ALTERING WORK TO REST RATIOS DIFFERENTIALLY
INFLUENCES FATIGUE INDICES DURING REPEATED
SPRINT ABILITY TESTING
MICHAEL B. LA MONICA, DAVID H. FUKUDA, KYLE S. BEYER, MATTAN W. HOFFMAN,
AMELIA A. MIRAMONTI, JOSH J. RIFFE, KAYLA M. BAKER, MAREN S. FRAGALA, JAY R. HOFFMAN,
AND JEFFREY R. STOUT
Institute of Exercise Physiology and Wellness, College of Education and Human Performance, University of Central Florida,
Orlando, Florida
ABSTRACT
La Monica, MB, Fukuda, DH, Beyer, KS, Hoffman, MW,
Miramonti, AA, Riffe, JJ, Baker, KM, Fragala, MS, Hoffman,
JR, and Stout, JR. Altering work to rest ratios differentially
influences fatigue indices during repeated sprint ability testing.
J Strength Cond Res 30(2): 400–406, 2016—This study exam-
ined the influence of recovery time on fatigue indices, perfor-
mance (total work [TW], peak power [PP], and mean power
[MP]), and oxygen consumption during repeated sprint ability
(RSA) on a cycle ergometer. Eight recreationally-trained men
performed 3 RSA protocols consisting of 10 3 6 s sprints with
12 s, 18 s, and 24 s rest intervals between each sprint. Fatigue
indices were determined as percent decrement (%Dec) and
rate of decline using either a log transform method or standard
slope approach for TW, PP, and MP during respective RSA
protocols. The maximal V_ O2 value in response to given sprint
intervals and the minimal V_ O2 value in response to given rest
periods (V_ O2work and V_ O2rest, respectively) were recorded. A
repeated measures analysis of variance was used to analyze all
variables. Average V_ O2work was not different among rest inter-
val trials. Average V_ O2rest with 12 s rest was greater than 18 s
and 24 s (2.16 6 0.17 L$min21, 1.91 6 0.18 L$min21, 1.72 6
0.15 L$min21, respectively), while 18 s was greater than 24 s.
Average TW and MP were greater with 24 s rest than 12 s
(4,604.44 6 915.98 J vs. 4,305.46 6 727.17 J, respectively),
with no differences between RSA protocols for PP. No differ-
ences in %Dec were observed. Both methods of calculating
rates of decline per sprint for PP and TW were greater during
12 s than 18 s or 24 s. Since changes were only noted
between the 12 s and 24 s protocols, a 6 s differential in rest
intervals may not be enough to elicit alterations in TW, PP, MP,
Address correspondence to David H. Fukuda, david.fukuda@ucf.edu.
30(2)/400–406
Journal of Strength and Conditioning Research
Ó 2016 National Strength and Conditioning Association
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400 Journal of Strength and Conditioning Research
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or %Dec in RSA performance. Rate of decline may be a more
sensitive measure of fatigue than %Dec.
KEY WORDS repeated sprints, oxygen response, recovery
INTRODUCTION
I
nterval training has become a popular method incor-
porated into many conditioning programs for individ-
uals and team sport athletes from recreational to elite
levels (12,19,26,38). Individuals who can maintain near
maximal sprints for a longer duration have a greater resistance
to fatigue which allows them to perform at higher levels
further into a competition or training session (12,15,19,27).
In an effort to quantify potential performance, and training
response, exercise scientists have developed protocols to mea-
sure repeated sprint ability (RSA), which is defined as the
athlete’s ability to recover and maintain maximal effort during
successive sprints (13). The appropriate RSA protocol should
be representative of the work to rest ratio similar to that
required in the competitive environment (38). For example,
a range of work to rest ratios (1:1–1:5) have been recommen-
ded for preseason soccer training and basketball (1,19,33). De-
pending on the number of sprints needed, the rest period will
need to be sufficient enough to resynthesize phosphocreatine
(PCr), remove metabolic waste, and oxidize lactate (3,15,38).
RSA protocols have been investigated with numerous work
to rest ratios during cycle ergometry (3,4,11,15,23). According
to an investigation by Morin et al. (25), the most common
cycling protocol reported in the existing literature is 6 seconds
of maximal sprints with 24 seconds active, passive, or static rest.
Furthermore, high intensity efforts with less than 30 seconds of
rest can lower adenosine triphosphate (ATP) concentrations,
inhibit the rate of PCr resynthesis, and increase fatigue, thereby
decreasing subsequent sprint performance (37). Longer rest
intervals have elicited greater peak power (PP), mean power
(MP), and lower V _ O2 at rest (15) potentially due to enhanced
PCr contribution to ATP resynthesis. Although recovery dura-
tion has been shown to significantly affect acute V _ O2 response,
muscle oxygen demands may supersede pulmonary V _ O2 (2,6).

