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The Wilbarger Approach to Treatment of Sensory Defensiveness

A Review of the Literature on Sensory Defensiveness and the Wilbarger Approach

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In the current review, seventeen pieces of literature and one course presented by the creators of the protocol specifically mentioned or studied the Wilbarger protocol of intervention for sensory defensiveness or the therapeutic use of brushing. The information provided a range of categories; including brief descriptive accounts of its use, primarily descriptive works focused of the protocol, survey information on the use of the protocol in occupational therapy, case studies and AB research designs with individual subjects or small groups. Only one study utilized a control group and all studies demonstrated methodological limitations. Even with limitations taken into account, the evidence that has accumulated so far is sufficiently suggestive, in regard to the potential efficacy of the protocol with a variety of populations, to warrant further study and continued professional use with caution. Greater emphasis must be placed on a stepwise approach to evaluation of the effectiveness of the protocol. The studies conducted to date present a mishmash of research types, subject types and interpretations of what is acceptable use of the protocol. Many do not provide well defined hypotheses, clearly defined samples or well operationalized behavioral measures which in turn makes replicating the results very difficult.

 

The Wilbarger approach in the literature

Lucy Jane Miller, coauthor of several recent studies which have gained at least primary support for the presence of the sensory modulation disorder as a discrete disorder, addresses the ‘Wilbarger protocol’ as one of a number of modalities that are considered complementary and alternative therapies (Miller, 2006, p. 294). Miller’s book, available in mainstream bookstores, can currently be seen at the front of stores such as Barnes & Noble. With increased public awareness of sensory processing disorders through books by Carol Stock Kranowitz (1998; 2003) and from Miller’s book, noted above, families are likely to be asking more questions and seeking out help for their children that demonstrate these challenges. For many of the families of children with sensory defensiveness it will be increasingly important that the treatment modality be substantiated by evidence, especially when the commitment is sizable as in the Wilbarger approach. Marilyn Chase of the Wall Street Journal phrases it nicely, when discussing sensory integration in general, stating “the therapy’s popularity is outpacing hard data proving that it works” (Chase, 1999). While this was in regard to sensory integration in general, it is certainly true for the Wilbarger approach and Therapressure more specifically. In this more mainstream article, Chase also briefly describes the Wilbarger protocol and presents a brief case report describing some of the benefits of the integrated sensory integration approach, utilizing Therapressure along with direct treatment, sensory diet, medication and Therapeutic Listening. Once again it must be reiterated, as Miller stated in regard to the Wilbarger approach and other complementary and alternative therapies, “Empirical research has not yet demonstrated their effectiveness” and this is a necessity in the future. Foss (2003) conducted a review of references, database search and articles identified through word of mouth and identified studies that related to the approach. However, the author stated that, while occupational therapists have been using brushing for decades, “published and objective evidence supporting the brushing protocol is scant” (Foss, 2003, p. 4).

 

Brushing as a therapeutic modality in occupational therapy

For decades, occupational therapists have utilized brushing as a form of therapy. Foss (2003) credits Margaret Rood as the originator of brushing a therapeutic tool. She advocated the use of a “soft brush driven electrically” as part of a treatment regime to promote normal movement patterns in children with spasticity (Ayres, 1964, Dorland, 2000). A. Jean Ayres, the founder of sensory integration, recommends “pressure applied along with cutaneous stimulation, as in rubbing with a rough cloth or soft plastic scrub brush” (Ayres, 1964, p. 10). Knickerbocker (1980) also mentions the techniques of “heavy brushing” as a tool “useful to quiet the child” with sensory defensiveness (p47). She also refers to “heavy touch pressure... using a plastic bristle brush”, along with more general heavy touch pressure such as “rubbing with a towel” when discussing measures for the reduction of voidance behaviors in children with sensory defensiveness (p. 113). More recently, a systematic protocol that requires use of a soft plastic bristle brush followed by joint compression has been developed as part of a therapeutic program for clients with sensory defensiveness, along with education, professionally guided treatment and sensory diet strategies, by Patricia Wilbarger and promoted in seminars and literature by Patricia and Julia Wilbarger (Wilbarger & Wilbarger, 1991; Wilbarger & Wilbarger, 2002; Wilbarger & Wilbarger, 2006). This method will be explained in detail below and will be the focus of the current literature review.

