Physiologic and Self-Report Assessment of a Multimodal Therapeutic Intervention for PTSD in US Firefighters: A Pilot Study

Physiologic and Self-Report Assessment of a Multimodal Therapeutic Intervention for PTSD in US Firefighters: A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Physiologic and Self-Report Assessment of a Multimodal Therapeutic Intervention for PTSD in US Firefighters: A Pilot Study Pritha Saha, Vereena Metry, Faith Streeter, Nathan Xiao Jin, Christopher Gowen, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3182536/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Fire service members are a population with high prevalence of post-traumatic stress disorder (PTSD) compared to the general population. Moreover, they are underrepresented in the literature with respect to traumatic stress and corresponding interventions. As such, there is a need to improve treatment of PTSD and its resultant symptoms specifically in fire service members. This pilot study aimed to evaluate the efficacy of a multimodal treatment intervention for US fire service members with PTSD. It aimed to (i) assess the effect of the 4-week intervention on self-report and physiologic symptoms, (ii) correlate self-report and physiologic measures of PTSD, and (iii) identify the measures most closely linked to treatment response. Self-report measures of BDI, PSQI, and PCL-5 showed weekly improvement, plateauing around four weeks. The physiologic data of blink reflex amplitude and heart rate variability did not appear to correlate with these self-report measures, but the methods of data collection may need further refinement. This study suggests interesting avenues for future research for PTSD treatment in fire service members, such as evaluating individual components of this intervention. Additionally, it indicates that a four-week period of study should be sufficient to see effects in participants’ symptoms of PTSD, depression, and sleep quality. PTSD Firefighters Tai Chi First responders Depression Acoustic startle response Heart rate variability Sleep quality PTSD intervention Posttraumatic symptomatology Figures Figure 1 Figure 2 INTRODUCTION Post-Traumatic Stress Disorder (PTSD) affects an estimated 4.7% of the United States (US) population every year [ 1 ], leading to increased rates of disability, suicide, substance use, and interpersonal difficulties. Compared to the general population, the prevalence of PTSD and related co-occurring disorders is higher for first responders, such as law enforcement officers (LEOs), emergency medical technicians (EMTs)/paramedics, and firefighters [ 2 , 3 ]. The firefighting community—including firefighters, paramedics, EMTs, and dispatch—have increased risk for traumatic exposure, but fire service members are underrepresented in the traumatic stress literature [ 4 , 5 , 6 , 7 , 8 , 9 ]. In addition to high rates of PTSD, many may suffer from symptoms associated with PTSD without meeting full criteria for PTSD (i.e., partial or sub-threshold PTSD), highlighting the need to capture posttraumatic symptomatology in this population [ 10 , 11 ]. They also have distinct barriers to treatment-seeking, in part due to their culture of volunteerism, heroism, and self-sacrifice [ 12 , 13 , 14 , 15 , 16 , 17 ]. Due to these considerations, fire service members need PTSD and its symptoms effectively diagnosed and treated. The International Association of Firefighters (IAFF) Center of Excellence (COE) for Behavioral Health Treatment and Recovery provides multimodal treatment of PTSD for its members. The center is a treatment facility specific to professional fire service members suffering from mental health disorders and/or substance use disorders and was established as a collaboration between the IAFF and Advanced Recovery Systems. Of note, during this study, the IAFF COE programming included a mindfulness-based intervention: Tai Chi Moving Mindfulness Meditation and Resilience Training (TCMMMRT). This intervention was an area of interest for the study investigators, as evidence suggests that mindfulness-based therapies are effective in reducing PTSD symptomatology [ 18 ]. This pilot study aimed to observe the process and outcomes of this multimodal intervention on self-reported and physiological symptoms of traumatic stress in US fire service members with PTSD. The purpose of this study was to describe the course of PTSD symptoms, physiological measures related to stress and startle, and their correlations over the four-week intervention in a population of firefighters with PTSD. Self-report outcome measures included the PTSD Checklist for DSM-V (PCL-5), Beck’s Depression Inventory (BDI), and Pittsburgh Sleep Quality Index (PSQI). Physiological measures included heart rate variability (HRV) and the acoustic startle response (ASR), quantified as amplitude of blink reflex (BR) measured using the Mobile Acoustic Startle Reflex-monitoring System (MARS). A secondary aim of this study was to identify the self-report measures (PCL-5, BDI, PSQI) most tightly associated with physiological measures (HRV and BR/ASR). METHODS Sample This study was approved by the Johns Hopkins Institutional Review Board (IRB) (IRB00226155). Participants were 67 male firefighters with PTSD, ages 18 to 65, who were recruited from the IAFF COE for Behavioral Health Treatment and Recovery in Prince George’s County, Maryland. The presence of PTSD was established by the IAFF COE clinicians. The study participants were actively undergoing treatment for PTSD, with a typical duration of stay ranging from four to five weeks. The treatment intervention could include combinations of medication management, medical and nursing resources, and clinical programming depending on the individual treatment plan. However, all participants participated weekly in Tai Chi Moving Mindfulness Meditation and Resilience Training (TCMMMRT). TCMMMRT