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.
Comments
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.
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
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.
Thank you!
Jamie Smith, OTR
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!
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
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.
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
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.
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..
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
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.
Thanks for your comments. I think that there has been a lot of criticism of craniosacral techniques. You won't find much of it here, admittedly, because I don't even consider it an OT modality. Therefore, I leave that to my PT colleagues to debunk!
The Wilbarger/Deep Pressure protocol is actually highly invasive on several levels. It requires the family to intervene with a physical intervention on the child every couple of hours throughout the entire day. Then if a child does not improve, one fundamental explanation is that the family has not been 'compliant.' I consider that a highly invasive methodology that has a large impact on a family.
As for the cortisol studies, there has been ample evidence that measured biomarkers like salivary cortisol are not reliable when used alone. There are just too many potentially confounding variables to make it useful - diurnal variation, problems with collecting from a child, etc etc.
Finally, I also think there has been a lot of willingness to criticize NDT, even though the evidence for it is stronger than the other methods you have listed. Still, people have moved past neurophysiological motor control models and are now using more evidence-based motor learning approaches. This change has been so dramatic and is easily noted by looking at successive editions of therapy textbooks over the last ten years. NDT is slowly working its way out of many textbooks.
Again, thanks for your comments. If I can help explain any of this further please let me know.
I love, love, love the common sense on this blog! I'm an OT in Australia with 6 years or so experience in pediatrics, but I also had a child on the Autism Spectrum who was the receipient of SI input over many years which did very little to assist him. I'm always sceptical and I aim to provide (as a sole therapist in a mobile practice) interventions that are as evidence based as possible. My interventions usually involve activities that target strengthening, co-ordination etc as well as lots of intervetions around heavy muscle work, dealing with anxiety and executive functioning issues if applicable, joint attention, and play. I also try to address lifestyle issues with families if required. My families seem happy, I see improvements and I feel good about what I do, but I often feel a bit of self doubt as I don't do as much "sensory" as my colleagues. I do some, but I figure there are a whole lot of other interventions with more evidence behind them that I can offer. Anyway, the Wilbargers are coming to Australia so I'm going to the training as I want to remain open-minded and have a look at what is on offer. I also figured that this training is only likely to happen once in my lifetime, so I'd better grab it. It's really hard as a pediatric therapist to be evidence based, the reliance on sensory interventions seems almost obsessive sometimes. But I don't want to throw the baby out with the bathwater.
So many things about the Wilbarger protocol don't quite add up to me: how do you know it is just the attentive input and touch from a parent or caregiver 5 times a day that is driving whatever improvement is noted? Why is evidence so limited? So few therapists properly trained in the technique, so many variants out there!
We'll see what happens! Thanks again for your wealth of very well-thought out information, Chris. It is invaluable.