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Acupuncture for Amblyopia

An recent article in the journal Ophthalmology reported the results of a clinical trial that evaluated acupuncture as an adjunctive treatment for anisometropic amblyopia. In the abstract, the authors conclude:

Acupuncture is a potentially useful complementary treatment modality that may provide sustainable adjunctive effect to refractive correction for anisometropic amblyopia in young children. Further large-scale studies seem warranted.

A little background information is in order.

In a healthy visual system the various structures in the eye focus light ambient light to form a sharp image on the retina. The retina functions like the CCD in a digital camera. Light energy is transduced to electrical signals, which are transmitted through the optic nerve. The signals from the optic nerve are relayed to the occipital cortex (at the very back of the brain) where they are interpreted into the experience of vision.

Amblyopia is often called “lazy eye”. If during childhood the brain is deprived of quality visual information it does not mature properly and loses the potential for good vision. Any opacity within the eye which significantly degrades the quality of the image forming on the retina (such as congenital cataract) can cause amblyopia. Strabismus (misalignment of the 2 eyes) can also cause amblyopia. If the eyes are not aligned, the brain has difficulty reconciling the disparate images from the 2 eyes. In order to avoid double vision the brain may “ignore” the input from one eye, and corresponding part of the visual cortex will not develop properly. Extreme, uncorrected, refractive errors (nearsightedness, farsightedness or astigmatism) can cause amblyopia. Patients with different refractive errors in their 2 eyes, a condition known as anisometropia, can also develop amblyopia in one eye.

Diagnosing and treating amblyopia during childhood is important. If the cause of the amblyopia is corrected during childhood, the brain can “learn” to see properly. As the child grows older, treatment becomes less effective, and amblyopia can become permanent. Often, intermittent patching of the unaffected is also used in the treatment of amblyopia.

The study under discussion involves the treatment of anisometropic amblyopia and was performed at the Joint Shantou International Eye Hospital in Shantou China. All children were treated with appropriate glasses to correct the refractive error. Patients were randomized into 2 treatment groups. For the first 15 weeks group 1 was treated with glasses alone; group 2 was treated with glasses plus acupuncture. After the initial 15 weeks, there was a crossover, and Group 1 was treated with glasses + acupuncture and Group 2 was treated with glasses alone for an additional 15 weeks. Both groups were then treated for 15 more weeks with glasses alone. Vision was measured every 5 weeks. The total duration of the study was 45 weeks, but the primary endpoint was considered to be at 15 weeks.

While assigned to acupuncture, patients received treatment 5 days per week for 15 weeks. Each treatment consisted of needling of 5 acupuncture points. They are described in greater detail in the paper, but in layman’s terms, needle placements were Baihui (in the scalp), Taiyang (beside the eye), Cuanazhu (in the eyebrow), Hegu (on the back of the hand), and Fuyang (in the lower leg). There was no sham acupuncture, or any attempt at masking patients to treatment assignment.

Imagine yourself as a patient with an eye problem reading a consent form describing a “double- blind study.” Because of the possible misinterpretation, in ophthalmology we avoid the terms “blind” or “blinding”, as in “double-blind study” to indicate measures taken to hide treatment assignment. We usually substitute the terms “masked” or “masking”.

At the primary (15 week) endpoint of the study both groups had improvement in vision, but Group 2 had improved 0.77 logMAR lines more than Group 1, a difference reported as statistically significant. LogMAR is an abbreviation for the logarithm of the minimal angle of resolution. I won’t go in to the arcane and tedious explanation of what 0.77 logMAR lines means, but it is quite a small difference. If you are familiar with audiology, one logMAR line is analogous to 1 decibel. On a relative scale a .77 logMAR line difference is roughly proportional to the difference between 14 and 12 point type. Within the context of clinical trials, differences of this magnitude are usually considered clinically insignificant.

At 30 and 45 weeks (after the crossover phase), the vision for the 2 groups was essentially equal.

First, the authors should be complimented for many things they did right. The designed a prospective, randomized trial. They used standardized methodologies. They reported well-characterized study groups. The sample size was fairly high for a pilot study, and followup was quite good. The paper was clearly written. However, all these virtues are outweighed by the omission of a sham acupuncture treatment group.

Measuring visual acuity is a deceptively complicated task. Ideally, it is an objective measure of the resolving power of the entire visual system. In practice, measurement of vision is never completely objective. It depends on patients reporting of their observations. In general, patients are asked to read progressively smaller letters on a chart until they can no longer reliably identify the letters. Surprisingly little is known about placebo effects on visual acuity. It is well known, however, that visual acuity measurement is highly dependent on the motivation, attention, and cooperation of the patient. This is especially true in children.

In clinical trials, vision is usually measured under highly controlled conditions, with standard lighting, a standard eyechart, etc. Because motivation and attention are so important in vision testing, the technician measuring the vision can have a significant influence on a patient’s performance. Call it the “cheerleader effect”. A highly engaging, encouraging tester, can generally squeeze a few additional letters from a patient compared to tester who is apathetic. The expectations of the tester can influence the way they collect and report the visual acuity measurements. In order to minimize potential bias, visual acuity examiners should be unaware of treatment assignment of the patients they are testing.

The paper states that vision was measured by an examiner who was masked to patient treatment assignment. Can an examiner can be truly masked to treatment when one group is having needles placed in their hand and face 5 days a week, 15 weeks at a time? By the time the patient reaches the primary 15 week endpoint, he or she has had needles placed at the same 5 spots 75 times, each. There were likely to be visible clues at some visits in some patients. Bruising was reported as an adverse event in 7.2% of participants. More subtle marks seem inevitable in a higher proportion of patients. If acupuncture treatments and visual acuity measurements were performed in the same building, visual acuity examiners could be unmasked simply by seeing the acupuncture kids in the building 25 times more frequently than the glasses-only kids. Given the very small differences in vision between the 2 groups, the possibility that examiners were unmasked in a small subset of patients could be significant.

Another important bias in this study is the very different experiences of the patients during different phases of the study. During the glasses-only intervals, patients came in every 5 weeks and had their vision measured. During the acupuncture intervals patients were brought to the office 5 days a week for 15 weeks and had needles pierce the skin at 5 points on their body. If the placebo effect influences vision measurement, this would seem to be a very provocative protocol.

