TELENEUROFEEDBACK WITH SPECIAL APPLICATION OF REALTIMENORMTRAINING Doerte Klein

TELE-NEUROFEEDBACK WITH SPECIAL APPLICATION OF REAL-TIME-NORMTRAINING Doerte Klein, EEG-TRAIN EEG-Biofeedback Trainingszentrum Hannover www. eegbiofeedback. de info@eegbiofeedback. de SAN – Congress Sevilla May 2008 17. 12. 2021 teleneurofeedback © EEGTRAIN 1

Tele-Neurofeedback Background: The special need for professional Neurotraining in face of limited professionals calls for distance training. There are demands for Tele-communication and Tele-training also concerning Neurofeedback Tele-Neurofeedback/Tele-medicine is not a “new” technique – it is the application of an existing method within a new frame – insofar existing standards have to be transmitted (i. e. privacy, data protection) Methods: „No Tele-Medicine without data protection“ - Luecke, 2008, „partnership for the heart“ The Z-Score-Real-Time Neurofeedback-option will be introduced as scientifical controlled method to train distance patients with neurofeedback A local co-therapist will be introduced, the frequency of supervision has to be set according to individual needs. Part of the Tele-Approach is an individual contact to the professional trainer/therapist in a setting, appropriate to the individual circumstances: fractionated treatment in practice or home visits. Results: Experiences with Tele-norm-training/neurofeedback proved the efficiency and effectivity of neurofeedback-training also in this setting, independently of group of / intensity of symptom. Basic technical settings are important to reflect. 17. 12. 2021 teleneurofeedback © EEG-TRAIN 2

Tele-communication in Health. Systems has a long history 17. 12. 2021 teleneurofeedback © EEGTRAIN 3

The Radio Doctor 1924 17. 12. 2021 teleneurofeedback © EEGTRAIN Fischer 2008 4

The portable electrocardiograph – 1925 Fischer 2008 17. 12. 2021 teleneurofeedback © EEGTRAIN 5

The Tele-Surgeon 1931 17. 12. 2021 teleneurofeedback © EEGTRAIN Fischer 2008 6

History Tradition of telephone diagnosis since 1897 1922 forecast of Th. Edison „radio has no future“ 1925 the portable Electrocardiograph 1931 the Tele-Surgeon Since the 70 th in the US: direct Patient-Computer. Interaction and remote systems 1972 -75 STARPHAC (Space Technology Applied to Rural Papago Advanced Health Care) – NASA – medical care for astronauts in the orbit, Bashshur, 1980 2008 – Telemedicine as reality, still to be integrated – Tele-Neurofeedback to be established 17. 12. 2021 teleneurofeedback © EEGTRAIN 7

Scepticism on the future of Telemedicine Depletion of communication & Encouragement of social isolation – „…computer-mediated communication … offers nothing to psychoanalytic practice, except to erode therapeutic alliance“ (Curtis, 2000) Lack of personal contact & Deprivation of medical cultur – „Cybermedicine …retards development of physician compassion and patient trust… encourages morally inappropriate patient-physician relationships“ (Bauer 2004) “There is no reason for anyone to have a computer in their home” – James Olson, CEO, digital equipment corporation (DEC) – 1978 (s. Collura) 17. 12. 2021 teleneurofeedback © EEGTRAIN 8 “Home neurofeedback training will never be practical” –

Actual state in health system Congress „Tele. Health 2008“ integrated in Ce. Bit, Hanover, march 2008 Questions: - Role of IT* in health care in the future ? - can IT in Health care contribute to cost reduction ? Topics: integration of hardware-solutions into existing clinic and practice it-systems and improvement of medical care and documentation of medical datas with electronic patient records ©(EPR) 17. 12. 2021 teleneurofeedback EEGTRAIN 9

Actual state in health system 2 Examples of research in Tele-Monitoring – s. Luecke 2008 Charité/Berlin: cardiovascular monitoring imbedded in emergency system, security/privacy criterias for data Claim: No Telemedicine without Data protection Criterias of requirement: - „techno“- education and written informed consent - limited use of datas - only for this special purpose - trustfulness - access to datas only by authorized persons - authenticity - authorized person clearly to be assigned - integrity - undistortability of collected, stored, transmitted or processed datas 17. 12. 2021 e teleneurofeedback © EEG 10 - availability - datas are available exactly when needed TRAIN

