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Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Special Needs


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This course reviews the latest scientific evidence supporting eye and vision care.

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Evidence Based Practice: Pediatrics, Binocular Vision and Patients with Special Needs

  1. 1. 29/07/2015 1 Confidential Evidence Based Clinical Practice:  Pediatrics, Binocular Vision and  Patients with Special Needs 1 Confidential Dominick M. Maino, OD, MEd,  FAAO, FCOVD‐A Professor, Illinois College of Optometry/Illinois Eye Institute 3241 S. Michigan Ave; Chicago, Il 60616 312-949-7282 Lyons Family Eye Care 3250 N. Lincoln Ave; Chicago, Il 60657 773-935-2020 2 Confidential Clinician’s View of Researchers 3 Confidential Researcher’s View of Clinicians Inconsistent Patient Populations 4 Confidential Patients’ View of Clinicians & Researchers 5 Confidential Do we need evidence for everything? There is no randomized, controlled trial (RCT) supporting the contention that evidence-based medicine is beneficial, and "evidence" is more than the information that can be obtained from RCTs. Systematic reviews have severe limitations of scope and reach, and RCTs can lead to false or contradictory conclusions. Most controlled studies enroll only highly selected groups of patients, specifically excluding those with complicating factors, yet real patients bring with them an abundance of messy heterogeneity. Considering this, we should not withhold potentially beneficial treatment just because we lack randomized controlled trials. The frequent lack of solid clinical evidence requires clinicians to invoke critical thinking, communication, judgment, and even intuition on behalf of their patients. Medical training is as much an apprenticeship as it is an education, and medicine as much a craft as it is an art. Hunter DG1Do we need evidence for everything? Am Orthopt J. 2010;60:59-62. . 6
  2. 2. 29/07/2015 2 Confidential Do we need evidence for everything? Attitudes and Barriers to Evidence-Based Practice in Optometry Educators A group of optometrists and academics new to implementing education in EBP displayed positive attitudes to EBP but considered that its application and teaching could be significantly hindered by a lack of time to access and appraise the large volume of available research evidence in the field of eye care. (Optom Vis Sci 2015;92:514Y523) 7 Confidential The Cochrane Database of Systematic Reviews (CDSR) is the leading resource for systematic reviews in health care. The CDSR includes Cochrane Reviews (the systematic reviews) and protocols for Cochrane Reviews as well as editorials. The CDSR also has occasional supplements. The CDSR is updated regularly as Cochrane Reviews are published ‘when ready’ and form monthly issues 8 Confidential Levels of Scientific Evidence 9 Confidential Levels of Scientific Evidence Level 5 1. Case report (a report of a single case) 2. Expert opinion 3. Personal observation Susan A. Cotter,* Lynn A. Cyert,† Joseph M. Miller,‡ and Graham E. Quinn§, for the National Expert Panel to the National Center for Children’s Vision and Eye Healtha. Vision Screening for Children 36 to <72 Months: Recommended Practices. Optom Vis Sci. 2015 Jan; 92(1): 6–16. Maino D. Ophthalmology Causes Myopia! J Optom Vis Dev 2004;35 (2):67-69. Maino D, Schlange D, Maino J, Caden B. Ocular anomalies in fragile X syndrome. J Am Optom Assoc 1990;61:316-23 10 Confidential Levels of Scientific Evidence Level 4 1. Case report/series A single subject study or a report of multiple patients with the same treatment, but no control group or comparison group 11 Confidential Levels of Scientific Evidence Level 3 1. Retrospective cohort study a study in which patient groups are separated non-randomly by exposure or treatment, with exposure occurring before the initiation of the study 2. Case-control study a study in which patient groups are separated by the current presence or absence of disease and examined for the prior exposure of interest 3. Meta-analysis of Level 3 studies 12
  3. 3. 29/07/2015 3 Confidential Levels of Scientific Evidence Level 2 1. Prospective comparative study (therapeutic) a study in which patient groups are separated non-randomly by exposure or treatment, with exposure occurring after the initiation of the study 2. Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results 13 Confidential Levels of Scientific Evidence Level 1 1. Randomized controlled trial (RCT) a study in which patients are randomly assigned to the treatment or control group and are followed prospectively 2. Meta-analysis of randomized trials with homogeneous results 14 Confidential Levels of Scientific Evidence Ia Scientific evidence obtained from meta-analyses of randomized clinical trials. Ib Scientific evidence obtained from at least one randomized clinical trial IIa Scientific evidence obtained from at least one well-designed, non- randomized controlled prospective study IIb Scientific evidence obtained from at least one well-designed, quasiexperimental study III Scientific evidence obtained from well-designed observational studies, such as comparative studies, correlation study or case-control studies. IV Scientific evidence obtained from documents or opinions of experts committees and/or clinical experiences of renowned opinion leaders. 15 Confidential Levels of Scientific Evidence Grades of Evidence A (Levels of SE Ia, Ib) It requires at least one randomized clinical trial as part of the scientific evidence with overall good quality and consistency in terms of the specific recommendation B (Levels of SE IIa, IIb, III) It requires methodologically correct clinical trials that are not randomized clinical trials on the topic of recommendation. It includes studies that do not meet A or C criteria. C (Level of SE IV) It requires documents or opinions of experts committees and/or clinical experiences of renowned opinion leaders. It indicates the absence of high quality, directly applicable clinical studies 16 Confidential Clinical Trial Information is a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world. Gives basic information about clinical trials for the public Fox Trial Finder was created by the Michael J. Fox Foundation to help increase the flow of willing participants — both people with Parkinson’s and control participants who do not have Parkinson’s — into the clinical trials that need them, accelerating the Parkinson’s drug development process. 17 Confidential Helps you find a clinical trial the world’s first online distribution network dedicated solely to clinical trials and patients, joining forces with dozens of communities, advocacy groups, patient portals, blogs, and charities, to reach a combined audience of 100+ million patients per month, we bring the best and latest clinical trial information directly to patients. is made up of 22 distinctive consortia and a Data Management and Coordinating Center that are working in concert to improve availability of rare disease information, treatment, clinical studies, and general awareness for both patients and the medical community. The RDCRN also aims to provide up-to-date information for patients and to assist in connecting patients with advocacy groups, expert doctors, and clinical research opportunities. 18
