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
(WB-EMS) has been introduced as an alternative
to physical training. The aim of the review is to sum-
marize the data about indications and side effects of
WB-EMS.
A literature search in PubMed disclosed 11 random-
ized trials, 3 cohort studies, and 7 case reports. From
healthy volunteers, enormous creatine kinase (CK) el-
evations were reported. There is a lack of data about
biological consequences of WB-EMS on other organs.
In randomized trials, CK levels were not investigated,
but several patients discontinued WB-EMS because
of “muscular discomfort.” Contraindications for WB-
EMS are not clearly defined. Nine cases of rhabdomy-
olysis after WB-EMS were found, preferentially after
the first application.
Regulatory authorities should increase the safety of
WB-EMS. Patients with a history of rhabdomyolysis
should not undergo WB-EMS and those experienc-
ing rhabdomyolysis should be neurologically investi-
gated. Since the value of WB-EMS as an alternative
to physical exercise is uncertain, we need to proof or
disproof its benefit.
Keywords Rhabdomyolysis · Electromyostimulation ·
Myopathy · Creatinin kinase · Physical exercise
Univ. Prof. Dr. C. Stöllberger · Univ. Prof. Dr. J. Finsterer
Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien,
Austria
Univ. Prof. Dr. C. Stöllberger ()
Steingasse 31/18, 1030 Wien, Austria
claudia.stoellberger@chello.at
K Side effects of whole-body electro-myo-stimulation
Nebenwirkungen der
Ganzkörperelektromyostimulation
Zusammenfassung Die Ganzkörperelektromyostimu-
lation (GK-EMS) wurde als Alternative zu körperli-
chem Training eingeführt. Ziel der Übersichtsarbeit
ist eine Zusammenfassung der Daten zu Indikationen
und Nebenwirkungen von GK-EMS.
Eine Recherche in PubMed erbrachte 11 randomi-
sierte Studien, 3 Kohortenstudien und 7 Fallberichte.
Bei gesunden Probanden wurden enorme Kreatin-
kinase(CK)-Anstiege nach GK-EMS beobachtet. Es
gibt keine Daten zu den biologischen Konsequen-
zen von GK-EMS für andere Organsysteme. In den
randomisierten Studien wurde die CK nicht unter-
sucht, mehrere Patienten brachen die GK-EMS aber
wegen „muskulärer Missempfindungen“ ab. Kontrain-
dikationen für GK-EMS sind uneinheitlich und nicht
eindeutig formuliert. Neun Fälle mit Rhabdomyolyse
nach GK-EMS wurden gefunden, hauptsächlich nach
der ersten Anwendung.
Die Gesundheitsbehörden sollten Anstrengungen un-
ternehmen, um die Sicherheit der GK-EMS zu erhö-
hen. Patienten mit Rhabdomyolyse in der Anamnese
sollten keine GK-EMS absolvieren. Nach GK-EMS-in-
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-
vität
Introduction
Transcutaneous electro-myo-stimulation (EMS) has
long been used as a non-pharmacologic therapy in
 review
deconditioned patients with the aim of increasing
muscle force [1]. In both healthy and impaired mus-
cles, it has been reported that EMS is an efficient
modality for increasing muscle mass, maximal volun-
tary strength, or exercise capacity. EMS can be used
for selected muscle groups or as whole-body EMS
(WB-EMS). WB-EMS is used as a complement to vol-
untary exercise in athletes, as an alternative form of
physical exercise for improving fitness and health in
healthy people and in patients who cannot perform
conventional forms of voluntary exercise because of
physical or mental illness [2–14].
Manufacturers claim WB-EMS to be useful tool for
increasing strength, loosing fat, or improving general
health. Because of time efficiency and joint friendli-
ness, WB-EMS is suggested as a good choice for peo-
ple unable or unwilling to perform conventional train-
ing [15, 16]. WB-EMS is easily accessible to the general
population. It is increasingly offered by fitness centers
in many countries, and devices for WB-EMS are avail-
able for purchase in fitness and sports shops and the
internet.
