to a standard brain for better
comparability and then spatially smoothed with a halflife
width of 12 mm in order to compensate for anatomical
differences between the patients. Finally, a mean normalization
was performed to compensate for any global signal
fluctuations in the PET scanner. All the steps described
above were performed with the software packages SPM 8
(Wellcome Trust Centre for Neuroimaging, London, UK) or
FSL 4.1 (FMRIB, Oxford, UK). After these preprocessing steps,
it was possible to directly compare the results of the two
examination days. An increase in the cerebral glucose metabolism
of more than ten percent was regarded as significant.
Results
Individual patients
Patient: G.J. (born 1985)
Symptoms: Gonalgia in the right knee after an accident at
work on 27.02.2007. Putting too much weight on the joint
led to increasing pain in the region of the right knee joint.
Subjectively, the pain was perceived as a nail being driven
upwards from the lower outer region into the joint.
Measurements: 1st PET-CT: 16.11.07, 2nd PET-CT: 20.11.07.
YNSA treatment points: Cranial nerve points (CNP) kidney,
pericardium, heart, gall bladder, liver, right G2, basic point D
ipsilaterally and extra point knee right (8 needles).
VAS values (0–100):
− before treatment: 26
− after treatment: 10
− after PET-CT: 0
Telephone follow-up on 09.03.2010:
After acupuncture treatment, pain did not reoccur in the
knee in the same form as previously subjectively perceived
before YNSA treatment. Only in the case of extreme strain,
e. g. protracted jogging, does the pain occur in isolated
cases during the activity.
Patient: K.S. (born 1964)
Symptoms: Condition after herniated vertebral disc 14 years
ago, muscular tension in the region of the lumbar spine and
the iliosacral joint, weakness in dorsal flexion of the foot and
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.
YNSA treatment points: CNP kidney, bladder, lung, stomach,
spleen, gall bladder, basic point D ipsilateral, master key
points lower extremities on both sides, basal ganglia
In J somatotope: lumbar spine (11 needles).
VAS values:
− before treatment: 68
− after treatment: 20
− after PET-CT: 5
Remarks: After acupuncture K.S. experienced a feeling of
warmth in the left foot. The second toe in the region of the
left foot had previously been completely numb. This
numbness disappeared completely after acupuncture.
Telephone follow-up on 08.03.2010:
K.S. said she had experienced no pain at all for a week but
due to her peroneal palsy she had twisted her foot and
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
objective evaluation of the first week after treatment.
Patient: R.R. (born 1960)
Symptoms: Gonalgia more extreme in the right knee than
the left, diffuse lumbar spine pain for three years. The pain
was subjectively perceived as being most severe behind the
kneecap, pain was also experienced in the front and central
region of the knee joint. Pain only occurred when weight
was placed on the joint.
Measurements: 1st PET-CT: 16.11.07, 2nd PET-CT: 20.11.07.
YNSA treatment points: CNP kidney left, extra point knee
right, G2 at the mastoid left, basal ganglia (4 needles).
VAS values:
− before treatment: 87
− after treatment: 18
− after PET-CT: 18
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
On the basis of the similar syndromes (pain of the lower
extremities, gonalgia) and combinations of points, we
decided to perform the evaluation on a group level. In the
following, we shall therefore not present any individual
results but rather only group results contrasting “YNSA
minus control measurement” (see Fig. 1). The figure thus
shows those areas where the neural activity was increased
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.
by acupuncture. As an aid to orientation, the PET data were
superimposed on a standard brain (MRT image). The data on
the coordinates refer to the stereotaxic atlas of Talairach and
Tournaux [7]. Only signal changes greater than ten percent
are shown.
During YNSA, we found a network of cortical and sub -
cortical activations including activations of the brainstem
and cere bellum (Fig. 1). Bilateral activations occurred in the
thalamus, cerebellum, lateral frontal and dorsolateral
prefrontal cortex (DLPFC), in the insula and also the medial
prefrontal cortex. Furthermore, activations were identified
medianly in the posterior cingulum (PCC, transition to the
precuneus), the ventromedial prefrontal cortex (VMPFC)
and in the peri aqueductal grey (PAG) of the brainstem.
Moreover, a significant focal cluster in the region of the left
basal ganglia was manifested in the form of an unpaired
activation outlier of the medial line.
Discussion
The good efficacy of YNSA for the most varied syndromes
has been described in numerous publications [8–18]. Objective
demonstrations of the efficacy of YNSA have so far only
been provided with the aid of real-time ultrasonic topo -
metry after Schumpe [15]. Of the almost 100 imaging
acupuncture studies performed using fMRT [19–23] or PET
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
with scalp acupuncture [3, 21], whereas all the others have
applied body acupuncture as used in traditional Chinese
medicine.
The study presented here used PET-CT for the first time to
investigate changes in the cerebral glucose metabolism – as
an indirect measure of neural activity – during YNSA for
patients with pain of the lower extremities.