Nonetheless, oxygen during rest periods play an integral part in
PCr resynthesis, subsequent performance, and has been linked
to percent decrement (%Dec) (5,10).
Previous studies have used fatigue indices to quantify the
amount of fatigue a participant endures (4,12,14,17,20,38); yet
the methods of calculating fatigue indices in protocols greater
than 10 sprints may fail to observe decrements because of
a plateau in performance variables (14). Percent decrement is
a relative function of total and ideal sprint performance and is
the most widely accepted method of estimating fatigue
(8,14,20,24,38); however its associated variability has been
questioned when measuring RSA performance. Buchheit
et al. (7) measured poor reliability (coefficient of variation
[CV] .20%) in %Dec with 6 shuttle runs lasting 5 seconds
and resting 25 seconds in between. Likewise, Hughes et al.
(20) found poor reliability (CV;30%) in %Dec in 6 six-
second sprints with 30 seconds of rest on a nonmotorized
treadmill. The high variance of %Dec may inhibit significant
Slope ¼ ðThe line of best fit for the natural log of PP ; MP ; or TW data3100Þ3ðNumber of sprints21Þ:
relationships in calculated fatigue rates between RSA tests
(12,29,30). Because the literature has not appeared to estab-
lish a gold-standard (28,30), the need for an index that can
distinguish between work to rest ratios may be warranted.
Glaister et al. (14) proposed an alternative rate of decline
formula that used the back transformation of the regression
line for log transformed MP values from RSA testing on
a cycle ergometer. As opposed to the traditional %Dec for-
mula, that uses values from either the first sprint or the sprint
with the best performance, the alternative rate of decline for-
mula considers power output from each sprint and a linear
relationship between sprint number and performance data
(14). Similar intraclass correlation coefficients (ICCs) have
been shown between the 2 measures and between different
rest intervals (14). Interestingly, a follow-up investigation (17)
demonstrated poor reliability in running-based RSA protocols.
The aim of this study was to distinguish between fatigue
indices, oxygen consumption, and sprint performance within
closely bound work to rest ratios, similar to those required in
a competitive environment during RSA testing on a cycle
ergometer. Our hypothesis is that larger work to rest ratios
of 1:2, 1:3, and 1:4 will elicit greater fatigue rates and oxygen
consumption accompanied by decreased performance (PP,
MP, and total work [TW]).
METHODS
Experimental Approach to the Problem
A within-subject, repeated measures study design was used
to compare physiological response (V_ O2) and performance
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(PP–the highest power output achieved during a 6-second
bout, TW–the accumulated work during a 6-second bout,
and MP–the average power output maintained throughout
a 6-second bout), during RSA testing. Percent decrement in
PP, MP, and TW over the RSA was calculated as previously
described (12,15) using the following formula (F1):
average value2maximum value
Percent decrement ¼ 3100:
maximum value
Secondly, the rate of decline was calculated as the back
transformation of the slope of the line of best fit for log-
transformed PP, MP, or TW values over 10 sprints (14,17,32)
using the following formula (F2):
 
Fatigue ¼ 1003EXP ½slope=10 2100 ;
where
Lastly, the rate of decline was also calculated as the slope
coefficient from the regression line formed by the relation-
ship between the number of sprints completed and the
relevant RSA performance variables, including PP
(W$sprint21), MP (W$sprint21), and TW (J$sprint21) (F3).
Each participant visited the Human Performance
Laboratory on 5 occasions. The first visit was for initial
screening during which anthropometric values were
collected and paperwork was completed; the second visit
involved a familiarization session during which each
participant performed a series of familiarization sprints.
The final 3 visits were the actual testing sessions. During
the testing visits, participants completed 3 different RSA
protocols to compare differences in oxygen consumption
and performance variables among varying work to rest
ratios. Participants completed the entire study over 3
weeks.
Subjects
Eight healthy, recreationally-trained men (23.5 6 4.0
years; 174.3 6 6.1 cm; 75.1 6 10.9 kg) between the ages
of 19 and 30 volunteered for this study. It was required that
these individuals exercise at least 2 days per week. Before
enrolling in the study, all participants completed a confi-
dential medical and activity questionnaire and a physical
activity readiness questionnaire to determine if they had
any physical limitations or chronic illnesses that would
affect their performance. Throughout the study, partici-
pants were asked to maintain their normal dietary and
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 Fatigue Indices During Repeated Sprint Ability Testing

