Lifting and Shoulder Pain

Bench Pressing is bad for your shoulders right? Lifting overhead is the worst thing you can do for your shoulders right? Long winded answer: WRONG. Anecdotally, I have bench pressed and overhead pressed heavy multiple times per week for years and have never had any serious shoulder injuries, never had to take any time off from lifting nor make any substantial modifications to lifting because of shoulder pain. Some of this is luck, sure, but the biggest key is the programming, how the lifts are implemented and trained. Just as medicine has an effective dose and too much can lead to bad outcomes and too little has no effect, your programming for bench and overhead pressing can be effective, potentially injurious, or ineffective. I believe bench and overhead pressing are associated with shoulder injuries because of 2 things: 1) people often get hurt doing these lifts because they are trying to max and push intensities they are not prepared to handle, which comes down to a programming issue. 2) In the medical field, you are only going to see people that get hurt, thus medical personnel are going to naturally be biased towards believing these lifts are dangerous and are typically in positions of authority to make such claims that are taken as gospel by patients and the general public.

Injuries and Lifting:

The overall incidence of injuries with lifting weights is low and the nature of injuries is uncommon (8), see my article: Lifting Weights Is Not As Dangerous As It Seems. However when you look at the shoulder injuries that actually do occur with lifting, the main contributing factors appear to be technical errors (31%) and fatigue or overloading (81%). (8) Notice that fatigue and overloading are a much higher contributor than technical errors, which further strengthens the argument that programming is more of a culprit than the technique or the nature of the lift itself. Oftentimes, people attempt weights and or volumes they are not prepared to handle and one of the best ways to get injured is to make sudden, drastic increases in training load: a programming issue.

Most common shoulder injuries with lifting:

Pectoralis major rupture- most commonly injured in the eccentric portion and towards the bottom of the bench press. Contributing factors are barbell load and fatigue, factors that can be accounted for with appropriate programming and progressions.(15)

Insertional tendinopathy of the Pectoralis Minor – most common factors relate to poor technique (which is better described as technique you do not tolerate vs “bad” or “poor”) and rapid increase in load and frequency which again is a programming error.(15)

Overuse injuries –are the most common injury with bench pressing, such as high exercise dose and repetitive strain, and are the most preventable – these are mostly the result of programming errors, but the programming can also serve as a troubleshooting solution.(15) They can be mitigated by adjusting or reducing training volume and/or intensity and adjusting technique to more tolerable positioning and movement.(15)

Modifying training and conservative treatment often improves the pain/injury while helping to avoid surgery, thus you can continue to train with needed modifications based on symptoms to improve shoulder injuries and there is a good chance that you will be able to return to symptom-free lifting. (8). There are many modifications and adjustments that can be made to pressing and pulling lifts that involve the shoulder that can allow an injury or pain issue to be trained around to improve pain and eventually allow return back to normal training. Examples include: changing grip width, adjusting arm positioning, changing grip from pronated to supinated, adjusting scapular positioning. Combinations of these can give you more than 27 different options to perform the lift!(7,8)

Rotator cuff tears:

You can still lift, be functional, and asymptomatic with a rotator cuff tear and surgery to fix tears does not always improve outcomes. (2). Higher levels of activity, such as lifting weights, do not appear to be associated with rotator cuff tear enlargement and the progression of tears can occur without the development of symptoms. (2,3, 4). Rotator cuff tears that become symptomatic may be associated with decreased strength and range of motion, and pain that occurs is actually more associated with lower shoulder activity levels (2,18). Thus improving strength and working your shoulder through a full ROM via lifting weights is likely a good way to help reduce the chance that an asymptomatic rotator cuff tear could become symptomatic. Even atraumatic full thickness rotator cuff tears can respond favorably to non-operative treatment and even demonstrate significant improvements. (3) Even very submaximal physical therapy interventions have demonstrated to be highly effective at alleviating pain in those with torn rotator cuffs (3), so imagine what progressively loading your shoulder through lifting heavier weights can do for it. You do not have to address a torn rotator cuff to keep lifting and improve your shoulder pain and function. If you had a traumatic instance that did actually cause a rotator cuff tear, then you may need surgical intervention. However, initially trying conservative treatment with modified lifting that is gradually progressed would still be a good initial place to start before determining if you need to go under the knife.

