Whole-Body Electromyostimulation – The Need for Common Sense! Rationale and Guideline for a Safe and Effective Training

Abstract

Whole-body electromyostimulation WB-EMS. is a young and time-effective training technology. Comparing the effect of WB-EMS with conventional resistance training, both methods were reported to be similarly effective on muscle mass, strength and cardiometabolic risk. However, due to its exceptional time efficiency, joint friendliness and individualized setting, WB-EMS may be a good choice for people unable or simply unwilling to conduct intense resistance training protocols. However, recent literature has reported negative side-effects concerning WB-EMS-induced rhabdomyolysis. Indeed, due to the ability to innervate large muscle areas simultaneously with dedicated individual intensity per muscle group, WB-EMS features many factors known to be associated with muscle damage. A recent WB-EMS study applying an initial application to exhaustion to healthy novices confirmed the reported exceptionally high creatine-kinase CK. concentrations. Although the study did not detect any of the reported clinical consequences of this “severe” rhabdomyolysis i.e. ≥50fold increase of resting CK., in less fit subjects who were neither optimally prepared nor supervised, initial WB-EMS to exertion may have more far-reaching consequences. Of importance, a subsequent WB-EMS conditioning phase of 10 weeks completed by a second WB-EMS test application to exhaustion demonstrated CK-peaks in the range of conventional resistance exercise. Thus, in summary a. too intense initial WB-EMS may indeed result in a severe rhabdomyolysis b. thus, initial WB-EMS application to exhaustion must be strictly avoided, and c. frequent WB-EMS application demonstrated a very pronounced repeated bout effect after a short conditioning phase.

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218 DEUTSCHE ZEITSCHRIFT FÜR SPORTMEDIZIN 67. Jahrgang 9/2016
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SHORT REPORT
Introduction
Whole-body electromyostimulation (WB-EMS) is a
young and time eective training technology that
focuses primarily on body composition (i.e. muscle,
bone, fat tissue) and strength-related parameters
(5, 7, 9, 13, 14). However, other health rela ted outcomes
(i.e. cardio-metabolic risk factors) (4) were also re-
ported to be positively aected by WB-EMS. A di-
rect comparison of WB-EMS and the slightly more
time-consuming High Intensity (Resistance) Trai-
ning (H IT) (WB-EMS: 1. 5x20 vs. HI T: 2x30 min/week)
Whole-Body Electromyostimulation –
The Need for Common Sense! Rationale and
Guideline for a Safe and Effective Training
Prof. Dr. Wolfgang Kemmler
Friedrich-Alexander University Erlangen
(FAU), Institute of Medical Physic s
Henkestras se 91
91054 Erlangen, Germany
: wolfgang .kemmler@imp.uni-e rlangen.de
SCHLÜSSELWÖRTER:
Elektrostimulation, Kreatinkinase, Rhabdomyolyse,
WB-EMS-Applikation
KEY WORDS:
Electrostimulation, Creatine-Kinase, Rhabdomyolysis,
Recommendation WB-EMS
› Whole-body electromyostimulation (WB-EMS) is a young
and time-ee ctive trai ning technolog y. Comparing the ee ct of
WB-E MS with conventional resista nce training , both methods
were report ed to be simil arly eective on mu scle mass, stre ngth
and card iometabolic risk . However, due to its exceptiona l time
eciency, joint friend liness and i ndividua lized set ting, W B-EMS
may be a good choice for people unable or simply unwilling t o
conduct inten se resistance t raining prot ocols.
›
However, recent literat ure has reported negative side -eects
concerning WB-EMS-induced rhabdomyolysis. Indeed, due
to the ability to innervate large muscle areas simultaneously
with ded icated ind ividual i ntensity per mus cle group, WB-E MS
features many fact ors known to be as sociated with mu scle da-
mage. A recent W B-EMS st udy applyi ng an initia l application t o
exhau stion to healthy nov ices conrmed the reported excepti-
onally h igh creatine-kinas e (CK) concentration s. Although the
study did not detect any of the r eported clinic al consequences
of this “severe” rha bdomyolysis (i.e. ≥50fold increa se of resting
CK), in less t su bjects who were neither opt imally pre pared nor
superv ised, init ial WB-EMS t o exertion may have more far-r ea-
ching consequences.
