Treatment Of Stroke-Related Motor Impairment By Yamamoto New Scalp Acupuncture (YNSA):
An Open, Prospective, Topometrically Controlled Study
Babak Boroojerdi, MD
Toshikatsu Yamamoto, MD
Günter Schumpe, MD
Thomas Schockert, MD
Background After coronary heart disease and cancer, apoplectic insult is the third major cause of death in Germany. Due to a lack of efficient treatment concepts in conventional medicine, strokes are the most frequent cause of invalidity in old age. Twenty percent of those affected die immediately as a result. Since only a minority of patients have access to lysis therapy, Yamamoto New Scalp Acupuncture (YNSA) may represent a valuable complement to existing treatment strategies.
Objectives To show the efficacy of YNSA in treating stroke patients with the aid of topometry.
Design, Setting, and Patients Twenty-three patients with stroke were examined neurologically immediately prior to YNSA. The mobility of their arms or legs with residual paralysis was documented objectively by topometry in 3 dimensions. After YNSA treatment, patients were assessed neurologically and topometrically again. They were questioned about their subjective impressions immediately after therapy and 3 weeks later.
Intervention YNSA of the brain points (basal ganglia, cerebrum, and cerebellum) and the so-called base points in the boundary between the forehead and hair were used. All patients were treated just once by needle acupuncture. The needles remained in position for 5-9 minutes.
Main Outcome Measures Improvement in mobility demonstrated on topometry and subjective impressions of mobility.
Results The topometric examination showed that 14 of the 23 patients experienced significantly improved mobility after a single treatment with YNSA. Subjectively, this positive effect continued for up to 17 days. In the neurological examination, it was not possible to verify an improvement in the mobility of the arm or leg before and after acupuncture.
Conclusions YNSA represents a valuable complement to existing therapy concepts. Patients may benefit subjectively and objectively from YNSA. Furthermore, successful YNSA treatment could lead to considerable economic benefits by eliminating the need for nursing care and by achieving reintegration of patients into working life.
Yamamoto New Scalp Acupuncture, YNSA, Topometry, Stroke
After coronary heart disease and cancer, apoplectic insult is the third major cause of death in Germany. Strokes are also the most frequent cause of invalidity in old age. Twenty percent of those affected do not survive the apoplectic insult; 70% retain some physical incapacity for the rest of their lives and, in some cases, are dependent on nursing care.1 Basic therapy for acute ischemic insult involves maintaining blood pressure at the higher end of the normal range, keeping the respiratory tract open and monitoring breathing function, establishing normoglycemia, optimizing cardiac output, lowering body temperature, reducing cerebral compression, and initiating nursing measures as an aspiration prophylaxis and to promote early mobility.2
As the only conventional cause-related therapeutic approach to stroke, lysis therapy is available only to a minority of those affected. Within a period of 18 months and as part of a study, 4,032 patients with the tentative diagnosis "acute stroke" were admitted to a hospital in Cologne, Germany. Of the 453 patients selected for acute lysis therapy, 100 fulfilled the criteria for systematic lysis with rt-PA (recombinant tissue plasminogen activator).3 The criteria were onset of symptoms less than 3 hours previously, patient younger than 80 years, and no severe disturbance of consciousness. The question therefore is what therapy options are available to patients who do not fulfill the criteria for systematic lysis therapy?
Yamamoto New Scalp Acupuncture (YNSA) was presented to the medical world for the first time in 1973. The therapy, consisting at that time of a 5-point system, has since been considerably extended by the discovery of new treatment points and microsystems, basic and Y points, pubic area, Yamamoto New Chest Acupuncture). An individual, selective, and efficient treatment accommodating a patient's needs can be applied based on the diagnostic possibilities offered by abdominal wall and neck diagnosis.
We have published previously on the efficiency of YNSA for pain of the locomotor system.4 The conclusion drawn from this study was that YNSA is an efficient therapy for pain of the locomotor system; a subjective improvement was achieved for 93.3% (n=104) of the patients treated. In addition, 58.5% experienced both an objectively measurable and subjectively experienced relief and absence of symptoms, in part, lasting longer than 1 year after a single treatment.4
Can YNSA positively influence partial and residual paralysis after apoplectic insult? Can such an effect be determined after a single treatment? How long can positive effects be subjectively experienced after a single treatment? Is YNSA therapy suitable for use by emergency medical services for the treatment of acute stroke?
