Physiological Demands of Playing Position in Volleyball During Competition: A Case Report

A Thesis

Presented to the

College of Rehabilitation Sciences

University of Santo Tomas

In Partial Fulfillment

of the Requirements of the Degree

Bachelor of Science in Sports Science

by

Kris Anthony T. Agarao MSHMS,XPS

Christine Bernadette L. Alvarez
Tiffany Vale D. Bautista
Katrina Mel E. Lantin
Nathan Ryan N. Lim
Gabriel Christian C. Lucero
Atlantis Marcus D. Tan

March 28,2019
Date:

CERTIFICATE OF APPROVAL

This is to certify that I approve the submission of final thesis to College of Rehabilitation
Sciences of the University of Santo Tomas through the Center for Health Research and
Movement Science. The final thesis contains revisions based on comments made by the
judges of oral presentation. As faculty primary author, I vouch that the thesis is ethically,
technically and scientifically sound.

Signed by:

_____________________________________________

Name of Faculty Author

1
 Physiological Demands of Playing Position in Volleyball During Competition: A Case Report

Kris Anthony T. Agarao MSHMS,XPS, Christine Bernadette L. Alvarez, Tiffany Vale D. Bautista,
Katrina Mel E. Lantin, Nathan Ryan N. Lim, Gabriel Christian C. Lucero, Atlantis Marcus D. Tan

College of Rehabilitation Sciences

University of Santo Tomas

Corresponding Authors

Kris Anthony T. Agarao MSHMS,XPS Christine Bernadette L. Alvarez

ktagarao@ust.edu.ph christinebernadette.alvarez.crs@ust.edu.ph

0917 512 7116 0916 872 7238

2
 Table of Contents

Content Page

1. Abstract…………………………………………………………………………………….. 8

2. Introduction.............................................................................................................. 9-11

3. Materials and Methods……………………………………………………………………. 11-18

4. Results……………………………………………………………………………………… 19-28

5. Discussion…………………………………………………………………………………. 29-34

6. Literature Cited……………………………………………………………………………. 35-36

7. Appendices………………………………………………………………………………… 37-35

3
 List of Figures

Figure Page

1. Figure 1. Camera Set up in the court…………………………………….……………….. 16

2. Figure 2.Heart Rate (HR%) of Libero........................................................................... 20

3. Figure 3. Heart Rate (HR%) of Setter ……………………………………………………. 20

4. Figure 4. Heart Rate (HR%) of Outside Spiker………………………………………….. 21

5. Figure 5. Heart Rate (HR%) of Middle Blocker……………………………………...…… 21

6. Figure 6. Heart Rate (HR%) of Opposite Spiker………………………………………. 22

7. Figure 7. Breathing Rate (BR%) of Libero……………………………………………….. 22

8. Figure 8.. Breathing Rate (BR%) of Setter……………………………………………… 23

9. Figure 9. Breathing Rate (BR%) of Outside Spiker……………………………………… 23

10. Figure 10. Breathing Rate (BR%) of Middle Blocker……………………………………. 24

11. Figure 11. Breathing Rate (BR%) of Opposite Spiker…………………………… 24

12. Figure 12. Estimated Core Temperature (ECT) of Libero……………………………… 25

13. Figure 13. Estimated Core Temperature (ECT) of Setter…………………………......... 25

14. Figure 14. Estimated Core Temperature (ECT) of Outside Spiker……....................... 26

15. Figure 15. Estimated Core Temperature (ECT) of Middle Blocker……....................... 26

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 16. Figure 16. Estimated Core Temperature (ECT) of Opposite Spiker……..................... 27

17. Figure 17, Total run frequency from sets 1-3………………………….......................... 28

18. Figure 18. Total jump frequency from set 1-3………………………….......................... 28

5
 List of Tables

Figure Page

1. Table 1. Inclusion and Exclusion Criteria……………………………………………. 11

2. Table 2. Demographic variables…………………………………………………… 19

3. Table 3. Time Frame of each activity during data gathering process……………... 19

4. Table 4 Frequency of Run per position during the 3 sets…………………………… 27

5. Table 5 Frequency of Jump per position during the 3 sets…………………………. 28

6
 List of Appendices

Appendix Page

1. Appendix A. Authorship Form …………………………………………………………. 37-39

2. Appendix B. Data Gathering Sheet……………………………………………………. 40

3. Appendix C. Letter to the head coach………………………………………………… 41

4. Appendix D. Participation Information Sheet Consent Form……………………… 42

5. Results of Raw Data……………………………………………………………………. 43

6. Appendix F. Ethical Approval Form…………………………………………………… 44

7
 ABSTRACT
Background: Prescribing appropriate training loads to help maximize an athlete’s performance
has become a daunting task for strength and conditioning coaches. The use of biomonitors can
help coaches to prescribe appropriate training loads that is anchored on the balance between the
of amount of work and recovery necessary to stimulate positive training adaptation.

Objectives: This study aims to monitor the on court physiological demands (heart rate,
respiratory/breathing rate, and Body Temperature) and movement frequency of running and
jumping of different playing positions in volleyball.

Methods: This research is a case report of a quantitative descriptive study. Five high school
volleyball players from grades 8-12 were recruited as the participants that would represent each
position in the sport. Heart rate (HR), breathing rate (BR), and estimated core temperature (ECT)
were monitored using the Zephyr bioharness. Sprint and jump frequency were tallied manually
during competition and retallied via video recording of the game.

Results: There was an increase in physiological load responses (HR, BR, ECT) during warm up
and were maintained in their increased measures throughout the game. Run and jump
frequencies were tallied per set with the setter having the highest jump count (53±15.39) and the
Opposite spiker for the run count (66.67± 12.09).

Conclusion:

Keywords: volleyball; physiologic demands; biomonitors; time-motion analysis

8
 INTRODUCTION

Prescribing appropriate training loads to help maximize an athlete’s performance while preventing
overtraining and injury has become a daunting task for strength and conditioning coaches. One
of the proposed solutions for this is through athlete monitoring through the use of biomonitors. A
study by Aoki, et al. in 2017 investigated on the dynamics of training load during a sports season.
The result of this study suggest that training loads imposed on the athlete should be carefully
monitored as this method provides coaches with a comprehensive understanding of the whole
training process, giving them the ability to reactively adjust their training programs based on the
athlete’s degree of freshness.