  4. 4. 29/07/2015 4 Confidential With ResearchKit, researchers can easily create apps that take advantage of iPhone features to gather new types of data on a scale never available before 19 Confidential Offit PA. Do you believe in Magic: The sense and nonsense of alternative medicine. Harper Collins, NY, NY;2013 Steve McQueen (The Great Escape, Thomas Crown Affair, Bullit) Mesothelioma. Laetrile: is another name for amygdalin. Amygdalin is found in the pits of many fruits, raw nuts, and Laetrile has shown little anticancer effect in laboratory studies, animal studies, or human studies. The side effects of laetrile are like the symptoms of cyanide poisoning Laetrile is not approved by the U.S. FDA. McQueen paid $80,000/month. Suffered. Died. 20 Confidential Offit PA. Do you believe in Magic: The sense and nonsense of alternative medicine. Harper Collins, NY, NY;2013 Steve Jobs Pancreatic Cancer. Treatable with surgery. Good success rate. He treated himself with acupuncture, herbal remedies, bowel cleansings, and a cancer diet of carrot and fruit juices for 9 months. Now it was too late. He died. 21 Confidential Research Gone Wrong Hubel & Wiesel: Amblyopia • Deprivational not functional amblyopia • Critical vs sensitive periods • Cats not human • OMD/scientist misinterpretation of the data: Deliberate? Political? • Decades of children and adults suffered • Ignored clinical experience • Perceptual Learning vs Optometric Vision Therapy • Amblyopia can be treated at any age! 22 Confidential Do we need evidence for everything? There is no randomized, controlled trial (RCT) supporting the contention that evidence-based medicine is beneficial ….and yet! 23 Confidential Vaccines You are just about to examine a 4 y/o, when you notice these red blotches on his skin. It looks like measles, but you know there is an effective vaccine for this disease. You ask mom if the child has had his shots. She says no because they cause autism. What’s your response? The Huffington Post has a story about your university closing down because of the number of students with measles. What is your response? USAToday has a story that in 2014 1100 individuals came down with mumps. What is your response? In the 1920’s, my dad’s youngest sister died from measles, have we returned to those times? 24
  5. 5. 29/07/2015 5 Confidential Vaccines Vaccines for preventing smallpox: Fairly effective. Several adverse side effects Vaccines for preventing rotavirus diarrhoea: Efficacy is lower in high- mortality countries, but absolute benefit higher Vaccines for preventing the common cold in healthy people: Not effective Can nicotine vaccines help people stop smoking or help stop recent quitters from relapsing? Currently no evidence that nicotine vaccines enhance long-term smoking cessation. 25 Confidential Using the combined vaccine for protection of children against measles, mumps and rubella: …at least one dose of MMR vaccine was 98% effective in preventing laboratory- confirmed measles cases; one or two MMR doses were respectively 92% and 95% effective in preventing secondary measles cases. 26 Confidential Vaccines and Autism …No significant association between MMR immunization and the following conditions: autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, or bacterial or viral infections … 27 Confidential Total Load Theory According to the total load theory, at some point, which varies widely between individuals, the body can no longer handle the “load” of stressors such as nutritional deficiencies and aggressive use of medications/vaccines, and begins to show signs of that burden. The signs of overload are the characteristic symptoms of attention deficiencies and developmental delays. No support for this theory at this time. 28 Confidential Nutrition/Supplements/Probiotics How many of your patients have adopted various nutritional regimens? How many take supplements to improve health and well being or to fight a current disease? How many use probiotics? How many of you use also participate in the use of diet interventions, supplements and probiotics? 29 Confidential Nutrition Mediterranean diet **…promising dietary tool for the primary prevention of diabetes **….fruits,nuts and vegetables reduce cancer risk **A dietary pattern characterized by high fruit, vegetable, legume, whole grain, nut, berry, seed, and fish intakes, and possibly by intakes of dairy, coffee, tea, chocolate, and alcohol (not in excess), but low meat and detrimentally processed foods is associated with reduced incidence of cardiovascular disease and rates of noncardiovascular, noncancer chronic inflammatory-related mortality. **…red wine and extra virgin olive oil may decrease risk of Alzheimer's disease. 30
  6. 6. 29/07/2015 6 Confidential Vegetarian diet **…vegetarian diets reduces mean body weight **…, improving the plasma lipid profile and in decreasing the incidence of high arterial blood pressure, cardiovascular disease, stroke, metabolic syndrome and arteriosclerosis. In addition, improved insulin sensitivity together with lower rates of diabetes and cancer has been observed. **…Mortality from all-cause, ischemic heart disease, and circulatory and cerebrovascular diseases was significantly lower in vegetarians … Adverse effects may include hyperhomocysteinaemia, protein deficiency, anaemia, decreased creatinine content in muscles and menstrual disruption in women who undertake increased physical activity. Reduced Vit B12 31 Confidential References Diabetes Metab Res Rev. 2015 Jun 24. doi: 10.1002/dmrr.2672. [Epub ahead of print] Adherence to Mediterranean diet and 10-year incidence (2012-2014) of diabetes; the mediating effect of inflammatory and oxidative stress biomarkers: results from ATTICA cohort study. Koloverou E1, Panagiotakos DB1, Pitsavos C2, Chrysohoou C2, Georgousopoulou EN1, Grekas A1, Christou A1, Chatzigeorgiou M1, Skoumas I2, Tousoulis D2,Stefanadis C2; ATTICA Study group. Br J Nutr. 2015 Apr;113 Suppl 2:S102-10. doi: 10.1017/S0007114515000148. Fruit and vegetables and cancer risk: a review of southern European studies. Turati F1, Rossi M1, Pelucchi C1, Levi F2, La Vecchia C3. Curr Opin Lipidol. 