Charité - 2 Data-Protection – methods: Access control - education and code only for authorized persons Access control - allowance of necessary access rights per login and password Input control User control - processing only by registered persons - access to datas only by authorized persons, no access to public internet, remote access only by own network Transmission control – where will which datas be sent to ? Transport control – prevention of reading, changing, or deleating 17. 12. 2021 of datas on teleneurofeedback © EEGTRAIN 11

Charité - 3 Examples of legal basics: (Medical) professional code of conduct: confidentiality Criminal code: authorization to inform third party on therapeutical datas EU privacy policy: a priori control by internal security administrator Social security code: agreement/compliance of patient National Data Protaction Act: no access to personal datas Federal Data Protraction Act… 17. 12. 2021 teleneurofeedback © EEGTRAIN 12

Actual state in health system Example best practise: MEDGATE – Telediagnostic and Teletherapy in Swiss Center for Telemedicine: since 1999, 150 physicians, up to 1. 600 contacts/day Teleconsultation: 80 % of calling patients Telediagnostics – Telebiometrie – Telecare: Teleadvice, Teletherapy (prescription per fax) Realconsultation: 20 % of patients 17. 12. 2021 teleneurofeedback © EEGTRAIN 13

Medgate - 2 Role of method of communication in therapeutic information transmission text telephone F 2 F 17. 12. 2021 teleneurofeedback © EEGTRAIN 14

low Preference high Classical assumption: „i have to see my patient. . . “ text 17. 12. 2021 sound video F 2 F Amount of information transmitted teleneurofeedback © EEGTRAIN 15

What we say and what we do (Schliemann et al, 2002) 17. 12. 2021 teleneurofeedback © EEGTRAIN 16

Actual state in health system Example for Tele-Diagnostik; Levine SR et al. : Telemedicine for acute stroke: When virtual is as good as reality. Neurology. 2007 Telemedical Pilot Project for Integrative Stroke Care (TEMPi. S) was started in February 2003. Twelve community hospitals with no or very limited stroke thrombolysis experience and two stroke centers were connected via a network providing online neurologic examination and transfer of neuroradiologic scans. CONCLUSIONS: Mortality rates and functional outcomes for telemedicine-linked community 17. 12. 2021 teleneurofeedback © EEG 17 hospitals and stroke centers were similar and TRAIN

Terms IT – Information Technology – general term Telematic = Telecommunication + Informatics Telearchitecture – serves with appropriate designs E-Health – art term of application Telemedicine - application Quality Management – general necessity Sustainability – claim Best practice – scientifical claim Telemonitoring – practise of distance monitoring AAL – Ambient Assisted Living – systemic aspect 17. 12. 2021 teleneurofeedback © EEGTRAIN 18

Definition E-Health/Tele. Medicine Eysenbach (2001). . . not only a technical development but also. . . a (special) way of thinking, attitude and obligation to networking and global thinking to improve medical care. . . by use of information and communication technology. Convergence internet and medicine can create something NEW – with chances and risks for all acteurs in health systems. 17. 12. 2021 teleneurofeedback © EEGTRAIN 19

Definition Telemedicine Def. in application: „telemedicine is the use of information and telecommunication technologies to provide and support healthcare when distance sepearates the participants (M. J. Field 1996, s. Oeser 1998, 9) Def. in structure: TM consists of sender – remote data transfer receiver; transfer individual-related or anonymous; datas as „classical“ information (text, sound, picture) or as information to control machines (e. g. telesurgery – online and realtime) Def. Oeser: TM… technique providing provision of medical information and services independently of their actual physical existence for the patients sake. Telemedicine is the delivery of care to patients anywhere in the world by combining communications technology with medical expertise. Telemedicine is an emerging field that could have a revolutionary 17. 12. 2021 teleneurofeedback © EEG 20 TRAIN care. . . The goal is to improve impact on the delivery of medical

Why Tele-Neurofeedback ? Quality control and cost management in several aspects Overcome geographical, time barriers (Collura, Remote Neurotherapy) - NFB-Therapist Network not jet compact enough - Distance training without distance driving (time) Create a natural extension of clinical practice (Collura) Multi-tele-modules simulates F 2 F situation Collura: There is no fundamental reason we cannot get neurofeedback into homes, schools, offices. • Telemedicine is the future of medicine. • Teleneurofeedback is the future of neurofeedback. 21 17. 12. 2021 teleneurofeedback © EEGTRAIN