is a novel intervention, developed and conducted by tai chi instructor Sifu Dan Jones. It aims to promote a meditative state of mind with mindfulness breathing and gentle, gross motor movements, related to those of traditional tai chi. Participants who endorsed use of stimulants or sedatives within 48 hours of study participation were excluded from immediate assessment and subsequent data analysis, prior to study enrollment, since these substances may interfere with the ASR and resultant BR. Self-Report Measures Qualtrics online survey software was used for data collection. Participant demographics (age, occupation, gender, current medications) and self-report symptom measures were collected. The self-reported measures were PTSD Checklist for DSM-5 (PCL-5), the Beck Depression Inventory (BDI), and the Pittsburgh Sleep Quality Index (PSQI). Physiological Measures Heart rate variability (HRV) was measured and recorded with the CameraHeartRate app, (A.S.M.A B.V.), prior to participation in each TCMMMRT session. This app used an iPhone to conduct one minute of photoplethysmography. Blink reflex (BR) data was collected with the novel MARS app (CodeFluegel GmbH) [ 19 ]. This app used an iPhone and wired earphones to play acoustic stimuli, record the corresponding blink response, and calculate the blink amplitude. RESULTS Self-Report Measures (See Fig. 1 ) Of 71 enrolled participants, 62 had at least one data point of self-report data at week 1, whether BDI, PSQI, or PCL. For those participants, average week 1 BDI scores were in the “borderline clinical depression” range (mean = 18.8, SD = 11.52). The week 1 PSQI had a mean score of 8.62 (SD = 2.32), with a score of 5 or greater typically indicating significant sleep disturbance. The week 1 PCL had a mean score of 41.61 (SD = 18.08) (Fig. 1 ), with a cut-off score of 31–33 indicating probable PTSD. Of note, PCL had the most missing observations (N = 18 missing) compared to BDI (N = 1 missing) and PSQI (N = 1 missing). To estimate the clinical trajectory of participants during the study, linear mixed-effects models were fit including all participants with at least 2 weeks of self-report observations (n = 34), with random effects being participants and fixed effects being the week of the observation. All clinical measures were estimated to improve with time, with regression coefficient for BDI − 3.06 per week (128 observation, 95% confidence interval (CI) of -3.90, -2.23); PSQI − 0.52/week (128 observations, 95% CI -0.79, -0.26); and PCL − 9.20 per week (85 observations, 95% CI -12.32, -6.14). Physiological Measures (See Fig. 2 ) Scatterplots and simple bivariate correlations between HRV and BDI, PCL, and PSQI showed little evidence of relationship, with the maximum correlation coefficient being r = 0.15. These were not analyzed further. Visual inspection of the sample distribution for BR amplitude showed the data were clearly bimodal, with one peak at exactly zero (41.12% zeros) and the remainder of the distribution roughly bell shaped (Fig. 2 ). Visual examination of the response distributions by sound pressure level (SPL) and frequency of the stimulus revealed steadily more nonzero responses with increasing SPL (38.56% for 65 dB, 63.60% for 90 dB, and 74.88% for 105 dB) (Fig. 2 ), and slightly more nonzero responses at the 4000 Hz frequency than 500 Hz (51.12% for 500 Hz and 65.72% for 4000 Hz) (Fig. 2 ). The proportion of non-zero responses by posture (sitting or standing) were identical. The proportion of non-zero responses by laterality were 67.84% for right eye and 52.22% for left eye, but there were more observations for the left (n = 766 left and 566 right). Overall, the pattern suggested the participants’ population distribution of reflex firing (i.e., nonzero response) varied by stimulus characteristics, particularly SPL (Fig. 2 ); and that the stimuli were not uniformly above the reflex threshold for all participants (Fig. 2 ). Because the reflex responses fit a fire/no-fire pattern more closely than a continuous distribution, a multivariate binomial regression model was fit to test the initial hypothesis that stimulus characteristics predicted nonzero responses. SPL and frequency were entered as ordinal predictors of nonzero response along with eye laterality. As expected from the first explorations, both increasing sound pressure level and higher frequency predicted increased reflex firing (SPL OR 3.13 95%CI 2.54, 3.88; right laterality OR 2.07, 95% CI 1.63 2.64; Frequency OR 1.50, 95% CI 1.27, 1.78; all p values < 0.001) To screen for the possibility that stimulus characteristics predicted magnitude of the response in addition to firing of the reflex, a zero-censored simple linear model was fit predicting magnitude of the nonzero responses using the same predictors and found no relationship (minimum p = 0.116 for laterality). To test for an overall relationship between time in treatment and nonzero response, generalized linear mixed effects binomial models with stimulus characteristics and week of treatment treatment modeled as fixed effects and individual participants modeled as random effects (36 participants, 1332 observations) showed no relationship between week and nonzero response (odds ratio 1.07, p = 0.325). To explore whether clinical measures were associated with MARS responses, binomial generalized linear mixed-effects models were fit with BDI, PCL, and PSQI entered as fixed effects along with SPL, frequency, and laterality; and random effects being participants. The models showed no relationship between the clinical measures and MARS reflex firing (minimum p value 0.191 for the BDI); though the prior relationships between reflex firing and SPL, frequency, and laterality were statistically significant in all models. DISCUSSION In this preliminary study, PTSD symptoms, depressive symptoms, and sleep disturbance seemed to improve