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Background Sarcopenic obesity (SO) is a geriatric syndrome characterized by the disproportion between the amount of lean mass and fat mass. Exercise decreases fat and maintains muscle mass; however, older people fail to exercise at doses sufficient to affect musculoskeletal and cardiometabolic risk factors. The aim of this study was to evaluate the effect of whole-body electromyostimulation (WB-EMS), a time-efficient, joint-friendly and highly individualized exercise technology, on sarcopenia and SO in older men. Materials and methods A total of 100 community-dwelling northern Bavarian men aged ≥70 years with sarcopenia and obesity were randomly (1–1–1) assigned to either 16 weeks of 1) WB-EMS and protein supplementation (WB-EMS&P), 2) isolated protein supplementation or 3) nonintervention control. WB-EMS consisted of 1.5×20 min (85 Hz, 350 µs, 4 s of strain to 4 s of rest) applied with moderate-to-high intensity while moving. We further generated a daily protein intake of 1.7–1.8 g/kg/body mass per day. The primary study end point was Sarcopenia Z-Score, and the secondary study end points were body fat rate (%), skeletal muscle mass index (SMI) and handgrip strength. Results Intention-to-treat analysis determined a significantly favorable effect of WB-EMS&P (P<0.001) and protein (P=0.007) vs control. Both groups significantly (P<0.001) lost body fat (WB-EMS&P: 2.1%; protein: 1.1%) and differed significantly (P≤0.004) from control (0.3%). Differences between WB-EMS&P and protein were significant for the Sarcopenia Z-Score (P=0.39) and borderline nonsignificant (P=0.051) for body fat. SMI increased significantly in both groups (P<0.001 and P=0.043) and decreased significantly in the control group (CG; P=0.033); differences between the verum groups and control were significant (P≤0.009). Handgrip strength increased in the WB-EMS group (1.90 kg; P<0.001; P=0.050 vs control) only. No adverse effects of WB-EMS or protein supplementation were recorded. Conclusion WB-EMS&P is a safe and efficient method for tackling sarcopenia and SO in older men. However, the suboptimum effect on functional parameters should be addressed by increased voluntary activation during WB-EMS application.
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Clinical Interventions in Aging 2017:12 1503–1513
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ORIGINAL RESEARCH
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Open Access Full Text Article
http://dx.doi.org/10.2147/CIA.S137987
Whole-body electromyostimulation and protein
supplementation favorably affect sarcopenic
obesity in community-dwelling older men at risk:
the randomized controlled FranSO study
Wolfgang Kemmler1
Anja Weissenfels1
Marc Teschler1
Sebastian Willert1
Michael Bebenek1
Mahdieh Shojaa1
Matthias Kohl2
Ellen Freiberger3
Cornel Sieber3
Simon von Stengel1
1Institute of Medical Physics,
Friedrich-Alexander University
of Erlangen-Nürnberg, Erlangen,
Germany; 2Facult y o f Medical and Life
Science, University of Furtwangen,
Schwenningen, Germany; 3Institute
of Biomedicine of Aging, Friedrich-
Alexander University of Erlangen-
Nürnberg, Nürnberg, Germany
Background: Sarcopenic obesity (SO) is a geriatric syndrome characterized by the disproportion
between the amount of lean mass and fat mass. Exercise decreases fat and maintains muscle
mass; however, older people fail to exercise at doses sufficient to affect musculoskeletal and
cardiometabolic risk factors. The aim of this study was to evaluate the effect of whole-body
electromyostimulation (WB-EMS), a time-efficient, joint-friendly and highly individualized
exercise technology, on sarcopenia and SO in older men.
Materials and methods: A total of 100 community-dwelling northern Bavarian men
aged $70 years with sarcopenia and obesity were randomly (1–1–1) assigned to either 16 weeks
of 1) WB-EMS and protein supplementation (WB-EMS&P), 2) isolated protein supplementation
or 3) nonintervention control. WB-EMS consisted of 1.5×20 min (85 Hz, 350 µs, 4 s of strain to
4 s of rest) applied with moderate-to-high intensity while moving. We further generated a daily
protein intake of 1.7–1.8 g/kg/body mass per day. The primary study end point was Sarcopenia
Z-Score, and the secondary study end points were body fat rate (%), skeletal muscle mass index
(SMI) and handgrip strength.
Results: Intention-to-treat analysis determined a significantly favorable effect of WB-EMS&P
(P,0.001) and protein (P=0.007) vs control. Both groups significantly (P,0.001) lost body fat
(WB-EMS&P: 2.1%; protein: 1.1%) and differed significantly (P#0.004) from control (0.3%).
Differences between WB-EMS&P and protein were significant for the Sarcopenia Z-Score
(P=0.39) and borderline nonsignificant (P=0.051) for body fat. SMI increased significantly
in both groups (P,0.001 and P=0.043) and decreased significantly in the control group (CG;
P=0.033); differences between the verum groups and control were significant (P#0.009).
Handgrip strength increased in the WB-EMS group (1.90 kg; P,0.001; P=0.050 vs control)
only. No adverse effects of WB-EMS or protein supplementation were recorded.
Conclusion: WB-EMS&P is a safe and efficient method for tackling sarcopenia and SO in
older men. However, the suboptimum effect on functional parameters should be addressed by
increased voluntary activation during WB-EMS application.
Keywords: sarcopenia, sarcopenic obesity, exercise, electrostimulation, older people
Introduction
Sarcopenic obesity (SO) is characterized by the disproportion between the amount of
lean mass and fat mass, ie, the discrepancy between engine and the mass to be moved.1
Apart from this functional aspect, the synergistic negative effect of skeletal muscle
and adipose tissue inflammation,2 which characterizes this “geriatric syndrome,”3
Correspondence: Wolfgang Kemmler
Institute of Medical Physics,
Friedrich-Alexander University of
Erlangen-Nürnberg, Henkestrasse 91,
91052 Erlangen, Germany
Tel +49 9131 852 3999
Fax +49 9131 852 2824
Email wolfgang.kemmler@imp.uni-
erlangen.de
Journal name: Clinical Interventions in Aging
Article Designation: Original Research
Year: 2017
Volume: 12
Running head verso: Kemmler et al
Running head recto: WB-EMS and sarcopenic obesity
DOI: http://dx.doi.org/10.2147/CIA.S137987
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has severe cardiometabolic implications4 that are highly
relevant for morbidity and mortality of older people.1,5
Resistance exercise favorably affects both, muscle mass6
and fat mass7 in older adults; thus, it should be quite an
effective tool for preventing or treating sarcopenia and SO.8
However, only a minority of people9,10 achieve the exercise
doses recommended for positively impacting muscle mass,
disabling conditions or obesity.11 Frequent reasons given
for absence from exercise are time constraints, physical
limitations or little enthusiasm for exercise conducted
alone.12,13 Hence, innovative, time-efficient, joint-friendly
and highly individualized exercise technologies, foremost
whole-body electromyostimulation (WB-EMS), may be a
good choice for older subjects at risk for sarcopenia or SO.
Besides exercise, protein supplementation may favorably
address sarcopenia and SO in older people.14,15 Most prom-
ising, a combined therapy with WB-EMS and additional
protein intake should be an appropriate low-threshold/
non-pharmacologic intervention and transferable even to
physically limited older persons with low enthusiasm for
exercise. The aim of this study was to determine the effect
of a combined WB-EMS and (whey) protein vs an isolated
whey protein supplementation vs a noninterventional control
on sarcopenia and SO in community-dwelling men aged
70 years and older with (morphometric) SO.
