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.
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.