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Guideline Summary
Guideline Title
Best evidence statement (BESt). Deep-pressure proprioceptive protocols to improve sensory processing skills in children.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Deep-pressure proprioceptive protocols to improve sensory processing skills in children. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Aug 24. 6 p. [9 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Sensory processing difficulties

Guideline Category
Assessment of Therapeutic Effectiveness
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Pediatrics
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To provide recommendations for use of deep-pressure proprioceptive protocols by occupational therapists and physical therapists to improve sensory processing skills in children

Target Population

Children aged 6 months or older with sensory processing difficulties, including those with over-responsiveness to sensory input (formerly known as sensory defensiveness) or under-responsiveness to sensory input

Note: Do not complete the protocol if the following conditions exist: skin lesions, burns, rashes, or other obviously tender or sensitive skin areas, weeping tissue, or open wounds.

Interventions and Practices Considered
  1. Deep-pressure proprioceptive protocol* in conjunction with a sensory diet
    • Therapressure Program
    • Protective Response Regimen
  2. Monitoring of progression/effectiveness of the protocol

*Protocols that involve the use of deep pressure and proprioceptive input with a specially designed surgical scrub brush to address sensory defensiveness

Major Outcomes Considered

Sensory processing skills

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search Strategy

  1. Databases
    OVID MEDLINE
    OVID CINAHL
    Pedro
    All Ovid EBM Reviews – Cochrane DSR, ACD Journal Club
    EBSCOhost
    www.otseeker.com External Web Site Policy
  2. Search Terms: deep touch, pressure, proprioceptive, occupational therapy, autism, sensory (integration, processing), Wilbarger, Protective Response Regimen, children
  3. Limits and Filters: English, humans
  4. Additional articles: from reference lists
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life

Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Reviewed by Clinical Effectiveness

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a to 5) are defined at the end of the "Major Recommendations" field.

The following are recommendations for using one of the two deep-pressure proprioceptive protocols,* the Therapressure Program or the Protective Response Regimen.

  1. It is recommended that a deep-pressure proprioceptive protocol be used in conjunction with a sensory diet (see the National Guideline Clearinghouse [NGC] summary of the Best Evidence Statement Use of sensory diet in children with sensory processing difficulties) (Wilbarger & Wilbarger, 1991 [5], 2006 [5]; Foss et al., 2003 [5]; Hanschu, 2002 [5]).
  2. It is recommended that the family and therapist develop a minimum of one specific functional goal regarding the expected outcome of the protocol (Wilbarger & Wilbarger, 2008 [5]; Foss et al., 2003 [5]; Hanschu, 2002 [5]; Local Consensus [5]).
  3. It is recommended that the protocol be completed every 2 hours of waking time until symptoms improve (Wilbarger & Wilbarger, 2008 [5]), approximately 4 to 6 weeks (Local Consensus [5]).

    Note: If the family is not able to maintain this frequency, then after 2 weeks decrease to 3 to 5 times per day.

  4. It is recommended that progression/effectiveness of the protocol be monitored closely by the treating therapist (Wilbarger & Wilbarger, 2008 [5]) to determine if the protocol is meeting desired functional goal(s) and if it is being completed correctly and at the proper frequency (Segal & Beyer, 2006 [5]; Foss et al., 2003 [5]; Local Consensus [5]). Ideally, this is assessed each week while the protocol is being completed (Wilbarger & Wilbarger, 2008 [5]; Local Consensus [5]).

    Note: As the child's symptoms improve, one can either fade the use of a protocol (meaning gradually decrease frequency by one application every 3 to 4 days (Local Consensus [5]) and monitor the child's reaction for signs of regression with sensory processing (Hanschu, 2002 [5]) or stop completely without fading (Wilbarger & Wilbarger, 2008 [5]).

    Note: If a child is not showing improvements toward meeting desired functional goals(s) after 2 to 3 weeks and the protocol is reviewed with the caregiver to ensure that it is completed properly, the protocol can be stopped completely without fading (Local Consensus [5]).

  5. It is recommended that using the protocol prior to stressful situations or activities (i.e., dentist, haircut, starting school, etc.) be considered to help the child tolerate participation in these stressful activities (Kimball et al., 2007 [5]; Local Consensus [5]).
  6. It is recommended that the protocol be administered by a therapist trained by a qualified trainer and able to demonstrate appropriate knowledge of the protocol (Local Consensus [5]).

