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Delivery of the Wilbarger Protocol: A survey of pediatric occupational therapy

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DOI: 10.1080/19411243.2016.1169243

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 Journal of Occupational Therapy, Schools, & Early
Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

Delivery of the Wilbarger Protocol: A survey of

pediatric occupational therapy practitioners

Stephanie Lancaster OTR/L, Anne Zachry OTR/L, Ashleigh Duck MOTS,

Alexandria Harris MOTS, Ellen Page MOTS & Jordan Sanders MOTS

To cite this article: Stephanie Lancaster OTR/L, Anne Zachry OTR/L, Ashleigh Duck
MOTS, Alexandria Harris MOTS, Ellen Page MOTS & Jordan Sanders MOTS (2016) Delivery
of the Wilbarger Protocol: A survey of pediatric occupational therapy practitioners,
Journal of Occupational Therapy, Schools, & Early Intervention, 9:3, 281-289, DOI:
10.1080/19411243.2016.1169243

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JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
2016, VOL. 9, NO. 3, 281–289
http://dx.doi.org/10.1080/19411243.2016.1169243

Delivery of the Wilbarger Protocol: A survey of pediatric

occupational therapy practitioners
Stephanie Lancaster, OTR/L, Anne Zachry, OTR/L, Ashleigh Duck, MOTS,
Alexandria Harris, MOTS, Ellen Page, MOTS, and Jordan Sanders, MOTS
Masters of Occupational Therapy Program, University of Tennessee Health Science Center, Memphis,
Tennessee

ABSTRACT ARTICLE HISTORY

The Wilbarger Therapressure Program is a commonly used treatment Received 21 December 2015
approach utilized by occupational therapy professionals for the treat- Accepted 18 March 2016
ment of sensory defensiveness. The purpose of the current study was KEYWORDS
to investigate occupational therapy practitioners’ sources of training Assistive technology; special
in the administration of Wilbarger Therapressure Program, the uni- education; sensory
formity of administration in practice, and the diagnoses for which processing; occupational
therapists recommend this treatment approach. Occupational thera- therapy; paediatrics
pists from across the United States participated in an online survey
investigating specifics related to training and implementation of the
brushing protocol. A total of 153 respondents reported using the
Wilbarger Therapressure Program in practice. Almost half of the
respondents received their education on the Therapressure program
by attending the workshop offered by the Wilbargers. Forty eight
percent of survey participants reported learning how to administer
the Therapressure program by participating in hands-on training
provided by another occupational therapy practitioner, 39% by
attending the course taught by the Wilbargers, 7% by information
obtained through word of mouth from another occupational therapy
practitioner, 3% by information obtained through online research,
and 3% by other means. The results of this study reveal that a variety
of approaches exist related to the training and implementation of the
protocol. It is the responsibility of all occupational therapy practi-
tioners to obtain the proper training prior to recommending and
implementing the Therapressure program. Because a standardized
protocol for implementation of the protocol has not been published,
the optimal means of training is for practitioners to attend the
Wilbarger workshop.

Background
The Wilbarger Therapressure Program was designed as a treatment approach for sensory
defensiveness in children and adults by Patricia Wilbarger, M.Ed., OTR, FAOTA,
(Wilbarger & Wilbarger, 1991). Sensory defensiveness (SD), also called sensory over-
responsivity, is an overreaction to sensory stimuli from one or more sensory systems
that result in an aversive response (Miller, 2014; Wilbarger & Wilbarger, 2014). If left
untreated, SD has the potential to negatively impact an individual’s daily occupations

CONTACT Stephanie Lancaster slancas4@uthsc.edu University of Tennessee Health Science Center, 930 Madison
Ave. Suite 620, Memphis, TN 38163.
© 2016 Taylor & Francis
282 S. LANCASTER ET AL.