Remember, also, that in this study acupuncture was an adjunctive treatment. The primary treatment, administered to every patient, was refractive correction (glasses). In order to get the benefit of the primary treatment, the children had to actually wear their glasses. Compliance is a known issue in amblyopia therapy, and getting 3 to 7 year old children to wear glasses is not as trivial as it may sound. Children with amblyopia in one eye generally do not perceive that they have any problem with their vision, and often find glasses more an annoyance than a help.

By receiving acupuncture treatment 75 times over 15 weeks, the children and their parents received constant reminders of their condition, and to the fact that they were in a clinical trial. During these visits they are under the real or perceived scrutiny of eyecare professionals. Sometimes know as the Hawthorne effect, these factors are strong motivators for compliance with any medical treatment. In comparison, patients in the glasses only group came to the hospital once every 5 weeks to have their vision measured.

The authors of the paper did attempt to address the question of compliance with glasses. Parents were asked to keep calendars documenting the use glasses over the first 30 weeks of the study. The parents reported that every child wore their glasses >90% of their waking hours. The authors concluded that differential compliance in use of glasses between the treatment groups did not likely explain the difference in visual acuity. Perhaps parents and children in this study were especially compliant, but universal >90% compliance challenges credibility. Patient (or parent) reported compliance is a flawed metric. Can any parent know what their 3-7 year-old is doing 90% of the time? I could find no studies looking at the reliability of parent-reported diaries of glasses use, but a found a quite interesting paper looking at use of orthodontia headgear. The authors devised an ingenious way of objectively monitoring the actual hours of use. Parents estimated that their children used their headgear about twice as long as documented by the objective measuring tool. I suspect this study has some relevance to parent reported use of eyeglasses. The difference in vision between the 2 groups was so small, that even a small difference in hours of glasses use could be significant.

In the discussion the authors did acknowledge that omission of sham treatment was a weakness of the study, and concede the possibility that placebo effects may have contributed to their observations.

Finally, we did not include a sham acupuncture group, which is considered necessary for evaluation of the effectiveness of acupuncture for such conditions as pain control. Although VA [visual acuity] testing is relatively objective and may thus be less influenced by psychological effects, we cannot totally rule out the possibility that part of the observed treatment effects were attributed to a placebo effect from acupuncture.

They go on to say that further studies using sham controls are warranted. It remains to be seen whether of not such trials will be done. Given the very small treatment effect seen in this open-label study, is likely that any measurable effect will vanish with appropriate controls and masking. The authors appear to anticipate this result as well, and have given themselves a preemptive fail-safe explanation.

It is also possible that sham acupuncture may activate the same mechanism as true acupuncture, leading to similar treatment effects.

In other words, acupuncture works, it just doesn’t require actual acupuncture. This gambit has been used before to explain the inconvenient truth of data showing that acupuncture works no better than sham acupuncture. This fantasy has also been deconstructed in previous SBM posts.

In conclusion, the authors of this study reported a statistically significant, but clinically insignificant benefit associated with the use of acupuncture as an adjunctive treatment for anisometropic amblyopia. Given the implausibility of the treatment modality, and the lack of masking, it is likely that the very small difference between groups is due to one or more sources of bias inherent in the study design.

About the Author

David Weinberg is a full-time academic vitreoretinal surgeon, and professor of ophthalmology at the Medical College of Wisconsin, Milwaukee. He completed a fellowship in vitreoretinal diseases and surgery at the Harvard Medical School, and has authored or co-authored over 70 publications in the peer-reviewed literature and 10 book chapters.

His interest in the less-than-science-based aspects of medicine was sparked by inquiries from his patients. Researching their questions led to his discovery of numerous grandiose claims for implausible, unproven treatments of potentially blinding eye diseases.

All opinions expressed by Dr. Weinberg are his alone, and do not represent those of his employer or any other organization with which he is affiliated.

Posted in: Acupuncture, Ophthalmology, Science and Medicine

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30 thoughts on “Acupuncture for Amblyopia

  1. kirkmc says:

    Off the topic of the article, I’d like to take this opportunity to ask Dr Weinberg if there has been any progress in reversing amblyopia in adults. Mine was caught too late for a patch or glasses to help, and since I have a neurological problem, the lack of sufficient vision in my weak eye contributes to balance problems. In my research, I’ve seen mentions of a few possibilities for reversing amblyopia, but nothing that seems serious.

  2. DrRobert says:

    Questions:

    1. Why do journals publish studies like these that have such glaring errors and non-results?

    2. Isn’t it absurd to think that putting needles in the muscles of facial expression will somehow help your superior/inferior/medial/lateral rectus and inferior/superior oblique muscles? They’re on opposite sides (I mean, inside vs outside) of the skull and controlled by completely different cranial nerves.

    3. Not to be “close-minded” but given China’s history of acupuncture studies, I’d be suspect of virtually anything thy put out.

    4. Why do people continue to investigate acupuncture when there is still no biologically plausible explanation for how it “works” beyond “balancing Chi”?

  3. Janet Camp says:

    It’s good to know there is one more skeptic in Milwaukee–where the woo is much stronger than you might think. You cannot even read through a community education booklet without dozens of entries for classes to be taught by chiropractors, complementary “physicians”, “nutritionists” and of course, acupuncturists! It’s always called “Health and Wellness”.

    My granddaughter recently had surgery for her strabismus (cross-eyes?) and I’m happy to say no acupuncture was recommended. I’m seeing someone at your institution later this month, so this comes as timely reassurance that I won’t be offered any “integrative” medicine.

    I also would like to know why respectable journals publish these studies–perhaps to discredit such notions and inform doctors like yourself who will get questions about these things.

    The worst thing is that the authors want to continue such studies and fail to discuss the smallness of the supposed improvement. No matter how much evidence you produce, some people will continue to believe what they already believe–sadly, even highly trained professionals are subject to this phenomenon. Surely these authors were aware of the previous literature on acupuncture?

  4. kirkmc says:

    These studies are published because there’s a lot of money in accupuncture. Big Needle has a lot of lobbyists.

  5. David Weinberg says:

    DrRobert

    Just to be clear, the type of amblyopia being treated in this study is not due to any sort of dysfunction of the extraocular muscles (the 6 muscles that move each eye). The proposed mechanism of the acupuncture was likewise not attributed to effects on the extraocular muscles.

