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How to Cue the Scapula During Shoulder Exercises

In today’s video, I share my thoughts on the common cue of retracting your scapulae together while performing shoulder exercises.  I’m not sure this is the most advantageous cue, despite it’s popularity.  Instead, I focus on facilitating normal scapulohumeral motion.  I don’t want to restrict the scapula while moving the arm.

Learn more about how to cue the scapula during shoulder exercises in the video below.

 

How to Cue the Scapula During Shoulder Exercises

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Learn How I Evaluate and Treat the Shoulder

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The Influence of Pain on Shoulder Biomechanics

The influence of pain on how well the shoulder moves and functions has been researched several times in the past.  It is often though that impaired movement patterns may lead to pain the shoulder.

A recent two part study published in JOSPT analyzed the biomechanics of the shoulder, scapula, and clavicle in people with and without shoulder pain to determine in differences existed between the groups.  Part one assessed the scapula and clavicle.  Part two assess the shoulder.

The subjects with pain were not in acute pain, but rather had chronic issues with their shoulders for an average of 10 years.  The authors used electromagnetic sensors that were rigidly fixed to transcortical bone screws and inserted into each of the bones to accurately track motion analysis.

The studies were interesting and worth a full read, but I wanted to discuss some of the highlights.

 

The Influence of Pain on Shoulder Biomechanics

In regard to the scapula, the authors found:

  • Upward rotation of the scapula less in subjects with pain
  • This decrease in upward rotation was present at lower angles of elevation, not in the overhead position

It is important to assess scapular upward rotation in people with shoulder pain, particularly emphasizing the beginning of motion.  Realize that no differences were observed in upward rotation past 60 degrees of elevation, implying that the symptomatic group’s upward rotation caught up to the asymptomatic group.  This may imply that there is a timing issue, more than a true lack of scapular upward elevation issue.  They are upwardly rotating, but perhaps just too late?

The study also found the following in regard to shoulder motion:

  • Shoulder elevation was greater in subjects with pain
  • This increase in shoulder elevation was present at lower angles of elevation, not in the overhead position

Noticed how I intentionally presented it similar to the scapula findings?  if you put the two finings together, it appears that people with shoulder pain have a higher ratio of shoulder movement in comparison to scapular movement at the beginning of arm elevation.  The shoulder caught up again overhead, so it appears that the timing between shoulder and scapular movement may have an impact.

The Influence of Pain on Shoulder Mechanics

As you can see, it is important to assess both shoulder and scapular movement together, and not in isolation, as movement impairments at one join likely influence the other.  The brain is exceptionally good at getting from point A to point B and finding the path of least resistance to get there.

I should note that in studies like this, it is impossible to tell if the pain caused the movement changes or the movement changes caused the pain.  So keep that in mind.  Regardless of causation, our treatment programs should be designed with these findings in mind.

There are so many other great findings in the study that I encourage everyone to explore these further, but I thought these findings were worth discussing.  Based on these findings, it appears worthwhile to assess the relative contribution of scapular and shoulder movement during the initial phases of shoulder elevation.

Interested in advancing your understanding of the shoulder?  My extensive online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com is on sale now for $150 off!  That is a huge discount that you don’t want to miss!  Click here to enroll in the program today, the sale ends at the end of the month!

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Great Exercise to Enhance Posterior Shoulder Strength, Endurance, and Overhead Stability

I wanted to share an exercise I have been incorporating into my programs lately to develop posterior shoulder strength, endurance, and overhead stability.  I call it the ER Press as it combines shoulder external rotation in an abducted position with an overhead press.  When performed with exercise tubing, it provides an anterior force that the posterior musculature must resist during the movement.  The key is to resist the pull of the band while you press overhead.

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I use this drill a lot with my baseball players and overhead athletes.  I think it’s a great drill that hits many of the areas that I focus on when training a strong posterior chain of the trunk and arm.

It’s also becoming a favorite of my Crossfit and olympic lifting athletes, who are reporting that they feel more comfortable overhead and have more stability with their snatches and overhead squats.

There are numerous progressions that can be performed by simply changing the position the athlete is in, including tall kneeling, half kneel, and split squat stances.  You can also perform some rhythmic stabilizations at the top range of motion once to increase the challenge.

