Percutaneous electrical stimulation in strength training: an update

Numerous studies have used percutaneous electrical stimulation (PES) in the context of training programs to develop strength and physical performance in healthy populations (sedentary or trained). Significant increases in muscle and fiber cross-sectional area, isokinetic peak torque, maximal isometric and dynamic strength, and motor performance skills have been found after PES training. These strength gains are explained on the basis of the characteristics of PES motor units (MUs) recruitment: (a) a continuous and exhausting contractile activity in the same pool of MUs during the entire exercise period, (b) a supramaximal temporal recruitment imposed by the high frequency chosen (up to 40 Hz), and (c) a synchronous recruitment of neighboring fibers. The PES training method is complementary to voluntary training, mainly because the application of PES causes an unconventional spatial recruitment of MUs that, depending on the muscular topography, may entail the preferential recruitment of the fast-twitch MUs. In addition, the method does not specifically develop elasticity in skeletal muscle, and it must be accompanied by a technical workout.     

Prolonged electrical muscle stimulation exercise improves strength and aerobic capacity in healthy sedentary adults.

This investigation evaluated training responses to prolonged electrical muscle stimulation (EMS) in sedentary adults. Fifteen healthy subjects (10 men, 5 women) with a sedentary lifestyle completed a 6-wk training program during which they completed an average of 29 1-h EMS sessions. The form of EMS used by the subjects was capable of eliciting a cardiovascular exercise response without loading the limbs or joints. It achieved this by means of inducing rapid, rhythmical contractions in the large leg muscles. A crossover study design was employed with subjects undergoing their habitual activity levels during the nontraining phase of the study. The training effect was evaluated by means of a treadmill test to determine peak aerobic capacity [peak oxygen consumption (Vo(2))], a 6-min walking distance test, and measurement of body mass index (BMI) and quadriceps muscle strength. At baseline, the mean values for peak Vo(2), 6-min walking distance, quadriceps strength, and BMI were 2.46 +/- 0.57 l/min, 493.3 +/- 36.8 m, 360.8 +/- 108.7 N, and 26.9 +/- 3.4 kg/m(2), respectively. After training, subjects demonstrated statistically significant improvements in all variables except BMI. Peak Vo(2) increased by an average of 0.24 +/- 0.16 l/min (P < 0.05), walking distance increased by 36.6 +/- 19.7 m (P < 0.005), and quadriceps strength increased by 87.5 +/- 55.9 N (P < 0.005); we did not observe a significant effect due to training on BMI (P > 0.05). These results suggest that EMS can be used in sedentary adults to improve physical fitness. It may provide a viable alternative to more conventional forms of exercise in this population.     

Modeling investigation of learning a fast elbow flexion in the horizontal plane—prediction of muscle forces and motor units action

Experimental investigation of practicing a dynamic, goal-directed movement reveals significant changes in kinematics. Modeling can provide insight into the alterations in muscle activity, associated with the kinematic adaptations, and reveal the potential motor unit (MU) firing patterns that underlie those changes. In this paper, a previously developed muscle model and software (Raikova and Aladjov, Journal of Biomechanics, 35, 2002) have been used to investigate changes in MU control, while practicing fast elbow flexion to a target in the horizontal plane. The first trial (before practice) and the last trial (after extensive practice) of two subjects have been simulated. The inputs for the simulation were the calculated external moments at the elbow joint. The external moments were countered by the action of three flexor muscles and two extensor ones. The muscles have been modeled as a mixture of MUs of different types. The software has chosen the MU firing times necessary to accomplish the movement. The muscle forces and MUs firing statistics were then calculated. Three hypotheses were tested and confirmed: (1) peak muscle forces and antagonist co-contraction increase during training; (2) there is an increase in the firing frequency and the synchronization between MUs; and (3) the recruitment of fast-twitch MUs dominates the action.     

