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Explore the global rise of whole-body EMS (electrical muscle stimulation) training, driven by health awareness and advanced technology. Learn how Germany's pioneering standards for safety, training, and equipment have built trust and shaped this efficient fitness solution.

The global market for whole-body EMS training (electrical muscle stimulation) has seen dynamic growth in recent years, driven by increasing health awareness, technological advances and a growing demand for efficient and time-saving training solutions. The combination of personal supervision, fixed regular appointments and highly efficient application ensures a broad target group appeal and the widespread availability of services.

Germany, as a pioneer in the field of whole-body EMS training, offers valuable insights into the development and establishment of this market. Several key findings can be derived from the experience gained there:

1. Structured studios and franchise concepts: The establishment of professional studio and franchise models has contributed significantly to standardisation and quality assurance, while also promoting the scalability of the business model.
2. Regulatory framework and equipment safety: The clear definition of training standards, legal requirements for application and compliance with medical technology standards for equipment safety have created trust among consumers and providers. These requirements not only guarantee safe application, but also strengthen acceptance among the general population.
3. Targeted approach: The focus on different target groups – from fitness enthusiasts to older people and those with health restrictions – has increased the market breadth and enabled lasting customer loyalty.
4. Synergy of technology and care: The combination of state-of-the-art EMS technology with individual support from qualified personnel has shown that quality and personal interaction are crucial to success.
5. Recommendation marketing as a driver: The high level of customer satisfaction has proven to be a key driver of organic growth, as recommendations and positive experiences play a key role in market penetration.

These insights underscore the importance of a structured and secure approach to developing the whole-body EMS market. In particular, regulatory frameworks, including device safety requirements in line with medical technology standards, play a key role in ensuring quality and establishing trust among users and providers. A closer look at these regulatory requirements shows how they form the basis for sustainable and secure market development.

Definition of training standards

A key aspect of the regulatory framework for whole-body EMS training is the definition of clear training standards. These ensure that trainers and providers have the necessary expertise to use the technology safely and effectively. The training includes both theoretical knowledge about the physiological basics and mechanisms of action of electrical muscle stimulation and practical skills for the correct application and individual adaptation of training programmes.

In Germany, binding qualifications have been established to ensure that EMS training is only carried out under the supervision of qualified specialists. Particularly noteworthy is the certificate of competence in accordance with the Ordinance for Protection against Non-ionising Radiation when used on humans (NiSV). This certification has been mandatory since 2023 and ensures that trainers have the necessary know-how to ensure user safety and comply with regulatory requirements. These standards not only promote the safety and effectiveness of the training, but also help to build customer confidence in the method.

Safety of the equipment

Another central component of the regulatory framework is the safety of the equipment used for whole-body EMS training. Regardless of whether the equipment is used for medical, preventive or purely fitness-related purposes, it must meet the requirements of the medical technology standard.

This standard defines comprehensive safety and quality requirements concerning, among other things, electrical safety, biocompatible materials and the accuracy of the electrical impulse output. The aim is to minimise potential risks for users and ensure a consistently high quality of application.

Adherence to these requirements is not only a legal obligation, but also an essential factor for the acceptance and dissemination of the technology. Device manufacturers are obliged to carry out extensive testing and certification before their products can be launched on the market. This not only creates transparency, but also strengthens user confidence in the safety and reliability of EMS technology.

Training guidelines

In addition to device safety, the guidelines for use are also crucial to ensuring safe and effective whole-body EMS training. These concern both the conditions for implementation and the responsibility of the provider.

One of the most important requirements is that EMS applications may only be carried out under the supervision of trained and qualified personnel. This ensures that the individual needs and health conditions of the users are taken into account. In particular, in the case of pre-existing conditions or special physiological circumstances, careful anamnesis and counselling is essential.

Another key aspect of the requirements is the maximum 2:1 supervision ratio, which means that a specialist may supervise a maximum of two people at a time. This close supervision ratio enables the training to be specifically and individually adapted to the respective user requirements and contributes significantly to the safety and effectiveness of the application.

In addition, there are clear guidelines on the duration and intensity of the sessions to avoid overloading or potential side effects. Regular technical inspections of the equipment and seamless documentation of the applications are also mandatory to ensure high quality and traceability.

These requirements are designed to minimise the risk to users while achieving the best possible results from EMS technology. They form an essential basis for confidence in whole-body EMS training as a safe and effective training method.

The Mayo Clinic's study on Whole-Body Electromyostimulation (WB-EMS) highlights its time-efficient and effective benefits for cardiovascular health. Published in the International Journal of Cardiology, the research led by Dr. Jaskanwal D. Sara and Dr. Amir Lerman shows WB-EMS improves cardiovascular biomarkers, enhances joint protection, and activates more muscle fibers compared to conventional training. With just 20 minutes per week, WB-EMS offers a gentler yet powerful alternative, ideal for those seeking efficient, low-impact exercise.

The Mayo Clinic is considered one of the world's most renowned medical centres and is particularly known for its clinical excellence, research and innovative spirit in medicine.

The study "Physical Training Augmented with Whole Body Electronic Muscle Stimulation (WB-EMS) Favourably Impacts Cardiovascular Biomarkers in Healthy Adults" was conducted by a Mayo Clinic research team led by Dr Jaskanwal D. Sara and Dr. Amir Lerman and was published in November in the International Journal of Cardiology. This journal is one of the most renowned publications in the field of cardiology and regularly publishes new research findings on cardiovascular diseases and preventive cardiology. The results were also presented at the annual meeting of the American Heart Association.

According to the Mayo Clinic study, supervised whole-body electrical muscle stimulation (WB-EMS) training has some notable advantages over conventional training methods, particularly in terms of efficiency and effectiveness for cardiovascular health indicators.

The main advantages of WB-EMS compared to conventional training are:

1. Time efficiency:
   WB-EMS training sessions last only 20 minutes per week, which is a time saving compared to traditional training methods that can take several hours to achieve similar muscle activation and intensity. This makes WB-EMS particularly attractive for people with a limited time budget.
2. Better cardiovascular results:
   The study shows that WB-EMS produces a significant improvement in cardiovascular biomarkers, such as a greater reduction in waist-to-hip ratio and total cholesterol levels compared to conventional exercise. Anaerobic capacity and respiratory efficiency also improved significantly with WB-EMS, which means better oxygen utilisation and energy supply for muscles.
   
   
3. Joint protection:
   As WB-EMS triggers muscle contractions via electrical impulses without high mechanical stress, it is suitable for people who are unable to perform conventional training due to joint problems or other physical limitations. It can be an alternative for people who want to build muscle and promote cardiovascular health but need to avoid intense physical exertion.
   
   
4. Activation of a higher number of muscle fibres:
   WB-EMS simultaneously activates over 90% of large muscle groups and a greater number of muscle fibres compared to conventional training, resulting in higher muscle recruitment. This leads to more intense muscle contractions and potentially better strength gains in less time.

In summary, supervised WB-EMS offers a time-efficient, gentler and more intensive training alternative that is particularly suitable for people who need efficiency and less joint stress or who want to optimise their training.

Discover the costs and options for EMS-training, from home systems to one-on-one sessions. Learn about pricing, effectiveness, and which training format suits your goals best.

If you are considering EMS training for the first time, you probably have many questions: How effective is the training actually? How much is a session? What do I need to look for in a trainer? What about health considerations? In fact, these questions are adequately answered by science, training institutes and countless long-time operators in Germany and other European countries. The consensus is that it all depends on how EMS training is offered.