 

How to Enhance Your Success After Rotator Cuff Repair Surgery

Rotator cuff tears are very common injuries for people of all ages.  Depending on the study you read, it has been reported that 13% of people over the age of 50 years and 50% of people over the age of 80 years will have a rotator cuff tear.  Naturally, rotator cuff repair surgery has become equally as common.  Over the last several decades we have made great progress in our rotator cuff repair surgical techniques, transitioning from an open procedure, to a less invasive “mini-open” procedure, and now full arthroscopic.

arthroscopic rotator cuff repairThe newer arthroscopic rotator cuff repairs tend to less painful and allow people to do more sooner.  However, one mild little fact that we often do not hear about is that the failure rate after rotator cuff repair surgery is still too high.

Past studies have shown up to 75% of people following a rotator cuff repair will technically “fail” if you define surgical failure as the cuff is not intact again after surgery.  A recent systematic review published in JOSPT reported a failure rate between 18% and 40% over 10 different research reports.

Despite these “failure” rates, most research studies have shown that patient satisfaction after surgery is still very high.  This tells me that the rehabilitation process may be far more important than the actual surgery.  That is great news, even if the rotator cuff is found to not be intact again after surgery, pain, motion, strength, function, and satisfaction can all still be improved significantly.

Regardless, we should all be doing everything we can to maximize your success after rotator cuff repair surgery.

A recent systematic literature review publish in JOSPT sought to determine the prognostic factors associated with a successful recover following arthroscopic rotator cuff repair surgery.  Based on this paper, we can identify several factors that can help maximize your outcomes following surgery.  While, not all of these factors are easily addressed, many are, and it is always my goal to assure you put yourself in the best position to succeed.

 

Factors Associated with Successful Recovery Following Rotator Cuff Repair

The review focused on 10 papers that met the authors’ strict guidelines for inclusion.  Based on these 10 papers, they were able to identify 12 factors that were correlated to better outcomes following rotator cuff repair surgery.  These 12 factors were divided into 4 categories: demographic factors, clinical factors, factors related to the rotator cuff integrity, and factors related to the surgical procedure.

I am going to discuss the first 3 as they relate to things we may be able (or not able) to do to enhance outcomes following rotator cuff surgery.  In regard to surgical factors, one study showed that performing additional procedures to the biceps or acromioclavicular joint was associated with poorer outcomes.  We can’t really control the surgical procedures, but perhaps this information may be beneficial to the surgeons.

 

Demographic Factors

The most significant finding in regard to general demographics was related to patient age at the time of surgery.  Older age had a negative effect on recovery.

The studies demonstrated that the older you are, the less your chance of tendon healing.  Those under the age of 55 years have the best outcomes with between 88-95% chance of tendon healing.  In contrast, people aged over 60 years had between 43-65% chance of tendon healing.

While you can’t control when your rotator cuff becomes troublesome, these results do imply that we should not ignore symptoms and allow your shoulder and rotator cuff to gradually become more degenerative.  Addressing issues earlier should help with outcomes.  We have all seen it, most people put off addressing their shoulder soreness for years, attempting to work through the discomfort.  We don’t usually seek help until our functional level is significantly impaired.

 

Clinical Factors

Not surprising, bone mineral density and diabetes were both associated with poorer tissue healing.  Obesity was also associated with less successful outcomes.  People that were considered obese had a 12% less chance of successful outcomes.

I thought a very interesting finding involved your activity level prior to surgery.  People who rarely participated in physical activities had poorer outcomes that those that participated in medium- and high-intensity sports, such as golf, swimming, cycling, running, and tennis.

In regard to strength and motion, it was determined that the best predictor of final strength was initial strength.  Preoperative should stiffness also had a negative effect on recovery time, delaying return to activity.

While some of these factors, like bone mineral density and diabetes, may not be avoided, you can assure that these are under control medically before surgery.  However, factors such as obesity, activity level, strength, and mobility are all likely related and can be addressed prior to surgery.  This underscores the importance of performing physical therapy PRIOR to surgery.  I always say, the better you look going into the surgery, the better you’ll look coming out of surgery.