Our primary hypothesis was, that WB-EMS and whey
protein (WB-EMS&P), but not isolated whey protein
supplementation (Protein) significantly affects sarcopenia
(ie, Sarcopenia Z-Score) compared with a non-training non-
protein supplemented control group (CG).
Our secondary hypothesis was that WB-EMS&P and
isolated protein supplementation significantly affected
obesity (specified as “total body fat rate”) compared with a
non-training, nonprotein-supplemented control.
Our third hypothesis was that WB-EMS&P and isolated
protein supplementation significantly affected skeletal
muscle mass compared with a non-training, nonprotein-
supplemented control.
Materials and methods
The Franconian (Franconia is the northern part of Bavaria)
Sarcopenic Obesity (FranSO) study focused on two main
aims: 1) to determine the prevalence of sarcopenia and SO in
community-dwelling (CDW) older men and 2) to determine
the effects of two interventions: a) WB-EMS&P and b) iso-
lated protein supplementation (protein); vs an untreated CG
on sarcopenia and SO in this cohort. FranSO is a randomized
controlled trial with a parallel group design with the three
balanced (1–1–1) study arms listed earlier. The study was
planned, implemented and conducted between February and
December 2016 by the Institute of Medical Physics (IMP).
The IMP was supported by the Institute of Biomedicine of
Aging, both part of the University of Erlangen-Nürnberg
(FAU), Germany. The University Ethics Committee of the
FAU (Ethikantrag 67_15b) approved the FranSO study in
April 2015. The study complied with the Declaration of
Helsinki’s “Ethical Principles for Medical Research Involv-
ing Human Subjects.” After detailed information, all the study
participants gave their written informed consent. The project
was registered under ClinicalTrials.gov: NCT2857660.
Participants
During the screening process, about 6,800 men aged 70 years
and older living independently in the area of Erlangen–
Nürnberg, Germany, were contacted by personal letters
using citizen registers provided by the municipality.16 Of
importance, the letters already included some eligibility
criteria (ie, age and independency). A total of 1,045 persons
replied to the letters and were further contacted to check for
more specified eligibility criteria (ie, contraindications for
assessments) by phone calls and structured interviews. Fol-
lowing our eligibility criteria for the screening assessment,
we included 1) men, 70 years and older, 2) living indepen-
dently at home and 3) able to visit our laboratory, and we
excluded men with 1) total or partial amputation of the limbs
and 2) contraindication for bio-impedance analysis (BIA)
assessment (eg, cardiac pacemaker); accordingly, altogether
965 subjects of Caucasian race were screened.
Applying the main study eligibility criteria of “SO,” only
36 men (3.7%) could be classified as sarcopenic according to
the Foundation of the National Institutes of Health (FNIH)17
(European Working Group on Sarcopenia in Older People
[EWGSOP]:18 n=47). Using a body fat-based approach as
well (28%),19 only 31 (3.2%) eligible men remained.16
Proceeding with the interventional part of FranSO, only
25 of these 31 eligible men agreed to participate in the
project. Therefore, we had to relax our sarcopenia criteria
and focus on morphometric sarcopenia alone (ie, without
dyna[mo]penic or functional aspects). We applied the
skeletal muscle mass index (SMI) cutoff point of ,0.789
suggested by the FNIH17 for sarcopenia and the cutoff .27%
body fat for obesity recommended by Baumgartner.20 Imple-
menting these cutoffs, 137 men fell within our diagnostic
criteria of SO. Due to the trial exclusion criteria, 1) use of
medication (eg, glucocorticoids) or diseases (eg, Cushing
syndrome) affecting muscle mass or preventing WB-EMS
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WB-EMS and sarcopenic obesity
application (eg, cardiac pacemaker): n=11, 2) resistance-
trained status (.45 min/week of any type of resistance
exercise): n=4, 3) more than 2 weeks of absence during
the interventional period: n=5 and 4) regular high alcohol
abuse (.80 g/day on 5 days/week; eg, .4×0.5 L/day beer
with volume 4.8%): n=2, finally, 115 men were eligible to
participate in the trial. A total of 15 men refused to par-
ticipate; however, six of them reported the inability to join
the preferred study group due the randomization process
as the reason for their withdrawal. Correspondingly, 100
participants were allocated randomly and balanced (details
are given in the following sections to three study groups:
1) WB-EMS&P and 2) isolated protein supplementation
(Protein) and 3) untreated CG). Figure 1 shows the flowchart
of the interventional part of the trial.
Intervention
WB-EMS intervention
We used WB-EMS equipment (miha bodytec®, Gersthofen,
Germany) that enables us to simultaneously stimulate thighs
and upper arms, hip/bottom, abdomen, chest, lower back
and upper back with an overall area of stimulation of about
2,600 cm2 (Figure 2). Of importance, the system allows a
selectable and thus dedicated intensity for each of the regions.
In the current study, we applied a consistently supervised,
video-guided WB-EMS program in a standing position
1.5 times per week (eg, each Monday and every second
Thursday) for 16 weeks. We applied bipolar electric current
with a frequency of 85 Hz and an impulse width of 350 µs and
used an interval approach with 4 s of electromyostimulation
using a direct impulse boost and 4 s of rest. Of importance,
low-intensity movements or exercises were conducted during
the 4-s stimulation period.21,22 The duration of the session
was progressively increased from 14 min to 20 min after
4 weeks.
Due to regional and individual variations in current sensi-
tivity, we used a rate of perceived exertion (RPE) to generate
a sufficient but tolerable intensity of the EMS application.
Participants were encouraged by the instructors to exercise
at an RPE of “6–7” (ie, hard+ to very hard) on the Borg
CR10 Scale.23 In detail, (current) intensity was individually
adapted for each body region in close interaction with the
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Figure 1 Diagram of participant ow through the different study phases.
Abbreviations: EMS, electromyostimulation; FU, follow-up; ITT, intention to treat; WB-EMS&P, whole-body EMS and protein supplementation.
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participant during the second session and then again after
4, 8 and 12 weeks. The settings were saved to generate a
fast, reliable and valid setting in the subsequent sessions.
Based on these initial settings, instructors slightly increased
(current) intensity every 3 min in close cooperation with the
participants to maintain/slightly increase the prescribed RPE
during the session.
Protein and vitamin D supplementation
Based on a 4-day dietary protocol completed by all study
participants (details are given in the following paragraphs),
the WB-EMS&P and protein groups were supplemented
with whey protein powder (Inkospor Active; Inkospor,
Roth, Germany) to achieve a daily total protein intake of
1.7–1.8 g/kg per day body mass. The chemical score of this
product is 159; 100 g/day represented a caloric value of
1,526 kJ (360 kcal) and contained 80 g of (whey) protein
with a high l-leucine (9 g) and essential amino acid (EAA;
57 g) component. Further, the supplement contains 2.8%
of fat and 6.4% of carbohydrates (CHO). Participants were
asked to take the protein powder with water, doses of more
than 40 g had to be split; however, we did not focus on an
intake at a specific time of the day. During a corresponding
meeting, all participants were instructed in detail how to take
the protein supplementation; participants were also regularly
interviewed about and encouraged to maintain their protein
intake habits during the WB-EMS sessions.
All participants were provided with cholecalciferol
(Taxofit, Cologne, Germany) and were requested to take a
daily dose of 800 IU.
Outcomes
Primary outcome
• FNIH17-based Sarcopenia Z-Score at baseline and after
16 weeks of intervention.
Secondary outcome
• Total body fat at baseline and after 16 weeks of
intervention
• SMI according to FNIH17 at baseline and after 16 weeks
of intervention
• Handgrip strength at baseline and after 16 weeks of
intervention.
