A double-blind, sham-controlled, trial of home-administered rhythmic 10Hz median nerve stimulation for the reduction of tics, and suppression of the urge-to-tic, in individuals with Tourette syndrome and chronic tic disorder

Tourette syndrome (TS) and chronic tic disorder (CTD) are neurological disorders of childhood onset characterised by the occurrence of tics; repetitive, purposeless, movements or vocalisations of short duration which can occur many times throughout a day. Currently, effective treatment for tic disorders is an area of considerable unmet clinical need. We aimed to evaluate the efficacy of a home-administered neuromodulation treatment for tics involving the delivery of rhythmic pulse trains of median nerve stimulation (MNS) delivered via a wearable ‘watch-like’ device worn at the wrist. We conducted a UK-wide parallel double-blind sham-controlled trial for the reduction of tics in individuals with tic disorder. The device was programmed to deliver rhythmic (10Hz) trains of low-intensity (1-19 mA) electrical stimulation to the median nerve for a pre-determined duration each day, and was intended to be used by each participant in their home once each day, 5 days each week, for a period of 4 weeks. Between 18th March 2022 and 26th September 2022 135 participants (45 per group) were initially allocated, using stratified randomisation, to one of the following groups; active stimulation; sham stimulation; or a to waitlist (i.e., treatment as usual) control group. Recruited participants were individuals with confirmed or suspected TS/CTD aged 12 years of age or upward with moderate to severe tics. Researchers involved in the collection or processing of measurement outcomes and assessing the outcomes, as well as participants in the active and sham groups and their legal guardians were all blind to the group allocation. The primary outcome measure used to assess the ‘offline’ or treatment effect of stimulation was the Yale Global Tic Severity Scale - Total Tic Severity Score (YGTSS-TTSS) assessed at the conclusion of 4-weeks of stimulation. The primary outcome measure used to assess the ‘online’ effects of stimulation was tic frequency, measured as the number of tics per minute (TPM) observed, based upon blind analysis of daily video recordings obtained while stimulation was delivered. The results demonstrated that after 4-weeks stimulation, tic severity (YGTSS-TTSS) had reduced by 7.1 points (35% reduction) for the active stimulation group compared to 2.13/2.11points for the sham stimulation and waitlist control groups. The reduction in YGTSS-TTSS for the active stimulation group was substantially larger, clinically meaningful (effect size = 0.5), and statistically significant (p = 0.02) compared to both the sham stimulation and waitlist control groups, which did not differ from one another (effect-size = -0.03). Furthermore, blind analyses of video recordings demonstrated that tic frequency (tics per minute) reduced substantially (−15.6 TPM) during active stimulation compared to sham stimulation (−7.7 TPM). This difference represents a statistically significant (p < 0.03) and clinically meaningful reduction in tic frequency (> 25% reduction: effect-size = 0.3). These findings indicate that home-administered rhythmic MNS delivered through a wearable wrist-worn device has potential as an effective community-based treatment for tic disorders.

This study reports a clinical trial that was conducted by the University of Nottingham in partnership with the Nottingham University Hospitals NHS Trust and Neurotherapeutics Ltd, a University of Nottingham spin-out company. Neurotherapeutics supplied the Neupulse devices used in the clinical trial and several of the study authors were employees of Neurotherapeutics Ltd during the completion of the trial and participated in double-blind data collection. These were: Barbara Morera Marquez; Chia-Ping Chou; Belinda Kasbiac; Ciara McCready; Hannah Wright; and Jessica K. Jackson. Analyses of the data were conducted independently by University of Nottingham scientists.

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