Coaches nowadays have never been more pressured to win. Due to this, coaches tend to train
their athletes to their physical and physiological limitations to stimulate training adaptation (Piggot.
2008). Sadly, this practice of unmonitored introduction of high training stress in a short amount of
time has led to an increase in the incidence of injury and/or overtraining (Anderson, et. al. 2003).
The use of biomonitors in sport such as basketball, football and volleyball has been widely used
in the western countries to monitor training load (Karkazis, et. al. 2017). Biomonitors provide
useful information such as heart rate, breathing rate and estimated core temperature during
competitive games and training. These parameters have been used to monitor an athlete’s
response to a given load whether in-game or training (Couts & Cormack. 2014). These data can
help coaches prescribe appropriate training loads that is anchored on the balance between the of
amount of work and recovery necessary to stimulate positive training adaptation (Scanlan, et. al.
2014).

One of the popular wearable system that has been utilized in sports is the Zephyr Bioharness
3.0 (BH3). The system has been specifically designed for training optimization of athletes by
spontaneously tracking several biological parameters that include heart rate, breathing rate and
estimated core temperature. The said wearable system has been proven reliable and valid tool to
7,8,9
monitor physiological information during both field and laboratory setting.

9
Application of the wearable system in a sport like volleyball would help coaches to rethink their
training strategies and methods to maximize performance. High demanding sports such as
volleyball utilizes both aerobic and anaerobic power to successfully perform necessary movement
skills during competition. High intensity rallies and short time for rest puts increased demands on
the physiological level of the athletes. Due to the demands of the sport, a specific energy system
will be utilized for maximum performance. Volleyball is a sport normally dominated by the
anaerobic system. Due to the structure of the game, players experience repetitive bouts of high
intensity movements but a period for recovery is also present. Work period is defined as when
the ball is in play. The recovery period is when ball is not in play. Volleyball players must therefore
be capable of generating energy rapidly and also must be capable of recovering given a short
period of time in anticipation of the next point. As a result, the aerobic and the anaerobic systems
plus the ATP-PC system must be well trained and developed to perform maximum athletic
performance (VanHeest, 2003). Player positions specialization strategies greatly impact the
physiologic demands among volleyball players. (Sheppard et al 2009) In comparison with setters,
attack jumps were frequently done by the middle hitters. Middle hitters were taller therefore having
them an increased reach height and body mass compared to outside spikers. (Sheppard et al,
2009)

In general, what is known from the current literature according to multiple sources, are stated as
follows: the psychological factors such as situational or external factors (Mohammadzadeh,
2014), physiological and anatomical elements referring to compensations or changes in the
anatomical integrity as a result of functional adaptations (Lidor, R & Ziv, G., 2010), anthropometric
components implying fitness and physiologic testing (Gioldasis, 2016) as a whole, brings about
significant effects and changes upon all the physiological parameters and adaptations of that of
the general female collegiate volleyball athlete population. Majority of the research papers
gathered obtained a reasonable score in the CASP. Although the scores were high, most of the
articles did the same tests. Studies found would have been more relevant if there were tests that
show variation. Varying positions showed differences in physiologic demands (Sheppard et. al.,
2009). Another gap was that the articles were only about the skills of the players, the strength and
conditioning status were not recorded in which it may also be a cause of an improvement or an
unsatisfactory performance. And also limited resources were generated from Filipino volleyball
players and aside from this, other sports have “during competition” literature however it lacks for

10
Volleyball. The researchers will contribute to the connection of physiological demands needed
per position played in the sports and how this can affect performance. There were no articles that
took record in a live game or practice. The previous studies gathered their data regarding time
motion analysis using a video recording (Croitoru et. al., 2013), Most of the gathered articles took
their data from video recording, failing to consider the possible factors from the players when
assessed in person. There were also limited articles available in the country.

Based from the review of literature, this study aims to:

1. Monitor the on court physiological demands (such as heart rate, respiratory/breathing

rate, and Body Temperature) of different playing positions in volleyball.
2. Assess the frequency of run and jump performed by volleyball players of different playing
positions.

METHODOLOGY

11
Ethical Considerations

This research was conducted in accordance with the ethical principles that originated from the
Declaration of Helsinki and are consistent with the Good Clinical Practice Guidelines. To ensure
compliance, faculty and student authors of this paper were all certified by the UST-CRS Ethics
Review Board on Good Research Practice Guidelines. Moreover, ethical approval has been
sought from the Ethics Review Committee of the College of Rehabilitation Sciences, University of
Santo Tomas.

The following procedures were conducted to ensure safety of the participants once ethical
approval has been sought:
● Prior to the study, the researchers asked permission to the head coach of the team
for the recruitment of the female volleyball players as participants of the study.
● Upon recruitment, all participants were asked to fill-out an Informed consent form
(Appendix B) approved by the UST-CRS Ethical Review Board.
● The participants were informed during the orientation and the day of data gathering
that they may choose to back out if they feel any type of discomfort when wearing the
Zephyr Biomonitor during the dry run and games.
● Participants were also informed that data obtained from this study will be kept
confidential and codes were used instead of their real names. All personal information
gathered from the participants were encoded to a password protected laptop
computer that can only be accessed by the researchers and the ethical review board.
All data had been deleted two years after the study was conducted.
● All completed questionnaires were kept in a sealed brown envelope that can only be
accessed by the researchers. After data analysis, all data was transferred at the
Center for Research on Health and Movement Science for a period of two years.
● Any adverse effect of assessment protocols was immediately reported to the UST-
CRS Ethical Review Board and other concerned organizations.
● There was no conflict of interests presumed to occur between the researchers and
the participants of this study.
● A copy of the final manuscript has been submitted at the UST-CRS-ERB after the
research writing course.

12
Study Design

In order to fulfill the objectives of the study, the researchers utilized a descriptive case series
research design since one athlete per volleyball position were monitored during volleyball games.
Physiological load response (Heart Rate, Breathing Frequency, Estimated Core temperature) and
frequency of run and jump during a volleyball game were tracked over one (1) non-competitive
volleyball game.

The study period can be divided into two (2) phases; the first phase of the study involved a dry
run of the procedures while the second phase is the actual conduct of the research.

Phase 1: Dry Run of Procedures

The dry run of procedures was conducted for one (1) practice game utilizing the female volleyball
players as participants. Dry run testing was conducted with the following purpose:

● To familiarize the researchers on how to operate the wearable system.