Assessment
Tests were conducted at baseline and after 16 weeks consis-
tently by the same method and research assistant at the same
time of day (±1 h). Of importance, we did not use the screen-
ing data as the baseline data but conducted new assessments
for all primary and secondary outcomes immediately prior
to the intervention.
Body height and circumferences were measured using
calibrated devices. Body mass and composition were deter-
mined via direct-segmental, multifrequency BIA (InBody
770, Seoul, Korea). This device measures impedance of the
trunk, arms and legs separately using a tetrapolar 8-point
tactile electrode system that applies six frequencies (1, 5, 50,
250, 500 and 1,000 kHz). Participants were asked to avoid
severe physical activity and to fast 3 hours prior to the BIA
assessment. Body mass index (BMI) was calculated as body
mass/body height (kg/m2). Appendicular skeletal muscle
Figure 2 WB-EMS equipment with operator device and electrodes (vest, arm-, leg-, gluteal-cuffs).
Abbreviation: WB-EMS, whole-body electromyostimulation.
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WB-EMS and sarcopenic obesity
mass (ASMM) was calculated using the results for upper and
lower limbs provided by the BIA device. SMI was calculated
as ASMM/BMI.17
Handgrip strength of the dominant hand was tested
using a Jamar hand dynamometer (Sammons Preston Inc.,
Bolingbrook, IL, USA). The dynamometer grip width was
adjusted individually to participant hand size. Tests were
performed in an upright standing position, arms down by
the side. The standardized instruction to the participants was
consistently “squeeze as strongly as possible.” Two tests
intermitted by 20 s of rest were performed for the dominant
hand, and the higher result was included in the analysis.
Demographic parameters (eg, family/educational status
and occupational career), diseases (indication, duration,
severity), medication (type, dose, duration), operations (eg,
hip, knee and shoulder total endoprosthesis), physical limi-
tations, injuries or falls within the last year, low-traumatic
fractures, pain severity and frequency at different skeletal
sites and lifestyle with special emphasis on physical activity,
exercise and nutrition24 were determined using a standard-
ized questionnaire completed by the participants while
visiting our laboratory. In addition, we used the abridged
version of the Late Life Function and Disability Instru-
ment (LLFDI).25 Research assistants carefully checked the
completeness and accuracy of the questionnaire together
with the participants. During this interaction, the degree of
independence and autonomy, family status, social network
and use of ambulatory nursing services were ascertained
in more detail.
After careful briefing and instructions, the participants’
dietary intake was assessed immediately before and after the
trial by 4-day dietary protocols conducted by all participants.
The consumed food was analyzed using the Freiburger
Nutrition Protocol (Nutri-Science, Hausach, Germany). In
case of dubious results (ie, energy consumption ,1,000
or .3,500 kcal/day), participants were interviewed, briefed
and asked to properly complete another dietary protocol
based on more representative days.
Changes of trial outcomes after trial
commencement
No changes of trial outcomes were conducted after trial
commencement.
Sarcopenia and obesity denition
In contrast to recognized sarcopenia definitions,17,18,26,27 we
focused on the morphometric aspect of sarcopenia only.
We used appendicular skeletal muscle mass (ASMM)/BMI
approach17 to calculate the SMI. In detail, men with an ASMM/
BMI of ,0.789 were classified as sarcopenic without further
applying a functional criterion (ie, grip strength ,26 kg).
Obesity was diagnosed using the body fat rate instead of
BMI since the latter criterion is obviously inappropriate in
the context of SO. According to Baumgartner,20 we applied
a cutoff point of .27% body fat to diagnose obesity.
To avoid multiple testing, we summarized the two
sarcopenia criteria (SMI and handgrip strength) suggested
by the FNIH17 in one single factor. Using the individual
participant’s data, the FNIH sarcopenia cutoff values for
handgrip strength (26 kg) and SMI (0.789) listed earlier and
the standard deviation (SD) obtained from the baseline data
of the FranSO cohort, we calculated a Sarcopenia Z-Score
according to a recent approach,28 albeit applying the less-
stringent EWGSOP definition there.
Z = ((26 - individual grip strength)/SD grip strength)
+ ((0.789 - individual SMI)/SD SMI).
Contrary to the T- or Z-Scores in osteoporosis research,
negative Z-Scores were favorable, and reducing the Sarcope-
nia Z-Score decreases the corresponding risk.
Sample size
Sample size analysis was based on a recent study28 that
determined an WB-EMS&P-related effect (WB-EMS&P vs
control) on Sarcopenia Z-Score of 1.3±1.2 (index). Apply-
ing a T-Score-based sample size analysis and using a more
conservative assumption of 1.0±1.4 (index), 31 participants
per group were necessary to generate 80% power and a two-
sided significance level of 5%. However, to maintain the
power for an additional per-protocol analysis, we slightly
increased the sample size per group to allow for “loss-to
follow-up.”
Randomization procedures
Using strata of 5 years, 100 participants were randomly
assigned to three study arms: 1) WB-EMS&P, 2) Protein and
3) CG by a uniform allocation rate of 1:1:1 (Figure 1). For the
allocation, lots were drawn by the participants themselves.
Each of the lots was put in opaque plastic shells (“kinder egg”;
Ferrero, Alba, Italy) and drawn from a bowl. Of importance,
neither participants nor researchers knew the allocation
beforehand. Subsequently, the primary assessment inves-
tigator responsible for the randomization procedure (AW)
enrolled participants and instructed them in detail about their
status including corresponding dos and don’ts.
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Table 1 Baseline characteristics of the FranSO study
Variable WB-EMS&P (n=33);
MV ± SD
Protein (n=33);
MV ± SD
CG (n=34);
MV ± SD
P-value
Age (years) 77.1±4.3 78.1±5.1 76.9±5.1 0.571
Body height (cm) 170.3±5.0 170.2±5.9 171.5±6.3 0.909
Body weight (kg) 75.8±7.5 76.2±9.0 76.7±9.3 0.584
Soft LBM (kg)a,b 46.3±3.7 46.6±4.6 47.0±4.8 0.799
Sarcopenia (FNIH) (%)c24 24 26 0.885
Sarcopenia (EWGSOP) (%)d30 24 26 0.848
Habitual gait velocity (m/s)e1.26±0.20 1.24±0.16 1.27±0.18 0.857
Number of diseases (n) 2.71±0.76 2.78±0.90 2.56±0.89 0.584
Hip or knee arthrosis (%) 24 29 36 0.560
Number of medications (n) 3.3±1.6 3.5±1.5 3.4±1.7 0.801
LLFDI (index)f1.52±0.59 1.58±0.56 1.53±0.45 0.193
Physical activity (index)g4.35±1.48 4.16±1.39 4.68±1.65 0.371
Training volume (min/week) 36±34 35±31 40±34 0.810
Energy intake (kcal/day)h2,187±474 2,017±704 2,321±679 0.352
Protein intake (g/kg/day)h1.17±0.33 1.01±0.32 1.21±0.43 0.066
CHO/fat/alcohol (g/kg)h218/86/20 223/80/20 242/89/19 ,0.239
Notes: a(Soft) lean body mass. bAs determined by BIA (InBody 770, Seoul, Korea). cAccording to the Foundation of the National Institutes of Health.17 dAccording to the
EWGSOP. eAs determined over a 10-m track.18 fLate Life Function and Disability Instrument25 (scale from [1] “no problem” to [5] “impossible”). gScale from (1) very low to
(7) very high.24 hAs determined by a 4-day dietary record.
Abbreviations: BIA, bioelectrical impedance analysis; CG, control group; CHO, carbohydrates; EWGSOP, European Working Group on Sarcopenia in Older People; FNIH,
Foundation of the National Institutes of Health; FranSO, Franconian Sarcopenic Obesity; LBM, (soft) lean body mass; LLFDI, late life function and disability instrument; MV,
mean value; SD, standard deviation; WB-EMS&P, whole-body electromyostimulation and protein supplementation.
