Tests are an important part of any student’s educational career. Students who suffer from anxiety during exams have difficulty expressing their abilities optimally, which can lead to frustration and impair their learning. Test anxiety is a combination of physiological over-arousal, tension, and somatic symptoms, along with worry, dread, fear of failure, and catastrophizing, which occur before or during test situations (Zeidner, 1998). Technological changes and environmental factors such as a general decrease in an individual’s quality of life may affect test anxiety levels (Alyahya and Almutairi, 2019; Chalutz Ben-Gal, 2020). Several test anxiety treatments have been assessed and reviewed, using various performance outcomes (Tryon, 1980). However, despite advances in test anxiety prevention and management, the worldwide prevalence of newly-diagnosed individuals with anxiety in general, and test anxiety in particular, is expected to rise in the near future due to the COVID-19 pandemic outbreak in December 2019 (Fessell and Cherniss, 2020; World Health Organization, 2020). Furthermore, it has been shown that distance learners are especially prone to mental disorders in general and, more specifically to stress (Harrer et al., 2019).

In recent years, there has been an increase in the implementation of anxiety reduction measures by means of psychological, social, cognitive and educational interventions within educational institutions (Van Dinther et al., 2011; Yeager and Walton, 2011). These interventions also include contemplative practices such as yoga, journaling (Ergas, 2014), and mindfulness (Praissman, 2008; Tarrasch, 2015; Garrison, 2017). Such programs help in supporting students with a variety of challenges as for example learning disabilities and test anxiety (Vaughn et al., 2015; Mitchell and Gansemer-Topf, 2016; von der Embse et al., 2018; Alyahya and Almutairi, 2019). A recent study among higher education students compared two non-pharmacological interventions: mindfulness and device-guided slow breathing, and found that both interventions led to stress reduction (Gabriely et al., 2020). In this paper, we refer to Device-Guided Breathing (DGB), as an exercise that aims at lowering the respiratory frequency to less than 10 breaths per minute with prolonged exhalation guided by an electronic device called RESPeRATE™ (2breathe Technologies Ltd., Israel). This device was cleared by the FDA as an over-the-counter device for self-treatment of hypertension and stress (more details are given below). A growing body of research has emerged over the last few decades examining the effect of DGB on various physiological and psychological symptoms. Several studies have shown that DGB usage decreases general anxiety levels (Gavish, 2010; Ovadia-Blechman et al., 2017) and anxiety experienced by individuals in medical settings (Morarend et al., 2011) and various clinical heart conditions (Lachowska et al., 2019b). In addition, it also aids in post-traumatic stress disorder (PTSD) symptoms (Fonkoue et al., 2018), and in reducing elevated sympathetic nervous activity (Oneda et al., 2010; Harada et al., 2014; Ovadia-Blechman et al., 2017; Fonkoue et al., 2018), and in sensitizing the baroreflex function, which enhances the blood pressure control (Fonkoue et al., 2018). Recent evidence supports the view that slow DGB improves cardiovascular reactivity to mental stress and health-related quality of life in heart failure patients (Lachowska et al., 2019a,b). Deep slow breathing eventually leads to a reduction in cortisol release. In detail, the mechanism underlying cortisol reduction is that deep slow breathing leads to pulmonary stretch receptors activity (Russo et al., 2017), which in turn may cause an increase in heart rate during inspiration and decrease during expiration. This change affects the baroreflex and chemoreceptors, that in turn modulate epinephrine release and the HPA-axis and modulate corticotropic-releasing hormone, which mediates release of adrenocorticotropic hormone (ACTH). Finally, ACTH reduction reduces release of cortisol from the adrenal cortex, thus reducing stress (Dancy and Kim, 2018). It has been shown that reductions in salivary cortisol are also associated with mood improvement (Cruess et al., 2000).

However, despite this evidence, the effects of DGB on students experiencing test anxiety (which impacts test performance) have not yet been evaluated. Accordingly, the objective of the present study was to evaluate the effect of DGB on anxiety levels of students experiencing test anxiety.

