Talk:Vision therapy

Speaking as an Autistic who has recently been referred to a Developmental Optometrist (who diagnosed retained primitive reflexes), it behooves us to focus on the neurological angle, both theory and practice. Does any professional organization track referrals? Have they risen over the decades? Abnormal primitive reflexes are an early indicator of autism. Etc. (I can't speak to the pedagogical aspect.) kencf0618 (talk) 03:15, 26 July 2023 (UTC)

Do you have any sources for this? And that indicate that it's relevant to this article. Brunton (talk) 18:23, 27 July 2023 (UTC)

A major issue with this page is that it identifies behavioral optometry and vision therapy. It is true that at least two major sources for the article make this identification: Novella, whose article is an essentially an op-ed, and https://doi.org/10.1017%2F9781316798096.007. But behavioral optometry is a subfield of optometry, whereas vision therapy is a practice consisting in a set of procedures (vision exercises) designed to treat specific visual disorders, and is prescribed by neuro-optometrists, behavioral optometrists, and orthoptic specialists. This is a semantic distinction and recourse to an identification between two pragmatically and semantically distinct terms in an academic text or an op-ed is not sufficient evidence to disclaim such a distinction.

By conflating the two terms the article conflates systematic doubts about the claims of behavioral optometry as a field (more specifically, the inferences some behavioral optometrists draw from the scientifically uncontroversial fact that some vision exercises are effective at treating convergence insufficiency to larger claims about the role of visual issues in learning disorders) with the efficacy of a subset of these treatments. This is unacceptable and should be addressed in a revison. AtavisticPillow (talk) 01:50, 10 October 2023 (UTC)

Let's keep following the independent sources. Bon courage (talk) 06:29, 10 October 2023 (UTC)

Even if the sources are not reflective of a) the general usage of of the key terms in question, and b) the self-understanding of the discipline being analyzed? Both concern me: a quick look at this info page for for the Australian College for Behavioral Optometrists, for instance, shows that vision therapy and behavioural optometry are not identified (vision therapy is there mentioned as a possible treatment for certain eye issues). It also shows a considerably more modest mission statement than is attributed to behavioral optometry by the two sources just mentioned. This is just one website, to be sure, but these discrepancies continue to concern me. AtavisticPillow (talk) 12:59, 10 October 2023 (UTC)

The point is to use independent WP:FRIND sources, rather than the in-universe thinking peculiar to the believers. Bon courage (talk) 13:25, 10 October 2023 (UTC)

Sure, but don't we have to differentiate between two levels of claims here? On the one hand there is the question of the validity of the field of medicine in question – here the claims of the practitioners in a suspect field should not be taken at face value, because demonstrating the validity of a scientific claim requires that certain institutional and methodological criteria be met for the knowledge to be verified and enter general acceptance. On the other hand, there is the empirical question of what is actually practiced and believed by these practitioners. Here the evidentiary standard is obviously different since all we need is the empirical details of the practice, which will have to rely on publicly available information from both practitioners and observers. If there is a discrepancy between the public statements about practitioners and the self-description of practitioners (independent of the question of validity) – and I strongly believe this to be the case here – then the source of this discrepancy has to be placed into a larger context that takes into account this difference and the potential source of the discrepancy.

In other words, we have to accurately characterize the "in-universe" thinking in order to accurately evaluate it, and this cannot be done without direct reference to this "universe" itself. AtavisticPillow (talk) 14:17, 10 October 2023 (UTC)

For many types of woo the terminology is (sometimes deliberately) obfuscated and/or confused, and woo-practitioners are often coy about what they do. If there are more independent sources, or sources which discuss the confusion by all means produce them as they would be useful. Bon courage (talk) 14:33, 10 October 2023 (UTC)

Fair enough. I'll have to look through the relevant sources and literature. AtavisticPillow (talk) 14:35, 10 October 2023 (UTC)

I spent some time looking over the some of the sources for this article, as well as additional sources for added context. To that end I would like to propose a few revisions. Novella (2018) and LaBrot Z, Dufrene B (2019) are cited for the claim that vision therapy is quackery and pseudoscience. Both of these sources are primarily relying on Barrett (2008), although LaBrot Z, Dufrene B (2019) also rely on Handler SM, Fierson WM (2011). Given this, I would argue we should take Barrett (2008) as a more neutral source: nowhere does he describe vision therapy as quackery or pseudoscience, but he does emphasize that a majority of vision therapy practices are “not evidence based,” and at multiple points suggests that more control-tested clinical trials are needed to verify such practices. The need for further clinical trials is a recurring theme in recent neurology and ophthalmology literature (most strongly emphasized here) – a literature that is highly skeptical of the claims of behavioral optometry/vision therapy/neuro-optometry.

