Welcome to the December 2007 edition of The SPD Companion Newsletter. Thank you so much for taking time out of this busy holiday season to spend your valuable time with me. It is greatly appreciated! Today's topic? The Wilbarger Protocol for sensory defensiveness.

First let's clarify some terms. Did you know the NEW name for The Wilbarger Protocol (what some used to call the Wilbarger Brushing Protocol, or WBP) is now The Wilbarger Deep Pressure and Proprioceptive Technique (DPPT)?

Patricia Wilbarger's Deep Pressure Proprioceptive Technique for sensory defensiveness is often a controversial topic. The technique, the protocol, who can do it, how often it should be done, who can benefit, it's effectiveness and the research behind it. But, I will say this... if you ask the people who have been properly trained, followed the protocol consistently and regularly, and used it on their children (or children they have worked with) who have sensory defensiveness, they will attest to it's effectiveness! Thousands have been helped using this protocol. I feel it is an important program to address and talk about as it can be very effective and is widely used and accepted amongst many OT's treating children with Autism and/or Sensory Processing Disorders.

However, it is a fine line to discuss the protocol without actually telling you the entire protocol. And I don't want to cross that line! So, I want to talk about it, but not “fully” talk about it. You see, it would be “unethical” for me to put The Wilbarger Deep Pressure Proprioceptive Technique (DPPT) in whole here, as it requires you to be trained and specifically shown, hands on, how to do it. Not only that, but it is copyrighted and not reproducible without permission from the Wilbargers. I would assume they would be highly unlikely to give this permission, as the “words”, on paper, just aren't enough.

But, what I WILL do is give you the general information you will need to: get the training yourself, talk to your OT about it with some beginning/thorough background information, know whether you are using the proper brush, ask to be shown this technique by someone who has received the training, or to know if you have been given the proper information and training regarding the specific protocol.

At the end of this newsletter I will provide information on how to receive the official training and resources that will assist you in making sure you are doing the protocol correctly. Please take advantage of this information.

I am concerned that there are OT's and/or parents who are doing this protocol without having been trained directly, or through an OT who has been "unofficially" trained, and, who may not be following the protocol correctly or without being closely monitored by a trained OT. I am concerned that the controversy exists partly due to this lack of information or education! If trained properly and done properly, anecdotal evidence and specific case studies have shown remarkable results. The Wilbarger's and others in the field can validate this if you seek out this information. But, there appear to be too many mistakes being made and misinformation given. THIS is what causes the controversy... in my humble opinion.

Please make sure you find out if your OT has been to the courses developed by Patricia Wilbarger and Julia Wilbarger. These courses are still being presented, despite what some have said. Training is still accessible (which I will provide at the end). If you are an OT using this technique, you must be trained! If you are a parent or caregiver, you must be trained! If you have not been, stop doing it until you have. Generally speaking, it is not harmful, per se, but it will not be effective if; not done properly, not done for the right diagnosis, done in isolation, or not monitored closely. The only evidence that it could “hurt” a child is if the wrong brush is used, not used properly, or not monitored properly. We don't want this! And, this, I believe is when the controversy erupts.

And, if you are trained, know there there are updates to this protocol as the years go by, so a one time training, say 5-10 years ago, is not enough. The protocol is not widely publicized directly on the web because it is a “hands on training”... you cannot do this online. You will find some information about it, and some have been bold enough to post the actual protocol. I advise you not to use THESE as your “training”. Use them instead as information only!! These sources may give you the information about it, but not behind it, and are sometimes outdated. They will also not teach you what you need to do in monitoring how effective the program is with a particular child and what clinical reasoning skills to use to adapt, monitor, continue or discontinue the program. Online sources that discuss the actual protocol may give you some general and much needed information (as I hope I am doing), but the official training is what counts to be “qualified”. Ideally, an OT who is both SIPT certified (as it requires additional training about sensory integration theory and practice) and who has attended the Wilbarger's course on sensory defensiveness will be your best bet. For more about what to look for specifically in an OT and how to get the most out of therapy, please read last month's newsletter Sensory Integrative OT... What You Need To Know Before Starting

On one online discussion board, a question was raised as to whether the protocol is still being used and taught. A SIPT Certified OT writes...