TABLE 1. Comparison of physiological and performance variables.*

12 s (n = 8) 18 s (n = 8) 24 s (n = 8)

V_ O2work (L$min21) 3.77 6 0.53 3.87 6 0.75 3.68 6 0.72

V_ O2rest (L$min21) 2.16 6 0.17†z 1.91 6 0.18§ 1.72 6 0.15
Average TW (J) 4,305.46 6 727.17† 4,494.99 6 890.75 4,604.44 6 915.98
Average MP (W) 735.01 6 122.05† 764.46 6 148.27 785.09 6 154.53
Average PP (W) 1,091.23 6 203.23 1,098.85 6 227.22 1,105.83 6 245.27
_ O2work = maximal V_ O2 response to work bout; V_ O2rest = minimal V_ O2 response to rest interval; TW = total work per sprint; MP =
*V
mean power per sprint; PP = peak power per sprint.
†Significantly different (p # 0.05) between 12 and 24 s.
zSignificantly different (p # 0.05) between 12 and 18 s.
§Significantly different (p # 0.05) between 18 and 24 s.

nutritional intakes around each scheduled testing day.
Participants were also told to refrain from vigorous exer-
cise within 48 hours before each testing day which would
result in residual soreness or fatigue. The study was
approved by the university institutional review board and
all participants provided written informed consent before
beginning the study.
Procedures
Familiarization. Participants who met the preliminary study
criteria returned to the Human Performance Laboratory
and were familiarized with the experimental procedures.
The participants performed approximately 10 six-second
maximal sprints against a load, equivalent to 0.75 N$kg21
of body mass interspersed by 24 seconds of unloaded
cycling.
Gas Exchange Analysis. All gas exchange data were col-
lected using open circuit spirometry (True One Metabolic
Cart, Parvo Medics, Inc., Sandy, UT, USA).
Twenty minutes before each RSA protocol, the unit was
calibrated with room air and gases of known concentra-
tion. Flowmeter calibration was also performed before
exercise to determine the accuracy of flow volume while
collecting data. Participants wore a head unit and mouth
piece that stabilized a one-way valve around their mouth.
Breath-by-breath oxygen and carbon dioxide values were
analyzed through a sampling line after the gases pass
through a heated pneumo-
tach and mixing chamber.

Repeated Sprint Ability Testing.

The participants performed
a 4 minute warm-up at a self-
selected intensity interspersed
with 4 submaximal sprints last-
ing 4 to 6 seconds on a cycle
ergometer. After the warm-up,
participants were asked to per-
form 3 maximal 6-second
sprints interspersed with 24
seconds of rest to establish PP
output. The average of the 3
maximal sprints was used to
establish PP output (11) and
the first sprint was verified, at
or greater than 85% PP
output, to ensure participants
Figure 1. Breath-by-breath V_ O2 response in relation to each sprint. W = V_ O2work (maximal V_ O2 value attained in were giving near maximal
response to a given sprint interval). R = V_ O2rest (lowest V_ O2 value attained in response to a given rest period). The
rest bouts (24 s, 18 s, and 12 s) illustrate each of the 3 RSA protocols all with 6 s maximal sprints as the work effort throughout the trials.
bout. V_ O2 = oxygen response. The warm-up and peak power
establishment was followed by
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402 Journal of Strength and Conditioning Research