I would also suggest we follow Barrett (2008) when he says: “there are areas where the available evidence is consistent with claims made by behavioural optometrists (most notably in relation to the treatment of convergence insufficiency, the use of yoked prisms in neurological patients, and in vision rehabilitation after brain disease/injury.” There is relatively substantial medical literature which recommends neuro-optometric rehabilitation, a variety of vision therapy, after a concussion (1, 2, 3); I think the article should reflect this.

Finally, as others have argued I think the article should make explicit the mutual mistrust between mainstream ophthalmology and optometry. Optometry sources continually insist that there is available evidence for the efficacy of vision therapy. Non-optometry sources disagree because of the quality of the data. But both of the sources just listed insist that better studies are needed. So the basic lay of the land is this: many of the claims about the efficacy of vision therapy have not been proven with the best possible data, but unlike chiropractic (which has been definitively disproven), there is large agreement that more data is needed to verify the practice and efficacy of vision therapy. This could be better demonstrated in the article itself; it is certainly true that behavioral optometrists do not operate with the best scientific practices, but the current characterization that vision therapy is quackery pure and simple (aside from incidentally treating convergence insufficiency) is not accurate or reflective of the state of knowledge in the medical field at large. AtavisticPillow (talk) 15:39, 11 October 2023 (UTC)

Are you editing logged-out? Bon courage (talk) 15:41, 11 October 2023 (UTC)

Apologies didn't realize I was logged out. Yes I made this post. AtavisticPillow (talk) 16:03, 11 October 2023 (UTC)

Seems to privilege the most outdated source, so I think that's a bad idea. Chiropractic has not been 'definitively disproven'. Any stuff about 'mutual mistrust' would need good sourcing on exactly that; as I recall this is just a story used by the quacks to elevate themselves into the respectability of an apparent realm of debate. We don't say VT is 'quackery pure and simple' (far from it). I think from this point it would be advisable in future for you to make very specific edit requests detailing the textual change desired with associated sources. Bon courage (talk) 18:01, 11 October 2023 (UTC)

Two points, then an edit request.

1) The newer sources – the ones used to characterize vision therapy as pseudoscience – use Barrett (2008) to directly substantiate their claims. But Barrett doesn't claim that vision therapy is pseudoscience, just that many of the treatment methods remain unproven. Hence thinking we should be more cautious about that characterization of vision therapy as a whole, especially since it's in the first sentence.

2) The remainder of the article is more balanced than I have given credit. It's really the opening that I feel needs revision, since it makes a categorical claim that is not substantiated by the rest of the article (that vision therapy as a whole is based around a pseudo-scientific claim; the various qualifications the larger article offers refutes this, in my eyes).

So the specific edit request would be to rewrite the opening paragraph as follows:

Vision therapy (VT), or behavioral optometry, is an umbrella term for a variety of alternative medicine treatments using eye exercises. Unlike orthoptics, with which it shares some treatment methods, vision therapy has not been shown to be effective using scientific studies, except for helping with convergence insufficiency. Most claims—for example that the therapy can address educational and spatial difficulties—lack supporting evidence. In recent years, vision therapy has been increasingly employed for the treatment of concussion, although the practice remains controversial. Neither the American Academy of Pediatrics nor the American Academy of Ophthalmology support the use of vision therapy.