 

Rotator Cuff Integrity Factors

rotator cuff tear retractionThere were 4 factors in regard to the integrity of the rotator cuff that related to poor outcomes: tear size, the number of rotator cuff muscles involved, the amount of tendon retraction, and the amount of fatty infiltration.  These factors are all associated with tissue degeneration, and perhaps even associated with age.

Essentially, the more degenerative the tissue, the worse the outcomes.  Over time, your cuff tear will progress in size, potentially start to pull off the bone (retract), and become weak.

These factors are probably more associated with my comments on age above.  Perhaps we should be more proactive with our decisions regarding taking care of our shoulders prior to the tear becoming more involved and the tissue more degenerative.  Something to consider, repair of a small rotator cuff tear had a 96.7% chance of healing after surgery in comparison to a 58.8% chance if that tear becomes large.

 

What You Can Do to Enhance Outcome Following Rotator Cuff Repair Surgery

I feel like this study shed some light on several things we can do to enhance your outcomes following rotator cuff repair surgery:

  • Do not unnecessarily put off surgery as outcomes are less successful the older you are at the time of surgery.
  • In regard to the above, also consider that putting off surgery may allow the rotator cuff to become degenerative.  The larger the tear and the more degenerative the tissue, the less successful the outcome.
  • Being physically active and losing weight are both associated with better outcomes.  Get off your butt.
  • Begin physical therapy prior to surgery.  The stronger and more mobile your shoulder is at the time of surgery, the better off you’ll be after surgery.  You’ll be stronger and return to activities sooner.  Plus, some studies have shown that physical therapy can help you avoid rotator cuff surgery.
  • Assure that medical conditions, such as bone mineral density and diabetes, are being addressed and under control prior to surgery.

For the clinicians reading this, we can also use this information to determine our rate of progression during rotator cuff repair rehabilitation.  The more prognostic factors that your patient may have indicating a less successful outcome, the more conservative you may need to progress.

Would you progress some that is a 52 years old physical active person with a small rotator cuff tear and no other health issues at the same pace as a 74 year old with a large tear, weakness, and diabetes?  Of course not.  We can’t just blindly follow a protocol.  Protocols are useful and necessary, but they just provide structure that you adjust if factors dictate that you should be more conservative.

There are ways to enhance your success after rotator cuff repair surgery, many of which are controllable.  Use these findings to help you or your client’s maximize your outcomes following surgery.

 

 

Hip Rotator Cuff

Hip Rotator CuffThe latest Inner Circle webinar recording on the Hip Rotator Cuff is now available.

Hip Rotator Cuff

This month’s Inner Circle webinar on the rotator cuff of the hip was great.  We discussed how our knowledge of the hip has continued to increase over the last decade and has resulted in a much better understanding of how the hip is involved in the mechanics of the lower body and stabilization in multiple planes of motion.  We then broke down the hip musculature as either prime movers or prime stabilizers, and discussed how different positions and exercises impact both of these different muscles groups.

If this sounds familiar, it is, we use the analogy of the shoulder to show the similarities between the hip and the shoulder.

To access the webinar, please be sure you are logged in and are a member f the Inner Circle program.  If you are currently logged in, you will see the webinars below.  If not, please log in below and then scroll down to the “webinar archives” section.  If you are not a member, learn how to access this and ALL my other webinars for only $5.

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Kevin Wilk’s New Rotator Cuff Injury DVD

I am excited to announce that AdvancedCEU has just released Kevin Wilk’s brand new DVD on the Current Concepts in the Treatment of Rotator Cuff Injuries.

Kevin Wilk Rotator Cuff DVD

If you follow me and my website, then I am sure you know Kevin well.  Kevin has an amazing ability to take a ton of research and apply it to what we need to know clinically.

This is the second in a series of new DVDs from Kevin that are dedicated to specific clinical pathologies, he previously released a DVD on Shoulder Instability last spring.

 

Current Concepts in the Treatment of Rotator Cuff Injuries

There are 3-DVDs of almost 4 hours of content from Kevin Wilk, one of the leading clinicians when it comes to treating disorders of the shoulder.  This DVD set is great in that it reviews the most current concepts, techniques, and specific principles associated with both nonoperative and postoperative rehabilitation of rotator cuff injuries.