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Figure 2. Average mean power data for the 3 RSA protocols. The rest
bouts (24 s, 18 s, and 12 s) illustrate each of the 3 RSA protocols all
with 6 s maximal sprints as the work bout.
5 minutes of passive rest to ensure adequate recovery (1).
The participants then performed 10 six-second sprints
against a load, equivalent to 0.75 N$kg21 of body mass
interspersed by 24 seconds of unloaded cycling. The
participants were asked to place their legs in a standardized
starting position with their feet firmly strapped into
the metal pedals. Before each sprint, the dominant
foot was set in a standardized position as previously
described (3).
This protocol was repeated during 2 additional testing
sessions (visit 4 and visit 5) with a minimum of 48 hours of
recovery between each visit. The rest intervals during
successive repeated sprint protocols were 18 seconds and
12 seconds, respectively. Gas exchange analysis (as
described above) was conducted throughout the test to
determine oxygen uptake (V_ O2). During breath-by-breath
V_ O2 analysis, the maximal V_ O2 value attained in response to
a given sprint interval was deemed V_ O2work and the lowest
V_ O2 value attained in response to a given rest period was
deemed V_ O2rest.
Figure 3. Average total work data for the 3 RSA protocols. The rest
bouts (24 s, 18 s, and 12 s) illustrate each of the 3 RSA protocols all
with 6 s maximal sprints as the work bout.
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Statistical Analyses
Breath-by-breath gas exchange analysis data was converted
to text files and further analyzed using a custom program
within the LabVIEW software (National Instruments,
Austin, TX, USA). All RSA V_ O2 data were fit with a cubic
spline interpolation function and plotted over time for each
trial and analyzed for each high and low value throughout the
trial. To smooth out the V_ O2 data, a low pass Butterworth
digital filter with a cut-off frequency of 0.06 Hz was used as
suggested by Robergs, et al. (35). V_ O2work and V_ O2rest
were also collated as averages for each RSA trial to further
compare physiological response between the work to rest
ratios. Statistically significant changes and differences between
trials were determined using SPSS (version 21.0; SPSS, Inc.,
Chicago, IL, USA). Data were analyzed for normality via the
Kolmogorov–Smirnov test and parametric statistics were con-
ducted. Repeated measures analysis of variance was used to
analyze the changes in all variables. In the event of statistical
significance, least significant difference (LSD) tests were used
for post hoc analyses. Results were considered significant at
an alpha level of p # 0.05.
RESULTS
The physiological response and performance values are
listed in Table 1.
Physiological Response
When analyzing V _ O2work during RSA trials there were no
significant differences among trials (F = 0.755, p = 0.488, h2 =
0.097). However, V_ O2rest was significantly different between
trials (F = 21.084, p , 0.001, h2 = 0.751) with 12 seconds
being significantly greater than 18 seconds (p = 0.001) and 24
seconds (p = 0.001), and 18 s being significantly greater than
24 seconds (p = 0.045). The average oxygen response
(V_ O2work and V_ O2rest) for each sprint across the RSAs are
represented in Figure 1.
Performance Response
When analyzing average TW throughout the RSA trials,
there were significant differences between trials (F = 4.867,
p = 0.025, h2 = 0.410) with 12 seconds significantly less than
24 seconds (p = 0.012) (Table 1). For average MP, there was
a significant difference between trials (F = 5.412, p = 0.018,
h2 = 0.436) with 12 seconds significant less than 24 seconds
(p = 0.013). However, for average PP, there were no signif-
icant differences among trials (F = 0.146, p = 0.866, h2 =
0.020) (Table 1). The average MP and TW for each sprint
across the RSAs are represented in Figures 2 and 3.
Fatigue Indices
Fatigue indices are listed in Table 2. When analyzing the %
Dec during the RSA trials, there were no significant differ-
ences among trials in PP (F = 17.608, p = 0.071, h2 = 0.315),
TW (F = 29.266, p = 0.141, h2 = 0.244), or MP (F = 0.760,
p = 0.486, h2 = 0.098). When analyzing the rate of decline
(F2), there was significant difference between trials for PP
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 Fatigue Indices During Repeated Sprint Ability Testing

(F = 4.045, p = 0.041, h2 = 0.366) with 12 seconds signifi-

cantly greater than 24 seconds (p = 0.019), and 12 seconds

*PP = peak power; MP = mean power; TW = total work; F1 = percent decrement; F2 = back transformation of the slope of the line of best fit for log-transformed PP, MP, or TW;
14.13 6 9.93 13.23 6 5.09 15.14 6 9.07†z 79.5 6 51.64†z
significantly greater than 18 seconds (p = 0.028) and 24

F3 (J$sprint21)

