TELE-NEUROFEEDBACK
WITH SPECIAL APPLICATION OF REAL-TIME-NORM-TRAINING
Doerte Klein, EEG-TRAIN EEG-Biofeedback Trainingszentrum Hannover
www.eegbiofeedback.de info@eegbiofeedback.de
SAN – Congress Sevilla May 2008
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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.
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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.
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Tele-communication in HealthSystems has a long history
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The Radio Doctor 1924
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The portable electrocardiograph – 1925
Fischer 2008
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The Tele-Surgeon 1931
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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 70th 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
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Scepticism on the future of Telemedicine
Depletion of communication & Encouragement of social isolation
– „…computer-mediated communication … offers nothing to psychoanalytic practice,
except to erode the 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)
“Home neurofeedback training will never be practical” – Anonymous
clinician - 2002 (s. Collura, Remote Neurotherapy)
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Actual state in health system
Congress „TeleHealth 2008“ integrated in CeBit,
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)
* IT - Information Technology
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Actual state in health system - 2
Examples of research in Tele-Monitoring – s. Luecke 2008
Charité/Berlin: cardiovascular monitoring imbedded in emergency system,
criterias for data security/privacy
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
- availability
- datas are available exactly when needed
- validity
- datas must be valid
- traceability – origin and author of processing should be reproducable at any time
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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
- processing only by registered persons
User control
- 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 of datas on
their transport way (coding, VPN, private net)
Organisation control - control of all methods by data security officials, ongoing
education, patient/therapist confidentiality (written)
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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…
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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
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Medgate - 2
Role of method of communication in therapeutic
information transmission
text
telephone
F2F
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Preference
high
Classical assumption:
„i have to see my patient...“
text
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sound video
F2F
Amount of information transmitted
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What we say and what we do
(Schliemann et al, 2002)
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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 (TEMPiS)
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 hospitals and stroke centers were
similar and comparable to the results from randomized trials.
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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
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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.
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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 impact on the delivery of medical care. .. The goal is to
improve access to high-quality medical care at afordable cost. ..challenge for policy
makers, healthcare organizations, and providers…Goldberg, 1995, s. Oeser, 2001
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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 F2F 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.
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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 numbers
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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
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Intake
Inicial setting: personal contact in clinic or home visit
Decision: ongoing F2F-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-neurofeedback (client)
- own responsability for risks (client)
- privacy, data security/protection, and professionality (therapist)
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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
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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 training)
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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
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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 in case of patient in vegetative state
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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 thalamocortical 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 5x/week)
Co-therapist conducts symptom tracking over internet
Appropriate professionel supervised sessions by tele-contacts, initially 2 x /week
Home visits therapist 1/month (300 km)
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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
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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
No change in treatment strategy without tele-supervision
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Local Co-Trainer
If necessary
Parents, relatives, friends
other therapists (i.e. physiotherapist, ergo-therapist,
logotherapist, medical or psychological collegues)
Suffient and necessary amount of coaching, education
Ongoing support
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Equipment for client/patient
aquisition of equipment
Renting – purchasing
„remote“-system important to prevent malpractice
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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
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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
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Treatment settings – 2a
Continuum in treatment conditions:
clinic
remote telephone support
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 reducing for patient/health
system
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Treatment settings – 2b
Clients:
= patients
= schools
= artists, musicians
= sportsmen
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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
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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
- password test – next
- define location – home/private
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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
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Remote service – configuration - 2
For Client
Windows XP
Important:
For Client
Windows Vista
VNC connection only over secured VPN net
Start
System control
Security center
Management of security settings for
Windows Firewall
Expanded
Mark VPN connection „EEG“
Settings
Add
Description „VNC“
Name or IP adress (…) localhost
Extern port-#: 5900
Intern port-#: 5900
Confirm all windows with OK or close
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Start
System control
Security center
Top left: Windows Firewall
Top left: start or stop Windows Firewall
Top: expanded
Remove mark with network connection „EEG“
Confirm all windows with OK or close
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Tele-Session
Replay z-score session
Demonstration setting for first tele-neurofeedback
Demonstration of Tele-Managing
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Evaluation
Ongoing evaluation with z-score training
Fractionated start – middle – end
EEG-datas (QEEG), questionaires (online-tracking),
achievement criterias, ratings parents, teachers, …
Another fractionated clinic sessions
Evaluating end of treatment
What do with the equipment ?
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Further solutions of remote NFB
„Walk-in-lab“
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Literature
* Allen, A.: When the ship.com comes in. Editor's note. Telemed Today, 7, 6 (1999) S. 7.
* Bauer, J. C.: Consumerism redefined ... the e-health imperative. Mich Health Hosp., 36, 4 (2000) S. 42.
