Kettlebell Training In Clinical Practice: A Scoping Review

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Meigh et al. BMC Sports Science, Medicine and 130-z(2019) 11:19RESEARCH ARTICLEOpen AccessKettlebell training in clinical practice: ascoping reviewNeil J. Meigh1* , Justin W. L. Keogh1,2,3, Ben Schram1 and Wayne A. Hing1AbstractBackground: A scoping review of scientific literature on the effects of kettlebell training. There are no authoritativeguidelines or recommendations for using kettlebells within a primary care setting. Our review objectives were toidentify the extent, range and nature of the available evidence, to report on the types of evidence currentlyavailable to inform clinical practice, to synthesise key concepts, and identify gaps in the research knowledge base.Methods: Following the PRISMA-ScR Checklist, we conducted a search of 10 electronic databases from inception to1 February 2019. There were no exclusions in searching for publications. A single reviewer screened the literatureand abstracted data from relevant publications. Articles were grouped and charted by concepts and themesrelevant to primary care, and narratively synthesised. Effect sizes from longitudinal studies were identified orcalculated, and randomised controlled trials assessed for methodological quality.Results: Eight hundred and twenty-nine records were identified to 1 February 2019. Four hundred and ninety-sixwere screened and 170 assessed for eligibility. Ninety-nine publications met the inclusion criteria. Effect sizes weretypically trivial to small. One trial used a pragmatic hardstyle training program among healthy college-ageparticipants. Two trials reported the effects of kettlebell training in clinical conditions. Thirty-three studies explicitlyused ‘hardstyle’ techniques and 4 investigated kettlebell sport. Also included were 6 reviews, 22 clinical/expertopinions and 3 case reports of injury. Two reviewers independently evaluated studies using a modified Downs &Black checklist.Conclusions: A small number of longitudinal studies, which are largely underpowered and of low methodologicalquality, provide the evidence-informed therapist with little guidance to inform the therapeutic prescription ofkettlebells within primary care. Confidence in reported effects is low to very low. The strength of recommendationfor kettlebell training improving measures of physical function is weak, based on the current body of literature.Further research on reported effects is warranted, with inclusion of clinical populations and investigations ofmusculoskeletal conditions common to primary care. There is a need for an externally valid, standardised approachto the training and testing of kettlebell interventions, which better informs the therapeutic use of kettlebells inprimary care.Keywords: Scoping review, Kettlebell, Physiotherapy, ExerciseBackgroundHistoryThe kettlebell is a round-shaped steel or cast ironweight, commonly described as resembling a cannonballwith a handle [1]. In Russia, kettlebells are a matter ofpride and a symbol of strength, with a colourful historythroughout the twentieth Century from circus strong* Correspondence: nmeigh@bond.edu.au1Faculty of Health Sciences and Medicine, Bond University, Institute of Health& Sport, Gold Coast, Queensland 4226, AustraliaFull list of author information is available at the end of the articlemen to the Red Army. Use of kettlebells as measures ofweight dates back to Russia in the 1700s [2] and theword girya (kettlebell) first appears in a Russian dictionary in 1704 [3], with excavations in Poland pre-datingearly kettlebells to the seventeenth century [4].Kettlebell sport, also referred to as Girevoy Sport originated in Eastern Europe in 1948 [5]. The InternationalUnion of Kettlebell Lifting World Championship held inOctober 2018 attracted more than 500 competitors from32 countries, testament to its popularity and growth. The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.

