Thomas Schockert Ralph Schnitker, Babak Boroojerdi, Klaus Vietzke, Im Qua-Smith, Toshikatsu Yamamoto, Frank Kastrau

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

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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

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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

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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

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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

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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

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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.

References 1. Schockert T, Schnitker R, Boroojerdi B et al. Kortikale Aktivierungen durch Yamamoto Neue Schädelakupunktur in der Behandlung von Schlaganfallpatienten – eine placebokontrollierte Studie mit Hilfe der funktionellen Kernspintomographie (fMRI), Abstractband, Dt. Akupunktur Kongress 2007 Bad Nauheim 2. Fang JL, Krings T, Weidemann J et al. Functional MRI in haelthy subjects during acupuncture: different effects of needle rotation in real and false acupoints. Neuroradiology 2004; May;46,5:359–62. Springer 3. Kong J, Ma L, Gollub RL et al. A pilot study of functional magnetic resonance imaging of the brain during manual and electroacupuncture stimulation of acupuncture point ( LI 4 Hegu) in normal subjects reveals differential brain activation between methods. Alternative Complementary Medicine. 2002 Aug;8,4;411–9 4. Lee JD, Chon JS, Jeong HK et al. The cerebrovascular response to traditional acupunkture after stroke. Neuroradiology.2003 Nov;45,11;780–4 5. Shao GR, Yan B, Liu C et al. Acupuncture of Weizhong (Bl 40) and Zusanli (St 36) on the study of brain function by PET/CT imaging. Chin J Nucl Med 2006; 26,1:54–6 6. Siedentopf CM, Golaszewski SM, Mottaghy FM et al. Die funktionelle Magnetresonanztomographie in der Akupunkturforschung. Dt Ztschr f Akup. 2004; 47,3:6–13 7. Yoo SS, Teh EK, Blinder RA. Modulation auf cerebellar activities by acupuncture stimulation: evidence from fMRI study. Neuroimage 2004 Jun:22,2:932–40 8. Schockert T. Neue Akupunkturnadeln für Kernspinforschung, Dt Ztschr f Akup. Supplement 2, 2006,49:122–3 9. Yamamoto T, Yamamoto H, Yamamoto MM. Yamamoto Neue Schädelakupunktur. Verlag für Ganzheitliche Medizin, Bad Kötzting 2005 10. www.5dt.com . Datenhandschuh, Fifth Dimention Technologies, Image courtesy 11. Jansen O, Schellinger PD, Fiebach JB et al. Magnetresonanztomographie beim akuten Schlaganfall, Deutsches Ärzteblatt Jg. 99, Heft 20, 17.05.2002, A1361–A70

12. Hasenbein U, Schulze A, Kuß O. Leitlinienkonformes Wissen am Beispiel Schlaganfall, Deutsches Ärzteblatt Jg. 103, Heft 24, 16.06.2006 A 1672–9 13. Nelles G, Diener HC. Prävention und Rehabilitation des Schlaganfalls im Alter. Der Internist 2002;8:941–948 14. Allport LE, Parsons MW, Butcher KS et al. Elevated hematocrit is associated with reduced reperfusion and tissue survival in acute stroke. NEUROLOGY 2005;65: 1382–87 15. Weimar C, Diener HC. Diagnose und Therapie der Schlaganfallbehandlung in Deutschland, Deutsches Ärzteblatt Jg. 100, Heft 40, 03.10.2003, A2576–82 16. Hui KK, Liu J, Makris N et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Human Brain Mapping 2000;9,1:13–25 17. Daskalakis ZJ, Christensen BK, Fitzgerald PB et al. The mechanisms of interhemispheric inhibition in the human motor cortex;J. Physiol 2002; 543 (Pt 1):317– 326, Human Brain Mapping 2000;9,1:13–25 18. Schockert T, Schumpe G, Nicolay C. Effizienz der Yamamoto Neuen Schädelakupunktur (YNSA) bei Schmerzen am Bewegungsapparat – eine offene, prospektive, topometrisch kontrollierte Studie, Dt Ztschr f Akup. 2002;2:93–100 19. Rothgangel A. Spiegeltherapie nach einem Schlaganfall – ein Neuer Weg in der Neurologischen Rehabilitation. www.spiegeltherapie.com 20. Weiller C. Spiegeltherapie soll Schlaganfallpatienten helfen – Mitglieder des Kompetenznetzes Schlaganfall erforschen neue Möglichkeiten nach Schlaganfall, Presseinformation13.03.2008, www.kompetenznetz-schlaganfall.de 21. Anwar S, Khan MMS, Qazi FM et al. Aculaser Therapy for the Treatment of Cerebral palsy. www.gancao.net 22. Yamamoto T, Schockert T, Boroojerdi B. Treatment of juvenile stroke using Yamamoto New Scalp Acupuncture (YNSA) – a case report. Acupuncture in Medicine 2007;25,4:200–202 23. Popp FA. Akupunktur. In: Biophotonen – Neue Horizonte in der Medizin. Stuttgart 2006:172–81 24. Li SM, Costi JM, Teixeira JEM. Sham Acupuncture Is Not a Placebo, Arch Intern Med, 2008;68,9, www.archinternmed.com 25. Rüdinger H. Der Akupunkturpunkt und die Zukunft der Akupunkturforschung. Dt Ztschr f Akup. 2008;51:5–7 26. Ryan D. Toward improving the reliability of clinical acupuncture trials: arguments against the validity of „sham acupuncture“ as control. Am J Acupunct. 1999;27,1– 2:105–9 27. Warnke U. Placebo-/Noceboeffekte durch quantenphilosophische Realitätsschaltung. 11. Mainzer Akup.-Symp.,14. Juni 2008 28. Zaslawski C, Rogers C, Garvey M et al. Strategies to maintain the credibility of sham acupuncture used as acontrol traetment in clinical trials. J Altern Complement Med. 1997;3,3:257–66 29. Boroojerdi B, Yamamoto T, Schumpe G et al. Treatment of Stroke Related Motor Impairment By YNSA: An Open, Prospective, Topometrically Controlled Study. Medical Acupuncture. 2005;17,1:24–8

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.

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