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review

Wien Med Wochenschr


https://doi.org/10.1007/s10354-018-0655-x

Side effects of whole-body electro-myo-stimulation


Claudia Stöllberger · Josef Finsterer

Received: 26 March 2018 / Accepted: 2 August 2018


© Springer-Verlag GmbH Austria, ein Teil von Springer Nature 2018

Summary Whole-body-electro-myo-stimulation Nebenwirkungen der


(WB-EMS) has been introduced as an alternative Ganzkörperelektromyostimulation
to physical training. The aim of the review is to sum-
marize the data about indications and side effects of Zusammenfassung Die Ganzkörperelektromyostimu-
WB-EMS. lation (GK-EMS) wurde als Alternative zu körperli-
A literature search in PubMed disclosed 11 random- chem Training eingeführt. Ziel der Übersichtsarbeit
ized trials, 3 cohort studies, and 7 case reports. From ist eine Zusammenfassung der Daten zu Indikationen
healthy volunteers, enormous creatine kinase (CK) el- und Nebenwirkungen von GK-EMS.
evations were reported. There is a lack of data about Eine Recherche in PubMed erbrachte 11 randomi-
biological consequences of WB-EMS on other organs. sierte Studien, 3 Kohortenstudien und 7 Fallberichte.
In randomized trials, CK levels were not investigated, Bei gesunden Probanden wurden enorme Kreatin-
but several patients discontinued WB-EMS because kinase(CK)-Anstiege nach GK-EMS beobachtet. Es
of “muscular discomfort.” Contraindications for WB- gibt keine Daten zu den biologischen Konsequen-
EMS are not clearly defined. Nine cases of rhabdomy- zen von GK-EMS für andere Organsysteme. In den
olysis after WB-EMS were found, preferentially after randomisierten Studien wurde die CK nicht unter-
the first application. sucht, mehrere Patienten brachen die GK-EMS aber
Regulatory authorities should increase the safety of wegen „muskulärer Missempfindungen“ ab. Kontrain-
WB-EMS. Patients with a history of rhabdomyolysis dikationen für GK-EMS sind uneinheitlich und nicht
should not undergo WB-EMS and those experienc- eindeutig formuliert. Neun Fälle mit Rhabdomyolyse
ing rhabdomyolysis should be neurologically investi- nach GK-EMS wurden gefunden, hauptsächlich nach
gated. Since the value of WB-EMS as an alternative der ersten Anwendung.
to physical exercise is uncertain, we need to proof or Die Gesundheitsbehörden sollten Anstrengungen un-
disproof its benefit. ternehmen, um die Sicherheit der GK-EMS zu erhö-
hen. Patienten mit Rhabdomyolyse in der Anamnese
Keywords Rhabdomyolysis · Electromyostimulation · sollten keine GK-EMS absolvieren. Nach GK-EMS-in-
Myopathy · Creatinin kinase · Physical exercise duzierter Rhabdomyolyse sollten die Patienten neu-
rologisch untersucht werden. Die Rolle der GK-EMS
als Alternative zu körperlichem Training ist umstrit-
ten und sollte besser erforscht werden.

Schlüsselwörter Rhabdomyolyse · Elektromyostimu-


lation · Myopathie · Kreatinkinase · Körperliche Akti-
Univ. Prof. Dr. C. Stöllberger · Univ. Prof. Dr. J. Finsterer vität
Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien,
Austria Introduction
Univ. Prof. Dr. C. Stöllberger ()
Steingasse 31/18, 1030 Wien, Austria Transcutaneous electro-myo-stimulation (EMS) has
claudia.stoellberger@chello.at long been used as a non-pharmacologic therapy in

