1. Miha bodytec distributor meeting
Gersthofen, Germany 14./15.09.2022
TOPIC I
Evidence of WB-EMS in
(chronic unspecific) low back pain
Anja Weissenfels, Lorenz Karl Konrad, Matthias Kohl, Simon von
Stengel, Bernd Wegener, Wolfgang Kemmler
Professor Dr. Wolfgang Kemmler
Institute of Medical Physics, Institute of Radiology
Friedrich-Alexander-University of Erlangen-Nürnberg
Germany
3. Rational for WB-EMS as a therapy for
chronic unspecific (low) back pain
• Almost everyone suffers from back pain at least once in their life (lifetime
prevalence: 74% to 85%) [Schmidt et. al 2007].
• Back pain is considered "No. 1" in disability-adjusted life years (DALYs), the
incidence has increased by 47% since 1990 [Global Burden of Diseases Study
2017].
• Many studies show that particularly strengthening and stabilizing training
methods can reduce pain intensity and frequency [Searle et al. 2015].
• However: Due to several reasons (e.g. lack of time, joint limitations,
kinesiophobia) many people are unable, unmotivated or unwilling to conduct
conventional (RT) exercise programs [Korsch et al. 2016;Luning et al. 2012].
…… new therapies/exercise approaches might be an option:
• Time efficiency (WB-EMS: 1x 20min/w.; WBV: 2x 15min/w.)…
• joint friendliness (slight) movements/exercises with low ROM…
• slightly lower perceived exertion (in average)…
• highly customizable and supervised…
4. Study I: Ambulatory cohort (RCT)
Comparison of novel training technologies such as whole-body electro-
myostimulation (WB-EMS) and whole-body vibration (WBV) with a
conventional back strengthening program (and CG) for chronic, un-
specific back pain patients.
Randomized, semi-blinded, controlled, multi-center study (RCT) of the
University Erlangen – Nürnberg and the German Sports University Cologne:
Phase I
April – July 2017 (12 weeks)
Comparison with control group
Phase II
Sep – Dec 2017 (12 weeks)
Start: Comparison with RT, WBV
Phase III
April – Juli 2018 (12 weeks)
Phase III
Sep - Dez 2018
(12 weeks)
Phase IV
Feb – May 2019 (12 weeks)
165 participants
Phase II: Cologne
240 participants
5. Methods Study I (ER/Co)
Participants:
• 40 to 70 years, independent living (m/f), outpatient application
• In the last 3 months at least 50% of the days pain in the lumbar spine
area (>1 on NRS 1-10) -> chronic LBP! (mean MV±SD: 4.1±1.9)
• No specific reasons (acute disc prolapse, stenosis, arthrosis, tumor,
cortisone therapy) for LBP -> unspecific LBP!
Study interventions (considering „usual care“ protocols):
• WB-EMS (1x 20min/week, 85Hz, 350µs, 6s-4s, 1 s; slight exercises)
• WBV (2x 15min/week, 5-10Hz, side-alterning)
• RT-circuit (1x 45min week, 10 exercise à 2 sets, 8-15 reps)
• All intervention were supervised (WBV not consistently)
Primary study outcome:
• Average pain-intensity as assessed for 4 weeks each (NRS 1-10)
6. Results „average pain intensity“
(primary study outcome)
Phase 1 (n=21/group) Phase 4 (n=80/group)
Summary: Significant differences between CG and WB-EMS in phase 1 (i.e. proof of
principle). No differences of WB-EMS compared to recognized interventions in phase
4. Most favorable (time) effectiveness and adherence in the WB-EMS group (n.s.).
I.e.: WB-EMS with marginal back-specific adaptations provide similarly positive
effects compared to specific back-strengthening RT:
A “dream result” for patients and physicians that now have a further non-
pharmacologic therapy option for chronic unspecific LBP!