›
Of importance, a subsequent WB-EMS conditioning phase
of 10 weeks complete d by a second WB-EM S test application t o
exhau stion demonstra ted CK-peaks i n the range of convention al
resistance exercise.
› Thus, in summary (a) too inten se initial W B-EMS may indee d
result in a s evere rhabdomyolysis (b) thus, in itial WB-EM S ap-
plicat ion to exhaus tion must be str ictly avoided, a nd (c) frequent
WB-E MS applicati on demonstrated a ver y pronounced repe ated
bout eect af ter a short condit ioning phase.
›
Ganzkörper-Elektromyostimulation (WB-EMS) erfreut
sich durch Zeit ezienz, Indi vidualisierba rkeit und Eektiv ität
zunehmender Beliebtheit. In jüngster Vergangenheit wurden
nach Erst anwendung von WB-E MS in Einzelf ällen jedoch (ex-
trem) hohe Kreat inkinase (CK)-Werte berichtet, die i n einem
gesundheitlich bedenk lichen Bereich liegen. Bed ingt durch die
ächige si multane Appli kation mit dez idierter An steuerung der
Stimula tionsächen treen f ür WB-EMS du rchaus die meisten
Voraussetzu ngen für eine „e xertional R habdomyolysis“, also ei ne
ausgeprä gte körper traini ngs-induzier te Muskelschä digun g zu.
›
Tatsächlich zeigte eine kürzlich erschienene Untersuchung
mit gesunden Spor tlern ohne WB -EMS Vorerfahrung n ach aus-
belaste ter, also hochintensiver, WB-EMS -Erstapplika tion eine
117-fache Erhöhung der CK-Konzentrations-Werte im Bereich
einer schweren („severe“) Rh abdomyolyse (≥50-fache Erhöhung
des Ruhe-C K). Obwohl für keinen der 26 St udienteilneh mer die in
der Literatu r berichten negati ven renale und kard ialen Indizien
einer (schweren) Rhabdomyolyse vorlagen , mögen die Konse-
quenzen bei vorges chädigt en, leistun gsschwachen und sc hlecht
vorbereiteten Ind ividuen deutlich dr amatischer ausfa llen.
›
Eine nachfolgende Untersuchung, welche den Eekt regel-
mäßigen W B-EMS-Trainings ev aluierte, zeig te nach 10-wöchi-
gem Konditionier ungszeitraum und anschließender, wieder-
um ausbelasteter, WB-EMS-Applikation einen ausgeprägten
„repeate d bout eect“ mit CK-Spitzenw erten im unteren B ereich
konventionellen K raftt raini ngs (<1000 IE/l), also in ei nem unbe-
denkl ichen Bereich.
›
Als Fazit le iten wir ab, d ass (a) unsachgemäße W B-EMS-Er stap-
plikation durchaus negative gesundheitliche Konsequen-
zen haben kann, (b) eine ausbelastende bzw. sehr intensive
WB-E MS-Erstapp likation i n jedem Fall zu unter bleiben hat und
(c) ein rascher G ewöhnungseek t auch hinsichtl ich ausbelaste -
ter WB -EMS-Appli kation auf tritt. L etzteres ist z ur Realis ierung
relevanter E ekte, vergleichba r einem konventionellen K rafttr ai-
ning , nicht zwin gend nötig.
July 2 016
10.5960/dzsm.2 016.24 6
Kemmler W, Froehlich M, von
Stengel S, Kleinöder H. Whole-Body
Electromy ostimulation – The Need for
Common Sense! Rationale and Guideline
for a Safe and Effe ctive Training. Dtsch Z
Sportmed . 2016; 67: 218-221.