Isolating and training the rotator cuff:

Spoiler: You cannot isolate the rotator cuff since it is involved with most all movements of the shoulder in which other muscles also contribute. Doing “rotator cuff” strengthening exercises such as resisted external rotation does not isolate the rotator cuff no matter how you tweak and perform the exercise

Simply training the compound movements of the upper body involving vertical and horizontal pushing and pulling also effectively trains the rotator cuff. There is some difference in what rotator cuff muscles are recruited and the degree in which they are with compound movements such as bench pressing and rowing (12). The supraspinatus (top part of rotator cuff) is higher with bench pressing and the subscapularis (front part of the rotator cuff) is higher with rowing (12). The rotator cuff muscles act more in a manner to oppose the pull of the prime movers of the exercise during compound movement such as pressing and pulling/rowing, thus the reason for the difference in recruitment between pressing and pulling (12). Pushing and rowing exercises demonstrate high to very high rotator cuff activity (13). Forms of push ups have shown some of the highest activity in 3 of the 4 rotator cuff muscles (14) and this can likely also be extrapolated to the bench press since it is a similar movement pattern that can be loaded.

Labral tears:

Labral tears are yet another example of common structural issues that are found on imaging frequently in people without symptoms. Particularly, when we look at shoulders of people who are older, 45 years of age or more, there can be up to 75% of asymptomatic shoulders with labral tears (21). Another issue with imaging the shoulder in terms of labral pathology is that MRIs have become more detailed which may lead to incidental findings (21,22). Thus if the picture is better, the more you’ll find, but these may not exactly be findings that are the cause of pain:

Labral tears may be responsible for painful symptoms, but special care must be taken attributing these abnormalities to symptoms given how common signal abnormalities are on imaging (21)

Here are further statistics on the prevalence of labral tears in asymptomatic populations:

53 asymptomatic shoulders were found to have 55-72% prevalence of SLAP tears (22)

22 of 28 throwing shoulders with signal abnormalities and 5 of 11 (45%) throwing, 5 of 11 (45%) non-throwing shoulders in asymptomatic shoulders had labral tears in professional baseball players (22)

58% of asymptomatic dominant shoulders of 12 elite volleyball players had labral changes (22)

83% of 6 elite gymnasts had labral changes in their right, asymptomatic shoulders (22)

21 asymptomatic professional baseball pitchers had 47% SLAP tears, and 62% had anterior or posterior labral tears (22)

Repairing labral tears such as SLAP lesions, has historically demonstrated good outcomes, however, as evidence evolves we are finding more complications and less satisfactory results (22). So it may not always be as beneficial to repair it as it would seem.

What it really comes down to in my opinion and based on the above information: if your shoulder pain is tolerable enough to train then the best option is to begin or continue training with necessary modifications and progress as you are able to even if you may have a labral tear. It is highly likely the tear could be part of the normal aging process and may not even be the cause of the symptoms (22). And further, if you can still function and train with your shoulder, don’t go have a surgery just because you find a labral tear on MRI (22).

Shoulder instability:

Shoulder instability is referring to situations where individuals have either traumatic or atraumatic shoulder dislocations or hyper mobility spectrum disorder affecting the shoulder.

Potential factors that can improve shoulder function and potentially reduce the risk for further injury relating to shoulder joint instability are:  improved neuromuscular function, muscle hypertrophy, tendon stiffness, and improved proprioception or shoulder joint position awareness. (18, 19, 20). Barbell training can certainly provide all of these benefits.

Typical clinical recommendations for hypermobility spectrum disorders involve low load or no load exercises and protecting the involved joint. However, there is one particular study that involved heavy resistive exercises for this population, with the shoulder being the involved joint, and actually yielded positive results in pain and decreased kinesiophobia (fear of movement) and ultimately determined that heavy shoulder strengthening exercise is feasible and safe for this population, contrary to common recommendations (20).