7. Issue/Hypothesis I
(Evaluation of baseline differences)
Patients - without back pain
no muscular diseases
not neurological. Diseases
no dizziness / balance
-> no chronic back pain
Issue 2
(Differences CG- vs. WB-EMS)
Multimodal therapy concept
4 weeks stationary day clinic
Patients – with back pain
no muscular diseases
not neurological. Diseases
no dizziness / balance
chronic unspecific LBP
Study design
WB-EMS
1x 30 min/week for
6 months
Study II: (Semi) Stationary Cohort: WB-EMS for
chronic back pain Karl L. Konrad
Bernd Wegener
9. Karl L. Konrad
Bernd Wegener
Methods: Interventions, study outcome
• WB-EMS (1x 30min/week, 85Hz, 350µs, 6s-4s, slight
back specific movements/exercises)
Interventions:
WB-EMS „therapy“:
Multimodal therapy:
4 week of stationary day clinics (Mo-Fr):
• Physiotherapy: strength training, stabilization, coordination
• Psychology: Self-help strategies and relaxation techniques
• Ergotherapy: Training in ergonomic behaviour
• Physical therapy: hydro- and thermotherapy
• Medical information and education
Outcomes:
• Primary: Average pain-intensity as assessed for 1 week each (NRS 1-10)
• Sekundary: Oswestry Disability Index
(=Score for limitations caused by back pain)
10. Results on NRS and Oswestry
Disability Index
Karl L. Konrad
Bernd Wegener
* *
Conclusion: Significantly higher pain reduction in WB-EMS compared to the
multimodal program (NRS, ODI)!!! Progressive effect up to study end (24 weeks)
Limitations: no randomization; blinding (?); short comparison period (4 weeks)
11. Study design, Methods:
Study III: WB-EMS in patients with chronic low back
pain pain - who benefits the most?
Research Question:
• Are the improvements in pain intensity comparable between
patients with low, moderate and high initial pain levels?
Methods:
• Pooled cohorts of Erlangen/Cologne (lower baseline LBP-pain
intensity levels) and Munich (higher baseline pain level).
• Widely comparable WB-EMS protocol over 12 weeks (however,
20 vs. 30 min/session)
• Similar assessment tool (NRS 1-10); (however, assessment
period differ: 4 vs. 1 week)
12. Study III: Results on chronic LBP
Pain level
LBP
NRS n Baseline
LBP
absolute
(%)
Effect-
size
≥ 2
(%)
Low
Moderate
High
>2-3 27 2,80.3 -0,81* -29* 0,58 26*
>3-4 24 3,90,3 -1,34* -35* 0,67 38*
>4-5 13 4,80.3 -1,99* -41* 0,81 54*
>5-6 16 6,00,1 -1,97* -33* 0,80 63*
>6-7 9 6,80,3 -1,68* -25* 0,84 33*
>7 5 8,31,2 -3,72* -45* 0,90 80*
* p<.05
In summary, all categories of patients benefit from WB-EMS with signifi-
cantreduction of LBP-intensity. Of course, considering the absolute
changes, cohorts with higher baseline levels benefit considerably more,
however, based on %-changes no significant differences were observed
13. Conclusion and prospects
• The effectiveness of WB-EMS application in chronic, unspecific
low back pain is now confirmed with a high evidence level
(evidence levels 1b and 2a), high effect size and significance.
• The positive effect of WB-EMS on chronic LBP is widely
independent of the baseline LBP level of the patient
• Thus, the "negative recommendation” for electrotherapy
(including WB-EMS) of the mandatory guideline of the “NVL
Kreuzschmerz” (relaunch 22) have to be converted into a "have
to" recommendation (evidence recommendation level "a")!
• At the latest after the publication of the final results of the RCT
(ER/K) this (change in guideline) should be tackled with stamina.
• We suggest, that the topic of "WB-EMS and chronic unspecific
back pain" can now be more actively addressed and advertised
based on the corresponding evidence.
14. Fazit WB-EMS
Angesichts der sehr deutlichen Effekte auf die Muskulatur eher
ernüchternde, moderate Effekte auf die Knochendichte.
• Muskel-Knochen-Interaktion (bei EMS primärer „Knochenfaktor“)
doch nicht so eng wie postuliert?
Attraktive Trainingsmaßnahme für die überwiegende Mehrheit
der TEST-III WB-EMS-Teilnehmer.
• Individualisierte Betreuung (1 zu 3), Exklusivität
• Zeiteffektivität (20 min 3 x in 2 Wochen)
Adjuvante Effekte auf Muskulatur (Sturzprophylaxe!!) und
Rückenschmerzproblematik in TEST-III
Vertretbare Kosten der Intervention
(-) relativ teure Geräte, Betreuungsaufwand
(+) geringer Flächenbedarf
In Abhängigkeit von Priorisierung attraktive „alternative
Trainingstechnologie“ im Spannungsfeld „Frakturprophylaxe“
Thank you for your attention!
wolfgang.kemmler@imp.uni-erlangen.de
www.imp.uni-erlangen.de
The authors declare that they
have no conflict of interest
15. Miha bodytec distributor meeting
Gersthofen, Germany 14./15.09.2022
TOPIC II
Evidence of WB-EMS in
Sarcopenia Research
Wolfgang Kemmler, Matthias Kohl, Simon von Stengel
Professor Dr. Wolfgang Kemmler
Institute of Medical Physics, Institute of Radiology,
Friedrich-Alexander University of Erlangen-Nürnberg,
Germany
16. Background and rationals:
• In addition to the loss of muscle mass and -function,
there is an increase in body fat during adults ageing.
