Crazy Things In PT: Postural Restoration

Welcome to our series on “Crazy Things In PT.” You find other posts in the series via these links – Crazy Manual Therapy, Stupid ExercisesOutdated Interventions. First, here’s a little note from the management:

These articles are intended to show some of the things currently done by physical therapists around the US and around the globe. There are many very well meaning PTs out there and we are not in this to shame or accuse specific people of evil motives, only to expose specific theories and/or interventions in physical therapy. We acknowledge that patients do get improvement with some of these techniques, but strong claims call for strong evidence to back it up.
Individuals will be used as examples from their own videos or published articles, but in every case we will use as much of their own material as possible so they can speak for themselves. Oh, and this is not an educational/research site, so if you have a problem with satire you should just move on.

Postural restoration (in the following to be referred to as PR) started from the observations of Ron Hruska. He noticed common asymmetry patterns, how they occured with overuse injuries, and how that was also related to common postural adaptations that can affect other muscle systems. Here is a brief explanation of “posture” by Ron from his website:

“Posture is a reflection of the “position” of many systems that are regulated, determined and created through limited functional patterns. These patterns reflect our ability and inability to breathe, rotate, and rest, symmetrically with the left and right hemispheres of our axial structure.

“Limited functional patterns” refers to movement that is restricted in directions, planes or normal boundaries of functional range, as a result of improper joint, muscle, and mediastinum rest position. Function is therefore limited because soft tissue and osseous restrictions prevent one from using muscles and joints in their normal range. Adaptation and compensation for these limitations require neuromotor encoding and hyperactivity of muscle that is placed in improper positions that exceed normal physiological length, or in positions that make them a mover or counter-mover in planes and directions that are not observed when one is in a neutral or more symmetrical state of rest. This compensatory activity and hyperactivity usually becomes dysynchronous in the accessory muscles of respiration and at the appendicular flexors and axial extensors, thus limiting functional rotation at the trunk and through the lumbo-pelvic-femoral and cranial-mandibular-cervical complex.”

I’ll just let that speak for itself.

I reached out to several physical therapist via email and Twitter on their thoughts regarding PR. Many responded very similarly with quotes like, “The first class was great, a different way of looking at things.” “I was okay with it at first, but the farther you get in the crazier it gets.” “They lost me for good when they started talking about mobilizing cranial bones and how every pain possible in your body is from your rib and pelvic position.”

So, I started digging around…and it certainly did get crazy. But don’t take my word for it, here are some videos that will explain things for you.

I guess how you breathe can give you plantar fasciitis?

I never knew how crucial tongue and jaw reciprocal movement are in runners!

This apparently is one of the main exercises they use in PR…

And someone sent me this link. I guess they have a vision center as well? Here is a statement from the page link.

“…they have discovered that when they use a very specific and specialized eyeglass prescription along with a patient-specific program of PRI exercises, the brain and nervous system seem to re-wire themselves and this new nervous function can become permanent for long term results. The simplest way to explain how PRI Vision works is to say that we can purposely turn off muscles that are over-active and tight (called too much extension tone), and turn on muscles that are under performing and weak. This is true for muscles from your head all the way down to your feet. This rewiring allows the patient to override their dysfunctional way of moving and doing things.”

It really is miraculous. Consider this video that I found as 100% proof. Really…Just watch it, please.

I find it interesting that the Postural Restoration Institute has a tab called ‘The Science’…  which has no scientific references at all…it’s really just an explanation of the terms they use and theory behind PR. I thought I had finally found some actual research when I saw the section of the website called “research topics” but was more than a little disappointed to find out it was only a list of things they recommend researching… Ummm… Yeah…

But then I struck gold! Here’s the area that lists articles from the media, from PRI, and peer reviewed journals. There is an article written by Ron Hruska from 2005 entitled “PRI – An Evidence Based Approach” which lists no specific evidence for PR, but promises to follow up on getting that research going. And then you find this article, which is the only research they have on the site that isn’t a case study or an explanation of the theory behind PR. It involves 13 subjects and is used to show that abdominal and hamstring muscle activation can decrease a positive Ober’s test and also decrease LBP. One would assume that over the last 10 years there would be some kind of research specific to PR. And the one article linked before is flawed in so many ways (no control group, no follow up, etc, etc, etc) that there is no way to make a serious conclusion that PR is actually beneficial.