The DVDs were recorded during a recent live seminar, which I love because you get to see Kevin teaching in action.  This is where he is at his best, interacting with a group of people.

The DVD is regularly priced at $79.95 but is on sale for the release for only $69.95 this week ONLY (until end of day Sunday January 26th at midnight EST).  You can also save another $20 by purchasing both DVDs together.

Click below for more information, Kevin’s new DVD:

Kevin Wilk Shoulder DVDsClick Here –> Kevin Wilk DVD – Current Concepts in the Treatment of Rotator Cuff Injuries

Act now, the special $69.95 sale price only lasts until Sunday January 26th!

 

 

Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?

Rotator cuff repair surgery and postoperative rehabilitation continue to be some of the most debated topics on the shoulder at orthopedic and physical therapy conferences.  Numerous studies have been published showing the failure rate of rotator cuff repair surgery ranges anywhere from 25-90%.

rotator cuff tearWhile this failure rate is certainly alarming, the term “failure” must be defined.  In traditional study models, success is defined as an intact rotator cuff, which makes sense.  However, one of the more interesting findings in most of these studies is that despite the “failed” repair, most patients are quite satisfied with their functional status and outcome.  This really does have to make you question how we define “failure” as patient outcomes and satisfaction seems more important than radiological findings.

These studies have sparked debate over the role of postoperative physical therapy follow rotator cuff repair surgery, with many physicians becoming more conservative and slowing down their protocols.  This obviously implies that some physicians believe that early physical therapy is the reason why failures occur.  This thinking may be flawed and factors such as tissue quality, tear severity, patient selection, surgical technique, and others may be more likely related to ultimate failure rates.

Another perspective to consider is that despite having a failed rotator cuff repair, patient satisfactions were good.  From experience, I can tell you that patients are satisfied when they:

  1. Have less pain
  2. Regain their mobility
  3. Return to functional activities

So the question really should be asked – if there is up to a 90% surgical failure rate but significant increase in satisfaction and outcomes, can physical therapy for rotator cuff tears alone without surgery be just as beneficial at helping patients reduce pain, regain mobility, and return to their activities?

 

Can Physical Therapy for Rotator Cuff Tears Prevent the Need for Surgery?

A recent study in the Journal of Shoulder and Elbow Surgery looked at this exact question.  The MOON Shoulder Group, which is a multi-center network of research teams around the country, followed a group of 381 patients with atraumatic full-thickness tears of the rotator cuff for a minimum of two tears.  The mean age of the patients was 62 years with a range of 31-90 years.

The patients performed 6-12 weeks of nonoperative physical therapy focusing on basic rotator cuff strengthening, soft tissue mobilization, and joint mobilizations.

At the six-week mark, patients were assessed and 9% chose to have rotator cuff repair surgery.  Patients were again assessed and the 12-week mark.  At 12-weeks, an additional 6% chose to have surgery.  In total, 26% of patients decided to have surgery by the 2-year follow-up mark.  Statistical analysis revealed that if a patient does not choose to have surgery within the first 12-weeks of nonoperative rehabilitation, they are unlikely to need to surgery.

Nearly 75% of patients avoided rotator cuff repair surgery by performing physical therapy despite having full thickness cuff tears. [Click to Tweet]

That is a pretty significant finding.

 

Keys to Nonoperative Rotator Cuff Rehabilitation

The results of this study could have a large impact on how we treat rotator cuff tears.  Physical therapy should be attempted prior to surgery, even in the case of a full thickness tear.  To maxmize these outcomes, a comprehensive rehabilitation program should be developed.  When working on patients with rotator cuff tears, I tend to focus on 3 key areas.

Restore Shoulder Mobility

This includes both passive and active mobility.  For passive mobility, it seems to me that shoulder range of motion is gradually lost as the rotator cuff symptoms increase.   Perhaps it is a pain avoidance strategy, disuse, or some other factor.  You’ll often find glenohumeral joint capsule hypomobility and soft tissue restrictions.  Soft tissue mobilization, joint mobilizations, and range of motion exercises should be designed based on the specific loss of motion exhibited by the patient.