If you plan on doing EMS training on a regular basis, you need to choose an offer that works for you - that goes for both the training itself and the respective price. As a rule of thumb, you should expect to pay between $120 and $220 per training session. It all depends on how extensive the individual care is that your trainer or studio can offer. There are some important differences to consider here. What these are and what sensible training formats you can choose from, we are going to show in the following overview.

When it comes to the price of a whole-body EMS session, individual care and service quality makes all thedifference!

Option 1: EMS Training With Your Own Device At Home 

This sounds simple enough. Your own EMS system in the comfort of your home. An EMS session whenever and wherever you want it.

Cost:

Home EMS systems start at around $800 for the whole set-up. Some gyms, EMS studios and other providers offer a rent-at-home model that starts at $49/month

Effectiveness:

Without the guidance of a qualified personal trainer, it can be difficult and tedious to find the ideal intensity, motivation, training program and ultimately results. Also, like any other home training machine, an EMS system can easily end up unused in a box under your bed or as the most expensive coat hanger you own.

Evaluation:

Very critical! There is a severe risk of misapplication and overtraining.

EMS-Training requires constant attention and interaction by a qualified trainer, physical therapist or Chiropractor Since safety in a private setting cannot be guaranteed, scientists and the German Commission on Radiological Protection even recommend prohibiting private EMS application.

 

Option 2: One On One EMS Personal Training 

It doesn’t get any better than this! Whether with a trainer at your home, at a studio, gym or a physical therapy practice, one on one EMS Personal Training is the best way to go!

Cost:

The price for an individual EMS session with a personal trainer is somewhere between $120 and 200$. If you use a trainer’s at home or concierge service, there are also travel expenses to consider. Most personal training operators offer a membership model with options for 3, 6 or 12 month packages.

Effectiveness:

A qualified and experienced trainer or therapist can customize your workout for optimal results. Close interaction between trainer and trainee ensures maximum motivation and correct form. Your trainer also monitors the adherence to regular appointments and helps you to develop a safe and effective workout routine with lasting results.

Evaluation:

Ideal! Your trainer monitors and manages the intensity at all times. Individual coaching and planning for maximum safety and noticeable results!

Option 3: One To Two EMS Personal Training 

Effective, motivating and safe - with two users supervised by a qualified trainer or therapist, one to two training can offer the best value for money.

Cost:

The price for an EMS partner session is $75 to $120. Usually this option is offered as a membership package based on 6, 12 or 24 months.

Effectiveness:

A qualified and experienced trainer can carry out a standardized workout with a maximum of 2 people in a highly efficient way. The close interaction between the trainer and the trainees provides the maximum drive. The trainer also manages training appointments and helps you develop a workout routine and motivation, which ensures lasting results.

Evaluation:

Very good! - and probably the most frequently offered EMS training option. While one to two training is, of course, a little less individualized, it boasts a very attractive efficiency and excellent results.

Option 4: EMS Group Training 

The group dynamic and a cheaper price are an interesting alternative at first glance…

Cost:

Little supervision and only limited professional support. One trainer is responsible for more than two trainees at the same time. It is mostly gyms that offer EMS training in this form - for a small additional fee in addition to the membership rates.

Effectiveness:

Without close supervision by a trainer and direct communication, finding the optimal intensity is only possible to a very limited extent. As a result, you may not even achieve a relevant degree of hypertrophy. With an increasing group size, the trainer's ability to personally attend to each individual client decreases. A high level of intrinsic motivation is necessary. Trainees are likely to no see any results if they are not being attended to by the trainer.

Evaluation:

Critical! There is a high risk of misapplication and overtraining. A quick response to individual participants' potential problems is difficult to ensure.

According to scientific research, even an experienced trainer is only capable of monitoring and controlling an effective intensity for a maximum of two users. EMS-Training requires constant supervision and interaction by a specially licensed trainer or physiotherapist. 

Keeping that in mind: Save your money and meet your friends for other group activities. ;-)

Non-specific back pain is widespread and often chronic. EMS-Training offers a time-efficient, joint-sparing solution for treatment and prevention by specifically strengthening the core muscles – effective in just 20 minutes a week.

Non-specific back pain is particularly prevalent in high-income countries where sedentary lifestyles and a lack of physical activity are common [1, 2]. This causes muscles in the trunk area in particular to atrophy and lose strength and stabilisation power [3].

EMS-Training is a highly effective and sustainable treatment. This innovative concept, based on a modern form of electrotherapy, offers a time-efficient solution for strengthening the core muscles – both in prevention and in therapy. Numerous studies show a comparatively high level of effectiveness compared to conventional strategies for back strengthening, including the multimodal treatment programme considered the gold standard [4, 5].

 

Back pain: The most common cause of incapacity to work and early retirement

Back pain is one of the most common complaints among the population: around three quarters of all Germans suffer from back pain at least once in their lives [6]. 70–80% of back pain is pain in the lower lumbar area (low back pain, LBP) [7]. The complaints affect more women than men and mainly people in middle age between the ages of 40 and 69 [7].

Since back pain is the most common reason for being unable to work and the second most common cause of early retirement after mental illness and behavioural disorders, the economic impact is also considerable [6]. Depending on their cause, back pain is categorised as either specific or non-specific. In 80% of cases, the pain is non-specific and must be distinguished from back pain caused by a specific condition, such as a herniated disc, infection, fracture or tumour, based on a targeted medical history and physical examination. If there are no neurological symptoms, extravertebral causes or so-called ‘red flags’ (warning signs), the diagnosis of non-specific back pain can be made [6].

 

Therapy:  EMS-Training as a way out of the vicious circle

Non-specific back pain often leads to a vicious circle that hinders active pain control. In most cases, this results in chronicity. On average, two-thirds of those affected (42–75 %) report persistent symptoms after 12 months. Accordingly, avoiding chronification is the declared therapeutic goal in the treatment of non-specific back pain. Risk factors for chronification include sedentary work, low physical fitness, stress, smoking and obesity, but also psychosocial, workplace-related or iatrogenic factors [6]. Non-specific back pain is treated symptomatically and based on the quality and intensity of the pain, the degree of functional impairment and the temporal course of the symptoms (acute (< 6 weeks), subacute [6–12 weeks] and chronic (> 12 weeks) non-specific back pain).

In addition to maintaining physical activity, initial adjunctive analgesic, pharmacological and non-pharmacological treatment options such as acupuncture, relaxation techniques, functional training, manual therapy, heat therapy, etc. can be used. Evaluating and addressing any risk factors and teaching health-conscious behaviour also play an important role in the treatment of non-specific back pain. If the symptoms persist or there is a risk of chronicity or if it already exists, national and European guidelines offer a multimodal treatment programme that is individually tailored to the patient and consists of physiotherapy, physical therapy, psychotherapy, occupational therapy and education [6]. This programme, which can be carried out in both an outpatient and inpatient setting, is currently considered the gold standard for the treatment of non-specific back pain – however, it is very costly and time-consuming.

A more time-efficient method of treating non-specific back pain, which according to study data is comparably effective, is medical electrical muscle stimulation (EMS-Training). A prospective, controlled non-randomised clinical study showed that medical EMS-Training is just as effective as the gold standard of a multimodal therapeutic approach in treating non-specific back pain – and it only takes 20 minutes a week [4].

