10 Realities of the OT Brushing Protocol

If you are familiar with occupational therapy in a pediatric or sensory setting, you have likely been introduced to “the brush.” But how much do you really know about this intervention tool?

1. You’re not supposed to call it “brushing.”

Officially, this intervention is called the Wilbarger Deep Pressure and Proprioceptive Technique, or DPPT. The term “brushing” is supposed to be avoided, because the goal of the intervention is to provide deep pressure, and the creators have noted that “brushing” doesn’t accurately represent that intention.

2. The technique was developed for sensory defensiveness.

The creator of the technique, Patricia Wilbarger, MEd, OTR, FAOTA, is a leading expert on sensory defensiveness. (This is basically when the nervous system over-reacts to stimuli that would not typically be perceived as negative or harmful.) The entire technique takes around 3 minutes, and includes deep pressure input applied to the child’s hands, arms, back, legs and feet, followed by joint compressions to the extremities. This is typically followed up by engagement in “sensory diet” activities.

While the technique was created based on this concept of sensory defensiveness, many occupational therapists introduce the DPPT as a way to provide deep pressure input to sensory “seekers” or those with higher thresholds for sensory input.

3. There’s only one brush officially recommended by the creators.

The Therapressure brush was designed specifically for the DPPT, supposedly for its ergonomic shape and appropriate bristle density. It also tends to make it more expensive. (Of course, anything with the term “therapy” applied to it instantly becomes more expensive.) However, in the reality of practice I’ve seen tons of brushes used other than the official Therapressure brush.

4. You should be taught by someone with specialized training, but that’s hard to do.

One of the most important components of this intervention is applying the “right” amount of pressure, which is why learning in-person is key. However, finding a way to get trained as a therapist is hard to do these days. I haven’t seen consistent seminars offered by the Wilbargers for a long time. However, after some searching, I was able to locate one training seminar… in Ireland. So you might just have to settle for being trained by someone who was trained by someone years ago. (This just happens to be how I acquired my “hands-on” training on the subject.)

5. It’s a high intensity intervention.

The recommendation is to complete the technique every 90-120 minutes of a child’s waking hours. Yes, you read that right. Sometimes that recommendation alone is enough to scare a parent away from trying it. According to the theory, this is the amount of time the positive, modulating effects of deep pressure and proprioception last in the nervous system.

6. Even if you follow the protocol, there are several factors that make it difficult to implement.

There are many nuanced components of this technique. The amount and consistency of pressure, how you move the brush across the skin, how you transition between the arms/legs/back, keeping track of the brush when you take it home… it’s a lot to remember and complete with confidence.

Parents have come to me saying they just couldn’t get their child to engage at home the way we could in a session. Sometimes parents or children have anxiety with the anticipation of applying touch, and the process suddenly becomes a whole big “thing” or source of stress. We never want to force any intervention on a child, especially within the context of sensory integration theory.

We also typically ask parents to try it at the recommended frequency for at least two weeks in order to gauge effectiveness. However, I rarely see follow through for the entire two weeks. Often, if results aren’t seen right away, the technique is quickly abandoned.

7. There are things you aren’t supposed to do.

This is where that whole training thing comes in handy. There are areas of the body to avoid with the brush, such as the stomach or face. Completing the protocol sporadically might cause more issues than it helps. Using too light of touch might actually tickle or scratch as opposed to provide deep pressure. There may be individual precautions due to other diagnoses related to nervous system function. The list goes on…

8. There are many versions or variations online, which is not a good sign.

A quick internet search will lead you to YouTube videos, online tutorials, or various different websites. In fact, almost every OT I’ve ever met has their own DPPT “worksheet” to give parents in order to explain the protocol. And guess what? Every one of those is slightly different. Information is passed between therapists, collected from different settings, and becomes somewhat of a game of intervention “telephone.” For something we describe as a protocol, one might expect more uniformity in the execution.

9. The evidence that it’s effective is virtually nonexistent.

Harsh reality time: The evidence, if you want to call it that, is largely anecdotal. You’ll hear many therapists and parents swear that it works based on their own experiences, but high quality studies just don’t exist. Weeks, Boshoff, & Stewart (2012) screened over 300 research studies related to the effectiveness of the Wilbarger protocol. After a systematic review, their results concluded that there wasn’t “high quality evidence” to support or refute this technique. As therapists that should be relying on evidence based practice, this can raise some serious questions about whether or not we should be implementing this technique in our daily practice without further evidence of its effectiveness.

