As physical therapists, some of our most important duties to our patients include helping them regain lost strength, and then encouraging them to trust their body. If patients get discharged without feeling physically empowered, they might not trust their body and strength when confronted with many of the ADLs that initially gave them problems.
When looking to build strength, there are many tools that can be employed. However, in a small clinic where space is limited, or when budgets are tight, it helps to be realistic about what is possible. Buying a specific machine, a large set of dumbbells, or a barbell with a platform, is not only expensive, but also consumes quite a bit of space. In addition, these tools provide limited use depending on exercise selection and the current strength of the patient.
Kettlebells work well with the deadlift because, unlike dumbbells, the movement can be initiated from the ground up, the handle can accommodate either one or two hands, and unlike the barbell, the movement is not restricted by tibial position, and is less intimidating to the average patient. It can also be progressed into the swing, which is a great movement for power development, and force acceleration/deceleration.
Patterning the Hip Hinge
Quadruped Hip Hinge
- This is the starting point for patterning the hip hinge.
- The goal of this movement is to help teach patients to feel the difference between lumbar and hip flexion.
- Give the patient feedback if they cannot feel the difference. When you see hip flexion end and lumbar flexion begin, instruct the patient to do small oscillations in that range to feel where the change occurs.
- Since the movement is gravity eliminated, we can look at pure mobility of the hips without worrying too much about motor control.
Tall Kneeling Hip Hinge
- The next step is to take away some of the proprioceptive feedback from the ground, and introduce a motor control component.
- Instruct the patient to keep their spine within a neutral range, and hinge back from their hips. The necessary mobility for this movement should have been addressed in the quadruped position, so now we can begin teaching the patient how to control this movement.
- The addition of the dowel gives the patient feedback on spine positioning, and can be removed once they have developed the necessary body awareness.
Hip Hinge Wall Tap
- This drill works well to introduce hip hinging through the use of a wall as an external cue.
- The kinesthetic feedback provided by the dowel lets the patient feel where the movement is coming from. If their lower back begins to flex as they sit back, they will immediately feel it against their hand. The patient can then reset, and try again to move from their hips.
- If the movement begins to look more like a squat, emphasize that the hips should go back to the wall, not down.
- When the patient gets proficient at this range, they can take a step forward to explore a new range.
Reach to Kettlebell
- Place the kettlebell a few inches behind the patient’s heels. The patient will have to reach back with their hips to find the handle, as opposed to dropping straight down.
- Cue them to reach and touch the handle by pushing their hips back while keeping their gaze forward.
- Return to the starting position by pushing their hips forward, rather than extending through their spine.
- By placing the kettlebell behind them, they are forced to hinge back with their hips. If you place the kettlebell too far forward, many people will have a tendency to either flex their spine instead of their hips, or squat and shift their knees too far forward.
- If they cannot reach the bell, add a small box so they do not have to hinge as far.
Loading the Kettlebell Deadlift
Kettlebells are an ideal choice to begin teaching this exercise because of their size relative to a barbell, and their shape relative to a dumbbell. A barbell would be great for adding load, but due to it’s size, it is unrealistic for most clinics. With a dumbbell, it is difficult to begin the movement from the ground up. The handle of kettlebells are high enough to mimic the act of picking up objects from the ground.
- Begin in the same position with the feet placed slightly wider than shoulder width apart, with the kettlebell several inches behind the heels.
- A good cue to use to keep the patient from hyperextending their neck is to tell them to keep their eyes focused on the corner formed where the wall meets the floor.
- The patient can also use the internal cue of driving their hips forward as opposed to pulling up through their back.
Double Kettlebell Deadlift
- Adding in another kettlebell adds a load that is difficult to attain without the use of a barbell.
- Since the two weights are symmetrical, this alternative works well to build pure strength without worrying too much about added neuromuscular control.
- This can be done with a narrower stance as well, with the kettlebells outside the feet.
Challenging Multiple Planes at Once
Again, kettlebells work well because the loaded position begins from the ground up, so the patient can learn to brace and stabilize against different forces in a flexed position.
Mixed Load Deadlift
- This variation adds a subtle anti-rotation component to the lift. By using kettlebells of slightly different weight, the patient is forced to stabilize their spine simultaneously against flexion and rotation.
- Cue the patient to keep their hands at the same level. This gives them something to see, rather than feel, when trying to keep their shoulders and spine from rotating.
Single Arm Deadlift
- This exercise magnifies the anti-rotation component, but still requires force production in the sagittal plane.
- Again, try to keep the hands at the same level to resist rotation.
- For a more advanced progression, place the kettlebell outside the feet. This creates a much larger anti-rotation and anti-lateral flexion effect.
Developing the Single Leg Stance – Strength and Balance
Single Leg Deadlift
- Hip hinging on one side while holding the kettlebell on the other side creates a nice integration effect from the hips to the opposite shoulder. Whether or not you subscribe to the idea of myofascial slings, there is certainly a unique change in muscle activation once you remove a point of contact from the ground.
- Cue the patient to keep the hips level by keeping the non-planted foot facing the ground.
- Again, try to keep the hands level to prevent rotation.
- Reaching the non-planted foot back as far as possible will reinforce the hip hinge rather than simply folding the trunk forward.
Anterior Core Training
- The kettlebell works great for this movement since the offset weight naturally pulls one towards spine extension.
- By adding in small shoulder circles, the offset weight pulls in multiple directions, forcing the patient to resist spine extension and rotation.
- Cue the patient to keep their ribs pulled down with a more flattened lumbar curve.
- Add another challenge by only holding and making small circles with one kettlebell. The asymmetry creates a much larger rotary stability component.
- Like the deadlift, this movement teaches the patient to keep their spine within a neutral range while moving about the hips.
- Start with a bend in the knee, and progress the exercise by adding in more knee extension to create a longer moment arm.
- Like the previous exercise, emphasize rib and lumbar spine position.
- Progress this further by only using one kettlebell to create a much larger rotary stability component.