with time during treatment at the IAFF COE. Visual inspection of outcomes by time suggested that improvements plateau around four weeks of intervention (Fig. 1 ). The physiological data of BR and HRV did not correlate with these self-report measures. However, we suspect these methods need further refinement in how they are studied in such populations, discussed further in limitations. It is also worth noting that scientific literature regarding treatment interventions in US firefighters is difficult to find. As such, while these findings are preliminary, they provide important insight regarding the efficacy of tailored interventions in this population. LIMITATIONS There are some limitations to consider in this pilot study. The sample shows significant weekly attrition. This may be due to participants being constrained for time; they are restricted by extensive programming obligations over the course of treatment. Moreover, these participants volunteered their spare time without financial compensation. Future studies may recruit a larger study population to account for a higher level of drop-out and offer participant incentives to improve retention. Additionally, self-report measures are susceptible to various biases, such as self-report and social desirability bias. These biases may be especially pertinent for fire service members due to their culture of heroism and volunteerism. With respect to physiological measures, HRV data was only collected once per week for the duration of a minute. Continuous measurement through wearable devices may enable future studies to reflect associations of HRV and PTSD as established in the scientific literature [ 12 ]. The field of ASR also still faces unanswered questions regarding the potential of BR as a marker. Further investigation is needed to determine the nuances of calibrating appropriate acoustic stimuli and analyzing resultant BR. Furthermore, this study population does not reflect the diversity of the US fire service population. In particular, the participants were largely male, Caucasian fire fighters. Further work should consider sex, gender, race/ethnicity, rural versus urban status to help identify potential disparities in PTSD intervention for the US fire service population. CONCLUSION Despite these limitations, this pilot study suggests interesting avenues for future research to improve treatment of PTSD in fire service members. Future work should analyze the individual components of this multimodal intervention. For example, TCMMMRT was common to all participants, and study with a non-interventional control could further illuminate its potential in reducing PTSD symptoms in fire service members. This study also indicates that a four-week period of study should be sufficient to see effects in participants’ depressive symptoms, PTSD symptoms, and sleep quality. ABBREVIATIONS PTSD Post-traumatic stress disorder US United States LEO Law enforcement officers EMT Emergency medical technicians IAFF International Association of Firefighters COE Center of Excellence PCL-5 PTSD Checklist for DSM-V BDI Beck’s Depression Inventory PSQI Pittsburgh Sleep Quality Index HRV heart rate variability ASR acoustic startle response BR blink reflex MARS Mobile Acoustic Startle Reflex-monitoring System TCMMMRT Tai Chi Moving Mindfulness Meditation and Resilience Training PPG photoplethysmography CSV comma-separated value SD Standard deviation SPL sound pressure level Hz Hertz CI confidence interval Declarations Ethics approval and consent to participate All methods were carried out in accordance with relevant guidelines and regulations as approved by the Johns Hopkins Institutional Review Board (IRB). All patients voluntarily participated and provided informed consent based on IRB guidelines and could withdraw consent at any point in the study. Details of ethics approval and consent process can be found via e-IRB: IRB00226155. Consent for publication Participants provided informed consent prior to data collection. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available to protect participant privacy and confidentiality but are available from the corresponding author on reasonable request. Competing interests DJ is the creator of the tai chi intervention, TCMMMRT, and is the founder and director of Moving Stillness Healing Arts LLC. All other authors declare that they have no competing interests in this section. Funding This study was completed without internal or external funding. Researchers and participants volunteered their time. Authors' contributions CG, CLW, and UDM conceptualized the study. CG, CLW, PS, VM, FS, JC, DJ, and CPC participated in study design and coordination. PS, VM, FS, and NXJ supported data collection, data processing, and contributed to methods and limitations. JC and DJ supported data collection and contributed to introduction and methods. PS, FS, JC, and DJ developed supplemental materials. CPC conducted statistical analysis, interpreted the data, created figures, and drafted the results section. PS prepared the original draft, and reviewed and edited the manuscript. All listed authors have reviewed the manuscript and given consent for publication. Acknowledgements The research team wishes to extend their appreciation to the staff at the IAFF COE as well as the participants who volunteered their time and energy to support this endeavor. Authors' information (optional) Author information can be found on our lab website: https://www.hopkinsmedicine.org/psychiatry/research/mccannlab.html References Trauma- and Stressor-Related Disorders. Diagnostic and Statistical Manual of Mental Disorders: American Psychiatric Association Publishing; 2022. Obuobi-Donkor G, Oluwasina F, Nkire N, Agyapong VIO. A Scoping Review on the Prevalence and Determinants of Post-Traumatic Stress Disorder among Military Personnel and Firefighters: Implications for Public Policy and Practice. Int J Environ Res Public Health 2022 Jan 29;19(3):1565. doi: 10.3390/ijerph19031565. Lewis-Schroeder NF, Kieran K, Murphy BL, Wolff JD, Robinson MA, Kaufman ML. Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harv Rev Psychiatry 2018;26(4):216-227. Fraess-Phillips A, Wagner S, R Luke Harris. Firefighters and traumatic stress: a review. International Journal of Emergency Services 2017;6(1):67-80. Haugen PT, Evces M, Weiss DS. Treating posttraumatic stress disorder in first responders: a systematic review. Clin Psychol Rev 2012 Jul;32(5):370-380. Alden L, Matthews L, Wagner S, Fyfe T, Randall C, Regehr C, et al. Systematic literature review of psychological interventions for first responders. Work & Stress 2020;35:1-23. Alshahrani KM, Johnson J, Prudenzi A, O'Connor DB. The effectiveness of psychological interventions for reducing PTSD and psychological distress in first responders: A systematic review and meta-analysis. PLoS One 2022 Aug 24;17(8):e0272732. McFarlane AC, Bryant RA. Post-traumatic stress disorder in occupational settings: anticipating and managing the risk. Occup Med (Lond) 2007 Sep;57(6):404-410. Bahji A, Di Nota PM, Groll D, Carleton RN, Anderson GS. Psychological interventions for post-traumatic stress injuries among public safety personnel: a systematic review and meta-analysis. Syst Rev 2022 Nov 25;11(1):255-1. Jahnke SA, Poston WSC, Haddock CK, Murphy B. Firefighting and mental health:experiences of repeated exposure to trauma. Emmitsburg, MD: National Emergency Training Center; 2016. Klimley KE, Van Hasselt VB, Stripling AM. Posttraumatic stress disorder in police, firefighters, and emergency dispatchers. Aggression and Violent Behavior 2018;43:33-44. Jones S, Agud K, McSweeney J. Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness”. J Am Psychiatr Nurses Assoc 2020;26(1):43-54. Jones S, Nagel C, McSweeney J, Curran G. Prevalence and correlates of psychiatric symptoms among first responders in a Southern State. Arch Psychiatr Nurs 2018 Dec;32(6):828-835. Dill J, Loew C. Suicide in the Fire and Emergency Services. The National Volunteer Fire Council (NVFC) 2012. DeMoulin D, Jacobs S, Nam Y, Harding AB, Moskowitz AF, Shi Y, et al. Mental Health Among Firefighters: Understanding the Mental Health Risks, Treatment Barriers, and Coping Strategies. J Occup Environ Med 2022 Nov 1;64(11):e714-e721. Haugen PT, McCrillis AM, Smid GE, Nijdam MJ. Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. J Psychiatr Res 2017 Nov;94:218-229. Bryant RA. The nature of posttraumatic stress disorder in treatment-seeking first responders. Eur J Psychotraumatol 2022 Jan 26;13(1):2011602. Boyd JE, Lanius RA, McKinnon MC. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J Psychiatry Neurosci. 2018 Jan;43(1):7-25. doi: 10.1503/jpn.170021. Epub 2017 Oct 2. PMID: 29252162; PMCID: PMC5747539. Gowen CL, Khwaounjoo P, Cakmak YO. EMG-Free Monitorization of the Acoustic Startle Reflex with a Mobile Phone: Implications of Sound Parameters with Posture Related Responses. Sensors (Basel) 2020 Oct 22;20(21):5996. doi: 10.3390/s20215996. Additional Declarations Competing interest reported. DJ is the creator of the tai chi intervention, TCMMMRT, and is the founder and director of Moving Stillness Healing Arts LLC. All other authors declare that they have no competing interests in this section. Supplementary Files FILESSuppBRandPTSD.docx FILESSuppHRVandPTSD.docx FILESSuppIAFFCOEIntroduction.docx FILESSuppTCMMMRTProgramIntroduction.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3182536","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":222281397,"identity":"40cf6fc3-f203-44b8-84f9-1a80d06ba53c","order_by":0,"name":"Pritha 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DJ is the creator of the tai chi intervention, TCMMMRT, and is the founder and director of Moving Stillness Healing Arts LLC. All other authors declare that they have no competing interests in this section.","formattedTitle":"\u003cp\u003ePhysiologic and Self-Report Assessment of a Multimodal Therapeutic Intervention for PTSD in US Firefighters: A Pilot Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePost-Traumatic Stress Disorder (PTSD) affects an estimated 4.7% of the United States (US) population every year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], leading to increased rates of disability, suicide, substance use, and interpersonal difficulties. Compared to the general population, the prevalence of PTSD and related co-occurring disorders is higher for first responders, such as law enforcement officers (LEOs), emergency medical technicians (EMTs)/paramedics, and firefighters [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe firefighting community\u0026mdash;including firefighters, paramedics, EMTs, and dispatch\u0026mdash;have increased risk for traumatic exposure, but fire service members are underrepresented in the traumatic stress literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition to high rates of PTSD, many may suffer from symptoms associated with PTSD without meeting full criteria for PTSD (i.e., partial or sub-threshold PTSD), highlighting the need to capture posttraumatic symptomatology in this population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. They also have distinct barriers to treatment-seeking, in part due to their culture of volunteerism, heroism, and self-sacrifice [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Due to these considerations, fire service members need PTSD and its symptoms effectively diagnosed and treated.