The equipment for WB-EMS, used most frequently
in Europe and reported in many publications, is the
Miha Bodytec® device (Miha Bodytec, Gersthofen,
Germany). It enables simultaneous stimulation of
thighs and upper arms, hip/bottom, chest, lower
back, and upper back with an overall area of stimu-
lation of about 2600 cm2 [2–13]. The WB-EMS device
enables the simultaneous activation of muscle groups
with different selectable intensities. The electrodes
are fixed in the inside surface of a dedicated suit
and connected via electrical cords to the application
unit. The standard WB-EMS protocol uses biphasic
rectangular wave pulsed currents (80 Hz) with an im-
pulse width of 350 μs, 4–6 s of EMS stimulation with
an immediate impulse burst, and an impulse pause
of 4 s. The stimulation intensity is set separately for
each muscle group by using the Borg rating of per-
ceived exertion scale, which is a subjective measure.
This stimulation protocol was used in most of the
randomized trials. Unfortunately, the current types
applied and the stimulation intensity in mA are not
reported in any of the publications. A further WB-
EMS apparatus, produced by Miracle (Seoul, Korea),
uses wireless materials. The electrical strength of
the suit is controlled by an Ipad or cellular phone
via Bluetooth [14]. WB-EMS can be combined with
basic movements [10, 14]. The duration of a WB-EMS
training session should be 15-20 min and an interval
of ≥4 days must be held between training units.
The following muscular changes after EMS have
been reported: In healthy subjects, maximum vol-
untary strength and neural activation significantly
increased after EMS [17]. Muscle biopsies taken be-
fore and after EMS disclosed that both type 1 and 2
muscle fibers showed significant hypertrophy [17].
After EMS, a transition from fast to slow muscle fibers
was found. Proteomic map spots, obtained from
Side effects of whole-body electro-myo-stimulation
muscle biopsies before and after training, showed
changes typical of resistance and endurance training.
These EMS-induced changes can be attributed to the
peculiar motor unit recruitment pattern associated
with EMS [17]. When comparing maximal voluntary
and EMS-induced contractions of the elbow flexors
in healthy subjects, EMS resulted in greater decreases
in maximal voluntary contraction strength, increases
in plasma creatine kinase (CK) activity, and muscle
soreness. It seems likely that the muscle damage in
EMS is associated with high mechanical stress on the
activated muscle fibers due to the specificity of motor
unit recruitment [18]. A further study in healthy sub-
jects compared maximal voluntary contraction with
EMS-induced contractions of the elbow flexors to in-
vestigate whether EMS would induce greater muscle
damage than voluntary contractions [19]. Serum CK
activity increased only after EMS, and the muscles
became more sore and tender after EMS than after
voluntary contractions. It seems likely that higher
mechanical stress imposed on the activated muscle
fibers, due to the specificity of motor unit recruitment
in EMS, caused more muscle damage than voluntary
contraction [19]. Physiologic recruitment of motor
units follows the size principle, whereas EMS recruits
all motor units simultaneously [19].
Histological analyses showed larger myofiber dam-
age of the quadriceps muscle after EMS-induced
lengthening contractions as compared with maximal
voluntary eccentric contractions [20]. Furthermore,
altered muscle microstructure and related inflamma-
tory/edematous processes have been reported after
EMS [21]. Disturbed pH homeostasis and impaired
mitochondrial function 4 days after a single bout of
isometric EMS have been additionally reported [22].
WB-EMS is not without health risks. Especially
its potential of triggering rhabdomyolysis has cre-
ated considerable concerns, forcing the authorities
of a country to take actions to regulate the use of
WB-EMS devices [15, 23, 24]. Furthermore, there are
only few data about the physiologic consequences of
WB-EMS on other organ systems. One study com-
pared heart rate, systolic blood pressure, diastolic
blood pressure, and oxygen uptake in 68 healthy
subjects randomized to a physical exercise program
combined with or without WB-EMS. After a 6-week
training period, there were no abnormal changes in
the cardiopulmonary variables of either group [14].