● To identify possible problems that may occur during athlete monitoring
● To test if the athletes will experience discomfort wearing the Zephyr Bioharness during the
duration of the game.
● To serve as sample data for analysis

Procedures for dry run

30 minutes before training the researchers set up the two video cameras at the practice court
illustrated in (Figure 1). The Zephyr Bioharness 3.0 (BH3) system was then prepared by doing
the following steps:

● Assembly of the Zephyr Bioharness sensor & strap

● Set up of the Zephyr Echo gateway transmitter
● Turn on the laptop with installed Zephyr software
● Encoding of demographic data of the dry run participants (name, age, height, weight)

13
20 minutes prior training the researchers asked the head coach on which players will constitute
the starting six. The five (5) of the identified starting six was then selected for monitoring of
physiological variables and time motion analysis during the dry run. The selected participants
were assisted by the researchers in wearing the Zephyr Bioharness. After the Bioharness has
been worn by all the participants, the researchers checked if the players feel any type of pain and
discomfort. In the event that an athlete complaint of discomfort, the researchers immediately
adjusted the tightness of the Bioharness. This steps in monitoring the participants were done
repeatedly before, during and after warm up.

During the game, each selected athlete was assigned with one researcher. The assigned
researcher was tasked to perform Frequency count of run and jump and was responsible for
monitoring if the athlete felt any type of pain or discomfort during the game. A separate researcher
was also assigned to operate the laptop with installed Zephyr software to check if all the devices
are transmitting data. In the event that one of the devices failed to transmit data, the assigned
researcher immediately informed one of the coaching staff so that the researchers made the
necessary adjustments during break.

After training, the researchers assisted the participants in removing the Zephyr Bioharness.
Simultaneously, another set of researchers performed after care on the video camera, laptop,
transmitter and receiver that were used.

All problems encountered during the dry run were listed and possible solutions were formulated
before commencing the data gathering in pre-season games.

Phase 2: Actual conduct of study

Sampling Procedure & Participants

Purposive sampling was utilized to identify high-school volleyball players playing in different
positions (outside spiker, opposite spiker, setter, middle blocker & libero). All participants have
met the inclusion criteria summarized in Table 1.

14
Table 1. Inclusion and Exclusion Criteria
Inclusions Exclusions
Grades 8-12 high school female volleyball Any player who has musculoskeletal injury, not
athlete cleared by physician

Greater than one(1) year of playing experience Players who underwent surgery 1 year prior
the conduct of the study

Setting of the Study

The dry run of procedures was measured at the Sports Science laboratory located at the 1st
floor of the Quadricentennial Pavilion University of Santo Tomas, España Manila. Data
gathering and all anthropometric measurements were conducted at the covered volleyball court
located at the training gym of Hope Christian High School, Sta,Cruz Manila.

Outcome Measures

Primary outcome measures

A. Physiological Load Response including %Heart Rate, Breathing Frequency and Estimated
Core Temperature were monitored using a multivariable portable monitoring device which
is the Zephyr Bioharness 3.0 (BH3). This wearable system has been proven valid and
reliable to monitor physiological load response both in the field and in the laboratory
(Johnstone, et. al. 2012). For heart rate (bpm), the multivariable portable monitoring
device have a high test retest reliability (r=0.91, p<0.001: CV < 7.6) using the Polar T31
(Polar Electro) as a criterion. Breathing Frequency (Brpm) has also been reported to have
a moderate degree of reliability (r=0.61, p<0.001: CV <23.7) using Cortex Metalyser
Spirometer as a criterion. Estimated core temperature ( 0C), on the other hand, reported
high degree of reliability (r=0.86) using a standard rectal Thermometer as a criterion (Seo,
et. al. 2016).

Frequency of run and jump during the game were through the manual tallying of the
researchers. A tally for jump includes jumps during the serve,spike, block and set. A run
was tallied if there was a minimum of three step displacement forward, backward, and
sideward. This include approach before a spike, lateral shuffle before a block, and back
pedal. The data obtained from the manual tallying were then crossed-checked using a

15
 video review. One video camera was placed on the playing side of our participants to
record the game. Camera placement is illustrated in Figure 1.

Figure 1. Camera set-up in the court

Secondary outcome measures

Anthropometric measurements including the height and weight of the participants were measured
using a Detecto weighing scale and stadiometer. This data were utilized to describe the
participants and was also encoded at the Zephyr Bioharness 3.0 (BH3) System.

Procedure
A. Pretest Preparations
The researchers conducted an orientation for the coaches and athletes two days prior to
the data gathering. In the orientation, participants were asked to read and sign an informed
consent form wherein all-important information were clearly stated.

Calibration and inspection of equipment was also performed three days before and on the
day of the actual data gathering to ensure that all equipment were functional. Also, data
gathering sheets were prepared and checked on the same time period.

16
 B. Data Gathering
The study was conducted in one volleyball practice game. During the game day,
approximately 1-2 hours before the match, participants were asked to wear the Zephyr
Bioharness that was connected to the laptop computer. The Bioharness was worn around
the chest via an elastic strap. Attached in the elastic chest strap was a sensor which acts
as a data logger or transmitter. Once the Bioharness starts to transmit data, the
participants were asked to sit quietly and prevent unnecessary movements for 5 minutes
to obtain resting value of heart rate, breathing frequency and estimated core temperature.
This point will be marked as “baseline” or marker 1 in the function found within the
wearable software. Markers were also placed on the time before and after warm-up and
physiological load response were also noted. After warm-up, the athletes were checked
by the researchers if the Bioharness strap is causing any type of pain or discomfort. This
was also the time to adjust the tightness of the Bioharness strap.

At the start of the actual game, another marker was placed to denote the start of the game.
Markers were also placed at the start and end of timeouts, dead-balls and any type of
activity not related to the game. This procedure was repeated for the whole three sets of
the game. For the frequency of run and jump, a video camera was placed on the playing
side of the participants and started recording once the game commences. Each
researcher was also assigned with one (1) participant for manual tallying.