2015 Jun 22. [Epub ahead of print] What an anticardiovascular diet should be in 2015. Jacobs DR Jr1, Tapsell LC Adv Exp Med Biol. 2015;863:1-20. doi: 10.1007/978-3-319-18365-7_1. Olive Oil Phenols as Promising Multi-targeting Agents Against Alzheimer's Disease. Rigacci S1. J Acad Nutr Diet. 2015 Jun;115(6):954-69. doi: 10.1016/j.jand.2014.11.016. Epub 2015 Jan 22. A systematic review and meta-analysis of changes in body weight in clinical trials of vegetarian diets. Barnard ND, Levin SM, Yokoyama Y. Rocz Panstw Zakl Hig. 2014;65(1):9-14. Health benefits and risk associated with adopting a vegetarian diet. Pilis W, Stec K, Zych M, Pilis A. J Sci Food Agric. 2014 Jan 30;94(2):169-73. doi: 10.1002/jsfa.6362. Epub 2013 Oct 2. Effect of the vegetarian diet on non- communicable diseases. Li D1. . 32 Confidential Vitamins **…Vit B Mood/cognitive improvement with seniors with normal Vit B levels. When used to treat peripheral neuropathy, it is not clear if it helps … Not enough evidence to determine if giving women vitamin C/E during pregnancy helps prevent babies dying, being born too soon or being born small. …No evidence that folic acid, thiamine, vitamin D or vitamin E improve seizure control or prevent side effects for people with epilepsy …Vit C Trials of high doses of vitamin C administered therapeutically, starting after the onset of symptoms, showed no consistent effect on the duration or severity of common cold symptoms 33 Confidential Nutrition/Supplements/Probiotics Vitamins …Due to the small number of studies, the methodological quality of studies, and small sample sizes, no recommendation can be advanced regarding the use of B6-Mg as a treatment for autism. …Quinine low quality evidence that quinine significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity **…Folate may have a potential role as a supplement to other treatments for depression …Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A (Sao Paulo Med J. 2015 Mar-Apr;133(2):164-5. doi: 10.1590/1516-3180.20151332T1. Epub 2015 Apr 1. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C.) 34 Confidential Nutrition/Supplements/Probiotics Vitamins The bottom line appears to be to obtain your vitamin needs mostly through the food you eat and not out of a bottle! 35 Confidential Nutrition/Supplements/Probiotics Sugar …statistically significant associations between both sugar and artificially sweetened soda consumption and HTN Surprisingly few reviews noted in PubMed! 36
  7. 7. 29/07/2015 7 Confidential Chocolate **…evidence suggests that higher chocolate intake is associated with a lower risk of future cardiovascular events (Heart. 2015 Jun 15. pii: heartjnl-2014-307050. doi: 10.1136/heartjnl-2014-307050. [Epub ahead of print] Habitual chocolate consumption and risk of cardiovascular disease among healthy men and women. Kwok CS1, Boekholdt SM2, Lentjes MA3, Loke YK4, Luben RN3, Yeong JK5, Wareham NJ6, Myint PK7, Khaw KT3.) **… an inverse relation of chocolate intake with incident DM (Am J Clin Nutr. 2015 Feb;101(2):362-7. doi: 10.3945/ajcn.114.092221. Epub 2014 Nov 26. Chocolate consumption and risk of diabetes mellitus in the Physicians' Health Study. Matsumoto C1, Petrone AB1, Sesso HD1, Gaziano JM1, Djoussé L1) **… improvements in various contributors to cardiovascular disease (CVD) including hypertension, platelet aggregation and adhesion, insulin resistance, and hypercholesterolemia (J Clin Hypertens (Greenwich). 2014 Feb;16(2):101-6.Chocolate--guilty pleasure or healthy supplement? Latham LS, Hensen ZK, Minor DS.) 37 Confidential Coffee **…light to moderate coffee intake is associated with a reduced risk of death from all causes, particularly in women (Public Health Nutr. 2015 May;18(7):1282-91. doi: 10.1017/S1368980014001438. Epub 2014 Aug 4.Association of coffee drinking with all- cause mortality: a systematic review and meta-analysis. Zhao Y1, Wu K1, Zheng J1, Zuo R1, Li D1) **… coffee consumption may reduce the risk of urologic cancer (Int Urol Nephrol. 2014 Aug;46(8):1481-93. doi: 10.1007/s11255-014-0699-9. Epub 2014 Mar 28. Coffee consumption and urologic cancer risk: a meta-analysis of cohort studies. Huang TB1, Guo ZF, Zhang XL, Zhang XP, Liu H, Geng J, Yao XD, Zheng JH) **…coffee consumption is associated with a reduced risk of total mortality (Br J Nutr. 2014 Apr 14;111(7):1162-73. doi: 10.1017/S0007114513003814. Epub 2013 Nov 27.Coffee consumption and total mortality: a meta-analysis of twenty prospective cohort studies. Je Y1, Giovannucci E2) 38 Confidential Nutrition/Supplements/Probiotics Omega-3 **Positive benefits for Bipolar Disorder (depressive) **…decreases central arterial stiffness in older, but not young healthy adults **…may play an important role in the maintenance of cardiovascular health and disease prevention. **… beneficial effects: cardio-protective effects, reduce ischemic stroke risk in both men and women and total stroke risk in women, increase insulin sensitivity in Asians, decrease risk of breast cancer and colorectal cancer in men. **….reduces inflammation **…. supplementing some dyslexics' diets with fish oils (DHA) can …improve their magnocellular (where) function and reading. 39 Confidential Nutrition/Supplements/Probiotics Omega-3 **…..positive effects on inflammation, hyperlipidemia, platelet aggregation, and hypertension 40 Confidential Nutrition/Supplements/Probiotics Omega-3 …unfavourable effects on type 2 diabetes in Caucasians Dementia/Cognitive function: No evidence to support use AMD: No evidence to support use Learning Disorders: Insufficiency evidence Cognition: marginal positive evidence, no evidence of an effect in the general population or those with neurodevelopmental disorders. Academic Performance: not supported 41 Confidential Ginkgo biloba Cochrane Review: The evidence that Ginkgo biloba has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unreliable Gingo biloba and AMD questionable Ginkgo biloba in the treatment of attention-deficit/hyperactivity disorder in children and adolescents. A randomized, placebo-controlled, trial ( **…improved inattention symptoms but has no significant effects on hyperactivity-impulsivity symptoms. **…increased the clinical treatment response rate of methylphenidate by 35%. 42
