Whole-Body EMS-Training: Contraindications

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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.

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