Electromyostimulation--a systematic review of the influence of training regimens and stimulation parameters on effectiveness in electromyostimulation training of selected strength parameters

Our first review from our 2-part series investigated the effects of percutaneous electromyostimulation (EMS) on maximal strength, speed strength, jumping and sprinting ability, and power, revealing the effectiveness of different EMS methods for the enhancement of strength parameters. On the basis of these results, this second study systematically reviews training regimens and stimulation parameters to determine their influence on the effectiveness of strength training with EMS. Out of about 200 studies, 89 trials were selected according to predefined criteria: subject age (<35 years), subject health (unimpaired), EMS type (percutaneus stimulation), and study duration (>7 days). To evaluate these trials, we first defined appropriate categories according to the type of EMS (local or whole-body) and type of muscle contraction (isometric, dynamic, isokinetic). Unlike former reviews, this study differentiates between 3 categories of subjects based on their level of fitness (untrained subjects, trained subjects, and elite athletes) and on the types of EMS methods used (local, whole-body, combination). Special focus was on trained and elite athletes. Untrained subjects were investigated for comparison purposes. The primary purpose of this study was to point out the preconditions for producing a stimulus above the training threshold with EMS that activates strength adaptations to give guidelines for implementing EMS effectively in strength training especially in high-performance sports. As a result, the analysis reveals a significant relationship (p < 0.05) between a stimulation intensity of ≥50% maximum voluntary contraction (MVC; 63.2 ± 19.8%) and significant strength gains. To generate this level of MVC, it was possible to identify guidelines for effectively combining training regimens (4.4 ± 1.5 weeks, 3.2 ± 0.9 sessions per week, 17.7 ± 10.9 minutes per session, 6.0 ± 2.4 seconds per contraction with 20.3 ± 9.0% duty cycle) with relevant stimulation parameters (impulse width 306.9 ± 105.1 microseconds, impulse frequency 76.4 ± 20.9 Hz, impulse intensity 63.7 ± 15.9 mA) to optimize training for systematically developing strength abilities (maximal strength, speed strength, jumping and sprinting ability, power).     

Effects of electrical muscle stimulation on body composition, muscle strength, and physical appearance

Electrical muscle stimulation devices (EMS) have been advertised to increase muscle strength, to decrease body weight and body fat, and to improve muscle firmness and tone in healthy individuals. This study sought to test those claims. Twenty-seven college-aged volunteers were assigned to either an EMS (n = 16) or control group (n = 11). The EMS group underwent stimulation 3 times per week following the manufacturer's recommendations, whereas the control group underwent concurrent sham stimulation sessions. Bilaterally, the muscles stimulated included the biceps femoris, quadriceps, biceps, triceps, and abdominals (rectus abdominus and obliques). An identical pre- and posttesting battery included measurements of body weight, body fat (via skinfolds), girths, isometric and isokinetic strength (biceps, triceps, quadriceps, hamstrings), and appearance (via photographs from the front, side, and back). EMS had no significant effect on the any of the measured parameters. Thus, claims relative to the effectiveness of EMS for the apparently healthy individual are not supported by the findings of this study.     

Muscular strength and power are correlated with motor unit action potential amplitudes,but not myosin heavy chain isoforms in sedentary males and females

It remains unclear if the sizes of higher-threshold motor units (MU) are associated with muscular strength and power. Therefore, the purpose of this study was to examine sex-related differences in muscle cross-sectional area (mCSA), percent myosin heavy chain (%MHC) isoform expression, and the MU action potential amplitudes (MUAP_AMPS)-recruitment threshold (RT) relationships of the vastus lateralis and isometric peak torque, isokinetic peak torque and mean power at 1.05 rad·s⁻¹ of the leg extensors. Surface electromyographic decomposition techniques were used to quantify MUAP_AMPS recorded during isometric muscle actions at 70% of maximal voluntary contractions and regressed against RTs with the slopes calculated. Ultrasound images were used to measure mCSA. Males had greater slopes from the MUAP_AMP-RT relationship than the females (P < 0.05). The greater slopes likely reflected larger higher-threshold MUs for the males. The mCSAs and slopes from the relationships were strongly correlated with isometric and isokinetic peak torque and isokinetic mean power (r = 0.78–0.82), however, type I %MHC isoform was only moderately correlated with isometric peak torque (r = −0.54). The results indicated that sex-related differences in muscular strength and power were associated more so with the sizes of the higher-threshold MUs (slopes) and mCSA than MHC isoforms. The amount of cross-bridge activity within muscle fibers that comprise higher-threshold MUs may be the primary contributor to muscular strength and power rather than the contractile properties of the muscle.     