  6. WilliamLawrenceUtridge says:

    DrRobert:

    1. Why do journals publish studies like these that have such glaring errors and non-results?

    Actually, I would argue that compared to many studies on acupuncture this one is pretty good. There are lots of really terrible ones. The lack of a control group is IMO the worst, but even control within acupuncture is fraugth with difficulties as there are so many variables to be accounted for – needle position, needle penetration, acupuncturist demeanor, school of thought for selection of positions, depths, thickness of needle, number of needles used, etc. Why are these studies published? Acupuncture is an interesting topic for a variety of reasons, and it takes a while and a lot of reading before you get to the point that you realize how it’s almost certainly nothing much more than an elaborate (and extremely effective) placebo.

    3. Not to be “close-minded” but given China’s history of acupuncture studies, I’d be suspect of virtually anything thy put out.

    Edzard Ernst makes that very point along with Simon Singh in Trick or Treatment and if you haven’t read it yet, you really, really should. Very readable and informative. If you’re a masochist you could also read Kim Taylor’s Chinese Medicine in Early Communist China, 1945-63: a Medicine of Revolution. I tried, got perhaps 20 pages in (very interesting pages) and ended up having to return it. Kimball Atwood reviewed it here a while back, and hits most of the salient points. The amusing thing to me when arguing with acupuncturists is just how little they know of the history of their discipline – they’re learning more about the mindset of Communist Chinese revolutionary thought than they are about the Wisdom of the Ancients as described in the Yellow Emperor’s Inner Canon.

    4. Why do people continue to investigate acupuncture when there is still no biologically plausible explanation for how it “works” beyond “balancing Chi”?

    There’s a lot of theories regarding how acupuncture could “work” in a way that aligns it with modern biology such as pain gate, trigger points, counter-irritation, local anaesthesia, etc. beyond merely “manipulates chi“. One explanation that is only now being considered is the placebo effect. Whenever arguing about acupuncture, one of my favourite factoids to convey is the lack of uniformity of the placebo effect – injections work better than pills, mock surgery works better than injection, doctor demeanor has a large impact as does a lengthy consultation, two needles are better than one, perceived “exoticness” also enhances the effect and my personal favourite – dramatic interventions are better than boring ones. There’s few things more dramatic than seeing a person absolutely peppered with needles yet in no apparent pain. So there is much research on what could be responsible for acupuncture’s purported effectiveness beyond an unmeasurable energy – but little of it considers the most parsimonious explanation.

    My personal favourite/most hated counter-argument regarding Traditional Chinese Medicine in general is that somehow the Chinese were the only people on the planet who managed to develop an accurate, effective form of intervention in the absence of an empirical tradition, dissection of corpses or microscopes. However, they used metaphor and symbolism to explain these things, and thus the problem is we don’t understand their deep, meaningful, accurate insights. Naturally this is abject nonsense but it’s none the less a fairly standard talking point for proponents.

  7. WilliamLawrenceUtridge says:

    Oops, HTML fail. There should be a link to the review of Taylor’s book by Atwood:

    http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-from-chairman-mao-part-iii/

  8. DW says:

    Another interesting eye-related topic might be “vision therapy” for kids with reading difficulties. Quickly searching this site I don’t find anything on this, but I have the impression it’s probably pseudoscience.

  9. CitizenJimserac says:

    Well, as someone who has amblyopia and had surgery in childhood to correct strabismus and am currently a licensed Acupuncturist in Florida, I would like to make some comments on the necessity and presumed validity of the “testing” which is supposed to, somehow, validate the value of acupuncture as an “adjunctive” therapy for the stated condition. And this irrespective that I am somewhat, though not entirely, skeptical of its use for that purpose.

    The key is this statement by the study authors:

    “It is also possible that sham acupuncture may activate the same mechanism as true acupuncture, leading to similar treatment effects.”

    In point of fact, it is my belief that allusions to “sham” acupuncture reflect a fundamental ignorance of aspects of Acupuncture itself which are due to political, historical and language barriers as well as inadequacies in the modern teaching of it. The acupuncture that we study in school and of which the vast majority of practitioners utilize and are familiar with, at least in the west, is a “scientized” and “sanitized” version of what I’ll call real or classical acupuncture which reached its zenith centuries ago but was gradually lost through a system of passing and holding “secrets” a family based system of training, political turmoil and other disruptions. This scientized version of acupuncture is part of what is misleadingly termed “Traditional Chinese Medicine” and was encouraged by Chairman Mao when he wisely started initiatives to modernize the Chinese medical system and learned that huge numbers of people relied on and trusted traditional approaches. Surviving medical families were forced to give up their “secrets”. To recover or reconstruct some of this lost knowledge, a deep and elaborate study of hundreds of older and ancient texts, mostly in Chinese must be laboriously pursued. Experts such as Dr. Nguyen van Nghi, Dr. Manfred Porkert and others have pointed the way and begun the process. It will take decades, perhaps a century or more before this process is completed. A good basic overview, though with some errors, can be found in George Soulie De Morant’s book “Chinese Acupuncture” (L’ Acupuncture Chinoise).

    In studying the Acupuncture point locations, there is an elaborate system of “collateral” and sub and sub-sub meridians (again not the correct term but the best we have now) extending throughout the body. It is irrelevant to this discussion if these channels actually exist or are merely a fiction to rationalize the obvious physiological effects of some of the points which may actually depend on the nervous system or on other processes for their action. But the full extent of these meridians, rarely studied or even understood in detail by the average practitioners and knowledge of them and their effects is probably unknown or misunderstood by researchers attempting to force the western testing methods onto Acupuncture.

    That is why the reference to the invalidation of the test results, in either direction because of the possibility that the “sham” points might just not be, is a genuine possibility, in my opinion.

    The attempt to evaluate any alternative medicine modality by overemphasis or worse, sole reliance, on double blinded placebo controlled randomized testing represents, in my opinion, an intellectual fallacy, called by chemist Lionel Milgrom “scientism”. This represents an anti-scientific narrowing of acceptable “evidence” and a dangerous exclusion of the importance of clinical results, often of key significance, especially in medicine.

    See his well reasoned article, “Beware Scientism’s Onward March” which discuses the nature of the fallacy and exposes the intellectual charade of anti-alternative medicine populists such as Ernst and Singh as well as the possible logical positivist agenda behind it. Easily found on the web or read it here:

    http://www.anh-europe.org/news/anh-feature-beware-scientism%E2%80%99s-onward-march

  10. DrRobert says:

    WLU, re: your answer to my 4th question.

    I really worded that question poorly. What I should have asked was this:

    Acupuncture is defined as inserting needles into different and specific acupuncture points in order to balance chi. They teach that restoring the balance of chi cures disease.

