Diaphragmatic and Box Breathing on Heart Rate Variability and Perceived Stress (HRV DB BB PSS)

Enhancing Physiological and Psychological Resilience: A Comparative Study of Diaphragmatic and Box Breathing in Physical Therapy Students.

The goal of this clinical trial is to learn if diaphragmatic breathing and box breathing work to enhance resilience and manage stress in physical therapy students. It will also learn about their effects on overall physiological and psychological parameters. The main questions it aims to answer are:

Do these breathing techniques improve heart rate variability (HRV)?

How do these interventions affect participants' perceived stress levels, cognitive performance, and academic achievement?

Researchers will compare diaphragmatic breathing and box breathing to a control group to see if these non-invasive methods work to improve physiological adaptation and manage stress.

Participants will:

Be randomly assigned to practice diaphragmatic breathing, practice box breathing, or join a control group Have their heart rate variability (HRV) measured as a primary sign of physiological adaptation Complete assessments to evaluate their perceived stress, cognitive performance, and academic achievement

Study Overview

• Status: Not yet recruiting
• Conditions: Stress; Psychological Resilience; Healthy Students
• Intervention / Treatment: Behavioral: Diaphramatic Breathing Training; Behavioral: Box Breathing Training

Detailed Description

The Challenge: Stress in Healthcare Education University life is a demanding transitional period, and students training in healthcare fields like physical therapy often face immense academic and clinical pressures. Research shows that up to 50.1% of physiotherapy students experience high levels of stress, which can surge even higher during their hands-on clinical rotations. This stress is more than just an emotional burden; it actively impairs working memory, reduces attention span, and often leads to lower grades and poorer overall academic performance.

The Goal of the Study This study aims to discover if simple, accessible breathing exercises can help undergraduate physical therapy students build resilience and better manage their stress. Specifically, the research will compare the effectiveness of two distinct breathing techniques-diaphragmatic breathing and box breathing-to see how they impact both the mind (psychological stress and cognition) and the body (physiological adaptation).

How the Study Works The study will involve 60 undergraduate physical therapy students from Deraya University who are currently experiencing moderate to high levels of academic stress. These participants will be randomly divided into three equal groups: The Diaphragmatic Breathing Group: Participants will practice a relaxing, slow-paced breathing pattern. They will inhale through the nose for 4 seconds and exhale through the mouth for 6 seconds, focusing on expanding their abdomen. The Box Breathing Group: Participants will practice a structured technique often used in high-stress tactical environments to enhance stress tolerance. It involves a "4-4-4-4" cycle: inhaling for 4 seconds, holding the breath for 4 seconds, exhaling for 4 seconds, and holding the breath out for 4 seconds. The Control Group: Participants will simply continue their normal daily routines without any specific breathing interventions so researchers have a baseline for comparison. The two breathing groups will practice their designated techniques for 15 minutes a day, 6 days a week, over a 4-week period. What is Being Measured?To accurately determine if these techniques work, the study will evaluate several key areas:Heart Rate Variability (HRV): Using a highly accurate chest strap sensor (the Polar H10), researchers will measure the subtle variations in time between heartbeats. HRV is a primary indicator of how well the nervous system is regulating stress and keeping the body balanced. Stress and Resilience: Participants will complete standardized questionnaires to evaluate their perceived stress levels and their ability to "bounce back" from daily challenges. Cognitive and Academic Performance: The study will use specialized cognitive tests (like the Stroop Color-Word Test) to measure attention and executive functioning. It will also evaluate the students' confidence in their ability to manage time, prepare for exams, and succeed academically.

Why This Matters Because academic stress is incredibly prevalent among health sciences students, finding practical, non-medication-based ways to support their mental health is critical. By comparing these two breathing methods, this study hopes to identify an effective, non-invasive tool that students can easily use to lower their anxiety, improve their focus, and ultimately thrive in their demanding academic and clinical environments.

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Alaa N Abdelhameed Abdelmohsen, B.Sc. in Physical Therapy; Phone Number: +201061382864; Email: alaa.nasser@deraya.edu.eg
• Study Contact Backup: Name: Abdelrahman A Mohamed, B.Sc. in Physical Therapy; Phone Number: +201124079292; Email: abdelrahmanayman199810@gmail.com

Study Locations

• Egypt
  • Minya Province
    • Minya, Minya Province, Egypt
      • Faculty of Physical Therapy, Deraya University
      • Contact: Alaa N Abdelhameed Abdelmohsen, BSc in Physical Therapy; Phone Number: +201061382864; Email: alaa.nasser1713@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Academic Status: Currently enrolled, full-time undergraduate Physical Therapy students
• Age Range: 18-25 years
• Health Status: Generally healthy individuals with no known chronic respiratory or cardiovascular diseases.
• Informed Consent: Ability and willingness to provide written informed consent and commit to the 4-week protocol (6 sessions/week).
• Stress Level: A baseline score on the Perceived Stress Scale (PSS) indicating at least moderate stress.