Electromyostimulation--a systematic review of the effects of different electromyostimulation methods on selected strength parameters in trained and elite athletes

This is the first part of 2 studies that systematically review the current state of research and structure the results of selected electromyostimulation (EMS) studies in a way that makes accurate comparisons possible. This part will focus on the effects of EMS on strength enhancement. On the basis of these results, part 2 will deal with the influence of the training regimen and stimulation parameters on EMS training effectiveness to make recommendations for training control. Out of about 200 studies, 89 trials were selected according to predefined criteria: subject age (<35 years), subject health (unimpaired), EMS type (percutaneous stimulation), and study duration (>7 days). To evaluate these trials, we first defined appropriate categories according to the type of EMS (local or whole body) and type of muscle contraction (isometric, dynamic, isokinetic). Then, we established the most relevant strength parameters for high-performance sports: maximal strength, speed strength, power, jumping and sprinting ability. Unlike former reviews, this study differentiates between 3 categories of subjects based on their level of fitness (untrained subjects, trained subjects, and elite athletes) and on the types of EMS methods used (local, whole-body, combination). Special focus was on trained and elite athletes. Untrained athletes were investigated for comparison purposes. This scientific analysis revealed that EMS is effective for developing physical performance. After a stimulation period of 3-6 weeks, significant gains (p < 0.05) were shown in maximal strength (isometric Fmax +58.8%; dynamic Fmax +79.5%), speed strength (eccentric isokinetic Mmax +37.1%; concentric isokinetic Mmax + 41.3%; rate of force development + 74%; force impulse + 29%; vmax + 19%), and power (+67%). Developing these parameters increases vertical jump height by up to +25% (squat jump +21.4%, countermovement jump +19.2%, drop jump +12%) and improves sprint times by as much as -4.8% in trained and elite athletes. With regard to the level of fitness, the analysis shows that trained and elite athletes, despite their already high level of fitness, are able to significantly enhance their level of strength to same extent as is possible with untrained subjects. The EMS offers a promising alternative to traditional strength training for enhancing the strength parameters and motor abilities described above. Because of the clear-cut advantages in time management, especially when whole-body EMS is used, we can expect this method to see the increasing use in high-performance sports.     

Phosphorus-31 nuclear magnetic resonance study on the effects of endurance training in rat skeletal muscle

To evaluate changes in muscle energetics following endurance training, we measured phosphorus-31 nuclear magnetic resonance (31P NMR) spectra on rat muscle in vivo before and after training in the same animals. The endurance training lasted for 3 months. The 31P NMR spectra were obtained serially at rest, during exercise by electrical stimulation, and during recovery. Intramuscular phosphocreatine (PCr), inorganic phosphate (P(i)), adenosine 5'-triphosphate (ATP) and pH were determined from the NMR spectra. The ratio of PCr:(PCR + P(i) at rest showed no difference between the trained and control groups even after 3 months of training. During exercise, however, this ratio was significantly higher in the trained group than in the control group. The ratio also recovered more rapidly after exercise in the trained group. The intramuscular pH decreased slightly by approximately 0.1 pH unit during exercise but did not show a significant difference between the groups. These results indicated that endurance training of 3 months duration improved the ATP supply system in the muscle. They also demonstrated that 31P NMR is a potent method for evaluating the effects of training in the same individuals.     

Induction and adaptation of chaperone-assisted selective autophagy CASA in response to resistance exercise in human skeletal muscle

Chaperone-assisted selective autophagy (CASA) is a tension-induced degradation pathway essential for muscle maintenance. Impairment of CASA causes childhood muscle dystrophy and cardiomyopathy. However, the importance of CASA for muscle function in healthy individuals has remained elusive so far. Here we describe the impact of strength training on CASA in a group of healthy and moderately trained men. We show that strenuous resistance exercise causes an acute induction of CASA in affected muscles to degrade mechanically damaged cytoskeleton proteins. Moreover, repeated resistance exercise during 4 wk of training led to an increased expression of CASA components. In human skeletal muscle, CASA apparently acts as a central adaptation mechanism that responds to acute physical exercise and to repeated mechanical stimulation.     