The above is fun and all, but this page was by far my favorite. It describes how PR is a great conservative approach for treating scoliosis. I hope you don’t mind if I take some quotes from the page.

This is from the top of the page. “Clinical experience of Postural Restoration Certified therapists provides specific clinical data to support the use of PRI techniques as much as if not more so than other approaches to physical therapy.” Holy shit this is impressive! Now we’re getting somewhere. Let’s keep reading…

This little disclaimer is snuck in in the middle of the page…”At this time we have no supportive literature/research articles, pre-post x-rays, or case studies to support PRI intervention with scoliosis patients. We are still in the discovery stage of clinical data collection. Clinical outcomes, however, are very promising and positive especially when parents, patients, and physicians are all supportive of the PRI approach.” Hmmm…but, there’s surely more promises, right?

Yes! “Neutrality and stability of the pelvis can be achieved through Postural Restoration Institute™ non-manual techniques which activate the ipsilateral hamstrings and ischiocondylar adductor and contralateral gluteus maximus for sacral stability and neutral position.” Don’t you worry about citations for those claims, be impressed by the really big words!!!!!

You may want to check out Ron Hruska on Twitter. If so, here’s an interesting tweet I selected…

So, let’s close with some thoughts and advice from Uncle Awesome. There is a great danger in becoming a guru. You can fall into a situation where you are treated damn near royalty…or even divine. You can start to find yourself in that weird gray area between solid ground and fantasy land, and if you don’t have anyone in your life to tell you that you’ve gone over the edge, you’re a gone. The things that are helpful in PR are not exclusive to PR. Relaxation, focus on breathing, strengthening your hips and hamstrings, these are all great things for those dealing with LBP. But once you’ve gone down that rabbit hole, and thrown up the middle finger to science and research, there’s nothing at all to stop you from talking about putting on special glasses to take away your knee pain. And this is especially true if you have no grasp at all on the placebo effect.

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Frankly, this is why anecdotal evidence is dangerous. Hell, I can look back over my career and see multiple times where clients got better in spite of me and the interventions I used (cross friction massage for one)! Just because something works for one person does not mean you can extrapolate those results into every single person who has ever lived. I’m sure there are tons and tons of Postural Restoration therapists out there that are very well meaning and very sweet. But if you really feel that every single person who comes through the clinic doors needs to activate their left hamstring while reaching with their right arm to purposely focus on expanding a specific lobe of your lungs with a posterior pelvic tilt with your adductors engaged….you might have just jumped the shark. It’s appropriate to point out that some of the dumbest people I have ever met are also very intelligent. I had a client in Mensa who was easily the biggest fool ever for get rich quick scams. Just because you have a Doctorate or even a PhD doesn’t mean I’m going to simply take your word for it. If the best thing in 25 years that PR can come up with is case studies, they obviously have no intention of backing up their ridiculous claims.

Congratulations PR, you have officially made me feel like apologizing to the chiropractors. I’m not going to, but I feel like it!

As always, thanks for stopping by.

Late meme edition!
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40 Comments

Filed under Crazy Shit, Physical Therapy

40 responses to “Crazy Things In PT: Postural Restoration

  1. Cyrus

    I’m just here for the comments

    Like

  2. Ben

    I’m not drinking the Kool-Aid. Yikes!

    Like

  3. Ralph S

    Are you not entertained?! Perhaps the most entertaining thing I’ve read this morning…hahaha, just the right amount of spice to keep me reading; well written.

    Like

  4. It gets crazier when when you mention about the glasses! I cant believe that a hoax like this can come out of physical therapy practitioners. It’s just unthinkable! Glasses, really???

    Thanks for writing this. I’ve always wondered what these people teach. Now, what do you think of Anatomy Trains?

