“We shouldn't do brushing in OT to kids with epilepsy and seizure history”

It is widely repeated in occupational therapy circles that the Wilbarger brushing protocol — also called the Deep Pressure and Proprioceptive Technique (DPPT) — should not be used with children who have a history of epilepsy or seizures. This caution is often passed on as a firm rule during training or handover, without always being explained. Is it supported by evidence?

The Wilbarger DPPT involves applying a soft-bristled surgical scrub brush to a child's skin — typically hands, arms, back, legs, and feet — using firm, steady strokes, followed by joint compressions. It was developed by occupational therapist Patricia Wilbarger to address tactile defensiveness and sensory modulation difficulties. The protocol delivers repetitive, powerful tactile and proprioceptive input to the nervous system, typically every two hours during waking hours.

It is important to note upfront: the overall evidence base for the brushing protocol is weak. A critically appraised topic review from the University of Wisconsin-La Crosse found no strong evidence that the protocol is an effective sensory integration intervention. It is no longer widely taught or endorsed by AOTA. This context matters when weighing safety concerns — the intervention carries both uncertain benefit and uncertain risk.

The caution is not invented. It stems from a real and documented phenomenon: reflex epilepsy.

Reflex epilepsy refers to seizures that are triggered by a specific external stimulus. Somatosensory reflex epilepsy is the subtype most relevant here — seizures triggered by tactile stimulation (touching, rubbing, tapping, or brushing a specific region of the body, often called a "trigger zone"). This is a recognised category in neurology, affecting approximately 4–7% of all people with epilepsy.

For this specific group, repetitive brushing of the skin could, in principle, trigger a seizure — and the caution is well-founded. This is particularly relevant for:

• Reflex Myoclonic Epilepsy of Infancy (RMEI): a rare condition in which myoclonic seizures are triggered by sudden tactile or auditory stimuli
• Somatosensory focal epilepsy: where seizures originate in the sensory cortex and can be triggered by touch or skin stimulation in a specific trigger zone
• Children with poorly controlled or undiagnosed epilepsy, where the full seizure profile is not yet understood

The problem with "don't brush any child with a seizure history" is that epilepsy is not one condition — it is a broad category of dozens of distinct syndromes with very different seizure types, triggers, and levels of control.

• A child with well-controlled absence seizures triggered by hyperventilation is categorically different from a child with somatosensory reflex epilepsy
• A child whose seizures are triggered by fever, sleep deprivation, or flashing lights has no identified tactile trigger — brushing carries no more theoretical risk than other daily tactile activities like bathing or dressing
• A child whose epilepsy has been seizure-free for years on medication occupies a different risk category than a child with frequent, uncontrolled seizures

No published clinical trial or systematic review has found that the Wilbarger protocol triggers seizures in children with non-tactile-triggered epilepsy. The risk is theoretical for most epilepsy types, not empirically demonstrated.

• Tactile stimulation can trigger seizures in a specific subset of epilepsy — this is well established in neurological literature
• No published evidence directly demonstrates that the Wilbarger brushing protocol triggers seizures in children with epilepsy broadly
• The protocol has no well-established clinical contraindication list in the formal published literature — the seizure caution lives largely in training handouts and clinical tradition rather than peer-reviewed evidence
• Somatosensory and reflex epilepsies are rare — most children with autism and epilepsy do not have tactile-triggered seizure types

The statement is nuanced rather than a straightforward myth or supported claim. The underlying concern is real — tactile stimulation can trigger seizures in a small and specific subset of epilepsy — and applying caution is clinically sensible. But extending that caution into a blanket rule covering all children with any seizure history goes beyond what the evidence supports.

The appropriate clinical response is not to refuse brushing for all children with a seizure history, but to:

1. Consult the child's neurologist before initiating the brushing protocol — understand the specific seizure type and whether tactile triggers have been identified
2. Review the seizure history carefully — are seizures controlled? Have tactile triggers ever been identified?
3. Apply the protocol only under OT supervision and never train parents to use it at home without confirmed safety in a supervised setting
4. Err on the side of caution for uncontrolled or incompletely characterised epilepsy — not because brushing is proven harmful, but because the seizure profile is not yet fully understood

If your child has a seizure history and an OT is recommending the brushing protocol, it is entirely reasonable to ask:

• Has this been discussed with our neurologist?
• Does my child's specific seizure type involve any tactile triggers?
• Will the first sessions be supervised in clinic before we use this at home?

An OT who raises these questions proactively is following good clinical practice. An OT who applies a blanket refusal without exploring the individual clinical picture is being appropriately cautious — but may be applying a rule more broadly than the evidence strictly requires.

• Reflex Epilepsy — AboutKidsHealth
• Reflex Myoclonic Epilepsy of Infancy: Seizures Induced by Tactile Stimulation — Journal of Pediatrics / PubMed
• Reflex Seizures and Reflex Epilepsies — NCBI Bookshelf
• Therapeutic Brushing Techniques — OT-Innovations
• There is no evidence that a brushing protocol is an effective intervention — UW-La Crosse CAT Review
• Treatment summary for Wilbarger Brushing Protocol — ASAT
• Reflex seizure triggers — Epilepsy Action