Meigh et al. BMC Sports Science, Medicine and Rehabilitation(2019) 11:19Kettlebell sport uses competition kettlebells of standardised dimensions made of steel, most commonly available from 8 kg to 32 kg in 2-4 kg increments. Kettlebellsport techniques are the jerk and snatch in differenttimed events.Kettlebells described as ‘traditional’ in shape are typically made from cast iron, with dimensions increasingwith weight. Kettlebells are now widely available in anarray of construction materials, from 2 kg to 92 kg. Withincreasing popularity has come diversity in use andadaptation of common exercises, however only a limitednumber of styles are widely recognised: Sport, hardstyle,juggling, and a small number of techniques associatedwith CrossFit.The popularity of kettlebells outside of Eastern Europeand kettlebell sport can be largely attributed to Russianémigrés former World Champion Valery Fedorenko, andformer Soviet Special Forces physical training instructorand Master of Sport, Pavel Tsatsouline. Fedorenkofounded the American Kettlebell Club and Tsatsoulinethe hardstyle Russian Kettlebell Certification (RKC),which commenced training in 2001. Pavel has beenwidely credited with introducing kettlebells to the West[6] following a publication in the December 1998, Vol. 6,No. 3 Issue of MILO A Journal For Serious StrengthTraining Athletes. That was followed by Power to thePeople [7] which outlines many of the training principlesused in Enter the Kettlebell [3], and remains the foundation of hardstyle kettlebell training courses worldwide.Enter the Kettlebell has been the most widely cited textin academic publications where a hardstyle techniquehas been used. The six fundamental hardstyle techniquesare the Swing, Clean, Press, Squat, Snatch and Turkishget-up (TGU). Academic investigation of hardstyle training represents around 50% of publications (refer toResults: report characteristics), with the two-handedkettlebell swing investigated most frequently. Neitherkettlebell sport nor hardstyle are limited to only thetechniques listed.A third person of note is former Master RKC, KennethJay. A small unpublished Bachelor of Science study completed at the University of Copenhagen [8] investigatedthe VO2 and lactate effects from two weeks of dedicatedhardstyle kettlebell snatch training in a group of wellconditioned, kettlebell-trained college-age males. Jay’straining protocols later described in Viking WarriorConditioning [9] and those from Enter the Kettlebellrepresent the majority of study formats used to date.Conceptual and contextual backgroundExercise prescription is an integral part of Physiotherapy practice [10]. Prescription of exercise asmedicine for a broad range of chronic diseases andfor relieving pain and improving musculoskeletalPage 2 of 30function have been described [11, 12] with many atleast as effective as drug therapy [13]. The mechanisms of mechanotherapy in clinical practice havebeen reported [14, 15], with an understanding ofmechanobiology of musculoskeletal tissues critical toprimary care [16]. Therapists commonly seek to increase tissue capacity and build physical and psychological resilience in their patients, from the younginjured athlete to the elderly and frail.Evidence-based Physiotherapy is an area of study, research, and practice in which clinical decisions are basedon the best available evidence, integrating professionalpractice and expertise with ethical principles [17].Where high quality clinical research does not exist, goodpractice must be informed by knowledge derived fromother sources of information. When relevant and reliabledata is not available, clinicians still need to make decisions based upon the best available information [18].In elite sport, there is a constant need to increasestrength, power and endurance, and the kettlebell hasbecome a part of that effort [19]. Kettlebells have beenused in strength and conditioning research and injuryprevention programs for mixed martial arts [20], handball [21], shot put [22], sprinting [23] and soccer [24]. Inclinical practice, kettlebells have been included in programs for lower limb amputees [25], metabolic syndrome in women [26], early treatment of breast cancer[27], for osteoporosis and fall and fracture prevention[28], home-based Physiotherapy with older adults showing signs of frailty and following hip fracture [29], forhealthcare workers [30] and in programs for improvinghealth-related physical fitness [31].Military and law enforcement agencies train with kettlebells, reporting improvements in field performance[32]. Kettlebells have been recommended as part of theRoyal Air Force aircrew conditioning programme [33]and for simulated military task performance [34]. Thekettlebell deadlift has been recommended by the NorthAtlantic Treaty Organization to be used alongside theRanger test, which is a loaded step test, deemed to haveexcellent content validity and high inter-rater reliabilityin relation to five common physically demanding military work tasks for soldiers [35].Kettlebells have also been used to modify other common training protocols [36–38], and as a novel methodof providing valgus stress with good reliability, duringultrasound examination of the ulnar collateral ligamentof the elbow [39]. University studies have investigatedkettlebell training, including analysis of the TGU [40],for improving dynamic knee stability and performancein female netball players [41], in anterior cruciate ligament (ACL) injury prevention among female athletes[42], and for reducing work related musculoskeletal disorders of the low back [43].