 

Prevention: Effectiveness and motivation for lasting and holistic behavioural change

Exercise, especially strengthening and stabilising exercises for the core muscles, helps to prevent non-specific back pain. Regular training is essential to strengthen the muscles permanently [6].

With conventional training methods, it is necessary to train several times a week. This is not only time-consuming, but it also leads to increased strain on the joints and the affected musculoskeletal system. A lack of motivation is another factor that makes it particularly difficult to prevent back pain. EMS training offers an effective, particularly joint-friendly and time-efficient solution for long-term prevention – with proven effectiveness in various studies – in just 20 minutes per week [4, 5]. Personal support ensures the necessary motivation and regularity.

Discover how whole-body EMS is becoming a global standard for safe and effective muscle stimulation. Learn about DIN 33961-5 and new international guidelines shaping prevention and rehabilitation practices.

The application of whole-body electromyostimulation (EMS) requires a high level of safety due to the intense stimulation of the muscles. In recent years, scientific studies have further clarified the measures necessary for its safe and effective use. Alongside national standardization in Germany, the internationalization of safety standards is becoming increasingly significant.

As early as 2017, safety guidelines were developed in collaboration with leading exercise scientists from the universities of Cologne, Kaiserslautern, and Erlangen to establish clear standards for users, operators, and trainers. These guidelines were incorporated into the German DIN 33961-5 standard in 2019. By specifying the interaction between trainers and users, the standard ensures necessary control and minimizes risks such as rhabdomyolysis, a severe muscle injury.

With the growing global popularity of whole-body EMS, the importance of international standards is becoming increasingly clear. The international position paper by Kemmler et al. (2023), published in Frontiers in Physiology, marks a milestone in the harmonization of safe EMS applications. A research group comprising 20 experts from Germany, Spain, the United States, and other countries developed comprehensive guidelines for the safe and effective use of whole-body EMS. These guidelines are scientifically grounded and provide practical recommendations for implementation.

The paper highlights the potential of EMS in prevention and rehabilitation, provided strict safety standards are observed. It also underscores the importance of robust training for EMS trainers to ensure both effectiveness and safety. Combining national standards, such as DIN 33961-5, with international guidelines creates a reliable foundation for the safe use of EMS and enhances confidence in its health benefits.

These developments represent a crucial step toward establishing whole-body EMS as a safe and effective method in prevention and therapy—both in Germany and worldwide.

Whole-Body electromyostimulation – a guideline for safe and effective use

Definition

Whole-body EMS is a simultaneous application of current via at least six current channels involving all major muscle groups, with a current pulse that is effective in training and triggers adaptations.

In general,

1. Safe and effective whole-body EMS training must always be carried out with the support of a trained and licensed EMS trainer.
2. A trainer may supervise a maximum of two trainees at a time. For each newcomer, an anamnesis must be carried out before the first training session, with a written query of the contraindications. This is documented in writing, confirmed by the signature of the customer and the person querying, and archived. If there are any relevant abnormalities, training may only be carried out after medical clearance.

Preparation for training:

1. As with any intensive physical training, it is important to note that whole-body EMS training should only be carried out by people who are in good physical condition and do not experience pain. This includes not consuming alcohol, drugs, stimulants/muscle relaxants or exhaustive exercise beforehand. In particular, training should be avoided completely if you have a feverish illness.
2. Whole-body EMS training leads to a very high metabolic load on the organism due to the very high amount of muscle mass used. This condition should be taken into account by consuming a sufficient amount of carbohydrate-rich food in advance. If this is not possible, a carbohydrate-rich snack (≈250 kcal) that is not burdensome should be consumed ideally about 2 hours before training.
3. To counteract possible kidney stress (especially in the case of unknown pre-existing damage) caused by intensive WB-EMS application, an increased fluid intake (500 ml each) before/during and after training is to be ensured.

Conducting the training:

1. Regardless of the user's physical condition, previous sports experience and the corresponding desire, under no circumstances should a WB-EMS training session take place during the first training session or a trial training session. In the past, this approach in particular has led to undesirable side effects and negative health consequences and must therefore be avoided at all costs.
2. After a moderate initial WB-EMS application, the stimulus level or current intensity must be gradually increased and adapted to the individual goals. The highest level of exertion may only be applied after 8–10 weeks of systematic training at the earliest (user's subjective assessment of exertion: hard–hard+). A full exertion workout, especially in the sense of a painful, continuous tetanus during the current phase, must be avoided in general.
3. In addition, the initial training should take place with a reduced effective training time. A 5-minute impulse familiarisation and a shortened training session with a moderate stimulus intensity (user's subjective assessment of the level of difficulty: somewhat difficult) and intermittent loading with a short impulse phase (≈) over 12 minutes is recommended. The training duration should only be carefully increased after this and should ultimately not exceed a maximum of 20 minutes.
4. To ensure sufficient conditioning and to minimise or exclude possible health impairments, the training frequency must not exceed one training session per week during the first 8–10 weeks.
5. Even after this conditioning phase, a period of ≥4 days must be observed between training sessions to prevent the accumulation of muscle breakdown products, to ensure recovery and adaptation, and thus to ensure training success.

Safety aspects during and after training:

1. The trainer or trained and licensed personnel must attend exclusively to the needs of the user(s) during the training session. Before, during and after training, the trainer must check the condition of the user verbally and by visual inspection to rule out health risks and ensure effective training. If there are any contraindications, training must be stopped immediately.
2. The distance between trainer and trainee should only be such that the trainer can visually monitor the trainee, exchange information with the trainee without a greater spatial distance and reach the trainee within one second.
3. To control the intensity of the current, a verbal query about the individual strain and, if necessary, an adjustment of the current intensity must be made at least three times during a training session (usually 20 minutes of training) for each current channel or muscle group. This is the only way to ensure an effective training stimulus intensity on the one hand and to minimise the risk of overloading on the other.
4. During training, the device's controls must be directly accessible to the trainer and the trainee at all times. It must be possible to operate/adjust the device easily, quickly and precisely.

Conclusion:

In the context of these guidelines, the experts have only addressed supervised WB-EMS. In fact, there was general consensus that safe and effective WB-EMS application can only be guaranteed in this context. They therefore explicitly advise against private use of the technology without the supervision of a trained and licensed trainer or appropriately scientifically trained personnel. In this context, they are also critical of the approach taken by some providers of increasing the supervision ratio to such an extent that, even taking into account technical developments and the training of trainers, it no longer allows for personalised and thus safe and effective training.

 

Kemmler W, Fröhlich M, Ludwig O, Eifler C, Von Stengel S, Willert S, Teschler M, Weissenfels A, Kleinöder H, Micke F, Wirtz N, Zinner C, Filipovic A, Wegener B, Berger J, Evangelista A, D’ottavio S, Sara JDS, Lerman A, Perez De Arrilucea Le Floc’h UA, Carle-Calo A, Guitierrez A and Amaro-Gahete FJ (2023) Corrigendum: Position statement and updated international guideline for safe and effective whole-body electromyostimulation training-the need for common sense in WB-EMS application. Front. Physiol. 14:1207584. doi: 10.3389/fphys.2023.1207584

Applications of electric, magnetic and electromagnetic fields (EMF) in humans for non-medical purposes  - Recommendation by the German Commission on Radiological Protection with scientific background - Adopted by circulation on 12 August 2019 - BAnz AT 04.03.2020 B6

Find out everything there is to know about whole-body EMS training: scientifically proven benefits, risks and target groups. Experts debunk myths and explain how whole-body electrical stimulation can be used effectively, safely and individually – from rehabilitation to fitness.