In extreme, this phenomenon is called “Sarcopenic
Obesity”1; a high-risk cohort for musculoskeletal and
cardiometabolic conditions.
• Physical exercise significantly affect both risk factors.
The majority of older people, however, are often no
longer able/motivated to complete strenuous training
protocols.
• The joint-friendly, customizable and time-efficient
WB-EMS technology and accompanying dietary
approaches might be feasible options to intense
exercise protocols2.
1 Stenholm, S. et al. (2008) Curr Opin Clin Nutr Metab Care 11: 693-700
2 Kemmler, W. et al. (2010) J Strength Cond Res 24: 1880-1886
Rational for WB-EMS in older people
17. EWGSOP II (European Working Group on Sarcopenia in Older People)1
1 Cruz-Jentoft et al. Age Ageing 2019, 48 (1): 16-31; 2 Fielding et al. JAMDA 2011,
(4): 249-56; 3 Studenski et al. J Gerontol A Biol Sci Med Sci 2014, 69: 547–558
Recent definitions on Sarcopenia
IWGSA (International Working Group on Sarcopenia)2
Sarcopenia is consistent with a (habitual) gait speed <1
m/s and an objectively measured low muscle mass (SMI≤
(DXA) 7.23 kg/m2 in men and ≤ 5.67 kg/m2 in women)
FNIH (Foundation for the National Institutes of Health)3
Sarcopenia is consistent with a handgrip strength of <26 / 16 kg and an SMI
(DXA) ≤ 7.89 kg/m2 in men and ≤ 5.12 kg/m2 in women
Due to its geriatric background („geriatric syndrome“)
the relevance of functional parameters was considered
higher compared with the morphometic aspect!!
Of importance, since 2016 (Germany 2018) Sarcopenia is
recognized as an “Independent Condition” by an Inter-
national Classification of Disease, Tenth Revision, Clinical
Modification (ICD-10-CM) Code: M62.84/M62.50
18. 1 de Oliveira, et al J Bodyw Mov Ther 2022; 31: 134-145; 2 Kemmler, et al. Clin Interv
Aging 2017;12:1503-1513; 3Yang, et al. Exp Gerontol 2022 Vol. 166 Pages 111886
Meta-analyses results on WB-EMS effects on
„Sarcopenia“ parameters in Sarcopenic cohorts1
Sarcopenia-Z-Score2: Individual data adjusted to Sarcopenia cut-offs (rationale:
to generate one primary outcome) e.g. according to the FNIH-definition:
Z = ((26 – indiv. grip strength)/SD grip strength) + ((0.789 – indiv. SMI)/SD SMI).
Comparable results were provided by Yang et al. 3
Six studies with Sarcopenia/Sarcopenic Obesity (SO) cohorts included:
Sarcopenia Z-Score: SMD 1.52 (95% CI: 0.77 to 2.27; p<.001; I2: low)
Skeletal Muscle Mass Index: MD 1.27 kg/m2 (0.66 to 1.88; p<.001; I2: low)
Handgrip-strength: MD 1.13 kg (0.06 to 2.21; p=0.04; I2: moderate)
Habitual gait speed: MD: 0.04 m/s (0.02 to 0.06; p<.001; I2: moderate)
Conclusion
There is moderate to high evidence for a favorable effect of
exercise on Sarcopenia in individuals with Sarcopenia or SO.
Dependent on protein status Protein supplementation may
increase the WB-EMS effect.
However, based on our experience, meta-
analyses in the area of exercise and
musculoskeletal outcome should be
interpreted with caution!