(Stagnitti, Raison, & Ryan, 1999). The Wilbarger Therapressure Program is commonly
called the Wilbarger Protocol. It is also referred to as the Deep Pressure and
Proprioceptive Technique (DPPT) or the brushing and compression program (Bhopti &
Brown, 2013; Weeks, Boshoff, & Stewart, 2012; Wilbarger & Wilbarger, 2014).
The proper implementation of the Therapressure program is a three-step process: deep
pressure brushing, joint compressions, and a sensory diet (Segal & Beyer, 2006; Wilbarger
& Wilbarger, 2014). To begin the protocol, deep pressure is applied to the designated area
of the skin using a specific brush designed by Patricia Wilbarger and her daughter, Julia.
This deep pressure is administered by firmly brushing the surface of the arms, hands,
back, legs, and feet using the Therapressure brush. Next, joint compressions are per-
formed for additional proprioceptive input. The third component of the protocol is the
implementation of a sensory diet (Wilbarger & Wilbarger, 2014). A sensory diet is a home
program that involves incorporating tailored sensory input into daily routines to assist an
individual in maintaining a regulated arousal state (Bhopti & Brown, 2013).
The Wilbargers recommend that the full protocol be carried out every 90 to 120 minutes
each day for a period of 2 to 8 weeks depending on the child’s response (Wilbarger &
Wilbarger, 2014). According to the Wilbargers, hands-on-training by an individual who has
been specifically trained in the technique is the most effective way to be proficient with the
administration of the Wilbarger Therapressure Program (Wilbarger & Wilbarger, 2014).
The Therapressure program is an intervention that is sometimes used by occupational
therapy (OT) professionals (Foss, Swinth, McGruder, & Tomlin, 2003; Sudore, 2001).
Although the empirical research surrounding the effectiveness of the protocol is limited
(Weeks et al., 2012), anecdotal reports from therapists and parents indicate that the
protocol is effective in the treatment of SD (Kimball et al., 2007). A 2001 study of practices
related to implementation of the technique, however, revealed that many occupational
therapists using the protocol are not concerned about the limited empirical evidence
related to the effectiveness of this intervention (Sudore, 2001).
It is important that therapists adhere to specified procedures and carry out interven-
tions as defined in order to ensure treatment fidelity (Breckenridge & Jones, 2015;
Hildebrand et al., 2012). The purpose of the current study was to investigate the source
of training in the administration of the Wilbarger Therapressure Program for occupa-
tional therapy practitioners, uniformity of administration in OT practice, and the diag-
noses for which therapists recommend this treatment approach.

Methods
Research design
Occupational therapists and occupational therapy assistants were included in this online
survey, which was developed by the researchers. Prior to initiating the study, the research-
ers obtained approval from the University of Tennessee Health Science Center
Institutional Review Board.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 283

Participants
Occupational therapy practitioners’ email addresses were gathered by the researchers
using the Sensory Processing Disorder Foundation website database and public pediatric
therapy websites and compiled into a list of recipients. A total of 199 invitations to take
the survey were distributed via email through Qualtrics. Additionally, the survey link was
posted on pediatric therapy blogs, social media, and on the Tennessee Occupational
Therapy Association (TNOTA) website. Of the surveys started, 31 therapists reported
that they do not utilize the protocol; therefore, these respondents did not answer any
questions after Question #5. Thirty-five individuals started the survey but did complete it.
The answers to the 35 incomplete surveys were not included in the final analysis. A total of
153 respondents reported using the Wilbarger Therapressure Program in practice. The
link posted on the therapy blogs, social media, and the TNOTA was a direct link to the
survey in Qualtrics. Every respondent who clicked on the link was connected to the survey
site and, thus, was included in the tally of the response rate regardless of whether they
chose to begin the survey or to exit the site as a nonparticipant. The metrics did not
provide information distinguishing the response rate of invited therapists from the
response rate of therapists who accessed the survey site through social media or other
avenues.

Instrument
The purpose of the survey was to gather data on how occupational therapists were trained
to administer the Wilbarger Therapressure Program, the approaches used in the admin-
istration, and the diagnoses for which the protocol is recommended. After the researchers
developed the survey, pilot testing was completed with three occupational therapists
formally trained in the Wilbarger Therapressure Program and specializing in pediatrics.
Based on feedback provided by the practitioners, slight revisions were made to ensure that
the questions were clearly worded.
The survey consisted of 15 items in three sections covering participant demographics,
history of protocol implementation, and delivery specifics of the protocol. Specific ques-
tions inquired about the occupational therapy practitioners’ state of residence, areas of
practice, years of experience as an OT practitioner, training in the Therapressure program,
the frequency of implementation of the protocol, diagnoses used with treatment, addi-
tional components used in the protocol, and type of brush recommended with the
program.