  8. 8. 29/07/2015 8 Confidential Diseases & CAM Hypertension: Dietary supplements such as garlic, cocoa, vitamin C, coenzyme Q10, omega-3 fatty acids, and magnesium have been suggested for lowering blood pressure, but evidence is lacking. Asthma/Allergies:…little evidence to support with vitamins (A, C, and E), folate, and omega-3 and omega-6 Low back pain… the strongest evidence supports exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation, and acupuncture. Therapies with fair evidence include yoga, back schools, thermal modalities, acupressure, and cognitive- behavioral therapy. Poor or little evidence include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis, and aromatherapy.(Neuromodulation. 2014 Oct;17 Suppl 2:24-30. doi: 10.1111/ner.12078.Noninvasive and alternative management of chronic low back pain (efficacy and outcomes).Wellington J1.) 43 Confidential Nutrition/Supplements/Probiotics Probiotics (live bacteria and yeasts) Ecezema: Not enough evidence ** Probiotics were found to be better than placebo in reducing the number of participants experiencing episodes of acute URTI by about 47% and the duration of an episode of acute URTI by about 1.89 days. **Probiotics may slightly reduce antibiotic use and cold-related school absence. **One trial has shown a reduction in the rate of Gestational Diabetes Mellitus 44 Confidential Herbal and Plant Therapy **…in ulcerative colitis, aloe vera gel, triticum aestivum, andrographis paniculata extract and topical Xilei-san were superior to placebo in inducing remission or clinical response, and curcumin was superior to placebo in maintaining remission; boswellia serrata gum resin and plantago ovata seeds were as effective as mesalazine….In Crohn's disease, mastic gum, Artemisia absinthium, andTripterygium wilfordii were superior to placebo in inducing remission and preventing clinical postoperative recurrence Herbal therapies exert their therapeutic benefit by different mechanisms including immune regulation, antioxidant activity, inhibition of leukotriene B4 and nuclear factor-kappa B, and antiplatelet activity. 45 Confidential Acupuncture **Amblyopia: positive outcomes noted **Fibromyalgia: acupuncture is probably better than non-acupuncture treatment in reducing pain and stiffness and improving overall well-being and fatigue **Shoulder pain: improvement noted **Neck pain: moderate evidence to support use **Schizophrenia: May have positive result **Dermatitis, chloasma, pruritus, urticaria, hyperhidrosis, and facial elasticity: improved outcomes **Neurological Recovery in Spinal Cord Injury: some support noted Depression/Epilepsy/Stroke Rehab/Acute stroke: Insufficient evidence, no clear evidence Children with Asthma: unclear 46 Confidential Acupuncture ** Osteoarthritis: Support for its use ** Elbow Pain: Some support for its use Myopia, Bell’s Palsy, Restless Leg Syndrome, Tension Headache: little/inconsistent support for its use Glaucoma: Unknown Autism: No support 47 Confidential Chiropractic ** Lowback pain: slight improvement (?) **Weak evidence to support the use of hypnosis, psychotherapy, acupuncture, chiropractic and medicinal herbs but it was provided in each case by single small trials **…Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain (J Manipulative Physiol Ther. 2014 Jan;37(1):42-63. doi: 10.1016/j.jmpt.2013.08.010. Epub 2013 Nov 19.Evidence-based guidelines for the chiropractic treatment of adults with neck pain.Bryans R1, Decina P2, Descarreaux M3, Duranleau M4, Marcoux H5, Potter B6, Ruegg RP7, Shaw L8, Watkin R9, White E10.) 48
  9. 9. 29/07/2015 9 Confidential Homeopathy Homeopathy is a complementary healing system based on "curing like with like". It involves greatly diluting substances (potentising) in order to strengthen the body's own healing response to a problem. Chronic Asthma, Dementia, ADHD: No/absence of evidence, 49 Confidential Craniosacral therapy CranioSacral Therapy (CST) is a gentle, hands-on approach that releases tensions deep in the body to relieve pain and dysfunction and improve whole-body health and performance. It was pioneered and developed by Osteopathic Physician John E. Upledger after years of clinical testing and research at Michigan State University where he served as professor of biomechanics. No to little support for its use 50 Confidential Detoxification Detoxification is one of the more widely us ed treatments and concepts in alternative medicine. It is based on the principle that illnesses can be caused by the accumulation of toxic substances (toxins) in the body. Eliminating existing toxins and avoiding new toxins are essential parts of the healing process. Detoxification utilizes a variety of tests and techniques. No to little evidence to support it use 51 Confidential Son–Rise therapy Son-Rise is a home-based program for children with autism spectrum disorders and other developmental disabilities, which was developed by Barry Neil Kaufman and Samahria Lyte Kaufman for their autistic son, who is claimed to have fully recovered from his condition **…intensive intervention focused on fostering child-initiated interaction increases social-communicative behaviors in children with autism. Very limited evidence to support this. Only 4 studies found in PubMed In general information found from 33 Autism interventions on websites, only three have strong empirical support. 52 Confidential Developmental Individual Relationship-based (DIR) Model D (Developmental) part of the Model describes the building blocks of this foundation. Understanding where the child is developmentally is critical to planning a treatment program I (Individual differences) part of the Model describes the unique biologically- based ways each child takes in, regulates, responds to, and comprehends sensations such as sound, touch, and the planning and sequencing of actions and ideas. R (Relationship-based) part of the Model describes the learning relationships with caregivers, educators, therapists, peers, and others who tailor their affect based interactions to the child’s individual differences and developmental capacities to enable progress in mastering the essential foundations. Several pilot studies support this approach **… DIR™ can be considered as a possibility for evidence-based practice (EBP), but not as an evidence-based treatment (EBT). ( 53 Confidential Massage Therapy **…Massage appears to be beneficial for patients with low-back pain (Int J Nurs Pract. 2015 May;21 Suppl 2:32-7. doi: 10.1111/ijn.12299. Back massage intervention for relieving lower back pain in puerperal women: A randomized control trial study. Lee HJ1, Ko YL2). **… Massage therapy reduces pain and improves function compared to no treatment in some musculoskeletal conditions. (J Physiother. 2015 Jul;61(3):106-16. doi: 10.1016/j.jphys.2015.05.018. Epub 2015 Jun 17. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Bervoets DC1, Luijsterburg PA1, Alessie JJ2, Buijs MJ2, Verhagen AP1) Facial parelysis: Low quality evidence to support 54