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deconditioned patients with the aim of increasing muscle biopsies before and after training, showed
muscle force [1]. In both healthy and impaired mus- changes typical of resistance and endurance training.
cles, it has been reported that EMS is an efficient These EMS-induced changes can be attributed to the
modality for increasing muscle mass, maximal volun- peculiar motor unit recruitment pattern associated
tary strength, or exercise capacity. EMS can be used with EMS [17]. When comparing maximal voluntary
for selected muscle groups or as whole-body EMS and EMS-induced contractions of the elbow flexors
(WB-EMS). WB-EMS is used as a complement to vol- in healthy subjects, EMS resulted in greater decreases
untary exercise in athletes, as an alternative form of in maximal voluntary contraction strength, increases
physical exercise for improving fitness and health in in plasma creatine kinase (CK) activity, and muscle
healthy people and in patients who cannot perform soreness. It seems likely that the muscle damage in
conventional forms of voluntary exercise because of EMS is associated with high mechanical stress on the
physical or mental illness [2–14]. activated muscle fibers due to the specificity of motor
Manufacturers claim WB-EMS to be useful tool for unit recruitment [18]. A further study in healthy sub-
increasing strength, loosing fat, or improving general jects compared maximal voluntary contraction with
health. Because of time efficiency and joint friendli- EMS-induced contractions of the elbow flexors to in-
ness, WB-EMS is suggested as a good choice for peo- vestigate whether EMS would induce greater muscle
ple unable or unwilling to perform conventional train- damage than voluntary contractions [19]. Serum CK
ing [15, 16]. WB-EMS is easily accessible to the general activity increased only after EMS, and the muscles
population. It is increasingly offered by fitness centers became more sore and tender after EMS than after
in many countries, and devices for WB-EMS are avail- voluntary contractions. It seems likely that higher
able for purchase in fitness and sports shops and the mechanical stress imposed on the activated muscle
internet. fibers, due to the specificity of motor unit recruitment
The equipment for WB-EMS, used most frequently in EMS, caused more muscle damage than voluntary
in Europe and reported in many publications, is the contraction [19]. Physiologic recruitment of motor
Miha Bodytec® device (Miha Bodytec, Gersthofen, units follows the size principle, whereas EMS recruits
Germany). It enables simultaneous stimulation of all motor units simultaneously [19].
thighs and upper arms, hip/bottom, chest, lower Histological analyses showed larger myofiber dam-
back, and upper back with an overall area of stimu- age of the quadriceps muscle after EMS-induced
lation of about 2600 cm2 [2–13]. The WB-EMS device lengthening contractions as compared with maximal
enables the simultaneous activation of muscle groups voluntary eccentric contractions [20]. Furthermore,
with different selectable intensities. The electrodes altered muscle microstructure and related inflamma-
are fixed in the inside surface of a dedicated suit tory/edematous processes have been reported after
and connected via electrical cords to the application EMS [21]. Disturbed pH homeostasis and impaired
unit. The standard WB-EMS protocol uses biphasic mitochondrial function 4 days after a single bout of
rectangular wave pulsed currents (80 Hz) with an im- isometric EMS have been additionally reported [22].
pulse width of 350 μs, 4–6 s of EMS stimulation with WB-EMS is not without health risks. Especially
an immediate impulse burst, and an impulse pause its potential of triggering rhabdomyolysis has cre-
of 4 s. The stimulation intensity is set separately for ated considerable concerns, forcing the authorities
each muscle group by using the Borg rating of per- of a country to take actions to regulate the use of
ceived exertion scale, which is a subjective measure. WB-EMS devices [15, 23, 24]. Furthermore, there are
This stimulation protocol was used in most of the only few data about the physiologic consequences of
randomized trials. Unfortunately, the current types WB-EMS on other organ systems. One study com-
applied and the stimulation intensity in mA are not pared heart rate, systolic blood pressure, diastolic
reported in any of the publications. A further WB- blood pressure, and oxygen uptake in 68 healthy
EMS apparatus, produced by Miracle (Seoul, Korea), subjects randomized to a physical exercise program
uses wireless materials. The electrical strength of combined with or without WB-EMS. After a 6-week
the suit is controlled by an Ipad or cellular phone training period, there were no abnormal changes in
via Bluetooth [14]. WB-EMS can be combined with the cardiopulmonary variables of either group [14].
basic movements [10, 14]. The duration of a WB-EMS According to the manufacturers, WB-EMS is con-
training session should be 15-20 min and an interval traindicated in patients with implanted electronic
of ≥4 days must be held between training units. devices like pacemakers, implanted defibrillators,
The following muscular changes after EMS have neuro-stimulators or pain pumps because of potential
been reported: In healthy subjects, maximum vol- electrical interference. Apart from these contraindi-
untary strength and neural activation significantly cations, there are various diseases or conditions men-
increased after EMS [17]. Muscle biopsies taken be- tioned in the publications as exclusion criteria, as
fore and after EMS disclosed that both type 1 and 2 listed in Table 4. Obviously, there is a lack of clearly
muscle fibers showed significant hypertrophy [17]. defined and universally accepted contraindications
After EMS, a transition from fast to slow muscle fibers for WB-EMS.
was found. Proteomic map spots, obtained from

