Research Article Effects of Whole-Body ...downloads.hindawi.com/journals/ecam/2016/9236809.pdfResearch Article Effects of Whole-Body Electromyostimulation versus High-Intensity Resistance

Research ArticleEffects of Whole-Body Electromyostimulation versusHigh-Intensity Resistance Exercise on Body Composition andStrength A Randomized Controlled Study

Wolfgang Kemmler1 Marc Teschler1 Anja Weiszligenfels1 Michael Bebenek1

Michael Froumlhlich2 Matthias Kohl3 and Simon von Stengel1

1 Institute of Medical Physics Friedrich-Alexander University Erlangen-Nurnberg 91052 Erlangen Germany2Department of Sports Science University of Kaiserslautern 67663 Kaiserslautern Germany3Department of Medical and Life Sciences University of Furtwangen 78048 Schwenningen Germany

Correspondence should be addressed to Wolfgang Kemmler wolfgangkemmlerimpuni-erlangende

Received 3 November 2015 Revised 8 January 2016 Accepted 11 January 2016

Academic Editor Thomas Lundeberg

Copyright copy 2016 Wolfgang Kemmler et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

High-intensity (resistance) exercise (HIT) and whole-body electromyostimulation (WB-EMS) are both approaches to realize time-efficient favorable changes of body composition and strength The purpose of this study was to determine the effectiveness of WB-EMS compared with the gold standard reference HIT for improving body composition and muscle strength in middle-aged menForty-eight healthy untrained men 30ndash50 years old were randomly allocated to either HIT (2 sessionsweek) or aWB-EMS group(3 sessions2 weeks) that exercised for 16 weeks HIT was applied as ldquosingle-set-to-failure protocolrdquo whileWB-EMSwas conductedwith intermittent stimulation (6 sWB-EMS 4 s rest 85Hz 350ms) over 20minutesThemain outcome parameters were lean bodymass (LBM) as determined via dual-energy X-ray absorptiometry and maximum dynamic leg-extensor strength (isokinetic leg-press) LBM changes of both groups (HIT 125 plusmn 144 versus WB-EMS 093 plusmn 115) were significant (119901 = 001) however nosignificant group differences were detected (119901 = 395) Leg-extensor strength also increased in both groups (HIT 127 plusmn 147119901 = 002 versus WB-EMS 73 plusmn 103 119901 = 012) with no significant (119901 = 215) between-group difference Correspondingchanges were also determined for body fat and back-extensor strength Conclusion In summary WB-EMS can be considered asa time-efficient but pricy option to HIT-resistance exercise for people aiming at the improvement of general strength and bodycomposition

1 Introduction

Time constraints are frequently reported as the main hin-drance for frequent exercise thus time-saving exercise pro-tocols are attractive to people seeking to increase their perfor-mance attractiveness and health With respect to resistanceexercise low volume high-intensity training (HIT) protocolsseem to be the most time-efficient method to improve mus-cle mass and strength independent of the ongoing debatewhether resistance exercise with higher volume may bemore effective in general [1ndash5] However alternative trainingtechnologies tailored to commercial applicationsmay dispute

this position This includes in particular whole-body elec-tromyostimulation (WB-EMS) which is becoming increas-ingly popular in Europe Unlike the well-known local EMSapplication WB-EMS technology is able to stimulate all themain muscle groups with dedicated intensity simultaneouslyHIT andWB-EMS are often regarded as being similarly timeefficient and safe however the few studies comparing theeffects of both methods on muscle mass andor strength didnot show consistent results [6ndash10] Nevertheless commercialsuppliers advertise ldquooutcome effectsrdquo of up to 18-fold highercomparedwith conventional resistance exercise trainingThispromise is however primarily based on themisinterpretation

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2016 Article ID 9236809 9 pageshttpdxdoiorg10115520169236809

2 Evidence-Based Complementary and Alternative Medicine

Assessed for eligibility n = 67

Excluded n = 19Not meeting inclusion criteria n = 10

(i) Male 30ndash50 years old n = 3(ii) ldquoUntrained statusrdquo n = 3

(iii) ldquoConditions that prevent WB-EMSrdquo n = 1(iv) Absence for ge2 weeks during intervention n = 3

Declined to participate n = 9

Randomized n = 48Refused to participate in the allocated group n = 2

High intensity training (HIT) n = 23 Received allocated intervention n = 23

Electromyostimulation (WB-EMS) n = 23Received allocated intervention n = 23

ldquoLost to follow-uprdquo n = 3(i) Moved away n = 1

(ii) Withdrawn due to time constraints n = 2


(ii) Severe discomfort during WB-EMS n = 1

Analyzed (ldquocompleter analysisrdquo)HIT n = 20 WB-EMS n = 21

Figure 1 Flowchart of the study

of very pronounced creatine-kinase (CK) peaks after (too)intense initialWB-EMS application [11 12] whereas data thatclearly confirm the superiority of WB-EMS with respect torelevant outcomes (ie lean body mass strength) are stilllacking

To estimate the comparative relevance of WB-EMS forimproving body composition and muscle strength we com-pared WB-EMS with the comparably time-efficient goldstandard reference ldquoHITrdquo In order to conclude this issuewe conducted a randomized controlled trial with healthybut untrained males 30ndash50 years old aiming to improvetheir physical fitness and body composition Based on theresults of previous HIT [13] and WB-EMS [9 14 15] studiesour primary hypothesis was that HIT exercise training wassignificantly more effective for improving muscle mass andmaximum strength compared with WB-EMS

2 Methods

The aim of the study was to compare the effects of HIT-resistance training versus WB-electromyostimulation onbody composition and strength in healthy but untrainedmiddle-aged males living in the area of Herzogenaurach(Northern Bavaria Germany) To adequately address ourhypothesis we conducted a 16-week single-blinded (in thissection) randomized controlled exercise trial using a parallelgroup design (Figure 1)The trial was planned and conductedby the Institute of Medical Physics University of Erlangen(FAU) GermanyThe study complied with the Declaration ofHelsinki ldquoEthical Principles for Medical Research Involving