  10. 10. 29/07/2015 10 Confidential Aroma Therapy … limited evidence suggesting that aroma inhalation may be effective in controlling stress (Maturitas. 2014 Dec;79(4):362-9. doi: 10.1016/j.maturitas.2014.08.006. Epub 2014 Aug 21.Aromatherapy for stress reduction in healthy adults: a systematic review and meta-analysis of randomized clinical trials. Hur MH1, Song JA1, Lee J2, Lee MS3). 55 Confidential Syntonics/Phototherapy The use of light as therapy. No evidence for amblyopia, reading problems, etc. **SAD: fairly effective Ulcers: uncertain **Preterm, lowbirth weight neonatal jaundice: Support for its use Psoriasis: Inconclusive Sleep blue light therapy: Inconclusive **Nonseasonal depression: Modest antidepressive affect Dementia: No support 56 Confidential Essential Oils Eczema: no evidence **…antimicrobial activity **…suggested a positive effect of essential oils on sleep **…Efficacy studies of lavender, orange and peppermint essential oils to treat anxiety and nausea have shown positive results. For pain control uncertain results. (Evid Based Complement Alternat Med. 2014;2014:726341. doi: 10.1155/2014/726341. Epub 2014 Feb 24. Essential oils for complementary treatment of surgical patients: state of the art. Stea S1, Beraudi A2, De Pasquale D2.) 57 Confidential Music Therapy ( Autism: Promising results are reported for music therapy, sensory integration therapy, acupuncture, and massage.(Evid Based Complement Alternat Med. 2015;2015:258589. doi: 10.1155/2015/258589. Epub 2015 May 7.Complementary and Alternative Therapies for Autism Spectrum Disorder.Brondino N1, Fusar-Poli L1, Rocchetti M1, Provenzani U1, Barale F1, Politi P1.) **…improves behavior disorders, anxiety and agitation in subjects diagnosed with dementia (Neurologia. 2014 Dec 29. pii: S0213-4853(14)00248-5. doi: 10.1016/j.nrl.2014.11.001. [Epub ahead of print]Benefits of music therapy on behaviour disorders in subjects diagnosed with dementia: a systematic review.Gómez-Romero M1, Jiménez-Palomares M2, Rodríguez-Mansilla J3, Flores-Nieto A4, Garrido-Ardila EM2, González-LópezArza MV2.) **… improves global and social functioning in schizophrenia and/or serious mental disorders, gait and related activities in Parkinson's disease, depressive symptoms, and sleep quality. (Patient Prefer Adherence. 2014 May 16;8:727-54. doi: 10.2147/PPA.S61340. eCollection 2014. Effectiveness of music therapy: a summary of systematic reviews based on randomized controlled trials ofmusic interventions. Kamioka H1, Tsutani K2, Yamada M3, Park H4, Okuizumi H5, Tsuruoka K6, Honda T7, Okada S8, Park SJ8, Kitayuguchi J9, Abe T9, Handa S5, Oshio T10, Mutoh Y11.) 58 Confidential Occupational therapy From Cochrane Reviews: … conclusions can be stated whether or not occupational therapy improves outcomes in MS patients **…less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living **…positive effect on functional ability in patients with rheumatoid arthritis. …insufficient evidence to support or refute the view that perceptual interventions are effective …..OT intervention for CP inconclusive ( 59 Confidential Physical therapy Cochrane Reviews: Little to no evidence in many areas **…some positive evidence for upper extremity training ( **…positive outcomes for task specific activities ( **… evidence that aerobic and strength exercises and yoga reduce psychiatric symptoms, state anxiety, and psychological distress and improve health-related quality of life, that aerobic exercise improves short- term memory, and that progressive muscle relaxation reduces state anxiety and psychological distress. ( 60
  11. 11. 29/07/2015 11 Confidential Speech therapy Cochrane Reviews …insufficient evidence to conclusively support or refute the efficacy of SLT for speech problems in Parkinson's disease. …Firm evidence of the positive effects of SLT for children with cerebral palsy has not been demonstrated **… positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties 61 Confidential Dyslexia From Cochrane Reviews **… Phonics training appears to be effective for improving some reading skills. Little to no additional clinical trials on treatment of reading disabilities National Institutes of Health Clinical Trials Interventions for Children With Attention and Reading Disorders (ICARD) Started in 2010 no results published Comprehensive Program to Improve Reading and Writing Skills in At- Risk and Dyslexic Children: completed 2006/no study results posted 62 Confidential Dyslexia CITT-ART 63 Confidential Amblyopia Cochrane Reviews **… Occlusion appears to be more effective than refractive correction alone in the treatment of strabismic amblyopia. The benefit of combining near activities with occlusion is unproven. No RCTs were found that assessed the role of either partial occlusion or optical penalization to refractive correction for strabismic amblyopia. …Stimulus deprivation amblyopia: no clinical trials **…Both conventional occlusion and atropine penalization produce visual acuity improvement in the amblyopic eye. Atropine penalization appears to be as effective as conventional occlusion, although the magnitude of improvement differed among the three trials. Atropine penalization can be used as first line treatment for amblyopia. 64 Confidential Amblyopia Cochrane Reviews **… unilateral refractive amblyopia: treatment benefit from refractive correction alone. Where amblyopia persists there is evidence that adding occlusion further improves vision Is it better to do strabismus (squint) surgery before or after completing amblyopia (lazy eye) treatment? No RCTs available >>>>Hyperopia and strabismus/amblyopia: Although children who were allocated to the spectacle group were less likely to develop strabismus and less likely to have visual acuity worse than 20/30 children allocated to no spectacles, these effects may have been chance findings, or due to bias. Due to the high risk of bias and poor reporting of included trials, the true effect of spectacle correction for hyperopia on strabismus is still uncertain ********* ???????? 65 Confidential Amblyopia Cochrane Reviews Vision screening: The lack of data from randomized controlled trials makes it difficult to analyze the impact of existing screening programs on the prevalence of amblyopia. 66