”As an Occupational therapist with 24+ years of experience and 10 of them being strictly pediatric, I wanted to respond to your comments. I attended Patricia Wilbarger's course less than 5 years ago. I get mailings frequently from her organization about more courses. The training in the Deep Pressure and Proprioceptive Technique 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
(Tamora, I hope you don't mind me using this quote. I felt it was important and needed to be heard! I had no way to contact you. Please contact me if you want me to delete your name or the quote, ok? Thanks in advance.)

The authors of Building Bridges Through Sensory Integration make an interesting point about the Wilbarger Protocol...

”...[It] represents one of those difficulties in clinical practice where positive results are observed in treatment regimes that have not yet been fully validated by scientific research. However, because of the strength of anecdotal reporting and our own observations, we feel we would be doing a disservice if we did not advise our clients about this technique.”

Controversy is not in itself bad... through questions (and sometimes skepticism) it leads us to a more thorough understanding, the ensuring of best practices, and leads us to positive treatments and answers!! The more you research this topic, the more education you have regarding the nervous system and brain chemistry, the more this protocol makes sense. But, you need to do the research, and get the training. Without it, opinions don't “count”. Thousands have done it the proper way, thousands have been helped.

Know that, if this protocol does NOT work for your child, however, the underlying cause may not be sensory defensiveness, or, that you were not taught the proper technique. Some common mistakes are: brushing too lightly, not long enough, too quickly, not doing it as directed every two hours for two weeks, doing it inconsistently, or using the wrong brush.

From a sensory integrative frame of reference, the DPPT Protocol for sensory defensiveness really DOES make sense... how it works and why. The “new” name for it will help us understand it; The Deep Pressure Proprioceptive Technique. Basically, this therapeutic intervention addresses our three most important and largest sensory systems-- the tactile sense, the proprioceptive sense, and the vestibular sense. These three systems, when working properly, are extremely important in neural organization, and are at the core of sensory integration theory and practice.

The tactile system includes “receptors for receiving sensations of touch, pressure, texture, heat or cold, pain and movement of the hairs on the skin.” (Sensory Integration And The Child, 2005).

The proprioceptors include both the proprioceptive sense and the vestibular sense, according to A. Jean Ayres (2005). The vestibular system is the "sensory system that responds to the position of the head in relation to gravity and accelerated or decelerated movement... The vestibular system is the unifying system... All other types of sensations are processed in reference to...the basic vestibular information... Vestibular input seems to 'prime' the entire nervous system to function effectively." (Sensory Integration And The Child: 25th Anniversary Edition, 2005)

It is A. Jean Ayres's inclusion of the vestibular sense under the proprioceptive sense that causes me to include the vestibular system within this discussion of the protocol. And, if you look at the Wilbarger's entire program for sensory defensiveness it also includes defensiveness in the vestibular system and addresses this through the inclusion of vestibular activities as part of the child's sensory diet. Do know that the vestibular system is additionally important to address as it is a MAJOR influence on the organization of the central nervous system. And, when addressed with proper activities, the effects can last up to 8 hours! This is why it MUST be included as part of this protocol through activities throughout the day (a sensory diet). Specifically, calming vestibular activities are slow, rhythmical rocking or swinging... especially in one plane, from a single point on the ceiling. (Future articles will talk about this more.)

The proprioceptive sense refers to ”the sensory information caused by the contraction and stretching of muscles by the bending, straightening, pulling, and compression of the joints between the bones.” (Sensory Integration And The Child, 2005). The proprioceptive system is almost as large as the tactile system because there are so many muscles and joints in the body. Therefore, it's significance is huge! Yet, most of the sensory information from the proprioceptive system happens on an unconscious level and is processed in the brain. No wonder it can be difficult to identify the underlying problems when looked at by an untrained eye. And given the vast and complex influence of the core sensory systems, upon which sensory integration/sensory processing theories and treatment are based, it is not surprising that the program can have a major influence in many areas of sensory processing and function!