Blinding
Although blinding to protein (vs placebo) supplementa-
tion would have been possible, we conducted a blinded
approach with respect to the assessments only. Research
assistants/outcome assessors were unaware of participants’
group status (WB-EMS&P, Protein or CG) and were not
allowed to ask.
Statistical analyses
All participants who were randomly allocated were included
in the primary (intention to treat, ITT) analysis independent
of compliance or lost to follow-up. R statistics software29 was
used in combination with multiple imputation by Amelia II.30
The full data set was used for multiple imputation, with impu-
tation being repeated 100 times. Over-imputation diagnostic
plots confirmed that the multiple imputation worked well in
all cases. Based on a statistically (Shapiro–Wilkes test) and
graphically (QQ and box plots) checked normal distribution
of the primary and secondary outcomes presented in this
study, dependent t-tests were used to analyze within-group
changes. One-way ANOVA was applied to determine differ-
ences between the groups. We used the approach of Alison31
to combine the results of the imputed datasets. In case of
relevant (ANOVA) differences, pairwise multiple imputation
t-test comparisons with pooled SD were conducted.32 The
P-values obtained in the pairwise comparisons were adjusted
for multiple testing by the method of Holm.33 All tests were
two tailed, and significance was accepted at P#0.05 or
adjusted P,0.05 respectively.
Results
Table 1 lists the baseline characteristics of the participants
of the FranSO study. No relevant differences were observed.
About 80% of each group suffered from two or more diseases.
A total of 30 participants reported knee or hip arthrosis and
23 reported frequent or chronic (n=3) dorsal pain, with no
relevant difference between the groups (P#0.556).
Figure 1 shows the participant flow through the trial. Of
the 100 men included, eight subjects were lost to follow-up,
two gave study-related reasons (discomfort with WB-EMS,
aversion to protein supplementation) for their withdrawal.
Attendance rate for WB-EMS was excellent (91%±7%).
Compliance with the applied WB-EMS protocol with respect
to “strain intensity” was estimated using the subjects’ RPE
after 4, 6, 12 and 16 weeks. RPE was quite stable during the
intervention and averaged 6.8±0.3 representing a condition
of very hard. Compliance with protein intake was determined
by checking our list and by applying a questionnaire where
participants have to rate their compliance with the protein
protocol. Based on these results, we observed a lower pro-
tein intake than prescribed in both protein-supplemented
groups (WB-EMS: 43.5±23.3 vs 47.7±26.1 g/day P=0.119
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WB-EMS and sarcopenic obesity
and Protein: 51.2±21.4 vs 58.5±22.6 g/day; P=0.001).
However, due to the increased dietary protein intake in
both verum groups listed in the following section, total
protein intake at baseline and follow-up averaged around
1.78±0.09 g/kg per day. Correspondingly, with two
exceptions in the WB-EMS&P group (1.59 and 1.65 g/kg
per day), all the participants achieved the prescribed protein
intake of 1.7–1.8 g/kg body mass per day. With respect to
safety aspects, no injuries or adverse effects were observed
or reported by the participants during the interventional
periods.
Primary and secondary outcomes
Table 2 gives the result of the primary outcome “changes
of Sarcopenia Z-Score” in the three study groups. Based on
comparable baseline data (P=0.566), the Z-Score improved
significantly in the WB-EMS&P (P,0.001) and Protein
groups (P=0.007) and was maintained in the CG (P=0.61).
Both changes in the WB-EMS&P (P,0.001) and the Protein
groups (P=0.039) differed from the CG, while changes of the
WB-EMS&P were significantly more favorable (P=0.039)
compared with the protein-only intervention. In summary,
we have to reject our primary hypothesis that WB-EMS but
not protein supplementation (WB-EMS&P) significantly
affects the FNIH-based Sarcopenia Z-Score compared with
a non-training, nonprotein-supplemented control.
Table 3 presents the results of the secondary study end
points and parameters (SMI, grip strength) constituting the
Sarcopenia Z-Score according to FNIH.17 At baseline, rel-
evant group differences (P$0.730) were observed for none
of the parameters. With respect to sarcopenia, morphometric
sarcopenic aspects were more affected by the interventions
compared with functional aspects (Table 3). SMI increased
significantly after the WB-EMS&P (P,0.001) and Protein
(P,0.047) intervention and decreased significantly in the CG
(P=0.033). Both verum groups differed significantly from
control (WB-EMS&P: P,0.001; Protein: P=0.009) with
borderline nonsignificant differences between WB-EMS&P
and Protein (P=0.055). Thus, we confirmed our hypothesis
that WB-EMS&P “and” isolated protein supplementation
significantly affected skeletal muscle mass compared with
a non-training, nonprotein-supplemented control.
Grip strength increased significantly in the WB-EMS&P
(P,0.001) and borderline nonsignificantly in the Protein
groups (P=0.059), while slight positive changes (P=0.63)
were observed in the CG. Applying pairwise comparisons,
the difference between WB-EMS&P and CG was borderline
nonsignificant (P=0.050), while no other between-group
variations (P$0.17) were determined.
Total body fat rate decreased significantly in both inter-
vention groups (P,0.001) and increased slightly in the CG
(P=0.35). Both, the WB-EMS&P- and the Protein group
differed significantly from CG (P#0.004). The difference
between body fat changes in the WB-EMS&P and Protein
groups was borderline nonsignificant (P=0.051). Summing
up, we thus confirmed our secondary hypothesis that WB-
EMS&P “and” isolated protein supplementation significantly
affected “total body fat rate” compared with a non-training,
nonprotein-supplemented control.
Confounding factors
At follow-up, participants reported no changes of lifestyle,
including physical activity, diseases and medication during
the study period. Follow-up nutritional analysis demonstrated
no significant changes (P$0.270) or between-group differ-
ences (P$0.606) for energy intake (WB-EMS&P: 17±375 vs
Protein: 88±330 vs CG: 23±385 kcal), CHO (WB-EMS&P:
6±356 vs Protein: 4±53 vs CG: -1±63 g), fat (-1±26 vs
4±19 vs -2±20 g) or alcohol (-1±13 vs 1±16 vs ±0±12 g)
intake. However, borderline (non)significant differences
(P=0.056) along with a significant increase (P=0.001) in
dietary protein intake in the Protein group were observed
(WB-EMS&P: 3±17 vs Protein: 9±12 vs CG: -1±16 g) com-
pensating the lower-than-prescribed (as given earlier) protein
supplementation in the verum groups (WB-EMS&P: -4±11
vs Protein: -7±11 g).
Table 2 Baseline values and changes of the Sarcopenia Z-Score according to FNIH in the study groups
WB-EMS&P (n=33);
MV (95% CI)
Protein (n=33);
MV (95% CI)
CG (n=34);
MV (95% CI)
P-value
Sarcopenia Z-Score
Baseline -1.71 (-1.14 to -2.28) -1.63 (-1.12 to -2.14) -2.00 (-1.49 to -2.51) 0.566
Changes -0.50 (-0.34 to -0.66)*** -0.23 (-0.07 to -0.39)** -0.04 (-0.12 to 0.20)ns ,0.001
Notes: **P,0.01; ***P,0.001.
Abbreviations: CG, control group; CI, condence interval; FNIH, Foundation of the National Institutes of Health; MV, mean value; ns, nonsignicant; WB-EMS&P, whole-
body electromyostimulation and protein supplementation.
