The Treatments 

Neupulse is a treatment administered to people over the age of 12 who experience chronic tics and is a non-invasive stimulation technology, worn on the wrist. This wrist band is connected to an app and stimulates the median nerve with low-intensity electrical pulses. This reduces the frequency of tics and is paired with written and video guidance along with a technical support helpline. This Median Nerve Stimulation (MNS) could be an effective and more efficient alternative to repeated Transcranial Magnetic Stimulation (rTMS), which requires the direct application of stimulation to the scalp (Maiquez et al., 2023).  

Another treatment for tics and Tourette’s Syndrome under evaluation by NICE draft guidance is ORBIT (Online Remote Behavioral Intervention for Tics). ORBIT is a remote form of Exposure and Response Prevention (ERP) adapted from published treatment manuals by Verdellen and colleagues (2022) in the Netherlands. It involves the practice of controlling tics for extended periods as well as directly provoking premonitory urges and learning to prevent releasing the tics throughout (Hollis et al., 2021). It is currently being developed into a tool that can be used and delivered on a scale within the NHS and is being administered to children and adolescents.  

Neupulse has been in development based at the University of Nottingham, and ORBIT is being trialed and developed between the University of Nottingham, Great Ormond Street Hospital, East Midlands Health Innovation Network, Centre for Healthcare Equipment & Technology Adoption (CHEATA), commercial partner Blüm Health Ltd, and patient organisations Tourette Action and Neuro-diverse.org. 

Accessibility  

Due to the minimal therapist interaction, ORBIT is believed to have the potential to make behavioural therapy for tics and Tourette’s more accessible children and adolescents (Hollis et al., 2021). For example, this may be a very effective and accessible treatment for children and adolescents who live in more remote areas throughout the UK. Furthermore, where, for example, TMS would first require an MRI to be optimally effective, as well as direct stimulation to the scalp, MNS could be an effective community-based alternative (Maiquez et al., 2023). 

Additionally, an evidence based online therapy such as ORBIT could reduce the strain on the NHS and prevent children and adolescents going through inadequate care pathways resulting in less effective treatments and an unnecessary use of healthcare resources (Hall et al., 2024). 

Evidence Gaps  

In order for NICE to be able to recommend these treatments, they must first examine a number of factors. Currently ORBIT is still in the process of development with the aim of becoming patient-ready. Further assessment regarding the benefit to the NHS is required as well as comparing it to current NHS standard care, the effect on quality of life, further clinical validity and the long-term impact of using ORBIT. 

Neupulse, currently still being trialed, needs to be evaluated in terms of its clinical effectiveness compared to current NHS standard care as well as the impact of use on subgroups, long term impact and health related quality of life. As Neupulse is a treatment which requires a hardware device, it will need to be compared to other treatments in terms of effectiveness and use of resources. (NICE, 2024;2025) 

The recommendations and guidance for these treatments are expected to be published in April 2025 

• Hall, C. L., Novere, M. L., Murphy, T., McNally, E., Hollis, C., & Hunter, R. (2024). Healthcare utilisation and costs associated with poor access to diagnosis and treatment for children and young people with tic disorders. BMJ Mental Health, 27(1), e301241. https://doi.org/10.1136/bmjment-2024-301241 

• Heijerman-Holtgrefe, A., Huyser, C., Verdellen, C., Van De Griendt, J., Beljaars, L., Kan, K., Lindauer, R., Cath, D., Hoekstra, P., & Utens, L. (2022). Effectiveness of ‘Tackle Your Tics’, a brief, intensive group-based exposure therapy programme for children with tic disorders: study protocol of a randomised controlled trial. BMJ Open, 12(6), e058534. https://doi.org/10.1136/bmjopen-2021-058534 

• Hollis, C., Hall, C. L., Jones, R., Marston, L., Novere, M. L., Hunter, R., Brown, B. J., Sanderson, C., Andrén, P., Bennett, S. D., Chamberlain, L. R., Davies, E. B., Evans, A., Kouzoupi, N., McKenzie, C., Heyman, I., Khan, K., Kilgariff, J., Glazebrook, C., . . . Murray, E. (2021). Therapist-supported online remote behavioural intervention for tics in children and adolescents in England (ORBIT): a multicentre, parallel group, single-blind, randomised controlled trial. The Lancet Psychiatry, 8(10), 871–882. https://doi.org/10.1016/s2215-0366(21)00235-2 

• Maiquez, B. M., Smith, C., Dyke, K., Chou, C., Kasbia, B., McCready, C., Wright, H., Jackson, J. K., Farr, I., Badinger, E., Jackson, G. M., & Jackson, S. R. (2023). A double‐blind, sham‐controlled, trial of home‐administered rhythmic 10‐Hz median nerve stimulation for the reduction of tics, and suppression of the urge‐to‐tic, in individuals with Tourette syndrome and chronic tic disorder. Journal of Neuropsychology, 17(3), 540–563. https://doi.org/10.1111/jnp.12313 

• NICE. (2025, April 24). Consultation | Digital therapy for chronic tic disorders and Tourette syndrome: early value assessment | Guidance | NICE. https://www.nice.org.uk/guidance/indevelopment/gid-hte10056/consultation/html-content-5