    Like

  5. Chris

    Ever heard of a condition called Visual Midline Shift Syndrome? Well, it is in the research. It is mostly associated with some type of traumatic brain injury, but is it not possible that such could occur in a perfectly healthy brain? And, guess what? Specialized prism glasses seem to favor positive outcomes.

    It is very easy to frown upon new ideas because there is a lack of research. Well, let me tell you, as someone who has spent A LOT of time in the world of academia, the research is typically behind the practitioner because it’s such a long, arduous process.

    It would not be hard to study this from a biomechanical perspective, but universities are looking for big grants and large funding. They are more prone to pursue opportunities from NIH, DOD, etc. Those organizations are laying out the big bucks and funding the research.

    I encourage you to actually go sit in on a course and check it out. Feel free to be a critic. But, when you watch them repeatedly change someone’s range-of-motion in a matter of seconds through a few specific exercises, it’s hard not to think that there might be something to this. When you’ve referred people to a PRI-trained therapist and they have had extremely favorable outcomes in a short period of time, you tend to start buying in. And, if you really dig deep and look at the anatomy as it is presented by the folks at PRI, it just makes sense.

    Oh, and you never jumped on the dental stuff….there is research on dental occlusion and scoliosis as well as occlusions and posture.

    So, while there isn’t necessarily a lot to go on PRI-wise, there is research to back up many of the concepts that they are presenting. If you go into each course description, there is a mountain of research citations that go along with each course.

    Liked by 1 person

    • I once worked in the same clinic as a PRI therapist. She had tons and tons of clients that it didn’t work for… But guess what? Traditional PT worked for them!

      She would use the crazy exercises on 85 year olds with balance problems, 16 yo with ankle sprains, and every single patient she saw.

      My biggest issue is if you’re going to make the claims like you do in the comment section, you HAVE to be able to back it up with something besides a few case studies. The “good stuff” in PRI isn’t exclusive to PRI. Much like the other approaches I will cover in this series.

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      • Brent

        “They lost me for good when they started talking about mobilizing cranial bones and how every pain possible in your body is from your rib and pelvic position.”

        This was directly said at a PRI seminar? That every pain possible from your body is from rib and pelvic position? Interestingly enough the PRI therapist I work with would completely disagree with this statement. Pain is incredibly complex because there are so many variables to it. PRI doesn’t disregard the biopsychosocial aspect of pain (from what I’ve been told this was a huge component to their yearly conference this year too).

        “But once you’ve gone down that rabbit hole, and thrown up the middle finger to science and research, there’s nothing at all to stop you from talking about putting on special glasses to take away your knee pain.

        I admit some of the stuff about PRI confuses me, especially what appears to be the lack of controlled research into it, but are PT’s supposed to wait for proper funding and research to come in before using a technique on a patient? I have no idea how funding research works, and how easy it is to do it, but still question why one needs to only stick to established evidenced based research all the time (if this is what you are saying).

        “And this is especially true if you have no grasp at all on the placebo effect.””

        Huh? gross generalization right here. Not an expert on the placebo effect (so correct me if I’m wrong), but it’s not a matter of if there is a placebo effect with a PT treatment, but more a matter of degree. Placebo exists along a spectrum (so does nocebo) Every treatment has it to one degree or another (some more than others (i.e. acupuncture being nothing more than an elaborate placebo imo). Of course if someone has the expectation of benefit walking into a treatment the placebo effect will play a role I imagine, so it really is just a matter of degree. you can’t tell me the treatments you use don’t have a placebo (or nocebo) effect. Unless of course you blind your own patients in some fashion.

        I’d love to see a double blinded RCT on the PRI technique but I also dont’ think we should all wait for the controlled research to pop up before helping people.

        You bring up some interesting points (especially regarding the issue of lack of research) but trying to draw an analogy between chiro and PRI is just ridiculous. PRI is about understanding the primary role the nervous system plays and how patterns develop in the body because the nervous system dictates them. It’s not saying being in a left AIC is causing your pain, because pain is multifactorial. If a PT told me this, I’d spot them on it right away. I have yet to talk to a PRI person who thinks people are in pain because they can’t activate or inhibit (insert any muscle here). If they believe this then I think they are completely missing the pt. of PRI.