Procedures
The survey was distributed through direct email using the online software Qualtrics
starting in November 2014, and the survey link was posted on pediatric therapy blogs,
social media, and the TNOTA website. The survey was open for a 2-month time frame
with one reminder email sent during this time period.
284 S. LANCASTER ET AL.

Data collection and analysis

The final raw data were downloaded from Qualtrics into a Microsoft Excel file for analysis.
Descriptive statistics were used to analyze the answers provided by the survey participants.

Results
One hundred and forty five occupational therapists and eight occupational therapy
assistants completed the survey. Results from incomplete surveys were not included in
the analysis.

Section 1: Demographic information

Demographic information was collected in the first section of the survey. Participants
across 36 states provided responses with the majority coming from Tennessee (14.74%)
and California (10.9%). The number of years of experience as a practitioner included 0–5
years (22%), 6–10 years (14%), 11–15 years (14%), 16–20 years (16%), 21–25 years (11%),
and 26+ years (33%). Regarding primary practice settings, outpatient clinics (47%) and
school settings (22%) were the most common, with 3% of the therapists practicing in
home health (ages 3–18 years), 2% private practice, 2% in hospitals, 8% in early interven-
tion settings, and 16% other settings. The respondents who marked “other” indicated that
they worked in the following settings: independent school settings, pediatric outpatient
settings, and universities.

Section 2: Protocol training and implementation

Survey participants reported learning how to administer the Therapressure program by
participating in hands-on training provided by another occupational therapy practitioner
(48%), by attending the course taught by Patricia and Julia Wilbarger (39%), by informa-
tion obtained through word of mouth from another occupational therapy practitioner
(7%), by information obtained through online research (3%), and by other means (3%).
Respondents who marked “other” reported that they learned the technique in school or in
a course taught by another occupational therapist.
Regarding how long the respondents had been using the Therapressure Program as a
treatment approach in practice, 17% reported using it 1 year or less, 18% reported 1–3
years, 9% reported 3–5 years, 18% reported 5–10 years, and 38% reported having used the
protocol for more than 10 years. Twenty-six percent of survey participants reported that
over the last 3 years, they had recommended the protocol at least once a year; 16% had
recommended the protocol at least once per quarter; 14%, once a month; 23%, once per
week; and 20%, had not recommended the protocol at all. Additionally, when considering
caseloads over the last year, 72% of participants estimated having recommended the
intervention for less than 20% of their patients, 15% for 21–40% of their patients, 7%
for 41–60% of their patients, 5% for 61–80% of their patients, and 1% for 81–100% of their
patients.
Participants specified that they had recommended the protocol for patients with these
diagnoses: tactile defensiveness (80%), sensory defensiveness (76%), sensory processing
disorder (74%), autism spectrum disorder (63%), ADD/ADHD (30%), cerebral palsy
(14%), intellectual disability (6%), and other (11%). The following diagnoses were listed
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 285

under other: post-traumatic stress disorder, developmental coordination disorder, oral

defensiveness, and anxiety disorders. This question was formatted in a way that partici-
pants could select all that applied.

