Standardizing Tuina intervention for pediatric myopia: evidence-based guideline from a Delphi consensus panel

Abstract

Introduction Myopia is an escalating public health challenge worldwide, with a particularly high burden in China. Although conventional treatments are available, their effectiveness is often limited by issues related to adherence, cost, or safety. Traditional Chinese medicine (TCM), specifically Tuina therapy, offers a preventive approach, with studies suggesting its potential efficacy in the management of pediatric myopia. However, clinical adoption is hindered by lack of standardized treatment protocols. This study aimed to assess the efficacy and safety of Tuina therapy for pediatric myopia and establish a standardized protocol based on the Zhi Wei Bing (prevention first) theory. Methods A multi-method, consensus-based approach was employed, comprising three stages: (i) Problem Identification: Semi-structured expert interviews; (ii) Evidence Retrieval and Synthesis: A systematic literature search (up to September 2023) across Chinese and English databases; and (iii) Recommendation Formulation: A two-round Delphi process, involving 203 ophthalmologists and 76 Tuina specialists, achieved predefined agreement (≥60% consensus) on procedures, acupoint protocols, and TCM pattern differentiation. Recommendations were developed using evidence-to-decision frameworks and Good Practice Statements. Evidence quality and recommendation strength were assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Results Tuina therapy demonstrated favorable efficacy and safety in the prevention and treatment of low-degree myopia and pseudomyopia in children. A consensus was reached regarding five TCM patterns. A standardized acupoint protocol was established: 14 core acupoints for the preventive stage, 21 for progression management, and 25 for pattern differentiation. A combined strategy using both foundational and pattern-specific acupoints is recommended. The foundational protocol can be applied alone if no specific pattern is identified. Home-based eye exercises were endorsed as complementary strategies. Conclusion This study developed the first evidence-based standardized Tuina protocol for pediatric myopia, addressing a critical gap in non-pharmacological management. These findings suggest that Tuina is an effective and safe therapeutic approach.

Keywords

myopia / Tuina / complementary therapy / consensus / Delphi / prevention first

References

[1] Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016; 123(5):1036-1042.

[2] Wong YL, Saw SM. Epidemiology of pathologic myopia in Asia and worldwide. Asia Pac J Ophthalmol. 2016; 5(6):394-402.

[3] Liu H, Zhang K, Wang L, Chen J. Educational burden reduction, educational inequality, and enrollment pressure: Evidence from China. Econ Hum Biol. 2025; 56:101459.

[4] Pan Z, Xian H, Li F, et al. Myopia and high myopia trends in Chinese children and adolescents over 25 years: a nationwide study with projections to 2050. Lancet Reg Health West Pac 2025; 59:101577.

[5] Russo A, Boldini A, Romano D, et al. Myopia: mechanisms and strategies to slow down its progression. J Ophthalmol. 2022; 2022:1004977.

[6] Liu YM, Xie P. The safety of orthokeratology: a systematic review. Eye Contact Lens. 2016; 42(1):35-42.

[7] Sartor L, Hunter DS, Vo ML, Samarawickrama C. Benefits and risks of orthokeratology treatment: a systematic review and meta-analysis. Int Ophthalmol. 2024; 44(1):239.

[8] Logan NS, Wolffsohn JS. Role of un-correction, under-correction and over-correction of myopia as a strategy for slowing myopic progression. Clin Exp Optom. 2020; 103(2):133-137.

[9] Sun W, Wang R, Ouyang S, et al. “Weibing” in traditional Chinese medicine: biological basis and mathematical representation of disease-susceptible state. Acta Pharm Sin B. 2025; 15(5):2363-2371.

[10] Matos LC, Machado JP, Monteiro FJ, Greten HJ. Understanding traditional Chinese medicine therapeutics: an overview of the basics and clinical applications. Healthcare. 2021; 9(3):257.

[11] Yang C, Ling L, Zhou T. Association between Chinese eye exercises and myopia onset in children and adolescents: a meta-analysis. Chin J Evid Based Med. 2023; 23(1):59-66.

[12] The Ophthalmology Branch, China Association of Chinese Medicine. Guideline for traditional Chinese medicine in the prevention and control of myopia in children and adolescents (for community doctors and school doctors). China J Chin Ophthalmol. 2021; 31(7):461-465.

[13] The Ophthalmology Branch, China Association of Chinese Medicine. Clinical practice guideline for appropriate TCM techniques for the prevention and control of myopia in children and adolescents (Part Ⅱ). China J Chin Ophthalmol. 2022; 32(7):505-512.

[14] Talens-Estarelles C, Cerviño A, García-Lázaro S, Fogelton A, Sheppard A, Wolffsohn JS. The effects of breaks on digital eye strain, dry eye and binocular vision: testing the 20-20- 20 rule. Cont Lens Anterior Eye. 2023; 46(2):101744.

[15] Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction: GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011; 64(4):383-394.

[16] Xu Y, Ye C, Wang H, et al. Acupoint selection patterns of massage for preventing and treating myopia in children and adolescents. China J Chin Ophthalmol. 2025; 35(5):428-433,481.

[17] Deng M, Zhang Y. From perspective of “preventive treatment of disease” to discuss the prevention and treatment of adolescent regulatory myopia. China J Chin Ophthalmol. 2020; 30(1):68-71,74.

[18] Chinese Association of Integrative Medicine, Chinese Association of Chinese Medicine, Chinese Medical Association. Clinical practice guideline of integrative Chinese and Western medicine for myopia in children. China J Chin Ophthalmol. 2024; 60(1):13-34.