Functional Diagnostics in Mitochondrial Diseases

Mitochondrial diseases (MD) with respiratory chain defects are caused by genetic mutations that determine an impairment of the electron transport chain functioning. Diagnosis often requires a complex approach with measurements of serum lactate, magnetic resonance spectroscopy (MRS), muscle histology and ultrastructure, enzymology, genetic analysis, and exercise testing. The ubiquitous distribution of the mitochondria in the human body explains the multiple organ involvement. Exercise intolerance is a common symptom of MD, due to increased dependence of skeletal muscle on anaerobic metabolism, with an excess lactate generation, phosphocreatine depletion, enhanced free radical production, reduced oxygen extraction and electron flux through the respiratory chain. MD treatment has included antioxidants (vitamin E, alpha lipoic acid), coenzyme Q10, riboflavin, creatine monohydrate, dichloroacetate and exercise training. Exercise is a particularly important tool in diagnosis as well as in the management of these diseases.     

Effect of insulin and contraction up on glucose transport in skeletal muscle

The major glucose transporter protein expressed in skeletal muscle is GLUT4. Both muscle contraction and insulin induce translocation of GLUT4 from the intracellular pool to the plasma membrane. The intracellular pathways that lead to contraction- and insulin-stimulated GLUT4 translocation seem to be different, allowing the attainment of a maximal effect when acting together. Insulin utilizes a phosphatidylinositol 3-kinase-dependent mechanism, whereas the exercise signal may be initiated by calcium release from the sarcoplasmic reticulum or from autocrine- or paracrine-mediated activation of glucose transport. During exercise skeletal muscle utilizes more glucose than when at rest. However, endurance training leads to decreased glucose utilization during sub-maximal exercise, in spite of a large increase in the total GLUT4 content associated with training. The mechanisms involved in this reduction have not been totally elucidated, but appear to cause the decrease of the amount of GLUT4 translocated to the plasma membrane by altering the exercise-induced enhancement of glucose transport capacity. On the other hand, the effect of resistance training is controversial. Recent studies, however, demonstrated the improvement in insulin sensitivity correlated with increasing muscle mass. New studies should be designed to define the molecular basis for these important adaptations to skeletal muscle. Since during exercise the muscle may utilize insulin-independent mechanisms to increase glucose uptake, the mechanisms involved should provide important knowledge to the understanding and managing peripheral insulin resistance.     

Acute metabolic,hormonal, and psychological responses to strength training with superimposed EMS at the beginning and the end of a 6 week training period

Objectives:The aim was to determine metabolic and hormonal responses to strength training with or without superimposed electromyostimulation (EMS) at the beginning and the end of a 6 week training period.Methods:20 strength trained subjects were randomly assigned to two groups. The first group (S) performed 4 sets of back squats with a constantly adjusted additional load of their individual 10 repetition maximum (10 RM) twice a week over 6 weeks. The second group (S+E) did the same training program with superimposed EMS on leg and trunk muscles. Physiological responses were determined before and after the first (TS 1) and the last training session (TS 12).Results:No significant differences of hormonal responses could be observed between groups and TSs. However, small to large effects on metabolism occurred between groups and TSs. Delayed onset muscle soreness (DOMS) was significantly higher 48h after TS 1 for S+E.Conclusions:Despite a higher DOMS after S+E, there is no acute effect of superimposed EMS on hormonal response to exhaustive resistance exercise. We suggest that, because of the high resistance during 10 RM bouts, most of the muscle fibers are already activated and superimposed EMS only activates few additional muscle fibers.     

Skeletal muscle adaptation to exercise: a century of progress.

Skeletal muscle physiology and biochemistry is an established field with Nobel Prize-winning scientists, dating back to the 1920s. Not until the mid to late 1960s did there appear a major focus on physiological and biochemical training adaptations in skeletal muscle. The study of adaptations to exercise training reveals a wide range of integrative approaches, from the systemic to the molecular level. Advances in our understanding of training adaptations have come in waves caused by the introduction of new experimental approaches. Research has revealed that exercise can be effective at preventing and/or treating some of the most common chronic diseases of the latter half of the 20th century. Endurance-trained muscle is more effective at clearing plasma triglyceride, glucose, and free fatty acids. However, at the present time, most of the mechanisms underlying the adaptation of human skeletal muscle to exercise still remain to be discovered. Little is known about the regulatory factors (e.g., trans-acting proteins or signaling pathways) directly modulating the expression of exercise-responsive genes. Because so many potential physiological and biochemical signals change during exercise, it will be an important challenge in the next century to move beyond "correlational studies" and to identify responsible mechanisms. Skeletal muscle metabolic adaptations may prove to be a critical component to preventing diseases such as coronary heart disease, type 2 diabetes, and obesity. Therefore, training studies have had an impact on setting the stage for a potential "preventive medicine reformation" in a society needing a return to a naturally active lifestyle of our ancestors.     