Table 1 presents descriptive statistics of the study variables at pre and post 3 weeks of daily practice with device-guided breathing, separately for control and the experimental participants. Our main hypothesis concerning a larger reduction in anxiety in the device-guided breathing group (Figure 3), was non-significant [t(19) = 1.40, p = 0.18, Cohen’s d = 0.61], however the effect size was of a medium size. SBP percent change significantly differed between the groups [t(19) = 2.18, p = 0.04, Cohen’s d = 0.96], with a reduction in the experimental group, compared to an increase in the control group (Figure 4). DBP percent change did not significantly differ between the groups [t(19) = 0.90, p = 0.38, Cohen’s d = 0.40].

The purpose of this pilot study was to assess the effect of DGB on the anxiety levels of patients experiencing test anxiety. Our results indicate that daily practice using device-guided breathing may lead to reduced test anxiety. Although the reduction in anxiety in the DGB group was not significant (perhaps due to the small sample), the effect size was medium, suggesting a possible effect.

High test-anxious individuals display an increased sympathetic nervous system activity (Bian et al., 2022). The physiological mechanisms that can explain the beneficial effects of slow breathing or DGB on this condition are likely to be associated with reducing this elevated sympathetic activity as follows: the need to maintain oxygen supply requires that under isocapnic conditions slow breathing lead to greater lung inflation. Moderate lung inflation was demonstrated to almost completely inhibit muscle sympathetic neural activity from late inspiration to mid-expiration in normal subjects (Seals et al., 1990, 1993). Greater lung inflation that accompanies DGB, or during slow/deep breathing enhances the suppression of the neural sympathetic activity (Harada et al., 2014). The effect stems from activation of low-threshold pulmonary stretch receptors located in the lung and chest wall that initiate vagal afferents (Shepherd, 1981). This process leads to vasodilation in a number of vascular territories such as intact limb, skin, muscle, kidney and splanchnic vascular bed (Daly, 1995), resulting in lowering resistance to blood flow and acute reduction in blood pressure (Parati et al., 2007). Furthermore, local tissue perfusion is provided by microvessels (arterioles) that establish the peripheral resistance to blood flow, where the vessel’s diameter is determined by the tone of smooth muscles embedded in the arteriolar wall that is controlled by sympathetic neural activity (Burton, 1965). Arterioles display spontaneous and continuous diameter oscillations at about 6 cycles/min called “vasomotion” that plays an important role in controlling peripheral resistance (Intaglietta, 1990). Slow breathing at 5–6 breaths/min couples with vasomotion (via the respiration-driven oscillation in the sympathetic neural activity), which results in increased oscillations at the capillary blood flow in a resonance-like form that was observed during DGB (Ovadia-Blechman et al., 2017). A related phenomenon may be the resonance-like increase in the heart rate variability by slow breathing at a rate of 6 breaths/min called “resonance breathing,” which synchronizes increase/decrease in heart rate with the inhalation/exhalation, that are likely to couple with blood pressure oscillation via the baroreflex function (Vaschillo et al., 1983, 2002, 2006; Lehrer et al., 1997). “Prolonged exhalation,” as induced by DGB, reduces the chance of inspiratory muscle fatigue, since its perfusion occurs mainly (or solely) during exhalation. Inspiratory muscle fatigue leads to sympathetic activation (Roussos and Macklem, 1982).

According to previous studies, anxiety in general, and more specifically test anxiety are mental situations, which are accompanied by a wide range of psychological and physiological symptoms (Zeidner, 2010). The physiological symptoms are related to changes in central nervous system activity (CNS). The central nervous system is so named because it integrates information it receives, and coordinates and influences the activity of all parts of the body. Anxiety affects sympathetic nervous system activity and accordingly body functioning, diminishing a person’s ability to function effectively and efficiently (Khan et al., 2017).

Previous studies that investigated the influence of DGB as a clinical therapy for the treatment of the hyperventilation syndrome found reductions in anxiety that served as a relief factor from hyperventilation syndrome (Grossman et al., 1985). Another study (case report) supported the view that DGB decreases “fight-flight” reactions (de Jong and Boersma, 2010).

Research suggests that a slow and regular breathing pattern has a number of beneficial effects on the reflex control of the cardiovascular system (Gavish, 2010). Ten minutes of daily use of the DBG elicited a clinically significant reduction in the BP level in patients with hypertension (Grossman et al., 2001; Schein et al., 2001). Additional research based on DGB suggests that it may be useful as an adjunctive treatment for BP control (Sharma et al., 2011). In the current study, SBP percent change significantly differed between the groups. This finding stems from an increased SBP in the control group. This may be explained by increased stress during the study exams period. It may be possible that the DGB training prevented the increase in pressure observed in the control group (Figure 4). This explanation is supported by previous studies, mentioned above, which have shown the effect of DGB practice on reduction of blood pressure.