EMS training is becoming increasingly popular. Practical experience shows that the training is effective and safe. Nevertheless, prejudices and superficial knowledge persist, even though the use of ‘electricity’ originally comes from the field of medicine and healthcare. Today, the effects of EMS application have been scientifically evaluated and any risks are limited and calculable.

So if you don't want to rely on statements from providers or enthusiastic users, you can now consult current studies from well-known independent institutes.

For well over ten years, the University of Erlangen, under the direction of Prof. Dr. Kemmler, has been researching the application possibilities of whole-body electrical stimulation. In a recent interview, we asked him about the scientific perspectives, areas of application, risks and recommendations for EMS training.

Whole-body electromyostimulation (WB-EMS) is often advertised as ‘training without effort’. What is your opinion of this statement?

Prof. Dr. Kemmler: Hmm, that's an interesting question and depends on how ‘effort’ is understood. In fact, an appropriate application of electricity is an integral part of the current health WB-EMS method variant that generates the effects, so that the proportion of voluntary exertion remains relatively low. In training practice, this means that a suitably high stimulus intensity (via pulse strength) must be applied in close interaction between trainer and user, which should definitely be reported as ‘strenuous’. In particular, for WB-EMS users who are often less sport-oriented and have a correspondingly weak sense of exertion, this introduction to an appropriately high level of exertion and the development of a corresponding sensitisation of body awareness is the central ‘challenge’ for the trainer.

Critics often speak of little or no effect on functionality and coordination due to the ‘artificial’ activation of whole-body EMS training. What do you say to this criticism?

Prof. Dr. Kemmler: This opinion has since been refuted by a large number of EMS studies with significantly positive effects on a variety of functional parameters such as strength and performance. This argument may undoubtedly still apply to purely passive EMS application, but in training practice, especially in advanced therapeutic use, EMS is predominantly carried out in dynamics, i.e. using functional movements. Incidentally, this is where competitive sports applications differ from health-related applications. While competitive sports involve a high degree of voluntary activation with a moderate current intensity, which allows for an absolutely correct discipline-specific execution of the movement, the primary focus in the early stages of a therapeutic measure is on the current component as a stress instrument. However, this changes in the course of therapy, depending on the individual performance level of the patient. For older people, who need to positively influence muscle and fat mass in addition to (functional) training goals, a mixed training of both methods, ideally periodised with hypertrophically and functionally oriented sections, seems ideal.

A few years ago, the German Society for Clinical Neurophysiology and Functional Imaging (DGKN) warned against WB-EMS training. Can WB-EMS actually be harmful or dangerous?

Prof. Dr. Kemmler: This question regularly causes a stir in the media and unfortunately massively unsettles participants in EMS training. For this reason, we would like to address this question exhaustively and in a suitably differentiated manner within the scope of an interview. First of all, WB-EMS is definitely the training method of choice in our view with regard to acute orthopaedic and cardiac risks. A risk of EMS application that is repeatedly mentioned is associated with so-called rhabdomyolysis, in simple terms, stress-induced damage to muscle tissue. Due to its high sensitivity, CK (creatine kinase) is considered the primary serum marker of rhabdomyolysis. Based on resting CK values of below 200 IU/l, mild rhabdomyolysis is defined as an increase of up to 10 times, moderate rhabdomyolysis as an increase of between 11 and 50 times, and severe rhabdomyolysis as an increase of over 50 times the basal concentration. It is also important to note that there is a large intra-individual variance in CK concentration at the same relative load. In other words, some people react much more sensitively and with higher CK levels to physical exertion. In fact, WB-EMS is able to generate rhabdomyolysis due to the large number of muscle groups that can be stimulated simultaneously and, in extreme cases, supramaximally (i.e. higher than through voluntary innervation). A study closely monitored by a physician at our centre showed very high creatine kinase and (to a lesser extent) myoglobin values after the initial EMS application with individually maximum tolerable stimulation levels. On average, but not for all participants, these values were in the range of severe rhabdomyolysis. However, in line with the available literature, no clinical consequences were observed. Whether this result can be transferred to users with health limitations remains to be seen. However, a key finding of the study was that a very pronounced conditioning effect was observed in all subjects during the further course of WB-EMS training. In fact, after ten applications of EMS and another WB-EMS at full capacity, a 30-fold reduction in CK values was demonstrated, i.e. a concentration in the range of conventional strength training. The problem of EMS-induced rhabdomyolysis is therefore largely based on the application of inappropriately high-intensity electricity during the initial sessions. We have presented guidelines in the ‘Guidelines for the safe and effective application of whole-body electromyostimulation’ that comprehensively address this issue.

Your team at the University of Erlangen has been conducting research in the field of whole-body EMS for a long time and has played a major role in the guidelines for safe and effective use. In your opinion, what are the most important rules of conduct that a provider of EMS training must follow?

Prof. Dr. Kemmler: From our point of view, the focus is clearly on effectiveness and safety when using EMS. As already discussed, EMS is not an all-time effective and absolutely safe application that is a sure-fire success. In fact, to a greater extent than with other training methods, competent and trusting interaction between the user and therapist is the key feature of a successful and safe therapy measure for generating the best possible result. For this reason, we consider 1:1 supervision to be an important criterion for therapy. For preventive training, the supervision ratio is a maximum of two trainees per supervisor.

In addition, it is important that the provider has appropriate therapeutic and/or sports science training in order to ensure long-term success with regard to applicable training principles, contraindications and the recognition of certain load parameters for different clinical pictures. In terms of contraindications, the development is certainly not yet complete. In particular, in therapeutic and medical use, some absolute contraindications are currently changing to relative contraindications. In the therapeutic segment in particular, we expect to achieve greater safety through scientifically based findings, through education and cooperation with doctors and clinics.

The heart is also a muscle. Why is the heart not affected by the electrical impulses of electromyostimulation?

Prof. Dr. Kemmler: Like every muscle, the heart muscle also contracts when electrical signals depolarise the muscle fibres above a certain threshold. In this way, the heart is brought to rhythmic contraction via the autonomous conduction system. In principle, the heart muscle can also be influenced or disturbed by external currents, as can happen in the event of an electrical accident or during resuscitation with a defibrillator. In contrast to a socket or a defibrillator, which generate very high voltages and currents, the current intensity is very low during EMS application and the current flow is regionally limited. This is because extremely low currents are sufficient to activate the skeletal muscles. The main effect of electromyostimulation with low-frequency currents is the activation of the small motor nerve branches near the electrodes. If these are depolarised by the external current above a certain threshold, the nerves generate an action potential that automatically propagates in the direction of the muscle fibres and activates them. The fact that the external current ‘initiates’ the body's own physiological excitation means that the muscles are also activated in the depths and stimulated to a strong contraction. However, there is no relevant current flow outside the skeletal muscles through the chest to the heart. Nevertheless, cardiac arrhythmias and, in particular, pacemakers are a contraindication that should be strictly adhered to as a precaution. The positive cardiological effects of medical EMS training have been scientifically proven in a study at the German Heart Centre in Bad Oeynhausen.