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Table 3 Baseline values and changes of secondary study outcomes in the study groups
WB-EMS&P (n=33);
MV (95% CI)
Protein (n=33);
MV (95% CI)
CG (n=34);
MV (95% CI)
P-value
Total body fat (%)
Baseline 31.6 (30.5 to 32.9) 31.4 (30.4 to 32.4) 31.4 (0.34 to 0.94) 0.967
Changes -2.05 (-1.40 to -2.68)*** -1.13 (-0.48 to -1.78)*** 0.30 (-0.24 to 0.12)ns ,0.001
SMI (ASMM/BMI)
Baseline 0.709 (0.695 to 0.734) 0.703 (0.681 to 0.723) 0.710 (0.687 to 0.732) 0.730
Changes 0.018 (0.011 to 0.026)*** 0.008 (0.001 to 0.015)* -0.008 (-0.001 to -0.016)* ,0.001
Handgrip strength (kg)
Baseline 33.8 (31.0 to 36.6) 33.3 (31.2 to 35.4) 34.4 (31.1 to 36.6) 0.814
Changes 1.90 (0.99 to 2.82)*** 0.90 (-0.03 to 1.83)ns -0.35 (-0.56 to 1.25)ns 0.034
Notes: *P,0.05; ***P,0.001.
Abbreviations: ASMM, appendicular skeletal muscle mass; BMI, body mass index; CG, control group; CI, condence interval; MV, mean value; ns, nonsignicant; SMI,
skeletal muscle mass index; WB-EMS&P, whole-body electromyostimulation and protein supplementation.
Discussion
The key result of the study was that both WB-EMS&P and
isolated whey protein supplementation significantly affected
sarcopenia “and” obesity parameters in community-dwelling
men aged 70 years and older. Of importance, however,
the effects on Sarcopenia Z-Score and total body fat were
(borderline) significantly more pronounced after combined
WB-EMS&P. Comparable with other WB-EMS studies
with a similar protocol, the effects of WB-EMS28,34 were
considerably higher for morphometric compared with
dyna(mo)penic/functional parameters. This result can be
largely attributed to our EMS approach that focused on low
voluntary effort/low orthopedic strain during moderate-to-
high impulse intensity, specifically adjusted to this older,
less sportive cohort with orthopedic limitations (Table 1).
However, in summary, the effect of WB-EMS&P ranged
within our expectations. Our data confirmed the results of
the FORMOsA study with CDW women aged 70+ years with
SO,28 that reported similar effects on sarcopenia parameters.
However, unlike most of our WB-EMS studies21,22,35,36 and
the current trial, the FORMOsA study failed to generate
a significant reduction in body fat. One may argue that
the higher WB-EMS volume and intensity along with the
higher total protein intake (1.2–1.4 vs 1.7–1.8 g/kg body
mass per day) of the FranSO study might explain the vary-
ing result, but if that were the case then this pattern should
have impacted muscle parameters even more. As that may
be, due to the dominating role of obesity within the “cross
talk” of adipose tissue and skeletal muscle inflammation,2
the reduction in fat mass may also be a key aspect in the
therapy for sarcopenia.
Addressing protein supplementation, the clinical effec-
tiveness of isolated protein and amino acid supplementation
on lean body mass (LBM) in older people is still under
discussion.37–42 In their meta-analysis (n=9 studies), Xu et al40
reported a nonsignificant overall increase in LBM of 0.34
(95% CI: -0.42 to 1.10) kg in older people ($65 years). In
parallel in another meta-analysis by that research group (n=9),
only a low effect (0.18; -0.18 to 0.54 kg) of leucine supple-
mentation on LBM in people aged about 65 years and older
was determined.41 In contrast, the meta-analysis (16 studies)
of Komar et al,38 which also focused on the effect of leucine
supplementation (at least 2 g/day) in people $65 years,
reported a highly significant mean LBM difference (verum
vs placebo) of 0.99 kg (0.43–1.55 kg). Most similar to the
protein supplementation of the FranSo-study, Bauer et al37
supplemented 800 IU of vitamin D and 40 g/day of whey
protein for 380 people aged 70+ years with low muscle mass
and physical function. After 13 weeks, this randomized,
placebo-controlled trial (PROVIDE) showed a slight, but
significant ASMM net effect (protein vs placebo) of 0.17 kg
(0.01–0.34 kg). Although (whey) protein-induced effects on
LBM (0.69; 0.13–1.25 kg) and ASMM (0.30; 0.04–0.56 kg)
were higher in the FranSO-study, the clinical significance of
these effects (,2%) remains unclear,37 at least when consid-
ering the negligible-to-low effects of protein supplements on
strength parameters in healthy adults.38,40,43
Apart from the musculoskeletal burden of sarcopenia
and SO, there is an ongoing debate on the cardiometabolic
impact of sarcopenia and SO.44–46 Perna et al45 who compared
people aged 65+ years without and with sarcopenia or SO
confirmed the worse metabolic and inflammatory status of
the latter cohorts in general, however, with a better metabolic
profile of the SO compared with the sarcopenia patients.
Because we do not focus on the effects of WB-EMS47 and/
or protein supplementation48 on cardiometabolic risk factors
in this article, we refrain here from a deeper discussion of
this important topic.
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WB-EMS and sarcopenic obesity
To allow the reader to reflect on the results of the current
study, we would like to address some limitations and specific
features of the FranSO study. 1) The main limitation of the
study was the inability to include enough subjects with sar-
copenia according to recognized definitions.17,18,26,27 Although
this does not excuse our failure, we are not aware of any other
exercise or protein/EAA study that fully respects the recog-
nized criteria and cutoff points38 for sarcopenia. 2) We used
direct-segmental, multifrequency BIA to determine body
composition. However, the FNIH criteria of SMI are based
on “dual-energy X-ray absorptiometry” (DXA) assessments.
Some authors49,50 reported a systematic overestimation of
SMI by BIA compared with the gold standard “DXA,” while
others51 and we28,52 observed a good–excellent agreement
between both methods. While a potential overestimation of
muscle mass by BIA might have aggravated our recruitment,
it did not affect the outcome of this study. 3) We applied a
rather conventional WB-EMS protocol. After increasing
the duration to 20 min, we focused exclusively on adequate
(impulse) intensity. Thus, the main difference between
FranSO and commercially practiced WB-EMS protocols
is the slightly higher training frequency of 1.5 vs 1 session
per week. 4) The favorable effect of additional protein
supplementation to augment the hypertrophic response to
resistance exercise in older adults has not been consistently
determined.53–55 However, recent evidence suggests14,15,56 that
higher levels of protein intake overcome the lack of muscle
responsiveness to low-dosed protein intake in older adults.
This “anabolic resistance” provided support for our strategy
of combining WB-EMS and whey protein supplements above
the current recommendations for older adults (ie, 1.2–1.6 g/kg
per day)14,15 while considering the additional requirements
of exercise-induced repair and adaptation processes.57
5) We did not supply CHO to generate a placebo effect or
to ensure “isocaloric conditions”. While amino acids and
protein are essential for anabolic processes, their significance
on energy metabolism during energy balance in healthy
adults is minor.58 Further, considering the protein-induced
thermogenesis and decreased energy efficiency,59 supplying
the same amount of CHO and proteins60–62 might generate a
significant bias. Indeed, in contrast to FranSO, none of the
corresponding studies reported significant reductions in body
fat after protein supplementation.
Due to the specific nature of sarcopenia and SO,63
which includes aspects of inflammation,2,64,65 mitochondrial
abnormalities,66 oxidative stress67 and other factors that
may decrease muscle response to exercise, it is debat-
able whether results evaluated in healthy older adults can
be simply generalized to sarcopenic or SO cohorts. This
suggests, however, that future studies should compare
the effect of dedicated exercise programs in older cohorts
with and without sarcopenia and SO to allow a generaliza-
tion of the bulk of existing data to the field of sarcopenic/
SO cohorts.