22.33 6 37.80
4.09 6 11.39 9.53 6 5.18 4.72 6 10.56 22.55 6 62.88
seconds (p , 0.001) for TW (F = 6.465, p = 0.031, h2 =
0.480). When analyzing the rate of decline (F3) during RSA
trials, there were significant differences between trials for PP
(F = 3.921, p = 0.044, h2 = 0.359) with 12 seconds signifi-
cantly greater than 24 seconds (p = 0.034) and for TW (F =
6.067, p = 0.035, h2 = 0.464), with 12 seconds significantly
F2 (J$sprint21)

10.5 6 4.81 4.20 6 7.21

greater than 18 seconds (p = 0.034) and 24 seconds (p ,
TW

0.001). However, there were no significant differences

among trials for MP (F = 4.624, p = 0.058, h2 = 0.398).

DISCUSSION
F3 = slope coefficient from the regression line formed by the relationship between the number of sprints completed and PP, MP, or TW.

This investigation examined the influence of recovery on

F1 (%)

oxygen consumption, and performance measures utilizing

different work to rest ratios during RSA testing. Differences,
over 10 sprints, were observed in average V_ O2rest between
trials; however, no differences were seen in average
V_ O2work. Furthermore, performance differences were signif-
F2 (W$sprint21) F3 (W$sprint21)

5.95 6 8.05

icant among RSA trials in average TW and MP. Although no

differences were observed in %Dec for TW, MP, or PP,
differences were seen in both the log-transformed and stan-
dard slope methods of calculating the rate of decline for PP
and TW.
8.76 6 10.39 10.41 6 5.10 5.06 6 11.14

In this investigation, V_ O2rest was significantly greater in

17.86 6 7.48† 12.51 6 5.27 15.67 6 9.86
7.68 6 7.89 11.05 6 4.68 6.63 6 8.99

the 12-second trial as compared with the 18-second and 24-

MP

second trials (;12% and ;20% greater, respectively) and the

18-second trial was significantly greater than the 24-second
trial (;10% greater). These results were similar to those
TABLE 2. Comparison of various fatigue calculations among rest intervals.*

reported by Glaister et al. (15) who reported a ;16% differ-

ence in mean V_ O2 during recovery with the shorter rest pro-
F1 (%)

tocol (10 seconds) being greater than the longer rest

protocol (30 seconds), but over 20 sprints. Likewise, Balsom
et al. (2) observed higher V_ O2 at the end of shorter rest
periods (60 seconds) as compared with longer rest periods
F2 (W$sprint21) F3 (W$sprint21)

†Significantly different (p # 0.05) between 12 and 24 s.

zSignificantly different (p # 0.05) between 12 and 18 s.

(120 seconds) in 15 3 40 m sprints. V_ O2 off kinetics may help

explain why the oxygen consumption during the rest periods
was significantly different between RSA protocols. Because
maximal V_ O2 is not easily adapted, especially in short term
(1), the ability to return to pulmonary homeostasis can
severely be affected by the amount of rest because of char-
12 s 9.68 6 2.42 13.63 6 5.38†
18 s 6.86 6 2.90 6.66 6 6.33
24 s 7.45 6 3.48 6.80 6 7.09

acteristics of V_ O2 off kinetics and subsequent PCr resynthesis

PP

(34). This explanation is further supported by the relation-

ship between V_ O2 kinetics and RSA performance. Dupont
et al. (10) found a significant positive correlation with the
time constant associated with the fast component of V_ O2 off
kinetics following severe intensity exercise and %Dec of
F1 (%)

power over the course of repeated sprints. Although pulmo-

nary V_ O2 in relation to each sprint bout did not differ
between protocols, oxygen demand from the active muscles
was likely high and there may have been a greater reliance
Rest

on oxidative metabolism to restore PCr (5,31).