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Table 1 Results of liter- Search term Results, n Selected articles


ature research in PubMed
Electrostimulation AND side effects 178 RT [7], CR [28, 29]
(January 2000–May 2018)
Electrostimulation AND rhabdomyolysis 2 CR [28, 29]
Electromyostimulation AND side effects 12 RT [7], CR[26, 27, 30], CS [25]
Electromyostimulation AND rhabdomyolysis 4 CR [26, 27, 30], CS [25]
Whole-body electrostimulation AND side effects 3 CS [25]
Whole-body electrostimulation AND rhabdomyolysis 0 0
Whole-body electromyostimulation AND side effects 3 RT [7], CS [25], CR [30]
Whole-body electromyostimulation AND rhabdomyolysis 2 CR [30], CS [25]
Whole-body EMS AND side effects 5 RT [7], CS [25]
Whole-body EMS AND rhabdomyolysis 1 CS [25]
Whole-body EMS 34 RT [2, 5, 6, 8–14], CS [25]
Whole-body electromyostimulation 26 RT [5–14], CS [25], CR [30]
Electromyostimulation, heart failure 9 CS [3, 4]
Electrostimulation, heart failure 18 0
RT randomized trial, CR case report, CS cohort study

Thus, the aim of the present review is to summa- [2, 5–14]). Furthermore, we identified 3 cohort stud-
rize the current knowledge about indications and side ies and 5 case reports [3, 4, 25–30]. Two further case
effects of WB-EMS in healthy subjects and patients. reports were retrieved by screening the references of
the collected articles [23, 31]. The reported cases are
Methods listed in Table 3. No discrepancies occurred between
the reviewers in the selection process.
A literature search was carried out using PubMed from
2000 to May 2018. For general information about WB- Indications and results of WB-EMS
EMS, the search terms “whole-body electro-myo-
stimulation” or “whole-body EMS” were used. Fur- Athletes and healthy subjects
thermore, the search terms “electrostimulation” or A randomized study in elite soccer players compared
“electro-myo-stimulation” were combined with the WB-EMS with jump training (Table 2; [2]). WB-
term “heart failure.” For search of potential side EMS increased one-leg maximal strength, improved
effects of WB-EMS, we used the terms “electros- linear sprinting, sprinting with direction changes,
timulation,” “electromyostimulation,” “whole-body vertical jumping performance, and kicking veloc-
electromyostimulation,” “whole-body electrostimu- ity [2]. Of note, this is the only randomized study
lation,” “whole-body EMS,” AND “side effects” or where CK levels were investigated before and after
“rhabdomyolysis.” The research concentrated on ap- WB-EMS. A significant increase of CK was observed:
plications of WB-EMS in healthy subjects and patients pre-WB-EMS 530.30 ± 230.00 U/l, 24 h post-WB-EMS
with heart failure, osteoporosis, or sarcopenic obesity. 1199.89 ± 569.69 U/l. No increase in CK in the jump
Excluded were articles about application of EMS in training group was detected.
selected muscle groups or in patients with cerebral A further study in middle-aged men compared the
diseases or local muscular problems. Only data with effectiveness of WB-EMS with high-intensity (resis-
regard to humans were considered, in vitro studies tance) exercise (HIT) for improving lean body mass
and animal experiments were not considered. Both and muscle strength [10]. Forty-eight healthy un-
authors independently screened the titles and ab- trained men, 30–50 years old, were randomly allocated
stracts, identified articles of interest, and read them to either HIT or the WB-EMS group for 16 weeks. No
in full text. Considered were articles in English and differences were detected in the change of lean body
German. Of the selected articles, the references were mass and increase of leg-extensor strength (Table 2).
checked for further articles of interest. Randomized One of the 23 participants, allocated to the WB-EMS
clinical trials, subgroup analyses from randomized tri- group, discontinued the training because of “severe
als, longitudinal studies, case series, and case reports discomfort” during WB-EMS. No further details about
were included. the type of discomfort were reported [10].
In our literature research, we did not find any fur-
Results ther randomized trial comparing WB-EMS with con-
ventional training. Thus, it seems likely that in healthy
Results of literature research subjects, WB-EMS training is not more effective than
conventional resistance training for improving body
The results of the literature search are listed in composition and strength capacities. However, it is
Table 1. We found 11 randomized trials (Table 2; uncertain whether WB-EMS-induced strength gains