Conclusion
WB-EMS and/or whey protein supplements significantly
affected sarcopenia and SO in CDW men aged 70+ years with
SO. Due to the aspect that WB-EMS should be considered
as an option for people unable or unmotivated to exercise
conventionally, a corresponding comparison of effective-
ness may be regarded as superfluous. However, similar to a
previously reported WB-EMS study that directly compared
WB-EMS with an equally time-effective high intensity resis-
tance training protocol resistance protocol,35 the WB-EMS-
induced effect on muscle and fat mass on average fell within
the range of conventional resistance exercise.6,68 In summary,
WB-EMS&P can be considered as an effective, time saving,
joint-friendly and low-threshold intervention to fight both,
sarcopenia and obesity in older people at risk.
Acknowledgment
The authors would like to express their thanks for the
support from the nonprofit organization and health sport
club “Netzwerk Knochengesundheit e.V.”, which funded
the project.
Disclosure
The authors report no conflicts of interest in this work.
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... Für die Adipositas liegen mehrere Studien vor (Andre et al., 2021;Bellia et al., 2020;Kemmler et al., 2016c;Kemmler et al., 2017c;Kim & Jee, 2020;Ricci et al., 2020), die den Einfluss von WB-EMS auf den Körperfettgehalt unter verschiedenen Rahmenbedingungen erfassen. Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. ...
... Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. Im Gegensatz dazu wurde nach WB-EMS-Standardprogramm im korrespondierenden Männerkollektiv ein signifikanter Effekt berichtet (Kemmler et al., 2017c). Kim und Jee (2020), die ein Standardprotokoll -3 x 40 min pro Woche bei adipösen, postmenopausalen Frauen -applizieren, fanden nach acht Wochen eine Reduktion von ca. 4 kg Körperfett bei gleichzeitiger signifikanter Erhöhung der Muskelmasse gegenüber der inaktiven Kontrollgruppe. ...
... Die Handkraft ("handgripstrength") als hochgradig alltagsrelevante, funktionelle Fähigkeit des älteren Menschen, kann über WB-EMS ebenfalls klinisch relevant beeinflusst werden (u.a. (Kemmler et al., 2016c(Kemmler et al., , 2017c. ...
Chapter
Der obige Begriff der Muskelstimulation ist insofern irreführend, als dass die Schwelle zur Erregung motorischer Nerven deutlich niedriger liegt, als diejenige des korrespondierenden Muskels. Über die oberflächlich aufliegende Elektrode wird bei der WB-EMS zunächst der Nerv stimuliert, der über die Alpha-Motoneuronen und die motorischen Endplatten eine Muskelkontraktion bewirkt. Lässt man die Vielzahl der Applikationsmöglichkeiten elektrischer Ströme außer Acht und fokussiert sich auf die derzeit etablierte Technologie, so kommen bei der WB-EMS grundsätzlich bipolare (biphasische) Reizströme, im Niederfrequenz- (0–1000 Hz) und (modularen) Mittelfrequenzbereich (>1000 Hz– <1 MHz) zum Einsatz.
... Für die Adipositas liegen mehrere Studien vor (Andre et al., 2021;Bellia et al., 2020;Kemmler et al., 2016c;Kemmler et al., 2017c;Kim & Jee, 2020;Ricci et al., 2020), die den Einfluss von WB-EMS auf den Körperfettgehalt unter verschiedenen Rahmenbedingungen erfassen. Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. ...
... Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. Im Gegensatz dazu wurde nach WB-EMS-Standardprogramm im korrespondierenden Männerkollektiv ein signifikanter Effekt berichtet (Kemmler et al., 2017c). Kim und Jee (2020), die ein Standardprotokoll -3 x 40 min pro Woche bei adipösen, postmenopausalen Frauen -applizieren, fanden nach acht Wochen eine Reduktion von ca. 4 kg Körperfett bei gleichzeitiger signifikanter Erhöhung der Muskelmasse gegenüber der inaktiven Kontrollgruppe. ...
... Die Handkraft ("handgripstrength") als hochgradig alltagsrelevante, funktionelle Fähigkeit des älteren Menschen, kann über WB-EMS ebenfalls klinisch relevant beeinflusst werden (u.a. (Kemmler et al., 2016c(Kemmler et al., , 2017c. ...
... Für die Adipositas liegen mehrere Studien vor (Andre et al., 2021;Bellia et al., 2020;Kemmler et al., 2016c;Kemmler et al., 2017c;Kim & Jee, 2020;Ricci et al., 2020), die den Einfluss von WB-EMS auf den Körperfettgehalt unter verschiedenen Rahmenbedingungen erfassen. Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. ...
... Zwei dieser Untersuchungen erfassen die Sarcopenic Obesity des älteren Menschen und zeigen für eine Frauengruppe (Kemmler et al., 2016), die ein niedrigintensives WB-EMS-Protokoll absolviert hat, keine signifikanten Effekte auf den Körperfettgehalt. Im Gegensatz dazu wurde nach WB-EMS-Standardprogramm im korrespondierenden Männerkollektiv ein signifikanter Effekt berichtet (Kemmler et al., 2017c). Kim und Jee (2020), die ein Standardprotokoll -3 x 40 min pro Woche bei adipösen, postmenopausalen Frauen -applizieren, fanden nach acht Wochen eine Reduktion von ca. 4 kg Körperfett bei gleichzeitiger signifikanter Erhöhung der Muskelmasse gegenüber der inaktiven Kontrollgruppe. ...
... Die Handkraft ("handgripstrength") als hochgradig alltagsrelevante, funktionelle Fähigkeit des älteren Menschen, kann über WB-EMS ebenfalls klinisch relevant beeinflusst werden (u.a. (Kemmler et al., 2016c(Kemmler et al., , 2017c. ...
... Apesar da vasta documentação da suplementação da proteína do soro de forma isolada, estudos (Chanet et al., 2017;Kemmler et al., 2017) firmam que a combinação desta com exercício resistido (ER) podem potencializar os efeitos na força muscular e no desempenho físico à longo prazo. Por sua vez, esses podem obter melhores resultados na síntese e preservação das proteínas musculares quando associados a vitamina D (Rondanelli et al., 2016). ...
... Dos 12 artigos analisados, 10 relacionaram o uso da proteína do soro do leite enriquecida com vitamina D e 2 estudos avaliaram os efeitos da proteína do soro do leite. Ademais, 8 estudos (Chanet et al., 2017;Kemmler et al., 2017;Verreijen et al., 2015;Nabuco et al., 2018) avaliaram o efeito da suplementação proteica (combinada ou não com vitamina D) associada à ER e 4 estudos (Bauer et al., 2015;Bo et al., 2015) não realizaram nenhum tipo de exercício físico. Dos estudos que avaliaram a suplementação proteica sem a realização de ER, 3 estudos (Chanet et al., 2017;(Nabuco et al., 2018;Liberman et al, 2019) apresentaram a melhora da MMA e estado inflamatório subclínico, enquanto 2 estudos (Bo et al., 2015;Verlaan et al., 2018) apresentaram resultados satisfatórios com aumento da MMA e FPM. ...