According to the manufacturers, WB-EMS is con-
traindicated in patients with implanted electronic
devices like pacemakers, implanted defibrillators,
neuro-stimulators or pain pumps because of potential
electrical interference. Apart from these contraindi-
cations, there are various diseases or conditions men-
tioned in the publications as exclusion criteria, as
listed in Table 4. Obviously, there is a lack of clearly
defined and universally accepted contraindications
for WB-EMS.
K

Table 1 Results of liter- Search term
ature research in PubMed
Electrostimulation AND side effects
(January 2000–May 2018)
Electrostimulation AND rhabdomyolysis
Electromyostimulation AND side effects
Electromyostimulation AND rhabdomyolysis
Whole-body electrostimulation AND side effects
Whole-body electrostimulation AND rhabdomyolysis
Whole-body electromyostimulation AND side effects
Whole-body electromyostimulation AND rhabdomyolysis
Whole-body EMS AND side effects
Whole-body EMS AND rhabdomyolysis
Whole-body EMS
Whole-body electromyostimulation
Electromyostimulation, heart failure
Electrostimulation, heart failure
RT randomized trial, CR case report, CS cohort study
Thus, the aim of the present review is to summa-
rize the current knowledge about indications and side
effects of WB-EMS in healthy subjects and patients.
Methods
A literature search was carried out using PubMed from
2000 to May 2018. For general information about WB-
EMS, the search terms “whole-body electro-myo-
stimulation” or “whole-body EMS” were used. Fur-
thermore, the search terms “electrostimulation” or
“electro-myo-stimulation” were combined with the
term “heart failure.” For search of potential side
effects of WB-EMS, we used the terms “electros-
timulation,” “electromyostimulation,” “whole-body
electromyostimulation,” “whole-body electrostimu-
lation,” “whole-body EMS,” AND “side effects” or
“rhabdomyolysis.” The research concentrated on ap-
plications of WB-EMS in healthy subjects and patients
with heart failure, osteoporosis, or sarcopenic obesity.
Excluded were articles about application of EMS in
selected muscle groups or in patients with cerebral
diseases or local muscular problems. Only data with
regard to humans were considered, in vitro studies
and animal experiments were not considered. Both
authors independently screened the titles and ab-
stracts, identified articles of interest, and read them
in full text. Considered were articles in English and
German. Of the selected articles, the references were
checked for further articles of interest. Randomized
clinical trials, subgroup analyses from randomized tri-
als, longitudinal studies, case series, and case reports
were included.
Results
Results of literature research
The results of the literature search are listed in
Table 1. We found 11 randomized trials (Table 2;
K Side effects of whole-body electro-myo-stimulation
review
Results, n Selected articles
178 RT [7], CR [28, 29]
2 CR [28, 29]
12 RT [7], CR[26, 27, 30], CS [25]
4 CR [26, 27, 30], CS [25]
3 CS [25]
0 0
3 RT [7], CS [25], CR [30]
2 CR [30], CS [25]
5 RT [7], CS [25]
1 CS [25]
34 RT [2, 5, 6, 8–14], CS [25]
26 RT [5–14], CS [25], CR [30]
9 CS [3, 4]
18 0
[2, 5–14]). Furthermore, we identified 3 cohort stud-
ies and 5 case reports [3, 4, 25–30]. Two further case
reports were retrieved by screening the references of
the collected articles [23, 31]. The reported cases are
listed in Table 3. No discrepancies occurred between
the reviewers in the selection process.