 

Therapressure and the Wilbarger approach to treating sensory defensiveness

The Wilbarger approach to the treatment of sensory defensiveness is comprised of three components. These include education and increasing awareness of sensory defensiveness and its symptoms, individualized sensory diet and an individualized professionally guided treatment program.

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Education

When implementing the Wilbarger approach, the therapist provides information and awareness; to clients, families, educators and other caregivers; regarding what sensory defensiveness is, what effect it may have on the client and those close to the client, what behaviors may be present when sensory defensiveness occurs and how this relates to the client’s challenges. The Wilbargers suggest that this information is best derived from a clinical interview including experiences of sensations in daily life, challenges the client or family exhibits related to sensory defensiveness, and coping styles. This process should provide the therapist with a list of functional challenges which become the outcomes that will guide treatment and demonstrate progress and treatment efficacy.

 

Sensory diet

 A sensory diet is a form of home program intervention plan that incorporates organizing sensory input, or utilizes already existing sensory input, into everyday life in order to assist the person to maintain a regulated behavioral state, such as the calm, alert state required during certain school activities (Wilbarger & Wilbarger, 2006; Williams & Shellenberger, 1994; Cool, 1990). Sensory diet strategies may be implemented at regular intervals throughout the day. In particular, these strategies may be performed prior to times that may be considered challenging, in order to prepare or set up the body to maintain an organized state throughout the activity, or they may also be used during activities in order to assist the client to maintain an organized state throughout the activity (Williams & Shellenberger, 1994).

 

Every human uses sensory strategies, often non-consciously, to assist them to calm down, wake up, and/or maintain attention. Such strategies, when used consciously and strategically may be considered sensory diet strategies. These sensory diet strategies are individualized and vary from person to person; where one person may take a shower to become more awake, another to calm down, another for both reasons and another dislikes showers, preferring only to have baths. When helping clients and caregivers create and implement sensory diets, the occupational therapist collaborates with them to identify what challenges exist that may be assisted by a sensory diet, what sensory strategies does the client seek, what naturally occurring possibilities exist and/ or may be included and when to implement the strategies (Williams & Shellenberger, 1994).

 

It is important to note that not all sensory experiences are organizing, effects vary form one person to another and sensory experiences vary in how powerful they may be in assisting the person to regulate their behavior. For this reason, sensory diets are individualized to the specific person preferences and needs and monitored accordingly. Sensory diets generally include activities that incorporate proprioceptive input, deep pressure and movement but may also include other sensory experiences, such as visual, auditory as well as oral motor and respiration activities (Wilbarger, 2002). Many authors have discussed the calming effects of deep pressure and proprioception (Edelson, Goldberg Edelson, Kerr & Grandin, 1999; Grandin, 1992; Krauss, 1987; Zisserman, 1992). Sensory diets may also include environmental adaptations to assist functioning by promoting a more wakeful state such as opening the blinds in a room; or reducing distractions, such as decreasing visual stimuli on classroom walls.

 

For the child with sensory defensiveness, sensory diet strategies that are believed to decrease defensive behaviors are identified and used in the client’s activities of daily living at regular intervals. As will be noted with Therapressure, the Wilbargers suggest that deep pressure and proprioceptive input should be part of a sensory diet of a client with sensory defensiveness and should be implemented, as part of everyday activities, every 90-120 minutes throughout the day (Wilbarger & Wilbarger, 2006).