  12. 12. 29/07/2015 12 Confidential 67Pedig Amblyopia Studies Quinn GE, Beck RW, Holmes JM, Repka MX, Pediatric Eye Disease Investigator Group. Recent advances in the treatment of amblyopia. Pediatrics 2004;133(6):1800-2 Pediatric Eye Disease Investigator Group. A randomized pilot study of near activities versus non-near activities during patching therapy for amblyopia. J AAPOS 2005;9(2):129-36 Holmes JM, Lazar EL, Melia BM, Astle WF, Dagi LR, Donahue SP, Frazier MG, Hertle RW, Repka MX, Quinn GE, Weise KK, for the Pediatric Eye Disease Investigator Group. Effect of Age on Response to Amblyopia Treatment in Children. Arch Ophthalmol. 2011;129(11):1451-7 Confidential 68Pedig Amblyopia Studies Wallace DK, Lazar EL, Melia M, Birch EE, Holmes JM, Hopkins KB, Kraker RT, Kulp MT, Pang Y, Repka MX, Tamkins SM, Weise KK, on behalf of the Pediatric Eye Disease Investigator Group. Stereoacuity in Children with Anisometropic Amblyopia. J AAPOS 2011;15(5):455-61 Pediatric Eye Disease Investigator Group. A randomized trial comparing Bangerter filters and patching for the treatment of moderate amblyopia in children. Ophthalmology. 2010 May;117(5):998-1004 Pediatric Eye Disease Investigator Group. A Randomized Trial to Evaluate Combined Patching and Atropine for Residual Amblyopia. Arch Ophthalmol 2011;129(7):960-2 Confidential 69Pedig Amblyopia Studies Lyon DW, Hopkins K, Chu RH, Tamkins SM, Cotter SA, Melia M, Holmes JM, Repka MX, Wheeler DT, Sala NA, Dumas JD, Silbert DI, on behalf of Pediatric Eye Disease Investigator Group. Feasibility of a clinical trial of vision therapy for treatment of amblyopia. Optom Vis Sci 2013;90(5):475-81. Pediatric Eye Disease Investigator Group. A randomized trial to evaluate 2 hours of daily patching for strabismic and anisometropic amblyopia in children. Ophthalmology 2006;113(6):904-12 Pediatric Eye Disease Investigator Group. Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmology 2006;113(6):895-903 Confidential 70Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Treatment of strabismic amblyopia with refractive correction. Am J Ophthalmol 2007;143(6):1060-3 Pediatric Eye Disease Investigator Group. A randomized trial of near versus distance activities while patching for amblyopia in children aged 3 to less than 7 years. Ophthalmology 2008;115(11):2071-8 Pediatric Eye Disease Investigator Group. Treatment of bilateral refractive amblyopia in children three to less than 10 years of age. Am J Ophthalmol 2007;144(4):487-96 Confidential 71Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Pharmacologic plus optical penalization treatment for amblyopia: results of a randomized trial. Arch Ophthalmol 2009;127(1):22-30 Repka MX, Kraker RT, Beck RW, et al. Treatment of severe amblyopia with atropine: results from two randomized clinical trials. J AAPOS 2009;13(3):258-63 Pediatric Eye Disease Investigator Group. Patching vs atropine to treat amblyopia in children aged 7 to 12 years: a randomized trial. Arch Ophthalmol 2008;126(12):1634-42 Confidential 72Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Pharmacologic plus optical penalization treatment for amblyopia: results of a randomized trial. Arch Ophthalmol 2009;127(1):22-30 Repka MX, Kraker RT, Beck RW, et al. Treatment of severe amblyopia with atropine: results from two randomized clinical trials. J AAPOS 2009;13(3):258-63 Pediatric Eye Disease Investigator Group. Patching vs atropine to treat amblyopia in children aged 7 to 12 years: a randomized trial. Arch Ophthalmol 2008;126(12):1634-42
  13. 13. 29/07/2015 13 Confidential 73Pedig Amblyopia Studies Repka MX, Kraker RT, Beck RW, et al. Treatment of severe amblyopia with atropine: results from two randomized clinical trials. J AAPOS 2009;13(3):258-63 Felius J, Chandler DL, Holmes JM, et al. Pediatric Eye Disease Investigator Group. Evaluating the Burden of Amblyopia Treatment from the Parent and Child’s Perspective. J AAPOS. 2010; 14(5):389-95 Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120(3):268-78 Confidential 74Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Two-year follow-up of a 6- month randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2005;123(2):149-57 Repka MX, Holmes JM, Melia BM, et al. The effect of amblyopia therapy on ocular alignment. J AAPOS 2005;9(6):542-5 ( Repka MX, Melia M, Eibschitz-Tsimhoni M, et al. The effect on refractive error of unilateral atropine as compared with patching for the treatment of amblyopia. J AAPOS 2007;11(3):300-2 Holmes JM, Melia M, Bradfield YS, et al. Factors associated with recurrence of amblyopia on cessation of patching. Ophthalmology 2007;114(8):1427-32 Confidential 75Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs patching for treatment of moderate amblyopia: follow-up at age 10 years. Arch Ophthalmol 2008;126(8):1039-44 Repka MX, Kraker RT, Beck RW, et al. Contrast sensitivity following amblyopia treatment in children. Arch Ophthalmol 2009;127(9):1225-7 Kulp MT, Foster NC, Holmes JM, et al. Effect of Ocular Alignment on Emmetropization in Children <10 Years With Amblyopia. Am J Ophthalmol 2012;154(2): 297-302 Pediatric Eye Disease Investigator Group. Atropine vs patching for treatment of moderate amblyopia: follow-up at 15 years of age of a randomized clinical trial. JAMA Opthalmol. Jul 2014;132(7):799-805 Confidential 76Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Optical Treatment of Strabismic and Combined Strabismic-Anisometropic Amblyopia. Ophthalmology 2011;119(1):150-8 Repka MX, Kraker RT, Beck RW, et al. Pilot study of levodopa dose as treatment for residual amblyopia in children aged 8 years to younger than 18 years. Arch Ophthalmol. 2010 Sep;128(9):1215-7 Pediatric Eye Disease Investigator Group. A randomized trial of increasing patching for amblyopia. Ophthalmology. 2013 Nov;120(11):2270-7. Confidential 77Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. A randomized trial of adding a plano lens to atropine for amblyopia. J AAPOS. Feb 2015;19(1):42-48 Pediatric Eye Disease Investigator Group. A randomized trial of levodopa as treatment for residual amblyopia in older children. Ophthalmology. May 2015;122(5):874-881 Pediatric Eye Disease Investigator Group. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology 2003;110(11):2075-87 Pediatric Eye Disease Investigator Group. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003;121(5):603-11 Confidential 78Pedig Amblyopia Studies Pediatric Eye Disease Investigator Group. Risk of amblyopia recurrence after cessation of treatment. J AAPOS 2004;8(5):420-8 Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123(4):437-47 Many….many…..many ….more! And…the bottom line is:
  14. 14. 29/07/2015 14 Confidential 79Pedig Amblyopia Studies Bottom-line: Spectacles: Spectacles alone improves bilateral amblyopia (3-10 y/0); improves strabismic amblyopia Patching: 2 hrs often shows marked improvement in VA. Then consider 6 hrs. Use 6 hrs for severe amblyopia Atropine: Equal to patching; can improve severe amblyopia Bangerter filters: Use them. Fairly equal to patching. Maybe more readily acceptable to patient (Moderate amblyopia 20/40-20/80 VA) Eye alignment: Amblyopia therapy (patching/atropine) may improve alignment Confidential 80Pedig Amblyopia Studies Bottom-line: Age: Under age 7 better results, some remarkable improvement up to age 12. Older children (17) also show improvement in VA Non-PEDIG studies suggests improvement at any age Recurrence: High rate of recurrence after treatment stops (risk of recurrence is greater when patching is stopped abruptly rather than when it is reduced) Reading: Monocular oral reading ability was slightly worse when reading with previously treated amblyopic eyes in terms of rate, accuracy and fluency, but reading comprehension testing was similar. (Current PEDIG studies do not use binocular vision therapy to treat amblyopia. Could this account for the decreased reading ability?) Patching with near activities: Patching with/without similar results (crafts, reading, writing, and computer or video games) Confidential Amblyopia Treatment of Amblyopia (** supported by clinical trials) 1.) Rx spectacles, follow up 2-3 months ** 2.) Continue to monitor until no further improvement, change Rx as needed, start patching or atropine ** 3.) Continue to monitor (taper patching over time) 3.) Continue to monitor until no improvement, start HVT 4.) Continue to monitor until no improvement, start OVT Start binocular vision therapy sooner rather than later Vision Res. 2015 Apr 20. pii: S0042-6989(15)00052-8. doi: 10.1016/j.visres.2015.02.009. [Epub ahead of print]Amblyopia and the binocular approach to its therapy.Hess RF1, Thompson B2. Eye (Lond). 2014 Oct;28(10):1246-53. doi: 10.1038/eye.2014.165. Epub 2014 Jul 25. A binocular iPad treatment for amblyopic children. Li SL1, Jost RM1, Morale SE1, Stager DR2, Dao L3, Stager D3, Birch EE4. 81 Confidential Amblyopia Treatment of Amblyopia Start binocular vision therapy sooner rather than later Clin Exp Optom. 2014 Sep;97(5):389-98. doi: 10.1111/cxo.12192. Epub 2014 Aug 18. The iPod binocular home-based treatment for amblyopia in adults: efficacy and compliance. Hess RF1, Babu RJ, Clavagnier S, Black J, Bobier W, Thompson B. Strabismus. 2014 Mar;22(1):1-6. doi: 10.3109/09273972.2013.877945. Binocular training reduces amblyopic visual acuity impairment. Mansouri B1, Singh P, Globa A, Pearson P. Invest Ophthalmol Vis Sci. 2014 Apr 15;55(4):2384-91. doi: 10.1167/iovs.13-12627.Perceptual learning improves stereoacuity in amblyopia.Xi J1, Jia WL, Feng LX, Lu ZL, Huang CB. Amblyopia can be treated at any age. The younger the patient the better the outcome. All deserve an opportunity to improve vision function. 82 Confidential Adult Treatment of Amblyopia Levi DM. 2005. Perceptual learning in adults with amblyopia: A reevaluation of critical periods in human vision. Developmental Psychobiology 46: 222-232. Improving vision in adult amblyopia by perceptual learning. Uri Polat, Tova Ma-Naim, Michael Belkin, Dov Sagi ( Adult amblyopia reversed by contralateral cataract formation. ME Wilson - Journal of pediatric ophthalmology and strabismus, 1991 (Why did this take so many decades) Dichoptic training enables the adult amblyopic brain to learn. Jinrong Li, et al. ( ….and finally… 83 Confidential Adult Treatment of Amblyopia The Effect of Video Game Training on the Vision of Adults with Bilateral Deprivation Amblyopia. Seong Taek Jeon, et al. Seeing and Perceiving 25 (2012) 493–520 … there is enough residual plasticity in the adult visual system to effect improvements, even in cases of deep amblyopia caused by early bilateral deprivation…The game may be effective because it contains the components of perceptual learning (stimulus/response/feedback) based simultaneously on many aspects of vision presented in a visually complex and challenging environment in an immersive, engaging, and adaptive way… Sounds a lot like optometric vision therapy! 84
  15. 15. 29/07/2015 15 Confidential Yet another reason to treat amblyopia: Malpractice Dr. XYZ , in breach of the standard of care … failed to: perform DFE/Cyclo, failed to properly treat the amblyopia, failed to determine proper Rx, failed to monitor, failed to patch, failed to properly instruct parents about condition…. 85 Confidential Yet another reason to treat amblyopia: Malpractice 06-17-1999 Age 6 +4.00 OU (Rx varied over time, variable responses from child) Supposedly told mom nothing could be done after age 5yrs Mom looked it up on the Internet 86 Confidential The Power of a Pair of Spectacles 87 Confidential Strabismus Cochrane Reviews The majority of published literature on the use of botulinum toxin in the treatment of strabismus consists of retrospective studies, cohort studies or case reviews. Although these provide useful descriptive information, clarification is required as to the effective use of botulinum toxin as an independent treatment modality. Four RCTs on the therapeutic use of botulinum toxin in strabismus have shown varying responses ranging from a lack of evidence for prophylactic effect of botulinum toxin in acute sixth nerve palsy, to poor response in patients with horizontal strabismus without binocular vision, to no difference in response in patients that required retreatment for acquired esotropia or infantile esotropia. It was not possible to establish dose effect information. Complication rates for use of Botox™ or Dysport™ ranged from 24% to 55.54%. 88 Confidential Strabismus Cochrane Reviews Adjustable or non-adjustable sutures: No reliable conclusions could be reached regarding which technique Clinical management of intermittent exotropia: difficult to reliably interpret the results Interventions for infantile esotropia: No reliable conclusions 89 Confidential Vision therapy: Little to no information in Cochrane Reviews Convergence Insufficiency, Convergence excess Divergence insufficiency, Divergence excess Accommodative Disorders, Oculomotor disorders **Vision Therapy/Orthoptics: Current research suggests that outpatient vision therapy/orthoptics is more effective than home-based convergence exercises or home-based computer vision therapy/orthoptics for children. In adult population, evidence of the effectiveness of various non-surgical interventions is less consistent. Research on Vision Therapy Available From COVD at: 90