Why Remote Z-Score Training ? Quality management: Corresponds to qualitative assessement procedures Security to not training dysfunctional options T. F. Collura, 2007: Integrates QEEG analysis with training in real time – protocol automatically and dynamically adapts to what is most needed – consistend with established QEEG-based procedures with demonstrated efficacy (slide 35) Control for protocols by setting of age & session 17. 12. 2021 teleneurofeedback © EEG 22 TRAIN numbers

Special treatment settings of Tele-Neurofeedback Intake - Assessement Decision on possibility of tele-training Treatment planning Local co-trainer Equipment for client should be a remote system Treatment settings Tele settings Evaluation 17. 12. 2021 teleneurofeedback © EEGTRAIN 23

Intake Inicial setting: personal contact in clinic or home visit Decision: ongoing F 2 F-setting or remote setting? Co-trainer: client/patient or third person ? Fractionated therapy in clinic and/or remote sessions? Treatment contracts: - consent of voluntary desicion for tele 17. 12. 2021 © EEGneurofeedbackteleneurofeedback (client) TRAIN 24

Assessement Procedure as in clinic Anamnestic datas, different ass. Datas (Testreports, medical results & reports…) Questionaires Tests EEG-Assessements – Morphology, (Mini)QEEG Symptom- and localisation approach 17. 12. 2021 teleneurofeedback © EEGTRAIN 25

Decision about Tele-Training Intellectual understanding Computer skills Technical understanding Manual, technical abilities Responsabilities compliance SW & HW easy to use Ability to spent a certain amount of money (renting, purchasing equipment, technical 17. 12. 2021 training) teleneurofeedback © EEG 26 TRAIN

Equipment Remote option in software ensures user control Options for purchasing the equipment: - client keeps the e. (periods of ongoing training) - client-group shares the equipment - selling the e. second hand with therapists help 17. 12. 2021 teleneurofeedback © EEGTRAIN 27

Options „in-office“- and Teletraining Best: - initially 1 -2 weeks (at least 2 days) compact training in-office - 2 -3 sessions per day - technical training - Teletraining 1/week, home sessions 2 -3/week Optional: - decision for Tele-NFB during ongoing therapy - fractionated therapy (patient lives at a certain distance) - fractionated rental teletraining No clinic visits teleneurofeedback in case of ©patient in vegetative 28 EEGTRAIN state 17. 12. 2021

Short report on „ultimate“ Tele. Neurofeedback Patients in „vegetative state“ (or „state of minimal consciousness“? ), living at home Initial assessement (Mini-Q) – analyse by an expert („astonishing much thalamo-cortical activity“) Q-EEG after 4 months training – clinical analysis Dr. R. Thatcher Critical Question: is Neurofeedback possible? Is there a feedback ? Neurofeedback Test-Session (two dolphins with water sound) If Feedback works – fractionated home visits ? Or: Tele-Neurofeedback – 4 channel z-score-dll ? (first remote 4 -channel z-score system? ) Appropriate briefing and/or education local co-therapist (physiotherapist – visits patient 5 x/week) Co-therapist conducts symptom tracking over internet Appropriate professionel supervised sessions by tele-contacts, 29 17. 12. 2021 teleneurofeedback © EEGTRAIN initially 2 x /week

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Report - 2 Results so far Facial expression – improvement – relaxation Eye contact 50 % ↑ Constipation 50 % ↑ Circadian rhythm 50 % ↑ Pain – no results (s. eegexpert. com – symptom tracking, s. verbal reports from wife and co-therapist) „ultimate-plus“ could be: remote training with Mini -Q device 17. 12. 2021 teleneurofeedback © EEGTRAIN 31

$Treatment planning First fractionated sequence of sessions in clinic Important for client: trust in$

Treatment planning First fractionated sequence of sessions in clinic Important for client: trust in method Important for therapist: trust in client, in procedures = his own strategy for ongoing treatment, in protocol decisions Ensures professionality and quality standards Decision according to assessement outcome Adaptation of decisions according to treatment progress 17. 12. 2021 teleneurofeedback © EEG 32 TRAIN strategy without tele. No change in treatment