 

Professionally Guided Treatment and Therapressure

Treatment of sensory defensiveness should include professionally guided treatment based on the findings of clinical interviews, sensory history checklists such as the Sensory Profile (Dunn, 1999), observations and standardized assessment tools where appropriate. Collaborative treatment plans, developed with clients and families, should be individualized to the specific needs of the client and should be monitored and adjusted where appropriate. One possible component of a professionally guided treatment plan, used regularly by occupational therapists with clients who demonstrate sensory defensiveness, is called Therapressure (Wilbarger & Wilbarger, 2006).  It should be reiterated that Therapressure should not be an isolated treatment method but rather one part of a treatment plan focusing on all activities of daily living (Wilbarger & Wilbarger, 2002; Wilbarger & Wilbarger, 2006).  

 

Therapressure is the current title of the technique that the Wilbargers have developed utilizing a soft bristle plastic brush (Wilbarger & Wilbarger, 2006). This has been known by other names such as the ‘Wilbarger Protocol’, the ‘Wilbarger Deep Pressure & Proprioceptive Technique’, ‘Sensory Summation Technique’ and most commonly referred to as ‘Brushing’. The reason for it’s developing title has been an attempt by the developers to avoid the perception of brushing or scrubbing which is misleading and does not effectively describe the purpose, as Patricia Wilbarger stated, “There is nothing brushing about it” (Wilbarger & Wilbarger, 2006). The input should consist of deep pressure and proprioception, which is continuous where possible, and limiting light touch input. The developers are also conscious of misuse or misinterpretation where people may use brushes that are inappropriate or believe that it sounds easy and attempt it without sufficient training. The author has heard of people using hair brushes and even a scourer after hearing that ‘brushing’ may be effective. It is understandable that the Wilbargers should take such precautions and make attempts to limit misperceptions.

 

The Therapressure protocol consists of deep pressure input, with a soft and densely bristled plastic brush, provided to the hands, arms, feet, legs and back of clients. Therapressure should never be applied to the head, face, groin or buttocks. The developers, who are also the primary trainers of the protocol, require the use of one particular brush which they have screened and deemed appropriate, called the Therapressure Device by Clipper Mills (San Francisco, CA). The protocol should be administered throughout the day at approximately 90-120 minute intervals although this will depend on the client’s needs. This time frame reflects the time that deep pressure and proprioceptive input is believed to have a modulatory effect on the central nervous system promoting behavioral regulation. It is also therefore believed to be an important factor in maintaining the summative effect and long-lasting changes believed to occur in clients with sensory defensiveness who utilize this protocol (Cool, 1990; Wilbarger & Wilbarger, 2006). Finally, the protocol requires that the Therapressure be followed by joint compression to joints of the arms, legs and trunk. The entire process takes approximately 3 minutes. While the protocol is short and appears easy, it should be noted that training in the correct administration of the protocol is necessary and the actual protocol cannot be sufficiently taught in written form. Incorrect administration; including use of an incorrect device for administration, insufficient pressure, insufficient administration frequency and numerous other misinterpretations; may limit positive changes and could actually be dangerous to the client (Wilbarger & Wilbarger, 2002). Therapressure is not appropriate for infants below the age of two months or with clients who demonstrate autonomic, physiologic or CNS instability.

 

Impressions of occupational therapists using Therapressure

Occupational therapists throughout the United States and throughout the world use the Wilbarger approach to treating sensory defensiveness and Therapressure as a therapeutic modality in the treatment of children with sensory defensiveness. Over 10,000 people have been trained through official training seminars provided by Wilbarger & Wilbarger (Wilbarger & Wilbarger, 2006). It is assumed that many others who have not partaken in the official training also use what they believe to be the Wilbarger approach. Since this method of treatment is so prominent, research must be undertaken to evaluate its use and effectiveness with specific populations. One first step would be to identify how it is currently being used and what the perceptions are of those who use it.