[19] Chinese Optometric Association, Chinese Ophthalmological Society; Ophthalmology and Optometry Committee, Ophthalmologists Association, Chinese Doctor Association; Ophthalmology and Optometry Group, Ophthalmologic Committee, Chinese Non-government Medical Institutions Association; et al. Expert consensus on myopia management white paper (2022). Chin J Optom Ophthalmol Vis Sci. 2022; 24(9):641-646.

[20] Xue WH. Clinical Effect of Massage Combined with Compound Tropicamide Eye Drops in the Treatment of Children with Pseudomyopia [master’s thesis]. Fuzhou, China: Fujian University of Traditional Chinese Medicine; 2021.

[21] Xi QY. Clinical Observation of Liu’s Pediatric Tuina in the Treatment for Simple Low-grade Myopia in School-age Children [master’s thesis]. Changsha, China: Hunan University of Chinese Medicine; 2023.

[22] Huang T. Clinical Observation of “Siming Acupoint” Massage Technique in Treating Pseudomyopia in Children [master’s thesis]. Jinan, China: Shandong University of Traditional Chinese Medicine; 2024.

[23] Yang M. Prevention and treatment of pseudomyopia in children by ear point pressure and massage. Capital Food Med. 2019; 26(11):186-187.

[24] Zhao ZH, Luo GJ, Yu WQ, Huang XH, Pan P, Cheng JP. Observations on the efficacy of plum-blossom needle therapy plus massotherapy for juvenile pseudomyopia. Shanghai J Acupunct Moxibust. 2013; 32(7):578-580.

[25] Peng CB, Wang Y, Yang L, Xu MF, Hu J, Duan LX. Effect observation of integrated traditional Chinese and Western medicine nursing interventions on myopia in primary school students. Pract Clin J Integr Tradit Chin West Med. 2020; 20(16):155-156.

[26] Ni HY. Clinical Observation on the Treatment of Juvenile Pseudomyopia by Massage Manipulation Based on “Spleen and Kidney” Combined with Myopia Therapeutic Apparatus [master’s thesis]. Changchun, China: Changchun University of Chinese Medicine; 2017.

[27] Zhong RY, Wang Y, Li ZY. Prevention and control of children myopia with massage combined with wearing personalized myopia-lens based on theory of treating disease before its onset. J Guangzhou Univ Tradit Chin Med. 2018; 35(1):70-73.

[28] Li S, Yang C, Wu X, Li M, Yang Y. Clinical observation on the effect of acupoint massage combined with overlooking training in slowing down the progress of low-grade mixed myopia in children. China J Chin Ophthalmol. 2022; 32(8):614-618.

[29] Fu JM, Wang LJ, Li YX, Lin JX. 42 cases of myopia treated by auricular point sticking and pressing combined with acupoint massage around eyes. Chin J Ethnomed Ethnopharm. 2010; 19(18):121.

[30] Xu YP. Clinical efficacy analysis of acupressure with auricular pressure pill in the treatment of adolescent myopia. Guide Chin Med. 2015; 13(24):210-211.

[31] Li Q, Ye JT, Chen M. Clinical observation on the treatment of juvenile myopia by acupoint massage combined with auricular point pressing pill. Guangming J Chin Med. 2013; 28(12):2515-2516.

[32] Ding JJ, Tang Y. Observation on the effect of acupuncture combined with acupoint massage in the treatment of myopia in children. Contemp Med Symp. 2019; 17(18):61-62.

[33] Guo Q. Observation on the efficacy of massage in treating pseudomyopia in adolescents. Health Prot Promot. 2018(4):147-148.

[34] Liu F, Zhang S. Massage finger pressing meridian point therapy in the treatment of adolescent pseudomyopia. Guangming J Chin Med. 2024; 39(1):134-136.

[35] Wu MY, Hou DG, Lu HH, et al. Effect of massage on visual function of adolescents with low-grade myopia. Hunan J Tradit Chin Med. 2024; 40(3):81-83.

[36] Liang Z, Chen J, Zhang Y, Wu H. The effect of Zhuang medicine tendons on the sensitivity of children’s lenticular accommodation. J Chin Ophthalmol Otorhinolaryngol. 2019; 9(1):25-27.

[37] Standing Committee of the National People’s Congress. Infectious Disease Prevention and Control Law of the People’s Republic of China. National Database of Laws and Regulations Web site. http://www.npc.gov.cn/npc/c2/c30834/202504/t20250430_445085.html?sign=ABZ0cnNfd2NtX3ByZXZpZXdfYWNjZXNzAAAH6QAAAAQAAAAIAAAACQAAABcAAAAn. Accessed January 26, 2026.

[38] Lan X, Sun Y, Weng Z, et al. Development of international guidelines by Tuina practitioners for specific acupoints of paediatrics Tuina (2022 version). J Tradit Chin Med. 2024; 44(5):1044-1051.

[39] National Technical Committee on Acupuncture and Moxibustion of Standardization Administration of China ( SAC/TC 475). Nomenclature and Location of Meridian Points: GB/T 12346-2021. Beijing, China: Standards Press of China; 2021.

[40] National Technical Committee on Acupuncture and Moxibustion of Standardization Administration of China ( SAC/TC 475). Nomenclature and Location of Extra Points in Common Use: GB/T 40997-2021. Beijing, China: Standards Press of China; 2021.

[41] The State Council. Opinions of the State Council on implementing the Healthy China Initiative. http://www.gov.cn/zhengce/content/2019-07/15/content_5409492.htm. Issued July 15, 2019. Accessed March 20, 2024.

[42] Mo Y, Zhang W, Feng J. Construction and application exploration of the concept of “pre-disease”. China J Chin Ophthalmol. 2026; 36(2):172-176.