Article
Full-text available
Realizar uma revisão integrativa sobre o uso da proteína do soro do leite, combinada ou não com a suplementação de vitamina D e o exercício resistido na melhoria de parâmetros da sarcopenia em idosos. Trata-se de um estudo de revisão do tipo integrativa realizada na base de dados MedLine, Biblioteca Virtual em Saúde e PubMed, no qual foram selecionados ensaios clínicos randomizados, duplo-cego, controlado e multicêntrico. Foram avaliados 12 estudos que averiguaram a intervenção nos grupos controle versus placebo. Visto que 10 relacionaram o uso da proteína do soro do leite enriquecida com vitamina D e 2 estudos avaliaram os efeitos da proteína do soro do leite. Quanto a associação com exercício resistido (ER), 8 desses estudos tiveram associação com ER e 4 estudos não tiveram. Foi descrito resultados satisfatórios nos efeitos do escore Z da sarcopenia, no aumento dos parâmetros de força muscular, massa muscular, massa livre de gordura e desempenho físico. Existem benefícios na suplementação isolada de proteína de soro de leite na melhoria da massa muscular, força e desempenho físico de idosos com sarcopenia, quando combinada a vitamina D. A suplementação proteica associada ao ER mostrou resultados vantajosos para a sarcopenia no envelhecimento, potencializado com efeito da suplementação.
... WB-EMS has demonstrated to be effective in untrained and morphometrically sarcopenic (excluding the functional component) older people (Kemmler et al., 2016a;Kemmler et al., 2018;Kemmler et al., 2021). Limited evidence shows effects on muscle mass, handgrip and lower extremity strength, gait speed, cardiometabolic and anthropometric parameters Kemmler et al., 2016a;Kemmler et al., 2017;von Stengel et al., 2015) as well as reductions of low back pain intensity and frequency . However, participants in previous WB-EMS studies were overwhelmingly robust without functional impairments. ...
... Surprisingly, the adherence of 88% and retention rate of 83% in our study was quite high in this population (Provencher et al., 2014). In comparison to previous WB-EMS studies with older non-frail people, the adherence was comparable; however the dropout rate was higher (17 vs. 10%) (Kemmler et al., 2016a;Kemmler et al., 2017). ...
Article
Full-text available
Whole-body electromyostimulation (WB-EMS) induces high-intense stimuli to skeletal muscles with low strain on joints and the autonomic nervous system and may thus be suitable for frail, older people. However, if trained at very high intensities, WB-EMS may damage muscles and kidneys (rhabdomyolysis). This study aimed at investigating the feasibility, safety and preliminary efficacy of WB-EMS in frail, older people. Seven frail (81.3 ± 3.5 years), 11 robust (79.5 ± 3.6 years), 10 young (29.1 ± 6.4 years) participants completed an eight-week WB-EMS training (week 1–4: 1x/week; week 5–8: 1.5x/week) consisting of functional exercises addressing lower extremity strength and balance. Feasibility was assessed using recruitment, adherence, retention, and dropout rates. The satisfaction with WB-EMS was measured using the Physical Activity Enjoyment Scale for older adults (PACES-8). In week 1, 3, and 8 creatine kinase (CK) was assessed immediately before, 48 and 72 h after WB-EMS. Symptoms of rhabdomyolysis (muscle pain, muscle weakness, myoglobinuria) and adverse events were recorded. Functional capacity was assessed at baseline and after 8 weeks using the Short Physical Performance Battery (SPPB), Timed Up-and-Go Test (TUG), Choice Stepping Reaction Time Test (CSRT), 30-second Chair-Stand Test (30-STS), maximum isometric leg strength and handgrip strength. The recruitment rate of frail individuals was 46.2%, adherence 88.3% and the dropout rate 16.7%. All groups indicated a high satisfaction with WB-EMS. CK activity was more pronounced in young individuals with significant changes over time. Within older people CK increased borderline-significantly in the frail group from baseline to week 1 but not afterwards. In robust individuals CK increased significantly from baseline to week 1 and 3. No participant reached CK elevations close to the threshold of ≥5,000 U/l and no symptoms of rhabdomyolysis were observed. With the exception of the TUG (p = 0.173), frail individuals improved in all tests of functional capacity. Compared to the young and robust groups, frail individuals showed the greater improvements in the SPPB, handgrip strength, maximum isokinetic hip-/knee extension and flexion strength. WB-EMS is feasible for frail older people. There were no clinical signs of exertional rhabdomyolysis. WB-EMS proved to be sufficiently intense to induce meaningful changes in functional capacity with frail individuals showing greater improvements for several measures.
... This study is a narrative review of the nutritional and exercise interventions for sarcopenic obesity in which WB-EMS is pointed out as time-saving option for positively impacting body composition and functional capacity. According the H-index ( Figure 5), Wolgang Kemmler is the author of five of the six most relevant articles [1,34,36,59,69], in which the most relevant is the article by Sabine Goisser [32]. Interesting to note that the relevant articles are interventions made in special cohorts (sarcopenic obesity, postmenopausal woman and elderly). ...
Article
Full-text available
Whole Body Electromyostimulation [WB-EMS] is a training methodology that applies electrostimulation in the main muscle groups of the human body superimposed with active training exercises. This study aims to carry out a bibliometric analysis on WB-EMS to provide an overview of the state of research and provide new insights for research in the field. Method: One hundred and two citations extracted were examined using a bibliometric approach based on data stored in the Web of Science Core Collection, applying traditional bibliometric laws, and using VOSviewer and excel for data and metadata processing. Results: Among the results, this study points out that Germany is the country that produces more scientific knowledge on WB-EMS. Wolfgang Kemmler is the most relevant author in this field. Moreover, Frontier of Physiology is the journal where the authors publish the most. Conclusion: Research on WB-EMS has been growing in recent years. German and Spanish researchers lead two clusters where most studies and collaborations in this field are carried out. These findings will provide a better understanding of the state of WB-EMS research and may guide the emergence of new lines of investigation and research ideas.
... However, none of the trials investigated the reversibility of the syndrome. Two studies in SO reported a modified, z-transformed sarcopenia index and found improvements in skeletal muscle mass index, grip strength, gait speed, and a decrease in percentage body fat.49,50 The peak oxygen uptake (VO 2 max/peak), a measure of aerobic capacity, is an important indicator of cardiorespiratory fitness and a good proxy of health and health decline. ...
Article
Full-text available
Obesity and sarcopenic obesity (SO) are characterized by excess body fat with or without low muscle mass affecting bio‐psycho‐social health, functioning, and subsequently quality of life in older adults. We mapped outcomes addressed in randomized controlled trials (RCTs) on lifestyle interventions in community‐dwelling older people with (sarcopenic) obesity. Systematic searches in Medline, Embase, Cochrane Central, CINAHL, PsycInfo, Web of Science were conducted. Two reviewers independently performed screening and extracted data on outcomes, outcome domains, assessment methods, units, and measurement time. A bubble chart and heat maps were generated to visually display results. Fifty‐four RCTs (7 in SO) reporting 464 outcomes in the outcome domains: physical function (n = 42), body composition/anthropometry (n = 120), biomarkers (n = 190), physiological (n = 30), psychological (n = 47), quality of life (n = 14), pain (n = 4), sleep (n = 2), medications (n = 3), and risk of adverse health events (n = 5) were included. Heterogeneity in terms of outcome definition, assessment methods, measurement units, and measurement times was found. Psychological and quality of life domains were investigated in a minority of studies. There is almost no information beyond 52 weeks. This evidence map is the first step of a harmonization process to improve comparability of RCTs in older people with (sarcopenic) obesity and facilitate the derivation of evidence‐based clinical decisions.
... In this study, experimental groups A (EGa) and B (EGb) were given high-protein supplementation three times a week. EGa drank high-protein supplementation 10 minutes after completing the physical activity program (1.3 g/kg BW/day, 68 kg × 1.3 g = 88 g protein per day) [33,34], while EGb performed daily routines (such as reading newspapers and magazines, watching TV, walking, chatting, playing chess) and drank the high-protein supplementation 3 times a week. The intervention lasted for 3 months. ...