Methodology of YNSA
YNSA is a special form of traditional acupuncture. The method is based on a somatotope of the scalp. In the same way as in ear or mouth acupuncture, the total organism is projected onto a defined area on the scalp. The locomotor system is situated on either side of the boundary between forehead and hair; the internal organs are represented by Y points on both sides of the temple region. Scalp acupuncture distinguishes a Yin somatotope on the front of the scalp and a Yang somatotope on the rear. With the aid of special Japanese neck diagnostics, the related Y therapy points in the temple region are identified by means of pressure-sensitive points in the neck region. As a representative of every meridian, there is a pressure point on the neck and a related treatment point in the temple region. If, for instance, the Kidney point on the neck is pressure-sensitive, a needle is applied to the associated Y point in the temple. If the needle in the temple region is correctly positioned, the pressure sensitivity on the neck disappears successively, thus providing an immediate verification of the correct positioning of the needle.
In this study, we also concentrated on the brain points (basal ganglia, cerebrum, and cerebellum). The brain points requiring treatment were revealed by sensitivity to pressure on the sternum and the xiphoid process. If the needle has been applied correctly, a pressure sensitivity previously felt at the thorax also disappears. Furthermore, the so-called base points in the boundary between the forehead and hair were also used. In this case, the needle was applied to the maximum point of a pressure-sensitive region in the associated treatment area.5-8 Without exception, all patients were treated just once by needle acupuncture. The needles remained in position for 5-9 minutes, i.e., the length of time required to perform the topometric control measurements. We used exclusively sterile, disposable steel needles (0.25 x 25 mm).
Inclusion and Exclusion Criteria
The study involved patients who had paralysis or partial paralysis of the extremities after stroke. Minimal mobility of the arm or leg was desirable to facilitate the evaluation of comparative topometric measurements before and after acupuncture. Patients with sensorimotor aphasia or neglect syndrome were excluded from the study.
We examined 23 patients (8 women and 15 men, aged 38-86 years) who had experienced a stroke between 18 months and 11 years previously. In the case of 11 patients, the diagnosis was cerebral infarction and in 12 cases, cerebral hemorrhage. Patients gave their written consent before treatment began after having received comprehensive verbal and written information.
All patients were asked about their subjective perception of neurological deficits before and directly after the acupuncture. Moreover, a telephone interview was performed 2 weeks following the YNSA therapy to detect possible changes that may have lasted longer.
A neurological examination was performed to assess motoricity (degree of paralysis ranging from 0 to 5 on the MRC scale, reflexes, and pyramidal tract sign). In addition, all patients were assessed according to the motor part of the National Institutes of Health Stroke Scale (NIHSS) (paralysis of the face, arm, leg, and pyramidal tract sign). Results before and after YNSA were compared using a 2-sided paired t test.
Real-Time Ultrasonic Topometry
Complex issues in diagnosis and in progress control within the framework of training, therapy, and rehabilitation require an objective and reproducible measuring technique covering as many functional parameters as possible. This method must consider both the evaluation of the performance of the individual (isolated) articular muscles as well as the movement sequences involving several joints. In order to record the geometrical position of body points in space by the measuring technique, the measuring principle of running time measurements, TR, of ultrasonic pulses between spatially separated ultrasonic transmitters and ultrasonic receivers, was applied.
Multiplying the running time, TR, by the temperature-related speed of sound, vt, yields the distance covered by ultrasound, D1. If, in this way, 3 distances, D1,2,3 from an ultrasonic transmitter to 3 ultrasonic receivers located at fixed distances from each other in space, are measured, the location of the transmitter in relation to a predefined coordinate system (X, Y, Z) can be determined. A 4th receiver is fixed in a defined relation to the other 3 to verify the measured data. The correctness of the individual measurements can be verified by the 4th redundant measurement. If the measurement is repeated several times during 1 measuring period, the transmitter can be moved during this period, thus enabling a movement trace of the transmitter to be calculated.
The measuring system permits measuring frequencies, F, from 1-100 Hz. The resolution achievable during measurements with the ultrasonic topometer depends on the measuring period within which the data are recorded. This data acquisition time is 1/100,000 of a second (10 µs).