In the study mentioned above, they tested individuals with hypermobility spectrum disorder affecting the shoulder with a 5 rep max of various exercises which is quite heavy (roughly 85% of 1RM). Then they performed anywhere from 50% of that all the way up to an 8 rep max (roughly 75% of 1RM) for multiple sets throughout a 16 week program with no major adverse events, only short lasting soreness or pain fare ups. (20) This is a real world example of people with hypermobile shoulders lifting heavy without major issue and in fact experienced improvements in pain as well as decreased fear of movement of the shoulder (kinesiophobia). (20)

Strength training for the shoulder involving compound exercises such as bench press, overhead press, lat pulldowns and rows can help improve shoulder joint proprioception and position sense which can positively affect injury risk. (18) The decrease in proprioceptive reflexes secondary to trauma/dislocations of the shoulder may predispose an individual to subsequent injury. (19) Thus improving shoulder proprioception through strength training can help to reduce this risk. Exercise rehabilitation is supported in the non-operative management of primary traumatic shoulder dislocations (19). Shoulder strengthening is also commonly recommended for atraumatic shoulder instability (19). Strength training is recognized as being important for controlling the glenohumeral head to reduce risk of dislocation. (19)

Now, even with these studies finding positive outcomes from heavy resistance training, I want to point out that some of them did not use heavy compound barbell lifts. We know that these lifts are generally going to yield better strength improvements than isolated exercises, so I would argue that barbell training would yield even better results for shoulder instability than what the studies have found. I think the position sense/proprioceptive benefit as well as the decreasing kinesiophobia are going to be better with the barbell lifts as it involves moving multiple body parts including the shoulder through space in a large ROM while controlling a heavy barbell – think that doesn’t improve strength, coordination and control?

Arthritis (Osteoarthritis):

Arthritis is this scary inevitable thing that we are all going to face and all the lifting and sports we do is just causing wear and tear that will lead to it right? Well, kind of, but not entirely. Osteoarthritis has historically been thought of and viewed as a wear and tear issue where our joints degenerate, deteriorate and wear out over time leading to inevitable pain, decreased function and surgery. If we continue to subscribe to this line of thought, then there will be an inevitable decline of function and loss of quality of life (1), and this decline is preventable or at least modifiable to some degree. So, thinking that arthritis is going to cause us to lose function and deteriorate over time is more of a self-fulfilling prophecy we’ve created that needs to be challenged and changed!

Arthritis is yet another situation where imaging is going to show it, but whether it is actually the cause of symptoms is a different story. Around 50% of people have structural joint changes consistent with arthritis and don’t have symptoms (1). Further, what is important is if there is pain symptoms present, not only what is shown on imaging (1). You can have people who have the same degree of structural joint damage associated with arthritis, yet have widely different pain experiences and overall research has not found consistent associations of structural features/issues to symptoms (1).

As with all musculoskeletal pain issues I cover and discuss, pain associated with arthritis is nowhere near as simple as resulting from wear and tear nor solely contributable to physical, structural changes seen on imaging. The pain that does actually result from arthritis involves much more than just the degeneration in the joint itself and can be influenced by psychological, biological and social factors a person is experiencing (1) as well as factors potentially even beyond these realms (see my article How Can Lifting Weights Improve Pain for more explanation on the complexities of pain). Another viewpoint is the fact that pain does play a protective role to a degree, so trying to completely rid yourself of pain may not be a good goal, and working with some pain at times can just be part of normal life and not always a bad thing that equates to physical damage (1).

It is better to shift the mindset around arthritis and dealing with it to more of a symptom modification (1) and active approach vs trying to change and fix the cause or submit to inevitable decline. Strength training can be particularly effective in improving pain and function associated with arthritis (1,16). There is good evidence that muscle strengthening exercises improve pain, function and quality of life in people who have knee arthritis (1) which I think is reasonable to extrapolate to shoulder arthritis. The first line treatment for shoulder arthritis includes exercise and progressive shoulder exercises are feasible and safe for people with shoulder arthritis (17). I know it doesn’t make sense that something that seems like a wear and tear and degenerative issue responds well to actually loading and stressing it more. I’ve presented the information above to show you that arthritis is not simply a wear and tear issue. The belief that we are wearing our joints out is not accurate and there is further examples and evidence that strengthening does in fact improve arthritis symptoms. Additionally:

“People with osteoarthritis should be reassured that strength training is unlikely to make their pain worse, provided the movements and dosage of training is tolerable and appropriately dosed, and will likely actually improve their pain.” (16)

A big problem with arthritis and a major contributor to symptoms and progression is loss of muscle strength (16). Muscles around the arthritic joint influence loading and decreased strength is a primary contributing factor to pain and functional imitations from arthritis and has been observed in people with arthritis (1,16). So, if decreased strength is a contributing factor to symptomatic arthritis and leads to decreased function, then strength training directly and positively affects this (16).