Indications and results of WB-EMS
Athletes and healthy subjects
A randomized study in elite soccer players compared
WB-EMS with jump training (Table 2; [2]). WB-
EMS increased one-leg maximal strength, improved
linear sprinting, sprinting with direction changes,
vertical jumping performance, and kicking veloc-
ity [2]. Of note, this is the only randomized study
where CK levels were investigated before and after
WB-EMS. A significant increase of CK was observed:
pre-WB-EMS 530.30 ± 230.00 U/l, 24 h post-WB-EMS
1199.89 ± 569.69 U/l. No increase in CK in the jump
training group was detected.
A further study in middle-aged men compared the
effectiveness of WB-EMS with high-intensity (resis-
tance) exercise (HIT) for improving lean body mass
and muscle strength [10]. Forty-eight healthy un-
trained men, 30–50 years old, were randomly allocated
to either HIT or the WB-EMS group for 16 weeks. No
differences were detected in the change of lean body
mass and increase of leg-extensor strength (Table 2).
One of the 23 participants, allocated to the WB-EMS
group, discontinued the training because of “severe
discomfort” during WB-EMS. No further details about
the type of discomfort were reported [10].
In our literature research, we did not find any fur-
ther randomized trial comparing WB-EMS with con-
ventional training. Thus, it seems likely that in healthy
subjects, WB-EMS training is not more effective than
conventional resistance training for improving body
composition and strength capacities. However, it is
uncertain whether WB-EMS-induced strength gains
 review

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)

Side effects of whole-body electro-myo-stimulation K


Table 3 Case reports about Author Age/sex CK Max
rhabdomyolysis after elec-
[23] 20/m 129,250
tromyostimulation (EMS)
[26] 32/m 71,269
[26] 32/m 24,539
[27] 19/m 240,000
[27] 17/m 30,000
[28] 33/f 64,150
[29] 32/f 99,477
[30] 37/f 5387
[31] 26/m 2917
CK Max maximum creatine kinase activity, NI not indicated
are similar to voluntary physical exercise in untrained
healthy individuals. Physical exercise has various ef-
fects: In addition to reducing adipose tissue mass,
physical exercise has been shown to reduce inflam-
matory activity [32]. Furthermore, contracting mus-
cles release bioactive molecules known as myokines,
which alter the metabolic phenotype of adipose tissue
[32]. Additionally, physical exercise has been shown
to affect a large network of brain areas, equal to 82%
of the total grey matter volume [33]. It is unknown
whether WB-EMS induces the same physiological
responses on the nervous and endocrine system as
physical exercise.
Heart failure patients
The current guidelines of the European Society of Car-
diology recommend regular aerobic exercise in pa-
tients with heart failure to improve functional capacity
and symptoms, and to reduce the risk of heart failure-
related hospitalization as class I evidence level A [34].
As some heart failure patients are not in a position to
get involved in classical physical training, WB-EMS is
discussed as an elegant alternative for physical train-
ing.
A pilot study in 15 patients with congestive heart
failure investigated the impact of WB-EMS during
6 months on peak oxygen uptake, blood pressure,
and muscle volume [3]. An increase of the peak oxy-
gen uptake at the anaerobic threshold of up to 96%
was found. The diastolic blood pressure decreased.
A 14% gain in muscle volume was observed, while
overall body weight remained unchanged [3]. Mean
serum CK levels increased by 250 U/l, in single cases
to 2770 U/l, 24 h after WB-EMS.
A further non-randomized study in 34 heart failure
patients applied WB-EMS for 10 weeks twice weekly
for 20 min. The authors found a significant increase
in oxygen uptake at the aerobic threshold, and an in-
crease in the left ventricular ejection fraction from 38
to 43% [4]. From that study, no data about CK levels
are reported.
