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

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.

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

Individual participant data will not be shared to maintain participant privacy and strictly adhere to confidentiality agreements.