        Also, both Bill Hartman and Mike Reinold are two guys very well respected in the profession who utilize PRI. No, I’m not name dropping popular guys to validate PRI, I’m just saying that it would be far more interesting to have a conversation with them because they have used it for some time and might be able to provide a more nuanced perspective on PRI, rather than making some of the statements that were made in this blog that seem to be a gross mischaracterization of PRI and their techniques.

        Liked by 1 person

      • Yes. Take a look at the videos out there. Pain is from dysfunction cause by these patterns. It’s repeated to infinity.

        And you’re correct it’s untrue, so you’re making the case for me.

        If you don’t care for the style of this post, dripping with sarcasm and such, go read a scholarly article on postural restoration…. If you can find one.

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      • Brent

        you slam PRI case studies and anecdotes, but then use your own.

        Liked by 1 person

      • ???

        Telling my personal interaction wasn’t intended to appear as 100% proof that all PR therapists are crazy. If that’s your main critique, I don’t know what else to say.

        Like

  6. As a PT, my biggest pet peeve with other PTs is that they get lost in threories and are unable to see the common denominators in various treatment approaches. I agree PRI sells their ideas like an infomercial which makes one want to disprove them. However, if you break down want they are doing it is simply restoring the kinetic chain through a combination of muscle energy techniques, and manual myofascial release. They also use a test/re-test approach used by McKenzie, Maitland, Mulligan, etc. All of these approaches have different theories but are all effective. I actually love that they bring such a focus to the diaphragm and breathing. I don’t need to agree with everything they claim to receive benefit from teaching my patients to get more function from a central muscle involved in every breath taken. In my formal PT education breathing got very little attention. As far as the plantar fasciitis video, if you don’t understand that breathing can affect how you stabilize your lumbopelvic region, which can in turn affect how you make contact with the ground with every step, then you don’t have a great grasp on the kinetic chain. Which is expected with many PTs as it is not well taught in a formal education curriculum.

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    • We will agree to disagree on some parts. You can make a theoretical argument on just about anything though. Some of their biggest selling points, for example on posture causing pain and myofascial issues, have been disproven by recent research. This makes me question the rest of the structure of PRI since the foundation is in doubt.

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      • Show me what you mean by disproven. It has been disproven that sitting causes certain patterns of shortening in the body? Janda’s crossed syndromes have been disproven? My clinical assessment on each patient for 10 years would tell me differently but I am open to be shown what you are referring to. My point is that I don’t have to agree with PRI’s theories to get benefit from it. I have gone through the certification processes for Maitland, McKenzie, the FMS, and even Crossfit mobility. They all seem to refute each other in some way but the common denominator is that they are using non-invasive techniques through a test/re-test model. This model has been studied (actually by my colleague: http://www.manualtherapyjournal.com/article/S1356-689X(12)00050-1/abstract) but the research is still new and should be the direction in which we move as a profession. Our clients/patients are individual studies through this model and I for one will remain open minded to as many approaches that come along that fit this model. Protocol-based treatment based on structural diagnosis which is the common method of education in the PT curriculum makes PTs look like assistants to physicians. We are specialists in assessing movement and should develop theories based on our observations of patent position and movement, but these theories are less important than the techniques the demonstrate with-in session changes through a movement assessment.

        Hope I am making my point that I am not pro-PRI or supporting their theoretical arguments but nevertheless have found benefit with their techniques and use their assessment approach as one tool of many in my movement assessment tool box.

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      • I will agree with you on that. Every person is indeed different. What I was referring to was the biomechanical pain model. It used to be the foundation for how we understood pain, but much research is pointing to many of those in chronic pain don’t present with issues greater than those who are asymptomatic.

        Yes, many people can benefit from the principles of all of those things. My point with the article wasn’t that, but that those in the upper levels of PRI don’t stop there, in fact it reaches what I would call crazy levels.

        Sorry if I misunderstood your first comment. I bet if we had this convo over a beer we’d find out that we agree more than disagree.

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      • I think you are right. Open-minded discussions is how I learn best.

