It’s time to regulate the use of whole body electrical stimulation
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1693 (Published 30 March 2016) Cite this as: BMJ 2016;352:i1693
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Short time after issuing the warning, on February 11th 2016, after re-checking the issue, the Israeli Ministry of Health decided to changed their decision. They have canceled the warning and regulated EMS in Israel.
This is the new regulation:
http://www.health.gov.il/English/News_and_Events/Spokespersons_Messages/...
Competing interests: CEO of XBody Israel
Over the last few years, whole body electrical stimulation (ES) has been introduced as an alternative method of physical training. Despite the lack of clear evidence, manufacturers and fitness centers claim that whole body ES is a suitable tool for increasing strength, losing fat or improving general health. In a recent letter, Malnick and colleagues [1] reported several cases of rhabdomyolysis in young healthy subjects after a single session of whole body ES. The authors warned against these deleterious effects and asked for a worldwide regulation of whole body ES. On the basis of our 10-year experience in investigating the acute and chronic effects of electrical stimulation on skeletal muscle function, we would also like to raise several concerns about the risks associated with this artificial training modality.
Although single-muscle ES training may be effective for increasing voluntary strength and muscle size [2 3], recent studies have provided compelling evidence of potential deleterious effects of ES. In 2004, a first case of rhabdomyolysis was reported in a young healthy student after an excessive use of an electrical stimulator [4]. Since then, it has been consistently found that ES may be particularly harmful when a single muscle group is stimulated during lengthening actions [5 6] or under isometric conditions at a long muscle length [7-9]. For instance, histological analyses clearly showed larger myofiber damage of the quadriceps muscle after ES-induced lengthening contractions as compared with maximal voluntary eccentric contractions [6]. Furthermore, we reported increased plasma CK activity [8], reduced force production [8], altered muscle microstructure and related inflammatory/edematous processes [10 11], disturbed pH homeostasis and impaired mitochondrial function [12] four days after a single bout of isometric ES, illustrating the occurrence of severe muscle damage in young healthy subjects.
It must be pointed out that whole body ES typically relies on the simultaneous stimulation of several muscle groups while performing dynamic movements (e.g., squats or forearm extensions), thereby inevitably increasing the risks of extensive muscle injuries. Accordingly, a recent study [13], unfortunately only available in German, reported a huge increase in blood CK activity (28.545 ± 33.611 IU/l) 72-96h after a 20-min whole body ES session in healthy trained volunteers. Although these authors did not report rhabdomyolysis-induced complications, such CK levels are 2- to 20-fold higher than those measured after a single-muscle ES session (ranging from 1262 ± 339 IU/l to 12.460 ± 17.206 IU/l) [7 8], a marathon (2795 ± 883 IU/l) [13] or even an extreme 166-km mountain ultra-marathon (15.775 ± 17.166 IU/L) [14]. The exposure of healthy people to the risks of exertional rhabdomyolysis associated with such hyperCKemia [13] is therefore highly questionable, inasmuch as whole body ES training is not more effective than conventional resistance training for improving body composition and strength capacities [15].
Although whole body ES is likely to be successful for fitness business, the risk-benefit ratio remains to be carefully investigated by European Union regulatory authorities as highlighted in this letter [1]. Considering the potential harmfulness of whole body ES, on the basis of the precautionary principle, we strongly advise people who want to stay healthy to perform traditional and low-cost voluntary exercises.