Human Subjectsrdquo and was approved by the ethics committeeof the FAU (Ethikantrag 245 13b) and the Federal Bureau ofRadiation Protection (Z5-224622-2013-090) All the studyparticipants gave written informed consent prior to studyparticipation

The study was registered under clinicaltrialsgov(NCT02078986) After the commencement of the trial nofurther changes were made to the trial protocol We adheredto the Consolidated Standards of Reporting Trial (CON-SORT) for reporting (randomized) clinical trials [16]

21 Participants Figure 1 gives the participant flow of thestudy Using the public register 1500 male subjects between30 and 50 years old living in the area of HerzogenaurachGermany were contacted in two blocks (September andNovember 2014) Personalized letters gave detailed studyinformation including themost relevant eligibility criteria forthe study Sixty-seven males responded and were assessed foreligibility Applying our inclusion criteria of (a) male 30ndash50 years old (b) ldquountrained statusrdquo defined as no regularresistance exercise training (lt1 sessionweek) and less than anaverage of 90min exerciseweek at all (c) lack of pathologicalchanges of the muscle or heart or inflammatory diseases(d) lack of medicationdiseases affecting muscle metabolism(e) conditions that prevent WB-EMS (eg epilepsy cardiacpacemaker) and (f) absence of less than 2 weeks during theinterventional period led to a total of 57 subjects being eligi-ble After informative meetings presenting the detailed studydesign interventions andmeasurements nine subjects with-drewThemain reasons for withdrawal were unwillingness to

Evidence-Based Complementary and Alternative Medicine 3

Table 1 Baseline characteristics of the participants of the HIT andWB-EMS group

Variable HIT119899 = 23

WB-EMS119899 = 23

Difference(119901)

Age [years]a 419 plusmn 64 437 plusmn 61 429Body height [cm] 1816 plusmn 56 1793 plusmn 63 197Body weight [kg] 888 plusmn 125 915 plusmn 128 471BMI [kgm2] 269 plusmn 33 285 plusmn 41 151Total body fat DXA [] 247 plusmn 48 265 plusmn 52 220Physical activity [index]a 291 plusmn 108 322 plusmn 151 463Exercise volume[minweek] 459 plusmn 378 502 plusmn 352 689

Energy intake [kcald]b 2346 plusmn 463 2387 plusmn 712 828Protein intake [gkgd]b 107 plusmn 027 110 plusmn 028 695Alcohol [gd]b 100 plusmn 94 121 plusmn 100 514Smoker [119899] 7 6 743aSelf-rated physical activity score (1 to 7 1 very low 7 very high) [17]bassessed by a 4-day dietary protocol and analyzed using the ldquoFreiburgerErnahrungsprotokollrdquo (Freiburger Nutrition Protocol Nutri-Science Ger-many)

join the randomization procedure (119899 = 5) andor to conductthe WB-DXA assessment (119899 = 2) In order to increase com-pliance with the group allocation the remaining 48 subjectswere randomly allocated to one of the two study groups(a) high-intensity training (HIT) group and (b) whole-bodyelectromyostimulation (WB-EMS) group by drawing lots Indetail each of the 48 lots was placed in intransparent plasticshells (ldquoKinder Eggsrdquo Ferrero Italy) and placed in a bowlso that participants and researchers never knew the alloca-tion Although subjects were requested to be free for bothmethods two subjects allocated to the HIT-study arm imme-diately withdrew after randomization In order to generatecomparable baseline group sizes however the randomizationsequence was correspondingly corrected by replacing a WB-EMS lot by a HIT lot Thus 23 HIT and 23 WB-EMS groupsubjects each embarked on the exercise program All studyparticipantswere requested tomaintain their physical activityand exercise habits during the study period

Table 1 gives baseline characteristics of the participantsRandomization was effective parameters that may haveconfounded our results did not vary significantly between thegroups

22 Procedures

Main outcome parameters are as follows(i) Total lean body mass (LBM) as assessed by whole-

body dual-energy X-ray absorptiometry (WB-DXA)(ii) Maximum dynamic leg-extensor strength as assessed

by an isokinetic leg-press deviceSecondary outcome parameters are as follows

(i) Total body fat as assessed by WB-DXA(ii) Maximum isometric back-extensors strength as

assessed by an isometric test device

23 Measurements Each participant was tested at baselineand follow-up by the same researcher at the same time ofthe day (plusmn1 hour) All follow-up tests were conducted afterone week of rest (week 18) Tests were performed on oneday within 60min Assessments were determined in a(semi)blinded mode Accordingly testing staff and outcomeassessors were unaware of the participant status (ie WB-EMS or HIT) and were not allowed to ask

231 Anthropometry Body height weight and waist cir-cumference were measured by calibrated devices Body MassIndex was calculated by weight (kg)height (m2) Total andregional body composition was determined by dual-energyX-ray absorptiometry (QDR 4500a Discovery UpgradeHologic USA) using the default standard protocols of themanufacturer Two researchers analyzed all the scans inde-pendently Interrater reliability (intraclass correlation ICC)for LBM was 092

232 Strength Parameters Maximum strength of the legextensors was determined using a ConTrex isokinetic leg-press (Physiomed Laipersdorf Germany) Bilateral concen-tric leg extension (and flexion) was performed in a sittingslightly supine position (15∘) supported by chest and hipstraps ROM was selected between 30∘ and 90∘ (knee angle)with the ankle flexed 90∘ and positioned on a flexible slidingfootplate The standard default setting of 05ms was used

After warm-up and familiarization with the movementpattern participants were asked to conduct five concen-tric repetitions (flexionextension) with maximum voluntaryeffort Participants conducted 2 maximum trials with two-minute rest in between the higher value was used for dataanalysis ICC for themaximum leg extension test is 088 (95CI 082ndash093) in our lab

Maximum isometric strength of the back extensors wasmeasured using a Schnell Isometric Tester (Schnell Peuten-hausen Germany) Participants were positioned on the dyna-mometer seat in an upright position and were supported bythigh and hip strapsThe participants had to press backwards(trunk extension) against the fixed lever arm touching theacromial site (extension) After two initial trials of low inten-sity participants conducted 2 maximum efforts each lasting3ndash5 seconds with a 40-second rest period in betweenAgain the higher value was used for data analysis For eachmeasurement the length and axis of the lever armand the seatposition of the participant were recorded to ensure optimumrepeatability Reproducibility of the isometric trunk strengthtests (ICC) was 086 and 084 for back extension and flexionrespectively

233 Confounding Factors A standardized questionnairewas applied to determine confounding factors that couldaffect the projected outcome parameters Lifestyle diseasesand medications and pain intensity and frequency at dif-ferent skeletal sites were assessed at baseline and follow-up Changes of physical activity and exercise were alsodetermined by follow-up questionnaires [17] and personalinterviews ICC of the questionnaires were 078 [17] and 090Individual dietary intake was assessed before and after trial


by a 4-day protocol The consumed food was analyzed usingthe Freiburger Ernahrungsprotokoll (Freiburger NutritionProtocol) (Nutri-Science Hausach Germany)

24 Study Procedure Participants of the HIT and WB-EMS exercise group performed 16 weeks of either high-intensity exercise training or WB-EMS from November 2014until March 2015 and from January 2015 until May 2015respectively in a well-equipped local gym All the exercisesessions were consistently supervised furthermore partici-pants recorded intensity volume and frequency of exercisein 4-week training logs In both interventions (HIT andWB-EMS) all participants were requested to maintain their usualmedication dietary habits physical activity and exerciseoutside the trial protocol throughout the study course

241 Resistance Exercise Training (HIT) Protocol In thisstudy HIT-resistance exercise was defined as single-set-to-failure protocol with intensifying strategies (manipulations ofrest periods time under tension and exercise sequence loadreduction) The exercise protocol scheduled two rarely three(9th 13th and 16th week) consistently supervised exercisesessions per week on nonconsecutive days All main musclegroups were addressed by 10ndash13 dedicated exercisessessiontaken from a pool of 17 exercises (latissimus back andfront pulleys front chin-ups seated rowing back extensioninverse fly hyperextension sitting bench press shoulder-press military press butterfly with extended arms crunchesleg-press leg extension leg curls and leg adduction andabduction) conducted on resistance devices (TechnogymGambettola Italy) While eight core exercises were applied inevery session the other exercises were prescribed in only oneof the two or (rarely) three sessionsweek

During HIT period I two weeks of initial condition-ing with consistently 2 sets of 15 repetitions (reps) andincomplete work to failure (maximum effort 2-3 reps) wasfollowed by two weeks of single sets with 8ndash10 repetitionswithmaximum effort (1 rep) During this first 4-week periodmovement velocity (time under tension TUT) was con-sistently prescribed as the following 2 s (concentric) 1 s(isometric) and 2 s (eccentric)

During the second 4-week period the periodized HIT-training sequence started with the specification to work tomomentary muscular failure (MMF) Prescribing maximumeffort the number of repetitions decreased linearly over 3weeks (5th week 8ndash10 reps to 7th week 3ndash5 reps) witheach 4th week planned as a ldquorecreational weekrdquo with lowereffort (maximum effort 1 rep) In detail participants wererequested to choose a load so that they could just perform theprescribed number of repetitions Sets were always conductedto MMF even when participants failed to realize the givennumber of repetitions Rest periods were consistently set at2 minutes between exercises In parallel movement velocityvaried ranging from TUT ldquoexplosiverdquo 1 s 2 s for the higherrepetition ranges (9-10 reps) to 3 s 1 s and 4 s for the lowerrepetition ranges (3-4 reps)

Additionally during the third 4-week period supersetvariations were introduced Either agonist supersets (ldquocom-pound setsrdquo) using related muscle groups (ie back lat

pulleys seated rowing and front chins) or antagonisticsupersets (ie leg extension leg curl and leg-press) backto back with minor rest (lt20 s) between the exercises and2 minutes between the superset blocks were applied inalternating sessions Using this concept week 4 of this periodwas applied as a regeneration week with lower effort

During the last 4 weeks (period IV) additional dropsets were introduced In detail after MMF participants wererequested to reduce the load and exercise again up to MMFSingle reductions of 10ndash20 of the load were prescribedduring the first two weeks however during the last twoweeks the load reduction of 10 was followed by anotherreduction of 5ndash20 thus participants had to work 3 timesto MMF During the last period movement velocity wasconsistently prescribed as (TUT) 2 s 1 s and 2 s

242 Whole-Body Electromyostimulation (WB-EMS)Because WB-EMS technology is a rather novel technologya brief introduction will be given Most innovative anddifferent from the well-established local EMS current WB-EMS equipment enables the simultaneous activation of up to14ndash18 regions or 8ndash12 muscle groups (upper legs upper armsbottom abdomen chest lower back upper back latissimusdorsi and 4 free options) with different selectable intensities

Adding up the stimulated area 2800 cm2 of body surfacecan be activated simultaneously Strain or more precisecurrent intensity can be individually selected and modifiedduring the EMS session The WB-EMS protocol applied inthe present study scheduled the intermitted low intensitylowamplitude movement protocol slightly adapted from usualcommercial settings and elaborately described in recentstudies [14 15 18 19] In detail participants conducteda consistently guided and supervised 20-minute WB-EMSsession 3 times in 2 weeks (ie 15 times per week eachMonday or Tuesday and each second Thursday Friday orSaturday) always on two nonconsecutive days over 16 weeksGroups of three participants were coached by a certifiedinstructor the session was also acoustically and visuallyguided by videos that exactly mimic the 6 s movement and4 s rest rhythm of the protocol (see below) Using WB-EMS devices from miha bodytecreg (Gersthofen Germany)bipolar electric current was applied with a frequency of85Hz and a pulse breadth of 350 120583s intermittently with 6 sof EMS simulation to perform the movement and 4 s of rest(Table 2) Generally the WB-EMS protocol closely followedthe typical setting of commercialWB-EMS sessionswith theirlow loadinglow amplitude movement strategy In summarythe 6 basic movements (ldquocore exercisesrdquo) given in Table 2were combined and slightly modified (eg twisted crunch)to generate 12 dynamic exercises that were performedwithoutany additional weights in a standing position Exercises werestructured in 1-2 sets of 6ndash8 repetitions

Amplitude velocity and corresponding intensity gener-ated by the movement were set low (ie squat leg-flexionlt35∘) to prevent effects from the exercise per se Additionallyno progressive increment of intensity with respect to theexercises was applied during the study phase After a condi-tioning period of 5 WB-EMS sessions current intensity wasindividually adapted in accordance with the participants in


Table 2 ldquoCore exercisesrdquo applied during WB-EMS

Exercise movements(1) Squat (6 s down) and vertical chest presssquat (6 s up) andvertical rowing(2) Squat (6 s down) and lat pulldownsquat (6 s up) with militarypress(3) Deadlift (6 s down) with arm-curls (ext)deadlift (6 s up) witharm-curls (flex)(4) Squat (6 s down) crunch with butterflysquat (6 s up) andreverse fly(5) Squat (6 s down) and trunk flexion (crunches) return toupright position

order to generate a rate of perceived exertion (RPE) of ldquohardrdquoto ldquovery hardrdquo (Borg CR-10 Scale ldquo6rdquo of ldquo10rdquo (impossible)[20]) The corresponding current intensity was saved foreach region on chip cards to generate a fast reliable andvalid setting during the subsequent WB-EMS sessions Afterthis initial setting and a current conditioning period of 3ndash5minutes instructors slightly increased the current intensityevery 3ndash5 minutes in close cooperation with the participantsto maintain the RPE of ldquohardrdquo to ldquovery hardrdquo during thesession

25 Statistical Analysis The a priori sample size calculationreferred to lean body mass Based on a sample size of 21subjects per group and a Type 1 Error of 5 the statisticalpower (1 minus 120573) to detect a 10 plusmn 10 difference between thegroups was 90 Assuming a dropout rate of 20 our goalwas to recruit 25 participants per group

The data were analyzed following a finisher analysis forexample all the participants who took part in the follow-upmeasurements were included in the analysis irrespective oftheir compliance Baseline and follow-up data are reported asmean values and standard deviations

Changes between baseline and follow-up inHIT andWB-EMS were reported both as absolute (tables) and as per-centage changes (text) In addition mean differences (with95 confidence intervals) between HIT and WB-EMS basedon absolute changes were reported in Table 3 Differences ofbaseline characteristics (Table 2) were checked by Welch 119905-test Where applicable (normal data distribution) analyses ofvariance with repeated measurements adjusted for baselinevalues were performed to check time times group interactionsotherwise Welch 119905-test based on absolute differences wasused All tests were 2-tailed and statistical significance wasaccepted at 119901 lt 05 Effect sizes (ES) were calculated usingCohenrsquos 1198891015840 SPSS 210 (SPSS Inc Chicago IL) was used for allstatistical procedures

3 Results

During the interventional period of 16 weeks 3 participantsof the HIT and 2 participants of the WB-EMS group werelost to follow-up As described above two subjects refusedto join their allocated intervention (HIT) and quit the studyimmediately after randomization Reasons for withdrawal

were (a) job related relocation (HIT 119899 = 1 WB-EMS 119899 = 1)(b) job related time constraints (HIT 119899 = 2) and (c) severediscomfort during the WB-EMS application (119899 = 1)

Relative attendance rate was comparable between thegroups (HIT 933 plusmn 70 versus WB-EMS 895 plusmn 107119901 = 171) net length of training sequence (exercise protocolonly) however varied significantly (119901 lt 001) between thegroups (HIT 303 plusmn 23 versus WB-EMS 20 plusmn 0 minutes)However the differences for total ldquotime under loadrdquo betweenHIT and WB-EMS (WB-EMS 242 plusmn 22 versus HIT 365 plusmn46min 119901 lt 001) did not fully reflect the difference in totaltraining volume (WB-EMS 403plusmn37 versus HIT 847plusmn87min119901 lt 001)

As stated perceived exercise intensity of the WB-EMSparticipants was consistently adjusted to an RPE of 6 (5= ldquohardrdquo 7 = ldquovery hardrdquo) during the session In parallelthe HIT participantsrsquo regular training logs demonstrated acorresponding RPE of 475 plusmn 28 for the first 4-week period564plusmn44 for the second period 642plusmn39 for the third periodand 731plusmn 36 for the last 4-week period without consideringthe ldquorecreational weeksrdquo

During the study course no relevant negative side effectswith respect to musculoskeletal lesions or diseases relatedpotentially to the study intervention were recorded

31 Main Outcome Parameters Table 3 lists baseline follow-up and corresponding changes and group differences forLBM and maximum leg-extensor strength At baseline bor-derline significant differences were observed for maximumleg-extensor strength but not for LBMHowever analysis wasconsistently adjusted to baseline values

LBM increased significantly (119901 = 001) in both groups(HIT 125 plusmn 144 versus WB-EMS 093 plusmn 115) with nosignificant differences between the two groups (119901 = 395) Inparallel the significant changes (119901 lt 001) of appendicularskeletal muscle mass (ie lean soft tissue of the upper andlower limbs not given in Table 3) in the WB-EMS and HITgroup (048 plusmn 041 versus 060 plusmn 045 kg 119901 = 341) confirmedthe results of the LBM assessment

With respect to changes of regional LBM we observeda slight trend to more favorable trunk-LBM changes in theHIT group (119901 = 635) similar changes for the lower limbs(119901 = 968) and 63 higher upper limb LBM changes in theHIT group (119901 = 039) indicating that LBM changes were notuniform

Maximum leg-extensor strength changed favorably inboth groups (HIT 127 plusmn 147 119901 = 002 versus WB-EMS73 plusmn 103 119901 = 012) with nonsignificant (119901 = 215) higherchanges among the HIT group Isometric back extensionstrength increased significantly (119901 lt 001) in both groups(HIT 102 plusmn 88 versus 116 plusmn 100) with no significantgroup difference (119901 = 663)

Total body fatmass decreased significantly in both groups(HIT minus44 plusmn 75 119901 = 035 versus WB-EMS minus37 plusmn 39 119901 =001) Differences with respect to body fat changes adjusted forbaseline total body fat mass were nonsignificant (119901 = 829)

Thus we have to reject our hypothesis thatHIT-resistancetraining was significantly more effective for improving mus-cle mass and maximum strength than WB-EMS


Table 3 Baseline and follow-up data absolute changes and statistical parameters of primary endpoints in the HIT WB-EMS and controlgroup

HIT (119899 = 20)(MV plusmn SD)

WB-EMS (119899 = 22)(MV plusmn SD)

DifferenceMV (95 CI) 119901 Effect size (1198891015840)

Lean body mass [kg]a

Baseline 6824 plusmn 738 6749 plusmn 733 mdash 875 mdash16 weeks 6910 plusmn 723 6812 plusmn 742 mdash mdash mdashDifference 855 plusmn 973 (001) 625 plusmn 775 (001) 230 (minus324 to 785) 395 026

Maximum leg extension strength (leg-press) [N]Baseline 3201 plusmn 783 3605 plusmn 506 mdash 050 mdash16 weeks 3608 plusmn 467 3869 plusmn 218 mdash mdash mdashDifference 408 plusmn 521 (002) 264 plusmn 448 (012) 144 (minus159 to 447) 215 030a119899 = 21 in the WB-EMS group

Table 4 Baseline and follow-up data absolute changes and statistical parameters of secondary endpoints in the HIT WB-EMS and controlgroup




Maximum isometric back extension strength [N]Baseline 2899 plusmn 731 2915 plusmn 627 mdash 939 mdash16 weeks 3194 plusmn 704 3253 plusmn 693 mdash mdash mdashDifference 295 plusmn 198 (lt001) 338 plusmn 284 (lt001) 33 (minus122 to 188) 663 18

Total body fat [kg]a

Baseline 2309 plusmn 700 2432 plusmn 723 mdash 259 mdash16 weeks 2207 plusmn 678 2341 plusmn 700 mdash mdash mdashDifference 102 plusmn 201 (035) 91 plusmn 100 (001) 230 (minus324 to 785) 829 007a119899 = 21 in the WB-EMS group

32 Secondary Outcome Parameters Secondary outcomeparameters were given in Table 4

33 Confounding Parameters With respect to relevant dis-eases 5 participants listed treated hypertension (HIT 119899 = 2)5 reported slight allergic respiratory disorders (HIT 119899 = 1)2 suffered from depression (HIT 119899 = 1) and 3 men statedresection of the thyroid or hypothyroidism (HIT 119899 = 1)No relevant changes of disease status were reported after theinterventional period As per the study criteria participantsreceiving medication affecting the musculoskeletal systemwere not included Further apart from discontinued hyper-tension treatment in two participants no relevant changes ofmedication during the study period were reported

Changes of occupational and leisure time physical activity(119901 ge 650) were slight and did not differ between the groups(119901 = 793) Further average exercise participation andweeklyexercise volume did not change significantly in the HIT orWB-EMS However in response to specific inquiries twoparticipants (HIT 119899 = 1 versus WB-EMS 119899 = 1) admittedhaving performed endurance exercise training (running)with an average volume of 2 and 25 hoursweek in order toreduce body fat (Table 4)

Energy uptake increased nonsignificantly in the HIT(29plusmn99 119901 = 413) and significantly in theWB-EMS group

(78 plusmn 106 119901 = 010) however group differences werenot significant (119901 = 159) In parallel relative protein intake(gkgd) increased in both groups (HIT 83plusmn216 119901 = 349versus WB-EMS 110 plusmn 175 119901 = 030) with no significantdifferences between the groups (119901 = 685) Of importanceno participants said that they had reduced energy uptake inorder to reduce weight or body fat

4 Discussion

Time-efficient exercise protocols may be the best choice forimproving fitness and body composition of subjects withlimited time resources In the area of resistance exercise twomethods namely high-intensity training (HIT) and whole-body electromyostimulation (WB-EMS) were identified ascandidates that satisfy the time-effectiveness requirement Inrespect to body composition only a few studies determinedthe effect of WB-EMS on body fat andor fat-free mass inhealthy young or middle-aged cohorts [6ndash10] Two of thethree studies that addressed lean body mass reported signifi-cant increases of total LBM ([10] not given [9] 19) alongwith significant reductions of body fat mass (5 and 7resp) In contrast Boeckh-Behrens et al [6ndash8] listed either noeffects [6 7] or significant fat gains [8] in their cohort of sportsstudents albeit with (very) low body fat using a suboptimum


test device The favorable effect of WB-EMS on muscle massparameters (eg cross-sectional area (CSA) fiber size andgirth) was confirmed by studies that conducted local EMSapplication in healthy nonathletic nonparalyzed subjects[21ndash25]While no comparative studies were available forWB-EMS the few studies that compared the effect of local EMSand volitional contraction onmusclemass in healthy nonath-letic persons determined comparable significantly positive(CSA) changes through both methods [21 25] Howeveralthough we generally confirmed these results our approachwas much more pragmatic and focused on comparing twotime-efficient training methods with respect to endpoints(eg body composition) relevant for the potential user

With respect to strength gains the significant positiveeffect of WB-EMS in healthy untrained subjects is undis-puted [26 27] The maximum isometric andor dynamicstrength gain of the present study is comparable to data givenfor WB-EMS application in studies with trained cohorts (119899 =5) [6ndash8 14 28] Interestingly studies that applied local EMSreported higher average isometric (up to 58) or dynamicmaximum (up to 80) strength gains with more favorableresults in trained or elite athletes compared with untrainedsubjects [27]

More relevant for this topic is the question of whetherEMS-induced strength gains were similar to traditionalresistance exercise training in untrained healthy cohorts withhigher training volume Unfortunately different protocolsfor resistance exercise and EMS along with varying end-points and muscle areas addressed prevent a clear decisionA simple comparison of EMS applications and resistancetrainingwith respect to strength parameters (ie powermax-imumstrength)without considering any further specificationshowed either superiority of EMS [29] of volitional resistanceexercise training [30 31] or no difference [25 32 33] at leastin untrained healthy subjects Hainaut and Duchateau [34]conclude after an early review of the literature that there isbroad agreement ldquothat the force increases induced by EMS(NMS) are similar to but not greater than those induced byvoluntary trainingrdquoHowever it should be considered that thelevels of evidence generated by these studies conducted in theeighties are only moderate

Some study features and limitations may reduce theimpact of our results (1) compared with other studies [35]focusing on LBM in adults the study was relatively short (16weeks) further we did not apply intermitted tests Thus (a)we cannot exclude the possibility that we did not assess themain effect of the exercise protocols on LBM and (b) wereunable to evaluate strength kinetics (2) We failed slightlyto reach our calculated sample size of 25 participantsgrouphowever the dropout rate was lower than expected Hencethe power of the study ought to be sufficient to detect relevanteffects (3) We did not adjust either protocol for exerciseparameters (eg exercise volume) Instead we focused on areal-world comparison of a novel exercise technology versus aldquogold standardrdquo reference protocol with the common denom-inator (low) time expenditure However with respect toexercise intensity we tried to apply comparable prescriptionsof exercise intensity via RPE (4) The exercise protocol ofthe HIT group was very strenuous however due to the low

training frequency and regular regeneration periods we didnot expect that results were confounded by overreachingsymptoms (5) The assessment of exercise intensity by RPE(Borg CR-10 Scale) may be critical because this tool has sofar been validated by voluntary exercise However we thinkit is legitimate to use RPE in this context at least under thepremise that other more objective approaches to identify andprescribe exercise intensity duringWB-EMS andHIT are notavailableapplicable (6) We focused on untrained middle-aged men assuming that both WB-EMS and HIT-resistanceexercise training may be equally attractive and feasible forthis cohort and hence this topic may be of high interest withrespect to health promotion Further a comparison of EMSand resistance exercise in trained or athletic cohorts may bedefective due to previous adaption to voluntary exercise inthese cohorts

5 Conclusion

In summary we observed comparable or at least similarincreases of muscle parameters after 16 weeks of WB-EMScompared with the reference method ldquoHITrdquo Thus WB-EMS can be considered as an attractive time-efficient andeffective option to HIT-resistance exercise for people seekingto improve general strength and body composition On theother hand due to the close supervision of present WB-EMS applications this exercise technology is much moreexpensive However taking into account the fact that WB-EMS technology will become more feasible and cost efficientover the next few years the application of WB-EMS will beincreasingly implemented in commercial and noncommer-cial fitness settings

Conflict of Interests

None of the authors had any advisory board or financialinterests

Acknowledgments

The authors acknowledge support of the ldquoBenevitalrdquo FitnessClub Herzogenaurach Germany and the Health Sport ClubldquoVerein Netzwerk Knochengesundheit eVrdquo Erlangen Ger-many

References

[1] R N Carpinelli R M Otto and R A Winett ldquoA criticalanalysis of the ACSM Position stand on resistance traininginsufficient evidence to support recommended training proto-colsrdquo Journal of Exercise Physiology Online vol 7 no 3 pp 1ndash602004

[2] M Frohlich E Emrich and D Schmidtbleicher ldquoZur Effizienzdes einsatz-vs Mehrsatz-trainings Eine metaanalytische betra-chtungrdquo Sportwissenschaft vol 36 no 3 pp 269ndash291 2006

[3] M Frohlich E Emrich and D Schmidtbleicher ldquoOutcomeeffects of single-set versus multiple-set trainingmdashan advancedreplication studyrdquo Research in Sports Medicine vol 18 no 3 pp157ndash175 2010


[4] J W Krieger ldquoSingle vs multiple sets of resistance exercise formuscle hypertrophy a meta-analysisrdquo Journal of Strength andConditioning Research vol 24 no 4 pp 1150ndash1159 2010

[5] B L Wolfe L M LeMura and P J Cole ldquoQuantitative analysisof single- vs multiple-set programs in resistance trainingrdquoJournal of Strength and Conditioning Research vol 18 no 1 pp35ndash47 2004

[6] W Boeckh-Behrens and S Treu Vergleich der Trainingseffektevon konventionellem Krafttraining maxxF und EMS-Training inden Bereichen Korperzusammensetzung Korperformung Kraft-entwicklung Psyche und Befindlichkeit Institut fur Sportwissen-schaften der Universitat Bayreuth Bayreuth Germany 2002

[7] W Boeckh-Behrens and M Bengel Krafttraining durch Elek-tromyostimulation Empirische Untersuchung zu den Krafteffek-ten bei einem Elektromyostimulationstraining am BodyTrans-former mit Variation der Belastungsdichte Institut fur Sport-wissenschaften der Universitat Bayreuth Bayreuth Germany2005

[8] W Boeckh-Behrens and D Mainka Krafttraining durch Elek-tromyostimulation Empirische Untersuchung zu den Krafteffek-ten bei einem Elektromyostimulationstraining am Body Trans-former mit Variation der Trainingsdauer Institut fur Sport-wissenschaften der Universitat Bayreuth Bayreuth Germany2006

[9] W Kemmler M Teschler M Bebenek et al ldquoEffekt von Ganz-korper-Elektromyostimulation auf die ubergreifende sportmo-torische Leistungsfahigkeit im Handballrdquo Deutsche Zeitschriftfur Sportmedizin vol 62 article 271 2011

[10] J Vatter Elektrische Muskelstimulation als Ganzkorpertrain-ingmdashMulticenterstudie zum Einsatz von Ganzkorper-EMS imFitness-Studio AVM Munchen Germany 2010

[11] M Jubeau A Sartorio P G Marinone et al ldquoCompari-son between voluntary and stimulated contractions of thequadriceps femoris for growth hormone response and muscledamagerdquo Journal of Applied Physiology vol 104 no 1 pp 75ndash812008

[12] A Kastner M Braun and TMeyer ldquoTwo cases of rhabdomyol-ysis after training with electromyostimulation by 2 young maleprofessional soccer playersrdquo Clinical Journal of Sport Medicinevol 25 no 6 pp e71ndashe73 2015

[13] S von Stengel AWittkeM Bebenek et al ldquoEffekte eines Kraft-trainingsprogrammes mit und ohne EiweiszligsuppelmentierungaufMuskelmasse undKraftrdquoDeutsche Zeitschrift fur Sportmedi-zin vol 63 article 205 2014

[14] W Kemmler R Schliffka J L Mayhew and S von StengelldquoEffects of whole-body electromyostimulation on resting meta-bolic rate body composition and maximum strength in post-menopausal women the Training and ElectroStimulation Trial(TEST)rdquo The Journal of Strength amp Conditioning Research vol24 no 7 pp 1880ndash1886 2010

[15] W Kemmler A Birlauf and S von Stengel ldquoEinfluss von Ganz-korper-Elektromyostimulation auf das Metabolische Syndrombei alteren Mannern mit metabolischem Syndromrdquo DeutscheZeitschrift fur Sportmedizin vol 61 pp 117ndash123 2010

[16] D Moher S Hopewell K F Schulz et al ldquoCONSORT 2010explanation and elaboration updated guidelines for reportingparallel group randomised trialsrdquo British Medical Journal vol340 article c869 2010

[17] W Kemmler J Weineck W A Kalender and K Engelke ldquoTheeffect of habitual physical activity non-athletic exercise musclestrength and VO2max on bone mineral density is rather low

in early postmenopausal osteopenic womenrdquo Journal of Muscu-loskeletal Neuronal Interactions vol 4 no 3 pp 325ndash334 2004

[18] W Kemmler S von Stengel J Schwarz and J L MayhewldquoEffect of whole-body electromyostimulation on energy expen-diture during exerciserdquo Journal of Strength and ConditioningResearch vol 26 no 1 pp 240ndash245 2012

[19] W Kemmler M Bebenek K Engelke and S von StengelldquoImpact of whole-body electromyostimulation on body com-position in elderly women at risk for sarcopenia the Trainingand ElectroStimulation Trial (TEST-III)rdquo Age vol 36 no 1 pp395ndash406 2014

[20] E Borg and L Kaijser ldquoA comparison between three ratingscales for perceived exertion and two different work testsrdquo Scan-dinavian Journal of Medicine and Science in Sports vol 16 no 1pp 57ndash69 2006

[21] P Bezerra S Zhou Z Crowley L Brooks and A HooperldquoEffects of unilateral electromyostimulation superimposed onvoluntary training on strength and cross-sectional areardquoMuscleand Nerve vol 40 no 3 pp 430ndash437 2009

[22] M Cabric H J Appell and A Resic ldquoEffects of electricalstimulation of different frequencies on the myonuclei and fibersize in humanmusclerdquo International Journal of Sports Medicinevol 8 no 5 pp 323ndash326 1987

[23] M Cabric and H J Appell ldquoEffect of electrical stimulation ofhigh and low frequency onmaximum isometric force and somemorphological characteristics in menrdquo International Journal ofSports Medicine vol 8 no 4 pp 256ndash260 1987

[24] J Gondin M Guette Y Ballay and A Martin ldquoElectromyos-timulation training effects on neural drive and muscle architec-turerdquoMedicine and Science in Sports and Exercise vol 37 no 8pp 1291ndash1299 2005

[25] H Matsuse N Shiba Y Umezu et al ldquoMuscle training bymeans of combined electrical stimulation and volitional con-tractionrdquo Aviation Space and Environmental Medicine vol 77no 6 pp 581ndash585 2006

[26] A FilipoviH KleinodeUDorman and JMeste ldquoElectromyo-stimulationmdasha systematic review of the influence of trainingregimens and stimulation parameters on effectiveness in elec-tromyostimulation training of selected strength parametersrdquoJournal of Strength and Conditioning Research vol 25 no 11 pp3218ndash3238 2011

[27] A Filipovic H Kleinoder U Dormann and JMester ldquoElectro-myostimulationmdasha systematic review of the effects of differentelectromyostimulation methods on selected strength param-eters in trained and elite athletesrdquo Journal of Strength andConditioning Research vol 26 no 9 pp 2600ndash2614 2012

[28] U Speicher and H Kleinoder ldquoModerne Trainingsregularienzur Effektivitatsprufung aktueller Krafttrainingsverfahrenrdquo inDifferentielle Kraftdiagnostik und Moderne TrainingsregulationBISP Jahrbuch Ed Bundesinstitut fur SportwissenschaftenCologne Germany 2008

[29] G Alon S A McCombe and S Koutsantonis ldquoComparison ofthe effects of electrical stimulation and exercise on abdominalmusculaturerdquo Journal of Orthopaedic and Sports Physical Ther-apy vol 8 no 12 pp 567ndash573 1987

[30] J W Halbach and D Straus ldquoComparison of electro-myo stim-ulation to isokinetic training in increasing power of the kneeextensor mechanismrdquo Journal of Orthopaedic amp Sports PhysicalTherapy vol 2 no 1 pp 20ndash24 1980

[31] T Mohr B Carlson C Sulentic and R Landry ldquoComparisonof isometric exercise and high volt galvanic stimulation on


quadriceps femoris muscle strengthrdquo Physical Therapy vol 65no 5 pp 606ndash612 1985

[32] D P Currier and R Mann ldquoMuscular strength development byelectrical stimulation in healthy individualsrdquo Physical Therapyvol 63 no 6 pp 915ndash921 1983

[33] R J Kubiak K M Whitman and R M Johnston ldquoChangesin quadriceps femoris muscle strength using isometric exerciseversus electrical stimulationrdquo Journal of Orthopaedic and SportsPhysical Therapy vol 8 no 11 pp 537ndash541 1987

[34] K Hainaut and J Duchateau ldquoNeuromuscular electrical stim-ulation and voluntary exerciserdquo Sports Medicine vol 14 no 2pp 100ndash113 1992

[35] M D Peterson A Sen and P M Gordon ldquoInfluence of resis-tance exercise on lean body mass in aging adults a meta-analy-sisrdquo Medicine and Science in Sports and Exercise vol 43 no 2pp 249ndash258 2011

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


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EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

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Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Assessed for eligibility n = 67

Excluded n = 19Not meeting inclusion criteria n = 10

(i) Male 30ndash50 years old n = 3(ii) ldquoUntrained statusrdquo n = 3

(iii) ldquoConditions that prevent WB-EMSrdquo n = 1(iv) Absence for ge2 weeks during intervention n = 3

Declined to participate n = 9

Randomized n = 48Refused to participate in the allocated group n = 2

High intensity training (HIT) n = 23 Received allocated intervention n = 23

Electromyostimulation (WB-EMS) n = 23Received allocated intervention n = 23


(ii) Withdrawn due to time constraints n = 2


(ii) Severe discomfort during WB-EMS n = 1

Analyzed (ldquocompleter analysisrdquo)HIT n = 20 WB-EMS n = 21

Figure 1 Flowchart of the study

of very pronounced creatine-kinase (CK) peaks after (too)intense initialWB-EMS application [11 12] whereas data thatclearly confirm the superiority of WB-EMS with respect torelevant outcomes (ie lean body mass strength) are stilllacking

To estimate the comparative relevance of WB-EMS forimproving body composition and muscle strength we com-pared WB-EMS with the comparably time-efficient goldstandard reference ldquoHITrdquo In order to conclude this issuewe conducted a randomized controlled trial with healthybut untrained males 30ndash50 years old aiming to improvetheir physical fitness and body composition Based on theresults of previous HIT [13] and WB-EMS [9 14 15] studiesour primary hypothesis was that HIT exercise training wassignificantly more effective for improving muscle mass andmaximum strength compared with WB-EMS

2 Methods

The aim of the study was to compare the effects of HIT-resistance training versus WB-electromyostimulation onbody composition and strength in healthy but untrainedmiddle-aged males living in the area of Herzogenaurach(Northern Bavaria Germany) To adequately address ourhypothesis we conducted a 16-week single-blinded (in thissection) randomized controlled exercise trial using a parallelgroup design (Figure 1)The trial was planned and conductedby the Institute of Medical Physics University of Erlangen(FAU) GermanyThe study complied with the Declaration ofHelsinki ldquoEthical Principles for Medical Research Involving

Human Subjectsrdquo and was approved by the ethics committeeof the FAU (Ethikantrag 245 13b) and the Federal Bureau ofRadiation Protection (Z5-224622-2013-090) All the studyparticipants gave written informed consent prior to studyparticipation

The study was registered under clinicaltrialsgov(NCT02078986) After the commencement of the trial nofurther changes were made to the trial protocol We adheredto the Consolidated Standards of Reporting Trial (CON-SORT) for reporting (randomized) clinical trials [16]

21 Participants Figure 1 gives the participant flow of thestudy Using the public register 1500 male subjects between30 and 50 years old living in the area of HerzogenaurachGermany were contacted in two blocks (September andNovember 2014) Personalized letters gave detailed studyinformation including themost relevant eligibility criteria forthe study Sixty-seven males responded and were assessed foreligibility Applying our inclusion criteria of (a) male 30ndash50 years old (b) ldquountrained statusrdquo defined as no regularresistance exercise training (lt1 sessionweek) and less than anaverage of 90min exerciseweek at all (c) lack of pathologicalchanges of the muscle or heart or inflammatory diseases(d) lack of medicationdiseases affecting muscle metabolism(e) conditions that prevent WB-EMS (eg epilepsy cardiacpacemaker) and (f) absence of less than 2 weeks during theinterventional period led to a total of 57 subjects being eligi-ble After informative meetings presenting the detailed studydesign interventions andmeasurements nine subjects with-drewThemain reasons for withdrawal were unwillingness to




WB-EMS119899 = 23

Difference(119901)





22 Procedures































3 Results
































4 Discussion








5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















WB-EMS119899 = 23

Difference(119901)





22 Procedures































3 Results
































4 Discussion








5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



































3 Results
































4 Discussion








5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of























3 Results
































4 Discussion








5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




































4 Discussion








5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of






















5 Conclusion




Acknowledgments


References













































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

























































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Documents

Research Article Effects of Whole-Body ...downloads.hindawi.com/journals/ecam/2016/9236809.pdfResearch Article Effects of Whole-Body Electromyostimulation versus High-Intensity Resistance