Implementation of a Mobile Technology–Supported Diaphragmatic Breathing Intervention in Military mTBI With PTSD

Abstract

Background: Diaphragmatic breathing is an evidence-based intervention for managing stress and anxiety; however, some military veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) report challenges to learning and practicing the technique. BreatheWell Wear assists performance of breathing exercises through reminders, biofeedback, and visual, tactile, and auditory guidance. Objective: To evaluate feasibility of implementing BreatheWell Wear, a mobile smartwatch application with companion smartphone app, as an intervention for stress management in military veterans with mTBI and PTSD. Methods: Thirty veterans with chronic symptoms of mTBI and PTSD recruited from an interdisciplinary, intensive outpatient program participated in this pilot pragmatic clinical trial. Participants were randomly assigned to the experimental (BreatheWell Wear and conventional care) and control (conventional care) groups for 4 weeks. Conventional care included instruction on relaxation breathing and participation in behavioral health therapy. Effects on goal attainment, treatment adherence, diaphragmatic breathing technique knowledge, and stress were measured through surveys and diaries. Changes in symptoms, mood, and well-being were measured pre/postintervention via the Posttraumatic Checklist for DSM-5, Beck Anxiety Inventory, Beck Depression Inventory, and Flourishing Scale. Results: Person-centered goal attainment (t = 4.009, P < .001), treatment adherence (t = 2.742, P = .001), diaphragmatic breathing technique knowledge (t = 1.637, P < .001), and reported ease of remembering to practice (t = −3.075, P = .005) were significantly greater in the experimental group. As expected, measures of PTSD, anxiety, depression, and psychological well-being showed clinically meaningful change in both groups, and both groups demonstrated reduced stress following diaphragmatic breathing. Conclusion: These preliminary findings indicate that BreatheWell Wear may be a clinically feasible tool for supporting diaphragmatic breathing as an intervention in veterans with mTBI and PTSD, and a future effectiveness trial is warranted.

Introduction to Topical Issue on mHealth for Brain Injury Rehabilitation

“…The 6 articles included herein reflect both that TBI affects individuals across the life span and the myriad ways that various mHealth technologies can be potentially beneficial after TBI. These articles represent diverse technological solutions—including smartphone apps (all articles), wearable sensor technology,4,5 and conversational agents6—to address a variety of clinical applications, such as symptom monitoring,5,7,8 stress and symptom management,4,7,8 and behavior change 6,9. The studies in this issue echo many of the themes identified in recent reviews.…”

“…Some articles highlight examples of mHealth solutions that have been designed to pair with traditional clinician-delivered interventions in a hybrid model. 5,6,9 The mHealth apps in the study by Juengst et al 9 were designed to complement and promote ongoing engagement in 2 intensive healthy lifestyle interventions. RehaBot 6 is designed to pair with a clinician-delivered behavioral activation treatment of depression providing support and reminders for completing planned activities between sessions with a therapist.…”

“…Their study was the only one to include a gamified app to promote adherence; gamification is a well-established approach to maximizing engagement with mHealth apps. 10,11 5,6,9 illustrate models for incorporating mHealth with clinician-delivered interventions. mHealth developers and researchers must consider which therapeutic ingredients are appropriate for mHealth delivery on their own and which should be delivered with the supervision and guidance of a skilled clinician.…”

“…The 6 articles included herein reflect both that TBI affects individuals across the life span and the myriad ways that various mHealth technologies can be potentially beneficial after TBI. These articles represent diverse technological solutions-including smartphone apps (all articles), wearable sensor technology, 4,5…”

“…RehaBot6 is designed to pair with a clinician-delivered behavioral activation treatment of depression providing support and reminders for completing planned activities between sessions with a therapist. Wallace and colleagues5 examined the effects of an mHealth smartwatch/smartphone app system, designed to pair with a conventional clinician-delivered intervention, to prompt service members with mild TBI and posttraumatic stress disorder to practice diaphragmatic breathing with the aid of physiological sensors to guide proper technique. These examples demonstrate how mHealth can extend the reach of clinic-based treatments and provide preliminary evidence that these solutions may promote self-monitoring and practice of therapeutic skills in individuals' everyday environments. This topical issue contains multiple illustrations of the applicability of mobile technology that can be applied to enhance the in situ assessment of physical and neurobehavioral symptoms 4,7,8.…”