Data Management & Analysis

A. Physiological Load Response

All Physiological response data were extracted from the Omnisense Analysis Tool version
4.1.6. The data were saved on a portable Universal Serial Bus (USB) as a .csv file which
was compatible for any spreadsheet software. After extraction, all the data were
transferred in a password protected laptop which only the researchers have access
All data were accessed, cleansed and analyzed using a Microsoft Excel Office version
2018. Mean and standard deviation of the physiological load response per volleyball
playing were then computed per segment of each session (rest, start of jogging, start of
ball handling, start of 1 st set, start of 2nd set, start of 3rd set) to describe the data. In order
to illustrate the trend of the physiological load response, a per 20-seconds moving average

17
 was first employed to the individual data sets. The use of moving average was used to
smoothen out the data by reducing the noise in the data set. A scatter plot with a linear
regression line was then used to illustrate the trend of the physiological load response in
all volleyball playing positions. Percentage of heart rate max (%HRmax) was also
computed per game segment to further describe heart rate trend during the game. The
formula used to compute %HRmax are as follows: =(actualHR/maxHR)*100

A. Frequency of run and jump

All data from the manual tallying were encoded in a specifically built Microsoft Excel Office
version 2018 spreadsheet. After encoding, the researchers reviewed the video recording
of the game to cross-check if the manual tally and review would produce the same
frequencies. Once all data were corrected, mean and standard deviation were computed
for each individual data. Any 3-step displacement (forward, lateral, or backward) is
considered 1 tally for run. For jump, a tally is put if It came from a jump from serve, spike,
block, or set

18
 RESULTS

One player per volleyball position which included the libero, outside spiker, middle blocker,
Opposite spiker and setter participated in the study. Demographic data including the age, height,
and weight are presented in table 2. The participants were monitored in a 3-set tune-up game
that lasted for one hour, sixteen minutes and nine seconds. (1:16mins:09secs). The breakdown
of the whole data gathering process is illustrated in table 3.

Table 2. Demographic data

Position Age Height(cm) Weight(kg) %HR

Libero 17 161cm 64.5 60-160

Outside Spiker 18 166 cm 62 51-157

Middle Blocker 17 171 cm 72.7 57-171

Opposite Spiker 18 167 cm 63.4 48-164

Setter 18 165 cm 65.1 61-154

Table 3. Time frame each activity during the data gathering process

Time(hr:min:sec) Activity
0:00:00-0:05:00 Rest
0:05:50-0:10:29 Jogging
0:10:29-0:19:44 Ball handling
0:19:44-0:21:53 Transition from ball handling to 1st set
0:21:53-0:40:00 1st set
0:40:00-0:41:16 Transition from 1st to 2nd set
0:41:16-0:58:16 2nd set
0:58:16-0:59:03 Transition from 2nd to 3rd set
0:59:03-1:16:09 3rd set

The Physiological variables recorded during the study are the Heart rate, Breathing rate, and
estimated core temperature. Each position’s physiological variables were noted using the Zephyr
bioharness (Figures 2-16).

19
%Heart Rate

Figure 2. %HR of Libero

120
Libero
100

80
%HR

60

40

20

Resting heart rate was measured in the first five minutes. The results of the libero were between
43-56% (69-89bpm). While jogging, heart rate percentage increased to 66-99% (99-159bpm).
During ball handling, data was 59-100%(94-160bpm). On the first set of the game, heart rate
percentage was 60-91%(97-146bpm). On the second set, the range of the heart rate percentage
is 58.41-89(93-143bpm). Finally, on the third set, the range of the heart rate percentage is 56-
95%(90-152). Overall, the heart rate of the libero had increased with minimal increments from the
first to the third set.

Figure 3. %HR of Setter

Setter
120

100

80
HR

60

40

20

For the first five minutes the resting heart rate was measured. Results showed that the setter had
a heart rate percentage of 41-49%(64-75bpm). While jogging, heart rate percentage increased to
65-96%(100-148bpm). During the ball handling, the range of the heart rate percentage was 56-
96%(86-147bpm). On the first set of the game, heart rate percentage was between 50-99%(78-
152bpm). On the second set, the range of the heart rate percentage was 62-91%(95-141bpm).
Finally, on the third set, heart rate percentage was 59-88%(91-134bpm). Overall, the heart rate
of the setter had increased with minimal increments from the first to the third set.

20
Figure 4. %HR of Middle Blocker

Middle Blocker
120

100

80
%HR

60

40

20

For the first five minutes the resting heart rate was measured, the middle hitter had a heart rate
percentage of 37-49%(63-83bpm). While jogging, heart rate percentage went up from 50-66%(86-
114bpm). During ball handling drills, the range of heart rate increased from 56-88%(96-150bpm).
On the first set, heart rate raged from 49%-94%(83-160bpm). On the second set, heart rate was
60-100%(103-171bpm). On the third set heart rate was 65-94%(112-161bpm). Overall, the heart
rate of the middle blocker had increased with minimal increments from the first to the third set.

Figure 5. %HR of Outside Spiker

120
Outside Spiker
100

80
%HR

60

40

20

For the first five minutes, resting heart rate was measured. The opener had a heart rate
percentage of 34-41%(54-65bpm). While jogging, heart rate percentage was 57-96%(90-
150bpm). During ball handling drills, the heart rate percentage was 74-93%(116-146bpm). On the
first set of the game, the heart rate percentage raged between 60-89%(95-140bpm). On the
second set, the range of heart rate percentage was 58-97%(91-153bpm). Finally, on the third set,
the range of heart rate percentage was 69-97%(108-152bpm). Overall, the heart rate of the
outside spiker had increased with minimal increments from the first to the third set.

Figure 6. %HR of Opposite Spiker

21
 Opposite Spiker
120

100

80
%HR

60

40

20

The Opposite Spiker had a resting heart rate percentage of 32%-40%(52-66bpm) during the first
five minutes. While jogging, heart rate percentage increased to 56-91%(92-149bpm). During the
ball handling, heart rate percentage ranged from 65-91%(108-149bpm). On the first set of the
game, the range of the heart rate percentage was between 55-86%(90-141bpm). On the second
set, heart rate percentage was 61-98%(99-160bpm). Finally, on the third set, the range of the
heart rate percentage was 65-89%(107-146bpm). Overall, the heart rate of the opposite spiker
had increased with minimal increments from the first to the third set.

Breathing Rate

Figure 7. Breathing rate of Libero

Libero
60

50

40
BR

30

20

10

Baseline was measured in the first five minutes and the breathing rate ranged from 8-21 breaths
per minute. While jogging, the breathing rate ranged from 22-53 breaths per minute. During ball
handling, breathing rate was between 31-53 breaths per minute. On the actual game, the
breathing rate during the first set ranges from 20-39 breaths per minute, during the second set,
17-43 breaths per minute, lastly, on the third set, the results ranged from 31-37 breaths per
minute. Overall, the breathing rate of the libero had increased with minimal increments from the
first to the third set.