Section 3: Delivery and assessment of the protocol

When implementing the protocol, respondents stated that they had used several different
types of brushes. The brushes reported included the Therapressure brush (46% of partici-
pants), medical surgical scrub brush (48% of participants), corn silk brush (3% of partici-
pants), and other (4% of participants). The respondents who marked “other” reported that
they had used their hands, deep massage, and a sensory brush. In implementing the
intervention, respondents reported having included joint compressions (97%), brushing
(89%), sensory diet (74%), oral tactile technique (17%), and other techniques (7%). This
question was formatted in a way that participants could select all that applied.
Forty-one percent of respondents reported that they had recommended that the pro-
tocol be implemented every 90 minutes to 2 hours when the client is awake. Others
recommended that the protocol be implemented four to six times daily (23%), as often as
needed by the client (13%), once per day (6%), and other (17%). The respondents that
marked “other” reported the following: two to three times during the school day, three
times per day, six to seven times per day, as often as the child requests it, and as often as is
capable by the family.
The duration recommended by the respondents for the continued implementation of
the protocol included as long as needed (41%), 6 to 8 weeks (13%), 4 to 6 weeks (12%), 2
weeks (11%), 3 to 6 months (5%), and other (19%). The following responses were listed
under other: until symptoms clear, varies with the client, 2 weeks, 3 months, and until
goals are met.
The following answers were provided when asked who the practitioners recommend to
carry out the program: parent/caregiver (89%), teacher assistant/rehabilitation assistant
(29%), teacher (25%), only the individual trained (22%), client himself or herself (15%),
another occupational therapist (12%), practitioner in another discipline (PT, SLP, etc.)
(5%), and other (7%). Nanny, grandparent, therapist, direct service provider, and the
treating therapist were listed under “other.” This question was formatted in a way that
participants could select all that applied.
Respondents were given the choice of seven methods to choose from regarding
evaluating the success of the protocol. Success was determined by parent report (92%),
practitioner’s clinical observation (85%), teacher report (51%), report from other health
care professional (19%), nonstandardized testing (16%), standardized testing (5%), and
other (11%). Client self-report, when goals are met, functional changes, and goal attain-
ment scaling were listed under other.

Discussion
This research was completed in order to investigate how occupational therapists in the
current sample were trained to administer the Wilbarger Therapressure Program, the
approaches used in the administration, and the diagnoses for which the protocol is being
recommended. The results revealed that a variety of approaches exist related to the
training and implementation of the protocol.
286 S. LANCASTER ET AL.

According to the Wilbargers, the most effective method of training for administra-
tion of the protocol is to attend their hands-on training workshop (Segal & Beyer, 2006;
Wilbarger & Wilbarger, 2014). Of the 153 respondents who reported using the protocol
in their practice, 61 reported having attended the sensory defensiveness seminar led by
Julia and Patricia Wilbarger. This indicates that almost half of the respondents received
their education on the Therapressure program by attending the workshop, which is a
positive finding. Seventy-three (48%) of the 153 respondents reported being trained by
another occupational therapy practitioner. It is not known if the occupational therapy
practitioners who administered the training actually attended the Wilbarger workshop
or learned the protocol in another way. The 16 respondents who marked “other”
reported learning the Therapressure program by word of mouth from another OT
practitioner, in a course taught by an occupational therapist, or through online
research. Even though this is a small percentage of the respondents (10%), it is
important to note that the developers of the protocol state that though the techniques
appear simplistic, they are actually complex and challenging to learn correctly
(Wilbarger & Wilbarger, 2014). Regarding practitioner qualifications, the Wilbarger
Therapressure Program manual states that therapists who recommend the protocol
should have advanced instruction and awareness of the treatment approach, and they
must demonstrate the knowledge needed to carryout the procedures correctly. The
manual indicates that any therapists who are trained to carry out the protocol must
have direct and regular supervision by an experienced practitioner and must demon-
strate a prior thorough understanding of sensory processing theories. Additionally, all
technical personnel and nonhealth professionals who are trained to carry out the
protocol should receive ongoing supervision by a knowledgeable, trained health care
professional (Wilbarger & Wilbarger, 2014). In order to ensure treatment fidelity, it is
critical that occupational therapy practitioners adhere to the training requirements set
forth by the developers of the protocol.
According to the Wilbargers, the protocol was designed to be prescribed for
individuals with diagnosis of sensory defensiveness (Bhopti & Brown, 2013;
Wilbarger & Wilbarger, 2014). The responses in the current survey indicate that
practitioners recommend the protocol with individuals diagnosed with a variety of
diagnoses, including autism spectrum disorder, sensory processing disorder, cerebral
palsy, and ADD/ADHD. With the majority of responses, sensory defensiveness or
tactile defensiveness was marked along with the previously listed diagnoses. In these
cases, the recommendation of the protocol is appropriate. However, 11 respondents
reported recommending the Therapressure program for individuals diagnosed with
sensory processing disorder only. As explained in the Wilbarger training course, the
protocol is only appropriate to implement with clients who present with sensory or
tactile defensiveness.
The Therapressure program is designed to include three components: deep pressure,
joint compressions, and a sensory diet (Segal & Beyer, 2006; Wilbarger & Wilbarger,
2004). In compliance with this recommendation, a significant number of respondents
reported including these three components within their treatment. However, 30 partici-
pants indicated the recommendations of brushing and joint compressions only, with no
sensory diet included. Three respondents reported recommending brushing alone with no
joint compressions or sensory diet. Occupational therapy practitioners need to understand
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 287

