EPD
In my geographic area of practice there is a vocal OT practitioner who actively discredits any work in reflex integration as well a the Wilbarger brushing protocol, as part of OT intervention services.
In my clinical experience, I do not have much experience with working on reflex integration. Though, the concepts make sense to me to break the pattern elicited with the trigger movement/position. To me, without even the research to support it, the bilateral coordination piece/motor planning piece and postural control piece could justify at least a trial of related preparatory activities, given the typical deficits of the appropriate populations of children. I would appreciate any recommendations for reading research that supports working on reflex integration within the following populations: LD, ASD, SPD.
In my clinical experience, I have seen Wilbarger brushing protocol implemented differently be many different clinicians. I practice it as I was taught it and I believe that as long as you follow the basic tenets and buy into the preparatory method as a heavy pressure touch experience, there is some wiggle room for diversity in implementation. In my extensive clinical experience, I have trained parents to do brushing with long figure eight strokes that do not to go over the same spot repetitively, to brush with firm pressure, to brush with horizontal brush orientation over skin and vertical orientation over clothes, to brush to roughly a ten count on the limbs, up to a 15 count on the back (horizontal figure 8 across the shoulder blades and vertical figure 8s on the rest of the back, left to right and right to left). I teach the parent to "scrub" back and forth on both sides of the hands and feet, starting on the less sensitive dorsal side. I teach the parents to respect the child's sensitivity and if they pull back while the hands or feet are being brushed, to stop at that point. The goal is a ten count on both sides of the hands and feet, but often I start parents with a goal of a three count, then when I see that more is tolerated, I tell the parents to increase to a goal of 5 count and so on. (There is no brushing of the head/face/chest/abdomen.) I have introduced brushing to both the parent and the child with vibrating massage over the same areas as the brush first (few to multiple sessions). I have taught parents how to knuckle brush in the absence of a "brush" and I have taught kiddos how to knuckle brush their own hands or rub their hands together to get themselves ready for tactile media play. I have taught joint compression to parents (shoulder, elbow, wrist, thumb, fingers, hips, knees, ankles). For children who consistently toe walk and have muscle shortening/limitation in dorsiflexion, I do stretching and teach stretching of the ankle joint/foot to parents after joint compression.
The practice based evidence that I have seen in implementing this brushing program with children during therapy sessions (providing the deep pressure touch of brushing and the heavy work/deep proprioceptive input of joint compression) has been consistent across time and across many individual children. What I have seen, from start to finish in one brushing/joint compression session, has been consistently: increase focus & more joint attention, greater participation in the process, offering the next limb, counting with me (increase appropriate verbalization)... and finally, what I have seen in doing brushing and joint compression is a child who is ready to work on more functional tasks and activities as compared to when we do not prepare for this with brushing and joint compression. The gains seen in one brushing/joint compression session are seen throughout both the brushing and joint compression.
Across time, what I have seen, is a child who can increasingly tolerate touch and when paired with graded exposure to tactile media, a child who will not only better tolerate touch, but who begins to seek hugs from family members and play in bath water, etc... A child who will finger paint without aversion, facial grimace, hand withdrawal, or the need to constantly wipe.
When I teach brushing and joint compression, I tell the parent that the ideal is every 2 hours; but that it must make sense within their family lifestyle and that some is better than none. So, we talk about the habitutation piece of things and the family's routines & we work on agreeing on some great opportunities to make time for brushing and joint compression...often the good times are: upon wake-up (if one parent is a stay at home parent or works part time), upon nap (going down for nap or waking up from nap), prior to lunch, prior to dinner, prior to bath/shower, prior to bed, prior to or after returning from school.
So, clearly, I buy into brushing and joint compression as a preparatory method when working with the tactile defensive population, if done following the basic tenets. However, I am seeking recommended research readings to provide published evidence in the form of research to support this practice. (I'd like to have more than my practice based evidence in teaching this to OTA Students.)
Thanks & Best,
Evelyn 🙂