Restore The Ability of the Rotator Cuff to Dynamically Stabilize

This is essentially the same as restoring active mobility of the shoulder.  The rotator cuff has to function properly to allow active mobility without restrictions.  In a previous article, I discussed the suspension bridge concept and how you can have a rotator cuff tear without symptoms.  You can see in this diagram that if you have properly functioning anterior and posterior rotator cuff muscles, you can often still elevate the arm despite a tear to the supraspinatus.

rotator cuff suspension bridge concept

Exercises designed to enhance strength and dynamic stability of the shoulder should be incorporated.  In my experience external rotation strength tends to be the most limited and needs to most attention.

Reduce the Impact of the Kinetic Chain

In addition to restore mobility and stability of the shoulder, you should also consider the impact of the kinetic chain on shoulder function.  Read my past article on the different types of shoulder impingement to understand some of these concepts.  Any dysfunctions of the scapulothoracic joint, cervical spine, thoracic spine, and lumbopelvic complex should be assessed.  These areas all have a significant impact on the alignment, mobility, and stability of the glenohumeral joint.

If you want to learn more about how I perform nonoperative rehabilitation for rotator cuff tears, I have a past webinar on shoulder impingement that discusses many of the same keys to treatment.

Using these principles, you can formulate a rehabilitation program that could potentially save 75% of people with rotator cuff tears from needed rotator cuff repair surgery.  Hopefully studies like this will continue to shed light on the impact physical therapy can have on the satisfaction and outcomes of patients with rotator cuff tears, with or without surgery.

 

The Effect of Reactive Neuromuscular Training on Pitchers

It’s no question that the shoulder is a troublesome area for a great number of folks out there.  Most of you that read Mike’s website on a regular basis are looking to treat the shoulder in some capacity—either physical therapy or performance based.  Throughout my career as an Athletic Trainer and Strength Coach, I have worked predominantly with baseball players, or clients dealing with shoulder issues.

In regards to assessing and training for “good” shoulder function, I know Mike is a big advocate for determining what a muscle’s true “role” is beyond just direction(s) of movement and I couldn’t agree more.  The rotator cuff may abduct, internally and externally rotate the shoulder, but its true role is to center the humerus in the glenoid during these movements to maintain proper joint congruency.

Reactive Neuromuscular Training on PitchersRhythmic Stabilizations are great exercise variations that train rotator cuff timing and control in varying positions of instability. While I was completing my Master’s degree at Springfield College and working with their baseball program, I incorporated these exercises with everyone probably 2-3 times a week.  I loved that they were a good way to train rotator cuff control/timing in various positions without excessively loading up the shoulder—this was especially true as throwing volumes increased later in the off season and in season.

However, I always wondered what the efficacy of these drills had in the sense of shoulder performance.

Relative to baseball, this meant throwing velocity.  So I put this to the test!  I conducted my thesis research on the “Effect of Reactive Neuromuscular Training on Pitchers.”  In this study, I investigated how velocity was impacted immediately after performing rhythmic stabilization drills. My initial hypothesis was that velocity would improve.  Theoretically, these drills are intended to promote proximal joint control, therefore should improve the overall function of the shoulder.  Seemed simple enough, but let’s take a closer look at the study.

 

The Effect of Reactive Neuromuscular Training on Pitchers

Participants were 13 collegiate male baseball pitchers between the ages of 18-22.  Participants were free of any shoulder or elbow injury that withheld them from playing activity within the previous 6 weeks.

Test Day 1:

  • All participants were measured for total shoulder range of motion (Internal Rotation + External Rotation) with a goniometer. Total ROM ranged from (155-237 degrees).
  • Each participant threw 10 warm up pitches.
  • Each participant threw 10 four seam fastballs from the windup and pitching velocity was recorded with a radar gun.

Test Day 2:

  • 2-3 days later (depending if they were a starter or reliever)
  • Each participant threw 10 warm up pitches.
  • Each participant performed 2 separate drills.
  • Each participant threw 10 four seam fastballs from the windup while pitching velocity was measured with a radar gun.