And a note about sources:

I think this would be a great source here, since it directly addresses the terminological confusion surrounding vision therapy. Barrett (2008) directly makes the claim made in the second sentence (that VT shares treatment methods with orthoptics). I would use the sources cited in my previous post to support the claim that vision therapy is increasingly used as a treatment for concussion – the literature there is substantial, and recent. AtavisticPillow (talk) 21:13, 11 October 2023 (UTC)

Sources specialising in fringe topics are apt to make the pseudoscience/quackery call. Per policy we need to be very explicit when. something's pseudoscience, so I don't think your lede works. I can't see that the "Kitra Gray" source has any the hallmarks of quality Wikipedia looks for, so would be way of using it. Bon courage (talk) 05:08, 12 October 2023 (UTC)

Not wedded to the Kitra Gray source, just thought it broke down the terminological confusion well and was on a similar level of quality as the Novella source.

More to the point, what policy are you referring to? WP:FRINGE/QS definitively says that we should be cautious about the characterization "if a reasonable amount of academic debate still exists." I think I have shown that there is considerable academic debate about the use of vision therapy, with optometry literature as well as much mainstream concussion literature endorsing, while others remain skeptical. All I have done is remove the broad characterization of vision therapy as pseudoscience in the opening sentence as a result, virtually all other doubts and claims remain. I think I have more than met you half way; if there is a policy that I am unaware of please share it. AtavisticPillow (talk) 12:49, 12 October 2023 (UTC)

WP:PSCI and WP:GEVAL are germane. Bon courage (talk) 12:55, 12 October 2023 (UTC)

I fail to see how my proposed revision gives undue weight to fringe sources or fails to maintain a neutral point of view. The primary thing I have done is remove a claim that all vision therapy is based around a pseudo-scientific claim, something which is not borne out by the sources as a whole, the remainder of the article, or the current academic literature. I have left the view that it has been described as pseudoscience and quackery fully intact in the second paragraph, this is fine, I am simply trying to give a more accurate summary of the varieties of opinion in the literature.

I have cited academic literature on the treatment of concussion, as well as mainstream optometry journals. You earlier argued that you saw no evidence of there being a split between optometry and ophthalmology, and that any evidence of this would have to be sourced. That's fine, but in that case on what grounds are you dismissing the optometry journals as sources? AtavisticPillow (talk) 13:09, 12 October 2023 (UTC)

RS says it is pseudoscience, so Wikipedia must prominently do so too. I don't think there is "no evidence of there being a split between optometry and ophthalmology" it is, rather, the nature of that split which is misrepresented as a respectable disagreement rather than a repudiation of unscientific ways, Bon courage (talk) 13:24, 12 October 2023 (UTC)

I see. In that case I am going to add the claim that vision therapy is increasingly used in the treatment of concussion (as in my proposed edit). I am also going to change the source of the pseudoscience claim to LaBrot Z, Dufrene B (2019) rather than Novella, as that is the RS. And I am going to remove the word "neurological" in the third sentence, because even the harshest critics acknowledge that vision therapy has shown promise in the treatment of concussion (see Novella, for instance), and this is in direct contradiction to the claim made there. AtavisticPillow (talk) 13:40, 12 October 2023 (UTC)

The Novella source is strong RS, but not for biomedical claims. The lede summarizes the body so it's not particularly important which sources are (optionally) cited there. Bon courage (talk) 13:43, 12 October 2023 (UTC)

Went ahead and executed my final edit proposal, and added sources for the concussion claim. AtavisticPillow (talk) 17:10, 30 October 2023 (UTC)

Please don't bomb the lede. Also that source looks like it's from Vision therapists, so not WP:FRIND. Bon courage (talk) 17:37, 30 October 2023 (UTC)

I can add further information from the Acquired Brain Injury source to the body of the article in a relevant spot to avoid bombing the lede. It's from an academic textbook about treatment for brain injury, and the source was used as evidence for the claim that vision therapy was being employed as a treatment for traumatic brain injury (not any statements about demonstrated efficacy). The institutional context in which something is employed seem relevant enough to be stated in the lede.

I had thought based on your previous (Oct 12, 13:43) comment you were OK with these revisions. But perhaps I was mistaken? AtavisticPillow (talk) 18:03, 30 October 2023 (UTC)

I'd not seen any revisions at that point, but was commenting on the Novella source. I'm uncomfortable with mentioning something is "used" devoid of knowledge about efficacy, because it implies it works. Bon courage (talk) 18:14, 30 October 2023 (UTC)

Well initially I was only going for the weaker "it is used" claim about brain injury, but Barrett (2008) actually does make the efficacy claim when he says the following: "Although there are areas where the available evidence is consistent with behavioural optometry approaches (most notably in relation to the treatment of convergence insufficiency, the use of yoked prisms in neurological patients, and in vision rehabilitation after brain injury), a large majority of behavioural management approaches do not possess a solid evidence base, and thus they cannot be advocated." This is repeated on the Vision Therapy page in the "Techniques" section. But the claim here directly contradicts the claim in the lede that vision therapy is only effective for treating convergence insufficiency.