The manipulation of rest intervals also had a significant
effect on TW and MP, that were significantly lower in the 12
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seconds compared with 24 seconds protocol. The elevated
V_ O2rest observed during the shorter (e.g., 12 seconds) rest
intervals indicated that insufficient recovery was likely
related to insufficient PCr resynthesis over the course of 10
sprints which may explain the lower TW and MP compared
with the 24 seconds rest protocol. Dawson et al. (9) reported
that PCr concentrations after a single 6-second sprint were
55% of pre-exercise values and 27% of pre-exercise values
after 5 six-second sprints on a cycle ergometer indicating
that PCr levels are reduced for ATP resynthesis during
recovery (9,16,22,38). Glaister et al. (15) reported similar
findings among rest periods of 10 seconds and 30 seconds.
In addition, an accumulation of metabolic by-products such
as inorganic phosphate (Pi), which can affect calcium
release, may also play a significant role in fatigue (15,22).
Since removal of Pi is an oxygen dependent process, it ap-
pears that the 24 seconds rest interval allowed for the great-
est reduction in oxygen consumption and enhanced Pi
removal compared with the shorter rest intervals. However,
the rate of PCr resynthesis and removal of Pi likely did not
affect PP among the rest intervals; potentially due to the
initial phase of PCr resynthesis being unaffected by the met-
abolic environment (22,36,39). This is supported by Harris
et al. (18) who reported a time of 21–22 seconds to replenish
half of PCr stores in the initial fast phase of PCr resynthesis
after dynamic movement. Thus, the used work to rest ratios
may not have been high enough to stimulate changes in PP
during the 10 sprints. Therefore, the difference observed
among rest intervals may have been a result of the rate of
PCr resynthesis (15).
Despite differences in performance variables, there were
no significant differences in %Dec among the RSA protocols
in the current investigation. Negligible fatigue rates may
stem from the number of subsequent sprints and the
duration or intensity of the sprint and rest bouts (4,30).
Another possibility could be that the participants experi-
enced a training effect and became more economical as
a 20% decrease in muscle oxygen utilization has been shown
in as little as 2 high-intensity interval training sessions (21).
Many RSA studies have been conducted using recreationally
trained individuals which may lead to a lack of effort given
(14,17,20,24). While %Dec is commonly evaluated and re-
ported within the RSA literature, and it has been suggested
as the most appropriate fatigue rate measure (14), some evi-
dence suggests lack of validity and reliability (4,20,29,30).
The rates of decline produced using F2 and F3 demonstrated
the ability to discriminate between differing work to rest
ratios whereas %Dec did not. Both F2 and F3 took into
account performance for each of the 10 sprints, however,
the assumption that the performance variables over 10
sprints are linear may cause potential issues (14). Because
there is inconclusive evidence as to which fatigue rate is
most appropriate and there is not a gold-standard (14,17),
the rate of decline using either F2 or F3 should be consid-
ered viable options. Given the similar discriminative ability
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between these formulae, F3, with a less involved calculation
procedure, may provide a more straightforward and practi-
cal method of calculating fatigue during RSA testing.
Follow-up studies should consider the use of blood
lactate concentrations during RSA trials which may pro-
vide greater insight on performance variables and fatigue
rates. In addition, greater than 6 seconds between RSA
protocols should be used to elicit substantial differences in
performance variables over 10 sprints of 6-second maximal
work bouts. Because RSA testing was conducted on a cycle
ergometer, and most sports emphasize running as their
primary means, future studies should investigate RSA with
varying rest intervals on a treadmill or other sport-specific
modes.
PRACTICAL APPLICATIONS
In summary, this study indicates that V_ O2 response during
rest periods remains higher in RSA protocols with larger
work to rest ratios despite the absence of differences in %
Dec. Researchers should be aware that despite small changes
in rest periods, elevated V_ O2 during rest periods may have
profound effects on prolonged duration sprints and possibly
time to exhaustion. Because of the uncertainties in %Dec and
the results of this study, rate of decline may be a more
sensitive measure of fatigue because extremely high perfor-
mance values may affect the %Dec calculation. In particular,
the slope of the regression line formed by the number of
sprints completed and PP, MP, or TW may provide a similar
method of calculating rate of decline compared with the
back transformation of the slope of the line of best fit for
log-transformed PP, MP, or TW. Future investigations of
RSA should measure V_ O2max for baseline measurements
and use testing protocols with varying work to rest ratios.
These protocols should implement differences in the rest
intervals of greater than 6 seconds to elicit potential differ-
ences in performance. Furthermore, studies should examine
varying work to rest ratios on a treadmill to examine perfor-
mance differences with different modes of exercise.
ACKNOWLEDGMENTS
The authors thank the group of participants for their
dedication and the staff of the Institute of Exercise Physiol-
ogy and Wellness for their help with data collection and
analysis.
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