 

In an unpublished Masters Research thesis, Sudore (2001) conducted a survey of occupational therapists randomly chosen from a list of the members of the American Occupational Therapy Association (AOTA) and who were registered for the Sensory Integration Special Interest Section (SISIS) in the year 2000. Of 100 surveys mailed, 64 completed and returned the survey. The survey consisted of questions aimed at collecting information regarding the respondents’ use of the ‘Wilbarger brushing protocol’, views of the protocol’s effectiveness as an intervention tool for children who demonstrate sensory defensiveness, and area of employment.

 

The study reports that 78.1% (50 out of 64 respondents) reported that they used the protocol and 21.9% (14 respondents) reported that they did not. Sudore reports that out of the 62 that completed the question regarding area of employment, 71.9% worked as school-based occupational therapists, 20.3% worked in early intervention, 3.1% worked in private pediatric sensory integration therapy, 3.1% were self-employed and 1.6% worked in pediatric rehabilitation facilities.

 

The actual ability to generalize these results is limited in many regards. One limitation to the validity of this study is the limited response rate of 64%. Another limitation is that it is impossible to know whether those occupational therapists that are both members of AOTA and registered for SISIS are a representative sample of those therapists who use the protocol or whether those that completed and returned the surveys were representative either. It is possible that only therapists that feel strongly about the protocol would respond. It is also possible that therapists who do not have an interest in the protocol would not bother to respond. In this case the number of therapists that are reported to use the protocol in the treatment of children with sensory defensiveness (78.1%) is likely to be disproportionately higher than in the true population.

 

The use of percentages, in the presentation of the data, is somewhat misleading. The statement that 1.6% worked in pediatric rehabilitation facilities creates the idea of a greater number of the true population whereas it actually refers to one respondent. Further, in regard to why those respondents who did not use brushing chose not to use it; the author reported “others commented that brushing is not considered purposeful activity (7.1%)”. Hopefully this was inadvertently written because without reporting the actual number that responded in this way it is confusing and somewhat deceptive as 7.1% of the 14 who did not use brushing, referred to as “others”, amounts to a total of one respondent (p. 37). Regardless of these limitations within this study; valuable information was gathered regarding the use of the protocol in occupational therapy practice, its perceived efficacy and challenges related to its use as a treatment modality.

 

Perceptions of the effectiveness of the Wilbarger protocol

The participants in the study by Sudore, 2001, were questioned about their perception of the protocol’s effectiveness in decreasing the tactile defensiveness of the children they work with. Of the 47 that answered the question, 15 perceived the protocol to be very effective, 29 perceived it to be somewhat effective, one perceived it to be somewhat effective and two perceived it to be ineffective.

 

Of those who did not use the protocol, 4 responded that parent and teacher compliance of the protocol was poor, 4 responded that they did not feel sufficiently trained, 2 reported that it is too invasive, 1 reported that brushing is not considered purposeful activity and one respondent reported that there is too little research to support its use.

 

Rigor of treatment using the Wilbarger approach to treating sensory defensiveness

Sudore (2001) stated that the average daily frequency prescribed by therapists was 5 times per day or approximately every 3 hours. While Wilbarger & Wilbarger (1991, 2006) recommend a frequency of every 1 - 2 hours, or 6-8 times per day, much of the literature demonstrated a difficulty with achieving this level of frequency (Stagnitti, 1999; Moore, 2002; Withersty, 2005). Several respondents (percentage value was not clear) noted that ‘follow through’, of the protocol by parents and teachers, was a challenge. With summation of sensory input, and the subsequent long term changes associated, as a goal towards increased ability to function for people with sensory defensiveness it seems that therapists should make attempts to adhere to the protocol of at least every 2 hours, where possible and indicated, and to educate families on the purpose and need for such rigorous application. Research into the frequency of input required and on summation as it relates to the protocol is much-needed as indicated by the discrepancy between the trainer’s protocol and the actual frequency of administration noted in this and other studies noted above.