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Table 2 Results of randomized trials of whole-body electromyostimulation (WB-EMS)


Author Included subjects, Study design, Endpoint Results Side effects CK
Duration of trial
[2] Elite soccer players Muscular strength, soccer WB-EMS None Increased CK levels
WB-EMS n = 12 relevant sprint, jump and 24 h post WB-EMS,
Increased one-leg maximal strength
Jump-training n = 10 kicking velocity performance higher CK levels
14 weeks Improved linear sprinting, sprinting compared to the
with direction changes, vertical jump- jump-training group
ing performance, and kicking velocity
[5] Males ≥70 years with sarcopenic Fat distribution of the WB-EMS Severe NM
obesity mid-thigh, appendicular discomfort
Increased thigh muscle volume
WB-EMS plus protein, n = 33 muscle mass, trunk fat during
Control n = 34 Decreased appendicular muscle and WB-EMS, n =1
16 weeks trunk fat
[6] Males ≥70 years with sarcopenic Total body fat mass Total body fat mass decreased in the Discomfort NM
obesity WB-EMS plus protein and protein during
WB-EMS plus protein n = 33 groups, but not in the controls WB-EMS,
Protein n = 33 n= 1
Control n = 34
16 weeks
[7] Males >70 years, Sarcopenia Z score, WB-EMS improved 1/33 NM
WB-EMS n = 33 total body fat, skeletal
Sarcopenia Z score
Protein n = 33 muscle mass index, handgrip
Control n = 34 strength Skeletal muscle mass index
16 weeks Handgrip strength
WB-EMS decreased total body fat
[8]a Females >70 years, MetS Z-score: waist WB-EMS decreased Discomfort NM
WB-EMS n = 25 circumference, mean arterial during EMS,
MetS Z-score in both groups
WB-EMS plus protein n = 25 pressure, fasting plasma n= 1
Control n = 25 glucose, high-density Compared with controls, changes
6 months lipoprotein cholesterol were significant in only the WB-EMS
plus protein group
[9]a Females >70 years, Sarcopenia Z-score, skeletal WB-EMS improved 1/50 NM
WB-EMS n = 25 muscle mass index,
Sarcopenia Z score
WB-EMS plus protein n = 25 grip strength, gait speed,
Control n = 25 total body fat Skeletal muscle mass index
26 weeks Gait speed
WB-EMS had no effect on
Total body fat
Handgrip strength
[10] Healthy untrained males, Lean body mass, leg exten- Increase in both parameters, no Severe dis- NM
30–50 years sor strength differences between the randomized comfort dur-
WB-EMS n = 23 groups ing WB-EMS,
High intensity exercise n = 23 n= 1
16 weeks
[11]a Osteopenic females, >70 years, Bone mineral density at WB-EMS had no effect on bone min- None NM
WB-EMS n = 38 lumbar spine and total hip eral density
Control n = 38
1 year
[12]a Females >70 years, Appendicular skeletal muscle WB-EMS increased 1/38 NM
WB-EMS n = 38 mass, lean body mass
Appendicular skeletal muscle mass
Control n = 38
54 weeks Lean body mass
[13]a Females with abdominal obesity Appendicular muscle mass, WB-EMS Muscular NM
>70 years, abdominal fat mass soreness,
Increased appendicular muscle mass
WB-EMS n = 23 n= 1
Control n = 23 Decreased abdominal fat mass
12 months
[14] Healthy subjects, 20–25 years Heart rate, systolic and blood No difference in cardiopulmonary vari- None NM
WB-EMS n = 31 pressure, oxygen uptake and ables, WB-EMS decreased soreness,
High intensity exercise n = 33 psychophysiological factors anxiety, fatigability, and sleepless-
6 weeks ness
CK serum creatine kinase levels, n number of cases, NM not measured
a
Study supported by Miha Bodytec (Miha bodytec GmbH, 86368 Gersthofen, Germany)