Figure 8. Breathing rate of Setter

22
 Setter
50

40

30
BR

20

10

Baseline measurements were done in the first five minutes. Breathing rate of the setter ranged
from 13-27 breaths per minute. While jogging, the result was 19-40 breaths per minute. During
the ball handling, breathing rate was 27-40 breaths per minute. On the first set, result raged from
19-41 breaths per minute. During the second set, the breathing rate ranges from 27-39 breaths
per minute. Lastly, on the third set, breathing rate was 15-40 breaths per minute. Overall, the
breathing rate of the setter had increased with minimal increments from the first to the third set.

Figure 9. Breathing rate of Outside Spiker

Outside Spiker
50

40

30
BR

20

10

Baseline measurements were done in the first five minutes. The breathing rate ranged from 9-22
breaths per minute. Upon jogging, the result ranged from 22-40 breaths per minutes. During ball
handling, the breathing rate was 33-42 breaths per minute. On the actual game, the result on the
first set ranged from 20-36 breaths per minute. On the second set, breathing rate was 25-38
breaths per minute. Lastly, on the third set, the breathing rate ranged from 23-38 breaths per
minute. Overall, the breathing rate of the outside spiker had increased with minimal increments
from the first to the third set.

Figure 10. Breathing rate of Middle Blocker

23
 Middle Blocker
200

150
BR

100

50

For the first five minutes, baseline measurements for breathing rate were 10- 27 breaths per
minute. Upon jogging, breathing rate ranged from 28- 49 breaths per minutes. During ball
handling, the breathing rate ranged between 34- 50 breaths per minute. On the actual game,
breathing rate during the first set ranged from 11-40 breaths per minute. During the second set,
26-41 breaths per minute. Lastly, on the third set, breathing rate ranged between 29-41 breaths
per minute. Overall, the breathing rate of the middle blocker had increased with minimal
increments from the first to the third set.

Figure 11. Breathing rate of Opposite Spiker

60
Opposite Spiker
50

40
BR

30

20

10

Baseline was measured in the first five minutes. The breathing rate of the Opposite spiker ranged
from 9-26 breaths per minute. While jogging, breathing rate was 26-49 breaths per minute. During
the ball handling drill, breathing rate ranged between 33-48 breaths per minute. On the actual
game, the breathing rate during the first set ranges from 22-40 breaths per minute, 25-37 breaths
per minute for the second set and 22-38 breaths per minute for the last set. Overall, the breathing
rate of the opposite spiker had increased with minimal increments from the first to the third set.

Estimated Core temperature

24
Figure 12: Estimated core temperature of Libero

Libero
38

37.5
ECT

37

36.5

36

The baseline was measured for the first five minutes. The estimated core temperature of the setter
ranges from 36.5-36.6 degrees Celsius. While jogging, estimated core temperature ranges from
36.6-36.9 degrees Celsius. During ball handling, the estimated core temperature ranges between
36.9-37.3 degrees Celsius. In the first set of the game, estimated core temperature was 37.3-37.6
degrees Celsius. In the second set, estimated core temperature from 37.6-37.7 degrees Celsius.
On the third and last set, the estimated core temperature has a consistent value of 37.7 degrees
Celsius. Overall, the estimated core temperature of the libero had increased with minimal
increments from the first to the third set.

Figure 13. Estimated Core temperature of Setter

Setter
38.5

38

37.5
ECT

37

36.5

36

Baseline was measured during the first five minutes. The estimated core temperature of the setter
ranges from 36.4-36.5 degrees Celsius. While jogging, the estimated core temperature ranges
from 36.5-36.92 degrees Celsius and during the ball handling, estimated core temperature was
36.93-37.3 degrees Celsius. On the first set of the game, result ranged from 37.4-37.7 degrees
Celsius. During the second set, estimated core temperature was 37.7-37.8 degrees Celsius. On
the third and final set, the estimated core temperature has a consistent value of 37.8 degrees

25
Celsius. Overall, the estimated core temperature of the setter had increased with minimal
increments from the first to the third set.

Figure 14: Estimated core temperature of Middle Blocker

Middle Blocker
38.5

38
Estimated Core
Temperature

37.5

37

36.5

36

Baseline was measured during the first five minutes. The estimated core temperature was 36.7
degrees Celsius. While jogging, the estimated core temperature rose to 36.9 degrees Celsius.
During the ball handling drill, estimated core temperature ranged from 36.9 to 37.4 degrees
Celsius. On the actual game, estimated core temperature for the first set was 37.4-37.7 degrees
Celsius, during the second set, 37.7 to 37.9 degrees Celsius. Finally on the last set, the estimated
core temperature was 37.9 to 38 degrees Celsius. Overall, the estimated core temperature of the
middle blocker had increased with minimal increments from the first to the third set.

Figure 15. Estimated core temperature of Outside Spiker

Outside Spiker
38.5

38
Estimated Core
Temperature

37.5

37

36.5

36

Baseline was measured during the first five minutes. The estimated core temperature was 36.7
degrees Celsius. While jogging the estimated core temperature rose to 36.8 degrees Celsius.
During the ball handling drills, the estimated core temperature ranged from 36.8 to 37.3 degrees
Celsius. On the actual game, the estimated core temperature for the first set was 37.4-37.7
degrees Celsius. During the second set, 37.7 to 37.9 degrees Celsius. On the last set, the
estimated core temperature was 37.9 degrees Celsius. Overall, the estimated core temperature
of the outside spiker had increased with minimal increments from the first to the third set.

26
Figure 16. Estimated core temperature of Opposite Spiker

Opposite Spiker
38.5

38
Estimated Core
Temperature

37.5

37

36.5

36

Baseline was measured during the first five minutes. the estimated core temperature of the
Opposite spiker was between 36.5-36.6 degrees Celsius. Upon jogging, there was an increased
from 36.5-36.9 degrees Celsius. During the ball handling drills, estimated core temperature was
36.9-37.34 degrees Celsius. On the actual game, the estimated core temperature during the first
set was 37.4-37.7 degrees Celsius, 37.7-37.9 degrees Celsius for the second set, and a
consistent value of 37.9 degrees Celsius for the third and final set. Overall, the estimated core
temperature of the opposite spiker had increased with minimal increments from the first to the
third set.

