Use of Mobile Technology Paired with Heart Rate Monitor to Remotely Quantify Behavioral Health Markers among Military Reservists and First Responders.

INTRODUCTION: Heart rate variability (HRV) is a biological marker that reflects an individual's autonomic nervous system regulation. Psychological resilience is an individual's ability to recover from an adverse event and return to physiological homeostasis and mental well-being, indicated by higher resting HRV. The Biofeedback Assisted Resilience Training (BART) study evaluates a resilience-building intervention, with or without HRV biofeedback. This article evaluates the feasibility of remote psychophysiological research by validating the HRV data collected. MATERIALS AND METHODS: The BART platform consists of a mobile health application (BART app) paired to a wearable heart rate monitor. The BART app is installed on the participant's personal phone/tablet to track and collect self-report psychological and physiological data. The platform collects raw heart rate data and processes HRV to server as online biofeedback. The raw data is processed offline to derive HRV for statistical analysis. The following HRV parameters are validated: inter-beat interval, respiratory sinus arrhythmia, low-frequency HRV, biofeedback HRV, and heart period. Bland-Altman and scatter plots are used to compare and contrast online and offline HRV measures. Repeated-measures ANOVA are used to compared means across tasks during the stress (rest, stress, and recovery) and training (rest and paced breathing) sessions in order to validate autonomic nervous system changes to physiological challenges. RESULTS: The analyses included 245 participants. Bland-Altman plots showed excellent agreement and minimal bias between online and offline unedited inter-beat interval data during the stress session. RMANOVA during the training session indicated a significant strong effect on biofeedback HRV, F(11,390) = 967.96, P < .01. During the stress session, RMANOVA showed significant strong effect on respiratory sinus arrhythmia and low-frequency HRV, and a significant but weak effect on heart period. CONCLUSIONS: The BART digital health platform supports remote behavioral and physiological data collection, intervention delivery, and online HRV biofeedback.

Mental health, stress, and resilience correlates of heart rate variability among military reservists, guardsmen, and first responders.

The use of heart rate variability (HRV) for monitoring stress has been growing in the behavioral health literature, especially in the areas of posttraumatic stress disorder, stress reactivity, and resilience. Few studies, however, have included general populations under workplace conditions. This study evaluates whether military and other first responders show lower HRV during stress than at baseline and greater post stress rebound, controlling for a myriad of potential confounders. A convenience sample of Reserves, National Guard, veteran, fire, and police personnel provided HRV and self-reported questionnaire responses before, during, and after a cognitive-stressor task with a smart phone application. Timing of HRV application; mental and physical health scores; coping and posttraumatic growth indicators, including being open to new possibilities; and emotional support were predictors of trajectories of the HRV response to stress. Findings from this exploratory study emphasize the strong link between stress and relaxation breathing in both respiratory sinus arrhythmia and low frequency heart rate variability and the need for controlling potential covariates for understanding the relationship between HRV and the stress response and providing a basis for hypothesis driven research.

Biofeedback-Assisted Resilience Training for Traumatic and Operational Stress: Preliminary Analysis of a Self-Delivered Digital Health Methodology.

BACKGROUND: Psychological resilience is critical to minimize the health effects of traumatic events. Trauma may induce a chronic state of hyperarousal, resulting in problems such as anxiety, insomnia, or posttraumatic stress disorder. Mind-body practices, such as relaxation breathing and mindfulness meditation, help to reduce arousal and may reduce the likelihood of such psychological distress. To better understand resilience-building practices, we are conducting the Biofeedback-Assisted Resilience Training (BART) study to evaluate whether the practice of slow, paced breathing with or without heart rate variability biofeedback can be effectively learned via a smartphone app to enhance psychological resilience. OBJECTIVE: Our objective was to conduct a limited, interim review of user interactions and study data on use of the BART resilience training app and demonstrate analyses of real-time sensor-streaming data. METHODS: We developed the BART app to provide paced breathing resilience training, with or without heart rate variability biofeedback, via a self-managed 6-week protocol. The app receives streaming data from a Bluetooth-linked heart rate sensor and displays heart rate variability biofeedback to indicate movement between calmer and stressful states. To evaluate the app, a population of military personnel, veterans, and civilian first responders used the app for 6 weeks of resilience training. We analyzed app usage and heart rate variability measures during rest, cognitive stress, and paced breathing. Currently released for the BART research study, the BART app is being used to collect self-reported survey and heart rate sensor data for comparative evaluation of paced breathing relaxation training with and without heart rate variability biofeedback. RESULTS: To date, we have analyzed the results of 328 participants who began using the BART app for 6 weeks of stress relaxation training via a self-managed protocol. Of these, 207 (63.1%) followed the app-directed procedures and completed the training regimen. Our review of adherence to protocol and app-calculated heart rate variability measures indicated that the BART app acquired high-quality data for evaluating self-managed stress relaxation training programs. CONCLUSIONS: The BART app acquired high-quality data for studying changes in psychophysiological stress according to mind-body activity states, including conditions of rest, cognitive stress, and slow, paced breathing.