\u003c/p\u003e \u003cp\u003eThe International Association of Firefighters (IAFF) Center of Excellence (COE) for Behavioral Health Treatment and Recovery provides multimodal treatment of PTSD for its members. The center is a treatment facility specific to professional fire service members suffering from mental health disorders and/or substance use disorders and was established as a collaboration between the IAFF and Advanced Recovery Systems. Of note, during this study, the IAFF COE programming included a mindfulness-based intervention: Tai Chi Moving Mindfulness Meditation and Resilience Training (TCMMMRT). This intervention was an area of interest for the study investigators, as evidence suggests that mindfulness-based therapies are effective in reducing PTSD symptomatology [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis pilot study aimed to observe the process and outcomes of this multimodal intervention on self-reported and physiological symptoms of traumatic stress in US fire service members with PTSD. The purpose of this study was to describe the course of PTSD symptoms, physiological measures related to stress and startle, and their correlations over the four-week intervention in a population of firefighters with PTSD. Self-report outcome measures included the PTSD Checklist for DSM-V (PCL-5), Beck\u0026rsquo;s Depression Inventory (BDI), and Pittsburgh Sleep Quality Index (PSQI). Physiological measures included heart rate variability (HRV) and the acoustic startle response (ASR), quantified as amplitude of blink reflex (BR) measured using the Mobile Acoustic Startle Reflex-monitoring System (MARS). A secondary aim of this study was to identify the self-report measures (PCL-5, BDI, PSQI) most tightly associated with physiological measures (HRV and BR/ASR).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003e This study was approved by the Johns Hopkins Institutional Review Board (IRB) (IRB00226155). Participants were 67 male firefighters with PTSD, ages 18 to 65, who were recruited from the IAFF COE for Behavioral Health Treatment and Recovery in Prince George\u0026rsquo;s County, Maryland. The presence of PTSD was established by the IAFF COE clinicians. The study participants were actively undergoing treatment for PTSD, with a typical duration of stay ranging from four to five weeks. The treatment intervention could include combinations of medication management, medical and nursing resources, and clinical programming depending on the individual treatment plan. However, all participants participated weekly in Tai Chi Moving Mindfulness Meditation and Resilience Training (TCMMMRT). TCMMMRT is a novel intervention, developed and conducted by tai chi instructor Sifu Dan Jones. It aims to promote a meditative state of mind with mindfulness breathing and gentle, gross motor movements, related to those of traditional tai chi. Participants who endorsed use of stimulants or sedatives within 48 hours of study participation were excluded from immediate assessment and subsequent data analysis, prior to study enrollment, since these substances may interfere with the ASR and resultant BR.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSelf-Report Measures\u003c/h3\u003e\n\u003cp\u003eQualtrics online survey software was used for data collection. Participant demographics (age, occupation, gender, current medications) and self-report symptom measures were collected. The self-reported measures were PTSD Checklist for DSM-5 (PCL-5), the Beck Depression Inventory (BDI), and the Pittsburgh Sleep Quality Index (PSQI).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePhysiological Measures\u003c/h2\u003e \u003cp\u003eHeart rate variability (HRV) was measured and recorded with the CameraHeartRate app, (A.S.M.A B.V.), prior to participation in each TCMMMRT session. This app used an iPhone to conduct one minute of photoplethysmography. Blink reflex (BR) data was collected with the novel MARS app (CodeFluegel GmbH) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This app used an iPhone and wired earphones to play acoustic stimuli, record the corresponding blink response, and calculate the blink amplitude.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSelf-Report Measures (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eOf 71 enrolled participants, 62 had at least one data point of self-report data at week 1, whether BDI, PSQI, or PCL. For those participants, average week 1 BDI scores were in the \u0026ldquo;borderline clinical depression\u0026rdquo; range (mean\u0026thinsp;=\u0026thinsp;18.8, SD\u0026thinsp;=\u0026thinsp;11.52). The week 1 PSQI had a mean score of 8.62 (SD\u0026thinsp;=\u0026thinsp;2.32), with a score of 5 or greater typically indicating significant sleep disturbance. The week 1 PCL had a mean score of 41.61 (SD\u0026thinsp;=\u0026thinsp;18.08) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with a cut-off score of 31\u0026ndash;33 indicating probable PTSD. Of note, PCL had the most missing observations (N\u0026thinsp;=\u0026thinsp;18 missing) compared to BDI (N\u0026thinsp;=\u0026thinsp;1 missing) and PSQI (N\u0026thinsp;=\u0026thinsp;1 missing).\u003c/p\u003e \u003cp\u003eTo estimate the clinical trajectory of participants during the study, linear mixed-effects models were fit including all participants with at least 2 weeks of self-report observations (n\u0026thinsp;=\u0026thinsp;34), with random effects being participants and fixed effects being the week of the observation. All clinical measures were estimated to improve with time, with regression coefficient for BDI \u0026minus;\u0026thinsp;3.06 per week (128 observation, 95% confidence interval (CI) of -3.90, -2.23); PSQI \u0026minus;\u0026thinsp;0.52/week (128 observations, 95% CI -0.79, -0.26); and PCL \u0026minus;\u0026thinsp;9.20 per week (85 observations, 95% CI -12.32, -6.14).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePhysiological Measures (See Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eScatterplots and simple bivariate correlations between HRV and BDI, PCL, and PSQI showed little evidence of relationship, with the maximum correlation coefficient being r\u0026thinsp;=\u0026thinsp;0.15. These were not analyzed further.