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Table 3 Case reports about Author Age/sex CK Max Number/Type of EMS session Renal involvement
rhabdomyolysis after elec-
[23] 20/m 129,250 One/whole body No
tromyostimulation (EMS)
[26] 32/m 71,269 One/NI No
[26] 32/m 24,539 One/NI No
[27] 19/m 240,000 One/whole body Dark urine
[27] 17/m 30,000 One/whole body Protein+
[28] 33/f 64,150 One/gluteal region Myoglobinuria+++
[29] 32/f 99,477 One/whole body Dark urine, protein++
[30] 37/f 5387 Two/whole body No
[31] 26/m 2917 Weeks/NI No
CK Max maximum creatine kinase activity, NI not indicated

are similar to voluntary physical exercise in untrained WB-EMS is not applicable in many patients with
healthy individuals. Physical exercise has various ef- heart failure because of pacemakers, cardiac resyn-
fects: In addition to reducing adipose tissue mass, chronization devices, or implantable cardioverter/
physical exercise has been shown to reduce inflam- defibrillators. A considerable proportion of patients
matory activity [32]. Furthermore, contracting mus- with heart failure and systolic dysfunction (left ven-
cles release bioactive molecules known as myokines, tricular ejection fraction <35%) should receive these
which alter the metabolic phenotype of adipose tissue devices to protect against sudden cardiac death or to
[32]. Additionally, physical exercise has been shown improve systolic function [34]. Additionally, several
to affect a large network of brain areas, equal to 82% cardiac diseases, as listed in Table 4, were exclusion
of the total grey matter volume [33]. It is unknown criteria for patients in studies investigating WB-EMS.
whether WB-EMS induces the same physiological
responses on the nervous and endocrine system as Elderly patients with sarcopenic obesity
physical exercise. In elderly people, sarcopenic obesity leads to de-
creased health as well as reduced functional capacity
Heart failure patients and quality of life. Besides the problem of progressive
The current guidelines of the European Society of Car- loss of muscle mass, the adjuvant accumulation of ab-
diology recommend regular aerobic exercise in pa- dominal fat induces a higher risk for cardio-metabolic
tients with heart failure to improve functional capacity diseases. Physical exercise favorably affects most risk
and symptoms, and to reduce the risk of heart failure- factors and diseases in old people. However, many el-
related hospitalization as class I evidence level A [34]. derly people do not reach the recommended exercise
As some heart failure patients are not in a position to doses for a positive impact on muscle mass, obesity,
get involved in classical physical training, WB-EMS is or other issues of cardio-metabolic risk factors. WB-
discussed as an elegant alternative for physical train- EMS has been investigated as an intervention, some-
ing. times combined with additional protein supplement,
A pilot study in 15 patients with congestive heart in several randomized trials in elderly subjects, as
failure investigated the impact of WB-EMS during listed in Table 2 [7–9, 11–13]. These trials have shown
6 months on peak oxygen uptake, blood pressure, that WB-EMS improves some metabolic indices in
and muscle volume [3]. An increase of the peak oxy- elderly subjects; however, the clinical relevance of
gen uptake at the anaerobic threshold of up to 96% these findings is uncertain. Most of these trials were
was found. The diastolic blood pressure decreased. supported by a manufacturer of the WB-EMS device
A 14% gain in muscle volume was observed, while (Table 2). Discomfort during WB-EMS has been re-
overall body weight remained unchanged [3]. Mean ported several times, but no details about the type of
serum CK levels increased by 250 U/l, in single cases discomfort and CK levels were given.
to 2770 U/l, 24 h after WB-EMS.
A further non-randomized study in 34 heart failure Rhabdomyolysis after WB-EMS
patients applied WB-EMS for 10 weeks twice weekly
for 20 min. The authors found a significant increase Rhabdomyolysis is characterized by the rupture and
in oxygen uptake at the aerobic threshold, and an in- necrosis of muscle fibers, resulting in release of
crease in the left ventricular ejection fraction from 38 cell degradation products and intracellular elements
to 43% [4]. From that study, no data about CK levels within the bloodstream and extracellular space. The
are reported. proportion of patients with rhabdomyolysis who de-
It seems that WB-EMS is feasible in patients with velop acute kidney injury varies from 13% to over
heart failure. Its clinical benefit regarding functional 50%, according to both the cause and the clinical and
capacity, symptoms, and heart failure-related re-ad- organizational setting where they are diagnosed [35].
mittance, however, is not yet proven. Furthermore, The classic symptoms of rhabdomyolysis comprise

