Thursday, April 27, 2006

The Wilbarger Approach: How patient should we be?

I received an email today regarding a parent who was interested in finding training on how to implement a 'brushing' program on their five year old child. The child's therapist allegedly encouraged the parents to research it themselves - which seemed a little odd to me. This got me thinking: perhaps there is a population of therapists who just can't find resources on the Wilbarger Approach.

I can understand the frustration. There has been very little published in the literature about this approach - perhaps the two most-cited references of the authors themselves are Wilbarger and Wilbarger (1991) and Wilbarger and Wilbarger (2002). These are not research studies; they are just descriptions and theoretical ideas about the concept of sensory defensiveness. There are studies that have been published by others but they have been single subject designs or they have been published in newsletters. The Sensory Defensiveness website (allegedly sponsored by Patricia Wilbarger) has promised answers to frequently asked questions since sometime in the mid to late 1990s. I think it is an abandoned site.

For many years (going back to the early 1990s) I recall that the Wilbarger Protocol was a hot topic in the occupational therapy continuing education world. How many OTs attended those training sessions? Is it possible that 3,500 therapists paid for this training? At a hypothetical cost of $300 for a conference, is it possible that over $1 million dollars has been spent on learning about this intervention? That is an interesting question.

I was hard pressed to find a training session for the Wilbarger Protocol today. You can order a VHS tape for $30 at Professional Development Products. Is there no more demand in the OT market for the product that it has been relegated to the discount bin in the continuing education world?

Well for an intervention that was virtually ignored by researchers the Wilbarger Protocol certainly had some legs. It still does, if you use Google as any indicator of popular interest in a topic.

Lucy Miller made an extremely cogent argument about the need to "promote research that leads to better diagnoses and effective interventions" as opposed to making "unequivocal and emotional statements." I agree with her argument completely, but as the title of this entry implies - how long are we supposed to wait for this research to be done? The approach was developed and many people were trained. There were promises made that 'research is coming soon,' but I haven't seen it.

While surfing around tonight I think I found a potential source of very useful information - and I think we might be able to thank Ruth Segal. I believe that I met her a couple years ago at an SSO conference, and I wish I knew then that she was interested in this topic. Anyway, an old web page from NYU states that one of her research projects was on "The perspectives of children, caregivers, and therapists of the brushing and compression program for sensory defensiveness." I haven't been able to find out if this has been published, so if anyone knows I would be interested. The point here is that she thought this research might help us to "understand the phenomenon of embracing or rejecting new interventions." In my opinion, this really represents the 'bottom line' on this entire discussion. Why do OTs embrace these interventions - and why do OTs hold on to them in the absence of supporting research?

Most importantly, have we served the public interest by creating a 'demand' for a service that we have never supported with research and that we no longer even train therapists in?


References:

Miller, L.J. (2003). Empirical evidence related to therapies for sensory processing impairments. Communique’, 31(5), 34-37. Response to: Shaw, S.R. (2002). A school psychologist investigates sensory integration therapies: Promise, possibility, and the art of placebo. Communique’, 31(2), 5-6.

Wilbarger, P., & Wilbarger, J. L. (1991). Sensory defensiveness in children aged 2 - 12. Santa Barbara, CA: Avanti Educational Programs.

Wilbarger, J.L. & Wilbarger, P.L. (2002). Wilbarger approach to treating sensory defensiveness and Clinical Application of the Sensory Diet. Sections in Alternative and Complementary Programs for Intervention, Chapter 14. In Bundy, A.C., Murray, E.A., & Lane, S. (Eds.). Sensory Integration: Theory and Practice, 2nd Ed. F.A. Davis, Philadelphia, PA.

18 comments:

Anonymous said...

Hi, Chris,
I've just discovered your blog and greatly appreciate your perspective. As an occupational therapist who graduated from the University of Wisconsin way back in the 80's, I recently received an alumni newsletter detailing Professor Julie Wilbarger's course, Sensory Integration Theory and Practice at the University of Wisconsin-Madison. Like you, I was hopeful of SIT's potential 25 years ago. I have spoken with "street" practitioners who report anecdotal success using SIT, specifically with autism spectrum disorders. I've written Dr. Wilbarger and called her office requesting information on updated research for an article I'm writing on autism spectrum disorders and the use of sensory integration. Neither she nor anyone from her department has acknowledged my attempts.
I'd love to hear your perspective on what you believe is viable treatment for autism spectrum disorders. Thanks for your time and your thoughtful blog.

Tamora Elting said...

Chris and Anonymous,
As an Occupational therapist with 24+ years of experience and 10 of them being strictly pediatric, I wanted to repond to your comments. I attended Patricia Wilbarger's course less than 5 years ago. I get mailings freqently from her organization about more courses. The training in the Deep Pressure and Proprioceptive Techniques is definitely ongoing! Lucy Miller has been doing some interesting research on sensory defensiveness. And before research can be done on whether the DPPT is effective, we need to have research that determines that there is a diagnosis (a measurable, documentable diagnosis) of sensory defensiveness. And even without that research, the anecdotal evidence is strong enough for the DPPT to be considered as an treatment option with parents.
Tamora Elting, OTR/L SIPTC

Chris said...