 

Wilbarger & Wilbarger state that the duration of intervention program using the protocol should be based on clinical judgment and monitoring. It was interesting to note that the duration that the respondents reported as using the protocol ranged from 1 to 78 weeks, with 10 weeks being the average. It was unfortunate that the author did not comment on the distribution in more detail. It appears as though even one 78 week score could drastically bias the average and the author should have at very least reported the median number reported.

 

Sudore, 2001, noted that all participants who responded as using ‘brushing’ followed it with joint compression. The author did not appear to question whether the ‘brushing’ was used within the context of a greater intervention plan incorporating professionally guided treatment with education and sensory diet strategies. However several respondents commented on this in the open-ended ‘additional comments section’.

 

Measurement tools and procedures for determining effectiveness

47 respondents (all but 3) reported that they used “observations” to measure effectiveness, 31 used “subjective/ other” report (including parents, other professionals), 6 therapists reported using standardized testing and all identified the Sensory Profile (Dunn, 1999), 16 used non-standardized tools such as questionnaires and unpublished checklists and 3 reported using “other” and included Individual Educational Plan’s, journals and residential staff reports.

 

Additional comments   

In addition to challenges with rigor of the treatment protocol, participants also noted that the effectiveness of the protocol was variable, improvements seen in some children but not other children or symptoms returning. This may be due, at least in part, to insufficient adherence of the Wilbarger approach to treatment for sensory defensiveness. Other reasons could be use of the protocol with populations in which it is not appropriate or extraneous factors. This again points to the need for research into the effectiveness of the Wilbarger approach in the treatment of specific, well defined populations.

 

While the methodology and presentation of this study had many limitations and may only be generalized with great caution, it provided substantial food for thought regarding the protocol’s current use and the many unknowns related to the protocol (frequency or duration required, issues of compliance/ follow through), and perceptions of its effectiveness.

 

 

Research using the Wilbarger approach with children

While the Wilbarger approach to treating sensory defensiveness was original presented for use with children (Wilbarger & Wilbarger, 1991) and while it is most commonly associated with treatment of sensory defensiveness in children by occupational therapists, there are only a few studies that explore its use in this area. Apart for the brief case report presented in the Wall Street Journal by Chase (1999), 3 more detailed case studies have been presented in professional occupational therapy literature (Frick, 1989; Kinnealey, 1998; Stagnitti, Raison & Ryan, 1999). While case studies present with large methodological flaws and limitations, they are an important first stage in identifying hypotheses, populations and measures (Foss, 2003). Frick used the Wilbarger approach to treatment with a 6 year old child who had a diagnosis of autism and presented with sensory defensiveness symptoms (1989). The 3 year old girl presented in Kinnealey, 1998, had no diagnosis other than sensory defensiveness, and demonstrated a high level of intelligence. Stagnitti et. al. presented a 5 year old boy who also had no diagnosis beside sensory defensiveness although had been perceived as having Asperger’s syndrome prior to the diagnosis of sensory defensiveness. While each of these presents an approximation of the Wilbarger approach, they vary in the level of rigor adhered to in regard to the Therapressure regime. The case study in Frick receives Therapressure 12 times per day for the first week and then 4-6 times in the two following weeks with a total duration of three weeks. The case study in Stagnitti et. al. received Therapressure for two weeks, receiving it only 3 times per day for the first week and 4-5 times per day during the second week due to the family’s schedule. Following a behavioral regression five months later, Therapressure was resumed 3 times a day for two weeks. Kinnealey reported that Therapressure was administered to the child over a three months period and occurred “periodically throughout the day” although specifics were not provided. While progress was demonstrated in all three children, the myriad of techniques and measures used make it difficult to isolate which components were effective and which may not have been effective. This will be a challenge in future studies of the Wilbarger approach; being able to identify which single component or combination of components is responsible for changes seen; where the approach consists of education, sensory diet, and professionally guided treatment which may or may not include Therapressure. However, since evidence supporting the entire approach is limited, preliminary studies should focus on the three stage approach. If the three stage approach cannot be shown to be effective with any populations with sensory defensiveness, or if it is shown to be ineffective, then evaluation of the specific components would be redundant. In addition, the inability of the studies noted above to establish and maintain a consistent frequency of Therapressure makes the studies almost impossible to reproduce. This should be a focus of future studies. All three articles provide functional measures of treatment effectiveness however, as these are not measured in a systematic and continuous manner, it is difficult to rule out the effects of factors external to the treatment such as history. In order to provide measure that are replicable and limit the impact of external factors, therapists who are unable to attempt large group studies but would like to contribute to this area should consider single system designs (Ottenbacher, 1986; Kazdin, 1982). Well designed multiple baseline single system designs can provide powerful evidence and are suited to this particular line of study where treatment reversal or withdrawal may not be appropriate due to ethical concerns or the long-lasting impact of the treatment modality.