Exclusion Criteria:

• Pre-existing Breathing Expertise: Individuals with professional training in yoga (Pranayama), formal meditation, or advanced breath work that might bias the baseline results.
• Medical Conditions: Diagnosed respiratory conditions (e.g., Asthma, COPD).
• Cardiovascular issues (e.g., Arrhythmias, Hypertension).
• Clinical psychological disorders (e.g., Generalized Anxiety Disorder or Panic Disorder) that may require medication.
• Pharmacological Factors: Use of medications that influence the Autonomic Nervous System (e.g., Beta-blockers, antidepressants, or heavy use of stimulants/sedatives).
• Substance Use: Smokers/Vapers
• Excessive Caffeine "Participants consuming more than 400 mg of caffeine per day (equivalent to approximately 4 standard cups of brewed coffee) will be excluded.
• Recent Acute Illness: Any respiratory tract infection or fever within two weeks prior to the start of the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Diaphragmatic Breathing Group; Participants will sit comfortably with their hands in their abdomen. They will: Inhale through the nose for 4 seconds; Exhale through the mouth for 6 seconds; Focus on abdominal expansion and relaxation; Continue for 15 minutes, 6 sessions/week, for 4 weeks	Behavioral: Diaphramatic Breathing Training; Diaphragmatic Breathing Group: Participants will sit comfortably with their hands in their abdomen. They will: Inhale through the nose for 4 seconds; Exhale through the mouth for 6 seconds; Focus on abdominal expansion and relaxation; Continue for 15 minutes, 6 sessions/week, for 4 weeks
Experimental: Box Breathing Group; Participants will perform a structured breath cycle: Inhale for 4 seconds; Hold for 4 seconds; Exhale for 4 seconds; Hold for 4 seconds Sessions will last 15 minutes, 6 sessions/week, for 4 weeks	Behavioral: Box Breathing Training; Box Breathing Group: Participants will perform a structured breath cycle: Inhale for 4 seconds; Hold for 4 seconds; Exhale for 4 seconds; Hold for 4 seconds
No Intervention: Control Group; Participants will continue their normal daily routines and will not receive any breathing intervention during the study period

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Heart Rate Variability	HRV will be measured using the Polar H10 sensor and analyzed through Kubios HRV software to evaluate physiological resilience and autonomic nervous system regulation.	Baseline (pre-intervention) and at the end of the 4-week training period (post-intervention).
Perceived Stress	Stress will be measured using the Perceived Stress Scale (PSS-10). The total score ranges from a minimum of 0 to a maximum of 40. Higher scores indicate higher levels of perceived stress, representing a worse outcome	Baseline (pre-intervention) and at the end of the 4-week training period (post-intervention).
Resilience	Resilience will be measured using the Brief Resilience Scale (BRS). The score ranges from a minimum of 1 to a maximum of 5. Higher scores indicate higher levels of resilience, representing a better outcome	Baseline (pre-intervention) and at the end of the 4-week training period (post-intervention).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cognitive Performance	Cognitive performance will be assessed using the Stroop Color-Word Test. The score represents the number of correct responses. The minimum possible score is 0, with no strictly defined maximum. Higher scores indicate better cognitive performance, representing a better outcome	Baseline (pre-intervention) and at the end of the 4-week training period (post-intervention).
Academic Achievement	Academic achievement will be assessed using the 9-item Academic Self-Efficacy Scale (ASE). The total score ranges from a minimum of 9 to a maximum of 63. Higher scores indicate higher levels of academic self-efficacy, representing a better outcome	Baseline (pre-intervention) and at the end of the 4-week training period (post-intervention).

Collaborators and Investigators

• Sponsor: Cairo University
• Investigators: Study Chair: Rana H Elbanaa, Assoiate Professor, Cairo University; Study Director: Fatma Y Abdelsalam, Lecturer, Cairo University

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): December 30, 2026
• Study Completion (Estimated): March 1, 2027

Study Registration Dates

• First Submitted: July 7, 2026
• First Submitted That Met QC Criteria: July 7, 2026
• First Posted (Actual): July 13, 2026

Study Record Updates

• Last Update Posted (Actual): July 14, 2026
• Last Update Submitted That Met QC Criteria: July 13, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: CU-AN-19052026

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared to maintain participant privacy and strictly adhere to confidentiality agreements.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No