So I think we need to edit the lede to reflect that mainstream medical literature acknowledges as valid the use of vision therapy after brain injury (the yoked prism issue is more complicated and need not be addressed here). Given issues with my initial edit how would you feel if I simply added the brain injury claim to the second sentence of the lede?

It would then read: " Vision therapy has not been shown to be effective using scientific studies, except in the treatment of convergence insufficiency and in vision rehabilitation after brain injury." AtavisticPillow (talk) 18:50, 30 October 2023 (UTC)

It hasn't been "shown to be effective" after brain injury. Bon courage (talk) 19:00, 30 October 2023 (UTC)

Well then how about I change the sentence to more accurately reflect the claim by Barrett, who is the citation here. How about: "Vision therapy has not been shown to be effective using scientific studies, although some evidence supports its use in the treatment of convergence insufficiency and in vision rehabilitation after brain injury." AtavisticPillow (talk) 19:07, 30 October 2023 (UTC)

Barret just said the evidence, such as it was, was at least consistent (in 2009). But per PMID:32542907 the current state of knowledge is that VT is no good post brain injury - mirroring Novella. So we need to update that. Bon courage (talk) 19:10, 30 October 2023 (UTC)

Good source. But it doesn't say that VT is "no good" –rather, it says: "Visual complaints occur after mTBI. Some can be linked convincingly to problems such as convergence or accommodative insufficiency, and the best candidate for treatment efficacy may be therapy for post-traumatic vergence dysfunction, and possibly for accommodative insufficiency, but randomized trials are needed to establish that there is benefit beyond natural recovery."

Perhaps a short paragraph summarizing these results can be added to the efficacy section? AtavisticPillow (talk) 19:29, 30 October 2023 (UTC)

It can be summarized as "no good evidence". Bon courage (talk) 19:43, 30 October 2023 (UTC)

Apologies for long post but the "Treatment Types" section is long and messy and has issues with sourcing. I would like to propose a number of removals to clean it up. These proposals are:

1) Remove the "Eye Exercises" sub-section, because the sourcing issues are most serious there and the relevant information can be better presented in other sections (particularly "Techniques").

2) Remove the claim that vision therapy is practiced by unlicensed professionals, because this lacks a source and isn't borne out by the sources we do have, generally sources claim it is practiced by optometrists.

3) Remove "Conceptual basis and effectiveness" sub-section, because it repeats information already stated in the "Efficacy" section above.

4) The "techniques" section is little more than a lengthy summary of Barrett (2008) – perhaps this should be edited for concision, a more recent source should be added such as Barton and Ranalli (2020), and the section moved from a sub-section of "Treatment Types" to its own section.

5) Combine the "behavioral vision therapy" and "behavioral optometry" sub-sections because our best sources identify the two.

6) The sources are also pretty weak on the sports sub-section, and if we want to talk about this at all we should probably merge it with the "behavioral optometry" sub-section.

7) Finally, I think a section on neuro-optometric rehabilitation describing the way that vision therapy is employed for treatment of brain injury. This obviously would have put front and center the Barton and Ranalli (2020) source that claims this use currently lacks supporting evidence.

Executing this altogether would leave three major sections under Treatment Types: orthoptics, behavioral optometry, and neuro-optometric rehabilitation. So far as I can tell this better reflects the sources and the actually existing institutional layout of vision therapy. AtavisticPillow (talk) 00:55, 31 October 2023 (UTC)

@Bon courage: sorry to keep bothering you but I'd like to see your thoughts before I execute this. not trying to change any substantive claims, just trying to clean up the page and add a few sentences about the existence of neuro-optometric rehabilitation so perhaps we'll see eye to eye here? AtavisticPillow (talk) 00:39, 3 November 2023 (UTC)