References
1. Malnick SD, Band Y, Alin P, Maffiuletti NA. It's time to regulate the use of whole body electrical stimulation. Bmj 2016;352:i1693
2. Gondin J, Brocca L, Bellinzona E, et al. Neuromuscular electrical stimulation training induces atypical adaptations of the human skeletal muscle phenotype: a functional and proteomic analysis. J Appl Physiol (1985) 2011;110(2):433-50
3. Gondin J, Guette M, Ballay Y, Martin A. Electromyostimulation training effects on neural drive and muscle architecture. Med Sci Sports Exerc 2005;37(8):1291-9
4. Guarascio P, Lusi EA, Soccorsi F. Electronic muscular stimulators: a novel unsuspected cause of rhabdomyolysis. Br J Sports Med 2004;38(4):505; discussion 05
5. Black CD, McCully KK. Muscle injury after repeated bouts of voluntary and electrically stimulated exercise. Med Sci Sports Exerc 2008;40(9):1605-15
6. Crameri RM, Aagaard P, Qvortrup K, Langberg H, Olesen J, Kjaer M. Myofibre damage in human skeletal muscle: effects of electrical stimulation versus voluntary contraction. J Physiol 2007;583(Pt 1):365-80
7. Aldayel A, Jubeau M, McGuigan M, Nosaka K. Comparison between alternating and pulsed current electrical muscle stimulation for muscle and systemic acute responses. J Appl Physiol (1985) 2010;109(3):735-44
8. Foure A, Nosaka K, Wegrzyk J, et al. Time course of central and peripheral alterations after isometric neuromuscular electrical stimulation-induced muscle damage. PLoS One 2014;9(9):e107298
9. Jubeau M, Sartorio A, Marinone PG, et al. Comparison between voluntary and stimulated contractions of the quadriceps femoris for growth hormone response and muscle damage. J Appl Physiol (1985) 2008;104(1):75-81
10. Foure A, Duhamel G, Wegrzyk J, et al. Heterogeneity of muscle damage induced by electrostimulation: a multimodal MRI study. Med Sci Sports Exerc 2015;47(1):166-75
11. Foure A, Le Troter A, Guye M, Mattei JP, Bendahan D, Gondin J. Localization and quantification of intramuscular damage using statistical parametric mapping and skeletal muscle parcellation. Sci Rep 2015;5:18580
12. Foure A, Wegrzyk J, Le Fur Y, et al. Impaired mitochondrial function and reduced energy cost as a result of muscle damage. Med Sci Sports Exerc 2015;47(6):1135-44
13. Kemmler W, Teschler M, Bebenek M, von Stengel S. [(Very) high Creatinkinase concentration after exertional whole-body electromyostimulation application: health risks and longitudinal adaptations]. Wien Med Wochenschr 2015;165(21-22):427-35
14. Millet GY, Tomazin K, Verges S, et al. Neuromuscular consequences of an extreme mountain ultra-marathon. PLoS One 2011;6(2):e17059
15. Kemmler W, Teschler M, Weissenfels A, et al. Effects of Whole-Body Electromyostimulation versus High-Intensity Resistance Exercise on Body Composition and Strength: A Randomized Controlled Study. Evid Based Complement Alternat Med 2016;2016:9236809
Corresponding author: julien.gondin@univ-amu.fr
Competing interests: No competing interests
Re: It’s time to regulate the use of whole body electrical stimulation
Whole body electromyostimulation application – the need for more common sense!
Whole-body electromyostimulation (WB-EMS) is a young and effective training technology that focuses primarily on musculoskeletal parameters (1-5). In contrast to the local version, WB-EMS innervates large areas (12-14 electrodes with up to 2800 cm2) with dedicated intensity per muscle group. Comparing the effect of WB-EMS with the slightly more extensive High Intensity (Resistance) Training (HIT) (WB-EMS: 1.5x20 vs. HIT: 2x30 min/week) both methods were similarly effective in increasing muscle mass and strength (3). However, due to its exceptional time efficiency (3), joint friendliness and individualized setting, WB-EMS may be a good choice for people unable or simply unwilling to conduct intense resistance training protocols. However, recent popular (6) and scientific literature (7, 8) has reported negative side-effects concerning WB-EMS induced rhabdomyolysis. Indeed, WB-EMS features many factors known to be associated with muscle damage (9). Thus, inadequate WB-EMS application may lead to severe rhabdomyolysis and corresponding consequences for health. In a recent study (10) we applied a typical but borderline exhaustive WB-EMS protocol (20 min, bipolar, 85 Hz, 350 µs, rectangular, 6 s of current and 4 s of rest) to 37 healthy WB-EMS novices. And indeed, the CK increase after this borderline intense WB-EMS first application confirmed the reported exceptionally high CK levels. In detail, CK concentration rose 117-fold with a peak after 72 h and was 10x higher compared with CK levels after a marathon run that was monitored in parallel (28545±33611 vs. 2795±883 IU/l). Although we did not detect any of the reported clinical consequences (11) of this “severe” rhabdomyolysis (12), in less fit and healthy subjects neither optimally prepared nor supervised, initial WB-EMS to exertion may have more far-reaching consequences. Significantly, a subsequent WB-EMS conditioning phase of 10 weeks (1x20 min WB-EMS/week, see above) completed by a second WB-EMS test session to exhaustion demonstrated a very pronounced “repeated bout effect” with individual CK peaks below 2000 IU/l (906±500 IU/l), i.e. in the range of conventional resistance exercise training (9). Thus, we conclude that the problem of WB-EMS induced rhabdomyolysis can be easily prevented with a minimum of common sense. Firstly, although some groups of highly motivated WB-EMS-novices may request an exertional initial WB-EMS application, this approach should be strictly avoided. In parallel, no clear-thinking instructor would apply an intense eccentric resistance training protocol to muscular failure during the initial session. Secondly, as with conventional resistance exercise there is no need to focus on WB-EMS to exhaustion in order to generate relevant effects on body composition and functional capacity (3, 13). Additionally contraindications for WB-EMS should be strictly heeded and WB-EMS novices adequately informed so as to ensure a safe and successful WB-EMS application. In order to realize the latter aim, German researchers, educational institutions and WB-EMS manufacturers have defined corresponding guidelines that were recently disseminated and published (e.g. (14)).