    I read one study, that I don’t believe a word of, in which they inserted a couple of acupuncture needles and then hooked it up to electricity and ran a voltage through the skin and it provided anesthesia for surgery. It was published in a acupuncture journal by a Chinese hospital. Now, I’m pretty sure they weren’t doing this in China thousands of years ago, unless they were flying kites during a thunderstorm.

    Or, in another study, I believe I read it here on SBM, they inserted acupuncture needles and the hooked them up to little vibrators that ran at a ridiculously high cycle rate (multiple times faster than human muscles can twitch) and the patients claimed to have some relief in pain.

    And, other studies have shown that sticking needles in anywhere provides the same, if any, pain relief as traditional acupuncture, without having to worry about mythical acupuncture points, meridians, or anything else (which is the heart of acupuncture).

    At what point do these different acupuncture-style treatments stop being considered acupuncture?

    If we say “irritating your skin at a different location other than the site of injury can reduce the pain felt at the site of injury,” does that validate acupuncture? It’s not that you need acupuncture needles stuck in specific locations to balance a non-existant life force. Isn’t it molesting the original idea of acupuncture into something else that is somewhat related (but not really related at all and now proposed to work in a completely different way)?

    For me: I would say if the original idea of acupuncture doesn’t work the way it’s claimed (specific points, chi), then we have to say traditional chinese acupuncture is useless. If there is something remotely related to acupuncture, that provides some pain relief, then let’s investigate it, but quit referring to it as acupuncture. That’s just an attempt to validate something that is paranormal.

    By the way, it blows my mind that for something that is essentially useless, and certainly not better than anything else that exists, it’s pretty insane there are entire schools dedicated to teaching acupuncture. What a poor career choice.

  11. WilliamLawrenceUtridge says:

    DrRobert, I agree completely. Researchers need to, in my opinion, be a lot more careful in how they plan their experiments when testing acupuncture, because there are so many variables to consider. If they’re ever going to isolate the factors that make acupuncture useful beyond mere placebo, they need better experimental design. TCM acupuncture is obvious nonsense, with no reason to believe it has any relationship to reality. I would have far, far less issue with acupuncture if it were reformulated to drop the TCM and instead focussed on stimulating nonpenetrative objects, toothpicks would work fine, at points far away from anything that could get infected. However, you do that and you lose much of what makes acupuncture “successful” – the drama, the danger, the exoticness, the long consultation.

    Naturally, acupuncture + electricity isn’t acupuncture, it’s transcutaneous electrical nerve stimulation – a recognized treatment for pain not available until the voltaic pile in 1800.

  12. DevoutCatalyst says:

    “However, you do that and you lose much of what makes acupuncture “successful” – the drama, the danger, the exoticness, the long consultation.”

    You are confident of this? Point me to some further reading. Or write some more.

  13. DW says:

    CitizenJim, I think the reference to “sham” acupuncture has you befuddled. You need to look into what is meant when researchers refer to “sham” treatments in research design. It sounds like you think they are trying to say that the treatment is no good. But that isn’t what they mean. A “sham” treatment means that some subjects in the test will undergo a treatment that appears, superficially, just like the real one, such that subjects think they are getting the real treatment, but no real treatment is administered. It’s a way of trying to account for possible placebo effects.

  14. DrRobert says:

    CitizenJimserac,

    You said:

    “The attempt to evaluate any alternative medicine modality by overemphasis or worse, sole reliance, on double blinded placebo controlled randomized testing represents, in my opinion, an intellectual fallacy, called by chemist Lionel Milgrom “scientism”. This represents an anti-scientific narrowing of acceptable “evidence” and a dangerous exclusion of the importance of clinical results, often of key significance, especially in medicine.”

    I’m sitting here flabbergasted with my jaw agape. You’re basically saying that scientific investigation into alternative medicine is anti-scientific.

    What you should be asking yourself is “Why doesn’t alternative medicine stand up to the double blinded, placebo controlled randomized tests?” and “Why does alternative medicine fail when it is scientifically investigated?”

  15. Quill says:

    CitizenJimserac cites a concept

    “…called by chemist Lionel Milgrom ‘scientism’.”

    in an article by the same.

    I’m not sure citing an article by a homeopath known for somehow forgetting all the basic principles of the chemistry he learned to get a PhD in the subject is going to be very convincing.

  16. ConspicuousCarl says:

    CitizenJimseracon 27 Nov 2011 at 10:24 am
    To recover or reconstruct some of this lost knowledge, a deep and elaborate study of hundreds of older and ancient texts, mostly in Chinese must be laboriously pursued. Experts such as Dr. Nguyen van Nghi, Dr. Manfred Porkert and others have pointed the way and begun the process. It will take decades, perhaps a century or more before this process is completed.

    This sounds a lot like something recently said by a chiropractor commenting on another page.

    You seem to be certain that something is valid, but you also say that it was somehow lost to various modes of obliteration, going so far as the above quote in which you think it will take up to 100 years to reconstruct and understand. How can you be sure that it isn’t garbage if we are as much as 100 years away from resurrecting it?

    That is why the reference to the invalidation of the test results, in either direction because of the possibility that the “sham” points might just not be, is a genuine possibility, in my opinion.

    You are simultaneously saying that acupuncture is amazingly complex, with multiple levels of meridians which require hundreds of texts to understand, AND saying that random jabs into the placebo group are constantly hitting just the right spots to relieve whichever condition is being addressed in every trial. Those scientists sure are lucky bastards. Instead of wasting a century translating old Chinese books, why not just burn them and tell acupuncturists to jab people at random, since that seems to be a reliable way to hit the right spots?

  17. DrRobert says:

    Does anyone remember ever dissecting a cadaver and finding an acupuncture point? I sure don’t.

  18. dawshoss says:

    Good point Carl. What that made me think of is… well if something was both lost and valid what would be our basis for believing it was valid? As they say it’s been lost and therefore is not practiced correctly anymore. What we’re really doing is a priori holding the belief that it’s valid and then justifying poor or negligible results by saying it’s been lost.

    Historical reality though is that they slowly stopped doing it because it wasnt working and had large risk of infection, but then in the 1930′s one guy totally revamped it and more importantly Mao pushed it as an effort to look populist.