        I love the work that has been done by David Butler regarding the biopsychosocial model of pain. Once reading his stuff it made be totally rethink what I thought I knew about treating people with pain, but it also made me more open-minded to concepts that I thought were a little out there.

        I also rolled my eyes through the first two PRI courses due to the way the instructors presented the material, but I have found the techniques and assessment processes to be helpful. So there we are in agreement.

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  7. Jen

    If your philosophies and techniques are based on research then unfortunately you are 5+ years behind what everyone else who is trying to progress this profession are doing. New ideas and concepts that push the boundries of what we already know are how we progress as a profession. Rather than tearing apart each course, why not focus on the commonalities between them and perhaps take away a few things to better your practice? I have taken PRI, DNS, SFMA, ART, McKenzie, Graston, etc and I find holes in all of them. I believe any practioner who puts all their focus in just one technique will fall short because of these holes.

    Furthermore research takes time and is limited to the number of variables which can be tested. Unfortunately when it comes to the clinical world, things are multifactorial. One thing I am sure of is that research does not PROVE anything….it only suggests. There are research article to support and refute the same theory. Furthermore, reading just an abstract of an article hardly gives you the full picture. Plus are you sure the stats are done properly….can’t say many people are double checking those. As the saying goes, statistics are like a bikini, they reveal what is appealing and hides what is vital. While there may not be inductive research to directly support these “outside the box” concepts, abductive research is something we as clinicians do everyday. Abductive research then drives inductive research.

    As a practitioner who utilizes many techniques, I find the more diverse my training, the more people I am able to help. As you said, every patient is different. Some may respond to PRI, some to McKenzie, and some to SFMA. Those who are close minded to theories or techqniues that have not been “proven” are only limiting their own success. Now excuse me while I have my baseball pitchers blow up ballons to improve their throwing mechanics.

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  8. I have practiced using PRI principles in the orthopedic setting. I am a patient of the vision program and would say that PRI knows a lot about inhibition techniques and this is the main reason they started a vision program. Since the visual system plays a large role on how we process our environment, they can use the eyes to inhibit unwanted information that can cause hypertonicity (talk to a good neuro-optometrist and they would say the same thing). That being said, I can understand why PRI can look different and people can be skeptical. I feel if you look at a lot of the activities PRI uses they are not much different than isometric strengthening activities that are just placing a person in a position that is new for them or against a pattern that you assess for each treatment. They are more than “the diaphragm is the main problem” as suggested in this article. I completely understand this blog is meant to challenge people’s thought process (as I write my own blog for similar reasons), but it would be nice if the writer would have more experience with the technique. Think of PRI as a good way to inhibit muscle chains so that you can advance a patient to more dynamic/functional activities. Also I agree with previous posts saying that there is a lot of research about the asymmetry of the human body. If you are only looking at exercise based research articles you are missing a lot of information from dentists, optometrists, osteopathic physicians, and other medical professionals. Don’t forget the value of breathing on the nervous system for relaxation techniques as is researched. That is my 2 cents. Thank you for challenging us as clinicians.

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    • My main point in the post want that people can’t benefit from PRI, but that they are unable to back up many of the claims (especially regarding scoliosis).

      Thanks for your input. Always appreciate feedback.

      Like

      • what claims does PRI make regarding scoliosis?

        have you ever been to a PRI course? if so, which one and who taught it?

        looks like you got a lot of your material from the web, emails from friends, and twitter? interesting….

        and skimming your blog it looks like you took a lot of things out of context…. you can make anything look crazy and ridiculous when you take it out of context.

        Liked by 1 person

      • I can’t answer your question here because it’s already answered in the post…

        Like

  9. Pingback: Crazy Things In PT: Crazy Manual Therapy Techniques | The Awesome Physical Therapist

  10. Sorry Uncle Awesome, I didn’t see the claims as you did. Looks to me you took some sentences from a website and used them out of context.

    what about the other questions?

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  11. I have made up my mind after attending a few courses and gaining knowledge…. not by judging other peers, marketing websites, twitter, or emails from colleagues.