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Table 4 Disorders listed as exclusion criteria for patients public television, several individuals complaining of
in WB-EMS trials aching muscles after WB-EMS contacted the report-
Disorder Ref ing physician for advice. Two of them were diagnosed
Implanted electronic devices All WB-EMS studies with rhabdomyolysis [23].
Endoprosthesis, any internal metallic materials [8, 9, 13, 14] The influence of WB-EMS on CK levels was sys-
Cardiac decompensation in the past 3 months [3, 4] tematically investigated in 26 healthy trained vol-
unteers after 20-min of WB-EMS [25]. The authors
NYHA class IV [3, 4]
found a prominent CK elevation (28,545 ± 33,611 IU/l)
Left ventricular ejection fraction <25% [4]
72–96 h after WB-EMS. In that study, rhabdomyoly-
Left ventricular ejection fraction <20% [3] sis-induced complications like renal failure, hyper-
Severe cardiac arrhythmias [4] kalemia, or hypocalcemia were not detected. The
Cardiac arrhythmia Lown IV [3] CK increase, found after WB-EMS, was 2- to 20-
Cardiac arrhythmia [8, 9, 11–13] fold higher than that measured after a single-mus-
Relevant valve stenosis or regurgitation (de- [3, 4] cle EMS session (ranging from 1262 ± 339 IU/l to
gree > mild) 12,460 ± 17,206 IU/l) or a marathon (2795 ± 883 IU/l;
Myocardial infarction in the past 3 weeks [3] [25]). Interestingly, after 10 weeks of WB-EMS (1 ses-
Unstable angina [3] sion/week), CK reaction to WB-EMS was significantly
Any history of coronary arterial disease [14] blunted (906 ± 500 IU/l) and averaged in the area of
Active myocarditis [3, 4] conventional resistance exercise. The authors con-
clude from their findings that intensity of WB-EMS
Hypertrophic cardiomyopathy [3, 4]
should be carefully increased during the initial ses-
Pregnancy [3, 4]
sions [25]. Unfortunately, it was not reported if there
Epilepsy [8, 10–12] was a correlation between the total amount of current
Renal insufficiency [8, 9] applied and the CK levels.
Kidney dysfunction (creatinine >1.5 mg/dl) [4]
Alcohol consumption >80 g/d on 5 days/week [5, 6] Risk factors and precautions for rhabdomyolysis
Any history of cerebrovascular disease [14] after WB-EMS
Severe cerebral trauma [14]
Impairment of a major organ system [14] It is unknown whether rhabdomyolysis after WB-
Severe lung disease [14]
EMS may be favored by clinically silent or oligosymp-
tomatic myopathies, as speculated in two cases and
Uncontrolled hypertension [14]
reported in one female [26, 29]. It is also unclear if
Cancer [8, 14]
the subjects responded with CK elevation or rhab-
Psychiatric diseases [14] domyolysis to WB-EMS, or whether they took drugs
Abdomen/groin hernia [11, 12] which cause muscular side effects but which they
Extensive dermatologic disorders [3] did not report to the physicians, if they had previous
NYHA New York Heart Association infections, where dehydrated, or whether they carried
out additional exercise they did not report.
So far, only in Israel has the Ministry of Health is-
muscle pain, weakness, and dark urine. The affected sued regulations for the use of WB-EMS devices [24].
muscles may appear tense and swollen. However, According to these regulations, all WB-EMS devices
this classic triad is observed in only 10% of patients, have to be registered either as medical device or as
and up to 50% of patients only complain about non- device for physical training. The operator has to be
specific symptoms [35]. In these cases, the first sign a qualified fitness gym coach with a training of at least
may be the appearance of dark urine. Systemic mani- 30 h. Furthermore, it was indicated by the ministry
festations include fever, general malaise, tachycardia, that uncontrolled, unregulated use may cause medi-
nausea, and vomiting. cal damage and endanger health.
Our research disclosed 9 cases of rhabdomyolysis In Germany, a consensus conference in December
occurring after EMS, as listed in Table 3 [23, 26–31]. 2015 discussed the topic, and the scientific part of
In most of the cases, rhabdomyolysis occurred after the consortium formulated a general guideline [15].
the first WB-EMS application. Renal affection was This guideline recommends that WB-EMS must be ad-
found in several patients; however, dialysis was neces- vised and accompanied by a trained WB-EMS coach
sary in none of them. Rhabdomyolysis after WB-EMS and that before the first training session, a history of
has not only been reported in untrained individuals possible contraindications must be taken. Additional
but also in highly trained professional soccer players fluids should be consumed before and after training.
[27]. Most probably, the number of unreported cases After initial WB-EMS, the stimulation level must be
of rhabdomyolysis after WB-EMS is rather high. This successively increased. The guideline generally ad-
assumption is supported by the fact that after doc- vises against private use of WB-EMS technology with-
umentation of the potential dangers of WB-EMS in out support of a qualified and licensed trainer [15].