  19. David Weinberg says:

    CitizenJimserac said:

    “The attempt to evaluate any alternative medicine modality by overemphasis or worse, sole reliance, on double blinded placebo controlled randomized testing represents, in my opinion, an intellectual fallacy, called by chemist Lionel Milgrom “scientism”. This represents an anti-scientific narrowing of acceptable “evidence” and a dangerous exclusion of the importance of clinical results, often of key significance, especially in medicine.”

    Obviously, I disagree with you, but lets set that aside for the moment. According to your argument, double blind placebo controlled randomized trials should not be necessary to accept an alternative medicine modality. However, if an alternative treatment has repeatedly failed to succeed in multiple double blind randomized trials it should be sufficient to dismiss it.

  20. Harriet Hall says:

    @CitizenJimserac,
    Can you give us an example of a treatment that failed double-blind testing but that was proven to work by other kinds of acceptable evidence?

  21. CitizenJimserac says:

    Dr. Roberts stated:
    “I’m sitting here flabbergasted with my jaw agape. You’re basically saying that scientific investigation into alternative medicine is anti-scientific.”

    Reliance on an inappropriate and inapplicable method of testing, and its representation as the sole criterion of scientific investigation, IS anti-scientific. You must read Milgrom’s excellent article to understand the philosophical and epistemological basis of such a claim. To ignore it will continue to leave you in the “flabbergasted” state.

    That reference to Milgrom in no way implies that I agree with his crazy quantum theories of homeoapthy. I just found his comments on the scientific inadequacies of the “gold” standard so good as to be worthy of widespread dissemination and consideration. His criticism of Ernst and Singh is also spot on.

    Also this…
    “What you should be asking yourself is “Why doesn’t alternative medicine stand up to the double blinded, placebo controlled randomized tests?” and “Why does alternative medicine fail when it is scientifically investigated?””

    A reiteration of the implied premise, that that method of testing is the only sole and “gold” standard, does not somehow increase its validity nor reinforce its supposed applicability !! Hence the second question is answered automatically – what is failing here, alternative medicine or its supposed “scientific” investigation? What “evidence” is being disallowed, and on what basis?

    Regarding the “meridians” and acupuncture “points” and the elaborate theories of them from thousands of years of Chinese theory and treatment, it is a mistake to think that this is the result of some superstitious primitives sitting around the fire or using the I-Ching and astrology at the Imperial palace. It would probably astound people to learn of the extent they went through to verify their treatments and, as an extra added inducement, when treating some of the royals, a significant failed treatment or bad reputation could easily result in having one’s head chopped off. Their theories are are of enormous clinical and therapeutic value but are, of course, unscientific. And yes, there is enormous Confucian or Taoist baggage which comes along with it, including an elaborate system of concepts which must be understood before much of the classical writings becomes at all intelligible. To get some feel for this, the translations of the “Ling Shu” by van Nghi, despite being based on a supposedly pristine (and unavailable) unbowderlized ancient Vietnamese translation of the Ling Shu, and Dr. Manfred Porkert’s writings are of great help. This vast clinical knowledge, even when couched in metaphorical terminology, is hardly to be discounted, despite much of it being probably unintelligible to others.

    Keep in mind that the general economic and political decline in China by the early 1900′s gave rise to legions of charlatans, almost anyone could hang out a shingle and pretend they were expert Acupuncturists and herbalists. Appalled western Doctors who visited then gave rise to the reports of the dangerous and sometimes fatal “treatments” given to people and formed the basis for the widespread misgivings prevalent to this day in some quarters. A reaction set in by the Chinese government, eager to modernize and emulate the west, exactly as Japan had done several decades earlier, and they tried to ban such treatments by the 1920′s, but popular resistance, mainly in the provinces allowed the real traditional systems to persist until they were formally recognized and institutionalized by Mao. Today there are conventional and TCM treatment wings of many hospitals in China. Those unresponsive to western therapies are sent to the other side, if they wish and vice versa. But the herbalists in particular, as well the Acupuncturists, now document their cases and undertake elaborate studies of efficacy, clinical effectiveness and follow up progress, including comparisons with western treatment successes and failures. Some of this is now available in English. The results are impressive. It is these sorts of things you need to review rather than attempting exclusionary denunciations based on inappropriate lab testing designed for something else!

    Likewise, I am inclined to agree with, what’s his name, Dr. Felix Mann who studied the classical theories and espoused them for some time but later decided on a theory involving a wholly neurological basis. Either way, the idea that the final word on Acupuncture can be determined by a method of testing more appropriate for pharmaceuticals is something I find unacceptable. And, after passing those types of testing, what is the basis of the recall of the drugs when a preponderance of negative effects occurs? Clinical reports !! But… that’s “unscientific” isn’t it??!!

    Regarding Harriet Hall’s question. I have, unfortunately, seen her comments on Homeopathy, widely disseminated , for example this one “Homeopathy – Still Crazy After All these Years”. I have a question of my own – how can one possibly apply a system of testing used for pharmaceutical drugs of known biochemistry to highly dilute homeopathic remedies, indeed going right past the Avogadro limit, whose scientific mechanism of action, if any, remains unknown?

    Again I must reiterate, as a complete and total answer – a restatement of an implied premise, that that method of testing is the “gold” and only “standard”, does not somehow increase its validity nor reinforce its supposed applicability !! The possibility that the supposed “sham” point really is not – given the continued failure of emergence of a definitive physiological theory of Acupuncture, invalidates such an approach. The physiological neuro-humeral theories look interesting, but I’m not qualified to pass judgement – that is for MD/PhD researchers. Various medical acupuncture sites and organizations report this research, it is of interest and progress appears to be slowly occurring.

    Far better methods of testing need to be designed and implemented. Thankfully, technological advances will expedite this, for example the famous MRI imaging of the visual cortex stimulation when a supposed “eye point” on the leg was stimulated and the same MRI demonstrating visual cortex quiescence, or its baseline equivalent, when nearby non “eye points” were needled.

    Research must encompass many sources of knowledge and information, not some simpleton reductionism testing which provides skeptics with an excuse to throw the baby out with the bathwater… and claim “science” while doing it.

    1. Harriet Hall says:

      It’s not that RCTs are inappropriate for studying homeopathy and acupuncture, it’s that RCTs are often not well designed to test these modalities. A well designed RCT of homeopathy might allow homeopaths to treat patients as they usually do, and compare patients who got what the homeopath prescribed to patients who got a placebo, letting a third party actually dispense the remedies without the knowledge of homeopath or patient. With acupuncture, you are trying to have it both ways: first you say ancient wisdom established acupoints, then you say using other points is not a valid control because they work too! Those making claims for acupuncture should be able to come up with a placebo control that they would consider valid. They did, and when the placebo worked as well as acupuncture they rationalized and started making excuses.