* Braecklein, M., Lücke, S.: Datenschutz im Telemonitoring: Erfahrungen aus dem Projekt “Partnership for the Heart”, Talk TeleHealth, Cebit, Hannover 2008
* Collura, Thomas F: Targeting Strategies for EEG Biofeedback Using Normative Databases, 2007, http://www.brainm.com/kb/entry/229/
- Remote Neurotherapy, http://www.brainm.com/kb/entry/229/
- Remote Flowchart, http://www.brainm.com/kb/entry/229/
* Collura, Terri and Thomas F., The realities of remote neurofeedback http://www.brainm.com/kb/entry/229/
* Currell R et al.: Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Nurs Times. 2001
Aug 30-Sep 5;97(35):35. PMID 11957594.
* De Las Cuevas C et al.: Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric
treatment. Telemed J E Health. 2006 Jun;12(3):341-50. PMID 16796502
* Della Mea, V.: What is e-health (2): The Death of Telemedicine? Editorial. Journal of Medical Internet Research 2001; 3(2): e22.
http://www.jmir.org/2001/2/e22/
* Eysenbach, G.: What is e-health? J Med Internet Res 2001; 3 (2): e20 http://www.jmir.org/2001/2/e20/.
* Ferguson, T.: Consumer health informatics. Healthc Forum J 38, 1 (1995) S. 28.
* Ferguson, T.: From patients to end users. BMJ, 324 (2002), S. 555
* Fischer, A.: Doc around the clock – Telediagnostik und Teletherapie im Schweizer Zentrum für Telemedizin – Möglichkeiten, Notwendigkeiten und
Grenzen, Talk on TeleHealth, CeBit, Hannover 2008
* Goldstein, D.: The e-healthcare cybertsunami. Manag Care Q 8, 3 (2000) S. 9.
* Haas, Peter/ Meier, Andreas/ Sauerburger, Heinz: eHealth. Praxis der Wirtschaftsinformatik. HMD 251. dpunkt.Verlag. ISBN 3-89864-383-2
* Hankins, J.: The Internet. Adm Radiol., 10, 8 (1991) S. 69.
* IBM (Schweiz): Wege zur personalisierten Medizin in der Schweiz [2]
* Kraft, D.: Telematik im Gesundheitswesen, DuD-Fachbeiträge, Deutscher Universitäts-Verlag 2003, ISBN 3824421666
* Jäckel, A. (Hrsg.): Telemedizinführer Deutschland, Jahrbuch der Telemedizin 2007, 8. Ausgabe, Bad Nauheim 2006, ISBN 3-937948-05-8
* Jähn, K. u. Nagel, E. (Hrsg.): e-Health (2004)
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Literature – 2
* Levine SR et al.: Telemedicine for acute stroke: When virtual is as good as reality. Neurology. 2007 Aug 28;69(9):819-20. PMID 17724282
* PricewaterhouseCoopers (PWC): Pharma 2005. Marketing to the Individual, 1999.
* Oeser, R.: Projektmanagement aus Auftraggebersicht zur Umsetzung telemedizinischer Konzepte. Diplomarbeit TU-Wien (1999) Download
* Oeser, R.: Technologienabhängige Systembetrachtungsmethode zur Umsetzung telemedizinischer Konzepte, Diss., Wien 2001
* O'Reilly R et al.: Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr
Serv. 2007 Jun;58(6):836-43. PMID 17535945
* Ruskin PE et al.: Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. Am J
Psychiatry. 2004 Aug;161(8):1471-6. PMID 15285975
* Schuman, S. H.; H. B. Curry; M. L. Braunstein; R. Schneeweiss; G. C. Jebaily; H. M. Glazer; J. R. Cahn; W. H. Crigler: A computer
administered interview on life events: improving patient-doctor communication. J Fam Pract 2, 4 (1975) S. 263.
* Slack, W. V.; D. Porter; J. Witschi; M. Sullivan; R. Buxbaum; F. J. Stare: Dietary interviewing by computer. An experimental approach to
counseling. J Am Diet Assoc 69, 5 (1976) S. 514.
* Slack, W. V.; L. J. Van Cura: Patient reaction to computer-based medical interviewing. Comput Biomed Res 1, 5 (1968) S. 527.
* Slack, W.: Cybermedicine: How Computing Empowrs Doctors and Patients for Better Health Care. Jossey-Bass, San Francisco 1997.
* Szecsey A et al.: Telemedizinische Konsile in der Gerontopsychiatrie: Ein Pilotprojekt. NeuroGeriatrie 2004; 1 (1): 32-34.
Zusammenfassung
* Telemedicine in Gerontopsychiatry. European J Medical Research 7 Suppl, I, 7th Int Conf on the Med Aspects of Telemed - Integration of
Health, Telematics into Med Pract, Regensburg, Sept 2002, p 84, Szecsey A, Koch HJ
* Singh SP et al.: Accuracy of telepsychiatric assessment of new routine outpatient referrals. BMC Psychiatry. 2007 Oct 5;7(1):55 [Epub
ahead of print]. PMID 17919329
* Schwab S et al.: Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007 Aug 28;69(9):898-903.
PMID 17724293
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Tele-Neurofeedback
THANK YOU FOR LISTENING !
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