 

Research using the Wilbarger approach with adults who have sensory defensiveness as a primary diagnosis

Pfeiffer & Kinnealey (2003) present a pilot study in which 15 adult subjects, with a single diagnosis of sensory defensiveness, were assessed pre-treatment and post-treatment. The researchers investigated the relationship between sensory defensiveness and anxiety and also gained preliminary information regarding the effectiveness of an occupational therapy approach that approximated the Wilbarger approach. Treatment included education, sensory diet strategies and professionally guided treatment. The authors noted that a surgical scrub brush was used although it is unclear whether the actual Therapressure protocol was administered therefore impossible to know whether it was conducted with the rigor recommended by the developers of the approach. However, since all three components were utilized, this study does appear to evaluate an approach similar to the Wilbarger approach.

 

A significant correlation was found between sensory defensiveness and anxiety and positive change was noted when comparisons were made of pre-treatment and post-treatment scores of the Adult Sensory Interview (ADULT-SI) and the Beck Anxiety Inventory (BAI). Therefore, this study provides preliminary evidence to support the use of the Wilbarger approach in the treatment of sensory defensiveness, and anxiety that may be secondary to the sensory defensiveness, in adults. The study contained many limitations such as small sample size for a pre-post design, absence of control group or random assignment and recorder bias. While these limitations prevent the generalization of the results, it remains a beneficial pilot study and basis for further investigation.

 

Research using the Wilbarger approach with adolescents and adults with mental illness or ADHD and addiction as a primary diagnosis

Three studies were identified, through the literature search and review, relating to adolescents and adults with primary diagnoses other than sensory defensiveness. Stratton & Gailfus (1998) discussed the use of the Wilbarger approach in the treatment of adolescents with substance abuse problems who also exhibited sensory defensiveness symptoms that impeded their substance abuse treatment program. One case study was presented by the authors (Stratton & Gailfus, 1998). Moore & Henry evaluated the use of the Wilbarger treatment approach with three woman diagnosed with depression and either Post-Traumatic Stress Disorder, Dissociative Disorder or Borderline Personality Disorder who presented with self-injurious behaviors. They also demonstrated symptoms of sensory defensiveness. Thirdly, a pilot study was conducted that evaluated the impact of the Wilbarger approach with 30 individuals with schizophrenia (Withersty, Stout, Mogge, Nesland & Allen, 2005).

 

These studies presented with many limitations. Stratton & Gailfus (1998) is limited to primarily anecdotal descriptions of the program and of a single case study in which dramatic improvements were achieved although it is impossible to ascertain whether other variables were controlled in order to identify the impact of the Wilbarger approach. Moore & Henry (2002) presented insufficient measures, with only pre-treatment and post-treatment data obtained on with three individuals, and also failed to demonstrate efficient control of variables. The presentation by Withersty et. al. is brief and many details are excluded. The reader is not informed as to whether the subjects also have symptoms of sensory defensiveness in addition to schizophrenia. It is also not clear whether the entire Wilbarger approach was used, including education, sensory diet and professionally guided treatment. It states that it uses the ‘Wilbarger Intervention’ and mentions ‘brushing’ and ‘joint compression’. As noted in all other sections of this literature review, these methodological and presentation flaws limit the credibility of the evidence presented. However, they do provide so intriguing questions and hypotheses that may be answered in future, more systematic and methodologically sound research.