Frequency of run and jump during the game were also assessed using manual tallying of the
researchers. A jump is considered to be a tally if it came from the serve, set, spike and block. A
tally for run depends on any 3 step displacement (forward, backward and laterals).

Table 4. Frequency of Run per position during the 3 sets.

Outside Middle Opposite

Run Spiker Blocker Spiker Libero Setter
SET 1 49 20 76 62 65
SET 2 70 57 71 31 45
SET3 40 33 53 45 46
MEAN 53 36.66667 66.66667 46 52
SD 15.3948 18.77054 12.09683 15.52417 11.26943

Table 4 discussed the frequency of run per position during the 3 sets. It showed that the opposite
spiker maintained to have highest run frequency throughout the game with 76 runs on the first
set, 71 runs on the second set and 53 runs on the third set.

Figure 17. Total run count frequency from sets 1-3

27
Figure 17 discussed the total run count frequency from sets 1-3. It showed that the opposite spiker
had maintained the highest number of run frequency from first to third set with a total of 200 runs
on the three sets.(see table 4 for breakdown).

Table 5. Frequency of Jump per position each set

Outside Middle Opposite

Jump Spiker Blocker Spiker Libero Setter
SET 1 10 19 23 5 33
SET 2 31 11 17 6 12
SET 3 15 16 14 5 21
MEAN 18.66667 15.33333 18 5.333333 22
SD 10.96966 4.041452 4.582576 0.57735 10.53565

Table 5 discussed the frequency of jump per position each set. It showed that the setter had the
highest jump frequency on the 1st set with 33 jumps and 3rd set with 17 jumps. In contrast, the
outside spiker had the highest jump frequency on the 2nd set with 31 jumps.

Figure 18. Total jump frequency from sets 1-3

Figure 18 discussed the total jump frequency from set 1-3. It showed that the setter had the
highest frequency of jump throughout the 3 sets.

During the 1st set and 3rd set, the setter tallied the highest jump count among the players on the
court. For the 2nd set, the outside spiker performed more jumps than the other players (ta

DISCUSSION

28
The aim of this research was to find the physiological demands and movement frequency per
position in Volleyball. The results showed that all physiological variables such as heart rate,
breathing rate and estimated core temperature increased in all playing positions. Data showed
that there was an increase in all physiological variable after warm up and maintained throughout
the whole game. Warm-up generally consists of a period of both submaximal exercise and
stretching exercise as stated by Stewart, I. B., & Sleivert, G. G. (1998). The study stated that there
is an acute increase in peripheral, central circulation, core and muscle temperature which
prepares the body for exercise thus increasing heart rate and breathing rate. The increased heart
rate, core and body temperatures following warm-up at 60, 70 and 80% VO2max are probably
reflective of a higher blood flow. The increased blood flow is the result of the vasodilatory effect
of active warm-up on the precapillary resistance vessels and the local effect of increased
metabolism on the capillaries of the exercised muscle fibers.

According to Stewart, I. B., & Sleivert, G. G. (1998), The increased heart rate and core and body
temperatures following warm-up at 60, 70 and 80% VO2max are probably reflective of a higher
blood flow. The rise in blood flow is the result of the vasodilatory effect of active warm-up on the
precapillary resistance vessels and the local effect of increased metabolism on the capillaries of
the exercised muscle fibers.

Burton, D. A., Stokes, K., & Hall, G. M. (2004) claimed that Ventilation and Oxygen consumption
increases linearly with increases in work rate at submaximal exercise intensities. The increase in
pulmonary ventilation is attributable to a combination of increases in tidal volume and respiratory
rate and closely matches the increase in oxygen uptake and carbon dioxide output. In a study by
Burton, D. A., Stokes, K., & Hall, G. M. (2004), they found that Ventilation increases abruptly in
the initial stages of exercise and is then followed by a more gradual increase: rapid rise in
ventilation at the onset of exercise is thought to be attributable to motor centre activity and afferent
impulses (sensory inputs) from proprioceptors of the limbs, joints and muscles. According to
Burton, D. A., Stokes, K., & Hall, G. M. (2004) the mechanism of stimulation following this first
stage is not completely understood.

The temperature response to warm-up, as stated by Stewart, I. B., & Sleivert, G. G. (1998), can
either be a local effect in the muscles performing the warm-up activity or a general effect that
increases core temperature. In a study according to DeVries HA: Physiology of Exercise,
Dubuque, /A: Little, Brown, & Company. (1986), increases in muscle temperature occur within 5
to 10 minutes of initiation of exercise, while core temperature increases more gradually over a 30-
minute period. In another study reported by Burton, D. A., Stokes, K., & Hall, G. M. (2004).,
maximum efficiency for the conversion of energy nutrients into muscular work is 20–25%. The
remainder is released in a non-usable form as heat energy, which raises the body temperature.
To dissipate the extra heat generated as a result of increased metabolism during exercise, blood
supply to the skin must be increased. This is achieved by vasodilatation of cutaneous vessels by
inhibition of the vasoconstrictor tone. Burton, D. A., Stokes, K., & Hall, G. M. (2004) stated that
evaporation of sweat is also a major pathway for heat loss and further heat is lost in the expired
air with ventilation. Other research has suggested that a warm-up which increased body

29
temperature should enhance performance by means of a maintained reactive hyperaemia as
seen in the study of Buono, MJ Roby FB.

Multiple benefits are associated to the use of warm up. Smith (1994) stated that the general
purpose and benefits of warm up is to increase muscle and tendon suppleness, to stimulate blood
flow to the periphery, to increase muscle temperature, and to enhance free, coordinated
movement. According to Essentials of Strength and Conditioning (NSCA), Warm up is divided
into two components to temperature-related effects and the non-temperature-related effects
which works to benefit athlete’s performance in numerous ways. They have a warm up system
created especially for team sports called (RAMP) protocol which is proven to increase
physiological parameters and improve athlete’s performance. In a meta-analysis done by
Fradkins, A et al., (2010) 79% from the studies gathered positive effect on aerobic and anaerobic
sports, 3% had no significant difference and 17% induced negative impact on the performance.
There was a variety on the level of improvement indicating positive effects due to the wide range
of protocols available. The research recommended to employ warm up protocols specific to the
sports. Upon evaluation, negative correlation was due to the fact that the warm up given was not
suited to the movement mechanics in the sport. Specific tasks needed to the performance were
not complimented. Another factor was the duration of the warm up set did not last long enough to
increase muscle temperature.