We just trust in RCTs – thus, lets revisit the
original data
19. Inclusion criteria „Sarcopenic Obesity“;
• SMI < 7,26 kg/m2 (-2.0 SD T-Score); body-fat rate >28% (DXA)
Randomized allocation of 100 participants to 3 study groups:
• Control-group (CG; Vitamin-D)
• Protein-Group (Proteinsupplement + Vitamin-D)
• WB-EMS & Protein-group (WB-EMS + Proteinsupplement + Vit-D)
Primary Hypothesis:
• SMI: WB-EMS&P >*Protein >*control
Secondary Hypothesis:
• Body fat: WB-EMS&P >* Protein >* control
• Sarkopenia-Z-Score WB-EMS&P >* Protein ≥ control
• Funktional Parameter WB-EMS&P >* Protein = control
Franconian Sarcopenic Obesity Study
(FranSO-RCT):
WB-EMS trial with cdw men 70+ with SO
20. WB-EMS-Training
• 1,5 TE/week 20 min, 16 weeks (each Mo/Tue and each second Thu/Fr)
• Bipolar, intermittent (6-4 sec), 85 Hz, 350 µs, Impulse-raise 1 sec;
• 8-10 easy exercises in a standing position; 6-7 Borg CR 10
• 1-2 sets, 6-8 reps; with low amplitude/-intensity
• Consistently supervised by a certificated instuctor (1:2)
Protein-Supplementation
• Total uptake (with dietary protein)≈1.8 g/kg/BM/d;
• Whey protein with high Leucin content (Inkospor, Roth)
• Individually adjusted by dietary protocols and analysis
Vitamin-D-Supplements (all groups)
• 800 IE/d Cholecalciferol
FranSO: Intervention Period
(16 weeks)
22. Here: Parallelgroup-Design with WB-EMS&P vs. CG only; each n=27
Deeper insight on muscle:
„muscle density“, CSV mid-thigh (MRI)
WB-EMS&P
MV±SD
CG
MV±SD
Difference
MV±SD
p
Fat free cross-sectional muscle volume of the mid-thigh [cm3]
Baseline 297.8±38.2 292.1±37.5 ------------ .603
Changes 8.47±10.37*** 1.77±10.9 n.s. 6.69 (0.6 - 12.8) .033
Intra-fascial fat volume of the mid-thigh [cm3]
Baseline 59.8.±13.6 67.8±22.6 ------------ .143
Changes 0.19±2.65 n.s. 5.28±6.92*** 5.09 (2.10 - 8.1) .002
23. Results: Obesity
Significant effects (i.e. verum vs.
CG) for total and abdominal body-
fat without relevant changes for
BMI. Best practise example for use-
nessless of BMI as an endpoint for
obesity in exercise studies!!!
24. Results: leg/back extensor
strength
However, to compare:
An recent HIT-RT study with a similar
cohort generates leg extensor strength
changes of 25% after 16 weeks.
Lichtenberg, T. et al. The favorable effects of a high-
-intensity resistance training on sarcopenia …..
Clinical Interventions Aging, accepted for publication
25. The effects of this intensive WB-EMS („hard+“) protocol on muscle
mass, -function, body fat (and CMRF) in this cohort of cwd men 70+
with SO can be considered as very satisfying.
Higher protein dosage (1,7-1,8 g/kg/d body mass) resulted in significant
positive effects on muscle and fat mass (and CMRF), however, not or
only negligible on funktional parameters (e.g. „strength“).
Of importance, we did not detect negative side-effects of moderate-
intensive WB-EMS or higher dosed protein supplementation on health
or well beeing1
Conclusion FranSO-study
WB-EMS and „adequately high“ protein-supplementation
(ideally combined) resulted in clinically highly relevant
effects on parameters related with physical performance,
morbidity and independency of the older subject.
1 Kob, R. et al. Safety of a combined WB-EMS and high protein diet intervention in sarcopenic
obese elderly men. Nutritions (2019): accepted for publication.
26. Fazit WB-EMS
Angesichts der sehr deutlichen Effekte auf die Muskulatur eher ernüchternde,
moderate Effekte auf die Knochendichte.
• Muskel-Knochen-Interaktion (bei EMS primärer „Knochenfaktor“)
doch nicht so eng wie postuliert?
Attraktive Trainingsmaßnahme für die überwiegende Mehrheit der TEST-III WB-EMS-
Teilnehmer.
• Individualisierte Betreuung (1 zu 3), Exklusivität
• Zeiteffektivität (20 min 3 x in 2 Wochen)
Adjuvante Effekte auf Muskulatur (Sturzprophylaxe!!) und Rückenschmerzproblematik
in TEST-III
Vertretbare Kosten der Intervention
(-) relativ teure Geräte, Betreuungsaufwand
(+) geringer Flächenbedarf
In Abhängigkeit von Priorisierung attraktive „alternative
Trainingstechnologie“ im Spannungsfeld „Frakturprophylaxe“
Thank you for your Attention!
Wolfgang.kemmler@imp.uni-erlangen.de
www.imp.uni-erlangen.de
The authors declare that they
have no conflict of interest