\u003c/p\u003e \u003cp\u003eVisual inspection of the sample distribution for BR amplitude showed the data were clearly bimodal, with one peak at exactly zero (41.12% zeros) and the remainder of the distribution roughly bell shaped (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Visual examination of the response distributions by sound pressure level (SPL) and frequency of the stimulus revealed steadily more nonzero responses with increasing SPL (38.56% for 65 dB, 63.60% for 90 dB, and 74.88% for 105 dB) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and slightly more nonzero responses at the 4000 Hz frequency than 500 Hz (51.12% for 500 Hz and 65.72% for 4000 Hz) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The proportion of non-zero responses by posture (sitting or standing) were identical. The proportion of non-zero responses by laterality were 67.84% for right eye and 52.22% for left eye, but there were more observations for the left (n\u0026thinsp;=\u0026thinsp;766 left and 566 right). Overall, the pattern suggested the participants\u0026rsquo; population distribution of reflex firing (i.e., nonzero response) varied by stimulus characteristics, particularly SPL (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); and that the stimuli were not uniformly above the reflex threshold for all participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBecause the reflex responses fit a fire/no-fire pattern more closely than a continuous distribution, a multivariate binomial regression model was fit to test the initial hypothesis that stimulus characteristics predicted nonzero responses. SPL and frequency were entered as ordinal predictors of nonzero response along with eye laterality. As expected from the first explorations, both increasing sound pressure level and higher frequency predicted increased reflex firing (SPL OR 3.13 95%CI 2.54, 3.88; right laterality OR 2.07, 95% CI 1.63 2.64; Frequency OR 1.50, 95% CI 1.27, 1.78; all p values\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003eTo screen for the possibility that stimulus characteristics predicted magnitude of the response in addition to firing of the reflex, a zero-censored simple linear model was fit predicting magnitude of the nonzero responses using the same predictors and found no relationship (minimum p\u0026thinsp;=\u0026thinsp;0.116 for laterality).\u003c/p\u003e \u003cp\u003eTo test for an overall relationship between time in treatment and nonzero response, generalized linear mixed effects binomial models with stimulus characteristics and week of treatment treatment modeled as fixed effects and individual participants modeled as random effects (36 participants, 1332 observations) showed no relationship between week and nonzero response (odds ratio 1.07, p\u0026thinsp;=\u0026thinsp;0.325).\u003c/p\u003e \u003cp\u003eTo explore whether clinical measures were associated with MARS responses, binomial generalized linear mixed-effects models were fit with BDI, PCL, and PSQI entered as fixed effects along with SPL, frequency, and laterality; and random effects being participants. The models showed no relationship between the clinical measures and MARS reflex firing (minimum p value 0.191 for the BDI); though the prior relationships between reflex firing and SPL, frequency, and laterality were statistically significant in all models.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this preliminary study, PTSD symptoms, depressive symptoms, and sleep disturbance seemed to improve with time during treatment at the IAFF COE. Visual inspection of outcomes by time suggested that improvements plateau around four weeks of intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The physiological data of BR and HRV did not correlate with these self-report measures. However, we suspect these methods need further refinement in how they are studied in such populations, discussed further in limitations.\u003c/p\u003e \u003cp\u003eIt is also worth noting that scientific literature regarding treatment interventions in US firefighters is difficult to find. As such, while these findings are preliminary, they provide important insight regarding the efficacy of tailored interventions in this population.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThere are some limitations to consider in this pilot study.\u003c/p\u003e \u003cp\u003eThe sample shows significant weekly attrition. This may be due to participants being constrained for time; they are restricted by extensive programming obligations over the course of treatment. Moreover, these participants volunteered their spare time without financial compensation. Future studies may recruit a larger study population to account for a higher level of drop-out and offer participant incentives to improve retention. Additionally, self-report measures are susceptible to various biases, such as self-report and social desirability bias. These biases may be especially pertinent for fire service members due to their culture of heroism and volunteerism. With respect to physiological measures, HRV data was only collected once per week for the duration of a minute. Continuous measurement through wearable devices may enable future studies to reflect associations of HRV and PTSD as established in the scientific literature [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The field of ASR also still faces unanswered questions regarding the potential of BR as a marker. Further investigation is needed to determine the nuances of calibrating appropriate acoustic stimuli and analyzing resultant BR. Furthermore, this study population does not reflect the diversity of the US fire service population. In particular, the participants were largely male, Caucasian fire fighters. Further work should consider sex, gender, race/ethnicity, rural versus urban status to help identify potential disparities in PTSD intervention for the US fire service population.