Sept ember 2016
1. FRIEDRICH-ALEXANDER UNIVERSITY
ERLANGEN-NÜRNBERG, In stitute of
Medical Physics, Erlangen-Nürnberg,
Germany
2. UNIVERSITY OF KA ISERSLAUTERN,
Depar tment of Sport s Science,
Kaiserslautern, Germany
3. GERMAN SPORT UNIVERSITY COLOGNE,
Depar tment of Exerc ise Science s,
Cologne, Germany
Kemmler W 1, Froehlich M 2, von Stengel S 1, Kleinöder H 3
Ganzkörper-Elektromyostimulation –
eine Richtlinie zur sicheren und eektiven Anwendung

SHORT REPORT
219DEUTSCHE ZEITSCHRIFT FÜR SPORTMEDIZIN 67. Jahrgang 9/2016
WB-EMS Guideline
has shown that both methods are similarly eective in increa-
sing body composition, strength (7, 8) and cardio-metabolic
risk (4, 8). However, due to its exceptional time eciency (7),
joint friendliness and individualized setting, WB-EMS may be
a good choice for people unable or simply unwil ling to conduct
intense resistance training protocols. However, in a recent let-
ter to the British Medical Journal, Malnick et al. addressed the
potential risks of WB-EMS and “the need to regulate the use
of whole body electrical stimulation” (11). Indeed recent scien-
tic literature has reported negative side-eects concerning
WB-EMS induced increases in creatine-kinase up to a level of
severe rhabdomyolysis (i.e. >50-fold increases compared with
resting levels) (1, 2, 12).
Summarizing the mechanisms of exertional rhabdomyoly-
sis, in genera l WB-EMS u ndeniably features most of the factors
known t o be associated w ith (resista nce) exercise induc ed mus-
cle damage and very pronounced muscle soreness (10). Espe
-
cially the outstanding feature to innervate large muscle areas
(12-14 electrodes w ith up to 2,800 cm
2
) simultaneously, but wit h
dedicated indiv idual intensity p er electrode/muscle group, may
contribute to the problem of WB-EMS induced rhabdomyoly-
sis, at least when applying too high (current) intensity. us,
an adequate WB-EMS application is essential for preventing
rhabdomyolysis and corresponding renal, hepatic and cardiac
consequences.
In a recent study, we applied a ty pical but borderline ex haus-
tive WB-EMS protocol (20min , bipolar, 85Hz, 350µs, rectang u-
lar, 6s of current, 4s of rest) to 37 healthy WB-EMS novices (6).
And indeed, the CK increase af ter this borderline (too) intense
initial WB-EMS application conrmed the reported excep-
tionally high CK-levels and very pronounced muscle soreness
from 48h-96h (6). In detail, CK-concentration rose 117-fold
(28545±33 611 IU/l) with a peak a fter 72h and was 10 times hig h
-
er compared with the CK-levels after a marathon run that was
monitored in parallel (2795±883 IU/l after 48h). Although, we
did not detect any of the repor ted clinical consequences of t his
“severe” rhabdomyolysis on renal and cardiac risk factors (15),
in less t and healthy subjects neither optimally prepared
nor supervised, initial WB-EMS to exertion may have more
far-reaching consequences.
Signicantly, a subsequent WB-EMS conditioning phase of
10 weeks (1x20min WB-EMS/week, see above) completed by a
second WB-EMS te st session to exhaustion demonstrat ed a very
pronounced “repeated bout eect ” with indiv idual CK-peaks a ll
below 200 0 IU/l (MV±SD: 906±500 I U/l), i.e. in the lower ra nge of
conventional resista nce exercise trai ning (6, 10). is result
Guideline for Safe and Effective WB-EMS
In General
1. Safe and effective Whole-Body-EMS Training must be advised and ac-
companied by a trained and licensed WB-EMS trainer or scientifically
trained personnel familiar with this field of application.
2. Before the first training session of every beginner, an anamnesis of
possible contraindications based on a list of questions must be taken
and then documented in writing, confirmed by the client‘s signature
and archived. Where relevant anomalies are found, a doctor is to be
consulted and training only be commenced if clearance has been given.
Preparing for Training
1. As with any kind of intensive training, Whole-Body EMS training must
only be carried out in a good physical condition and free of pain. This
includes abstaining from alcohol, drugs, stimulants/muscle relaxants
or stress ahead of the training session. Training must never be carried
out by anybody suffering from an illness with fever.
2. Whole-Body-EMS training leads to very high metabolic stress of the
organism because of very high volume of muscle mass addressed. This
factor has to be taken into account through sufficient food intake that
is as high in carbohydrates as possible. If this is not possible, then at
least a high carbohydrate, but light snack (≈250kcal) should be eaten,
ideally about 2 hours before training.