Here are videos of the 2 reactive neuromuscular training drills:

Supine Rhythmic Stabilization

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Half-Kneeling Rhythmic Stabilization

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Key Findings

I am going to be honest; I was surprised by the results of this study! Most pitchers actually threw the ball slower than before!

Significant differences were noted in pre- and posttest Maximum (p < .004) and Average (p < .002) velocity.  This equated to a 1.56 MPH decrease in average velocity and 1.62 MPH decrease in maximal velocity!

Another key finding was that greater Total ROM was highly correlated (r= .61) with posttest Maximum velocity.  This means that those with greater shoulder ROM responded more favorably to these drills when compared to those with less shoulder ROM.  Also, players that possessed the greatest amount of shoulder ROM—loose shoulders—threw the hardest overall.

 

Clinical Implications

Like I said before, I was quite surprised by the results that I observed in this study, but after looking further into WHY I may have gotten those results, it made a bit more sense.  First, with any sort of isometric exercise, we are facilitating slow twitch type 1 muscle fibers that are in charge of posture and control.  Pitching is the fastest motion in all of sports, so this acute activation in slow twitch fibers may have had a negative impact on improving maximal pitching velocity, contrary to what I previously would have suspected.

Possibly the most interesting and re-affirming point that was drawn out of this particular study was that some pitchers responded more favorably to the exercise protocol than others! The big takeaway from this: there is no “secret program” or “one-size-fits-all” program that will make you throw harder, or make your shoulder feel better. IT ALL DEPENDS ON THE INDIVIDUAL.  There is a continuum: those who are “tight” (i.e. less total ROM), “loose” (i.e. more total ROM), and all those in between.  Based on this particular research, and concepts like joint centration and the core pendulum theory, it seems that if you are “tight” it may be best to improve joint mobility, address soft tissue concerns, or joint positioning to see improvements in joint function and performance.  If you are “loose”, it may behoove you to improve your overall joint control and just get stronger. This is why constantly assessing and individualizing programs for your athletes, clients, and patients is so crucial.  Otherwise, folks will fall through the cracks and you won’t maximize your results with those you work with regardless of what population it is.

 

Mike’s Thoughts

Great article Sam!  This is a nice research study looking at a topic very important to me.  I outlined how I incorporate rhythmic stabilizations into some of my programmin in my Optimal Shoulder Performance DVD with Eric Cressey.  Since that time, I am thrilled to see so many strength and conditioning coaches and personal trainers incorporating this into their programming.

I couldn’t agree more with Sam’s overall conclusion – each program must be individualized.  This is important as not every needs the same program or should have the same emphasis.  Based on this study it looks like performing rhythmic stabilizations prior to pitching should be included in pitchers that have been assessed and determined to be “loose.”  This makes sense to me.

In regard to the overall lose of velocity in the tight players, I think there may be many other factors that should be considered, including what happened in the 2-3 days between testing sessions.  Perhaps tight players bounce back differently?  More importantly, we don’t know if the lose of velocity was a normal occurrence in this group of subjects throwing 2-3 days later.  Future studies should randomize the groups and have half of the subjects perform rhythmic stabilizations before their first throwing session.

Another thing I would add is that the subjects were all college-aged pitchers.  I am a big believer that older pitchers may need more preperation work prior to throwing to get the rotator cuff firing and prepared to throw.  Perhaps these findings would be different in other age groups.

I’m not sure I am ready to stop performing rhythmic stabilizations before a game in those that are tight, however I will certainly keep this knowledge in mind when individualizing someone’s programs in the future, especially loose athletes.

Great research and article by Sam!  Thanks for contributing to our knowledge of how to treat baseball pitchers!

 

About The Author

Sam SturgisSam Sturgis holds a Bachelor’s Degree in Athletic Training from Quinnipiac University (2010) and Master’s Degree in Strength and Conditioning from Springfield College (2012).  A skilled Strength Coach and Athletic Trainer at Pure Performance Training in Needham, MA, Sam works primarily with baseball athletes and clients rehabilitating from injury.  Sam has developed a successful off-season baseball Strength & Conditioning program in which many athletes utilize.  Sam has also been a regular contributor to the Pure Performance Training website.

 

 

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