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDespite these limitations, this pilot study suggests interesting avenues for future research to improve treatment of PTSD in fire service members. Future work should analyze the individual components of this multimodal intervention. For example, TCMMMRT was common to all participants, and study with a non-interventional control could further illuminate its potential in reducing PTSD symptoms in fire service members. This study also indicates that a four-week period of study should be sufficient to see effects in participants\u0026rsquo; depressive symptoms, PTSD symptoms, and sleep quality.\u003c/p\u003e"},{"header":"ABBREVIATIONS ","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eLEO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eLaw enforcement officers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eEMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eEmergency medical technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eIAFF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eInternational Association of Firefighters\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eCOE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eCenter of Excellence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePCL-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePTSD Checklist for DSM-V\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eBDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eBeck\u0026rsquo;s Depression Inventory\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePSQI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePittsburgh Sleep Quality Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eHRV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eheart rate variability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eASR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eacoustic startle response\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eBR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eblink reflex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eMARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eMobile Acoustic Startle Reflex-monitoring System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eTCMMMRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eTai Chi Moving Mindfulness Meditation and Resilience Training\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePPG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ephotoplethysmography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eCSV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ecomma-separated value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eSPL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003esound pressure level\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eHz\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eHertz\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003econfidence interval\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations as approved by the Johns Hopkins Institutional Review Board (IRB). All patients voluntarily participated and provided informed consent based on IRB guidelines and could withdraw consent at any point in the study. Details of ethics approval and consent process can be found via e-IRB: IRB00226155.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eParticipants provided informed consent prior to data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available to protect participant privacy and confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eDJ is the creator of the tai chi intervention, TCMMMRT, and is the founder and director of Moving Stillness Healing Arts LLC. \u0026nbsp;All other authors declare that they have no competing interests in this section.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was completed without internal or external funding. Researchers and participants volunteered their time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eCG, CLW, and UDM conceptualized the study. CG, CLW, PS, VM, FS, JC, DJ, and CPC participated in study design and coordination. PS, VM, FS, and NXJ supported data collection, data processing, and contributed to methods and limitations. \u0026nbsp;JC and DJ supported data collection and contributed to introduction and methods. PS, FS, JC, and DJ developed supplemental materials. CPC conducted statistical analysis, interpreted the data, created figures, and drafted the results section. PS prepared the original draft, and reviewed and edited the manuscript. All listed authors have reviewed the manuscript and given consent for publication.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe research team wishes to extend their appreciation to the staff at the IAFF COE as well as the participants who volunteered their time and energy to support this endeavor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information (optional)\u003c/p\u003e\n\u003cp\u003eAuthor information can be found on our lab website: https://www.hopkinsmedicine.org/psychiatry/research/mccannlab.html\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTrauma- and Stressor-Related Disorders. Diagnostic and Statistical Manual of Mental Disorders: American Psychiatric Association Publishing; 2022.\u003c/li\u003e\n\u003cli\u003eObuobi-Donkor G, Oluwasina F, Nkire N, Agyapong VIO. A Scoping Review on the Prevalence and Determinants of Post-Traumatic Stress Disorder among Military Personnel and Firefighters: Implications for Public Policy and Practice. Int J Environ Res Public Health 2022 Jan 29;19(3):1565. doi: 10.3390/ijerph19031565.\u003c/li\u003e\n\u003cli\u003eLewis-Schroeder NF, Kieran K, Murphy BL, Wolff JD, Robinson MA, Kaufman ML. Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harv Rev Psychiatry 2018;26(4):216-227.