For several years, functional training has been considered a highly effective method for quickly and effectively achieving fitness and health goals. How do you see the connection/difference to EMS training here?

Prof. Dr. Kemmler: The comparison is actually interesting: functional training is often presented as the exact opposite of EMS training, since the focus is on exercises with complex movements involving several joints and muscle groups, while EMS, at least in the past, always had the aspect of statics and not functionality in mind. Now, modern and especially therapeutic EMS training is rarely applied statically, but predominantly dynamically. During their individual EMS training, therapists in particular prefer movements that are relevant to everyday life, involving several joints and, as far as possible, a large amplitude. In order to generate the necessary above-threshold intensity, classic functional training often uses various additional loads. With EMS training, the intensity is primarily controlled by the current pulse. The latter aspect contributes to a more favourable orthopaedic tolerance and lower risk of injury, especially for inexperienced and/or less athletically trained individuals. Aspects such as a limited time budget, health orientation/health limitations, little affinity for conventional training and excellent intensity control speak in favour of therapeutically guided EMS training.

In your opinion, who is the actual target group for whole-body EMS training?

Prof. Dr. Kemmler: Due to the training being particularly easy on the spine and joints, without heavy weights or pressure, EMS training can be used at an early stage and in parallel with individual physiotherapy treatment. Combining it with the functional exercises relevant to everyday life, as mentioned above, gives us an inexhaustible target group that is also unlimited in terms of time. Following the guidelines of ‘easy to hard’ and ‘simple to complex’, we address both young and old, trained or untrained, healthy or sick/injured. EMS training is therefore at least as widely applicable as conventional strength training. In our research group, we are currently specialising in musculoskeletal and cardiometabolic diseases and conditions, which are mostly associated with old age. Recently, more and more other target groups and areas of application have emerged. Through a research network with other scientific and medical institutions, we will continue to advance EMS research, identify important and meaningful areas of application and evaluate them together in the future. I think that EMS research will develop more prominently internationally in the next few years, so we can expect even more exciting research results on this topic.

EMS training in oncology offers cancer patients an innovative addition to exercise therapy. It enables effective muscle building and strength training that is easy on the joints, even during therapy. Initial experiences show potential for preparing for surgery and for combating weight and muscle mass loss (cachexia).

In November 2012, the Center for Integrated Oncology (CIO) Cologne Bonn, the University Hospital Cologne, and the German Sport University Cologne established a movement therapy training center exclusively for oncological patients.

In the past, cancer patients were advised to rest as much as possible and avoid exertion. This approach is now outdated. Today, medical professionals and scientists are convinced of a positive correlation between physical activity and the condition and mental state of cancer patients. In an area of approximately 110 square meters, cancer patients are trained by experienced and specially qualified therapists as part of their care and also within scientific studies.

What's special about Oncological Training Therapy in Cologne: Physicians, psychologists, and sports scientists work together under one roof, right where patients receive their medical care.

For over a year now, in addition to classic strength and endurance equipment, a medical EMS device from miha bodytec has also been in use.

Does EMS Training Work with Cancer Patients?

Our initial experiences with whole-body EMS training for oncological patients suggest that the training is not only feasible but also effective in building strength and muscle, potentially serving as a useful complement to conventional training methods. The training was very well implemented for patients before or after completed oncological therapy, but was also possible for patients undergoing acute medical treatment, such as chemotherapy or radiation. Of course, especially during acute therapy, specially trained oncology-specific trainers are needed to address possible contraindications and limitations due to the disease or therapy (e.g., low blood counts). Moreover, constant dialogue with patients before, during, and after training is mandatory.

The training itself should be conducted in a 1:1 setting, as oncological patients have very different prerequisites and limitations. For optimally effective training, intensities, exercises, and scope should be personalized. We found that patients approach this new training method with a healthy measure of caution in the first session, but become accustomed to the electrical stimulation during the initial training unit. Thus, the electrical impulses can and should be accompanied by everyday functional movements early on. By the second training session, many patients' initial inhibitions about higher intensities of electrical pulses were resolved, and the desired training ranges for muscle building could be achieved. This is an advantage over many conventional forms of training, where sufficient movement quality often needs to be established first to work safely at higher intensities. In EMS training, intensity regulation occurs through electrical application and is therefore passively administered to the patient, meaning that theoretically, one could train at very high intensities very quickly without special prior knowledge, at least in terms of muscle and strength training. This is where I see the primary application of EMS training in oncology. An effective and time-saving strength training that doesn't require special prior knowledge from cancer patients. Additionally, depending on the form of execution, the training can be conducted in a joint- and bone-sparing manner, which can be highly relevant in oncology in the context of osteoporosis, bones at risk of fracture, and chronic joint pain. I currently see no application for endurance training via EMS applications, as there are no discernible advantages over conventional methods for me.

Perspectives on EMS Training in Oncology

I consider EMS training to be a useful addition and extension to the movement therapy repertoire in oncology. Truly, EMS training is not suitable for everyone, but there are some situations where EMS training shows particular potential. On one hand, it needs to be clarified in the future whether EMS training is more effective compared to conventional strength training in maintaining or building muscle strength and mass. Tumor-associated weight and muscle mass loss (cachexia) often progresses rapidly and is difficult to treat. A multimodal approach with intensive strength training at initial weight loss could potentially slow down or halt the progression of cachexia, especially through the quickly achievable high intensities of EMS training for strength and muscle maintenance or building. Another potential of EMS training could be short-term interventions over a period of 2-3 weeks. This is often the timeframe between diagnosis and the start of therapy and offers the opportunity to conduct build-up training to best prepare patients for surgery or chemotherapy. Quickly learnable and effective training methods like EMS training are also suitable for this. Of course, these initial impressions still need to be demonstrated through high-quality studies. However, our first experiences already show initial positive trends. In my view, EMS training cannot replace proven training methods, but it offers an innovative addition to the existing movement therapy contingent in oncology.

Whole-body EMS training offers seniors a safe, joint-friendly and effective training option. Studies show positive effects on muscle mass, function and health. Find out more about the benefits and guidelines for seniors.

EMS training specifically for seniors? There are hardly any specific offers or targeted approaches for the senior target group so far. Prof. Dr. Wolfgang Kemmler from the Institute of Medical Physics at Friedrich-Alexander-University (FAU) Erlangen-Nuremberg raises the question of why this is the case. The whole-body EMS training method and the senior target group are a perfect match, even under scientific scrutiny.

"Dear Mr. Kemmler," said the elderly lady at the information event for our movement study, "I haven't done any sports for 50 years, so I won't start at 70 either." The lack of willingness and insight of many "sport-abstinent" seniors to begin regular and intensive physical training could not be put into words more clearly. The indication that physical training is effective at any age is usually "brushed off" with objections such as lack of time, shame, sweating/exertion, low performance, joint pain, and lack of individual care - interestingly, the financial aspect rarely plays a role.

Great Option for Seniors: Whole-Body EMS

Therefore, whole-body electromyostimulation (WB-EMS) appears to be a time-efficient, discreet, joint-friendly, and safe option for older, less sports-inclined people to positively influence health and performance on their own responsibility, at least in the currently recommended setting of close supervision [1]. In addition, even scientific critics of WB-EMS consider poorly trained, low-performance individuals as a suitable group for WB-EMS, an assessment confirmed by numerous studies with older people and predominantly positive results [2].