Unilateral Muscle Overuse Causes Bilateral Changes in Muscle Fiber Composition and Vascular Supply

Unilateral strength training can cause cross-transfer strength effects to the homologous contralateral muscles. However, the impact of the cross-over effects on the muscle tissue is unclear. To test the hypothesis that unilateral muscle overuse causes bilateral alterations in muscle fiber composition and vascular supply, we have used an experimental rabbit model with unilateral unloaded overstrain exercise via electrical muscle stimulation (E/EMS). The soleus (SOL) and gastrocnemius (GA) muscles of both exercised (E) and contralateral non-exercised (NE) legs (n = 24) were morphologically analyzed after 1w, 3w and 6w of EMS. Non-exercised rabbits served as controls (n = 6). After unilateral intervention the muscles of both E and NE legs showed myositis and structural and molecular tissue changes that to various degrees mirrored each other. The fiber area was bilaterally smaller than in controls after 3w of E/EMS in both SOL (E 4420 and NE 4333 µm² vs. 5183 µm², p<0.05) and GA (E 3572 and NE 2983 µm² vs. 4697 µm², p<0.02) muscles. After 6w of E/EMS, the percentage of slow MyHCI fibers was lower than in controls in the NE legs of SOL (88.1% vs. 98.1%, p<0.009), while the percentage of fast MyHCIIa fibers was higher in the NE legs of GA (25.7% vs. 15.8%, p = 0.02). The number of capillaries around fibers in the E and NE legs was lower (SOL 13% and 15%, respectively, GA 25% and 23%, respectively, p<0.05) than in controls. The overall alterations were more marked in the fast GA muscle than in the slow SOL muscle, which on the other hand showed more histopathological muscle changes. We conclude that unilateral repetitive unloaded overuse exercise via EMS causes myositis and muscle changes in fiber type proportions, fiber area and fiber capillarization not only in the exercised leg, but also in the homologous muscles in the non-exercised leg.     

The Effects of Exercise Training in Addition to Energy Restriction on Functional Capacities and Body Composition in Obese Adults during Weight Loss: A Systematic Review

Background

Obesity is associated with impairments of physical function, cardiovascular fitness, muscle strength and the capacity to perform activities of daily living. This review examines the specific effects of exercise training in relation to body composition and physical function demonstrated by changes in cardiovascular fitness, and muscle strength when obese adults undergo energy restriction.

Methods

Electronic databases were searched for randomised controlled trials comparing energy restriction plus exercise training to energy restriction alone. Studies published to May 2013 were included if they used multi-component methods for analysing body composition and assessed measures of fitness in obese adults.

Results

Fourteen RCTs met the inclusion criteria. Heterogeneity of study characteristics prevented meta-analysis. Energy restriction plus exercise training was more effective than energy restriction alone for improving cardiovascular fitness, muscle strength, and increasing fat mass loss and preserving lean body mass, depending on the type of exercise training.

Conclusion

Adding exercise training to energy restriction for obese middle-aged and older individuals results in favourable changes to fitness and body composition. Whilst weight loss should be encouraged for obese individuals, exercise training should be included in lifestyle interventions as it offers additional benefits.     

Summation of motor unit forces in rat medial gastrocnemius muscle

The summation of contractile forces of motor units (MUs) was analyzed by comparing the recorded force during parallel stimulation of two and four individual MUs or four groups of MUs to the algebraic sum of their individual forces. Contractions of functionally-isolated single MUs of the medial gastrocnemius muscle were evoked by electrical stimulation of thin filaments of the split L5 or L4 ventral roots of spinal nerves. Additionally, contractions of large groups of MUs were evoked by stimuli delivered to four parts of the divided L5 ventral root. Single twitches, 40 Hz unfused tetani, and 150 Hz fused maximum tetani were recorded. In these experimental situations the summation was more effective for unfused tetani than for twitches or maximum tetani. The results obtained for pairs of MUs were highly variable (more- or less-than-linear summation), but coactivation of more units led to progressively weaker effects of summation, which were usually less-than-linear in comparison to the algebraic sums of the individual forces. The variability of the results highlights the importance of the structure of the muscle and the architecture of its MUs. Moreover, the simultaneous activity of fast and slow MUs was considerably more effective than that of two fast units.     