With respect to their pain symptoms, all three test subjects
benefited significantly from a single application of
YNSA. This was clearly demonstrated by the reduction of
their subjective perception of pain measured by VAS.
The brain activations found can be roughly assigned to
three basic systems. The PAG, thalamus, insula and DLPFC
are typical areas of the nociceptive system [27]. The cerebellum
and basal ganglia can be assigned to the motor system
and, in particular, to movement control [28, 29]. The most
striking and most extensive activations are located in the
PCC and the lateral frontal cortices. These regions of the
brain play an important part in attention processes. All three
systems will be discussed in more detail in the following.
With respect to the attention system, the most striking
aspect is the PCC with an activity rise of more than 15 %.
In functional terms, it is an important part of the so-called
default mode network (DMN) [30]. As part of the so-called
resting state networks [31], in recent years this network has
become known for displaying considerable activity even in
the absence of cognitive tasks. As various other studies with
fMRT have already shown, this default mode of the brain can
be influenced by (body) acupuncture [32]. This is a possible
explanation for the appearance of such areas in our study.
This statement has to be qualified by saying that we cannot
rule out actual differences in the degree of attention be -
tween the two PET measurements. Particularly due to the
unaccustomed situation during the first acupuncture treatment
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
further inter pretation, we shall therefore exclude attentionrelevant
areas.
The nociceptive activations found can be interpreted in
two ways. On the one hand, it is possible that acupuncture
itself is perceived as pain and consequently the corresponding
areas are activated. In this case, the observed activa -
tions would merely be the body’s expected reaction to a
pain stimulus. It would therefore not be possible to speak of
a specific acupuncture effect. On the other hand, this interpretation
is contradicted by the fact that during the application
of YNSA all three patients experienced a significant
reduction of their chronic pain, as demonstrated by the VAS
data. Moreover, none of them regarded the acupuncture
treatment as unpleasant. This observation would suggest a
different interpretation, which would regard the activations
observed as the activation of the body’s own analgesic
system. This is particularly supported by the activation of
the PAG, which, amongst other functions, is responsible for
opioidergic descending pain suppression [33]. The activa -
tions observed may therefore be evaluated as a direct effect
of acupuncture stimulation.
Although the study was concerned with the treatment of
chronic pain of the lower extremities, the occurrence of
motor activations (cerebellum and basal ganglia) during
YNSA is probably the most interesting result. Since in both
cases the patients were lying motionless in the PET scanner
this cannot be an unspecific effect. Although it is known
from imaging pain research studies that both areas are
activated by strong pain stimuli [27], in this case we are
dealing with the motor response to pain, which usually
occurs immediately after the stimulus. Since the YNSA
needles had already been positioned before the start of PET
measurements, this possibility can be ruled out here. Consequently,
the observed rise in activity in the cerebellum and
the basal ganglia must be an actual effect of acupuncture.
It is interesting to note that for two of the three patients
the acupuncture needles were applied to the “basal ganglia”
point. This point was determined by neck diagnostics. It can
be combined with all other points from the most varied
somatotopes or be employed as an independent point.
According to the ideas of Dr. Toshikatsu Yamamoto, the
acupuncture point of the “basal ganglia” corresponds to the
equivalent neuro anatomical region. The fact that in the
present study a rise in activation was actually found in this
region of the brain during the application of acupuncture is
a clear indication of the correctness of this hypothesis.
Conclusions
In the present study, clear indications were found of a
specific effect of YNSA on the activity of cortical and sub -
cortical areas correlating to the observed therapeutic
effects. Whereas attention-related activations probably do
not represent a direct effect of acupuncture, in the authors’
opinion the rise in activity in the nociceptive and motor
areas indicates a specific effect of YNSA on pain processing
and the motor system.
Due to the limited number of patients, the findings
report ed here can only be regarded as provisional. In order
to verify the conclusions drawn here, the authors consider it
6 Thomas Schockert, Florian Beißner

desirable that YNSA should be investigated in further
studies on larger patient populations.
Acknowledgements
We would like to take this opportunity of thanking the patients
who volunteered to take part in this study. We are especially grateful to
Prof. Dr. Dr. Jürgen Ruhlmann, Medizin Center Bonn for per forming the PET-
CT measurements. Special thanks are also due to Prof. Dr. Albert Becker for
his critical review and discussion of the manuscript.
We gratefully acknowledge Mr Andreas Mang from the Institute
of Medical Engineering at the University of Lübeck (chair: Prof. Dr. Thorsten
Buzug), for providing a provisional statistical evaluation of the raw data.
Conflict of interests
None.
Authors
TS: original idea, organization of the study, project management, implementation
of the acupuncture, funding, writing the paper
FB: evaluation of the PET data, writing the paper
Financial support
Florian Beißner wishes to thank the Horst Görtz Foundation for financial
support.
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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.
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 Unive rsity 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