Many activities have a high dependence on the phosphagen system. Success in team sports,
weight lifting, field events (e.g., shot put and discus throwing, jumping events), swimming, tennis,
volleyball and so forth. All require short-term singular or a limited number of repeated intense
muscle contractions. In volleyball movements such as spiking, blocking, serving, receiving and
digging needs maximal effort in a short period of time. It has been generally accepted that with
an exercise period of maximal effort of up to 5 to 6 seconds duration, the phosphagen energy
system dominates in terms of the rate and proportion of total ATP regeneration [21–23].

All physiologic responses(HR,BR,ETC) increased during warm up and was maintained in an

increased state throughout the game. Since volleyball could be considered as a repeated sprint
activity, ATP PCr is continuously needed to be able to execute the movement demands of the
sport. In a study of repeated sprint ability, 26% of PCr stores are depleted after 6 seconds of
maximal exercise (Spencer et. al., 2012). ATP PCr depletion and resynthesis is a major factor in
volleyball for the maintenance of having increased figures. 30s sprints in a repeated sprint
exercise has been associated with PCr resynthesis. In a study by Spencer et al., during the
minimal rest bouts within the 30s cycle of repeated sprint activity, aerobic energy system
contributes 28-40% for PCr resynthesis to happen. The ability to produce high power outputs is
related to the capacity of PCr resynthesis. (see figures 2-16)

Ross & Leveritt (2001) stated that there is an increase in glycolytic enzyme activity after short and
long periods of sprints. 30s sprints in a repeated sprint exercise has been associated with PCr
resynthesis. The capacity for PCr resynthesis is related to the ability to produce high power
outputs

30
During the second set, the outside spiker had the highest frequency for run. The setter had the
highest frequency for jumps. One factor was that most of the sets were directed to her causing
an increased in approach movement. However, the same position produced the lowest heart rate
as compared to the others possibly because she was more conditioned. In the study of Martinelli,
F. et al, aerobic capacity of athletes would produce greater VO2 and power values in both
anaerobic threshold and peak effort. They found out that resting heart rate of cyclists were
significantly lower as compared to nonathletes. Evidence shows that the mechanism behind low
resting heart rate of trained athletes is the changes or adaptations in the intrinsic pattern of the
sinus node (natural pacemaker) and the alteration in the autonomic nervous system in which the
heart controls. Also, it has been stated that enhanced parasympathetic activity (vagal tone)
responsible for bringing one’s body to a “homeostatic” state and diminished sympathetic activity
contributes to resting bradycardia of athletes.

There is no current literature to support that the phosphagen energy system and the acute
physiological variables (post-exercise heart rate, breathing rate, and estimated core temperature)
have any relationship at all. Current literature is only focused on the glycolytic and oxidative
energy system training modalities such as high volume resistance trainings, high intensity interval
training, endurance training and their direct effects upon the acute physiological variables as
consequence.

The frequency of run and jump were also tallied and noted in the study. As seen in figure 18, the
Opposite spiker had the highest run frequency among the players on the court. A tally is given if
any player performs any 3-step displacement (forward, backward or laterals). An Opposite spiker
is also known as universal volleyball player as they need to perfect every aspect of the volleyball
game which includes spiking, blocking, digging, receiving, digging and setting. Every time the
setter gets the first ball when digging or receiving, it’s automatic for the Opposite spiker to run for
the second ball and set up the spikers to create a play to get the point. When receiving also,
Opposite spikers are an important part of the receiving formation together with the libero and
outside spikers. So they run for every serve and perfectly placed serves from the opponent.
Another task of Opposite spikers is that they play an important role in ball coverage as they
normally take hits from the down-the-line and cross court hits of the opponent’s Opposite and
outside spiker. This fast sprinting and running for a short period of time indicates that the Opposite
spikers dominantly utilizes a phosphagen energy system.

To tally a jump, it must come from a serve, block, set and spike. The results illustrated that the
setter elicited the highest frequency of jumps during the duration of the data gathering (First
explanation to this is the nature of setting as setters not only sets while standing, they also perform
majority of their setting in a jumping motion. The setter subject does majority of her sets while
jumping and it contributed to the increased jump frequency of the setter. She also jumps when
serving and it added a number of jump counts to her jump tally. Like any other player, she also
blocks. One thing unique about her blocking is the position of the opponent she is accustomed to
block. A setter block the other team’s outside spikers which contribute to majority of the other
side’s offensive powers. A lot of sets are given to outside spikers since if the team misreceives
the ball, the set would automatically go to the outside spiker. Which means the setter blocks

31
frequently thus resulting to increased tally of jump.The setter also does “dump balls” or attacks
the opponent during her setting motion by jumping and dumping the ball to the other court. This
strategy destroys the defensive rhythm of the opponent and that’s why the subject does this
strategy frequently. These actions also take place for short periods of time which means that the
setter also utilizes the phosphagen energy system.

More frequent running and jumping of the a volleyball player during the game dictated the
trendline of the physiologic responses with increased %HR,BR and ECT. The higher the intensity
of work the player does, the blood flow and cardiac output to exercising muscles are increased
which also results to increased HR, BR, and ECT. It shows that that the workload demands of a
specific player, for example the Opposite spiker and the setter, as stated above is greater than
the other playing positions that's why both positions elicited the highest frequency in run and jump
count respectively. Some players on the court remained on court at all times compared to the
other positions like liberos and players the libero switches to which includes the middle blockers
and outside spikers. Overall, these values illustrated that the players regardless of position
maintained elevated HR, BR and ECT throughout the match (see figures 2-16)

CONCLUSION

32
The objective of this research is to monitor the physiological demands and movement frequency
of jumping and running in volleyball players with different position. Throughout the duration of the
game, it was highly evident that the energy system being utilized predominantly by the athletes is
the Alactic-Phosphagen energy system since most of the sports-specific movements being
carried out can be characterized by high intensity, very short (not lasting more than a few seconds
of individual effort), explosive type efforts which directly falls under the criteria of Phosphagen
energy system. Despite of being an intermittent stop and go sport, emphasis on the phosphagen
system due to the explosive nature of the sport was supported with the results shown in figures
2-16. Development of this particular energy system is therefore a must for the aspiring athletes of
this sport in order to become proficient when it comes to sports performances. The movement
requirement frequency was done by tallying the jump and run count. The setter had the highest
jump count and the Opposite spiker had the highest run count.

