Are Weighted Vests Effective?

Are Weighted Vests Effective?

Written by Ben Bunting: BA, PGCert. (Sport & Exercise Nutrition) // British Army Physical Training Instructor // S&C Coach.

You may have seen them already, people wearing vests whilst on the treadmill or in the gym that resemble something a soldier would wear, but what's the fuss?

We shall cover the following main points:

  • What is a weighted vest
  • Tactical assault vests
  • Benefits
  • Murph WOD training
  • Weighted vest results
  • Weighted vest or backpack
  • Negatives
  • Workout routine
  • Pros and Cons
  • Conclusion

What is a Weighted Vest?

More importantly, how is it useful for fitness training?

In this article, we will address what a weighted vest is, how it has been used, how you can use it to enhance your training plus any negative points or issues it may cause.

What Are Weighted Vests Used For?

There are various names relating to load-bearing vests, some are used in a professional context, such as law enforcement and military, others are designed specifically to be used for fitness and performance.

They are known as:

  • Tactical vests
  • Weighted vests
  • Rigs
  • Webbing
  • Assault vests
  • MOLLE
  • Chest rigs

What do Weighted Vests Do?

For sport and fitness purposes, weighted vests increase the weight carried by the person to increase resistance. 

They are constructed of tough material and have openings or pockets in which additional weight can be carried. 

This could be a plate for the chest and rear, or it could be numerous pouches that can be filled with smaller weights for a more accurate adjustment. 

It fits like a waistcoat, sometimes with a main heavy-duty zip or velcro with adjustable clips so it can fit snug, and tight with the torso. 

There's usually lots of padding to make it as comfortable as possible. 

Sometimes the weight sits high on the chest and enables a good balance of the load so the weight is in a neutral position and doesn't place unwanted strain on the spine or hips. 

The additional weight carried during exercise can help increase muscle strength, bone strength, and mass. 

It is often speculated by many people, companies and websites that they contribute to improving physical performance. 

However, science is yet to determine this...

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Tactical Assault Vests

Traditionally, in a professional context, soldiers or police forces used belts or webbing to carry equipment.

For military use in the US, it was known as Load-Carrying Equipment.

Essentially this consisted of a belt with pouches for various items such as a water canteen, ammunition, first aid, and an entrenching tool.

The belt is then supported by over the shoulder harness known as suspenders to distribute the load more evenly across the body.

There have been different incarnations of this system over the years, and its basic design and principles are similar throughout many armed forces over the globe.

It could be suggested that its roots as a recognizable piece of equipment stem back to the late 1800s when the British Army was involved in the Boer War.

The load-carrying equipment comprised of a belt, haversack and ammunition pouches which proved unsuitable.

This set-up was also made from buffalo leather which deteriorated during use.

Due to much criticism of its design, it was hastily replaced with another system known as the 1903 Bandolier Equipment which, again, was constructed using leather. And, again, it was deemed unsuitable for field use. [1]

It wasn't until 1906 that the British Army moved forward significantly in the design of personal carrying equipment.

This design stemmed from equipment webbing that had been produced for the US Army which was manufactured using cotton, and more importantly, when the components were assembled, the whole 'rig' could be placed on and taken off like a jacket.

It was at this stage whereby personal load carrying equipment is similar and recognizable as today's standards.

The improved equipment consisted of nine components ranging from ammunition pouches, bayonet frog and even a haversack. Side-by-side, it is a set up that would be familiar to a modern-day soldier.

In fact, this particular equipment even saw service until the 1940's in some parts of the world.

Like today, it's purpose back then was to evenly distribute the load carried, and make it easy to operate in. And, like today, front line soldiers would carry loads weighing up to 52kg (114lbs). [2] [3]

This huge amount of weight contradicts the ratio of weight to be carried by mules found in the British Army Mule Pamphlet of 1928 which stipulates that the animals were to carry no more than 25% of their body weight. In contrast, today's soldiers carry 82% of their body weight on average. [4]

Design Changes

The fundamental design only sees significant changes when there is a change of either material used or a change of weapon system.

It wasn't until the late 1990s and around the early 2000s that we saw a further step away from the simple belt and harness webbing design that had been used in one form or another for around 100 years.

This was the introduction of MOLLE (Modular Lightweight Load-carrying Equipment) and is used by NATO forces, predominantly the US and British.

This modular system incorporates many different pieces of equipment that can be attached or harvested from each other to create a carrying system that is suitable for the current requirements, it also incorporates body armor.

It is this evolution of load-bearing equipment that has seen the introduction of the vest, be it called a tactical vest, assault panel, outer tactical vest, load-bearing vest or rig.

The idea is that a vest, waistcoat style or bib system is more comfortable to wear, can be attached with different modular pieces and spreads the weight more evenly across the wearer while being compatible with webbing and rucksacks which can give the operator the equipment and sustenance required for 48 hours or even weeks out in the field.

This vest design offers a platform to carry essential items more securely and with more stability.

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Weighted Vest Benefits

In a professional context (military and law enforcement), the benefits of a vest are that it can enhance mobility, wear duration, weight distribution, and overall comfort. [5]

However, these load-bearing vests have become commonplace in the fitness arena, with more people using them to enhance their workout regime and their overall fitness.

They are popular for those looking for a bit of extra weight to carry, particularly in CrossFit and those who participate in calisthenics traditionally performing bodyweight movements which exercise the large muscle groups.

This additional weight can work their muscles even harder.

It could be argued that the image of an assault vest often seen worn by special forces resonates well with those who favor intense and extreme workouts.

WOD with Vest

It also reflects the WOD (workout of the day) that many CrossFit enthusiasts prescribe to which usually involve a number of bodyweight exercises that participant (athlete) has to do for that day, this may entail something such as 100 burpees, 200 push-ups, 1000 meter run and 50 pull-ups.

Furthermore, there are 'Hero WODs', these are workouts that are dedicated to fallen military personnel and first responders from all over the world who were fans of CrossFit themselves. [6]

Yet, one of the most famous WOD's is called the 'Murph'.

Murph WOD Training

This is a particularly arduous workout, although, at first glance, you may think it isn't that difficult.

This could be attributed to the fact that it doesn't involve any technical lifts or equipment from the gym such as a barbell.

Weighted Vest Murph

The 'Murph' consists of all bodyweight exercises, apart from one thing...there's the option to wear a load-bearing vest tipping the scales at about 9kg (20lbs).

Now, there are different vests to wear.

You could choose a typical plate carrier that is used by certain military regiments and forces with the capability to attach your magazines, grenades, and a pistol.

Or you could opt for a vest that is designed to be used primarily for sporting activities and will not withstand small arms fire.

Either way, it does not really matter, what counts is that it adds more weight to your body, and therefore places more stress and challenge to your workout.

Murph WOD Story

As with many hero WOD's, the Murph is dedicated to a soldier who died in combat. Specifically, a Navy SEAL called Michael Murphy who was killed in action during 2005 during the War in Afganistan who enjoyed CrossFit, and this was his favorite workout.

His story is one of selfless bravery and courage.

As part of a four-man SEAL team, their mission was to find a key anti-coalition commander.

However, upon insertion, they were spotted by three goat herders, who it was believed reported the SEAL team's location to the Taliban.

Whilst on the side of a mountain, the SEAL team were met by a much larger enemy force, a fierce battle ensued.

With the situation being severe and already receiving a small arms fire wound, Murphy had to call for assistance over the radio. Their position made it impossible to contact headquarters.

Murphy, already injured, took it upon himself to move to the less sheltered ground while under fire to make transmit their position and situation.

His new position left him exposed which attracted more enemy fire. Nevertheless, Murphy made contact to request assistance from the Special Forces Quick Reaction Force relaying their position and the size of the enemy they were fighting.

While doing so he was shot in the back, however, he completed the call, returned fire and covered ground to return to the cover with his men to continue with the battle.

The end result was that three members of that particular SEAL team, including Murphy died, however, there's no doubt that his actions contributed to the rescue of the sole surviving SEAL member and the remains of the other SEALs. [7]

Murph CrossFit Training 

This particular workout was his favorite, as such, it is now known as the 'Murph'.

He used to refer to it as 'Body Armor', as a result, many people like to add the load-bearing vest to their participation of the 'Murph', although it is not a strict requirement.

Many people across the globe perform the Murph on memorial day in tribute of his bravery.

It consists of the following:

  • 1 mile run
  • 100 pull-ups
  • 200 push-ups
  • 300 air squats
  • 1 mile run

As mentioned, this is generally performed with a vest weighing in at 9kg (20lbs) and there is a standard 60 minute cut off point.

Needless to say, the popularity of the Murph is as big as the challenge.

Once a mere club tradition became part of the CrossFit games in 2015, those athletes who took part were pushed to their limitations with some falling foul to the intense heat and stresses caused.

The initial best time recorded for a male was 38:36.

The following year, in a fitting tribute, the male winning time was slashed by almost four minutes by ex-SEAL, Josh Bridges.

The Murph Tactics

Whichever way you look at it, the Murph is difficult. It has broken professional CrossFit athletes, and even the top performers only have around 20 minutes to spare.

Therefore, it pays to be rigorous about your approach to training for the event.

One theory is that you should train with no weight initially, and then over time slowly add increments, almost as you would with traditional weight training.

Another consideration is that you should start with the 20lbs but with much longer rest breaks.

Forgo the 60 minute cut off point, and break each exercise down into smaller chunks with long rest periods, even the one mile runs.

Therefore, you could do 5 pull-ups at a time or split the run into quarters with rest breaks in between.

As you progress, start to reduce the number of rests and the time spent recovering, then work towards fitting it all within the 60 minutes.

This way your body gets the full compliment of the weight from early on and can be conditioned.

Weighted Vest Results

We know and accept that doing any sort of physical activity whilst carrying more weight is more difficult.

Even wearing a fully laden backpack can become tiresome after a while with just low-intensity activity.

Therefore, we want to establish what the research suggests whilst performing an exercise with a load-carrying vest. Is it harmful, or not?

After all, the military is moving away from the traditional aerobic and endurance fitness principles to include much more muscular strength and conditioning elements. [8]

This is because lifting equipment, dragging people away from danger, or just simply carrying extreme heavy loads and transversing obstacles such as compound walls require a high level of physical robustness thus reflecting the roles soldiers tend to perform. [9]

Having the strength and capability to perform when laden with heavy equipment is imperative as it is reported that soldiers will carry anything up to 58kg (127lbs) when on operations. [10]

Therefore, is it beneficial to train whilst wearing a weighted vest that resembles body armor?

Do Weighted Vests Help?

A study which involved both young men and women who were considered physically active.

The group was dived into two. One group trained for 6 weeks wearing a load-bearing vest, while the control group did not.

The study ran the two groups through a number of military-style fitness tests prior to the training period and after the training to compare results.

Each of the tests was run through with both groups wearing military Personal Protective Equipment, this included ballistic vests weighing up to 10kg (22lbs) and helmets.

Interestingly, it was thought that the vest group would yield significant improvements, yet this was not the case.

There were improvements recorded, but nothing considered significant.

However, it was surmised that the 6 weeks training schedule was too short and that the trends shown by the results would prove more significant after a longer period of training with a vest. [11]

The result of that particular study focused on military fitness training, however, a further study published in the Journal of Strength and Conditioning Research looked at the effects a weighted vest would have on the performance of soccer players.

This focussed much more on sprinting, in rapid and short bursts.

However, again, while both the vest-wearing group and the control group increased their performance compared to results before and post-training, there was very little in differences between both groups regarding increased performance.

It's not that wearing a vest wasn't beneficial, it is just that it doesn't appear to be much more beneficial than the same training performed without a vest.

The caveat is that again, the training period lasted for just 6 weeks. [12]

So, it begs a question.

Is it worth training to increase your performance with a load-bearing or weighted vest if the end result is similar to someone else who is doing the same training but without the additional weight?

Perhaps.

An alternative study suggests that warming up before running whilst wearing a weighted vest is beneficial to running performance.

The study involved well trained long-distance runners.

Analysis of the results was surprising when we consider the previous lackluster data.

It seems that wearing a weighted vest does lead to increases of running economy, speed and leg stiffness.

These results were gained from a warm-up session that consisted of 10 minutes of a self-paced jog, and 5 minute submaximal run with a 10 minute recovery period.

The researchers from the Sports Performance Research Institute of AUT University in New Zealand concluded that it would translate to an enhanced performance. [13]

This set of conflicting and inconclusive results correlates with a systematic review of multiple studies investigating the impact on sprint performance for those trainees wearing weighted vests.

While it can be said that those wearing sprint vests could reach maximal velocity more effectively, that velocity could not be maintained. [14]

Additionally, there is evidence that jump training under resistance by using either a vest or other weights can potentially yield benefits that can translate to an increase in jump and sprint performance. [15]

However, there appears to be no definite answer whether light or heavier loads are advantageous.

Furthermore, while there is some early data supporting resistance training, findings lack replication and as such we are basing further advantages on hypothesis. [16]

There is another variable to consider, much of the results come from research whereby the vests are worn for periods of training.

Hypergravity Weight Training

Another study in the International Journal of Exercise Science and submitted by research from the University of North Alabama and Middle Tennessee State University conducted tests on 'hypergravity training'.

This means the participants wore their vests for eight hours per day over four days per week but did not wear them during training periods.

Again, there was conflicting evidence.

Hypergravity training yielded some positive findings for short-distance sprinting and shuttle running, although it did not seem to offer much benefit when tested on rugby players. [17]

Yet, again, the authors of the published article note that wearing a weighted vest to increase performance is merely a suggestion rather than a recommended training method.

Another hypergravity study whereby the participants wore a weighted vest for three days per week over a three week period saw a very slight improvement in agility, but the effect was small. [18]

Essentially, analysis of the collective findings could not establish a firm set of conclusive results, and realistically any improvements appear to be anecdotal rather than backed by multiple positive research findings.

Training while wearing a vest does not appear to significantly enhance performance, although wearing a vest while warming up prior to an event or wearing a weighted vest for long periods of the day during 'pre-season' does appear to be more beneficial. Albeit a fairly limited range.

How Effective are Weighted Vests?

Clearly, working out with a weighted vest for WOD's, for example, is going to increase physical exertion, and thus make it harder to complete.

Yet, there's little conclusive evidence that training for an event while wearing a vest result in better performance, unless it is used for a short period of time while warming up.

Likewise, there's limited evidence that wearing a vest for a long number of hours throughout the course of a day can yield some benefit.

What are Weighted Vests for?

While it seems that wearing a vest for training will not provide that significant step to get ahead of the competition, it could be argued that carrying a load is beneficial for your physiology.

Walking with Weighted Vest Benefits

Wearing a weighted vest for walks can help develop the growth of bone cells and as a result, inhibit bone loss. [19]

The benefit of wearing a vest is that the weight is balanced over your torso, as such is can prevent causing muscle imbalance that wearing weighted wrist or ankle straps can create.

In a different study focussing on user weight loss, the use of a weight vest whilst incorporated with a low-calorie diet to assist with reducing obesity did not bring a great deal of benefit over the control group who just had the diet.

Although it was surmised that it may help prevent the loss of lower body muscle mass. [20]

In another study involving Australian Army personnel, the soldiers saw an improvement in their psychophysical performance.

Therefore, they felt that their physical exertion after completing a ten-week training program, which utilized weighted walking with a 23kg (50.6lbs) vest, was reduced.

Other aspects of their fitness and performance improved, however, their ten-week training program also included other resistance exercise and was not limited to load carries. [21]

Weighted Vest for Fat Loss

A further study has found benefits for increased calorie expenditure and fatty acid oxidation.

This published study from the Journal of Strength and Conditioning Research saw considerable increases in both parameters compared to the control group. [22]

Where this differs compared to the earlier study is that these subjects were recreationally trained runners and physically fit whereas the other study contained obese subjects.

There is a glimmer of hope for those training in power cleans.

A study demonstrated that if 12% of body weight was transferred from the bar to a load-bearing vest a number of movements and parameters improved when compared to training conventionally and leaving all of the weight on the bar. [23]

A further benefit was noted for badminton players using a weighted vest in their warm-up phase before a game, in this study it showed that their change of direction speed benefited.

However, their vertical jump stayed that same as the control group without using weight as part of their warm-up routine. [24]

Are Weighted Vests Bad?

Not entirely.

Okay, the studies available show no performance benefit.

However, they tend to focus on whether times have improved, or agility increases after wearing the vest during training for a matter of weeks.

While many blog sites laud the use of a vest, the articles are often without supporting referenced studies and based on the belief that training with weighted resistance must yield benefit.

Although, we have seen the studies do not correlate with this assumption.

However, the tests performed focused on cardiovascular and movement. Yet, wearing a vest can potentially help build strength and muscle if worn when performing push-ups, chin-ups, and squats for example.

This is of course if you are not already pushing, pulling and squatting greater weight than what the vest offers.

Therefore, if you are thus far exercising with body weight, such as calisthenics more resistance can be placed on your body to develop your musculature.

And, there is strong evidence for the benefits of weight training. [25]

Although, this practice may not be of any benefit if you are already weightlifting with greater loads.

Weighted Vest or Backpack?

As we can see, according to numerous studies, training whilst wearing weight appears not to hold a large amount of value.

However, on the flip side of the coin, there is documented evidence that states there is value in warming up before an event whilst wearing a weighted vest.

Therefore, to gain from this form of preparation the simplist option could be to just wear a rucksack with weight in it, but there could be a problem going down that route.

The issue with wearing a backpack or rucksack is the imbalance of load.
It places strain on your muscles and joints, and when really heavy causes the wearer to lean forward which can lead to shoulder and back injuries, often seen in military personnel. [26] [27]

And, it is not that waring a backpack can really offer any additional benefit over weighted vests, with a study showing that wearing a backpack up to 35kg (77lbs) merely increases metabolic stress and can compromise the respiratory system. [28]

Plus, there's evidence to support using a vest rather than a backpack.

This study involving physically fit females saw no additional benefit in respect of VO2 peak or heart rate, however, they could exercise for longer due to the even weight distribution of the vest versus pack. [29]

Furthermore, a vest can be worn with a much greater fit around the body.
It can be fitted tightly to minimize movement when you are exercising, unlike a pack that may act as a pendulum swinging around your back making you unstable.

Wearing a vest can help you feel more in control and improve your posture.
It could be suggested that a backpack is cheaper and more flexible in terms of adding or reducing the weight carried.

However, vests can be had for a modest sum, and there are pouches that have small parcels of weight which can be taken out of added as required.

Load Carrying Vest Negatives

We have covered many negatives thus far, and, if you are going to wear a vest to increase the weight whilst doing chin-ups or squats, a vest can be a practical way of increasing the resistance and therefore build muscle.

After all, it is just like using weights in the gym, to a degree, and therefore largely safe.

Although, this can depend on your current strength and abilities.

Typically, in CrossFit, for the Murph the weight carried is 9kg. That's a considerable additional weight to carry for the whole duration of the exercise.

That is an additional weight that your musculoskeletal system has to endure. Hence why military recruits are often compounded with stress fractures, as reported by the Journal of Sport and Health Science. [30]

As such, jumping in to carrying additional weight or ramping up the intensity whilst performing exercise tasks on the move without prior conditioning and training can lead to injury. [31]

It is also a good reason to ensure that you are getting enough vitamin D in your diet.

The American Academy of Orthopaedic Surgeons find that stress fractures are more common during the winter months when vitamin D levels of lower in the body. [32]

It is also why we offer a massive amount of vitamin D in Military Muscle as part of our ingredient profile.

While weight training is proven to help strengthen bones, tendons, ligaments, muscles along with a host of additional physical and mental benefits. [33]

However, running whilst wearing or carrying weight comes with risks such as worsening back or joint problems. [34]

High impact loads can lead to over-use injuries, muscle strain and conditions such as shin splints. [35]

Obviously, as with any injury, it will then delay your training, it can cost you money for rehabilitation and essentially have the reverse effect you were looking to attain, with very little compulsive evidence that there are benefits to be achieved.

Also bear in mind that whilst challenges such as the Murph encourage a relatively modest weight, some load-carrying vests can exceed 60kg (140lbs)!

Weighted Vest Workout Routine

If you have already bought a vest, or definitely want to use one, low impact exercises are probably the best route to take.

As there is very little evidence to demonstrate that running with a weighted vest can improve performance (except for warming up routines) wearing a vest might be a viable alternative to using gym equipment such as a barbell or a belt to hang weight plates from.

Therefore, they can be used as a way to increase the resistance normally associated with bodyweight exercises or calisthenics.

Low impact exercises will help protect the musculoskeletal system.