Another thing that will really fly in the face of the old, outdated wear and tear idea is that strength training to improve arthritic symptoms also needs to provide progressive and consistent overload (16). So, not only is lifting weights/resistance training good for arthritis, but it also needs the good ol fashioned progressive overload for it to be effective. If arthritis were truly wear and tear, then how could this be?! Again, the wear and tear belief is inaccurate, too simplistic and outdated.

Experiencing some pain while training with arthritic symptoms is acceptable and ok to work through to a point, as with all musculoskeletal pain issues-pain does not always equal damage. There is evidence that people have experienced up to 5/10 pain during exercise in a particular study and no one dropped out due to injury. Further, people in this same study who had pain above 5/10 experienced this intensity earlier on in the training process and the pain did decrease over time (17). Thus, even experiencing pain that can be attributed to arthritis is acceptable to work through as you can tolerate and is likely to improve with continued consistent training over time.

A major caveat I would like to add about the information from resistance training studies is that the resistance element is typically implemented with therabands(light resistance bands) and light cuff weights or dumbbells. So, if there was benefit with rather low level exercises and if improving strength does improve symptoms and function, then performing resistance training more effectively such as with a barbell is likely to yield even better results.

Push to pull ratio:

There is a long held belief that you need to balance your upper body pushing exercises with equal or even more pulling exercises to help maintain muscle balance around the shoulder and prevent injury. Here is yet another situation where this sounds good, but is not thoroughly proven nor accurate.

Currently, there is no gold standard in the literature to assess the ratio between upper body push and pull strength. (9)

There exists no consensus as to precise strength ratios required for biomechanically correct shoulder function (11)

“A paucity of research has described shoulder joint and muscle characteristics among individuals participating in weight training, thus limiting the ability of clinicians and strength and conditioning specialists to recognize “at-risk” training patterns and provide the evidence-based education and instruction necessary to minimize shoulder injuries/disorders in this population” (11)  - I interpret this as suggesting there are no identifiable factors such as muscle imbalances that can reliably indicate injury risk

Further, when you look at strength assessments that compare pushing strength to pulling strength, people are generally stronger with pushing than pulling, indicating that it is normal to have differences with pushing and pulling (9, 10). If it is normal and natural to have more strength and ability to push than to pull, then why do we need to change that? We do not need to balance or “counteract” the volume of pushing with pulling volume. We are actually asymmetrical in many ways which are normal and usually results of adaptations that are desirable vs dysfunctional or bad.

“The ratios quantified in the RWT (recreational weight training) group were significantly greater than those of control participants, which may indicate an imbalance of their force couple relationship.” (11) - I believe this indicates desirable adaptation to resistance training which is not a bad thing. Also, the participants were not reported to have any shoulder pain or injury issues and there was no follow up done to determine whether they ever developed pain or an injury

Further, a lot of research that suggests muscle imbalances are to blame for situations such as shoulder pain look at muscle activity and movement characteristics in those currently in pain vs “normal”. The problem here is that what they are observing could be a response to the pain and not necessarily the cause. Further, their findings could have also been present before the pain started and may not even be related; they just happen to find them while looking during research and assigning significance and blame to this. 

“Descriptive studies have identified muscle imbalances among athletes with shoulder disorders along with imbalances that result from upper-extremity sports participation.” (11) - This is likely an example of a reaction and potentially beneficial adaptation vs a cause of pain

I would call in to question research that suggests muscle imbalances are to blame for pain issues. It is possible to bench and overhead press high volumes with comparatively much less or even no rowing/pulling volume and have shoulders that feel and function perfectly well. If the programming matches what you are capable of handling and the progression is tolerable and something you can adapt to, then however much pressing you want to do is acceptable. But again, there is the caveat that I mention all the time: pain is not solely due to biomechanical factors - you can still experience shoulder pain that has nothing to do with benching or overhead lifting.

Bench Press:

Even though the bench press gets a bad rap for causing shoulder injuries, there is no clear evidence regarding it’s technique and injury risk factors and no high quality data about injuries specific to the bench press (7). The evidence available suggests theories of mechanisms of injury but there is no biomechanical evidence to substantiate them (7).