 

Firstly, what is the incidence and impact of sensory defensiveness, which may go undiagnosed, in populations with other diagnoses such as individuals with ADHD and substance abuse issues (Stratton & Gailfus, 1998) or mental illness (Moore & Henry, 2002). Moore & Henry, 2002, in particular, reported tremendous functional changes when the subjects were treatment for symptoms of sensory defensiveness; including positive changes in occupational performance roles, and decreased self-injurious behaviors and hospitalizations. Stratton & Gailfus, 1998, state that participants in their program reported increased personal sense of independence, responsibility and empowerment over the environment. The authors also suggest that staff at the program have noted client improvements in the areas of anger management, decreased impulsive behaviors, heightened attention spans, decreased hyperarousal and increased relaxation. Withersty et. al. also poses fascinating questions regarding the impact of the Therapressure element of the Wilbarger approach on tactile discrimination and the questions regarding the frequency and duration required in order to achieve positive change. Subjects in this study demonstrated a significant improvement in measures of the sensory integration subscale of the Neurological Evaluation Scale (NES), with particular significance noted in graphesthesia and left-right discrimination. They further noted that subjects receiving greater than 90 administrations of the Therapressure demonstrated approximately double the amount of change in each subtest and on the sensory integration subscale total score. It should again be noted that the presentation by Withersty et. al. was brief, left out many details regarding the sample and their selection, choice of measures and tools, as well as details regarding what they called the ‘Wilbarger Intervention’ and the rigor with which is was administered. Once again, while these studies contain many methodological flaws which inhibit the validity and reliability of the studies, they provide an important first step in identifying questions and hypotheses regarding the use of the Wilbarger approach to treatment of sensory defensiveness with the population for which it was developed and also with other populations.

 

Summary

Poor compliance or follow through, by caregivers, of the Therapressure component of the Wilbarger approach, is an issue that has been documented in many of the studies reviewed (Sudore, 2001; Stagnitti et. al., 1999; Grzankowski, 2001). Several subjects who completed the survey in Sudore (2001) noted this, in a general comments section, as a challenge of the treatment modality or as a reason for not using Therapressure. Not only is this an area for future researchers to be aware of but it is important for therapists considering using Therapressure as a home program treatment strategy to be aware of this challenge and prescribe the approach with caution. Wilbarger and Wilbarger (2002) warn that application of Therapressure at a frequency that is less intense than recommended, or insufficient pressure, may not only be less effective but may also be detrimental (p. 337). One question that may be asked by a therapist would be, “Is this too much to expect of some families?” or more specifically discussing with each family under consideration whether they could achieve the recommended consistency. Timing is an important consideration when planning to use Sensory Diet strategies and Therapressure in treatment. Therapist should ask themselves and the family, “Is the family able to follow through with the frequency and intensity required in this program at this time in their life?” In the author’s experience, it is often an occurrence that follow through during school hours is either not possible or not preferable (i.e. socially for older children). In such cases waiting until school breaks may be an option that provides greater opportunity for successful follow through at the recommended frequency.

 