Article
Full-text available
The purpose of this study was to understand the effects of a physical activity program and high-protein supplementation on body composition and upper and lower extremity muscle strength in male older adults in rural areas. In this study, 60 healthy male older adults (mean age 77.5 ± 4.6 years) from rural areas were recruited and randomly assigned to experimental group A (intervention of the physical activity program and high-protein supplementation), experimental group B (daily routine, with only intervention of high-protein supplementation), or control group C (daily routine). Experimental group A (EGa) carried out a physical activity plan three times a week, with an exercise intensity and calorie consumption of 250 kcal (5METs × ⅔hr × 75) for 3 months and drank a high-protein supplement (1.3 g/kg BW/day) after each exercise; experimental group B (EGb) followed only the intervention of high-protein supplementation. All the participants underwent pre- and post-tests for body composition, waist–hip circumference (WC, HC), handgrip strength (HS), 30 s dominant arm curl, 30 s sit to stand, and 2 min step tests. The results of the study showed that EGa significantly decreased body mass index (BMI), body fat mass (BFM), body fat percentage (BFP), WC, HC, and waist-to-hip ratio (WHR) and increased basal metabolic rate and muscle mass. Although both EGa and EGb used high-protein supplementation, EGa’s added three-month intervention of a physical activity program made it easier for that group to increase muscle mass and muscle strength. The WHR decreased from 1.015 to 0.931, representing a decrease of 8.28%, and an obvious weight loss effect was achieved. Thus, we concluded that the best way to maintain muscle strength in older adults is through physical activity with resistance and protein supplementation, which can reduce muscle loss in older adults.
Article
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Resistance training has been known to have a positive effect on muscle performance in exercisers. Whole-body electromyostimulation (WB-EMS) is advertised as a smooth, time-efficient, and highly individualized resistance training technology. The purpose of this study is to evaluate the effects of WB-EMS training on maximum isometric elbow muscle strength and body composition in moderately trained males in comparison to traditional resistance training. The study was a randomized controlled single-blind trial. Twenty, moderately trained, male participants (25.15 ± 3.84, years) were randomly assigned to the following groups: a WB-EMS training group ( n = 11) and a traditional resistance training group (the control group [CG]: n = 9). Both training intervention programs consisted of 18 training sessions for six consecutive weeks. All subjects performed dynamic movements with the WB-EMS or external weights (CG). The primary outcome variables included maximum isometric elbow flexor strength (MIEFS), maximum isometric elbow extensor strength (MIEES) and surface electromyography amplitude (sEMG RMS ). Secondary outcomes involved lean body mass, body fat content, arm fat mass, and arm lean mass. ANOVAs, Friedman test and post hoc t -tests were used ( P = 0.05) to analyze the variables development after the 6-week intervention between the groups. Significant time × group interactions for MIEFS (η ² = 0.296, P Bonferroni = 0.013) were observed, the increase in the WB-EMS group were significantly superior to the CG [23.49 ± 6.48% vs. 17.01 ± 4.36%; MD (95% CI) = 6.48 (1.16, 11.80); d = 1.173, P = 0.020]. There were no significant differences were observed between interventions regarding MIEES, sEMG RMS and body composition. These findings indicate that in moderately trained males the effects of WB-EMS were similar to a traditional resistance training, with the only exception of a significantly greater increase in elbow flexor strength. WB-EMS can be considered as an effective exercise addition for moderately trained males.
Article
Background The patients with sarcopenic obesity (SO) have the characteristics of both sarcopenia and obesity, that is, less muscle mass and increased fat mass, and their morbidity, disability and mortality are higher than patients with sarcopenia or obesity alone. Objectives To investigate the effects of whole-body electromyostimulation (WB-EMS) training and protein supplementation intervention on body composition, physical function, metabolism and inflammatory biomarkers in middle-aged and elderly patients with SO. Methods We searched for randomized controlled trials in seven databases, including PubMed, Web of Science, Embase, Cochrane Library, Scopus, SinoMed, and CNKI as of July 3, 2021. The methodological quality of each included study was assessed using the Physiotherapy Evidence Database (PEDro) scale. The Cochrane Risk of Bias Tool was used to assess the risk of bias. Statistical analysis was performed using Review Manager 5.3. Results Eleven randomized controlled studies with a total of 779 participants were included in this meta-analysis. WB-EMS training improved sarcopenia Z-score (MD = −1.52, 95 % CI: −2.27, −0.77, P < 0.0001) and waist circumference (WC) (MD = −1.41, 95 % CI: −2.62, −0.20, P = 0.02), and increased skeletal muscle mass index (SMI) (MD = 1.27, 95 % CI: 0.66,1.88, P < 0.0001) and appendicular skeletal muscle mass (ASMM) (MD = 0.68, 95 % CI: 0.08, 1.27, P = 0.03). Protein supplementation intervention reduced body fat rate (BF%) (MD = −1.28, 95 % CI: −1.88, −0.68, P < 0.0001, I² = 0 %), total body fat (TBF) (MD = −0.98, 95 % CI: −1.65, −0.31, P = 0.004, I² = 0 %) and trunk body fat mass (TBFM) (MD = −0.50, 95 % CI: −0.94, −0.06, P = 0.03, I² = 0 %), and increased grip strength (GS) (MD = 1.13, 95 % CI: 0.06, 2.21, P = 0.04, I² = 0 %). The combination of WB-EMS and protein supplements is beneficial to most body components and physical functions, such as SMI (MD = 1.21, 95 % CI: 0.73, 1.51, P < 0.00001, I² = 0 %), GS (MD = 1.60, 95 % CI: 0.80, 2.40, P < 0.0001, I² = 45 %) and walking speed (WS) (MD = 0.04, 95 % CI: 0.02, 0.06, P < 0.0001, I² = 49 %). Compared with protein supplementation alone, WB-EMS could have an additional beneficial effect on BF% (MD = −0.92, 95 % CI: −1.80, −0.04, P = 0.04) and WC (MD = -1.03, 95 % CI: −1.70, −0.36, P = 0.003). Nevertheless, the addition of protein supplements did not provide any additional benefit compared with WB-EMS alone. In addition, there was almost no positive effect of WB-EMS and protein supplements on metabolic and inflammatory biomarkers. Conclusions As things stand, protein supplementation intervention can effectively reduce body fat percentage, fat mass, and increase grip strength in SO patients. Both WB-EMS and protein supplementation intervention had no significant effects on metabolic and inflammatory biomarkers. WB-EMS combined with protein supplementation intervention was beneficial for SO patients in many ways. Due to the small number of studies, further studies are needed to confirm the efficacy of WB-EMS alone or in combination with protein supplementation intervention in SO patients. Registration number INPLASY202190096 DOI:10.37766/inplasy2021.9.0096
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Maintaining independence, quality of life, and health is crucial for elderly adults. One of the major threats to living independently is the loss of muscle mass, strength, and function that progressively occurs with aging, known as sarcopenia. Several studies have identified protein (especially the essential amino acids) as a key nutrient for muscle health in elderly adults. Elderly adults are less responsive to the anabolic stimulus of low doses of amino acid intake compared to younger individuals. However, this lack of responsiveness in elderly adults can be overcome with higher levels of protein (or essential amino acid) consumption. The requirement for a larger dose of protein to generate responses in elderly adults similar to the responses in younger adults provides the support for a beneficial effect of increased protein in older populations. The purpose of this review is to present the current evidence related to dietary protein intake and muscle health in elderly adults.
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