Invited review: Effects of acute exercise and exercise training on insulin resistance.

Insulin resistance of skeletal muscle glucose transport is a key defect in the development of impaired glucose tolerance and Type 2 diabetes. It is well established that both an acute bout of exercise and chronic endurance exercise training can have beneficial effects on insulin action in insulin-resistant states. This review summarizes the present state of knowledge regarding these effects in the obese Zucker rat, a widely used rodent model of obesity-associated insulin resistance, and in insulin-resistant humans with impaired glucose tolerance or Type 2 diabetes. A single bout of prolonged aerobic exercise (30-60 min at approximately 60-70% of maximal oxygen consumption) can significantly lower plasma glucose levels, owing to normal contraction-induced stimulation of GLUT-4 glucose transporter translocation and glucose transport activity in insulin-resistant skeletal muscle. However, little is currently known about the effects of acute exercise on muscle insulin signaling in the postexercise state in insulin-resistant individuals. A well-established adaptive response to exercise training in conditions of insulin resistance is improved glucose tolerance and enhanced skeletal muscle insulin sensitivity of glucose transport. This training-induced enhancement of insulin action is associated with upregulation of specific components of the glucose transport system in insulin-resistant muscle and includes increased protein expression of GLUT-4 and insulin receptor substrate-1. It is clear that further investigations are needed to further elucidate the specific molecular mechanisms underlying the beneficial effects of acute exercise and exercise training on the glucose transport system in insulin-resistant mammalian skeletal muscle.     

Acute and chronic testosterone response to blood flow restricted exercise

The American College of Sports Medicine recommends lifting a weight of at least 70% 1RM to achieve muscular hypertrophy as it is believed that anything below this intensity rarely produces substantial muscle growth. At least part of this recommendation is related to elevated systemic hormones following heavy resistance training being associated with skeletal muscle hypertrophy. Despite benefits of high intensity resistance training, many individuals are unable to withstand the high mechanical stresses placed upon the joints during heavy resistance training. Blood flow restricted exercise offers a novel mode of exercise allowing skeletal muscle hypertrophy at low intensities, however the testosterone response to this exercise has yet to be discussed. The acute and chronic testosterone response to blood flow restricted exercise appears to be minimal when examining the current literature. Despite this lack of response, notable increases in both size and strength are observed with this type of exercise, which seems to support that systemic increases of endogenous testosterone are not necessary for muscular hypertrophy to occur. However, definitive conclusions cannot be made without a more thorough analysis of responses of androgen receptor density following blood flow restricted exercise. It may also be that there are differing mechanisms underlying hypertrophy induced by high intensity resistance training and via blood flow restricted exercise.     

Muscle Strength,Muscle Mass and Physical Impairment in Women with hypermobile Ehlers-Danlos syndrome and Hypermobility Spectrum Disorder

Objectives:To evaluate differences in physical impairment, muscle strength, muscle mass and muscle density between patients with hypermobile Ehlers Danlos Syndrome (hEDS), hypermobile spectrum disorder (HSD), and healthy controls.Methods:Female adults with hEDS (n=20) and HSD (n=23), diagnosed to the most recent criteria, and age-matched healthy controls (n=28) completed the Arthritis Impact Measurement Scale (physical functioning) and performed maximal muscle strength and strength endurance tests of lower and upper limbs (hand grip, posture maintenance, 30 seconds chair rise and isokinetic tests). Muscle mass and density were evaluated by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography.Results:No differences in physical functioning and muscle strength were found between adults with hEDS and HSD. Furthermore, no differences in muscle mass and density were observed between the three groups. Nevertheless, when both patient groups were compared to controls, physical functioning, maximal muscle strength and muscle strength endurance were significantly lower (all p<0.001), except for the hand flexors.Conclusion:Physical functioning, muscle strength, density and mass did not significantly differ between individuals with hEDS and HSD. Compared to controls, physical functioning and muscle strength (maximal and endurance) were significantly lower. Consequently, (functional) strength training in individuals with hEDS and HSD is necessary.