For comparison, in optical systems, this corresponds to an image repetition frequency of 100,000 images per second or a camera shutter speed of 0.00001 seconds. Within this period, a point moving at a speed of 125 m/s covers just 1 mm. The measuring accuracy is therefore sufficient to record a moving transmitter with an accuracy of better than 1 mm. The topometer can cover a measuring space of at least 5 x 4 x 3 m, the resolution of the individual transmitter pulses being independent of the distance from the receiver. Since, with the exception of some movement sequences in certain sports disciplines, human bodily movements never exceed these velocities, the transmitters can be attached to certain body points to record the body positions with this accuracy.
The dimensions of the ultrasonic transmitters are so small (diameter: 1-1.5 cm, height: 0.5-1 cm, weight: 2-3 g) that they can be attached to the human body without difficulty. The transmitters do not influence a person's sequence of movements. Furthermore, the transmitters have a largely spherically symmetrical emission of the pulsed wave (±55°) so that rotation of the transmitters about their axis of symmetry does not lead to a falsification of the measured data. Up to 12 transmitters distributed over various locations on the test subjects can be recorded simultaneously. This is sufficient to identify the patients' specific medical problems and to detect improvements to the locomotor system brought about by rehabilitation measures. These data can also be used to calculate moments of rotation, accelerations, velocities, etc., which have been used to measure the success of certain forms of rehabilitation.4,9-11
Criteria For Evaluating Topometry
Posture Angle (WT). The posture angle shows changes in the patients' mobility. In the recording, pain is indicated by disturbed, i.e., not sinusoidal, movement curves at the time of the change of posture. Measurements were made of the respective changes in the angle of the individual transmitters.
Angular Velocity (UW). The angular velocity provides information about coordination ability.
Angular Acceleration (AW). The angular acceleration provides information on how much force a person must exert for a movement. The angular acceleration therefore represents muscular strength plus gravity. If the angular acceleration alone has changed, then an improvement in the dynamics of the movement can be assumed; however, this is not visible to the eye. Only the measurement can detect such a positive change.
The parameters of posture angle, angular velocity, and angular acceleration must be evaluated in a differentiated manner. The information provided depends on the harmony of the movement and the reproducibility of a movement.
Harmony of the Movement. The harmony of the movement is the parameter providing the greatest amount of information since a sinusoidal, fluid, harmonious movement approximates most closely to that which can be called normal or physiological.
Secondary Movements. Secondary movements are an expression of unsteady sequences of movement distorted by pain and of movements perpendicular to the sequence of movement. For example, when rising from a seated position, patients throw their arms forward to gain momentum or bend their upper body forward to an unphysiological extent. Or, when the patient is asked to rotate the cervical vertebrae, a sideways movement of the cervical vertebrae unintentionally occurs as a secondary movement. The more secondary movements that occur, the further removed the patient is from a physiological, harmonious movement.
Reproducibility. The reproducibility of a movement corresponds to the ease with which patients move. Factors for a lack of reproducibility include lack of strength, lack of practice, pain, uncertainty, and control problems related to the cerebellum.
Two weeks before the start of the study, the case histories of the patients were recorded and they were informed about the nature of the tests. Before the measurements took place, the patients underwent a preliminary neurological examination by one of the authors; another performed the topometry. Fourteen patients were treated by one investigator and 9, by another. The topometric control was performed by one of the authors immediately after acupuncture. Finally, all the patients underwent a neurological examination.
The topometric examination revealed an improvement according to at least 1 of the above-mentioned assessment criteria for 14 of the 23 participants. The topometry did not reveal any change in mobility after the acupuncture treatment for 9 of the participants.
Figure 1. Topometrical curve before and after YNSA
Figure 1 shows an example of the change in the motoricity of a leg with residual paralysis by a representation of the topometry before and after acupuncture.
Subjective Perceptionof the Patients
Seventeen of the 23 patients experienced an improvement in their condition. Twelve patients agreed in reporting an improvement in the mobility of the extremities, effecting a feeling of loosening, lightness, decrease in spasticity, gain in well-being, and increase of confidence in their movements. All patients with improvements in their condition were interviewed by telephone 2 weeks following the YNSA therapy. Twelve patients reported subjective effects that lasted until the interview.
Neurological Examination and NIHSS
It was not possible to verify any improvement in the mobility of the arm or leg before and after acupuncture by a neurological examination. The NIHSS results did not show any significant change after scalp acupuncture for any of the 4 areas.
