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Technique and Safety Aspects of Resistance Exercises:

A Systematic Review of the Literature
Juan C. Colado, PhD; Xavier García-Massó

Abstract: A systematic review of the scientific literature was conducted to identify the optimal ranges of motion for preventing injury
in the main joints of the body during resistance exercise performance. These ranges of motion are independent of the type in which
the resistance exercises could be applied (ie, adults, elderly, athletes, recreational exercisers), and the regions examined include the
shoulder, spine, and knee, which are injured most often. It can be concluded that during the performance of any resistance exercise, it
is possible to put anatomical structures at risk with certain body positions; therefore, it is necessary to understand these movements
so injury can be avoided.
Keywords: weight training; injuries; prevention; shoulder; spine; knee

Juan C. Colado, PhD 1

Xavier García-Massó 1
Introduction
Adaptations from a resistance training program depend on both the prescription of optimal
1
University of Valencia,
Valencia, Spain
volume and intensity combination and the selection and execution of optimal exercises.1 Correct
exercise technique is a basic principle in all exercise programs and is not limited to the level of
physical conditioning of the exerciser or the type of program employed. Applying correct exercise
technique involves understanding the limits of the range of motion of every joint and avoiding
the joint positions that put the anatomical structures of the joint at risk. The primary problem
with many of the contraindicated exercises or joint positions in an exercise is that the injuries
are often not acute, but chronic injuries, which manifest over time. Therefore, the direct cause
of the injury is not obvious immediately.
It must be emphasized that resistance training is safe,2 but the level of safety is maximized
when resistance exercises are performed under the supervision of a professional with knowledge
of the proper exercise technique. Without knowledgeable professionals, the probability of soft
tissue and joint injury is higher, despite the fact that the risk of injury with this type of train-
ing is low when compared with other sport activities.2 Therefore, it is not recommended that
exercises carrying a higher level of risk be avoided altogether; rather, they should be performed
with the optimal range of motion to avoid the riskier joint positions. There are general variables
that can influence the magnitude of the potential for injury of some of the joint actions involved
in an exercise. 3
One variable is the capacity of the anatomic structures to withstand and adapt to the ten-
sion as a result of the tensile, compression, shear, and rotational forces that they are exposed
to during resistance training. Knudson 4 indicates that to minimize structural damage, the joint
range of motion of a movement should be limited to the range necessary to make improvements
Correspondence: in the movement. Ergonomic research has resulted in conclusions that the proximal and distal
Juan C. Colado, PhD,
Department of Physical extremes of the range of motion represent an increased risk of damage. 5 The second variable is
Education and Sports, the injury history of the tissues, and research supports the use of limited range of motion with
University of Valencia,
Valencia, 46010,
previously injured tissues.6 The final variables that can affect predisposition of tissues to injury
Spain. are the environmental conditions, such as ambient temperature or time of day. 7 This article aims
Tel: +34-667507636
Fax: +34-963864353
to identify the optimal ranges of motion for preventing injury on the main joints of the body
E-mail: juan.colado@uv.es during the performance of resistance exercises.

104 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
041509e

Materials and Methods
Literature Search Strategy
A review of the literature was performed to identify what
ranges of motion and joint actions must be avoided during
resistance exercises to reduce the risk of injury. A literature
search was performed using the following databases: PubMed,
ScienceDirect, SPORTDiscusTM, SpringerLink, and Web of
Science®. Several combinations of keywords were used. Some
works that authors already knew were also included in the
review. There were no time limitations, and the languages of
the search were English and Spanish.
Inclusion Criteria
All studies had to meet one inclusion criterion to be included in this
review. This criterion was that one aim of each study was to identify
what joint actions or ranges of motion must be avoided during the
performance of resistance exercises to reduce the risk of injury. After
the complete review of all selected works, an additional search was
performed to find articles mentioned in these works that apparently
passed the inclusion criterion. Authors then read the abstracts of
these newly selected articles, and finally, if they passed the inclusion
criterion, they were included in the review.
Summary
Injury Risk Analysis and Correct Technique
Shoulder
Durall et al8 noted that shoulder injuries are common in
individuals who train with resistance exercise, and poor
exercise technique can result in hyperlaxity (and with this,
glenohumeral instability). In addition, the hyperlaxity results
in a greater contribution of the rotator cuff; this compensatory
work may generate fatigue, tendonitis, and pain. Although
this particular research focuses primarily on individuals with
existing shoulder problems, these same considerations could
be used to avoid the development of injury in healthy subjects.
Many authors indicate that anterior glenohumeral
hyperlaxity is more common and is caused by movements of
abduction, extreme external rotation, and some horizontal
abduction.8–12 This maximizes the stress over the anterior
capsule of the glenohumeral joint and, more precisely, over
the anterior-inferior glenohumeral ligament. It is necessary
to point out that the repetitive movement of abduction and
external rotation in the extreme range may result in neural
alterations such as suprascapular neuropathy.13 Examples of
exercises that reproduce these contraindicated actions are the
© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
CLINICAL FEATURES
Safety During Resistance Exercises
lateral pulldown and press behind the neck and the pullover in
the supine position, performed with a greater range of motion.
Thus, it is recommended to perform the exercises in front of
the face for the lateral pulldown and vertical press and with
the arms in a position of a 30° angle forward with respect to
the scapular plane.8,12
The glenohumeral movements of extreme horizontal
abduction with a load can generate instability in the ante-
rior region of the shoulder and degenerative changes in the
acromioclavicular joint.8,11,14,15 This action can be common
in exercises such as a barbell bench press with a narrow grip
and in flies and bench presses with dumbbells (when they are
performed with a large range of motion). The correct range
of motion should consist of a maximum amplitude of a 30°
angle of horizontal abduction.16 One recommendation for
limiting the joint range of motion is to perform the eccentric
phase of the exercise until the depth of 4-cm width over the
sternum,8 and/or perform the exercises of bench press or
push-ups with intermediate grip width or hand placement
to avoid the extreme horizontal abduction with load.8 In this
case, according to the recommendation of Colado,17 it can be
useful to perform a grip or hand placement that permits the
wrist to stay aligned with the forearm during the major part
of the range of the exercise. This recommendation generally
avoids adduction of the wrist, which could cause scaphoid
overload. Also, it is necessary to consider that the usual wrist
hyperextension in pressing exercises with a narrow grip or
hand placement can cause carpal tunnel syndrome.13,17,18 In
these pressing movements (eg, the push-up exercise with a
very wide hand placement or with the hands rotated outward
such as in a 1-hand push-up), a potentially dangerous position
for the structural health of the elbow can be produced.19 The
same occurs in the 2-handed push-up, in which the hands are
placed in an internally rotated position,20 and it is more advised
to perform push-up exercises with 2 hands as opposed to 1.21
Fees et al10 and Durall et al8 indicate that the posterior
glenohumeral hyperlaxicity can be caused during pulling
movements of a 90° angle of flexion of the shoulder (eg,
during the eccentric phase of rowing exercise). Other kinds
of movements that result in a similar joint position, such as
extreme internal rotation at a 90° angle of flexion, can cause
compression syndrome.17,22 In this syndrome, pain and inflam-
mation are produced by the entrapment and compression
of the soft tissues between the head of the humerus and the
scapular acromion process and the coracoacromial ligament.
105
 CLINICAL FEATURES
Juan C. Colado and Xavier García-Massó
This contraindicated action is common when shoulder flexion
is performed with extreme internal rotation when the arm
reaches a 90° angle of shoulder flexion and in the push-up or
dumbbell bench press, in which extreme internal rotation is
performed at the end of the concentric phase. In addition to
performing the exercises with a correct technique, nutrition
supplement intake such as omega-3 polyunsaturated fatty
acids pinitol and glucosamine could be efficient to reduce
inflammation.23–25
Overuse of the repetitive movements of abduction over
an 80° angle of more extreme internal rotation of the gle-
nohumeral joint can cause the greater tubercle to pinch the
subdeltoid bursa and tendons of the rotator cuff against the
acromion.8,12,17 This results in the subacromiocoracoidae
syndrome of the anterior-superior type or also denominated as
in impingement syndrome. This process can result in tendonitis
of the supraspinatus, infraspinatus, and/or the long portion of
the biceps brachii. Examples of exercises that reproduce this
contraindicated action could be the lateral raise with extreme
internal rotation and upright rowing with glenohumeral
abduction of ⬎ an 80° angle with the bar in the dropped posi-
tion.8 Peterson and Renström26 also stated that repetitive
shoulder movements with the shoulder abducted between aa
80° and 120° angle, even without extreme internal rotation, can
cause subacromial bursitis and a decrease in blood flow, and
with this can increase the risk of other types of local injuries.
From these indications, it can be deduced that shoulder abduc-
tion must not be ⬎ 80° in these exercises that are performed
in constant horizontal abduction or adduction. These authors
also indicate that the prolonged use of the shoulder muscles
with an arm level equal or higher than the shoulder height can
cause tendonitis of the supraspinatus; thus, it is necessary to
reduce the volume of work in these actions.26
Another contraindicated action related to exercise per-
formance for the upper extremities is permitting that the
bar bounces or hits the body over the sternum in the bench
press exercise because this action can cause a sternal fracture,
sternoclavicular sprain, or dislocation and separation of
the costochondrals.27 Shankman27 stated that the risk of
acromioclavicular sprains in the eccentric phase of the
exercise (eg, in a shrug or an upright row) is not performed
in a controlled manner. Shankman27 also stated that there is
the possibility of causing an acromioclavicular ligament injury,
such as standing calf raise or even the hack squat, if muscular
tension is not maintained to prevent depression of the shoulder
106 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
girdle because of the high loads that are commonly used in
these exercises.
Finally, the forced movements of flexion, adduction,
and internal rotation of the glenohumeral region can cause
other manifestations of the impingement syndrome or
denominated such as in subacromiocoracoidae syndrome in
the anterior-internal type.28–31 This consists of inflammation of
the subcoracoid bursa for the friction with the lesser tubercle
of the humerus, and this inflammation can cause a reduction
of the area subsequent to compression of the surrounding soft
tissues. A typical exercise in which this contraindicated action
can be performed is the cable crossover, in which the arms
cross at the end of the range of motion, and on that point a
forced rotation movement is carried out.17
Vertebral Column
Lumbar pain is a significant problem in public health in
industrialized countries,32 and it is one of the main causes of
functional limitations in adults. There are approximately 10
million people who suffer lumbar pain daily.33 The lumbar
region is usually the most affected in all segments of the popu-
lation;33,34 within the lumbar region, the most affected vertebral
areas are those between L4 and L5 and between L5 and the first
sacrum.35 Fortunately, this common problem can be avoided
or at least reduced if the potential weaknesses of the spine are
known. Lumbar pain related to resistance training is often the
result of chronic repetitive performance of contraindicated
actions, such as performing exercises in poor postural posi-
tions.2,17 The most common injuries are in muscles that can be
easily rehabilitated. Fortunately, the percentage of injuries that
can affect the passive structures is not high, and this is more
important because it can cause serious functional incapacity.8
A fundamental guideline during resistance exercises
is that the spine must be in a neutral position, which is an
intermediate position between maximum flexion and exten-
sion in which the physiological curvatures are respected.36 The
posterior vertebral structures can be damaged when the spine
is in maximum extension, whereas the interarticular structures
and ligaments can be damaged when the spine is in flexion
and with vertical load.8,32 The degrees of amplitude of joint
movement of the spine for the following regions are: a) lumbar
region: flexion of 40°,16 extension of 25°37 or 30°,16 rotation of
5°,16 and lateral flexion of 20° to 30°;16 b) dorsal region: rotation
of 37°16 and lateral flexion of 20°;16 c) dorsolumbar region:
flexion of 105°,16 extension of 60°,16 and rotation of 45°;16,37

d) cervical region: flexion of 40°16 or 35° to 45°,37 extension
of 30°,37 rotation of 80°,16 and lateral flexion of 35° to 45°.16
The spine can support greater axial loads by maintaining
the correct position of the physical curvatures,38 where the
reduction of these curvatures increases the risks of sustaining
disk degeneration. 39,40 For example, if the physiological
curvature of the lumbar region is reduced during a
maintained seated position, it could increase the injury risk
of the posterior structures.41 Thus, the myth of maintaining
a flat position of the spine (inverting the curvatures) dur-
ing resistance exercises is rejected and is more important if
loads are used in a vertical position, with the weight placed
longitudinally over the spine.35 Thus, it is better to perform an
exercise that moves weight vertically in a standing position as
opposed to performing the exercise in a vertical seated posi-
tion in which there is an inversion of the spine curvatures.
An added benefit of standing exercises is the level of physical
conditioning of the trunk musculature; for maintaining the
correct spinal position in a seated position, it is not neces-
sary to have greater muscle activation,42 and it is possible
to easily obtain this in a standing position.43 Nonetheless,
for maintaining a neutral position of the spine curvatures
during a standing exercise, one must have knowledge of
the correct performance technique and a well-conditioned
muscular system of the area.36,44,45 This aspect is not common
in the beginning of a neuromuscular conditioning program,
so it is recommended that one progress from exercises with
external stabilization to others that demand greater active
stabilization of the trunk.46 For example, if a seated exercise
is necessary, it should be performed with a reclined seat
(between a 105°–110° angle), with the seat bottom raised to
an angle of 90° with respect to the seat back, and with the
placement of a device on the floor so the lower extremities
are in a good position (unless the seat is close to the floor)
so pelvic tilting and hyperlordosis is avoided.17,47
According to Durall and Manske, 48 there are several
exercises that may potentially damage the lumbar spine if
they are not performed correctly because, when performed
incorrectly, it is possible to have spine flexion that is further
aggravated by being combined with weight manipulation.
These exercises include good morning, deadlift, bent-over
row, bent-over raise, squats, and leg press (Figure 1). Also,
there could be a greater risk of injury at the lumbar level if
some actions are combined with the manipulation of weights
(eg, rotation with flexion or hyperextension).49
© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
CLINICAL FEATURES
Safety During Resistance Exercises
The cervical region can be damaged during resistance
exercises. It has been demonstrated that flexion of the cervical
region during the lateral pulldown behind the neck and the
vertical behind neck press is very damaging,9,10 and it has been
shown that cervical flexion during the lateral pulldown behind
the neck can produce a transitory neural injury of the brachial
plexus.10 Shankman27 indicated that placing the bar over the
spinous processes of the seventh cervical vertebrae during
the squat exercise can cause an avulsion of these processes.
It is also possible to cause damage to inferior cervical disks
when combining a movement of protraction of the chin with
the elevation of the shoulders by the energetic action of the
superior fibers of the trapezius muscle. This can occur when
the cervical neutral position is lost during the shrug, behind
the neck press, or extension of the ankle in a machine.50 How-
ever, it is possible in other exercises in which the trapezius is
working as a synergist (eg, the lateral raise in a standing posi-
tion, inclined bench press, or lateral pulldown in front of and
behind the neck).50
With respect to the movements that are performed over
the head, it must be noted that whatever movement of the
shoulder joint in which there is flexion between a 120° and
180° angle, it is necessary to perform a lumbar hyperlordosis.
If there is abduction between a 150° and 180° angle, it depends
on whether the movement is performed with 1 or 2 hands.
If the movement is performed with 1 hand, there must be
lateral flexion; if it is performed with 2 hands, there must be a
change of the abduction over to shoulder flexion with added
hyperlordosis.16
The time of day and the previous activities performed can
influence the way in which the intervertebral disks support
the load. For example, it is known that lifting weights early in
the morning is less than optimal and is worse when using a
maximum range of motion.51 Also, there is difficulty absorbing
the compressive loads after spending a lot of time in a seated
position or when a poor postural position is maintained for a
long period of time.52
The use of weight belts during resistance exercises is a
debated topic. The primary problem with weight belt use is that
it can reduce the muscular activation of the stabilizer muscles
of the body53 that can cause local muscular weakness and lack
of motor coordination, which is problematic when weight has
to be supported without a belt.35 Nonetheless, occasional use
is not harmful because it can limit the maximum degrees of
flexion, extension, lateral flexion, and rotation, and if correct
107
 CLINICAL FEATURES
Juan C. Colado and Xavier García-Massó
Figure 1. Examples of correct and incorrect exercise performance
technique during 4 typical resistance exercises.
A: Upright rowing performed with a dangerous technique. The neck is
forward bent and the thoracic spine is not in a neutral position.
B: Upright rowing performed with a correct technique. The neck
is straight and the thoracic spine is in a neutral position.
C: Lateral raise is performed with an excessive range of motion.
D: Lateral raise is performed in a safe range of motion.
E: Deadlift exercise performed with a harmful hiper-kiphosis.
F: Deadlift exercise performed with a correct position of the spine.
G: A horizontal abduction of the shoulder bigger of a 30° angle
during horizontal abduction in the bench press exercise.
H: A horizontal abduction of the shoulder lesser of
a 30° angle during bench press exercise.
108 © THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
health is maintained, it does not produce negative hemody-
namic effects.53 Finally, it is important to note that exercisers
and clients must be educated about correct techniques because
spine injuries are caused by incorrect movements during
physical conditioning activities,54,55 as well as incorrect pos-
tural positions during lifting tasks in daily activities at home
or at work.32,55,56
Knee
The knee is one of the more complex joints in the body. The
primary movements are flexion and extension in the sagittal
plane. It is composed of 3 joint areas: patellofemoral, medial
tibiofemoral, and lateral tibiofemoral. There are also different
passive structures that can provide both movement and
stabilization. In the patellofemoral joint region, the patella is
the primary structure of concern, and in the tibiofemoral joint
region, the menisci (internal and external), lateral ligaments
(internal and external), and cruciate ligaments (anterior and
posterior) are the primary structures of concern.
In programs of neuromuscular conditioning, the basic
movement for the lower extremities is flexion and extension
of the knee and hip, with a closed kinetic chain exercise, as this
action has similarities with daily activities (eg, walking, stair
climbing, and standing or rising from or lowering to a chair).
However, the maximal recommended amplitude of flexion for
these exercises is open to debate. Neitzel and Davies57 indicate
that the majority of daily activities are performed between a
0° and 40° angle range of motion in the knee. Thus, for func-
tional performance, it is recommended that the exercises be
performed to a maximum amplitude of flexion of a 50° angle.6
There are few situations in which this degree of flexion is not
sufficient, but there are some cases such as standing or sitting
in very low seats in which it is possible to obtain a 110° angle of
flexion58 or standing up from a seated position on the ground
with both legs.59 Nonetheless, in subjects without patellar pain,
it is possible to perform flexion (with a minimal risk of injury)
to a 115°60 or 120° angle.61,62 Increasing the degrees of knee
flexion is only recommended in subjects in whose athletic
specialties there is a deep knee flexion.6,63 In this case, however,
it is assumed that knee hyperflexion (defined as ⬎ 120° angle)
is associated with a greater stress within and around the joint,
which increases the probability of damage.6,64–67 Previously, it
was determined that performance of deep flexion during an
exercise such as a full squat was responsible for increasing the
laxity of the medial, lateral, and anterior cruciate ligaments.68

This hyperflexion increases the instability of the knee joint,
which can affect joint health and integrity.69
If the influence that the level of flexion and extension
has over some joint structures is examined, it can be stated
that hyperflexion movements of the knee could cause
patellofemoral syndrome, as a large force moment is caused
over the patella. Wretenberg et al70 compared force moments
of the patella in weightlifters during the full squat and parallel
squat and found that there was greater tension in the full squat.
This patellofemoral syndrome is one of the more common
disorders of the knee and is usually caused by overuse. The
cause is not sufficiently understood, but it is characterized
by increments of stress over the patellar cartilage and the
subchondral bone of the femur. This is usually generated in
a simple or combined manner by alteration in the patellar
movement, stiffness of the soft tissue, muscular weakness, or
with a high volume of joint actions with poor technique.71,72
Additionally, it is known that patellofemoral syndrome can be
present in situations in which internal rotation of the lower
extremities is increased while flexion and extension of the
knee is performed.71,73
With respect to other internal joint structures, injury of
the meniscus usually occurs with the combined movements
of deep flexion, rotation, and compression. This is more
pronounced with the degeneration that accompanies the aging
process.73 The combined actions during the performance
of closed kinetic chain exercises are not recommended in
the squat, leg press, and hack squat. An example of poor tech-
nique is when the knees are not aligned in the same direction
as the feet. Moreover, it is known that from a 110° to 120°
angle of tibiofemoral flexion, the risk of posterior subluxation
is increased,64,74 and in this case, there is a backward displace-
ment of the femoral condyles, which lose contact with the
tibia and maintain the position over the meniscal bodies.74
This aspect can cause pathologies of the meniscus.64,75 Thus,
to avoid this situation, it is recommended that only a small
external rotation of the tibia be performed, and the knee
flexion be limited to a 90° angle.74,76
With respect to other joint structures such as ligaments,
Signorile et al77 indicate that the performance of strong inter-
nal rotation can cause problems of joint instability because
greater stress over the connective tissue is created primarily
over the medial collateral ligament. Although Noble et al78
noted that during exercise performance for strengthening the
hip abduction muscles with pulleys, the point of application
© THE PHYSICIAN AND SPORTSMEDICINE • ISSN – 0091-3847, June 2009, No. 2, Volume 37
CLINICAL FEATURES
Safety During Resistance Exercises
of the force must be closer to the knee than the ankle to avoid
excessive stress. This can result in injuries of the collateral liga-
ments because of the dangerous lateral inclinations of the tibia
with respect to the femur. With respect to the anterior cruci-
ate ligament, injuries can occur with movements of extreme
internal rotation of the femur or with external rotation of the
tibia. Also, the anterior cruciate ligament can be injured in
movements in which there is a large anterior displacement
of the tibia.73 Considering this last aspect, closed kinetic
chain exercises can be recommended more often than open
kinetic chain exercises because they produce less strain on
the knee and promote a greater coactivation of the extensor
and flexor muscle groups, with a greater participation of the
gastrocnemius. All of these join in the compressive action of
the movement over the joint to cause the best mechanically
stable situation.79 Nonetheless, there exists a disparity of cri-
teria in the assessment of the damaging tension that the open
chain kinetic exercises can generate over the anterior cruci-
ate ligament in healthy knees,79 although there is unanimity
regarding the greater tension that results in these movements
when the knee is near full extension,80 with flexion between
a 40° and 10° angle with respect to full extension. Moreover,
this tension is greater during the eccentric phase of the move-
ment79 and when the resistance that is used is increased.81
The anterior cruciate ligament can also be damaged during a
closed kinetic chain exercise when the knee goes too far past
the point of the foot because a sagittal translation of the femur
with respect to the tibia is produced.79 Specifically, Kvist and
Gillquist79 indicate that the sagittal translation of the femur
with respect to the tibia can be reduced with closed kinetic
chain exercises that do not exceed a 70° angle of knee flexion.
Moreover, the authors point out that translation movement
can appear easily with an increase of the resistance; however,
this movement can be reduced if this exercise is performed
in a way in which the center of gravity stays behind the feet.
Thus, a general guideline for preventing injury is, when pos-
sible, some closed kinetic chain exercises can be performed
with placement of the feet a little more forward, such as in
the leg press machine (inclined and horizontal), hack squat
machine, and Smith machine. Another crucial aspect related
to the postural alignment during the performance of lower
extremity exercises is that individuals must avoid hyperexten-
sion of the knee at the time of performance and when the leg is
being used for support and is not the agonist of the movement.
Thirty percent of knee osteoarthritis problems can be avoided
109
 CLINICAL FEATURES
Juan C. Colado and Xavier García-Massó
if situations in which there is flexion of the knees and large
loads in the workplace are eliminated,82 as in the positions of
daily activities that are usual in the Asian population. In this
population, it has been demonstrated that these hyperflexion
postures cause a greater risk of tibiofemoral osteoarthritis
than in other populations who do not normally perform this
type of movement.83
Conclusion
When performed with proper technique, resistance exercises
are safe and beneficial for maintaining fitness and improving
performance. Proper technique includes performing
the exercise with the correct speed and resistance in the
appropriate plane of movement and within the optimal joint
range of motion to maximize adaptations and minimize risk
of injury. Figure 1 shows a summary of some of the concepts
in this article.
Acknowledgments
The authors would like to thank N. Travis Triplett, PhD,
CSCS*D for assisting with the translation and editing of
this paper.
Conflict of Interest Statement
Juan C. Colado, PhD, and Xavier García-Massó disclose no
conflicts of interest.
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