Notwithstanding, some studies addressed the challenges of using DGB as a self-treatment tool in the home setting. It was found that the relationship between breathing pattern and BP levels changed over the treatment period, indicating treatment effectiveness. Moreover, the treatment device successfully managed to reduce participants’ breathing rate effortlessly and prolong exhalation (Gavish, 2010), which leads to relaxation.

We believe that our findings may add additional information to both policymakers and students. Recently, scholars highlighted several interventions, with both social and behavioral ingredients, aimed at preventing and treating the indirect effects of the COVID-19 pandemic (Eaton and Kalichman, 2020). Thus, we view the pandemic as a potential trigger to consider DGB practice in educational settings after replicating the present results using larger randomized controlled trials. As a result of the COVID-19 pandemic, education has partly shifted to remote learning and is more technology-based. This form of learning may increase general as well as test anxiety levels among students (Clabaugh et al., 2021). We believe that our results, which implemented individual self-regulation of test anxiety, may have the potential to support possible amelioration in other domains such as quality of life (Chalutz Ben-Gal, 2020). Moreover, students and test-takers may benefit by successfully mastering test management, especially during stressful exam periods, as currently experienced. The adoption process can be implemented by preparation and practice in advance. DGB adoption has a great potential to aid due to its ease of administration, safety, portability, convenience, and non-invasive nature.

Device-guided breathing was found to be a potential tool for test-anxiety reduction. If confirmed in further studies, our results may suggest the adoption of DGB as an alternative treatment for test anxiety. We assume that such adoption may lead to improved test performance. Furthermore, DGB may also be relevant for general anxiety reduction, which is likely to increase due to the ongoing COVID-19 pandemic.

This study utilized a device-guided breathing medical device approved by the FDA and associated with no side effects. It offers an easy and enjoyable self-treatment tool. This may be specifically useful for higher education students who nowadays perform most of their studies remotely, challenged by the ongoing COVID-19 implications.

This study has some limitations. First, our sample was extremely small. Second, our results are based on an intentional clinical trial in the laboratory. As such, they may not indicate students’ actual and real-time performance indicators (e.g., final exam grade). Third, the second measure in our study was concomitant with the beginning of the exams period, and accordingly our results may have been affected by this fact. Accordingly, there is a need to further examine the clinical results on a larger sample, utilizing actual testing settings. Finally, we acknowledge that our main significant finding stems from physiological changes, rather than from actual shifts in anxiety levels in a real-life situation.

This research may be further developed through several avenues. First, we believe that the results of this study may be further assessed in accordance with the identified challenges resulting from the ongoing COVID-19 pandemic. The World Health Organization, as well as other public health authorities in the world, are acting to contain the pandemic. However, this time of crisis generates stress throughout the population. Key influences include mental health and psychosocial well-being in various target groups, including students who are actively engaged in learning (Fessell and Cherniss, 2020; World Health Organization, 2020). In line with WHO recommendations, there is a growing need to find opportunities to amplify positive and hopeful stories, as well as positive images of the future.

Second, several biological and psychological variables may be also collected and analyzed within various populations; for example, in work and organization-related contexts, where employees experience high levels of work stress (Lucini et al., 2007; Fessell and Cherniss, 2020). Third, an interesting line of research may be to examine test anxiety, together with physiological and psychological measures, to assess other interventions, such as mindfulness and relaxing activities (e.g., yoga), or examine the effect on students with learning disabilities and/or attention deficit hyperactivity disorders (Gabriely et al., 2020; Gál et al., 2021).

Finally, it would be interesting to analyze device-guided breathing utilization effects on quality-of-life parameters (Chalutz Ben-Gal, 2020) in the digital and technological era, which is still evolving.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The study was reviewed and approved by Tel-Aviv University Ethics Committee. Participants provided their written informed consent to participate in this study.

ZO-B: conceived the study and designed the trial, supervision, data analysis and data interpretation, writing—original draft, and writing—review and editing. RT: data analysis and data interpretation, writing—original draft, and writing—review and editing. MV: data presentation, writing—original draft, and writing—review and editing. HC: data interpretation, writing—original draft, and writing—review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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