The beauty of the bench press (along with most compound lifts) is that it is nearly infinitely scalable and modifiable to accommodate the ability to train in the presence of pain or injury. It is also a great lift for training multiple major muscle groups of the upper body as well as a fundamental movement of horizontal pushing. Simply adjusting grip width, shoulder abduction angle (arm position), and scapular positioning yields a total of 27 different variations of the bench press (7). There are even other factors that can be modified such as ROM, tempo, bar type, etc that can provide even further options.

Noteboom et al provides information on forces and stresses on various shoulder structures during the bench press with multiple different adjustments and variables. They do focus on the injury risk, basing this off of forces and biomechanical factors which I would refute (discussed below). Instead, I think the takeaway from their study is that there are multiple ways to adjust the movement and thus stresses about the shoulder to accommodate being able to train the bench press. Adjusting grip width, scapular positioning, range of motion, arm abduction angle, etc. provides many, many options to adjust the bench press to something you can tolerate via adjusting imposed stresses and forces to be able to train in the presence of pain and injury. (7) The bench press is a perfectly fine exercise to train and can be very beneficial in improving shoulder pain, function, and strength. While a wider, more abducted grip and shoulder angle can tend to aggravate shoulders and there is theoretical biomechanical evidence to suggest this, while benching, I don’t think it is necessarily bad in and of itself. I still believe it can be tolerated well provided you can tolerate the movement to begin with and you are able to tolerate and handle progression.

Overhead Press:

The overhead press has historically been blamed for causing shoulder impingement (now more commonly known as subacromial pain syndrome). However, studies and analysis have revealed that the movement and muscle forces around the shoulder actually help to mitigate vs cause shoulder impingement. (5) Overhead lifting has been often maligned in the medical field as well which is an unfounded belief. This likely comes from the fact that people seen for medical care with shoulder pain and injuries typically were involved in repetitive overhead work or doing heavy overhead lifting. There is always much more to the story of course: people doing repetitive overhead work often don’t strength train thus generally don’t have the capacity to handle such repetitive work and people that attempt to lift heavy overhead likely were not trained nor prepared for doing so. In each scenario, if there was a well programmed strength training aspect then the instance and likelihood of pain and injury would have been much different. 

There are considerable benefits to the overhead press which certainly outweigh the potential and relatively low risks. The overhead press can aid in improving shoulder and upper back mobility (5,6). The overhead press is one of the best tools to improve upper body strength and trunk stability. It works multiple muscle groups, multiple planes of movement, requires limited skill to learn, and can be modified in numerous ways to emphasize certain muscle groups and accommodate pain and injury situations (5).

Another argument with overhead pressing is that doing so behind the neck is more dangerous and bad for your shoulders. Well, this is another false statement without more context. The overhead press can be performed in front of the head or behind the neck – both are safe exercises if you have the mobility to do so and can tolerate the movement (6).

“the overhead press in its back variation… a more recent study defined it as a “safe exercise” for people with normal trunk stability and ideal shoulder ROM (McKean and Burkett, 2015), and we believe there should not be any reason to exclude it from the training routine (6).

I would even argue that the behind the neck press can help improve shoulder and upper back mobility more than the standard overhead press if you gradually work into the movement and tolerably, as well as gradually, load it.  

“once established the safety condition of the exercise (McKean and Burkett, 2015), back-BMP could be implemented in the training starting with light or very light loads (e.g., a broomstick) to be familiarized with the movement, and progressively increase the load” (6)

The behind the neck variations does work and stress the some of the shoulder muscles differently than the standard overhead press and may work the external rotators of the shoulder more so, which is an ideal effect for overhead athletes. It also is good for working postural mobility (although there is no perfect nor required posture-an argument for a different time):

“To throw fuel on the fire, back-BMP was shown here more effective in exciting posterior and medial deltoid, therefore should the external humerus rotators be targeted, this might be effectively included in the strength training programmes. Indeed, many overhead sports’ need for a reinforcement of the external rotators for performance and injury prevention purposes (Cools et al., 2015), and back overhead could be part of the shoulder muscles strengthening routine. In this regard, while acknowledging the importance of specific exercises for the external rotators of the humerus such as external rotations using dumbbells, cables or elastic bands, back-BMP implies the activation and consequently reinforcement of these muscles in a different context, i.e., a complex multi-joint exercise, where more control is needed. Importantly, such a consideration is still valid for sedentary or non-athlete populations, in which a “forward posture” favours a pronounced dorsal kyphosis and internal rotation of the humerus (Heneghan et al., 2018).” (6)

Low bar squatting and shoulder pain:

If you do experience shoulder pain as a lifter, a sneaky culprit could be the low bar squat. Now, the low bar squat is not inherently bad on your shoulders, but it could contribute to shoulder sensitivity at times. This could show up as pain during the bench since it loads the shoulder into the similar sensitized position as the rack position in the low bar squat – the squat is what is sensitizing the shoulder and the bench is what brings it out. If you notice your shoulder bothering you with squatting and are also noting pain showing up in the bench, then this may be what is happening. I have discovered this through personal experience. If this is occurring, look back and think about if anything has changed with your training. Have you increased intensity with low bar squatting such as peaking for a meet? The heavier weight could be shoving down on your arm/shoulder in the rack position more than the weights you had been accustomed to which could be where the pain sensitivity has come from. Any change in bench training could also be contributing. Have you started low bar squatting more frequently than you had been or have you just introduced low bar squatting? Your shoulder is now seeing more of this stress from the increased exposure and will take some time to adjust, provided it is not getting too overly sensitized (i.e. painful). Depending on the timing and situation as well as the nature of the pain, there are 4 general recommendations I have:

1. Play with and adjust your low bar squat rack position set up:

   1. Play with grip width, probably trying wider positions

   2. Play with elbow positioning such as pulling your elbows down or raising them up a little

   3. See if you can play around with and find arm and upper back positioning to where you feel the weight of the bar more on your back vs in your arms

2. Change squat programming –

   1. subbing other squat variations (high bar, safety or cambered bar, front squat) for the low bar squat so your shoulder is not stressed into the sensitized position as often or at all

   2. changing the volume or intensity of low bar squatting so your shoulder is not in the sensitive position as long (due to lower reps/sets) or there is not as much weight pushing down on your arm/shoulder

3. Change bench programming –

   1. Adjusting volume and/or intensity to more tolerance

   2. Working more variety such as wider and or closer grip benching or modifying ROM to tolerance

4. Continue training and give it time to adjust -

   1. If this is a newer issue and you just had a change in programming, your shoulder pain may improve as you adjust. As long as the pain is tolerable and not progressing to the point of not being tolerable to train the lifts, then you may not need to change anything and just give it time and continued training.

   2. If the programming change that is contributing to the pain is only for a short period of time such as peaking for a meet, then understand that things will likely cool off once you are done peaking, so continue through the peak with any adjustments you need to get through and still get the training effects and preparedness for the meet, then change programming afterwards to give it a different stimulus to help it calm down. The normal change in training load after a meet may be enough to let it calm down where you might not need to do anything particular for the shoulder.

Why biomechanical studies and evidence can’t be the only thing to base performance of a lift on or whether it’s safe or not:

Pain is multifactorial, see my article How can Lifting Weights Improve Pain, thus solely basing whether a lift can cause pain on biomechanical factors is short sighted and doesn’t account for several other factors. Everyone and every pain situation is unique and different. What if an individual experiences pain with a lower force part of a lift but is pain free at the higher force positions? This also means that just because it demonstrates high forces on structures, doesn’t mean it will cause pain or injury. What if the higher stresses involved are actually desirable and necessary? We have to take into account our ability to adapt and that it requires applied stress to cause desired adaptations. With that in mind, the higher stresses involved in the lift are likely beneficial if tolerated and gradually progressed. Just because there is mechanistic evidence doesn’t mean the outcome is going to follow like you would expect. The mechanism for injury can be there, but the real world evidence may not play out that way.

As I’ve said before, pain is a part of life and is going to happen whether you lift weights or not. Shoulder pain is no different. You can have structural issues and tears in your shoulder, but you can still lift and be pain free despite this. You can improve the symptomatic impacts of shoulder pain through lifting. You can certainly bench press and lift overhead heavily and not injure your shoulders. You might as well lift and get as strong as you can, including benching and overhead pressing. It will likely reduce your chances of shoulder injuries and pain. If you get injured, hell you’ll at least be strong which will likely help you get through the pain experience sooner and be better on the other end anyway.

Keep pressing on.

References:

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(https://www.sciencedirect.com/science/article/pii/S1063458413008224)

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