    Note 1: A qualified trainer will be able to:

    • Verbalize the theory behind the protocol to the trainee (Local Consensus [5])
    • Explain why/how the protocol affects the nervous system to the trainee (Local Consensus [5])
    • Demonstrate the protocol on the trainee (Local Consensus [5])

    Note 2: The therapist being trained will be able to demonstrate the protocol correctly to the trainer (Local Consensus [5]). This includes being able to:

    • Verbalize to the trainer the theory and neurological basis behind the intervention and identify situations in which it would or would not be appropriate to implement the protocol (Local Consensus [5])
    • Demonstrate ability to apply proper pressure with the brush and during joint compressions (Local Consensus [5])
    • Verbalize how to educate the family on completing the intervention correctly (Local Consensus [5])

    Note 3: Developers of these protocols strongly suggest that therapists be formally trained in theory and practice by attending the instructional course on the use of their respective techniques (Wilbarger & Wilbarger, 2008 [5]; Hanschu, 2002 [5]).

    *Deep-pressure proprioceptive protocols = protocols that involve the use of deep pressure and proprioceptive input with a specially designed surgical scrub brush to address sensory defensiveness. The Wilbarger protocol/Therapressure Protocol and Protective Response Regimen have often been referred to as "brushing." Brushing may imply touching a person lightly, which may be interpreted as harmful by individuals who are over-responsive to tactile input.

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life

Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Emerging evidence and expert opinion indicate that a deep-pressure proprioceptive protocol may be useful in helping children improve their ability to process sensory information effectively. These studies are indicating positive results for using a deep-pressure proprioceptive intervention as a treatment strategy for children with sensory modulation dysfunction.

Potential Harms

Reddening of the skin while implementing a deep-pressure proprioceptive protocol may indicate a histamine reaction. Joint problems should be taken into account and authorization from the responsible physician should be obtained before initiating protocol with an individual who has a fragile medical condition. The brush is not intended to be used on the inner thighs, stomach, groin area, and face.

Contraindications

Contraindications

The protocol should not be completed if the following conditions exist: skin lesions, burns, rashes, or other obviously tender or sensitive skin areas, weeping tissue, or open wounds.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Deep-pressure proprioceptive protocols to improve sensory processing skills in children. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Aug 24. 6 p. [9 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Aug 24
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Division of Occupational Therapy and Physical Therapy: Rebecca D. Reder, OTD, OTR/L, Senior Clinical Director, Occupational Therapy and Physical Therapy

BESt Development Team: Aurora Hoobler, OTR/L, MS, Team Leader, Division of Occupational Therapy and Physical Therapy; Christa Aylward, OTR/L, Division of Occupational Therapy and Physical Therapy; Carol Burch, PT, DPT, Division of Occupational Therapy and Physical Therapy; Karen Kovacs, OTR/L, MHS Division of Occupational Therapy and Physical Therapy; Vicki McQuiddy, OTR/L, MHS Division of Occupational Therapy and Physical Therapy

Reviewed by: Jamie Donovan, MOT, OTR/L, Division of Occupational Therapy and Physical Therapy; Amy Johnson, OTR/L, Division of Occupational Therapy and Physical Therapy; Kathy Krebs, OTR/L,Division of Occupational Therapy and Physical Therapy

Division of Health Policy & Clinical Effectiveness Support: Kim Mason, RN, MSN, PCNS-BC, Guidelines Program Administrator; Eloise Clark, MPH, MBA, Guidelines Program Administrator; Barbarie Hill, MLS, Pratt Library

Ohio State University: Reviewed by Alison Lane, PhD, OTR/L, Assistant Professor, School of Allied Medical Professions, College of Medicine

Financial Disclosures/Conflicts of Interest

All team members and clinical effectiveness support staff listed in the original guideline document have signed a conflict of interest declaration and none were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

  • Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Jan. 1 p.
  • Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 1 p.
  • Table of evidence levels. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Feb 29. 1 p.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 22, 2010.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence-based care.
  • Hyperlinks to the CCHMC website may be placed on the organization's website.
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
  • Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented, or hyperlinked by the organization is appreciated.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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