One of the reasons deep pressure touch (a type of proprioceptive input) is so calming is that it causes the release of both serotonin and dopamine in the brain. These are the “happy” neurotransmitters and produce a feeling of calm within our nervous system. They are the neurotransmitters that help keep us regulated. The Center Of Development And Pediatric Therapies (http://developmental-delay.com) say the following:

”Proprioceptive input is the best source of sensory input to help keep a good balance of serotonin in the brain which helps regulate all other brain chemistry and keep a neutral and relaxed learning state. Proprioceptive input is the best type of input to help with sensory modulation and regulation disorders.”

This discussion on serotonin and brain chemistry is too in depth to go into right now, but you can find much research about this online if interested; just “google” it.

Research has certainly shown us the effectiveness of deep pressure for calming and effective sensory processing/sensory integration. Articles and research done and written by Temple Grandin, are just some of MANY examples. The effects of deep pressure to induce a state of calm and regulate arousal levels are also well publicized in journals such as the American Occupational Therapy Journal (AJOT), the British Occupational Therapy Journal (BJOT), A. Jean Ayres's Sensory Integration And The Child; 25th Anniversary Edition, the Sensory Integration Special Interest Section Quarterly, and other child development and neurobiology resources outside of the Occupational Therapy frame of reference. Additionally, when you attend the trainings by the Wilbargers, you will be given the knowledge you need.

As a parent, your OT can and should explain the underlying theories behind how and why deep touch pressure/proprioceptive input works to calm, regulate, and organize the central nervous system. If you want these resources, this research, you CAN find them, but they are also beyond the scope of what I will include in this newsletter (ah, perhaps a future edition??). Those who don't have the information, or don't seek it out, can't discount this therapeutic protocol as ineffective, as far as I am concerned.

The Wilbarger DPPT Protocol Basics

Patricia Wilbarger, MEd, OTR, FAOTA, developed the Wilbarger Deep Pressure and Proprioceptive Technique (DPPT), formerly known as the Wilbarger Brushing Protocol or WBP, and the Oral Tactile Technique (OTT). Dr. Wilbarger, is an occupational therapist and clinical psychologist with over 40 years experience working with sensory processing theories. She has extensive clinical experience with sensory defensiveness, it's origins, and treatment techniques, and continues to practice privately in California to this day. It is her passion and interest in helping those with this sensory processing difficulty that resulted in the development of this protocol. It is based in sensory integrative and neuroscience theories and principles, and has truly helped thousands!

Most recently, she has changed the name, as explained, and has designed a new therapy brush for her protocol, the Therapressure Therapy Brush. She and Julia Wilbarger have been providing training for this program for decades, and still do today. Their training is a two day seminar that includes lectures, research, extensive hands on labs, and information needed to properly apply the protocol within homes and clinics worldwide. They give you the information and training you will need in order to use this particular program for sensory defensiveness and for monitoring it's effectiveness.

When therapists and/or parents have not been trained properly in the protocol, they can make several mistakes that lead to ineffectiveness, at best, and uncomfortableness and/or “pain” at worst. What we need to realize is that the “brushing” technique is only PART of the treatment for sensory defensiveness. It is not to be used in isolation if it is to be most effective.

There are really three parts to the Wilbarger Deep Pressure Proprioceptive Technique! Not one. Did you know that? These three parts include:

1. The actual deep pressure input provided through the use of a specific Therapressure brush (what looks like a surgical brush).

2. The joint compressions that follow each “brushing”.

3. A complete daily sensory diet which includes tactile, proprioceptive, and vestibular input as monitored and directed by the treating therapist.

General Guidelines For The Deep Pressure Proprioceptive Technique
(Wilbarger Protocol For Sensory Defensiveness):

Before beginning the protocol, sensory defensiveness must be identified through evaluation, sensory histories and/or The Sensory Profile, and clinical observations by a trained professional (i.e., OT, SLP, PT, etc. who has training in sensory integration theory, evaluation, and treatment).

Also, please understand that sensory defensiveness includes MANY potential areas. It is not JUST effectively used for tactile defensiveness. Other areas of defensiveness are intended to be addressed by the Deep Pressure Proprioceptive Technique. These include: