The Impact of Training With Whole Body-EMS
Phase: NA
Conditions: Healthy
Sponsor: Mayo Clinic

 
 
The Impact of Training with Whole Body EMS 
 
NCT04288154 
 
4/20/2022 

 
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The Impact of Training with Whole Body-EMS 
Version6 : April 20, 2022 
Aims and Objectives  
 
This study will be undertaken in healthy adults who are employees at Mayo Clinic, Rochester 
MN 
 
Primary Aim: 
To assess the impact of training with whole body-EMS for a 16-week period of time, involving 
1.0 x 20 minute training sessions per week, on peripheral endothelial function as measured using 
EndoPAT. 
 
Secondary Aims: 
To assess the impact of training with whole body-EMS for a 16-week period of time, involving 
1.0 x 20 minute training sessions per week, on: 
i) 
Body mass index, waist circumference, percentage body fat and distribution, and 
blood pressure 
ii) 
Serum lipid profile, blood glucose and HbA1c, blood inflammatory markers including 
high sensitivity-CRP and uric acid, and novel cardiovascular markers in the blood 
such as fibrinogen, homocysteine and lipoprotein 
iii) 
VO2 maximum (Cardiopulmonary exercise testing parameters) 
iv) 
Maximum strength and maximum power in chest press and leg press 

 
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v) 
Symptoms of angina as measured by the Rose Questionnaire 
vi) 
Quality of life as measured by the LASA Questionnaire, symptoms of depression as 
measured by the PHQ-9 Questionnaire, and symptoms of stress as measured on the 
Perceived Stress Scale 
vii) 
Temporal changes in blood levels of  creatinine kinase 
Sensorimotor characteristics (visual-motor reaction time, peak knee muscular force, muscular 
force steadiness, and balance/posture 
Hypotheses 
   
We hypothesize that healthy adults who are employees at Mayo Clinic, Rochester MN who 
undergo whole body-EMS training for a 16-week period of time, involving 1.0 x 20 minute 
training sessions per week, will experience: 
 
i) 
A significant improvement in peripheral endothelial function measured using 
EndoPAT  
ii) 
A significant improvement in body mass index, waist circumference, percentage body 
fat and distribution, and blood pressure  
iii) 
A significant improvement in lipid profile, blood glucose and HbA1c, blood 
inflammatory markers including high sensitivity-CRP and uric acid, and novel 
cardiovascular markers in the blood such as fibrinogen, homocysteine and lipoprotein  
iv) 
A significant improvement in VO2 maximum and cardiopulmonary exercise testing 
parameters 

 
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v) 
A significant improvement in maximum strength and maximum power in chest press 
and leg press  
vi) 
A significant improvement in symptoms of angina as measured by the Rose 
Questionnaire  
vii) 
A significant improvement in quality of life as measured by the LASA Questionnaire, 
symptoms of depression as measured by the PHQ-9 Questionnaire, and symptoms of 
stress as measured on the Perceived Stress Scale  
viii) 
No significant difference in blood levels of  creatinine kinase across time 
viii) 
A significant improvement in sensorimotor characteristics (visual-motor reaction 
time, peak knee muscular force, muscular force steadiness, standing balance, and 
overhead squatting posture) 
ix) 
  
 
Methods 
 
Trial Design 
This study will consist of a blinded randomized controlled prospective study design, and will 
include 80 healthy individuals who are employees at Mayo Clinic, Rochester MN.   
Excluded subjects will consist of: 
• Subjects under the age of 18 
• Pregnancy/or suspected pregnacy 
• Subjects with a history of liver or kidney disease, acute illness, taking medications (such 
as glucocorticoids) 
• Subjects who have conditions (such as chronic inflammatory muscular diseases or 
Cushing’s syndrome) that affect muscle mass 

 
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• Individuals with pacemakers and implantable cardiac defibrillators 
• Individuals who conduct any other type of resistance training (> 45 minutes/week) 
• Individuals who have regular “high” alcohol consumption (> 80g/day on 5 days a week), 
or are under acute influence of alcohol, drugs narcotics, and/or painkillers 
• Subjects unable to consent to or participate in the 16-week EMS intervention or be 
available for follow up (1).   
• Subjects who report recent surgeries 
• Cardiac arrhythmias 
• Active medical implants 
• Epilepsy 
• Seizures 
• Severe circulatory disorders 
• Arterial circulatory disorders 
• Strong bleeding tendencies (hemophilia) 
• Bleeding 
• Abdominal wall hernia 
• Inguinal hernia  
• Tuberculosis 
• Tumor diseases 
• Arteriosclerosis in advanced stage 
• Severe neurological disorders 
• Diabetes mellitus 
• Febrile diseases 
• Acute bacterial or viral infections 
• Liver diseases 
• Kidney diseases 
• Cardiovascular diseases 
• Coronary heart diseases 
• Infected or wounded areas of the skin 
• Skin cancer 
• Rhabdomyolysis 
 
All subjects in both groups who enroll into this study will undergo an assessment of peripheral 
endothelial function with reactive hyperemia-peripheral arterial tonometry (RH-PAT) testing 
using EndoPAT; an assessment of vital signs including heart rate, blood pressure, weight, height 
and body mass index; laboratory blood work; cardiorespiratory testing using treadmill testing to 
determine VO2 max and maximal tolerated heart rate; maximal strength and maximal power 

 
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testing on chest press and leg press testing; and ultrasound-based percent body fat and fat 
distribution testing at baseline, and at 16-weeks follow-up (immediately after completing a 16-
week training program using whole body-EMS) (Figure 1).   Baseline cardiovascular risk factors 
will be assessed by subject questionnaire and verified by chart review.  In addition, subjects will 
complete an angina/chest pain symptom questionnaire (Rose Questionnaire), quality of life 
questionnaire (LASA Questionnaire), depression questionnaire (Patient Health Questionaire-9) 
and perceived stress questionnaire (Perceived Stress Scale) to assess for psychosocial wellness at 
each point in the study.  Women of childbearing potential will have a urine pregnancy test to rule 
out pregnancy prior to enrollment. Sensorimotor characteristics such as visual-motor reaction time, 
Other sensorimotor characteristics (standing balance and posture) will be examined using a force 
plate and 2D camera with a commercially available app. .. . . Standing balance will be assessed by 
subjects standing on two legs for 30 seconds eyes-open and –closed. . Overhead squatting posture 
will be examined by analyzing static pictures of performing subjects with ipad-based postural 
assessment application (Posture Co, Inc, Trinity, FL, USA). 
 
Intervention 
Individuals who enroll in this study will be randomized to two groups, in a 1:1 ratio: intervention 
group and control group.  In the intervention group we will apply 16-weeks of conventional 
whole body-EMS training 1.0 time a week for a maximum of 20 minutes per session, with no 
intermittent breaks.  Individuals will undertake routine exercise maneuvers (including squatting, 
lunging, forward flexion etc.) under the guidance of certified trainers while simultaneously 
having percutaneous electrical stimulation applied to their bodies while exercising through the 

 
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whole body-EMS machine.  Individuals will be trained in a ratio of 2 subjects to 2 machines and 
one trainer.  Subjects in the control group will undergo training with a similar physical exercise 
program as those in the interventional group undertaking routine exercise maneuvers (including 
squatting, lunging, forward flexion etc.), and will use the same equipment and will be ‘dressed’ 
as if they were undergoing whole body-EMS, but will have no/subthreshold electricity signals 
applied to their body vest.  The EMS machine will be switched on and show normal wave 
patterns suggesting that it is working normally, but study participants will be blinded to whether 
or not they are receiving percutaneous electrical stimulation while doing the routine exercise 
maneuvers.  This will be applied for a 16-week training program 1.0 time a week for a maximum 
of 20 minutes per session, with no intermittent breaks.  Individuals will be trained in a ratio of 2 
subjects to 2 machines and one trainer.  Individuals will be randomized to each group, and they 
and the study investigators will be blinded to the intervention.  Otherwise, individuals in both 
groups will be asked to maintain their normal lifestyles. 
 
In order to generate a safe, individualized, joint-friendly, and time-efficient exercise protocol 
which will be potentially effective and feasible for a cohort that may have physical limitations, 
we plan to implement the same previously utilized whole body-EMS training protocol 
successfully applied in other whole body-EMS trials undertaken in Germany that have focused 
on body composition and functional parameters (1-4).  Briefly, with the whole body-EMS 
equipment (miha bodytec®, Gersthofen, Germany) we will apply a simultaneous but region 
specific stimulation of all the main muscle groups with an overall area of up to 2750 cm2. We 
will consistently run an guided whole body-EMS program in groups who will always supervised 

 
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and guided by two certified instructor (i.e., two applicants coached by one instructor). Whole 
body-EMS will be conducted on approximately the same day, once a week (i.e., 1.0 × week) for 
20 minutes.  The device will apply a bipolar electric current; we will select an impulse frequency 
of 85 Hz, an impulse width of 350 μs, and will apply an interval approach with 4 seconds of 
stimulation alternating with 4 seconds of rest.  Gentle slight dynamic exercises will be performed 
during the 4-second stimulation phase.  Each session will consist of 10–14 dynamic exercises 
structured in one to two sets of eight repetitions performed without any additional weights in a 
standing position. Most exercises will be based on a low amplitude squat exercise (< 35° leg 
flexion) with full amplitude movements of the arms (such as rowing, lat pulley, or butterfly).  
The emphasis of the protocol however will not be the effect on muscles induced by voluntary 
activation but by the application of whole body-EMS with high current intensity during 
functional movements. During the course of the study, the instructor will progressively increase 
the volume of stimulation by extending the length of the session from 14 up to 20 minutes after 4 
weeks of training.  The intensity of the stimulation will be regulated using a rate of perceived 
exertion (RPE) scale to generate a sufficient, but tolerable, intensity of EMS application to all 
stimulated areas. For each of the muscle groups stimulated, participants will be encouraged to 
exercise at a RPE of “6–7 out of 10” (i.e., “hard+ to very hard”) on the Borg CR10 Scale (5).  
This specification will be achieved in close interaction between the participant and instructor. 
Based on initial start settings determined after 4, 8, and 12 weeks, the impulse intensity will be 
increased slightly every 3 minutes to maintain/slightly increase the prescribed RPE during each 
session (refer to Supplemental Video). 
 

 
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Schedule of events 
 
Baseline  
Day 0 
Weeks 1-7 Week 8  
follow-up 
(+/- 7 days) 
Weeks 9-
15 
Week 16 
follow-up 
(+/-7 days) 
Informed Consent 
X 
 
 
 
 
Brief review of 
medical history 
X 
 
 
 
 
Exercise with EMS 
device 
X 
X 
X 
X 
X 
Blood draw and 
laboratory testing** 
 
X 
 
 
 
X 
Creatinine Kinase 
X 
 
X 
 
X 
Physical 
Assessment* 
X 
 
 
 
X 
Survey 
Questionnaires*** 
X 
 
 
 
X 
EndoPAT 
X 
 
 
X 
Ultrasound-Based 
Body fat and fat 
distribution 
measurements 
(Sports Medicine 
Testing) 
X 
 
 
X 
Urine pg test± 
X 
 
 
 
Sensorimotor tests 
X 
 
 
X 
 
*Physical assessment includes: body mass index, waist circumference, percentage body fat and 
distribution, blood pressure, maximum heart rate, VO2 maximum, maximum strength and 
maximum power in chest press and leg press  
 
**Laboratory Testing includes: high-sensitivity CRP, uric acid, fasting glucose, HbA1c, lipid 
panel, lipoprotein A, homocysteine fibrinogen.   
 
***Rose, LASA, PHQ-9, PSS Questionnaire 
±Women of childbearing potential only 
 
Outcomes and Measurements 

 
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 Research assistants will  perform all baseline, and follow-up tests at 16-weeks  based on 
availability of subjects schedule and tests equipment. 
 
Peripheral Endothelial Function: Endothelial function will be measured via the RH-PAT index 
as previously described (6-9).  The studies will be performed in a designated quiet, temperature 
controlled and uniformly lit room.  Individuals in the interventional and control groups will be 
tested at baseline, and will undergo re-testing after completing 16-weeks of training within their 
assigned arm (within 2 weeks of completion).  Subjects will be fasting for 4 hours before the study 
and will abstain from coffee or tobacco use on the day of the examination.  Subjects taking any 
vasoactive medications, including calcium channel blockers, nitrates, ACE-inhibitors or beta 
blockers, will discontinue these for 24 hours prior to testing.  The study will be conducted in the 
sitting position in a comfortable chair with armrests. A fitted blood pressure cuff will be placed on 
one arm, and the finger cuffs of the Endo-PAT 2000 device (Itamar Medical Inc. Ltd., Caesarea, 
Israel) will be placed on one finger of each hand (10).  Subjects will relax for 10 minutes before 
initiation of the protocol.  Baseline blood pressure and heart rate will be obtained via a digital 
automated blood pressure cuff (Omrom Healthcare, Inc., Vernon Hills, Illinois).  The EndoPAT 
2000 will be used specifically in this study because it is a Food and Drug Administration–approved 
noninvasive device, it allows continuous recording of the signal, and interpretation of the data is 
operator independent.  The use of a control arm will allow the elimination of systemic interference 
of the test and independence from the participant’s knowledge or conscious control of the signals 
(10-14).  The finger probes consist of inflatable latex air cuffs connected by pneumatic tubes to an 
inflating device controlled through a computer algorithm. A constant counter pressure 

 
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(predetermined by baseline diastolic blood pressure) will be applied through the air cushions. This 
prevents venous pooling and thereby venoarteriolar reflex vasoconstriction while not occluding 
arterial blood flow. Pulsatile volume changes of the distal digit induce pressure alterations in the 
finger cuff, which are sensed by pressure transducers and transmitted to and recorded by the Endo-
PAT device.  A decrease in the arterial blood volume in the distal fingertip causes a decrease in 
pulsatile arterial column changes, reflected as a decrease in the measured PAT signal, and vice 
versa. 
 
 
Previous studies have demonstrated dependence of the RH-PAT score on nitric oxide, 
confirming that reported RH-PAT scores indeed reflect changes in nitric oxide– dependent 
endothelial function, rather than neurohormonal activation (15).  The reactive hyperemia 
protocol will consist of a 16-minute reactive hyperemia test, in the following sequence.  A five-
minute baseline measurement, after which a blood pressure cuff on the test arm will be inflated 
to 60 mmHg above baseline systolic blood pressure, or at least 200 mmHg for five minutes 
(occlusion of pulsatile arterial flow will be confirmed by the reduction of the PAT tracing to 
zero) after which, the cuff will be deflated, and the post-deflation PAT tracing will be recorded 
for an additional six minutes. The ratio of the PAT signal after cuff release compared to baseline 
will be calculated through a computer algorithm automatically normalizing for baseline signal, 
and indexed to the contralateral arm. The calculated ratio reflects the RH-PAT score (scores 
below 1.7 will be considered consistent with abnormal peripheral endothelial function).  
Although RH-PAT scores may not be the gold standard for endothelial function, several studies 
have shown good correlation between these methods and more widely accepted methods of 

 
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endothelial function testing, such as intra-arterial acetylcholine infusion and brachial artery 
Doppler ultrasound following reactive hyperemia (11, 13, 14). 
 
Laboratory Testing: Laboratory testing will be undertaken in all participants at baseline, and at 
16-weeks follow-up in both the intervention and control group.  Venous blood will be drawn for 
high-sensitivity CRP, uric acid, fasting glucose, HbA1c, lipid panel, lipoprotein A, homocysteine 
and fibrinogen.  For patients in both groups, venous blood will also be tested for creatinine kinase 
levels at baseline, 8-weeks (halfway into the training programs), and 16-weeks (after completing 
each respective training program for both groups).  A blood sample of approximately 30 mL will 
be drawn and all samples will be sent to the Mayo Clinic central laboratory for analysis. 
 
Body Weight, Height, and Waist Circumference: Body height, weight and waist 
circumference will be measured using calibrated devices.  Body mass index will be calculated as 
mass (kg)/height (m2). 
 
 
 
  
 
VO2 MAX and Maximal Heart Rate: This will be tested using exercise treadmill testing in the 
conventional manner. 
 

 
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Questionnaires: Baseline clinical characteristics of all the participants will be carefully 
determined with validated baseline questionnaires (16).   Completeness and accuracy of the 
questionnaires will be carefully checked by research assistants in close cooperation with the 
participants.  In addition, all participants will complete four additional questionnaires at baseline, 
and 16-weeks follow-up in each of the intervention and non-intervention arms as follows: 
 
i) 
Rose Questionnaire Is a validated questionnaire that has been used previously to 
assess for symptoms of angina (17) 
 
ii) 
Linear Analog Self-Assessment (LASA) Mayo Clinic has developed a series of items 
that asks adults to rate their level of functioning on a scale from 0 (as bad as it can be) 
to 10 (as good as it can be).  The six items to be used in this study inquire about 
overall quality of life, and then cover the five domains of quality of life: (1) mental 
well-being, (2) physical well-being, (3) emotional well-being, (4) social well-being, 
and (5) spiritual well-being.(18, 19) 
 
iii) 
Patient Health Questionnaire-9 (PHQ-9) This is a questionnaire commonly used in 
clinical practice to assist in the assessment of patients who are suspected to have 
features consistent with a diagnosis of depression  
 
iv) 
Perceived Stress Scale (PSS) This is a 14-item self-report tool that provides a global 
measure of perceived stress.(20)  Responses range on a 5-point scale from “never” to 
“very often.”  A higher score indicates greater stress.  The PSS correlates well with 

 
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life-events stress measures and social anxiety, and has adequate reliability (α= .84, 
.85, .86) in three different samples.   
 
 
i) 
 
ii) 
Standing Balance: For standing balance test, participants will first stand on a portable 
force plate (Model6090-06, Bertec, Columbus, OH) with two feet as steady as possible 
for 30 seconds with eyes open. Then, the same procedures will be repeated with eyes 
closed. Next, the low back region will be strapped with a vibration device to stimulate 
the muscle spindles of the low back muscles during eyes-open and –closed balance. A 
total of three trials will be collected. Position and velocity data about the center of 
pressure (CoP) of the body will be calculated and used for analysis.  
 
Statistical Analysis  
This will be a randomized controlled trial in which there will be an interventional group and a 
control group into which individuals will be randomly assigned in a 1:1 ratio.  We will match 
individuals, a priori, as best as possible on age (within 5 years) and sex.  Baseline, demographic 
and risk factor distribution will be outlined in Table 1 of our analyses.  The following parameters 
will be measured in all subjects at baseline, and at 16-weeks follow-up (immediately after 
completing training in either study protocol depending on which group the participant is in): 
peripheral endothelial function measured with RH-PAT using EndoPAT; body weight and body 
mass index; waist circumference; blood pressure; total cholesterol, low and high density 

 
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lipoprotein cholesterol and triglycerides, fasting blood glucose and HbA1c; high sensitivity-CRP, 
uric acid, fibrinogen, homocysteine and lipoprotein A; percentage body fat; maximum strength 
and maximum power in  leg press; VO2 maximum, maximal heart rate, and scores measured on 
the Rose questionnaire, LASA questionnaire, PHQ-9 questionnaire and Perceived Stress Scale.  
In addition, serum creatinine kinase will be measured at baseline, 8 weeks and 16 weeks. 
 
We will compare values of each parameter between groups at baseline and after 16-weeks using 
unmatched analyses (using Student’s t-test when comparing the aforementioned measures as 
continuous variable and using Chi-squared test when characterizing variables in categories of 
normal vs. abnormal).  We will also assess for differences in the value of each parameter within 
groups between baseline and 16-weeks follow-up using matched analyses (using Student’s paired 
t-test when comparing the aforementioned measures as continuous variable and McNemar’s test 
when characterizing variables in categories of normal vs. abnormal).   Lastly, we will compare the 
differences between baseline and 16-weeks follow-up for each parameter between groups using 
unmatched analyses (using the student t-test when comparing the aforementioned measures as 
continuous variable and using Chi-squared test when characterizing variables in categories of 
normal vs. abnormal). 
 
Clinical Significance 
 
Cardiovascular disease (CVD) is the primary cause for morbidity, mortality, and the associated 
rising health care costs in the world (21). According to 2012 statistics, poor diet, smoking, and 

 
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lack of physical activity continue to account for an overwhelming majority of CVD and death (22). 
Recent data demonstrate that nearly one million people in the US have suffered an acute coronary 
syndrome (21) and recent reports highlight the increasing burden of CVD in the developing world 
(23). Despite these figures, the medical community has been unable to translate our current 
understanding of conventional cardiovascular risk factors and existing preventative strategies into 
a reduction in CVD morbidity and mortality (24). 
 
Strategies to Manage Risk of Cardiovascular Disease 
Major modifiable risk factors for CVD include hyperlipidemia, smoking (current or former), 
hypertension, abdominal obesity and diabetes mellitus, which are responsible for approximately 
80% of the population attributable risk for acute myocardial infarction in men and women (25).  
Identification of at-risk groups and appropriately addressing risk factors forms the cornerstone of 
successful management of CVD.  This is often achieved using multi-variable risk-prediction 
algorithms (26-29), of which the most widely used in clinical practice are the Framingham based 
models.  These scores assign weights to different levels of traditional risk factors such as age, 
total cholesterol and systolic blood pressure, which are combined to generate an absolute 
probability of developing CVD within a specified time frame.  Framingham based risk prediction 
models are well-established, practical and easy to use, supported by large amounts of data and in 
most cohorts discriminate risk well, after calibration where necessary (30).  Nevertheless, 
Framingham based scores are limited by incorporating only a limited number of risk factors, 
which have been identified from historically based population studies (31).  Further these 
conventional cardiovascular risk factors only account for between 58% and 72% of all incident 

 
16 
 
cases of coronary heart disease (CHD) (32).  Alternative nonconventional risk factors may 
account for some of this gap and are becoming increasingly important particularly as the effects 
of previously implemented attempts at managing conventional risk factors are being seen.  For 
example, one time trend analysis showed that patients presenting to the catheterization laboratory 
with CHD had better blood pressure and lipid profiles between 2006-2010, compared with 1994-
1999 (33), which may reflect improved uptake of primary and secondary preventative strategies 
such as smoking cessation (34) as well as a higher proportion of patients taking risk modifying 
cardiovascular medication (35).  Furthermore, in one study of young adults hospitalized with 
their first myocardial infarction, less than 25% would have qualified for lipid-lowering therapy. 
This is based on guidelines available at the time (36), and further demonstrates the limitation of 
current risk-based algorithms.  Thus, there is a need to identify, account for and manage novel 
risk factors not currently accounted for in traditional risk prevention models.  An example of 
such a factor is physical (in)activity and exercise. 
 
 
Physical Activity and Primary Prevention 
From 2006–2011, physical inactivity was associated with 11.1% of the aggregate healthcare 
spending in the USA, with inactive adults accounting for a 30% difference in mean annual US 
expenditure per capita compared with active adults ($1437 vs $713) (37).  Recent evidence has 
also indicated that time spent in sedentary behaviors is an independent risk factor for a number of 
adverse health consequences including obesity, metabolic syndrome, type 2 diabetes, some 
cancers, CVD-related mortality and all-cause mortality (38).  Physical inactivity has also been 

 
17 
 
shown to be associated with approximately 6% of CHD cases and a 0.68-year reduction in life 
expectancy (39).  Moderate-to-high levels of physical activity have clearly been shown to be 
protective against CVD (40, 41).  A dose response relationship between physical activity and 
cardioprotection has been shown, such that even small amounts of physical activity can have a 
beneficial effect on CVD risk (42).  Studies have shown that adults who maintain an active 
lifestyle as measured by accumulating more steps, and not necessarily through exercise per se, 
are likely to have a lower prevalence of metabolic syndrome (43) and regardless of exercising 
regularly or not, better cardiovascular health and longevity (44, 45).  A further study showed that 
postmenopausal women who either walk or vigorously exercise have substantial reductions in 
the incidence of CVD events (46).  Other large population-based studies have also shown a 
relationship between regular physical activity and reduced rates of CVD-related morbidity and 
mortality as well as favorable changes in risk factors for CVD such as systolic and diastolic 
blood pressure and lipid profile (47-50).  Physical activity also improves cardiorespiratory 
fitness, which also independently improves CVD risk profile (51). 
 
Physical Activity and Secondary Prevention 
Amongst patients with established CHD, exercise-based cardiac rehabilitation (CR) is the 
cornerstone of secondary prevention. CR consists of several core components including baseline 
patient assessment, nutritional and psychosocial counselling, risk factor management, as well as 
physical activity counselling and exercise training (52).  In patients with CHD, CR is associated 
with a 13% and 26% lower all-cause and CVD mortality, respectively, in addition to a 31% 
reduction in hospital admissions at 12 months (53).  CR participation is also associated with 

 
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improvements in CHD risk factors, reduced angina symptoms and depression, improved exercise 
capacity and enhanced health-related quality of life (54-56).  In patients with heart failure who 
are receiving optimal therapy, exercise-based CR programs confer an additional 11% reduction 
in all-cause mortality and hospitalization, a 15% reduction in CVD death and heart failure 
hospitalization, and improved quality of life (57-59).  In light of these significant benefits, most 
contemporary guidelines provide a Class I-level recommendation for referral to CR for eligible 
patients including those with stable angina, myocardial infarction within the past 12 months, 
cardiac surgery (coronary artery bypass grafting, valve repair/replacement or heart or lung 
transplant), percutaneous coronary intervention and systolic heart failure.  A careful history and 
physical examination are important to ensure that patients with CHD do not have residual 
ischemic symptoms, uncontrolled heart failure or threatening arrhythmias that may be triggered 
by vigorous exertion. The risks for these adverse events decrease significantly after the index 
cardiac event, allowing patients to safely enroll in CR as early as 1–2 weeks after hospital 
discharge (60).  Prior to prescribing physical activity for patients with CHD, patients’ exercise 
tolerance should be assessed by undertaking peak or symptom limited exercise testing to 
establish a baseline fitness level, and to evaluate for exercise-induced myocardial ischemia or 
arrhythmias that may alter ongoing medical management (60). Patients should be continued on 
their usual medications during exercise testing to simulate the anticipated hemodynamic 
responses during exercise training.   The safety of contemporary exercise based CR programs is 
well established, with a reported incidence of cardiac arrest and death of approximately 1 in 
115,000 and 1 in 750,000 patient hours of participation, respectively (53, 56, 60).  The general 
recommendation for patients is 30–60 minutes daily of moderate-intensity physical activity for at 

 
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least 5 days of the week and performed at an intensity of 40–80% of the peak heart rate (60).  For 
patients with ischemic signs or symptoms during exercise, the intensity of exercise should be 
prescribed at a heart rate at least 10 beats per minute below the ischemic or angina threshold 
(60).  While adverse CVD events are rare, increased medical supervision is necessary for those 
patients with moderate to high risk of complications.  A stable patient, however, can start CR as 
early as 1 week after discharge.  Due to the significant cardiovascular benefits of exercise, 
patients unable to attend supervised exercise sessions should continue to exercise independently. 
The recommended exercise intensity may be reduced to approximately 60% to 75% of the peak 
heart rate to decrease the risk of myocardial infarction or life-threatening arrhythmias (61).  
 
Lack of Uptake of Physical Activity 
In a recent study of 58,269 patients with acute myocardial infarction who were eligible for CR 
only 62.4% were referred to CR at the time of hospital discharge, and only 23.4% of all patients 
actually attended one or more CR sessions in the year following discharge, suggesting significant 
CR underutilization (62).  In addition, with regards to the primary prevention setting, though 
studies have shown a slight increase in physical activity amongst adults living in the United 
States between 1988 and 2000, 25% of American adults report no participation in leisure-time 
physical activity (63).  Further, most older people are unable or unwilling (64) to undertake the 
exercise doses recommended to favorably impact body composition and CVD risk (65).  Despite 
this the American Heart Association (AHA) and American College of Sports Medicine (ACSM) 
recommend at least 30 minutes of moderate-intensity physical activity 5 days a week, 20 minutes 

 
20 
 
of vigorous aerobic exercise 3 days a week or a combination thereof, in addition to 2-3 
days/week of resistance, flexibility and neuromotor exercises (66).   
 
Anecdotally, lack of time is a commonly cited reason for lack of widespread and consistent 
uptake of physical activity amongst healthy subjects as well as those with established CHD or 
heart failure.  A further reason may include lack of awareness and education in the potential 
benefits of engaging in frequent exercise as well as the harms of living a sedentary life.  
Additional reasons may include injury or fear of injury and indeed the most common risk 
associated with physical activity is musculoskeletal injury.  Unaccustomed vigorous physical 
activity may also trigger adverse cardiovascular responses including myocardial infarction and 
malignant arrhythmia.  Nevertheless, while musculoskeletal and cardiovascular complications 
from exercise increase with physical activity of increasing intensity, regular exercise and 
enhanced cardiorespiratory function unequivocally confer partial protection (67, 68).  Finally a 
lack of direction and monitoring as well as awareness in what type of exercise to do, how often 
to do it, and for how long further inhibits the widespread uptake of this habit whose integration 
into a day-to-day routine has proved challenging even for the most motivated of individuals. 
 
Existing Tools to Increase Uptake of Physical Activity 
To help improve the uptake of regular physical activity at the population level the US 
Preventative Service Task Force emphasizes the effectiveness of clinician counselling and 
specifically recommends that overweight adults with risk factors for CVD receive intense 
behavioral counselling (Grade B recommendation) (69).  When counselling patients, the AHA 

 
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recommends that clinicians use the following strategies: setting specific and short-term goals, 
providing feedback on progress, advocating strategies for self-monitoring, establishing a plan for 
frequency and duration of follow-up, using individually tailored interventions based on readiness 
to change, and motivational interviewing and enhancing patient self-efficacy (70). Health 
coaching, in which dedication towards one’s health is fostered via professional support and 
motivational interviewing, is generally well received and offers additional support in promoting 
lifestyle changes (71).  In an attempt to ensure physical activity is addressed frequently in the 
outpatient clinical setting, the American College of Sports Medicine and American Medical 
Association launched the initiative ‘Exercise is Medicine’ in 2007 (72).  The campaign calls for 
promoting physical activity as part of routine practice in healthcare, encouraging clinicians to 
evaluate their patients’ physical activity at every visit, ‘prescribing’ exercise at appropriate 
‘dosages,’ and where appropriate, referring patients to credentialed exercise professionals and to 
use technology to track participation (72).  This novel philosophy sees physical activity as a 
multi-disease targeting pharmaceutical equivalent that should be monitored, re-dosed and 
modified on an ongoing basis cultivating the mindset that exercise is indeed medicine.  Clearly, 
effectively enhancing the uptake of regular physical activity to improve population health 
requires a significant commitment in time and human capital, which are ever-present barriers 
encountered by patients and clinicians alike.  Rapidly evolving technology has helped to create 
adjunctive tools that assist in the promotion of physical activity by overcoming these barriers and 
upholding the key aforementioned strategies that help ensure lifestyle changes endure over time.   
 
Electronic Muscle Stimulation 

 
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These technological tools have included pedometers/accelerometers, mobile applications and 
social media, all of which have provided motivation and monitoring of progress (73).  Whole 
body electronic muscle stimulation (EMS), a method that primarily focusses on muscular 
dimensions, is a further development of local EMS application that enables all main muscle 
groups to be stimulated simultaneously with customizable intensity.  Whole body EMS provides 
a time efficient, joint friendly, highly adaptable training technology that forms a promising 
option to enhance the widespread and frequent uptake of physical activity, at least in middle-
aged and older people (2, 4) (see Figures 2 and 3).  While conventional exercise protocols may 
comprehensively influence cardiovascular risk factors and disease, as well as physical 
functioning amongst the elderly, decades of promoting physical activity has failed to enhance its 
widespread uptake such that only 30% of the European Union population aged 55 years and 
older exercise regularly (1).  This situation indicates the need for low-threshold interventions, 
which could at least offer the potential for improving some important health and functional 
parameters of advanced age. 
 
Furthermore, sarcopenic obesity (SO), defined as the combination of low muscle and high fat 
mass (74), is reported to be a frequent condition in elderly people, and is present in up to 94% of 
people aged  ≥ 60 years (75). SO is predominately caused by a decrease of physical activity in 
combination with stable caloric intake, malnutrition, and hormonal changes (76).  Older people 
with SO have demonstrated poor health, reduced functional capacity, and quality of life right up 
to loss of independence and institutionalization (74).  Besides the problems associated with 
progressive loss of muscle mass, the concurrent accumulation of (intra-)abdominal fat induces a 

 
23 
 
higher risk for cardio-metabolic diseases (77, 78).  Regular exercise favorably affect a number of 
cardiovascular risk factors and diseases in old age (79).  Indeed, resistance training is becoming 
an increasingly popular method of conditioning for recreational purposes and in competitive 
athletes.  In addition to recreation, resistance training is also increasingly being used in 
rehabilitation (80).  The benefits of resistance training on the skeletal muscle are well established 
(81), and may extend to the prevention and treatment of cardiovascular risk factors (82).  
However, the effect of resistance training on cardiac morphology and function remain equivocal.  
A cross-sectional cardiovascular MRI study by Fleck et al (83) showed concentric left 
ventricular myocardial adaption in individuals undergoing resistance training.  A further 
longitudinal cardiovascular MRI study showed that a relatively short period of high intensity 
resistance training in previously untrained men was associated with physiologically significant 
changes in cardiac atrial and ventricular morphology and function (84).  Apart from its potential 
use in endurance training, EMS could be of use in individuals who are not able to undertake 
physical training due to comorbidities or the underlying cardiac disease.  EMS has demonstrated 
positive effects on muscle and fat mass, and a gain of functional capacity in older sedentary 
people (85) (see below). However, even though there is some evidence that EMS may induce 
changes in body composition and could favorably decreased the metabolic syndrome amongst 
elderly patients (77), studies evaluating the potential role of EMS training on cardiac function 
and cardiovascular risk are lacking. 
 
Previous Studies Evaluating Electronic Muscle Stimulation 
 

 
24 
 
STUDY TITLE 
AIMS 
SAMPLE 
STUDY 
DESIGN 
MAIN 
RESULTS 
ADVERSE 
EFFECTS 
Kemmler et al. Evid 
Based Complement 
Alternat Med 2016 
Effects of Whole-
Body 
Electromyostimulation  
versus High-Intensity 
Resistance Exercise 
on Body Composition 
and Strength: A 
Randomized 
Controlled Trial (3) 
To 
determine 
the 
effectiveness 
of WB-EMS 
compared 
with the gold 
standard 
reference 
HIT, for 
improving 
body 
composition 
and muscle 
strength in 
middle-aged 
men 
Healthy 
untrained 
men, ages 30-
50 years 
N=48 
Randomized 
controlled trial: 
healthy 
untrained men 
aged 30-50 
years were 
randomly 
allocated to 
either HIT (2 
sessions/week) 
or a WB-EMS 
group (3 
sessions/2 
weeks) that 
exercised for 16 
weeks 
 
HIT was 
applied as 
"single-set-to-
failure 
protocol," while 
WB-EMS was 
conducted with 
Lean body mass 
changes of both 
groups (HIT 
1.25 ± 1.44% 
versus WB-
EMS 0.93 ± 
1.15%) were 
significant (p = 
.001); however, 
no significant 
group 
differences 
were detected 
(p = .395) 
 
Leg-extensor 
strength also 
increased in 
both groups 
(HIT 12.7 ± 
14.7%, p = 
.002, versus 
WB-EMS 7.3 ± 
10.3%, p = 
Nil reported 

 
25 
 
intermittent 
stimulation (6 s 
WB-EMS, 4 s 
rest; 85 Hz, 
350 ms) over 20 
minutes 
.012) with no 
significant (p = 
.215) between-
group 
difference 
 
Corresponding 
changes were 
also determined 
for body fat and 
back-extensor 
strength 
Kemmler, W. et al. 
Calcified Tissue 
International 2018 
 
Effects of combined 
whole body 
electromyostimulation 
and protein 
supplementation on 
local and overall 
muscle/fat distribution 
in older men with 
sarcopenic obesity: the 
Franso Study (1) 
To 
determine 
the 
combined 
effect of 
WB-EMS 
and 
protein 
supplements 
on local and 
overall 
muscle/fat 
distribution 
in older man 
Community 
dwelling men 
≥ 70 years 
with 
sarcopneic 
obesity  
 
N = 67  
 
Randomized 
controlled trial:  
WB-EMS and 
protein 
supplementation 
(n = 33) vs. 
a non-
intervention 
control group (n 
= 34) 
 
WB-EMS was 
conducted 1.5 
sessions of 20 
Thigh lean 
muscle volume 
increased 
significantly in 
the WB-EMS&P 
(p < 0.001) and 
increased 
slightly in the 
CG (p = 0.435) 
 
Fat volume 
increased 
significantly in 
the CG (p < 
3 participants in 
each of the WB-
EMS&P and 
control group 
were lost to 
follow-up: 1 
gave 
“discomfort 
during WB-EMS 
application” as a 
reason 
 

 
26 
 
 
with 
sarcopenic 
obesity 
min/week for 16 
weeks. Whey 
protein 
supplementation 
aimed to ensure 
a daily intake of 
1.8 g/kg body 
mass 
0.001) and was 
maintained in 
the WB-EMS&P 
group (p = 
0.728) 
 
Group 
differences for 
both 
parameters 
were 
significant (p = 
0.033 and p = 
0.002) 
 
Appendicular 
muscle mass 
and trunk fat 
also differed 
significantly 
(p < 0.001) 
between WB-
EMS and 
controls, with 
significant 
positive 
0 participants of 
the WB-EMS&P 
group 
reported serious 
problems; and 
no injuries or 
adverse 
effects were 
observed or 
reported by the 
participants 
 

 
27 
 
changes in the 
WB-EMS&P (p 
< 0.001) and 
no relevant 
changes in 
controls 
 
 Changes of 
gait velocity, 
leg-extensor 
strength, and 
advanced 
lower 
extremity 
function 
of the WB-
EMS&P group 
differed 
significantly 
from controls 
(p ≤ 0.002) 
Van Buuren et al. 
Rehabilitation 2014 
 
Electrical 
Myostimulation: 
To compare 
the effects of 
extended 
EMS to 
limited EMS 
Stable CHF 
patients 
(NYHA 
class II–III)  
were evaluate 
Randomized 
controlled trial: 
Extended EMS 
(n=18) vs. 
QoL was found 
to be improved 
in all 
No safety 
concerns or 
adverse effects 
were described 
 

 
28 
 
Improvement of 
Quality of Life, 
Oxygen Uptake and 
Left Ventricular 
Function in Chronic 
Heart Failure (86) 
on physical 
performance, 
left 
ventricular 
ejection 
function, and 
quality of 
life in 
congestive 
heart failure 
patients 
 
N=31 
limited EMS 
(n=13) 
 
Training 
was performed 
for 10 weeks 
twice weekly 
for 
20 minutes 
domains of the 
SF-36 
questionnaire 
 
In the extended 
EMS group 
there was a 
significant 
improvement in 
the domain 
physical 
functioning 
and emotional 
role 
 
Limited EMS 
group showed 
significant 
improvement in 
the domain 
vitality 
 
There was a 
significant 
increase in 
oxygen uptake 
Patients with 
pacemakers or 
implantable 
cardiac devices 
had been 
excluded from 
this study 
 
 

 
29 
 
at aerobic 
threshold in all 
groups (exEMS: 
+ 29.6 %, 
p < 0.001; 
limEMS + 17.5 
%, p < 0.001) 
 
EF increased 
from 36.94 ± 
8.6 to 42.36 ± 
9.1 % ( + 14.7 
%, 
p = 0.003) in 
the extended 
EMS group and 
37.7 ± 3.6 
to 40.3 ± 5.9 % 
[ + 6.9 %, p = 
0.18] in the 
limited EMS 
group 
Wittman et al. Clinical 
Interventions in Aging 
2016 
 
 
To 
determine 
the 
combined 
Community 
dwelling 
women ≥ 70 
years with 
Randomized 
controlled trial:   
6 months of 
WB-EMS with 
 Metabolic 
syndrome Z-
score decreased 
in both groups; 
No safety 
concerns or 
adverse effects 
were described 

 
30 
 
 Impact of whole body 
electromyostimulation 
on cardiometabolic 
risk factors in older 
women with 
sarcopenic obesity: the 
randomized controlled 
FORMOsA-
sarcopenic obesity 
study (87) 
effect of 
WB-EMS 
and 
protein 
supplements 
on the 
metabolic 
syndrome in 
elderly 
community 
dwelling 
women with 
sarcopenic 
obesity 
sarcopneic 
obesity  
 
N = 75  
 
or without 
protein 
supplementation 
(150 kcal/day, 
56% protein) 
vs. 
a non-
intervention 
control group  
(n=25 in each 
group) 
 
WB-EMS 
included one 
session of 20 
minutes (85 Hz, 
350 μs, 4 s of 
strain–4 s of 
rest) per week 
with moderate-
to-high intensity 
however, 
changes 
compared with 
the control 
group were 
significant 
(P=0.001) in the 
WB-EMS&P 
group only 
 
On analyzing 
the components 
of the metabolic 
syndrome, 
significant 
positive effects 
for both WB-
EMS groups 
were identified 
for mean 
arterial 
pressure, while 
the WB-EMS 
group 
significantly 
differed for 
 

 
31 
 
waist 
circumference, 
and the WB-
EMS&P group 
significantly 
differed for 
HDL-
cholesterol 
(P=0.006) from 
the control 
group 
 
No significant 
differences 
were observed 
between the 
WB-EMS 
groups 
 
Efficacy and Safety Considerations 
 
In voluntary strength training, the resistance of additional weight regulates the training intensity 
due to the maximum voluntary contraction (MVC), which is defined as one repetition maximum.  
In contrary to voluntary exercise, EMS activates muscle contraction artificially without using a 
resistance load.  For this reason, it is not possible to simply transfer conventional training 

 
32 
 
regimens into strength training with EMS.  Several studies have shown that electrical stimulus 
can be more intense than voluntary stimulus activated by the central nervous system  (88).   
In contrast to voluntary strength training, the MVC in EMS strength training is regulated 
according to the level of stimulation parameters. In turn, these parameters depend on the 
individual condition of the muscular system and on individual pain perception.  Under voluntary 
conditions, it is difficult to reach the absolute maximum level of contraction because 
accomplishing this depends on the individual’s level of strength and motivation. Some studies 
revealed that elite athletes with a high level of maximal strength are able to reach levels of MVC 
close to the absolute maximum, while average subjects only reach their maximum in extreme 
situations. For this reason, EMS could enable strength training at intensities that are otherwise 
difficult to reach because of personal motivation levels (88). 
 
In a previous study, Hortobagyi et al showed the effectiveness of different EMS methods for 
enhancing maximal strength, speed strength, jumping and sprinting ability, and power in trained 
and elite athletes (89).  In another review, the authors showed that EMS is effective for 
developing physical performance. Specifically, after a stimulation period of 3–6 weeks, 
significant gains were shown in maximal isometric and dynamic strength; eccentric isokinetic 
speed and concentric isokinetic speed strength; rate of force development; and power.  
Developing these parameters increased vertical jump height by up to 25% (squat jump +21.4%, 
countermovement jump +19.2%, drop jump + 12%) and improved sprint times by as much as -
4.8% in trained and elite athletes.  With regards to the level of fitness, the authors showed that 
trained and elite athletes, despite their already high level of fitness, were able to significantly 

 
33 
 
enhance their level of strength to the same extent as is possible with untrained subjects (90). 
Thus, EMS offers a promising alternative to traditional strength training.  However, compared to 
traditional voluntary strength training, several EMS parameters have to be considered in addition 
to parameters for common training regimens when undertaking strength training with EMS. This 
complexity of different combinations of training regimens and stimulation parameters makes it 
difficult to systematically implement EMS. 
 
 
In a review comparing different training regimens using EMS and their training effectiveness, 
Filipovic et al. highlighted a number of preconditions necessary for producing a stimulus above 
the training threshold using EMS to promote strength adaptations.  In doing so, they provided 
guidelines for implementing EMS effectively and safely  in strength training (88).  They showed 
a significant relationship between applying a stimulation intensity of ≥ 50% MCV and 
significant strength gains. To generate this level of MVC, they recommended training regimens 
that featured 4.4 +/- 1.5 weeks of training; 3.2 +/- 0.9 sessions per week for 17.7 +/- 10.9 
minutes per session.  They also recommended 6.0 +/- 2.4 seconds per contraction with 20.3 +/- 
9.0% duty cycle, with stimulation parameters as follows: impulse width 306.9 +/- 105.1 
microseconds; impulse frequency 76.4 +/- 20.9 Hz; and impulse intensity 63.7 +/- 15.9 mA to 
optimize training to systematically enhance abilities such as maximal strength, speed strength, 
jumping and sprinting ability, and power (88).  These formed acceptable training parameters that 
did not overstress the subjects’ muscular system that could in turn potentially hamper strength 
adaptations. 
 

 
34 
 
An important issue that has arisen with EMS training is the potential risk of elevation in blood 
creatinine kinase levels.  Studies investigating the effects of EMS on creatinine kinase levels 
have shown that the electrical stimulus from EMS can cause significantly more stress to the 
muscular system and therefore could lead to higher creatinine kinase levels compared to 
voluntary muscle contraction exercise (88, 91).  Indeed, due to the ability to innervate large 
muscle areas simultaneously with dedicated individual intensity to each muscle group, EMS can 
be associated with potential muscle injury.  One study showed that, compared to traditional 
strength training, the stress on the muscular system is about 40% higher after intensive EMS 
(88).  The authors arrived at the conclusion that the level of stimulation intensity is responsible 
for the elevation in creatinine kinase, while the duration of stimulation had no influence.  The 
authors also showed that subjects still exhibited high values after long periods ranging from 24 
hours to 4 days. Further stimulation within this time of decomposition would result in a 
cumulative rise in creatinine kinase levels (88), which in turn could overstress the muscular 
system further.  Further, one study in which whole body EMS was implemented to the point of 
exhaustion in healthy novices confirmed very high elevations in creatinine-kinase levels. 
Although this study did not detect any of the reported clinical consequences of this “severe” 
rhabdomyolysis, in less fit subjects who are neither optimally prepared nor supervised, initial 
whole body EMS to exertion may have more far-reaching consequences.  Consequently, EMS 
requires a greater interval between training sessions to prevent overstressing the muscular system 
and to ensure strength adaptations compared to conventional training.  Of note, a subsequent 
whole body EMS conditioning phase of 10 weeks completed by a second EMS test application to 
exhaustion demonstrated creatinine-kinase peaks in the range of conventional resistance exercise 

 
35 
 
(92).  Studies have also shown that the muscular system acclimatizes to the electrical stimulus in 
as little as 3 weeks, which in turn results in reduced creatinine kinase activity (88).  These results 
indicate that a short period of careful whole body EMS conditioning should be mandatorily 
implemented in order to realize a safe application.  Introducing the electrical stimulus to subjects 
before starting with the actual stimulation period as part of an acclimatization period might 
prevent a cumulative rise in creatinine kinase levels while helping to mitigate muscle soreness.  
Figure 4 highlights additional safety considerations.   
 
. 
Regarding the stimulation intensity, the aforementioned review showed that intensities of  ≥ 50% 
MVC were mostly produced with biphasic impulses (88).  Monophasic current flows from one 
electrode to the other in a fixed direction and can create an ionic current within the tissue. This 
can result in unpleasant side effects such as electrolysis and risk of chemical burning.  
Conversely, biphasic currents flow between both electrodes and thus have a zero net current.  
Accordingly, biphasic currents are perceived as more pleasant for the subjects’ muscles and thus 
subjects are able to tolerate biphasic currents better, which means that the impulses can be more 
intensive.  Consequently, biphasic currents offer advantages for applying high stimulation 
intensities and therefore have a positive influence on the enhancement of strength abilities. 
 
In regards to the influence of the impulse intensity (mA) on stimulation intensity (MVC), muscle 
contraction force can be regulated by varying the level of amperage (mA).  Accordingly, a higher 
impulse intensity (mA) results in a higher % MVC.  However, the impulse intensity depends on 
the resistance of different tissue structures, a major proportion of which is due to resistance of 

 
36 
 
the skin.  Therefore, it is not possible to precisely determine the impulse intensity (mA) that 
ultimately reaches the muscle. Consequently, most studies used the maximum pain threshold 
(maximum tolerated amperage) to regulate the maximum impulse intensity (88).  Nevertheless, 
the pain threshold depends on the subject’s individual pain perception on the particular muscle. 
Studies have shown that subjects quickly experience pain acclimatization with EMS, and thus in 
order to maintain a certain level of stimulation intensity the impulse intensity (mA) has to be 
continuously enhanced to adapt to the changing situation.  However, studies have also shown 
that when increasing the impulse intensity, a maximal level of muscle contraction force is 
achieved with intensities over 100 mA, above which no further positive effects result.  
Furthermore, maximal impulse intensities and thus high levels of muscle tension will limit 
dynamic movements, which are important when training with EMS.  Thus the impulse intensity 
(mA) has to be regulated to ensure unlimited and free movement.  This is an important 
consideration also when considering stimulation frequency.  While using 2–15 Hz stimulates 
mostly slow-twitch fibers (type 1), fast-twitch fibers (type 2), which are responsible for the 
development of high forces, may not contract below 35 Hz.  Any further increase in frequency 
can lead to a complete tetanus of the stimulated muscle.  There are different opinions about the 
maximum/ideal level of stimulation frequency and the authors of the aforementioned review 
have suggested a target range of 60 and 100 Hz as most effective.  Finally, studies have shown 
that a minimum impulse width of 500 microseconds is needed to develop high forces, and that 
lowering the impulse width significantly reduces the MVC.  Impulse widths of > 500 
microseconds should not be used as they would be unpleasant or even painful for the subject.  
Thus the authors of the aforementioned review concluded that an impulse width in a range 

 
37 
 
between 200 and 400 microseconds would be sufficient for generating the target stimulation 
intensities of ≥ 50% MVC.  Furthermore, this would also activate the deeper motor units without 
being unpleasant for the subject, and would still be intense enough to influence strength 
adaptations. 
 
 
Thus, EMS has to be applied intelligently and carefully, especially in untrained subjects who 
have to be trained with caution because of their lower resistance to intensive loads. Overloading 
the subjects’ muscular system by for example applying EMS with high stimulation intensity in 
combination with not enough regeneration time between sessions could inhibit or delay strength 
adaptations. This must be balanced against the fact that employing a load that is too low can 
result in a rapid decrease (within 2–4 weeks) in achieved strength gains, or to a lack of any 
significant enhancements in post-testing (88).  Nevertheless, significant strength gains have been 
demonstrated in individuals training appropriately with EMS after a period of only 2–6 weeks 
(88).  Several trials have also shown that when EMS is applied with optimal loads, the achieved 
strength gains can be kept at a constant level, amongst untrained and trained subjects, for up to 4 
weeks after post-testing without doing any exercise (88).   
 
Guidelines for safe and effective WB-EMS 
In general: 
1. Safe and effective Whole-Body-EMS Training must always be accompanied by a trained 
and licensed WB-EMS trainer or scientifically trained personnel familiar with this field of 
application. 
2. Before the first training session of every beginner, an anamnesis of possible 
contraindications based on a list of questions must be taken and then documented in 

 
38 
 
writing, confirmed by the client's signature and archived. Where relevant anomalies are 
found, a doctor is to be consulted and training only be commenced if clearance has been 
given. 
 
Preparing for training:  
1. As with any kind of intensive training, Whole-Body EMS training must only be carried out 
in a good physical condition and free of pain. This includes abstaining from alcohol, drugs, 
stimulants/muscle relaxants or stress ahead of the training session. Training must never be 
carried out by anybody suffering from an illness with fever.  
 
2. Whole-Body EMS training leads to very high metabolic stress of the organism because of 
very high volume of muscle mass addressed. This factor has to be taken into account 
through sufficient food intake that is as high in carbohydrates as possible. If this is not 
possible, then at least a high carbohydrate, but light snack (≈250 kcal) should be eaten, 
ideally about 2 hours before training.  
 
3. So as to avoid possible renal stress (especially with undiagnosed problems) through 
intensive WB-EMS, additional fluids should be consumed before/during and after training 
(500 ml each). 
 
4. Generally, medical – ideally sport-medicinal – consultation and clarification is advisable 
in the case of any discomfort, physical restrictions, infections or other internal, 
cardiological or orthopedic illnesses. 
 
Training: 
1. Regardless of physical status, sport experience and the user's wishes to that effect, under 
no circumstances may WB-EMS training to exhaustion take place during the first training 
session or trial training. This has led in the past to undesired side effects and negative health 
consequences and so must be avoided at all costs. 
2. After moderate initial WB-EMS, the stimulation level or current must be successively 
increased and adapted to the individual goals. The highest level is to be reached only after 
8-10 weeks of systematic training at the earliest (user's subjective effort impression: hard-
hard+). Training to complete exhaustion, especially in the sense of painful, continuous 
tetanus during the current phase, must generally be avoided. 
3. In addition, the initial training should be conducted with a reduced effective training period. 
Advisable is 5 min impulse familiarization and a curtailed training session with moderate 
stimulus intensity (user's subjective effort impression: a bit hard) and 12 min intermittent 
load with short impulse phase ( ). Only then should the training duration be cautiously 
increased and never exceed 20 minutes.  

 
39 
 
4. To ensure sufficient conditioning and to minimize or rule out possible health impairments, 
training frequency may not exceed one training unit per week during the first 8-10 weeks.  
5. Even after this conditioning phase, an interval of ≥4 days must be maintained between 
training units in order to avoid accumulation of muscle breakdown products, permit 
regeneration and adaptation and thus ensure a successful training outcome.  
 
Safety aspects during and after training 
1. During the training session, the trainer or the trained and qualified personnel should 
concentrate exclusively on the interests of the user(s). Before, during and after training 
the trainer verbally and visually checks the user's condition so as to rule out health risks 
and ensure effective training. Training is to be stopped immediately if there are any 
contraindications. A trainer can train a maximum of 2 people at the same time with EMS. 
 
2. During training, the equipment's operating controls must be directly in reach of the trainer 
and the user at all times. Operation/adjustment must be simple, quick and precise. 
 
 
Exercise and Endothelial Dysfunction 
 
Greater than > 40% of the risk reduction associated with exercise cannot be explained by 
changes in conventional risk factors.  This suggests a cardioprotective vascular conditioning 
effect of exercise that is characterized by enhanced nitric oxide vasodilator function, altered 
vascular structure and improved vascular reactivity (93, 94). Sedentary behavior has also been 
shown to impair endothelial function (95-98).  Endothelial dysfunction is the unique yet almost 
universal “response to injury” of the vasculature under various clinical circumstances (99, 100). 
It represents the first stage of atherosclerosis, and in fact, relates to plaque progression and 
vulnerability as well as a several fold increased risk of ischemic cardiac events and stroke (101-
106). In clinical practice it is most often recognized by an abnormal vasodilatory response to 
increased flow (shear stress) or endothelial-dependent vasodilating agents such as acetylcholine 

 
40 
 
(103, 107-109).  In the coronary vasculature, an attenuated increase or decrease in coronary 
blood flow (110-114) to acetylcholine marks the presence of microvascular endothelial 
dysfunction, whereas an angiographically evident vasoconstrictive response of the coronary 
arteries is indicative of epicardial endothelial dysfunction (103, 113, 115, 116).  Endothelial 
function can be assessed noninvasively, peripherally by the measurement of digital (finger) 
reactive hyperemia using peripheral arterial tonometry (RH-PAT) (117-119) (see below).  
Peripheral endothelial dysfunction (120) measured using RH-PAT correlates well with 
invasively measured coronary endothelial dysfunction and has been shown to be a strong 
independent predictor of adverse CVD outcomes (121, 122).  Observational data has 
demonstrated that people with minimal traditional risk factors for CVD but who have peripheral 
endothelial dysfunction have a higher incidence of heart disease, hospitalization, and death at 
follow-up compared to those without peripheral endothelial dysfunction (123-125).  Few clinical 
trials have evaluated the impact of physical activity and/or exercise on endothelial function as 
measured peripherally using RH-PAT.  One small trial demonstrated that when breaking 
prolonged sitting with very light activity, deterioration of endothelial function was avoided (97).  
Another study showed a strong relationship between lifetime physical activity level and reactive 
hyperemia index (RHI), but also showed higher levels of endothelial dysfunction in the group 
undergoing only low-moderate levels of activity, suggesting little beneficial effect (126).  A 
further study randomized patients with stable post-infarction heart failure to either moderate 
continuous training (70% of peak heart rate) or high intensity aerobic interval training (95% of 
peak heart rate) three times per week for 12 weeks or to a control group that received standard 
advice regarding physical activity.  The authors showed greater improvements in not only 

 
41 
 
cardiorespiratory function but also left ventricular remodeling and brachial artery flow-mediated 
dilation, an index of peripheral endothelial function, in the high-intensity aerobic interval 
training group compared to the moderate continuous training group (127).  High intensity 
training offers greater time efficiency in addition to superior cardiovascular effects, but the 
challenging nature of this form of training limits its widespread uptake.  An assessment of 
vascular health and endothelial function could provide an individualized and integrated index of 
cardiovascular risk, accounting for the cumulative effects of both harmful and protective factors, 
as the terminal pathway which precedes overt CVD.  Consequently, evaluating the link between 
exercise, and in particular, EMS as a novel tool in promoting time efficient, and highly 
individualizable physical training, and endothelial function forms an unique and interesting 
question that offers potential benefits to patients in the primary and secondary prevention setting 
alike. 
 
 
 
 
 
 
 
 
 
 

 
42 
 
 
 
 
 
 
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FIGURE 1 
 
 
 
 
 
Schematic outlining study flow 
 
 
 
 
 
 
 
 
 

 
53 
 
 
 
 
FIGURE 2 
 
 
 
 
 
 
The stimulation unit for the extended electronic muscle stimulation (vest with stimulation 
module for the legs) (courtesy of MihaBodytech Augsburg) 
 
 
 
 
 
 
 
 
 
 
 
 

 
54 
 
 
 
 
FIGURE 3 
 
 
 
 
 

 
55 
 
 
 
 
 
 
Demonstration of potential physical exercises that can be undertaken while applying whole body 
electronic muscle stimulation using the MihaBodyTec (Gersthofen, Germany) device 

 
56 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FIGURE 4 
 
 

 
57 
 
 
 
Safety recommendations put forward by a German consensus conference in December 2015, 
consisting of whole body-EMS manufacturers (miha-bodytec, Gersthofen, Germany), 
educational institutions (GluckerKolleg, Kornwestheim, Germany), Licensees (PT Lounge Koln, 
Cologne, Germany) and publishing researchers.  In April 2016, the scientific part of the 
consortium (Frohlich, M.; Kemmler, W.; Kleinoder, H. v. Stengel, S.) formulated these general 
safety guidelines