10. Regardless of the evidence, there is a high demand for this intervention.

This technique has kind of become “that thing pediatric OTs do.” I’ve seen it implemented in every clinic I’ve ever worked in, with slight variations, of course. Some parents come in with the sole purpose of being trained. And in all fairness, as a student, I was simply taught by other trained therapists that it was an effective intervention. However, after many unsuccessful attempts to appropriately implement the technique into home programs, and keeping up with the literature, I’m less inclined to rely on this technique as a “go-to” in practice.

 

Resources:

Weeks, S., Boshoff, K., & Stewart, H. (2012). Systematic review of the effectiveness of the Wilbarger protocol with children. Pediatric Health, Medicine and Therapeutics, 3, 79-89.

Wilbarger, J.L. & Wilbarger, P.L. (2002). Wilbarger approach to treating sensory defensiveness. Section 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. (pp 335-338). Philadelphia, PA: F.A. Davis.

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About TheAnonymousOT

Pediatric Occupational Therapist
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7 Responses to 10 Realities of the OT Brushing Protocol

  1. Jen says:

    We used this technique (along with a sensory diet) with my 4 year old son for tactile defensiveness. We did 3 weeks of the intense schedule before tapering off and I was at my wits end before we started so believe me – I set an alarm and we took that brush with us everywhere. After about 2 weeks the most amazing thing happened – he woke up and climbed on my lap and cuddled for about 20 minutes. He’d not voluntarily sat on my lap or accepted physical contact like that since he was probably 9 months old. It did not “fix” all his sensory issues, but when he gets hurt, he’ll climb on my lap for comfort, he gives me hugs and kisses, and often wakes up and climbs on my lap for morning cuddles. After years of being afraid to touch him because it made his “pain” reaction worse, nothing makes this mama’s heart happier than to be able to hold my boy when he gets hurt, and comfort him. It might not work for everyone and it might be hard to do, but it was worth every minute of it for us!

    • I love hearing a success story! So glad you found it to be effective.

    • Kiley Philp says:

      We had a similar positive effect with our son who was almost 8 at the time. It calmed him, reduced his sensory defensiveness, and led him to modulate and regulate his arousal. He enjoyed the protocol, asked for it, and we stuck to the joint compression for quite awhile afterwards, until he was adept at providing his own deep pressure activities.

  2. Sue says:

    I read the positive comments from some parents here. It made me think of what a fellow OT had brought up years ago. She said it would be nice to have a study where the control group consisted of a parent being very present with their child in a calm manner every 90 to 120 minutes. The other group would perform the protocol. It was speculated that the outcome may be the same. I was trained by the Wilbargers more than 20 years ago. I really wanted it to be all it was proposed to do. It never was but I value the idea of spending set engaged times with the children. Therefore I wrote up a routine that Laura Barker presented in a workshop. I call it “get ready” from the ready approach. So I think the Wilbargers were onto something I just don’t believe the “brush” was the answer.

  3. Julia Anderson says:

    I was very fortunate to have taken a course by Bonnie Hanshu on “The Ready Approach”. It was a very intensive three day course, complete with at least three hours of homework each night, and both a written exam and practicum at the end of the course. While I don’t use it too much in the school system, I feel comfortable discussing and training parents of some of our more involved kiddos who are defensive to tactile stimulation. I worked at a state MR/DD facility for 12 years, and implemented the full Approach protocol with two people on my caseload. Each of their transformations was nothing short of miraculous. So, yes, I put more credence into The Ready Approach, although the two seem similar.

  4. Phyllis Finkelstein OTR/L says:

    Many years ago I took the course offered by Pat Wilbarger, and some years later repepeated it, with Julia Wilbarger now accompanying Pat,when there were a few changes. The first child I used it with was a girl around 4 or 5 in preschool. She had considerable tactile defensiveness. Would not sit near classmates at table for snack, “scissored”her arms in front of her to clear a path thru the classroon, did not like mom to touch her. I went to the school and instructed her teacher, the phys ed teacher and even the principal (they were all very interested in helping),as well as mom, in the technique and had them practice on me. Then I asked them to keep daily records: how often, and any positive or negative new behavior, for up to 3 weeks. By the end of that time. These negative behaviors disappeared. She even went to her place on the gym floor to await the bus. The night before her birthday she was having trouble settling down for sleep. Mom asked her if she would like to be brushed. Yes she replied, it will make me feel calmer. When I told them it was time to stop, they were reluctant to do so, fearing the changes would disappear.

  5. Pingback: OT Corner: 10 Realities of the OT “Brushing Protocol” | PediaStaff Pediatric SLP, OT and PT Blog

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