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It is uncertain, however, whether this guideline is ap- consumption in patients with chronic heart failure: results
plied in everyday practice. from the exEMS study comparing different stimulation
strategies. Clin Res Cardiol. 2013;102:523–34.
5. Kemmler W, Grimm A, Bebenek M, et al. Effects of com-
Comments and conclusion binedwhole-body electromyostimulation andprotein sup-
plementation on local and overall muscle/fat distribution
Despite reports about rhabdomyolysis and CK eleva- in older men with sarcopenic obesity: the randomized
tion after WB-EMS, investigation of CK dynamics has controlled Franconia Sarcopenic obesity (FranSO) study.
not been implemented in the study protocols inves- Calcif Tissue Int. 2018; https://doi.org/10.1007/s00223-
tigating WB-EMS. There is a lack of knowledge about 018-0424-2.
6. Kemmler W, Kohl M, Freiberger E, etal. Effectof whole-body
side effects of WB-EMS on other organ systems.
electromyostimulation and/or protein supplementation
The list of potential contraindications to WB-EMS is on obesity and cardiometabolic risk in older men with
confusing and varies from study to study. The German sarcopenic obesity: the randomized controlled FranSO
guideline recommends that before the first training trial. Bmc Geriatr. 2018;18:70. https://doi.org/10.1186/
session, a history of possible contraindications must s12877-018-0759-6.
be taken. It is not indicated, however, where this list 7. Kemmler W, Weissenfels A, Teschler M, et al. Whole-
of contraindications is available and who should take body electromyostimulation and protein supplementation
favorably affect sarcopenic obesity in community-dwelling
the history. Should this be done by a physician or by older men at risk: the randomized controlled FranSO study.
a trained WB-EMS coach? Clin Interv Aging. 2017;12:1503–13.
In our view, subjects intending to perform WB- 8. Wittmann K, Sieber C, von Stengel S, et al. Impact of whole
EMS should undergo blood investigations and inves- body electromyostimulation on cardiometabolic risk fac-
tigation by a specialist in sports medicine or internal tors in older women with sarcopenic obesity: the random-
medicine. If there are indications for a muscular dis- ized controlled FORMOsA-sarcopenic obesity study. Clin
Interv Aging. 2016;11:1697–706.
order like a history of intensive muscle soreness after
9. Kemmler W, Teschler M, Weissenfels A, et al. Whole-
exercise, a neurological examination should be car- body electromyostimulation to fight sarcopenic obesity
ried out before starting with WB-EMS. Furthermore, in community-dwelling older women at risk. Results of
patients who develop rhabdomyolysis after WB-EMS the randomized controlled FORMOsA-sarcopenic obesity
should be investigated by a neurologist. study. Osteoporos Int. 2016;27:3261–70.
In view of the increase in marketing and use of WB- 10. Kemmler W, Teschler M, Weißenfels A, et al. Effects of
EMS worldwide and in view of the health challenges, whole-body electromyostimulation versus high-intensity
resistance exercise on body composition and strength: a
there is an urgent need for regulatory authorities to
randomized controlled study. Evid Based Complement
become aware of the problem. Those working in the Alternat Med. 2016;2016:9236809.
field should be encouraged to start an initiative on 11. vonStengelS,BebenekM,EngelkeK,etal. Whole-bodyelec-
the European level to increase the safety of WB-EMS. tromyostimulation to fight osteopenia in elderly females:
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they have no competing interests. https://doi.org/10.2147/CIA.S52337.
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