Such exercises could be the following:

  • Push-ups
  • Dips
  • Pull-ups
  • Squats
  • Lunges
  • Sit-ups (with the rear weights/plate taken out)
  • Plank
  • Single-leg squat
  • Side lunge
  • Plie-squat
  • Heel raises

Obviously, if you are currently now performing 10 reps for each exercise and are looking for the next step, wearing a full 60kg weighted vest is going to be a huge strain.

As such, you should gradually increase the weight on the vest and thus make progressive gains.

Weighted Vest Pros and Cons

In this article, we have looked at the history, uses, benefits, implications and the studies surrounding load bearing vests and whether we should use them or not as part of our fitness regime.

On the whole, it does appear, that according to the studies. Wearing a vest that is loaded with weight during your training does not support the hypothesis that it will enhance your performance.

So let's run through the pros and cons of buying and using a weighted vest in the context of exercising.

Pros

Studies have demonstrated that using a vest during the warm-up phase before an event can increase your physical performance such as change of direction speed as documented with research on badminton players.

Casual and leisurely walking whilst wearing a vest no more than 10% of your body weight can help strengthen bones whilst reducing bone loss. Another study confirms that wearing a vest can increase fat acid oxidization and improve calorie expenditure, helping those looking to reduce fat.

Building muscle and strength can also be increased by wearing a vest for low impact calisthenic exercises.

Furthermore, for competitive weight lifters, it has been shown that by transferring some of the weight lifted fro the barbell to a vest, they have then been able to lift more weight overall.

There is also the advantage of evenly distributed load balance by wearing a vest compared to a backpack. This can reduce back discomfort and injury. Which in turn, can lead to longer exercise duration due to the even distribution of weight.

Points:

  • Increase certain parameters of performance, such as weightlifting totals and change of direction speed
  • Improves performance when used for warm-up routines
  • Help improve bone health
  • Burn calories and contribute to fat loss
  • Better load balance than a backpack
  • Can safely enhance low impact bodyweight exercises 

Cons

One of the main issues surrounding the use of a load-carrying vest is the misconception that they are able to increase your all-round physical performance such as running speed, endurance, and VO2 max.

This, unfortunately, does not bear much in the way of conclusive proof from a range of studies.

There's also the risk of using a weighted vest during high impact exercise such as running, as well as the restrictive nature wearing a vest can have on your respiratory system due to the external pressure.

Points:

  • Conflicting evidence that training with a vest can increase your competitive performance
  • High risk of injuries such as joints, fractures, and overuse
  • Extra pressure on the respiratory system
  • While looking at this breakdown, you could be forgiven for thinking that a weighted vest would be a good investment.

However, there are more effective alternatives to many of the pros such as using resistance machines or free weights in the gym which do offer a variety of proven benefits minus the risks presented in the cons list.

Weighted Vest Conclusion

Is a load-carrying vest a good investment? Will they help to enhance your physical performance?

From the research of the available studies, which are relatively low in number, it is difficult to make a compelling case for their use. Especially considering their widespread use and the vast array of them being sold.

It is not to be said that they do not have their uses or benefits. They do, but from the scientific proof available, their use is limited.

Furthermore, there is a wealth of material available online that promotes the use of these vests on nothing more than the notion and hypothesis that because it is more difficult to perform an exercise, it, therefore, must enhance your performance to wear one.

Yet, the 'difficulty', physical challenge or perceived increased exertion from wearing one can be attributed to the restrictive nature a vest can place on the respiratory system and the additional strains placed on the musculoskeletal system rather than conclusive evidence that training with one results in comprehensive improvements of our performance.

In addition, the majority of benefits can be attained from using other equipment such as weights or machines in a gym with lower risk to fractures or injury that can be sustained from the additional impact placed on our joints, tendons, and ligaments.

Yet, if you are adamant about training with weight, or you need to condition yourself for military training and load carries for marching, a vest is more ideal than a backpack due to the improved load distribution.

To conclude, wearing a load-bearing vest does have some (limited) benefits, although there are other forms of equipment that can be used more effectively.

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[30] https://www.ncbi.nlm.nih.gov/pubmed/31534823
[31] https://core.ac.uk/download/pdf/81839818.pdf
[32] https://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures-of-the-foot-and-ankle
[33] https://www.heart.org/en/healthy-living/fitness/fitness-basics/strength-and-resistance-training-exercise
[34] https://americanbonehealth.org/exercise/weighted-vests-for-bone-health
[35] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264561/

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