      By the way, drugs are not recalled just because of clinical reports. Clinical reports must be evaluated scientifically to determine if the clinical observations are correlated to or caused by the drug.

  22. WilliamLawrenceUtridge says:

    How is a double-blind, randomized, controlled trial an inappropriate way of testing acupuncture?

    Do you know why researchers use blinding, randomization, experimental control and statistics for their testing? Each has a unique and valid reason, can you explain them?

    How should acupuncture otherwise be tested? Aren’t you assuming it works rather than demonstrating it works? The “it’s been used for a long time” argument doesn’t really work – bloodletting was used for just as long, Egyptian magical papyruses predate acupuncture texts by more than a thousand years, but I doubt you use crocodile dung for birth control.

    How did ancient acupuncturists control for placebo effects? And why would our way of controlling for those effects have different results?

    How did acupuncturists determine where acupuncture points and meridians were? How do you distinguish the complexity of a true medical system from the complexity of speculating about the body in the absence of knowledge of how it works?

    Acupuncture was also falling out of favour in all but the peasant class in China well before modernization. It was being replaced by apothecaries and related herbal/druggist practices.

    The use of clinical reports can be empirical when withdrawing a product because it is looking for rare side effects in otherwise effective medication. And withdrawing a product should be easier and less rigorous than approving it, for obvious reasons.

    I have a question of my own – how can one possibly apply a system of testing used for pharmaceutical drugs of known biochemistry to highly dilute homeopathic remedies, indeed going right past the Avogadro limit, whose scientific mechanism of action, if any, remains unknown?

    Easy answer – most scientists reject homeopathy out of hand because it can’t work. The only reason homeopathy is tested is because it is popular; had most doctors their way, they would discard it like bloodletting.

    The possibility that the supposed “sham” point really is not – given the continued failure of emergence of a definitive physiological theory of Acupuncture, invalidates such an approach.

    Your comment presupposes that acupuncture points actually exist. There’s not really evidence they do; the fact that the location of needling appears to have no effect suggests that these points are imaginary. The placebo effect suggests that the elaborate process to locate them might be what is actually responsible for a large amount of acupuncture’s “success”.

    Research must encompass many sources of knowledge and information, not some simpleton reductionism testing which provides skeptics with an excuse to throw the baby out with the bathwater… and claim “science” while doing it.

    The whole point of research is that it is rigorous, replicable, builds on past research, and reduces all parameters to their most basic. Insistence that acupuncture can’t be tested or changed is the opposite of research. Skeptics don’t want to “throw out” acupuncture – they want to see if it works, and if it does, then if it can be made safer or more effective. That’s what science is. Pseudoscience is adopting the trappings and language of science while ignoring the methods and cherry picking the results. It’s faith cloaking itself in science.

  23. DrRobert says:

    WLU,

    On the contrary, crocodile dung has proven quite effective for birth control. Ever since I started rubbing it on me, no woman will sleep with me!

    CitizenJim,

    It’s interesting that you believe all of these wonderful things about acupuncture, and yet the evidence to support these beliefs has not yet been discovered, by your own admission.

  24. CitizenJimserac

    There’s a lot of mythology about the supposed ancient origins of acupuncture that doesn’t really hold up under close scrutiny.

    “Regarding the “meridians” and acupuncture “points” and the elaborate theories of them from thousands of years of Chinese theory and treatment, it is a mistake to think that this is the result of some superstitious primitives sitting around the fire or using the I-Ching and astrology at the Imperial palace.”

    It would seem you have not read Ben Kavoussi’s post “Astrology with Needles”, the link for which can easily be found on the SBM Topic-Based Reference page under acupuncture.

    Also highly worthwhile reading is Kimball Atwood’s four part magnum opus on acupuncture anesthesia:

    Part I is here: http://www.sciencebasedmedicine.org/index.php/acupuncture-anesthesia-a-proclamation-of-chairman-mao-part-i/

    Arguments from antiquity & popularity are not valid logical support for a position. It has been pointed out numerous times before that bloodletting, the burning of witches, live sacrifices, and exorcisms were all forms of ancient practices which were long considered standard of practice in their days.

    Baring any new, dramatic scientific evidence, I think acupuncture’s day has passed as well. It’s generally useless in well controlled and blinded studies for any objective outcome, and for subjective outcomes in well controlled and blinded studies, it doesn’t matter where you needle or if you poke rather than needle. There’s just no there there. The emperor is nude.

  25. CitizenJimserac says:

    Some final comments based on a generalized readings of the, as expected, responses.

    I make no claims whatsoever for the existence or non-existence of the so called meridians and points and gave up trying to figure out if they are real or not by about the second year of TCM medical college. Even as ficitionalizations they are quite useful in understanding classical theory and in day to day practice. The very term “meridians” is under attack as a misinterpretation by George Soulie de Morant who, in the early 1900′s in China was taught classical Acupuncture by some genuine experts and brought his knowledge back to Europe later. My suspicions were aroused by contradictory descriptions in the textbooks which emphasized the importance of exactly finding the points but then the anatomical descriptions were sometimes exact, sometimes vague. Porkert emphasizes an exactitude of anatomical approach and suggests that the Chinese had an exact basis all along but it has been lost in a quagmire of scientization, linguistic misinterpretation and just plain ignorance of classical Chinese. Be aware that the vast majority of Acupuncture texts in the west, coming from about the 1970′s onward, carry the TCM “party” line, with a few exceptions such as those by van Nghi. The naming of the points is a nightmare of linguistic misinterpretation, historical inaccuracy or obscure allusions and just plain errors though the Chinese still tend to use their point names rather than the International system of meridian-point numbering.

    By all means AVOID the book “Grasping the Wind”, supposedly explaining the names of the points, which is filled with inaccuracies, misinformation, omissions and was poorly written despite the excellence of the author in other books. It is a certainty this book has added to the confusion about points rather than enlightened anyone about them. The title, named after one of the points, ends up having a connotation hilariously opposite to what the author intended. It took me a year of research and self study after college to even begin to clear up the confusion and start learning real Chinese medicine where the names, irrespective of metaphoricals actually do make sense as I gradually uncovered a vast and unexpected “underground” of information, tantalizingly hinted at in English books but really only available to the Chinese, particularly classical Chinese readers. Such research was dangerous because the national board exams test one on the TCM knowledge, and not on the classical approach. After much searching the best modern book summary of this classical knowledge I could find was (in Chinese) “Zhong Yi Xue Gai Lun” , I don’t recall the author’s name right now, originally published around 1959.