Toward Preventing Post-Traumatic Stress Disorder: Development and Testing of a Pilot Predeployment Stress Inoculation Training Program.

The objective of this pilot study was to design, develop, and evaluate a predeployment stress inoculation training (PRESIT) preventive intervention to enable deploying personnel to cope better with combat-related stressors and mitigate the negative effects of trauma exposure. The PRESIT program consisted of three predeployment training modules: (1) educational materials on combat and operational stress control, (2) coping skills training involving focused and relaxation breathing exercises with biofeedback, and (3) exposure to a video multimedia stressor environment to practice knowledge and skills learned in the first two modules. Heart rate variability assessed the degree to which a subset of participants learned the coping skills. With a cluster randomized design, data from 351 Marines randomized into PRESIT and control groups were collected at predeployment and from 259 of these who responded to surveys on return from deployment. Findings showed that the PRESIT group reduced their physiological arousal through increased respiratory sinus arrhythmia during and after breathing training relative to controls. Logistic regression, corrected for clustering at the platoon level, examined group effects on post-traumatic stress disorder (PTSD) as measured by the Post-traumatic Stress Checklist after controlling for relevant covariates. Results showed that PRESIT protected against PTSD among Marines without baseline mental health problems. Although limited by a small number of participants who screened positive for PTSD, this study supports the benefits of PRESIT as a potential preventive strategy in the U.S. military personnel.

Relaxation training assisted by heart rate variability biofeedback: Implication for a military predeployment stress inoculation protocol.

Decreased heart rate variability (HRV) is associated with posttraumatic stress disorder (PTSD) and depression symptoms, but PTSD's effects on the autonomic stress response and the potential influence of HRV biofeedback in stress relaxation training on improving PTSD symptoms are not well understood. The objective of this study was to examine the impact of a predeployment stress inoculation training (PRESTINT) protocol on physiologic measures of HRV in a large sample of the military population randomly assigned to experimental HRV biofeedback-assisted relaxation training versus a control condition. PRESTINT altered the parasympathetic regulation of cardiac activity, with experimental subjects exhibiting greater HRV, that is, less arousal, during a posttraining combat simulation designed to heighten arousal. Autonomic reactivity was also found to be related to PTSD and self-reported use of mental health services. Future PRESTINT training could be appropriate for efficiently teaching self-help skills to reduce the psychological harm following trauma exposure by increasing the capacity for parasympathetically modulated reactions to stress and providing a coping tool (i.e., relaxation method) for use following a stressful situation.

The efficacy and cost-effectiveness of a community weight management intervention: a randomized controlled trial of the health weight management demonstration.

PURPOSE: The study investigated the efficacy and cost-effectiveness of a cognitive-behavioral weight management program, complemented by an interactive Web site and brief telephone/e-mail coaching. METHODS: In 2006-2007, 1755 overweight, non-active-duty TRICARE beneficiaries were randomized to one of three conditions with increasing intervention intensity: written materials and basic Web access (RCT1), plus an interactive Web site (RCT2), plus brief telephone/e-mail coaching support (RCT3). The study assessed changes in weight, blood pressure, and physical activity from baseline to 6, 12, and 15-18 months. (Study retention was 31% at 12 months.) Average and incremental cost-effectiveness and cost-offset analyses were conducted. RESULTS: Participants experienced significant weight loss (-4.0%, -4.0%, and -5.3%, respectively, in each RCT group after 12 months and -3.5%, -3.8%, and -5.1%, respectively, after 15 to 18 months), increased physical activity, and decreased blood pressure. Cost-effectiveness ratios were $900 to $1100/quality-adjusted life year (QALY) for RCT1 and RCT2 and $1900/QALY for RCT3. The cost recovery period to the government was 3 years for RCTs 1 and 2 and 6 years for RCT3. CONCLUSION: A relatively inexpensive cognitive-behavioral weight management intervention improved patient outcomes. Extrapolation of savings for the entire TRICARE population would significantly reduce direct medical costs.

Approaches to the primary prevention of posttraumatic stress disorder in the military: a review of the stress control literature.

Numerous studies are underway, using data collected from clinical studies and data collected from surveys of combat troops, to determine the most efficacious treatment options for those diagnosed with posttraumatic stress disorder (PTSD). In contrast, little is known about the effectiveness of predeployment training in preventing or mitigating the impact of combat-related stressors on the development of PTSD. We conducted a comprehensive review of literature pertaining to primary prevention efforts to stem the advent of PTSD and other combat and operational stress injuries in military populations using databases from the peer-reviewed literature as well as online searches and colleague referrals. Results show that, as with treatment for PTSD, the most promising preventive approaches appear to utilize exposure strategies, especially those in conjunction with education and stress reduction skills training.

Use of upright positioning with epidural analgesia: findings from an observational study.

PURPOSE: To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia. STUDY DESIGN AND METHODS: This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol. RESULTS: All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented. CLINICAL IMPLICATIONS: Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.