that in order to ensure treatment fidelity with the implementation of the Therapressure
program, all three components of the protocol must be prescribed and carried out as
recommended by the developers.
Concerning the frequency and duration for which practitioners recommended that the
protocol be carried out, responses varied. Respondents did not consistently recommend
implementation every 90–120 minutes each day for a period of 2–8 weeks as directed by
the Wilbargers (Wilbarger & Wilbarger, 2014). A large percentage of respondents stated
that the success of the protocol was determined through parental report, practitioner
observations, and teacher report.
The lack of a solid outcome measure for the Wilbarger Therapressure program
protocol is a concern. The protocol has limited evidence and is essentially untested.
Therapeutic interventions should be applied only with accurate outcome measures to
ensure their effectiveness for that client. Without appropriate outcome measures, the
protocol efficacy will never be adequately tested and established. It is important that
therapists determine the effectiveness of any treatment approach through objective
outcome measures, for example, by utilizing data collection, such as checklists or
other specific documentation methods.
The Wilbargers recommend that only the Therapressure brush be used during
administration of the protocol. Findings from the current survey suggest that a variety
of types of brushes are used during implementation. The incorrect use of instrumenta-
tion may impact the effectiveness of the treatment protocol and possibly lead to adverse
reactions. It is the responsibility of all occupational therapy practitioners to obtain the
proper training prior to recommending and implementing the Therapressure program.
Because a standardized protocol for implementation of the protocol has not been
published, the ideal means of training is for practitioners to attend the Wilbarger
workshop.

Limitations
The current study presents with several limitations. One limitation is the small sample
size. Also, the sample consisted only of occupational therapists and occupational therapy
assistants. Including additional health care practitioners in future surveys will allow for a
more comprehensive understanding of the protocol. The survey did not include a question
that provided information regarding whether or not therapists who were trained to
administer the protocol by other occupational therapists received supervision after the
training occurred. This is important information to obtain, because the protocol manual
states that practitioners should be directly supervised and mentored by a knowledgeable,
trained practitioner (Wilbarger & Wilbarger, 2014).

Implications for future research and clinical practice

Further research is needed related to the training and implementation of the
Therapressure protocol. Because there are limited studies investigating the effectiveness
of the Therapressure program, additional research is needed to examine the effectiveness
of the protocol to increase evidence-based support for the intervention. With the current
sample, there were limitations with uniformity regarding the recommendation and
288 S. LANCASTER ET AL.

implementation of the protocol. It is critical that occupational therapy practitioners who

utilize the Therapressure protocol are properly trained to ensure competency and con-
sistency with recommendations and implementation. Additionally, all therapists who
recommend the protocol need to be aware of the contraindications for administration,
including no open wounds or skin rashes, and they must be aware of the importance of
watching for autonomic system responses such as an increased breathing rate or flushing
of skin color.
The developers of the protocol may want to consider developing a more detailed
treatment manual. Additionally, more extensive training and supervision could be
required, with a certification requirement put into place for practitioners to administer
the Wilbarger program. Additionally, developing a video that provides instruction related
to the specifics of the protocol may improve the consistency of implementation. In order
to improve treatment fidelity, Hildebrand et al. (2012) recommends that trainees model
the intervention, with the trainer observing frequently and providing feedback. Robust
methods for teaching, training, and supervising therapists are necessary to ensure that the
protocol is administered accurately and consistently. Every effort should be made to
manualize the Wilbarger Therapressure Program to further enhance competence and
ensure treatment fidelity.

References
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