Meigh et al. BMC Sports Science, Medicine and Rehabilitation(2019) 11:19Whilst kettlebells have been adopted by popular fitnessprograms such as CrossFit, the use of kettlebells remainsa relatively niche sport and knowing how to use a kettlebell is perhaps not as intuitive as the more popular barbells, dumbbells and machine weights. In spite of this,kettlebells have been recommended for their ease ofteaching, cost effectiveness and being less intimidatingto use [44]. Kettlebells have already been integrated intoclinical practice but does the current body of evidencesupport their use for therapeutic purposes, and howdoes the evidence help inform clinical decision making?The aim of this review is to identify what is knownabout the effect of kettlebell training from publishedacademic research, with the objective to systematicallyevaluate and critically appraise the literature and highlight areas for further investigation.Kettlebell swing descriptorsThe ‘hip hinge’ is associated with a deadlift movementpattern and a hardstyle kettlebell swing. This has alsobeen described as a “Russian swing”, or a swing to chestheight. It can be performed with one or two hands holding the bell. The two-handed overhead swing is associated with a ‘squatting’ motion of the lower limbs, alsodescribed as an “American swing” and most commonlylinked with CrossFit. The ‘double-knee-bend’ pattern isassociated with kettlebell sport.MethodsA scoping review was conducted to synthesise currentevidence of kettlebell training as it applies to therapistsworking in primary care, where movement and loadingare used clinically for therapeutic purposes. As an evolving field of research, the scoping review was chosen toprovide an overview of kettlebell training, to identify keyconcepts, knowledge gaps, and types of evidence currently available.Research questionWhat evidence is available to guide therapists using kettlebells within a clinical therapeutic framework?ProtocolThis scoping review was conducted by a single researcher (NM) using the PRISMA Extension for ScopingReviews (PRISMA-ScR): Checklist and Explanation [45].A priori protocol was not developed.Study designThe scoping methodology proposed by Arksey andO’Malley [46] was used to map the concepts and typesof science-based evidence that exists on kettlebell training. The methodology was informed by later recommendations [47] and guided by the Joanna Briggs InstitutePage 3 of 30framework [48, 49]. This framework includes the following steps: 1) Identify the research question by clarifyingand linking the purpose and research question, 2) identify relevant studies by balancing feasibility with breadthand comprehensiveness, 3) select studies using an iterative team approach to study selection and data extraction, 4) chart the data incorporating numerical summaryand qualitative thematic analysis, 5) collate, summarizeand report the results, including the implications for policy, practice or research [50].Information sources and literature searchA search was conducted, assisted by a health sciences librarian, on 10 electronic databases (CINAHL, CochraneLibrary, Embase, Medline, PEDro, ProQuest, PubMed,SportDISCUS, Web of Science, Google Scholar) frominception to 1 February 2019, using search terms “kettlebell”, “kettle bell”, “kettlebells”, “kettle bells” in the Titleor Abstract. The search strategy was not limited bystudy design, publication type, or language. Duplicate records were removed in EndNote. Backward referencesearching was performed, and additional studies wereidentified by consultation with subject matter experts.Eligibility criteriaThe eligibility criteria were defined by the Population(therapists in primary care), Concept (prescription ofkettlebells for therapeutic purposes) and Context (evidence-based practice: research evidence and clinical expertise). All types of study design and reviews wereincluded where kettlebells were the primary modality ofinvestigation. Any population, intervention, comparator,outcome, and setting were included, together with thesesand unpublished material from academic settings. Articles/publications were excluded if, a) they were unrelated to kettlebell training (e.g. gave historical contextonly), b) were not specific to kettlebell training (e.g. interventions involving kettlebells and other equipmentwhere the outcome(s) could not be attributed to thekettlebell), c) were unavailable in full text, or d) werestudies conducted on Eastern European Military populations. The absence of standardised reporting guidelines(as recommended by the Enhancing the QUAlity andTransparency Of health Research network), and style ofreporting from countries of the former Soviet Union,were deemed incompatible for synthesis. The followingwere also excluded from our review: books, patents, fitness articles, web pages, blogs and opinion pieces fromnon-clinical or non-academic/clinical authors. Resourcelimitations precluded the translation of articles not published in English. One exception was a clinical trial ofhardstyle kettlebell training for people with Parkinson’sdisease, published in Portuguese with an English abstract; this was deemed to be specifically relevant to the

