Intended for healthcare professionals

CCBYNC Open access

Rapid response to:


Transcutaneous electrical nerve stimulation as adjunct to primary care management for tennis elbow: pragmatic randomised controlled trial (TATE trial)

BMJ 2013; 347 doi: (Published 02 September 2013) Cite this as: BMJ 2013;347:f5160

Rapid Response:

It’s Time to Regulate the Use of Whole-body Electrical Stimulation

It’s Time to Regulate the Use of Whole-body Electrical Stimulation

Authors and affiliations:
Stephen D H Malnick,1 director, Yael Band,1 resident, Pavel Alin,1 senior physician, Nicola A Maffiuletti,2 director

1 Department of Internal Medicine, Kaplan Medical Center, Rehovot, Israel
2 Human Performance Lab, Schulthess Clinic, Zurich, Switzerland

Transcutaneous electrical stimulation (ES) of human nerves and muscles has long been used as a nonpharmacological treatment for pain relief [1] and/or as a rehabilitation modality to either preserve or restore skeletal muscle mass and function during and after a period of disuse due to injury, surgery or illness [2]. More recently, whole-body ES has emerged as an alternative form of physical exercise for improving fitness and health among healthy people. Despite limited scientific evidence on the safety and effectiveness of this form of exercise, several ES company-sponsored fitness centers have recently been opened in different countries worldwide [3], making this technology easily accessible to the general population.

On August 4, 2015, a 20-year-old man presented to our hospital with severe muscle pain shortly after one session of gym-based whole-body ES exercise supervised by a fitness professional. Urine and blood testing revealed myoglobinuria, leukocytosis and elevated levels of creatine kinase (129,250 IU/L) and myoglobin (15,450 ng/mL). A diagnosis of rhabdomyolysis was made and he was hospitalized and treated with 11 liters of intravenous 0.9% saline for 5 days. As his condition improved clinically, there was a concomitant decline in creatine kinase levels and a progressive regression of symptoms, similarly to the other cases of whole-body ES-induced rhabdomyolysis described in the literature [4, 5].

On December 3, 2015, an Israeli public television channel presented the potential dangers of whole-body ES in a documentary, in which two of us (SDHM and NAM) were interviewed [6]. We basically warned against inappropriate use of whole-body ES (even if gym-based), discussed the increased risk of rhabdomyolysis and recommended a more active involvement of the regulatory authorities.

During the first few days following the documentary, several other individuals complaining of aching muscles after exerting themselves with whole-body ES contacted our hospital for advice. Two of them were diagnosed with rhabdomyolysis and were hospitalized and treated with intravenous saline for several days. We suspect that the true number of people injured by this form of exercise may be much higher but they are undiagnosed.

On January 11, 2016, the Health Ministry of Israel issued an official warning about ES safety, and recommended that ES devices must not be used in gyms and without medical supervision [7].

Regulatory authorities, clinicians and users need a greater understanding and awareness of the risk of ES-induced rhabdomyolysis, heightened ability to recognize this condition, and more diligent strategies to prevent this potentially-harmful effect. The Health Ministry of Israel has played a key in role in this regard, and this should serve as an example to other regulatory authorities worldwide.

1. Chesterton LS, Lewis AM, Sim J, et al. Transcutaneous electrical nerve stimulation as adjunct to primary care management for tennis elbow: pragmatic randomised controlled trial (TATE trial). BMJ 2013;347:f5160.
2. Gibson JN, Smith K, Rennie MJ. Prevention of disuse muscle atrophy by means of electrical stimulation: maintenance of protein synthesis. Lancet 1988;2:767-770.
3. Herrero AJ, Martin J, Benito PJ, Gonzalo-Martinez I, Chulvi-Medrano I, Garcia-Lopez D. National Strength and Conditioning Association-Spain position stand. Whole-body electromyostimulation training [Posicionamiento de la National Strength and Conditioning Association-Spain. Entrenamiento con electroestimulación de cuerpo completo]. [Article in Spanish.]. Revista Andaluza de Medicina del Deporte 2015;8:155-62.
4. Kastner A, Braun M, Meyer T. Two cases of rhabdomyolysis after training with electromyostimulation by 2 young male professional soccer players. Clin J Sports Med. 2015;25:e71-3.
5. Finsterer J, Stollberger C. Severe rhabdomyolysis after MIHA-bodytech® electrostimulation with previous mild hyper-CK-emia and noncompaction. Int J Cardiol. 2015;180:100-102.
6. Television documentary on the potential dangers of whole-body electrical stimulation. Channel 10. December 3, 2015: Accessed March 14, 2016.
7. Warning to the public of the health risks involved in the use of EMS devices in gyms and privately. Israel Health Ministry. January 11, 2016: Accessed March 14, 2016.

Patient consent obtained.

Competing interests: No competing interests

16 March 2016
Nicola A. Maffiuletti
Stephen D.H. Malnick, Yael Band, Pavel Alin,
Human Performance Lab, Schulthess Clinic
Lengghalde 2, 8008 Zurich, Switzerland