Study Situation with Consistently Positive Results

If one wants to evaluate the effectiveness of a WB-EMS application on risk factors and diseases of older age, a number of evidence-based studies are already available in this field. As a "resistance-type exercise", WB-EMS naturally has a particularly prominent effect on muscular parameters (overview in [3]). Focusing first on muscle mass, in addition to the influence on muscle function, there is also a central importance in the area of basal metabolic rate [4], increased capillarization and maximum oxygen uptake [5], and thermoregulation [6, 7]. Since muscle mass provides the highest contribution to basal metabolic rate, muscle mass plays an important role in the area of obesity [8] or sarcopenic obesity [9]. Several studies with older people (overview in [3]) show a significant increase in muscle mass in the range of HIT strength training [10]. An accompanying protein intake in the range of 1.5-1.7 g/d/kg body weight may further significantly enhance this WB-EMS induced effect [12, 13]. Also in the area of muscle function, which is particularly relevant for older people, WB-EMS concepts with adjuvant light forms of movement show a highly relevant influence on muscle function (overview in [3]). Regarding dynamic maximum strength, changes in strength in the range of 15-25% could be demonstrated after 12-16 weeks of WB-EMS application (1.5 x 20 min/week), which, in relation to the strength of hip and knee extensor muscles, is only slightly below the corresponding effects of a HIT-RT intervention [10]. Given the very positive effects on musculature, the effect of WB-EMS training on bone density as a surrogate for fracture resistance is less prominent [14]. Nevertheless, in our opinion, positive data [14] in the field of whole-body vibration can be expected [15].

In addition to musculoskeletal parameters, factors correlated with cardiometabolic risk factors and diseases also show favorable changes after WB-EMS application [3]. The effects on total and abdominal fat mass are particularly prominent. Almost all available studies show a reduction in total body fat that is somewhat higher than the increase in muscle mass [3]. In addition to classic cardiometabolic risk factors (blood pressure, blood lipids, glucose), some WB-EMS studies [17-19] also show effects in people with heart failure, including a higher ejection fraction [17, 18].

High Acceptance

Moreover, the existing studies with older people showed no significant "undesirable" side effects [3]. It is also noteworthy that the acceptance of WB-EMS training by seniors, at least in a closely supervised setting, is very high.

An Ideal and Effective Tool for Older People

Therefore, WB-EMS appears to be an ideal "tool" for health-oriented training of older people. However, for successful EMS training with seniors, some points need to be considered to a special degree. Particularly important for the application of WB-EMS within the often fragile group of older people with little body awareness and lack of reference for stress stimuli is the question of safety and tolerability.

A consistent review and application of exclusion criteria and medical contraindications is mandatory. For seniors who want a medical clearance for EMS training, even the mostly non-WB-EMS-savvy family doctor can be enabled to make a reliable decision for or against WB-EMS through an information flyer with a link to additional neutral information sources. Collaborations between doctors and EMS providers facilitate the medical decision through knowledge of the qualification of the facility and its staff.

Guidelines for Safe EMS Application

In addition, we consider the application of the WB-EMS guidelines [1] to be absolutely binding, not only, but especially for seniors. A central aspect of the guidelines is very close supervision, where a maximum of two trainees are supervised by one therapist. Older people who are neither sports nor technology-savvy benefit particularly from this very close supervision and interaction. Therefore, the closest possible supervision ratio is an absolute quality criterion not only in terms of safety but also effectiveness.

Great Potential with High Benefits

In conclusion, considering the very high potential and special features of WB-EMS training with seniors, it is surprising that senior-specific offers or at least senior-specific addressing of the existing, in some cases definitely high-quality offer in health-oriented WB-EMS currently hardly play a role.

Whole-body electromyostimulation (WB-EMS) is a time-efficient, high-intensity training method targeting all major muscle groups simultaneously. While effective and safe when applied correctly, improper use can cause severe risks like rhabdomyolysis. This guide outlines absolute and relative contraindications, ensuring safe WB-EMS application in therapy, prevention, and sports contexts. Learn essential precautions, updates, and best practices for optimal results and risk management

Whole-body electromyostimulation (WB-EMS) refers to the simultaneous stimulation of all major muscle groups (using at least six applied current channels) with a training-effective stimulus that triggers adaptations. It is used as a highly intensive and time-efficient form of training in therapy and prevention, as well as in recreational, amateur and professional sports (Berger, 2021; Kemmler, Kleinöder & Fröhlich, 2020).

When applied correctly, GK-EMS is an effective and safe form of training. However, due to the extensive application and simultaneous contraction of large muscle groups, it also carries a certain risk if not performed correctly. Supramaximal stimulation of the individual body regions and the resulting high metabolic stress for the organism can lead to undesirable side effects, including overuse, which in the worst case can result in rhabdomyolysis (muscle tissue breakdown) caused by a massive increase in creatine kinase (CK), which is an enzyme that occurs when muscle tissue is damaged (Teschler et al., 2016). In general, there is an adequate increase in CK after every sporting activity. However, an excessive increase due to overloading the muscles is a factor that must be avoided at all costs in GK-EMS. In past studies, an initial GK-EMS application that was too intensive led to a massive increase in CK values, from which it was concluded that the initial GK-EMS training units in particular to slowly get the organism used to the new form of training and to prevent rhabdomyolysis (Kemmler, Fröhlich, Stengel & Kleinöder, 2016).

As with any new form of training, the start of GK-EMS training should therefore be done cautiously and with consideration of the current state of health of the user, as well as with professional support from trained specialists. Apart from aspects of individualised and adequate implementation, there are other essential criteria for GK-EMS that must be met before the first application can take place (Berger, 2022; Kemmler et al., 2019). Due to the involuntary contraction of the musculature and – in the event of improper use – the resulting potential for danger, GK-EMS can only be compared to a limited extent with classic strength or endurance training. For this reason, it seems essential to formulate guidelines for the safe and effective implementation of GK-EMS. The first instructions regarding anamnesis, initial instruction, the care relationship and the safe implementation of training were therefore already published in 2016 (Kemmler et al., 2016). Based on this, the test criteria of DIN 33961 – Part 5 include further formalised regulations regarding contraindications to the use of GK-EMS. These are intended to serve as a guide in daily practice by defining exclusion criteria for GK-EMS training.

A distinction is made between relative and absolute contraindications (Kemmler et al., 2019). In the presence of absolute contraindications, GK-EMS application must be categorically rejected due to the acute risk to the trainee, as it can lead to physical impairments that are significantly detrimental to health. Thus, GK-EMS application would be associated with too high risks and should not be carried out under any circumstances due to the duty of care towards customers/patients.

Absolute contraindications

The absolute contraindications, as well as the relative contraindications discussed later, must be checked in advance of the first GK-EMS training session and archived in a separate medical history sheet. The following factors are considered absolute contraindications:

• Acute illnesses, bacterial infections and inflammatory processes:
  During athletic exertion, the body experiences an increased immunological stress situation. In the presence of acute illnesses, bacterial infections and inflammatory processes, the body is already significantly weakened before training and more susceptible to further infections, which is why athletic exertion and accordingly GK-EMS training is generally not recommended (Baum & Liesen, 1998).
  