It will be important for researchers to answer the question of “how much is required to obtain long-lasting benefits?” assuming that long-lasting benefits are shown to be obtainable for at least certain populations. In other words, “What daily frequency is required?” and “For how many days, weeks, or months?” In her case study, Frick (1989) stated that the family reported performing the Therapressure 12 times per day during the first week and then progressively less as weeks continued with positive results. Other case studies (Stagnitti et. al., 1999; Kinnealey, 1998) reported much lower frequency of administration although also suggesting positive results. Grzankowski (2001) asked families to administer the Therapressure protocol only twice per day, yet the average actually administered was closer to once per day. In regard to the question of “how long should the program continue?”, the creators and teachers of the protocol suggest that this will be specific to the individual and that therapist will need to use professional judgment (Wilbarger & Wilbarger, 2002). With a nice choice of words, Knickerbocker (1980), referring to an earlier protocol of brushing, stated, “the child who has a history of being ‘feisty’ around other children no longer needs brushing when he stops reacting negatively to touch”. She also adds improvement of tactile discrimination as a sign of improvement although Wilbarger and Wilbarger (2006) suggest that problems of sensory defensiveness are no longer considered on the same continuum as problems with tactile discrimination. Withersty et. al. (2005), when reviewing data collected from thirty patients with schizophrenia, noted that those subjects who received greater than 90 treatments of the Therapressure demonstrated scores that were double the scores of those who received less than 90 treatments. Julie Wilbarger stated that current experts in the area of Fragile X Syndrome believe that the effects of Therapressure on this population are substantial but do not appear to be long lasting (Wilbarger & Wilbarger, 2006). In regard to research possibilities, this may be a population in which a single system design with a treatment withdrawal phase may be utilized effectively to demonstrate treatment effects when the Therapressure protocol is administered.

 

With the difficulty of family follow through noted, it may not be until there is sufficient evidence; regarding the need, use, intensity required and effects for different populations; that families will be more able to invest the time required and commit themselves to providing sufficient administration with the knowledge that great changes are not only possible but are likely.

 

Future researchers will need to utilize this information in identifying populations and possible measures that are like to demonstrate effects. Following this; systematic, well operationalized design must be created that are replicable. The importance of replication cannot be understated in the endeavor to gain evidence supporting, or disproving, techniques currently in use in occupational therapy such as the Wilbarger approach to the treatment of sensory defensiveness. This is particularly important as funding is often limited, and funding sufficient to perform large studies with control groups is not likely to be available until there is greater evidence suggesting that the money would be well spent, i.e. previous smaller studies with acceptable methodologies and clear outcomes. Therefore, occupational therapists must not try to ‘prove’ the effectiveness of the protocol with one study but rather they should attempt to ‘improve’ knowledge in this area by creating clear, well defined, well operationalized studies that can be replicated and will form a strong foundation upon which further investigation can be built (Ottenbacher, 1986, p. ). In this era of evidence-based practice, occupational therapists should have well-defined, measurable goals for individuals in treatment and should be should be applying a logical, prioritized approach to intervention with ongoing progress being monitored regularly (Bundy, 2002). With this taken into account, large amounts of data are taken and measured continuously. Such information could form the basic structure of replicable single system designs that could present valuable information and when combined could present powerful empirical and clinical evidence in the form of a multiple baseline single system design across subjects or a meta-analysis of simple AB designs where sufficient baseline measures are taken and used to compare to treatment measures (Ottenbacher, 1986). Such designs are suitable to most occupational therapy environments, economical both in time and financial consumption and certainly more achievable for most practicing occupational therapists than more quantitative, larger group studies.

 

Many therapists use the Wilbarger approach to the treatment of sensory defensiveness is when treating individuals with sensory defensiveness. Over 10,000 therapists have attended official training seminars number. However, research and literature providing methodologically sound empirical evidence into the effectiveness of the Wilbarger approach is extremely limited. In this study, a systematic literature search was conducted across several databases and the University of Sydney catalogue as well as through literature reviewed, seminar attendance and from word of mouth. The literature obtained was reviewed and critiqued. The existing literature on the Wilbarger approach to sensory defensiveness contained many methodological flaws and generally small numbers. However, it is the author’s opinion that the evidence provided within these studies is sufficiently suggestive as to warrant further study into the use of the approach with various populations, particularly those with sensory defensiveness. It will be important for future studies to produce design that are methodologically sound and take a systematic approach to investigation within this area. A systematic approach would suggest that a greater number of methodologically sound, qualitative studies are required before funds will be made available for larger studies.

The Wilbarger Approach to Treatment of Sensory Defensiveness