    Do read “Chinese Medicine as a Scientific System – its History, Philosophy and Practice and How it Fits with the Medicine of the West by Sinologist Dr. Manfred Porkert. He explains what I’ve been trying to say far better than I ever could. More details are in his MIT Press (English translation), the title is something like “Chinese Medicine A System of Correspondences”. His expertise and scholarship in Acupuncture and Chinese language is genuine and impressive, as is his other books. The Acupuncture book by Dr. Quirico is quite good, ideal for MDs who prefer a grounding in exact anatomical description. A similar book by Porkert, entitled something like “Anatomia Acupunctura” is unfortunately only in German and out of print. Also the book by Claudia Focks is good.

    In my area of current research, Chinese herbal medicine, be aware of the absurd TCM attempt to scientize it as a supposed “system” with acupuncture by mentioning which “channel” the herb go into. You can be sure no known digestive process sends magical energy from the herbs down certain channels or meridians and I’m not at all sure that learning this was even useful as a study aid or aid in use. Some most certainly can and do affect certain parts of the body. The books by Chen and Chen, I believe a husband and wife team, are superb and I use them daily and they do reference current pharmacology. Once again, it becomes necessary to search for the classics going back to books written hundreds of years ago and start from there. Doing so will uncover the incredible lengths to which the ancient Chinese went to catalog, and verify their knowledge. One chap was commissioned by the emperor to update a classic book on herbal knowledge. He, and probably a few assistants, spent 30 years (!!) going from city to city and form village to village, checking on local herbal formulas, indexing herb species and preparations, making note of epidemics and what seemed to help cure or protect and like research. It was pre scientific but some of those books are incredibly useful even today once one learns the terminology. Just about every herbal formula was tested and retested to verify that it did what the classics said. To give some idea of the vast stretches of knowledge as yet not within our immediate purview, most of the “Golden Mirror of Medicine” a 40 volume encyclopedic compendium of treatments commissioned by the Emperor Kanxi in the late 1700′s remains untranslated into English.

    On the matter of the double blinded research, I remain steadfast that such simple means of testing can hardly be justified, both as to its methodology and as to the sweeping conclusions that are made from them when applied to various systems of so called alternative medicine. The skeptics of the “scientism” persuasion, most are unaware that they have fallen under its actual anti-scientific spell, seem to be hell bent on finding the magic touchstone to easily dismiss entire systems of medicine using absurdly narrow interpretations of “evidence” based on inappropriate misapplications of a single method of testing more correctly applied to the pharmaceuticals of known biochemistry for which such methods of testing somehow manage to still produce prematurely released drugs which are later “withdrawn” based on horrid “side effects”. I submit that such attempts are, in and of themselves, anti-scientific despite the demonstrable statistical basis which gives a false sense of “certainty” over areas for which far deeper and wider knowledge and research, most certainly involving clinical research, are required.

  26. DW says:

    “On the matter of the double blinded research, I remain steadfast that such simple means of testing can hardly be justified, both as to its methodology and as to the sweeping conclusions that are made from them when applied to various systems of so called alternative medicine.”

    I think there are a few things you probably don’t understand. The “sweeping conclusions” (after testing a given “alternative” remedy) to which you allude are usually along the lines of, “It doesn’t work” (and perhaps a secondary conclusion that given that goofy purported mechanism, it probably CAN’T work). This isn’t a sweeping conclusion. The burden of proof is on the person making the claim. It isn’t a sweeping conclusion to test it and say, “Nope, didn’t work.”

    Probably a sort of feeling of “sweepingness” comes on peddlers of bogus remedies at this point … they can see that with every failed test, the likelihood decreases of similar remedies even reaching (let alone passing) such tests. I speculate this is where the complaints about “sweeping conclusions” that in reality aren’t at all sweeping come from.

  27. WilliamLawrenceUtridge says:

    CitizenJimserac, one issue you overlook completely is prior probability – there’s no real reason to expect the Chinese managed to do what no other culture managed to do, create an effective, non-placebo medical system in the absence of a proper understanding of the body and empirical testing. There’s no reason to believe or insist that acupuncture offers anything meaningful, particularly in the face of so much disconfirming evidence. And give the lack of evidence for even efficacy of specific point needling, there’s certainly no reason to invest any time in memorizing their names, locations, or the supposed historical basis for them. Why not instead spend time learning more detailed actual anatomy through textbooks and cadavers, so you can avoid accidentally needling a nerve, blood vessel or organ? To ignore reality at the expense of the “wisdom of the ages” commits several logical fallacies for no real reason bar ideology. I’m sorry you spent much time, energy and presumably money learning the Chinese equivalent of balancing phlegm with black bile by calculating the exact amount of blood to remove, perhaps instead of trying to square the circle you might consider investing in science-based education. I’m really not sure why you would read many hundred-year-old books when you have pubmed to draw upon. If you genuinely want to pursue TCM in a scientific fashion, surely a post-doctoral fellowship in pharmacognosy at a recognized post-secondary school would be a much better way of determining which herbs have biological effects, how they work, how they can be purified into a standard dose and synthesized most efficiently. This would give genuine, evidence-based interventions that you could offer to the world at large. More people would benefit because these standardized extracts (i.e. drugs) would become part of the scientific medical toolkit accepted around the world, reaching far, far more people than acupuncture, TCM and all other forms of CAM.

    Of course, it would require you essentially abandon your belief that the pre-modern Chinese had a unique ability to see what nobody else saw before a microscope and reagent kit. After all – if they genuinely did have effective herbs, you can prove it! And if they didn’t, then you can stop people from wasting their money on ineffective treatments.

    On the matter of the double blinded research, I remain steadfast that such simple means of testing can hardly be justified, both as to its methodology and as to the sweeping conclusions that are made from them when applied to various systems of so called alternative medicine.

    You still haven’t explained why. Why is double-blind research incredibly effective at plumbing the reality of pharmacological agents, physical reactions, biological activity and medicine in general, but would fall down on TCM? Consider this simple test – take two groups, get both diagnosed by a TCM practitioner, and bring their prescriptions to a Chinese herbalist. Half get what the TCM diagnosis indicates, the other half gets a similar looking preparation that is inert. Count the number of people who get better in each group. Why would that not work? That’s the basis of a randomized, controlled trial.