1 Kemmler W, Schliffka R, Mayhew JL, et al. Effects of Whole-Body-Electromyostimulation on Resting Metabolic Rate, Anthropometric and Neuromuscular Parameters in the Elderly. The Training and ElectroStimulation Trial (TEST). J Strength Cond Res 2010;24: 1880-1886
2 Kemmler W, von Stengel S. Whole-body electromyostimulation as a means to impact muscle mass and abdominal body fat in lean, sedentary, older female adults: subanalysis of the TEST-III trial. Clin Interv Aging 2013;8: 1353-64
3 Kemmler W, Teschler M, Weissenfels A, et al. Effects of Whole-Body Electromyostimulation versus High-Intensity Resistance Exercise on Body Composition and Strength: A Randomized Controlled Study. Evid Based Complement Alternat Med 2016;2016: 9236809
4 von Stengel S, Bebenek M, Engelke K, et al. Whole-Body Electromyostimulation to Fight Osteopenia in Elderly Females: The Randomized Controlled Training and Electrostimulation Trial (TEST-III). Journal of Osteoporosis 2015;Volume 2015: Article ID 643520
5 Wirtz N, Zinner C, Doermann U, et al. Effects of Loaded Squat Exercise with and without Application of Superimposed EMS on Physical Performance. J Sports Sci Med 2016;15: 26-33
6 Habich I. Muskelkraft durch EMS-Training: Gefährliche Stromstöße. Spiegel Online. http://www.spiegel.de/gesundheit/ernaehrung/ems-risiken-des-elektrostimu....
7 Finsterer J, Stollberger C. Severe rhabdomyolysis after MIHA-bodytec(R) electrostimulation with previous mild hyper-CK-emia and noncompaction. Int J Cardiol 2015;180: 100-2
8 Kastner A, Braun M, Meyer T. Two Cases of Rhabdomyolysis After Training With Electromyostimulation by 2 Young Male Professional Soccer Players. Clin J Sport Med 2014;25: 71-73
9 Koch AJ, Pereira R, Machado M. The creatine kinase response to resistance exercise. J Musculoskelet Neuronal Interact 2014;14: 68-77
10 Kemmler W, Teschler M, Bebenek M, et al. [(Very) high Creatinkinase concentration after exertional whole-body electromyostimulation application: health risks and longitudinal adaptations.]. Wien Med Wochenschr 2015;165: :427–435
11 Zutt R, van der Kooi AJ, Linthorst GE, et al. Rhabdomyolysis: review of the literature. Neuromuscul Disord 2014;24: 651-9
12 Visweswaran P, Guntupalli J. Rhabdomyolysis. Crit Care Clin 1999;15: 415-28, ix-x
13 Kemmler W, Bebenek M, Engelke K, et al. Impact of whole-body electromyostimulation on body composition in elderly women at risk for sarcopenia: the Training and ElectroStimulation Trial (TEST-III). Age (Dordr) 2014;36: 395-406
14 Vatter J, Autherieth S, Müller S. EMS consulting and training manual. Stuttgart: CPI - Ebner und Spiegel, 2016
Competing interests: No competing interests