Meigh et al. BMC Sports Science, Medicine and Rehabilitation(2019) 11:19population, concept and context of the review and included but not translated. All levels of evidence [51]were considered.Data abstraction and data itemsA standardised data abstraction form was not utilised. Asingle reviewer (NM) independently screened titles andabstracts for relevance and obtained full text articles ofpublications potentially relevant. As the scope and nature of the available evidence was not known in advance,the development of categories and grouping for mappingpurposes was developed iteratively as the data was extracted and tabulated. Effect sizes were extracted wheregiven, or calculated if enough data had been provided.Cohen’s δ or standardised mean difference (SMD) wereused and magnitude of effect compared based on participant’s resistance training status: untrained, recreationallytrained or highly trained [52].Methodological quality appraisalWith the primary intent to inform clinical practice,the authors chose to critically appraise the randomised controlled trials using a modified Downs andBlack quality checklist [53]. This scoring system isbased on a checklist of 27 questions and has beenfound to be valid and reliable for critically evaluatingexperimental and nonexperimental studies. Thechecklist included 4 categories for evaluation: reporting, external validity, internal validity/bias, andinternal validity/confounding [54]. Studies wereappraised by a second independent reviewer. Discrepancies were resolved by discussion and agreement reached. Quality of evidence and strength ofrecommendation was based upon the GRADEapproach [55, 56].SynthesisData were narratively synthesised by author-defined category: (1) acute profiling, (2) athletic performance, (3)health-related physical fitness, (4) injury & rehabilitation,(5) expert/clinical option and (6) Review, with key characteristics and findings discussed. Publications weregrouped by nature of the study (acute vs longitudinal)and measures/outcomes. Acute profiling studies werefurther categorised by outcome: ‘sEMG’, ‘motion analysis’, ‘hormonal response’, ‘cardiometabolic’, ‘mechanicaldemand’ or ‘performance’. Experiments and trials weremapped based on the population profile (age, gender,training history, kettlebell experience), types of exercise(s) used, style (hardstyle, sport or ‘other’), trainingformat (work-to-rest ratio, frequency, duration, intensity/load), measurements (sEMG, motion analysis,ground reaction force, HR, RPE, VO2), outcomes, andstudy design.Page 4 of 30ResultsThe literature search yielded a total of 829 citations(Fig. 1). Three hundred and thirty-two records wereremoved as duplicates or not meeting the inclusioncriteria. Upon completion of the title and abstractscreening, 170 were potentially relevant and screened.Subsequently, 99 publications fulfilled the eligibilitycriteria and were included. Study flow diagram Fig. 1.Publications by category Fig. 2.Report characteristics (extent, range, nature)The number of academic publications relating to the useof kettlebells has increased steadily since 2009 (Fig. 3)Sixty-eight (69%) of the publications were research studies, including 47 (70%) measures of acute trainingresponse and 21 (31%) longitudinal investigations. Twolongitudinal trials involved clinical populations. Publications were categorised as ‘acute profiling’ [47], ‘Athleticperformance’ [11], ‘Health related physical fitness’ [9],‘Injury & rehabilitation’ [4], ‘Opinion’ [22] or ‘Review [6](Fig. 4). Included in these were a Systematic Review, oneClinical Review, four Brief/Narrative Reviews, and 3 casereports from medical practitioners of injury attributed tokettlebell training. Acute profiling studies, which represent almost half of the publications, were further categorised based on outcomes: ‘sEMG’ [11], ‘motionanalysis’ [6], ‘hormonal response’ [3], ‘cardiometabolic’[16], ‘mechanical demand’ [6], ‘performance’ [2] or notcategorised [3] (Fig. 5).Fifty-four experiments and trials (79%) used healthycollege-age participants, with participants in 62 studies(91%) recreationally active. In fifty-five studies ( 80%),participants were novices unfamiliar with kettlebelltraining, and almost half (n 33) explicitly used hardstyle techniques and/or training principles described byTsatsouline. Only 4 investigations (2 acute, 2 longitudinal) involved kettlebell sport. Of the 68 experimentsand trials, 43 were published in peer-reviewed journals.The remainder were un-published conference presentations [5], Theses [9], Pilot studies [3], papers acceptedfor publication [4], and University publications [4]. Results described herein as significant where reported withp

Kettlebell training in clinical practice: a scoping review Neil J. Meigh1*, Justin W. L. Keogh1,2,3, Ben Schram1 and Wayne A. Hing1 Abstract Background: A scoping review of scientific literature on the effects of kettlebell training. There are no authoritative guidelines or recommendat

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