Stroke is the 3rd major cause of death in Germany and worldwide, and it is the most frequent cause of invalidity in old age.1,12 Apart from in-patient lysis treatment for a minority of those affected, no efficient methods of treatment addressing the cause of the insult are availablefor stroke patients. There is an 8.8% risk of cerebral hemorrhage after lysis therapy.13 As a valuable complement to this type of therapy, YNSA can be offered to all stroke patients who do not fulfill the criteria for lysis treatment.3
The need for improved medical care for stroke patients has also been identified14 since lysis is available only for a minority of patients. The World Health Organization (WHO) and the National Institutes of Health (NIH) approve acupuncture for the treatment of stroke patients.15,16 This therapy has been applied worldwide on many occasions and is recommended on the basis of its effectiveness.5-8,17-26 Ernst and White27 conclude that acupuncture is helpful in rehabilitation after stroke. Zhang28 regards stroke treatment by acupuncture as indispensable for modern neurology since, in China, 90% of patients treated by acupuncture after apoplectic insult are discharged from hospitals alive.
Pei et al29 show that early acupuncture treatment in the case of acute stroke considerably improves motor functions and also provides relief in performing the activities of everyday life. Critical voices argue that the needle acupuncture of Traditional Chinese Medicine (TCM) is not appropriate for achieving any improvement in stroke patients.30-34 In particular, the lack of sham acupuncture and control groups has frequently been criticized in meta-analyses. In response, it must be said that due to the lack of experience with sham acupuncture, this approach cannot be regarded as completely reliable.35
Although the earliest possible treatment with YNSA is recommended, even 10 years after an apoplectic insult, scalp acupuncture treatment is still of considerable benefit. Early treatment with YNSA gives rise to the hope that both mortality and secondary diseases can be reduced in frequency and severity. In China and Japan, acupuncture treatment for stroke begins as early as possible. Grotte19 also proposes that treatment should start early, as in hospital emergency departments.
There are currently no reliable studies providing recommendations for the most favorable point to begin acupuncture treatment of stroke patients.17 The studies described in the literature on acupuncture treatment for stroke patients all refer without exception to the application of traditional Chinese needle acupuncture, electroacupuncture, or transcutaneous electric nerve stimulation,36 and are in part extremely contradictory.27,31
A definitive assessment of the effectiveness of acupuncture in follow-up treatment for stroke in meta-analyses seems particularly difficult to some critics because the quality and design of studies on Chinese acupuncture are limited. Some authors consider that the benefits of Chinese needle acupuncture for stroke treatment have not yet been proven.32,34
No ongoing studies on the efficacy of YNSA in stroke treatment are available at present. Since such good retrospective experience with YNSA for stroke patients is available, we decided not to make use of sham acupuncture for ethical reasons. As use was made of topometry, we did not consider it necessary to include a blind test or control groups. Attention should focus on the significance of topometry, which is able to record sequences of movements in 3 dimensions with an accuracy in the millimeter range. In the present study, the medical treatment, the technical observation by topometry, and the physical examination were strictly separated.
Sham acupuncture was rejected because the continuous development of the various acupuncture systems with the discovery of new points means that the presence of an acupuncture point at a particular point on the body can never be ruled out with absolute certainty. The placebo acupuncture needle developed by Streitberger was also not used because even acupressure or micropressure37 could possibly initiate a therapeutically positive response.35,38,39
The immediate effects achieved by YNSA thus point to the superiority of Japanese scalp acupuncture in comparison to traditional Chinese needle acupuncture for stroke treatment. The positive effects described by patients after a single application of YNSA, lasting up to 17 days, support this assumption.
Attention should focus on the considerable economic benefits of this method. According to information from a health insurance company (Techniker Krankenkasse in Aachen), care of a stroke patient in the first 6 months of illness costs on average $110,000. Even if only a fraction of those affected had their motoricity improved by YNSA to such an extent that (for example) nursing care would no longer be necessary, this would be an extremely valuable service for those affected. Economic factors are also involved in the realistic possibility that a considerable number of patients could be quickly reintegrated into the work process. Speech disorders can also be positively influenced and treated by YSNA.5,8
No appreciable additional costs would have to be borne by the patient's health insurance for in-patient YNSA treatment. Five to 10 needles are used for treatment, resulting in maximum costs of about $2. Sponsors are currently being sought for promoting the YNSA training of physicians throughout Germany.
