Better Habits for Better Health: Lifestyle Intervention Studies
As the WTC patient cohort ages, it’s become imperative that we identify and understand early indicators of age-related disease. More importantly, it’s necessary to understand these factors in relation to the unique health circumstances of 9/11 responders: how they might present differently, affect existing conditions or in fact develop as a result of those conditions, and react to treatment in unexpected ways. Our wellness studies enhance patient monitoring tremendously, as they allow us to identify issues that might otherwise go unnoticed and help us understand how to slow the progression of age-related disease. It’s the hope of our clinicians and researchers that our protocol becomes a model for state-of-the-art preventive care in general medicine.
Using the Montreal Cognitive Assessment (MoCA)
This cognitive assessment was developed specifically for use in a clinical setting; it is administered to all of our CCE patients during their monitoring visit and offers a measurement of cognitive levels. The MoCA, which includes assessments for visuospatial tasks and word fluency, allows the clinician to observe firsthand changes in cognitive ability and identify impairments, such as Alzheimer’s, in their early stages.
The self-report fatigue assessment is another measure we use in the clinical setting. Building on post-Gulf War findings that linked trauma to chronic fatigue syndrome in males, this looks specifically at rates of high fatigue in WTC responders. Our researchers have found that the mental and physical function of more than 21% of those studied were significantly affected by fatigue. There was also a meaningful association between level of fatigue and diagnosed PTSD and depression, and, to a lesser extent, GERD and lower respiratory disease. We’re also investigating fatigability, or, the tendency to get very tired by everyday activities, a measure that may be an early indicator of inflammatory disease. Such work has important implications in discovering causation as well as identifying potential treatments.
Observing physical function is a critical tool in understanding age-related decline and how it relates to WTC responder health concerns. One simple assessment uses a dynamometer to measure an individual’s grip strength, which is a strong biological indicator of risk for disease and physical impairment. Another employs a physical function battery developed by renowned researcher Dr. Jack Guralnik (University of MD, former National Institute on Aging, NIH), in which the patient’s lower extremity functioning is tested with a brief set of sit, stand, balance, and gait commands. D. Guralnik’s study found associations with self-reports of disability and prediction of mortality; this test takes only a few minutes but has profound implications.
While cigarette use is life-threatening in any population, it’s particularly insidious to WTC responders, who characteristically suffer from persistent respiratory problems as a result of their work at the World Trade Center sites. Adding to this is the scientifically documented fact that quitting can be a particularly tough goal to achieve when an individual experiences symptoms of PTSD (or other anxiety disorders)—not only are they more likely to fail standard methods, but they’re likelier to relapse. This combination of factors creates the perfect storm for our patient population—a significant number of whom have comorbid respiratory illness and PTSD.
Building on a decade of research collaborations on the links between anxiety and smoking, scientists at Stony Brook University evaluated a new method to help these responders with a smoking cessation intervention that also alleviates PTSD: the Enhanced Smoking Cessation Intervention for WTC Responders. With the participation of 100 smokers displaying significant WTC-related PTSD symptoms, the eight-week program offers half the participants standard smoking cessation treatments while the other half receive that therapy augmented by cognitive behavioral therapies using a protocol developed by Dr. Michael Zvolensky (director of the Anxiety and Health Research Laboratory and Substance Use Treatment Clinic, University of Houston). Its effectiveness is then measured for a subsequent six months’ time by monitoring smoking abstinence, improvements in PTSD, and improvements in respiratory symptoms. This $1.5m study is one in a cadre of new interventions pioneered by the Stony Brook WTC Wellness Program to address continued health and wellness with special attention to the population it serves.
In spite of the specialized healthcare offered by our clinicians, many WTC responders continue to be affected by comorbid respiratory illness and PTSD. The Mind Body Treatment for WTC Responders with Comorbid PTSD and Respiratory Illness study directly addresses both the needs of these individuals and existing knowledge gaps by utilizing a pioneering treatment protocol specifically designed to focus on both problems. The cost-effective and valuable intervention (the Relaxation Response Resiliency Program—3RP—designed at Harvard by Drs. Benson and Park et al.) has been adapted to the needs of our responder population and involves relaxation training and the teaching of cognitive-behavioral skills.
While the 3RP is known for reducing psychological distress and physical problems, its effect on PTSD and respiratory illness specifically has never before been studied. In fact, this study is the first ever randomized controlled trial to test the impact of the 3RP: this has important implications for outcomes ranging from quality of life and healthcare costs to morbidity and even mortality in both the WTC responders and the population at large. Thus far, feedback from participants has been excellent.
As part of the groundbreaking research on the interplay between PTSD and lower respiratory issues, this study, with funding of $1m, allows our multi-disciplinary team of researchers to collect real-time data on symptoms experienced by participants. Using smart phone technology, responders will record PTSD and respiratory symptoms three times daily; heart rate, cortisol levels, and respiratory inflammation levels will also be measured.
What’s remarkable about this relatively simple change in data collection methods is that, for the first time, researchers are able to accurately assess daily symptom occurrence and level of impairment and determine the potential existence of mediators between these maladies—until now, documentation depended on patient recall during clinical visits and was, consequently, far less accurate. Comparing this information with other data will allow for more precise measures of prevalence and symptom severity and reveal findings on the biology of PTSD’s relationship to respiratory illness. In turn, our doctors and other clinicians will be better equipped to offer more effective diagnosis and treatment, serving both the immediate needs of our own patients while also addressing a primary mandate of the Zadroga Act and creating a framework to treat persons affected in similar ways by other disasters.
When Hurricane Sandy made landfall on the Eastern seaboard in October 2012, it left behind in its wake severe destruction and resulted in more than 100 deaths. Long Island experienced major flooding and powerful winds that left many without electricity for weeks, destroyed homes, and resulted in the proliferation of mold and other environmental toxins.
Many WTC responders who live and work in the affected areas were active responders to Sandy and/or victims to the disaster, all while still struggling with 9/11-related health consequences. Researchers at the Stony Brook WTC Wellness Program knew that this event would have a grave impact on the center’s patients, and so they launched a number of projects that would address the various issues at hand. The first study collected data on 550 WTC responders from highly affected areas, evaluating levels of exposure to environmental toxins and psychological trauma resulting from Hurricane Sandy and their effects on respiratory and mental health.
Researchers soon embarked on a follow-up study in collaboration with other institutions, allowing two populations to be studied: disaster responders who were previously exposed to the WTC disaster and community members exposed to Sandy. This collaboration created a unique opportunity to better understand how individuals recover and grow from disasters; a key component of this study is a collection of videotaped oral histories detailing individual’s firsthand accounts of the hurricane and related psychological impact. This longitudinal study’s innovative design and dynamic cohort allows for great strides to be made in the understanding of post-traumatic growth.
Most recently, a third groundbreaking study with significant implications for communities far beyond those involved with the WTC disaster has emerged. Researchers are adapting and testing the efficacy of the NIEHS Disasters Worker Resilience Training (DWRT) program, originally designed for responders to the 2010 Deepwater Horizon oil spill. Most previous work in this area has focused on acute interventions, whereas this methodology is based on a number of empirically tested treatments to enhance resiliency in disaster workers before exposure to potentially traumatic events. This cutting-edge work is the first randomized clinical trial to evaluate the efficacy of a brief intervention for resilience training in active responders; will strengthen future disaster preparedness, response, and recovery efforts; and provides a manualized training program that can be adapted for use with other disaster responders. It is expected that three months post-intervention, participants will demonstrate lower perceived stress and greater posttraumatic growth; increased knowledge regarding potential mental health problems post-disaster; and an increased willingness to access mental health care.