    The skeptics of the “scientism” persuasion, most are unaware that they have fallen under its actual anti-scientific spell, seem to be hell bent on finding the magic touchstone to easily dismiss entire systems of medicine using absurdly narrow interpretations of “evidence” based on inappropriate misapplications of a single method of testing more correctly applied to the pharmaceuticals of known biochemistry for which such methods of testing somehow manage to still produce prematurely released drugs which are later “withdrawn” based on horrid “side effects”. I submit that such attempts are, in and of themselves, anti-scientific despite the demonstrable statistical basis which gives a false sense of “certainty” over areas for which far deeper and wider knowledge and research, most certainly involving clinical research, are required.

    That’s quite a strawman. Scientists don’t dismiss prescientific systems of medicine. They merely insist that, like all medicine, it pass some basic testing for efficacy and discard that which does not pass.

    If TCM doesn’t work through pharmacokinetics like a drug does, how does it work?

    The fact that drugs have side effects ignores the fact that a) any TCM preparation that is effective may also have side effects and b) the fact that drugs have side effects fails to prove that TCM is effective. This is what’s known as a false dilemma – forcing a choice between two options that aren’t the only two options. Drugs have side effects. On a completely unrelated note, TCM might not be effective.

    And finally, your argument for a different standard of testing is a pretty standard CAM talking point – insisting that, despite failing testing multiple times, X CAM modality is still effective. The problem is never “homeopathy/acupuncture/TCM/reiki/laetrile doesn’t work”, the problem is always “the science is wrong”. At some point you should consider whether science might be right. Otherwise you’ll never change your mind – and changing your mind is a virtue. What better reason is there to change your mind than “we keep testing something and it keeps not working”? If you try opening your front door with the same key and it keeps failing to unlock, why wouldn’t you try a different key or a different door?

  28. WilliamLawrenceUtridge says:

    Oops, pharmacognosy should be linked. Comments seriously need an edit button.

  29. Calli Arcale says:

    DW

    Another interesting eye-related topic might be “vision therapy” for kids with reading difficulties. Quickly searching this site I don’t find anything on this, but I have the impression it’s probably pseudoscience.

    As my daughter has been prescribed vision therapy and my brother underwent vision therapy, this is definitely a topic I’d like to read more about. From what I’ve been able to find in my University of Google research (I am, after all, a software engineer and not an opthamologist), a large part of the problem is that there are pretty wide range of things that get described as “vision therapy”. Patching to correct strabismus can count. There is a fairly long history of a wide range of strange glasses which supposedly would improve a person’s vision — I seem to recall there’s a century-old example of such a device at the Science Museum of Minnesota, which inherited the fabulous collection of quackery previously maintained at the Museum of Questionable Medical Devices (which closed down when the owner retired; he donated his collection to SMM, and they cycle bits of it in and out of an exhibit next to the anthropological section), so vision therapy quackery certainly has a long history. Thus, one is right to be cautious.

    My brother was very nearly a SIDS statistic. Fortunately, the episode occurred during the day, as he napped while the rest of us dug for fossils alongside the road. (Yeah, I grew up among nerds. :-D) Someone noticed that he had turned blue, and my dad began CPR. He began breathing again, but did not regain consciousness for about two months. At the end of that time, he was listless and paralyzed down the left side of his body. It was only later that we realized this had included one of his eyes. I think he was 8 when he began therapy, but it might have been older; this was years ago, so I don’t remember clearly. There was patching, and a variety of tools (such as the Brock String, which my daughter is using now — it’s an exercise in convergence accuracy) and eventually his left eye not only began functioning again in concert with the other eye, but he was able to move it back more towards the midline. The muscles on one side of the eye had atrophied, however. He was not considered a candidate for surgery, so he was eventually prescribed prismatic eyeglasses to correct the resulting double vision. Ironically, he is to this day the only person in my family with uncorrected 20/20 vision. ;-) (Well, my youngest still doesn’t need glasses, but she went from 20/20 to 20/30 between her last two pediatrician visits, so I suspect this will not last.)

    My daughter was referred for vision therapy to correct what was termed “convergence insufficiency”, though issues with her saccades were also noted by the optometrist. The opthamologist in charge of the vision therapy felt the convergence was a bigger issue. It has been interesting, especially for a skeptic attempting to determine how much of it is beneficial. It’s very difficult for me, an untrained person, to judge effectiveness. I know she’s definitely getting better at doing the exercises. When we started, she literally could not follow the tip of my finger if I moved it around in front of her. Her eyes would jump all over the place. She can do it easily now. I believe she’ll be up for the mid-course evaluation soon, and it will be interesting to see whether and how much the objective* measures have changed. Subjectively, I know her reading skills have improved dramatically over this time. She was a very early reader, but hit a massive wall when it came to reading chapter books and anything else with more than three lines of text. She’d claim it was too small, but isolated text of the same size was no problem, and getting glasses didn’t help — clearly, it wasn’t acuity. The vision therapist believes it’s a problem of tracking coordination. To read effectively, you have to be able to maintain lock on a point, to be able to follow the line of text, and, crucially, to be able to rapidly jump around without losing your spot. People’s eyes flick around a lot more when reading than they think; you use saccades to look further down the word or even down the sentence so you can get the context needed to decode the word. (Fluent reading goes well beyond phonetics. If you read only one word at a time, you cannot read effectively, because you have to be able to make deductions about the form of the sentence so you know what function a particular word is taking at the time.) But if you do not jump back to where you started accurately, the whole chain is thrown off.

    My daughter used to pause for perceptibly long periods midsentence when reading. Sometimes it would be quite long, and if she couldn’t find her place again, she’d give up. It was just too much work. Today, she reads fluently, and although she is still reluctant to try the sort of books I was reading at her age, we’re managing to sneak more challenging stuff onto her lap, and she is reading it successfully and with pleasure. Is this due to the vision therapy? Or did she just happen to mature right at that time? I can’t say, but it sure looks compelling to me. I’d really like to see a large study to ferret out whether it was the therapy or whether it would have happened anyway, but from my data set of two, it seems that vision therapy is not always quackery. Sometimes it definitely is, though.

    *For a certain value of “objective”, of course, though I was impressed with this man’s skill at gaining her cooperation and thereby maximum effort. He’s like a kid whisperer. :-D

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