Men and women have subjectively reported an often-considerable increase in well-being, quality of life, and an improvement in motor activities after a single application of YNSA. Even in cases in which no objective demonstration of improved motoricity was possible by topometry, patients nonetheless experienced a subjective benefit.
In contrast, the neurological examination did not reveal any significant change after YNSA. The data presented here should be investigated in further, more extensive studies.
On the basis of 30 years of experience with YNSA and the unanimously positive reports from therapists and patients worldwide, it appears meaningful and appropriate that stroke patients in Europe and the United States should also be offered complementary YNSA treatment.5-8,18,20,24 The results of this pilot study also confirm retrospective observations by Yamamoto from 1983. In his textbook, YNSA, Yamamoto describes the effectiveness of YNSA for the efficient treatment of partial paralysis after apoplectic insult.5 Given that scalp acupuncture is relatively easy to perform after proper training, treatment could be initiated by emergency physicians, continued in hospitals, during rehabilitation, and applied by the patient's physician.
YNSA represents a valuable complement to existing therapies for stroke. Patients may benefit subjectively and objectively from YNSA. Furthermore, successful YNSA treatment could lead to considerable economic benefits by eliminating the need for nursing care and by achieving reintegration of patients into working life. While YNSA requires further study, it should be applied immediately for the benefit of stroke patients.
We would like to thank the patients who participated in this study.
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- Einhäuptl KM, et al. Behandlung des akuten ischämischen Insultes. Deutsch Ärzteblatt. 1999;B868-B874.
- Martin G, et al. Das Kölner Modell zur Akutversorgung des Schlaganfalls. Deutsch Ärzteblatt. 1999;B-863 F.
- Schockert T, Schumpe G, Nicolay C. Effizienz der Yamamoto Neue Schädelakupunktur bei Schmerzen am Bewegungsapparat – eine offene prospektive topometrisch kontrollierte Studie. Ztschr Akup. 2002;2:93-100.
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- Yamamoto T, Schockert T. Folgen von Schlaganfall und Schmerzen lindern. Naturarzt. 2000:8.
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- Schumpe M. Ganguntersuchungen und funktionelle Wirbelsäulever-messungen mittels eines neu entwickelten Echtzeit-Ultraschalltopometers (EU ST in der Orthopädie). Enke. 1979:69.
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- Zou X, Wang D. Comparative study of cerebral infarction treated with acupuncture at 6 acupoints of yang meridian and calan. Zhong Xi Yi Jie He Za Zhi. 1990;10(4):199-202.
- Ernst E, White AR. Acupuncture as an adjuvant therapy in stroke rehabilitation? Wien Med Wochenschr. 1996;146(21-22):556-558.
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- Pei J, Sun L, Chen R, Zhu T, Qian Y, Yuan D. The effect of electro-acupuncture on motor function recovery in patients with acute cerebral infarction: a randomly controlled trial. J Tradit Chin Med. 2001;21(4):270-272.
- Johansson BB, Haker E, von Arbin M, et al; Swedish Collaboration on Sensory Stimulation After Stroke. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke. 2001;32(3):707-713.
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Dr Babak Boroojerdi is a Neurologist at the Department of Neurology, University Hospital in Aachen, Germany.
Babak Boroojerdi, MD
Neurologische Klinik, Universitätsklinikum Aachen
52074 Aachen Germany
Dr Toshikatsu Yamamoto's specialties are Anesthesiology and Obstetrics & Gynecology. Dr Yamamoto is a Physician, Licensed Acupuncturist, Inventor of Yamamoto New Scalp Acupuncture (YNSA), and Head of Aishinkai Yamamoto Hospital und Yamamoto Rehabilitation Clinic in Miyazaki, Japan.
Toshikatsu Yamamoto, MD
1-10-15 Chuodori, Nichinan
Prof Dr Günter Schumpe is a Physician, and Engineer at the Department of Orthopedic Surgery, Biomechanics and Biophysics, University Hospital in Bonn, Germany.
Prof Gunter Schumpe, MD
53127 Bonn Germany
Dr Thomas Schockert's specialty is General Medicine in Nideggen, Germany.
Thomas Schockert, MD*
Acupuncture and Nature Medicine
Am Eisernen Kreuz 2c
52385 Nideggen Germany