\u003c/li\u003e\n\u003cli\u003eFraess-Phillips A, Wagner S, R Luke Harris. Firefighters and traumatic stress: a review. International Journal of Emergency Services 2017;6(1):67-80.\u003c/li\u003e\n\u003cli\u003eHaugen PT, Evces M, Weiss DS. Treating posttraumatic stress disorder in first responders: a systematic review. Clin Psychol Rev 2012 Jul;32(5):370-380.\u003c/li\u003e\n\u003cli\u003eAlden L, Matthews L, Wagner S, Fyfe T, Randall C, Regehr C, et al. Systematic literature review of psychological interventions for first responders. Work \u0026amp; Stress 2020;35:1-23.\u003c/li\u003e\n\u003cli\u003eAlshahrani KM, Johnson J, Prudenzi A, O\u0026apos;Connor DB. The effectiveness of psychological interventions for reducing PTSD and psychological distress in first responders: A systematic review and meta-analysis. PLoS One 2022 Aug 24;17(8):e0272732.\u003c/li\u003e\n\u003cli\u003eMcFarlane AC, Bryant RA. Post-traumatic stress disorder in occupational settings: anticipating and managing the risk. Occup Med (Lond) 2007 Sep;57(6):404-410.\u003c/li\u003e\n\u003cli\u003eBahji A, Di Nota PM, Groll D, Carleton RN, Anderson GS. Psychological interventions for post-traumatic stress injuries among public safety personnel: a systematic review and meta-analysis. Syst Rev 2022 Nov 25;11(1):255-1.\u003c/li\u003e\n\u003cli\u003eJahnke SA, Poston WSC, Haddock CK, Murphy B. Firefighting and mental health:experiences of repeated exposure to trauma. Emmitsburg, MD: National Emergency Training Center; 2016.\u003c/li\u003e\n\u003cli\u003eKlimley KE, Van Hasselt VB, Stripling AM. Posttraumatic stress disorder in police, firefighters, and emergency dispatchers. Aggression and Violent Behavior 2018;43:33-44.\u003c/li\u003e\n\u003cli\u003eJones S, Agud K, McSweeney J. Barriers and Facilitators to Seeking Mental Health Care Among First Responders: \u0026ldquo;Removing the Darkness\u0026rdquo;. J Am Psychiatr Nurses Assoc 2020;26(1):43-54. \u003c/li\u003e\n\u003cli\u003eJones S, Nagel C, McSweeney J, Curran G. Prevalence and correlates of psychiatric symptoms among first responders in a Southern State. Arch Psychiatr Nurs 2018 Dec;32(6):828-835.\u003c/li\u003e\n\u003cli\u003eDill J, Loew C. Suicide in the Fire and Emergency Services. The National Volunteer Fire Council (NVFC) 2012.\u003c/li\u003e\n\u003cli\u003eDeMoulin D, Jacobs S, Nam Y, Harding AB, Moskowitz AF, Shi Y, et al. Mental Health Among Firefighters: Understanding the Mental Health Risks, Treatment Barriers, and Coping Strategies. J Occup Environ Med 2022 Nov 1;64(11):e714-e721.\u003c/li\u003e\n\u003cli\u003eHaugen PT, McCrillis AM, Smid GE, Nijdam MJ. Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. J Psychiatr Res 2017 Nov;94:218-229.\u003c/li\u003e\n\u003cli\u003eBryant RA. The nature of posttraumatic stress disorder in treatment-seeking first responders. Eur J Psychotraumatol 2022 Jan 26;13(1):2011602.\u003c/li\u003e\n\u003cli\u003eBoyd JE, Lanius RA, McKinnon MC. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J Psychiatry Neurosci. 2018 Jan;43(1):7-25. doi: 10.1503/jpn.170021. Epub 2017 Oct 2. PMID: 29252162; PMCID: PMC5747539.\u003c/li\u003e\n\u003cli\u003eGowen CL, Khwaounjoo P, Cakmak YO. EMG-Free Monitorization of the Acoustic Startle Reflex with a Mobile Phone: Implications of Sound Parameters with Posture Related Responses. Sensors (Basel) 2020 Oct 22;20(21):5996. doi: 10.3390/s20215996.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PTSD, Firefighters, Tai Chi, First responders, Depression, Acoustic startle response, Heart rate variability, Sleep quality, PTSD intervention, Posttraumatic symptomatology","lastPublishedDoi":"10.21203/rs.3.rs-3182536/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3182536/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFire service members are a population with high prevalence of post-traumatic stress disorder (PTSD) compared to the general population. Moreover, they are underrepresented in the literature with respect to traumatic stress and corresponding interventions. As such, there is a need to improve treatment of PTSD and its resultant symptoms specifically in fire service members. This pilot study aimed to evaluate the efficacy of a multimodal treatment intervention for US fire service members with PTSD. It aimed to (i) assess the effect of the 4-week intervention on self-report and physiologic symptoms, (ii) correlate self-report and physiologic measures of PTSD, and (iii) identify the measures most closely linked to treatment response.\u003c/p\u003e \u003cp\u003eSelf-report measures of BDI, PSQI, and PCL-5 showed weekly improvement, plateauing around four weeks. The physiologic data of blink reflex amplitude and heart rate variability did not appear to correlate with these self-report measures, but the methods of data collection may need further refinement. This study suggests interesting avenues for future research for PTSD treatment in fire service members, such as evaluating individual components of this intervention. Additionally, it indicates that a four-week period of study should be sufficient to see effects in participants\u0026rsquo; symptoms of PTSD, depression, and sleep quality.\u003c/p\u003e","manuscriptTitle":"Physiologic and Self-Report Assessment of a Multimodal Therapeutic Intervention for PTSD in US Firefighters: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-02 17:25:41","doi":"10.21203/rs.3.rs-3182536/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7e78c8c-d0f2-4478-b413-977012782eb7","owner":[],"postedDate":"August 2nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-28T11:14:21+00:00","versionOfRecord":[],"versionCreatedAt":"2023-08-02 17:25:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3182536","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3182536","identity":"rs-3182536","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}