Local Co-Trainer If necessary Parents, relatives, friends otherapists (i. e. physiotherapist, ergotherapist, logotherapist, medical or psychological collegues) Suffient and necessary amount of coaching, education Ongoing support 17. 12. 2021 teleneurofeedback © EEGTRAIN 33

Equipment for client/patient aquisition of equipment Renting – purchasing „remote“-system important to prevent malpractice 17. 12. 2021 teleneurofeedback © EEGTRAIN 34

Treatment settings - Tele. Neurofeedback Installation of software & equipment Installation of VPN (Virtual Private Network - a secured „tunnel“ in the internet) Installation of remote service software (i. e. teamviewer, Real VNC – Real Virtuel Network Computing) Important: local pc professional – settings for internet security, minimum computer experience 17. 12. 2021 teleneurofeedback © EEGTRAIN 35

Treatment settings - 2 SW-HW Installation: help and support should be an important part – experience of different basic knowledge with clients/patients! Keeps compliance, motivation Remote Option in SW: Packed NFP protocols easy to transfer back & forth - blank by clinician - With sessions by client/patient 17. 12. 2021 teleneurofeedback © EEGTRAIN 36

Treatment settings – 2 a Continuum in treatment conditions: clinic remote telephone support / protocols by email VPN-remote training (plus audio-video contact or plus telephone) Shift in treatment setting: less time per client/patient, more patient to be treated, cost 17. 12. 2021 teleneurofeedback © EEGreducing for patient/health system TRAIN 37

Treatment settings – 2 b Clients: = patients = schools = artists, musicians = sportsmen 17. 12. 2021 teleneurofeedback © EEGTRAIN 38

Treatment settings – 3 VPN – Virtual private network (private = separated from internet and exclusively to be used by partners) Uses „tunnel-technique“ within internet System as VPN-rooter with i. e. ) windows server 2003/ 2008 operating system Connection of therapist pc and client pc to VPN Connection therapist pc and client pc via remote service sw (Real VNC, Teamviewer etc. ) Note: connection over VPN stops other internet connection 17. 12. 2021 teleneurofeedback © EEGTRAIN 39

VPN Client - Connecting with VPN Windows XP Client - Connecting with VPN Windows Vista - Start - System control - Network connection - (top left) setup of new network – next - option „create connection with network on computer“ – next - choose VPN connection – next - name - i. e. „EEG“ - next - webadress teleneurofedback. dnsalias. net – next - finish - Start - System control -classical view - Network- and Opening Center – next - (left) setup of connection or network - next - establish connection with computer – next - no, establish a new connection next - domain: teleneurofeedback. dnsalias. net - name: test – next username client ©- EEG 40 - password test – next 17. 12. 2021 teleneurofeedback TRAIN

Remote service – configuration - 1 i. e. Real VNC (Virtual Network Computing) For client: server For therapist: viewer The following settings will stop the Firewall completely for the VPN network 17. 12. 2021 teleneurofeedback © EEGTRAIN 41

Remote service – configuration - 2 For Client Windows XP Important: only over For Client Windows Vista VNC connection secured VPN net Start System control Security center Management of security settings for Top left: Windows Firewall Top left: start or stop Windows Firewall Expanded Top: expanded Mark VPN connection „EEG“ Remove mark with network connection Settings Add „EEG“ Description „VNC“ Confirm all windows with OK or close Name or IP adress (…) localhost Extern port-#: 5900 Intern port-#: 5900 Confirm all windows with OK or close 17. 12. 2021 teleneurofeedback © EEG 42 TRAIN

Tele-Session Replay z-score session Demonstration setting for first teleneurofeedback Demonstration of Tele-Managing 17. 12. 2021 teleneurofeedback © EEGTRAIN 43

Evaluation Ongoing evaluation with z-score training Fractionated start – middle – end EEG-datas (QEEG), questionaires (onlinetracking), achievement criterias, ratings parents, teachers, … Another fractionated clinic sessions Evaluating end of treatment What do with the equipment ? 17. 12. 2021 teleneurofeedback © EEGTRAIN 44

Further solutions of remote NFB „Walk-in-lab“ 17. 12. 2021 teleneurofeedback © EEGTRAIN 45

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