LIMITATIONS

The results found in the study are specific to the tested population of high school volleyball
players. General movements like run and jump instead of sport-specific movements were tallied.
Some of the movement frequency results may vary across the population of the subjects because
of different tactics and style of play each coach or team instills in their system. Due to small sample
size, results may be different to different set of volleyball players. In getting the physiologic
responses, the court temperature was not taken into consideration.

RECOMMENDATIONS

Future researches should include more volleyball-specific movements like dig, spike, block, and
serve for movement requirement frequency and not only jump and run count. Such study could
provide an in-depth description and differences per demand per position and can benefit exercise
prescription by giving very specific training program per player. Assessing the physiological
demands could also be done in training sessions to assess and compare the difference with
competition results. Further studies may also recruit collegiate or professional volleyball players
or even international players as their subjects.

DECLARATION OF CONFLICT OF INTEREST

The authors declare no conflicting interest.

ACKNOWLEDGEMENTS

Firstly, the researchers would like to give praises and thanks to our Lord for the strength, wisdom,
knowledge and support that He has given throughout the research process that lead to a
successful research work.

The authors are thankful and grateful to our parents, friends and loved ones for the never ending
love, prayers, support and sacrifices that they showered all the time. Without these important
people in the lives of the authors, this study will not be possible.

33
The authors would also like to thank the Hope Girls Volleyball team and Coach Jerry Yee in
helping and cooperating with the data gathering process.

We are also very much thankful to the Sports Science Department professors, Mrs. Karen Leslie
Pineda MSPH,RND, Mr. Reil Vinard S. Espino,CSCS, MSHMS,MTAI, Mr. Saul Anthony I.
Sibayan, MSS,TSAC-F, Ms. Josephine Joy B. Reyes,MPE, for their help, understanding and
invaluable support to complete this research study.

LITERATURE CITED

34
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APPENDIX A.

Authorship Form

36
Use this form to determine authorship. Use as much space as required.

Date: March 27,2019

Research Output Type:

Journal Article

Title:

Physiological Demands of Playing Position in Volleyball During Competition: A Case Report

Abstract of Thesis:

Bio monitors determine the physiological demands through detecting parameters like heart rate
and breathing rate in volleyball players. Powerful skills involving physical and mental athletic
performance are requirements for skillful play in volleyball. What is known currently from this
research are the physiologic demands of the sport during training sessions only, there were no
local researches found by the authors. As such, measurements of physiological elements are
important to identify which demands are needed to be prioritized in certain positions.
Biomonitors are tools that can help in recognizing physiological variables that are essential
during play. The Zephyr gives live feedback regarding the athlete’s vital signs during
competition. Another tool is the Time motion analysis which analyzes the player’s game
statistics such as work rest ratio, distance covered, duration of each movement. Since volleyball
is a sport that requires high intensity rallies and short time of rest, the importance of monitoring
the physiological demands of the game is crucial to provide a better training regimen and to
maximize the athlete’s anaerobic energy system during game as well as the aerobic system
during rest periods.

Contributors (Authors and Non-Authors):

Kris Anthony T. Agarao MSHMS,XPS

Christine Bernadette L. Alvarez
Tiffany Vale D. Bautista
Katrina Mel E. Lantin
Nathan Ryan N. Lim
Gabriel Christian C. Lucero
Atlantis Marcus D. Tan

Authors in Order:

Kris Anthony T. Agarao MSHMS,XPS

Christine Bernadette L. Alvarez

37
Tiffany Vale D. Bautista
Katrina Mel E. Lantin
Nathan Ryan N. Lim
Gabriel Christian C. Lucero
Atlantis Marcus D. Tan

Contributions Each Author Will Made:

Kris Anthony T. Agarao (Faculty Author, Conceptualization and Paper)

Christine Bernadette L. Alvarez (Leader, Conceptualization, Papers and Data Gathering
Process)
Tiffany Vale D. Bautista (Data Gathering Process and Papers)
Katrina Mel E. Lantin (Data Gathering Process and Procurement)
Nathan Ryan N. Lim (Procurement and Data Gathering Process)
Gabriel Christian C. Lucero (Data Gathering Process and Papers)
Atlantis Marcus D. Tan (Data Gathering Process and Papers)
Expected Dates of Submission and/or Publication/Communication:

March 25, 2019 - Submission of Final Draft

April 22-27, 2019 - Poster Presentation
April 27, 2019 - Paper Presentation

Expected Place/s of Publication/Communication:

This form records agreement between contributors for the authorship of research outputs.
Research authors certify their inclusion or exclusion as authors by printing their name and
signing below.

Certification:

Kris Anthony T. Agarao MSHMS,XPS

Christine Bernadette L. Alvarez
Tiffany Vale D. Bautista
Katrina Mel E. Lantin

38
Nathan Ryan N. Lim
Gabriel Christian C. Lucero
Atlantis Marcus D. Tan

39
 APPENDIX B. DATA GATHERING SHEET

Zephyr Code:

Position:

TIME MOTION ANALYSIS

Jumps

Set 1

Set 2

Set 3

Sprints

Set 1

Set 2

Set 3

40
 Appendix C. Letter to head coach

Jerry Yee
Head Coach
Hope Girls Volleyball Team

Dear Mr. Yee,

A pleasant day to you!

We are fourth year students from the University of Santo Tomas - College of Rehabilitation Sciences
(UST-CRS) of the Department of Sports Science, and we are conducting a study entitled
"Physiological Demands of different playing position in Volleyball during Competition: A Case
Study” to assess the physiological demands of female volleyball players and to analyze the movement
frequency of the sport.

In line with this, we would like to request for your approval for the Hope Girls Volleyball Team to
participate in our study. This research will utilize a sophisticated biomonitoring device that can be
worn during a match and can monitor several physiological variables such as heart rate, breathing
rate and estimated core temperature. These variables can give us an in depth understanding of the
physiological and movement frequency in volleyball. The researchers will discuss all the findings after the
study has been completed and will recommend training programs that is specific to every player position
in volleyball for further improvement. Thank you for your kind consideration and hope to hear from
you!

Respectfully yours,

Christine Bernadette L. Alvarez

Liason Officer
Department of Sports Science

Kris Anthony T. Agarao MSHMS, XPS

Faculty Author
Department of Sports Science

41
Appendix D. Participant Information and Informed Consent

42
Appendix E. Results of raw data

43
Appendix F. Ethical Approval Form

44