It seems that WB-EMS is feasible in patients with
heart failure. Its clinical benefit regarding functional
capacity, symptoms, and heart failure-related re-ad-
mittance, however, is not yet proven. Furthermore,
K Side effects of whole-body electro-myo-stimulation
review
Number/Type of EMS session Renal involvement
One/whole body No
One/NI No
One/NI No
One/whole body Dark urine
One/whole body Protein+
One/gluteal region Myoglobinuria+++
One/whole body Dark urine, protein++
Two/whole body No
Weeks/NI No
WB-EMS is not applicable in many patients with
heart failure because of pacemakers, cardiac resyn-
chronization devices, or implantable cardioverter/
defibrillators. A considerable proportion of patients
with heart failure and systolic dysfunction (left ven-
tricular ejection fraction <35%) should receive these
devices to protect against sudden cardiac death or to
improve systolic function [34]. Additionally, several
cardiac diseases, as listed in Table 4, were exclusion
criteria for patients in studies investigating WB-EMS.
Elderly patients with sarcopenic obesity
In elderly people, sarcopenic obesity leads to de-
creased health as well as reduced functional capacity
and quality of life. Besides the problem of progressive
loss of muscle mass, the adjuvant accumulation of ab-
dominal fat induces a higher risk for cardio-metabolic
diseases. Physical exercise favorably affects most risk
factors and diseases in old people. However, many el-
derly people do not reach the recommended exercise
doses for a positive impact on muscle mass, obesity,
or other issues of cardio-metabolic risk factors. WB-
EMS has been investigated as an intervention, some-
times combined with additional protein supplement,
in several randomized trials in elderly subjects, as
listed in Table 2 [7–9, 11–13]. These trials have shown
that WB-EMS improves some metabolic indices in
elderly subjects; however, the clinical relevance of
these findings is uncertain. Most of these trials were
supported by a manufacturer of the WB-EMS device
(Table 2). Discomfort during WB-EMS has been re-
ported several times, but no details about the type of
discomfort and CK levels were given.
Rhabdomyolysis after WB-EMS
Rhabdomyolysis is characterized by the rupture and
necrosis of muscle fibers, resulting in release of
cell degradation products and intracellular elements
within the bloodstream and extracellular space. The
proportion of patients with rhabdomyolysis who de-
velop acute kidney injury varies from 13% to over
50%, according to both the cause and the clinical and
organizational setting where they are diagnosed [35].
The classic symptoms of rhabdomyolysis comprise
 review

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].

Side effects of whole-body electro-myo-stimulation K


It is uncertain, however, whether this guideline is ap-
plied in everyday practice.
Comments and conclusion
Despite reports about rhabdomyolysis and CK eleva-
tion after WB-EMS, investigation of CK dynamics has
not been implemented in the study protocols inves-
tigating WB-EMS. There is a lack of knowledge about
side effects of WB-EMS on other organ systems.
The list of potential contraindications to WB-EMS is
confusing and varies from study to study. The German
guideline recommends that before the first training
session, a history of possible contraindications must
be taken. It is not indicated, however, where this list
of contraindications is available and who should take
the history. Should this be done by a physician or by
a trained WB-EMS coach?
In our view, subjects intending to perform WB-
EMS should undergo blood investigations and inves-
tigation by a specialist in sports medicine or internal
medicine. If there are indications for a muscular dis-
order like a history of intensive muscle soreness after
exercise, a neurological examination should be car-
ried out before starting with WB-EMS. Furthermore,
patients who develop rhabdomyolysis after WB-EMS
should be investigated by a neurologist.
In view of the increase in marketing and use of WB-
EMS worldwide and in view of the health challenges,
there is an urgent need for regulatory authorities to
become aware of the problem. Those working in the
field should be encouraged to start an initiative on
the European level to increase the safety of WB-EMS.
There exist some positive data about the effects of
WB-EMS on muscle strength, and if applied in a cor-
rect way, it may be helpful in some cases. As long
as the clinical value of WB-EMS as an alternative to
physical exercise is still uncertain, instead of WB-EMS,
we should preferably recommend methods of exercise
like dancing, which are associated with a proven ben-
efit on physical health outcomes, to our patients [36].
Conflict of interest C. Stöllberger and J. Finsterer declare that
they have no competing interests.
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