3. So as to avoid possible renal stress (especially with undiagnosed prob-
lems) through intensive WB-EMS, additional fluids should be consumed
before/during and after training (500ml each).
4. Generally, medical – ideally sport-medicinal – consultation and clarifi-
cation is advisable in the case of any discomfort, physical restrictions,
infections or other internal, cardiological or orthopedic illnesses.
Training
1. Regardless of physical status, sport experience and the user‘s wishes
to that effect, under no circumstances may WB-EMS training to
exhaustion take place during the first training session or trial training.
In the past, this has led to undesired side effects and negative health
consequences and must be avoided at all costs.
2. After moderate initial WB-EMS, the stimulation level or current must
be successively increased and adapted to the individual goals. The
highest level is to be reached only after 8-10 weeks of systematic trai-
ning at the earliest (user‘s subjective effort impression: hard-hard+).
Training to complete exhaustion, especially in the sense of painful, con-
tinuous tetanus during the current phase, must generally be avoided.
3. In addition, the initial training should be conducted with a reduced
effective training period. Advisable is 5min impulse familiarization and
a curtailed training session with moderate stimulus intensity (user‘s
subjective effort impression: a bit hard) and 12min intermittent load
with short impulse phase (~4s). Only then should the training duration
be cautiously increased and never exceed 20min.
4. To ensure sufficient conditioning and to minimize or rule out possible
health impairments, training frequency may not exceed one training
unit per week during the first 8-10 weeks.
5. Even after this conditioning phase, an interval of ≥4 days must be
maintained between training units in order to avoid accumulation of
muscle breakdown products, permit regeneration and adaptation and
thus ensure a successful training outcome.
Safety Aspects During and After Training
1. During the training session, the trainer or the trained and qualified
personnel should concentrate exclusively on the interests of the user(s).
Before, during and after training the trainer verbally and visually
checks the user‘s condition so as to rule out health risks and ensure
effective training. Training is to be stopped immediately if there are any
contraindications.
2. During training, the equipment‘s operating controls must be directly
in reach of the trainer and the user at all times. Operation/adjustment
must be simple, quick and precise.
3. Actually, we generally advise against private use of technology without
support of a qualified and licensed trainer/instructor or correspon-
dingly scientifically trained personnel.

SHORT REPORT
220 DEUTSCHE ZEITSCHRIFT FÜR SPORTMEDIZIN 67. Jahrgang 9/2016
Richtlinien Ganzkörper-EMS
indicates that a short period of careful W B-EMS conditioning
should be mandatorily implemented in order to realize a safe
application.
Conclusion
We conclude that the problem of WB-EMS induced rhab-
domyolysis can be easily prevented with a minimum of com-
mon sense. Firstly, although some groups of highly motivated
WB-EMS novices may request an exertional initial WB-EMS
application, this approach should be strictly avoided. In pa ral-
lel, no clear-thinking instructor would apply an intense eccen-
tric resistance traini ng protocol to muscular failure during the
initial session to a resistance t raining nov ice. Secondly, as wit h
conventional resistance exercise there is no need to focus on
WB-EMS to ex haustion in order to generate relevant eects on
body composition and functional capacity (3, 7). Additionally,
contraindications for WB-EMS should be strictly heeded and
WB-EMS novices adequately informed so as to ensure a safe
and successful WB-EMS application. In order to realize the
latter aim, in a German consensus conference in December
2015, WB-E MS manufact urers (miha-body tec, Gersthofen, Ger -
many), educational institutions (GluckerKolleg, Kornwestheim,
Germa ny), Licensees (P T Lounge Köln, Colog ne, Germany) and
publishing researchers (see below) discussed the topic. Finally
in April 2016, the scientic part of the consortium (Fröhlich,
M.; Kemmler, W.; Kleinöder, H. v. Stengel, S.) has formulated a
general guideline, that we would like to disseminate and pub-
lish here. We are aw are that WB-EMS is a young and innovative
technolog y with considerable f urther potential, thu s extensions
and changes of this guideline may be necessary in the nearest
futu re. However, we think t he general recommendation s listed
may be a rst step to a more safe and eective WB-EMS appli-
cation.
Conict of Interest
e authors are aware that some commercial partners may have
had a conict of interest with respect to some issues. However,
the nal responsibility for the generation of this guideline clearly
lies by the authors.
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