  
• Recently performed surgery:
  If there is an open or sutured wound in the application area of the GK-EMS electrodes due to surgery, this fundamentally precludes training. Outpatient procedures such as the removal of a mole are not directly affected by this, provided the wound is not directly under an electrode. Physical exertion of any kind should be avoided as long as the wound has not yet closed on its own and has been sutured. In general, it is important to note that complete recovery from the condition that necessitated the operation must have occurred before GK-EMS training. To be on the safe side, consult with the doctor treating you.
  
  
• Arteriosclerosis and arterial circulatory disorders:
  Atherosclerosis is also known as hardening of the arteries and describes the deposits of blood lipids, blood clots, connective tissue and calcium (so-called plaques) on the inner wall of arterial vessels. As a result, the affected muscles and organs are no longer supplied with sufficient blood due to the narrowing and hardening of the arteries. In the worst case, a blood clot (thrombus) forms on the deposits, causing the artery to close and resulting in a heart attack or stroke (Marées, 2003). The effects of GK-EMS in particular on arteriosclerotic diseases have not been sufficiently researched at this time. However, since the progression of the disease can be life-threatening, GK-EMS training should be avoided at all costs in the context of the clinical picture described here (Kemmler et al., 2019).
  
  
• Stents and bypasses that have been active for less than six months:
  Stents are used to stabilise and widen narrowed vessels and, as vascular supports, ensure that the artery does not become narrowed or blocked again. Bypasses bypass narrowed blood vessels and thus redirect the blood flow. Both procedures represent a major intervention in the human organism, which is why it is important, especially during the rehabilitation phase, to slowly get the patient used to sporting activities. Intensive training should therefore be avoided at all costs in order not to put too much strain on the new structures. Recommendations of the German Heart Foundation include light endurance training in the form of fast walking or participating in a cardiac sports group. In comparison, GK-EMS is a much more intensive form of training, which puts many times more strain on the organism and all the structures involved in the movement. Therefore, it should only be performed in postoperative rehabilitation (lasting six months) after sufficient recovery and medical clearance (Albrecht & Mooren, 2018).
  
  
• Untreated high blood pressure:
  High blood pressure (arterial hypertension) is one of the main risk factors for cardiovascular diseases and is one of the most common chronic conditions worldwide. As blood pressure rises, so does the risk of stroke and heart attack, and there is an increased risk of kidney failure (Reimers & Völker, 2018). Once high blood pressure has been treated, an adapted, medically supervised sporting activity is possible without any problems – however, untreated high blood pressure must be medically clarified in order to avoid possible consequences and fundamentally excludes a sporting training programme, including GK-EMS (Predel, 2007).
  
  
• Diabetes mellitus:
  Diabetes mellitus, a disorder of carbohydrate metabolism, occurs in different forms and can be categorised into type 1 diabetes mellitus (absolute insulin deficiency), type 2 diabetes mellitus (insulin resistance and different insulin availability) and other specific forms of diabetes (endocrinopathies, drug-induced forms, etc.). Depending on the severity of the disease, physical activity can have a positive effect on the organism. However, the simultaneous strain on many large muscle groups and the resulting high metabolic load can lead to complications such as hypoglycaemia in the present clinical picture. Although the exact influence of GK-EMS on the organism of a diabetic person has not yet been conclusively clarified, diabetes mellitus is to be regarded as an absolute contraindication due to the high risk potential (Kemmler et al., 2019).
  => Update June 2024: Diabetes is no longer an absolute contraindication for EMS, but a relative contraindication that requires careful evaluation and individual adjustment. When used correctly and under medical supervision, EMS training can be a valuable addition to the management of diabetes.
  
  
• Pregnancy:
  There are currently no scientific findings regarding the risks of using GK-EMS during pregnancy. However, this lack of information contributes to its classification as an absolute contraindication, since a lack of evidence of harmful effects is not synonymous with the safe use of GK-EMS during pregnancy. The protection of both mother and child is paramount, which is why any potential risk posed by GK-EMS must be ruled out.
  
  
• Electrical implants and pacemakers:
  Electrical implants and pacemakers measure cardiac activity using a sensor in the ventricle or in direct contact with the heart muscle. In the event of cardiac dysfunction, the necessary countermeasure can be taken immediately in the form of an electrical impulse, e.g. in the case of ventricular fibrillation, which is a life-sustaining measure. Since electrical impulses are also used in GK-EMS and so far there is no manufacturer information about potential interference of these impulses with those of the implants, a negative influence of the GK-EMS cannot be fundamentally excluded. Therefore, there is a possibility that, in the worst case, the stimulation could endanger the life of the trainee, which is why electrical implants and pacemakers are listed as absolute contraindications.
  
  
• Cardiac arrhythmias:
  After extensive diagnosis of an existing cardiac arrhythmia, training at an adequate intensity can in many cases have a health-promoting effect, although this depends to a large extent on the exact nature of the condition. To date, there is no evidence-based information on whether high-intensity GK-EMS training can be performed despite cardiac arrhythmias, which is why its use should be ruled out due to potentially life-threatening consequences (Hordern et al., 2012).
  
  
• Tumours and cancer:
  In the case of tumours and cancer, physical activity is usually recommended, even at a high intensity (Dimeo & Thiel, 2008). At present, there are no evidence-based statements regarding the design of GK-EMS training for the treatment of this disease. Furthermore, there are no findings on potential tumour growth due to GK-EMS in the acute therapy phase, which is why GK-EMS training should be excluded. After the acute therapy phase has ended, GK-EMS application can be considered after prior medical clarification.
  => Update June 2024: Cancer is now viewed in a differentiated way and is no longer seen as an absolute contraindication, but as a relative contraindication that requires careful individual evaluation. Close coordination between patient, doctor and trainer is always a prerequisite for the use of EMS to ensure that the training is safe and beneficial.
  
  
• Bleeding disorder and bleeding tendency (haemophilia):
  In the case of a bleeding disorder, also known as haemophilia, wounds close more slowly and spontaneous bleeding may occur, e.g. in the form of joint bleeding. Wounds close much more slowly in those affected, occur more frequently and can lead to high blood loss. Since the effects of GK-EMS on bleeding disorders or bleeding tendencies have not yet been fully researched, GK-EMS training is categorically excluded due to the high risk for the affected patients (Kemmler et al., 2019).
  
  
• Neuronal diseases, epilepsy and severe sensitivity disorders:
  In GK-EMS, the involuntary contraction of the musculature is caused by stimulation of the nerve fibres located under the electrode, which transmits the signal to the muscle. In the case of epileptic disorders or hyper-excitability of nerve cells, this external stimulation could already lead to an increased tendency to have seizures, which is why GK-EMS is contraindicated due to the increased risk potential.
  
  
• Abdominal wall and inguinal hernias:
  As an acute and serious injury to the abdomen, an abdominal or inguinal hernia could be aggravated by physical exertion or pressure and tensile stress on the corresponding wound. This can result in the potential leakage or damage of internal organs. In this case, direct medical attention is required and therefore excludes any kind of sporting activity, including GK-EMS.
  
  
• Acute influence of alcohol, drugs or intoxicants:
  Due to the risk of massive damage to the organism under the influence of alcohol, drugs or intoxicants, physical training must be ruled out.