I took my Sensory Defensiveness course in 1990 - 17 years ago - so perhaps I am a little more impatient about this issue.

I believe that this is an issue of ethics. There is a clear distinction between clinical research and clinical care. We are afforded all kinds of freedoms with clinical research to try new and experimental treatments that lack supporting evidence, but subjects (patients) are protected by informed consent and institutional review boards.

At what point in time are we responsible for protecting the public from interventions that have no research support and that a profession is providing in a clinical context? Is it ethically responsible to continue to provide an intervention in a clinical context WITHOUT informed consent and IRB oversight, if after nearly a generation of time has passed and there is still no supporting research?

Anecdotal evidence is fine - but it is a primitive form of evidence. I believe that our patients deserve more after nearly 20 years of this intervention.

That's why I still wonder how patient we should be.

Thanks for your comments.

Anonymous said...

I am a new graduate and I also have mixed feelings about the DTPP. One internship that I was on used it religiously, all of the OTRs were certified, and we saw some improvements (whether those improvements would have been made without the DTPP, I'm not sure). I did another observation at a pediatric outpatient clinic before my first job and they use the protocol for seldom, however, none of them are certified. On another note, since I am coming right out of school, our pediatric class did not focus any class time on this intervention, it was simply stated that it was an option and that was it. Evidence-based practice is very important to me; therefore, I would like to conduct a research project if I am able. I am wondering if anyone has some ideas that we could discuss together or any projects that are being started in which you may need some extra help.

Thank you!
Jamie Smith, OTR

Chris said...

I recently got mailings about some conferences being given by the Wilbargers so there are still educational opportunities out there if people want to get educated on their current thinking.

I am not aware that there are any 'certifications' to their intervention approaches.

If this is a forum that people want to use to coordinate and discuss research proposals, I will again reiterate that I will publish, in full and unedited, anyone's opinions or ideas on these issues. We need to share ideas.

Knowledge leads to Power (Francis Bacon empiricism) - still holds true today!

Fred said...

Chris,

I too must add my voice to the some-what skeptical side of the discussion. I have 10 years pediatric OT experience and have seen limited success with the Wilbarger Technique and children with the diagnosis of autism. I don’t believe the anecdotal evidence is very strong. I have never seen the Wilbarger technique done in isolation. It is usually performed in conjunction with other modalities designed to address behaviors consistent with autism by the speech or behavioral therapist. I have even seen it used with autistic students who do not have a so-called sensory defensiveness.

Occupational therapists are not the only ones who adhere to out-of-date, non-research supported theories. In the September 3, 2007 Advance for Speech-language Pathologist & Audiologist, Gregory Lof says that 85% of polled SLPs use non-speech oral motor exercises to change speech sound production when there is “no evidence whatsoever that there was any benefit.” Behavioral optometrists have “vision therapy”, SLPs have “Facilitated Communication” and we have SI. Can anyone say, “Reflex Integration?”

I have seen many OTs doing the “brushing technique” without the Wilbarger training let along the clear understanding of the theory. I know therapists who simply do brushing because “that is what OTs do.” This is just plain negligent. I no longer use this technique and probably won’t until there is good clinical evidence support to it.

WE CAN AND MUST DO BETTER!

Thank you for presenting this article.

FP, OT/R

Lindsay said...

I have definitely found that there are many out there that do their own "version" of the Wilbrager DPPT- they dont even know what it is called and simply refer to it as "brushing"!

Personally, if I am working with a child that I think may benefit form the DPPT, I do it myself (after being trained at a Wilbarger conference) and ask the parents to give me feedback about the childs behavior the rest of the day. If I observe, or the parent feels there were any changes, then I teach them the technique but also caution them that there is NO hard scientific research to back up the technique. I dont even epproach it with families that are unlikely to follow through. I too wish there was som ehad research to back up this treatment technique.

Anonymous said...

I am so glad to have found you!! I am a pediatric OT and VERY frustrated with the availability of DPPT training. All references insist on proper and professional training, however, I have yet to find a course (I've been trying for a couple of years now.) The scary part is, if you go to You Tube there are several different videos of caregivers demonstrating their version of the "proper" way to administer DPPT!! Every therapist I speak with has little differences in their application of the technique. If the Wilbargers want to promote this and have it as an evidenced based practice, then there should be more communication and opportunities for training available. At this point, I am not even considering this as a treatment approach for fear it will be counter productive.

kimot17 said...