    Here’s another quote from a website you might find interesting:

    “When trying to make a case for some position or idea, we frequently encounter questions which challenge the coherency or validity of that position. When we are able to adequately answer those questions, our position becomes stronger. When we cannot answer the questions, then our position is weaker. If, however, we avoid the question altogether, then our reasoning process itself is revealed as possibly weak… Another possible reason is that answering the question might lead one to the realization that their position isn’t valid, but that position plays an important role in their self-image. For example, someone’s ego might be dependent upon the premise that some other group is inferior to them — in such a situation, the person might be strongly inclined not to directly answer questions about the justification of that alleged inferiority, otherwise they might have to acknowledge that they aren’t so superior after all”

    We all are certainly entitled to our own opinions and editorials. That’s the great thing about the internet and social media.

    Wish you well too!!! Hope you find some more crazy things in PT to poke fun at! Sounds like an important job…. lucky you 🙂

    Like

    • You haven’t been able to provide evidence for the claims made for PRI, so why should I answer your questions?

      If you’re familiar with logic, than you would know you have the burden of proof. It’s not my job to prove you wrong, it’s your job to prove you’re right.

      That make sense to you? That’s why I don’t care to answer your questions. Do you see how that quote you posted actually refers to you Postural Restoration folks?

      Also, don’t hold onto that anger. It’s like drinking poison and waiting for the other person to die.

      Okay, now it’s your turn so you can have the last word.

      Like

  12. Ok well if you insist 🙂

    I have nothing I need to prove to you and neither does PRI 🙂 I’m not the one seeking attention by blogging and putting down a system without ever taking even a primary course. I’m not the one seeking evidence off of youtube and twitter and taking things out of context to try to prove an opinion and validate myself.

    I support PRI and many other continuing education series because that’s what I believe awesome PTs do. Believe me, Uncle Awesome, there’s no anger here. I and many others find this very comical. Obviously many people see the value in PRI and it continues to grow. We thank you for helping us spread the word. Honestly! Smart respectable people will see right through your tactics 🙂

    Wish you well!!!

    Like

  13. andrew

    My boss paid and took us all on a PRI course as he had treatment for back pain from a friend PT for a back problem. Quite honestly it was one of the most embarrassing CEU courses I have been on from the point of view of evidence based practice. Whenever I asked questions about research for some of their claims they said that journals were blocking their publications… Some of their claims are not hard for one to design a study for but they have not done so. I am sure some of their techniques can work but no sound basis was provided, much like some of this fascia stuff theat is being pumped out… My boss was so disappointed he didn’t finish the final day, emarassed he had paid for 7 of us to go out of state for this @$*& (his words). I have been on many and varied courses and worked with top PTs from around the world; to see this get a foothold in the US is, for me, an embarrassment for our profession. If we want to be primary care providers and taken seriously we need base our practice around an evidence base and where one doesn’t exist but results are good we need to create one. PRI does not meet that challenge so i thank you for writing an article that highlights this. Sorry you are going to get pathetic replies to it from the PRI cult, but my experience at the course, where someone retaking that first level course was being described as a guru and having his ego pumped, pretty much guarantees that response!

    Keep going where certain PTs will not! Be Awesome!

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  14. Pingback: Crazy Things In PT: Outdated Interventions | The Awesome Physical Therapist

  15. Appreciate the satire as well as the intent of the post. I am trying to think of what it would sound like for an oncologist to say they were going to treat their patients with their own set of treatment protocols – chemo, radiation, grapefruit cocktails, etc – that had no solid research to validate the outcome but that they had seen great results in “many” of their patients? That they couldn’t stand around and wait for the research to catch up with their brilliance? How can you legitimately know that you’re “doing no harm” if you’re not practicing evidence-based medicine? Conspiracy theories about big pharma aside, practices based principally on anecdotal evidence belong more in the “alternative – as in principally not scientifically validated – medicine” arena. Anyway I’m a 30 + year fitness professional who works in the sports performance and medical exercise fields – not corrective exercise mind you – and I know my scope of practice and unlike most in my field I don’t use FMS to convince all my clients that their postural asymmetries require immediate intervention. I do still have my course work from one of the very first Chain Reaction workshops but I never stopped using leg extensions either 🙂

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