  16. 16. 29/07/2015 16 Confidential Pansell T1, Hellgren K, Jacobson L, Brautaset R, Tedroff K. The accommodative process in children with cerebral palsy: different strategies to obtain clear vision at short distance. Dev Med Child Neurol. 2014 Feb;56(2):171-7. doi: 10.1111/dmcn.12266. Epub 2013 Sep 4. Children with CP exhibit problems in generating an appropriate accommodative response. This can affect everyday living and reading skills. McClelland JF1, Parkes J, Hill N, Jackson AJ, Saunders KJ. Accommodative dysfunction in children with cerebral palsy: a population-based study. Invest Ophthalmol Vis Sci. 2006 May;47(5):1824-30. significantly reduced accommodative responses J Am Optom Assoc. 1984 Apr;55(4):281-3. Accommodation in cerebral palsy: function and remediation. Duckman RH. Accommodation dysfunction in CP can be improved Oculomotor, accommodative, vergence dysfunctions. High incidence of strabismus. Rx Bifocals Cochrane Reviews: Little to no information in terms of clinical trials and reviews of these trials Cerebral Palsy 91 Confidential Down Syndrome Woodhouse M. Maino D. Down Syndrome. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams & Wilkins. New York, NY;2012:31-40. Strabismus: functional in nature (accommodative ET) Accommodative “weakness” (insufficiency): Bifocals both compensating and therapeutic Little to nothing in Cochrane Reviews 92 Confidential TBI/Concussion Effect of binasal occlusion (BNO) on the visual-evoked potential (VEP) in mild traumatic brain injury (mTBI) 2013, Vol. 27, No. 1 ,41-47 Kenneth J. Ciuffreda, Naveen K. Yadav, and Diana P. Ludlam …. individuals with mTBI habitually attempt to suppress visual information in the near retinal periphery to reduce their abnormal visual motion sensitivity , with addition of the BNO negating the suppressive influence and thus producing a widespread disinhibition effect and resultant increase in VEP amplitude… 93 Confidential TBI/Concussion Vision Diagnoses Are Common After Concussion in Adolescents. Christina L. Master, et al. ( 7/07/0009922815594367.abstract) …100 adolescents were examined, with a mean age of 14.5 years. Overall, 69% had one or more of the following vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (29%). In all, 46% of patients had more than one vision diagnosis. … 94 Confidential TBI/Concussion Effect of oculomotor rehabilitation on vergence responsivity in mild traumatic brain injury. JRRD Preethi Thiagarajan,et al. ( 9/jrrd-2012-12-0235.html …The significant improvement in most aspects of vergence eye movements following oculomotor training demonstrates considerable residual brain plasticity via oculomotor learning. The improved vergence affected positively on nearwork-related symptoms and visual attention…. 95 Confidential TBI/Concussion: Post Trauma Vision Syndrome Blurred vision Sensitivity to light, glare sensitivity Reading difficulties; words appear to move Comprehension difficulty Attention and concentration difficulty Memory difficulty Double vision Aching eyes Headaches with visual tasks Inability to maintain visual contact Reduction or loss of visual field Difficulties with eye movements Perceptual Midline Shift 96
  17. 17. 29/07/2015 17 Confidential Brief Review of Various Disabilities Fragile X syndrome: Strabismus Berrry-Kravis E, Maino D. Fragile X Syndrome. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams & Wilkins. New York, NY;2012:41-48. Autism: Strabismus, Perceptual Dysfunction, Oculomotor Pediatric Cortical Visual Impairment: 97 Confidential Evidence Based Practice Vaccines Nutrition Vitamins Supplements Acupuncture Chiropractic Other CAM Therapies 98 Evidence Based Practice Syntonics OT/PT/Speech/Lang Amblyopia Vision Therapy Strabismus Surgery Patients with Special Needs Which of these do you use and/or recommend? Which has the research behind it? Confidential Summary Do we need evidence for everything? Yes and No. Use your clinical experience and judgement, AOA Clinical Guidelines, and research to determine the best approach for each patient, who unlike subjects in a clinical trial, tend to be heterogeneous, idiosyncratic, and unique. Taylor your approach to the individual patient. 99 Confidential Additional References Lipids Health Dis. 2015 Jun 6;14(1):53. doi: 10.1186/s12944-015-0049-7. A review of the effect of omega-3 polyunsaturated fatty acids on blood triacylglycerol levels in normolipidemic and borderline hyperlipidemic individuals. Leslie MA1, Cohen DJ2, Liddle DM3, Robinson LE4, Ma DW5. Am Fam Physician. 2015 Jun 1;91(11):772-6. Nonpharmacologic management of hypertension: what works? Oza R1, Garcellano M1. Asia Pac J Clin Nutr. 2015;24(1):10-5. doi: 10.6133/apjcn.2015.24.1.21. Omega-3 polyunsaturated fatty acids and non-communicable diseases: meta-analysis based systematic review. Li D1,2,3. Curr Opin Allergy Clin Immunol. 2015 Aug;15(4):369-74. Diet and asthma: an update. Han YY1, Forno E, Holguin F, Celedón JC. J Psychopharmacol. 2015 Jul;29(7):753-763. Epub 2015 Jun 3.Omega-3 polyunsaturated fatty acid supplementation and cognition: A systematic review and meta-analysis. Cooper RE1, Tye C2, Kuntsi J2, Vassos E2, Asherson P2. Omega 3 fatty acids for preventing or slowing the progression of age-related macular degeneration. Cochrane Database Syst Rev. 2015 Apr 9;4:CD010015 Lawrenson JG, Evans JR. Ann Gastroenterol. 2015 Apr-Jun;28(2):210-220. Herbal and plant therapy in patients with inflammatory bowel disease. Triantafyllidi A1, Xanthos T1, Papalois A2, Triantafillidis JK3. Inflammopharmacology. 2015 Jun;23(2-3):79-89. doi: 10.1007/s10787-015-0228-1. Epub 2015 Feb 14. Role of fish oil in human health and possible mechanism to reduce the inflammation. Ellulu MS1, Khaza'ai H, Abed Y, Rahmat A, Ismail P, Ranneh Y. Nutrients. 2014 Oct 3;6(10):4058-73. doi: 10.3390/nu6104058. The role for dietary omega-3 fatty acids supplementation in older adults. Molfino A1, Gioia G2, Rossi Fanelli F3, Muscaritoli M4. Eur J Clin Nutr. 2015 Apr;69(4):419-24. doi: 10.1038/ejcn.2014.155. Epub 2014 Aug 13. Omega-3 supplementation during the first 5 years of life and later academic performance: a randomised controlled trial. Brew BK1, Toelle BG2, Webb KL3, Almqvist C4, Marks GB1; CAPS investigators. 100 Confidential References J Altern Complement Med. 2015 Jun 26. [Epub ahead of print] Acupuncture as a Treatment Modality in Dermatology: A Systematic Review. Ma C1, Sivamani RK1. J Neurotrauma. 2015 Jun 16. [Epub ahead of print] The Impact of Acupuncture on Neurological Recovery in Spinal Cord Injury:A Systematic Review and Meta-analysis. Ma R1,2, Liu X3,4,5, Clark J6, Williams GM7, Doi SA8. Evid Based Complement Alternat Med. 2013;2013:648054. doi: 10.1155/2013/648054. Epub 2013 Apr 30.A meta-analysis of randomized controlled trials on acupuncture for amblyopia. Yan X1, Zhu T, Ma C, Liu A, Dong L, Wang J. J Commun Disord. 2013 Sep-Dec;46(5-6):495-506. doi: 10.1016/j.jcomdis.2013.09.004. Epub 2013 Oct 10. Promoting child-initiated social- communication in children with autism: Son-Rise Program intervention effects. Houghton K1, Schuchard J, Lewis C, Thompson CK. 101 Confidential Dominick M. Maino, OD, MEd,  FAAO, FCOVD‐A Professor, Illinois College of Optometry/Illinois Eye Institute 3241 S. Michigan Ave; Chicago, Il 60616 312-949-7282 Lyons Family Eye Care 3250 N. Lincoln Ave; Chicago, Il 60657 773-935-2020 102