I am an OT with 9 years experience. I currently work for a school district with 3 other OTs. The OTs have been encouraging teaching staff to perform DPPT with the children and staff are resisting it tremendously. The teaching assistants have even brought their union and lawyers into the mix. Their argument is...they are not trained in this technique, they do not want to be left alone with the children to do it, and they feel that this is on the boundaries of inappropriate touching. I can't say that I blame them since not one of us OTs have attended a Wilbarger conference. Why are we pushing this if we don't even have the training or research to back it up? Today I called Avanti Educational Programs, supposedly the ONLY agency that runs Wilbarger conferences. The woman stated that she receives this type of call all day long. She has no contact with the Wilbargers and has no idea when the next Wilbarger conference will be. Now how frustrating is that?

kimot17 said...

I am an OT with 9 years experience. I currently work for a school district with 3 other OTs. The OTs have been encouraging teaching staff to perform DPPT with the children and staff are resisting it tremendously. The teaching assistants have even brought their union and lawyers into the mix. Their argument is...they are not trained in this technique, they do not want to be left alone with the children to do it, and they feel that this is on the boundaries of inappropriate touching. I can't say that I blame them since not one of us OTs have attended a Wilbarger conference. Why are we pushing this if we don't even have the training or research to back it up? Today I called Avanti Educational Programs, supposedly the ONLY agency that runs Wilbarger conferences. The woman stated that she receives this type of call all day long. She has no contact with the Wilbargers and has no idea when the next Wilbarger conference will be. Now how frustrating is that?

Denise said...

I have a child who is 2 1/2 and had a stroke at birth. Another OT showed them brushing and they never followed through. This child has sensory defensiveness in the stroke palm especially and arm and probably neglect. We tried the brush and the dad took it out. This child who was hard to touch, just laid on the ground and relaxed completely. They have been continuing and I know it is not the protocol. I am also frustrated by no teaching on the DPPT, BUT it is making a world of difference. She is using her hand more, she is more aware of that side. We can touch the arm more without real negative resistance. No, it's not the protocol. It is more like a desensitization technique. And it is working!

Anonymous said...

Hi. Can anyone please explain the precise theory behind this technique.
Stimulation of nerve endings obviously makes mind body more aware of each other. Old news. But what else does it do?
Why can you not stimulate the head, face, chest and abdomen?
Why this brush and not a paint or make up brush like other techniques do?
Why not follow dermatomes or sclerotomes?
Compressing a joint to stimulate proprioception. Would not moving a joint through its full range of motion be better?
I am eager and willing to learn.
Thanks Ian

Anonymous said...

I learned the protocol from the Wilbargers in 1998 at a conference. Can any one tell me if the protocol has changed in any way since that time? I have heard that the order has changed such as brushing one extremity and doing joint compression on that extremity before moving on. I would appreciate some clarification from someone who has been to a recent conference

Chris said...

Dear Anonymous,

I am very hopeful that after so many years and absolutely no research evidence that people are abandoning this intervention strategy.

In the 2010 Case-Smith OT for Children (6th ed.) there is no entry in the index under Wilbarger, brushing, sensory diet, deep pressure protocol, etc.

I hope that means we are making progress away from unsupported interventions.

Anonymous said...

Hello Folks,
This thread is very interesting.
I am surprised the DPPT Trainings are not happening in the United States but that trainings are happening in Ireland in 2011. However the course content does not say if the research evidence has grown since the previous trainings.
All the comments are very reflective and like Chris says, it would be good to share experiences.And hopefully more recent ones..

Dorothy said...

I've been reading the blog on wilbarger and I wonder why OTs are waiting for some one else to produce the evidence. Surely we're all trained in evidence based practice and research skill - come on OTs, don't be so dependent - why not generate the evidence for or against yourselves and publish it No need to sit around waiting for some-one else to do it if this is an area that interests you. Dorothy

Anonymous said...

Dear Chris;

Thank you for your thoughts about this technique. I was trained over ten years ago with the Wilbargers and used this technique in a clinic setting. Sometimes I felt there was a short term effect and sometimes none at all but overall I always questioned progress because the child was receiving input from a variety of professionals.

I now find myself in a middle school setting and given the culture and legal mandate of educational relevance I do not think this technique is appropriate in a school setting. Often middle school students are dealing with 'coming of age' issues and need to learn appropriate boundaries. Furthermore many school personnel are uncomfortable with the intimacy factor given that they are instructed to not touch or hug even preschool students. The school is a public setting and everything that they do is under the eye of the public. I have a situation where the private therapist is insisting on this procedure in the schools in a dogmatic and inappropriate way. As a school therapist my interventions must be ethical and evidence based. I would suggest caution to school based therapists about this procedure. We must consider what is defensible in court.

Anne

Chris said...

I agree, Anne - thanks for your post.

I understand the physical contact issues and actually have a lot of thoughts about that. I think it is really unfortunate that as a society we have gotten to the point where we have to fear the hug given by a preschooler - but I understand the issues and how we are at this point. I think that the best conversation about any 'brushing' type of intervention is best about evidence and not so much about the physical contact factors.

Thanks again for your comments.