Relative contraindications

Relative contraindications describe indications that must be clarified by a specialist before GK-EMS training can be carried out or that exclude application to certain areas of the body. They are not general exclusion criteria for GK-EMS training and leave a certain amount of room for interpretation and action, which can, however, lead to uncertainties in practical implementation. The relative contraindications include the following factors:

• Acute back pain without diagnosis
• Acute neuralgia, herniated discs
• Implants that are older than six months
• Diseases of the internal organs, especially kidney disease
• Cardiovascular diseases
• Motion sickness
• Larger fluid accumulations in the body, oedema
• Open skin injuries, wounds, eczema, burns
• Taking certain medications

The relative contraindications, some of which are broadly and imprecisely formulated, are not intended to deter customers/patients, as indications must be clarified in advance with a medical professional. Rather, they serve a protective purpose: serious health impairments are to be recorded in order to determine whether these could have a direct influence on the resilience of the exercisers. This ensures safe and effective GK-EMS training. Medical conditions or episodes of pain that occurred some time ago do not constitute acute impairments. The decision as to whether or not to request a medical clearance ultimately depends on the overall medical history of the individual and the overall assessment of their state of health and their level of resilience.

If the impairments are only minor or occurred some time ago, this does not necessarily have to lead to a classification as a relative contraindication. Neuralgia (pain in the area supplied by a nerve) or herniated discs, for example, are only relative contraindications in the acute phase, as they lead to an impairment of the functional state, whereby the performance of the intervention is not possible without restrictions.

Relative contraindications such as oedema formation (accumulation of fluid in the body) or motion sickness (dizziness when moving) are symptoms whose cause usually remains unknown without medical clarification. These causes may be harmless; however, they could also be a leading symptom of a serious illness. Therefore, a specialist medical examination is essential in order to be able to carry out safe and effective GC-EMS training. However, if this is carried out within the scope of responsibility and competence of the trainer or therapist, care should be taken to ensure that the health benefits of GC-EMS application are weighed against the risks of the illnesses when checking for potentially existing relative contraindications. The aim of the query should not be to dramatise minor health impairments by classifying them as relative contraindications and only allowing GK-EMS training to take place after medical clearance.

In summary, it should be noted that the query of absolute and relative contraindications in accordance with scientific guidelines and in compliance with national regulations (e.g. DIN 33961 – Part 5) supports the effective and safe implementation of training and is of great advantage for both the customer/patient and the trainer/therapist.

Whole-body EMS training offers an effective and time-saving solution for the prevention and therapy of muscle atrophy and sarcopenia, especially for older people or those who are not very sporty. With individual supervision in a 1:1 or 1:2 setting, a high stimulus intensity is achieved that promotes muscle mass, strength and function, while being easier on the joints and less stressful than traditional strength training. Studies show the effectiveness of EMS in old age, particularly in terms of muscle building and maintenance.

The ageing process of the human body is not only reflected in wrinkled skin and grey hair. In youth and young adulthood, muscle mass and strength usually increase and reach maximum values, stagnate in mid-life and decrease again with advancing age.

Whole-body EMS training offers a simple and effective way to start building and maintaining muscle mass and function early on, because this is the prerequisite for counteracting muscle loss in old age or sarcopenia. Maintaining and building muscle helps to maintain quality of life in the long term [4, 5].

Extent and causes of age-related muscle loss

The ageing process is associated with a generalised and progressive loss of muscle mass and strength. From the age of 50, muscle mass decreases by around 1–2 % and muscle strength by 1.5–5 % per year [1]. The loss of fast-twitch type 2 muscle fibres is particularly rapid [2]. This is associated with a decrease in functional performance, which manifests itself, for example, in difficulties with walking, standing up or carrying. Mobility and independence are increasingly affected [2].

A variety of complex age-related processes are responsible for muscle loss, including:

• changes in hormonal balance
• changes in muscle protein synthesis and breakdown
• neurodegeneration
• increase in inflammatory factors
• insulin resistance
• reduction in the number and activation of satellite cells
• oxidative stress

Factors that promote muscle anabolism, such as insulin-like growth factor-1 (IGF-1) or testosterone, decrease. Factors that contribute to skeletal muscle breakdown, such as inflammatory cytokines, increase. In old age, connective tissue and fat are also increasingly deposited in and around the muscles [2-4].

 

Sarcopenia: definition and measurement methods

Sarcopenia is generally defined as an excessive, progressive, generalised loss of muscle mass, strength and function. Sarcopenia is now considered a skeletal muscle disease caused by adverse muscle changes that occur over the course of a lifetime.

Sarcopenia is common among older adults, with prevalence/incidence increasing with age. However, younger people can also suffer from it [5, 6]. Sarcopenia is considered ‘primary’ (or age-related) if no other specific cause for muscle loss can be identified beyond aging. If other causal factors are present (or in addition to aging), it is considered ‘secondary’. These include systemic diseases such as cancer, endocrine, neurological and, in particular, inflammatory diseases [5]. In addition, physical inactivity, for example due to a sedentary lifestyle or illness-related immobility, as well as poor nutrition with insufficient energy and/or protein intake, can lead to the development of sarcopenia [4, 5].

Consequences of sarcopenia

Sarcopenia is associated with a number of negative, often serious, consequences. For those affected, coping with everyday life becomes increasingly difficult. Sarcopenia leads to an increased risk of falling [7, 8], impaired mobility [9] and a progressive loss of independence [10] and quality of life [11, 12]. Sarcopenia is a major cause of the geriatric syndrome frailty [13] and is associated with osteoporosis [12], type 2 diabetes [14], heart disease [15], respiratory disease [16] and cognitive impairment [17]. Ultimately, sarcopenia is associated with disability [5], hospitalisation [18], the need for care [19] and a 3.6-fold increase in mortality [7].

Prevention and treatment of muscle loss in old age/sarcopenia

Physical activity, especially strength training, is considered the most effective intervention for the prevention and treatment of normal and excessive (sarcopenia) age-related muscle loss – and is also recommended in the guidelines. It improves muscle strength, muscle mass and physical performance. [4, 6]

To prevent or delay sarcopenia as much as possible, the musculature should be maximised in youth and young adulthood, maintained in middle age, and muscle loss minimised in old age [5, 20]. Regular strength training in middle to old age can slow muscle loss, prevent sarcopenia, and maintain physical function, mobility, independence, and quality of life for longer.

Whole-body EMS training is an ideal prevention and therapy option into old age.

Not all older people are able to achieve the comparatively high stimulus intensity required for good muscle building and maintenance in strength training, or to perform conventional high-intensity strength training. Furthermore, many people refuse to do strength training several times a week. In addition to a lack of motivation and convenience, a lack of time often plays a major role. [21, 22]

For this group of people who are not very sporty or are already weakened, whole-body EMS training is an attractive and effective option [21, 22]. It overcomes the challenges and hurdles of conventional strength training for muscle building – for people of all ages.

The application takes place under individual supervision in a 1:2 or 1:1 setting and, at once a week for about 20 minutes, is a time-saving procedure in which the effect of light, subliminal physical exercises is intensified to an effective level and a high stimulus intensity is achieved. EMS training also ensures immediate, continuous recruitment of type 2 muscle fibres [21-24]. Since no weights are used, whole-body EMS training is particularly gentle on the joints and subjectively less demanding.

The effectiveness and safety of whole-body EMS for the prevention and therapy of age-related muscle loss and sarcopenia has been demonstrated in various studies. Among other things, it has been shown to have a positive influence on muscle mass, strength, function, functional performance and abdominal fat [25-29]. At the molecular level, EMS modulates factors, particularly IGF-1, that promote muscle protein synthesis, inhibit muscle breakdown and activate satellite cells [30, 31].