Welcome back to the Healing Pain Podcast with Physiotherapist Tom Young
As always, it’s an honor to be with you. Many of you know that I’m going to be launching a new act for chronic pain course that will come out in later January. Throughout the month of January, there’ll be at least one, if not four different podcast episodes with regard to ACT, which is Acceptance and Commitment Therapy and the model of psychological flexibility. If you’re interested in learning more about ACT, make sure you check out the course and sign up for the wait list at the Integrative Pain Science Institute. The way you can do that, go to the IntegrativePainScienceInstitute.com and go to the Courses tab where you can sign up for the latest course release. There is a lot involved in Acceptance and Commitment Therapy for the treatment of chronic pain. The general goal of ACT is to increase something that’s called psychological flexibility. Psychological flexibility can be defined as the ability to contact the present moment and change your persistent behavior when doing so, serves a valued end. That basically means when your behavior serves the things that you love or the things that you value in life.
Building patterns of behavior that promotes psychological flexibility is important to help people open up and we’ll only approach some discomfort as they recover from chronic pain. Psychological flexibility is also important for practitioners to develop, particularly for a practitioner who has been trained in a traditional biomedical model of pain. If you are a practitioner who is starting to implement different types of psychologically informed care into your practice, know that psychological flexibility helps you as a practitioner drop the storyline that you’re here to either fix or cure someone with pain. Instead, it places you in a position where you can walk arm and arm with someone as you help and support them through their journey to overcome pain.
It’s a very different perspective when you look at the biomedical model versus a biopsychosocial model or using ACT as a method of psychologically informed care. Here to speak to us about psychological flexibility and ACT is physiotherapist, Tom Young. Tom has worked both in the United Kingdom and Canada as a physiotherapist with a specialization in chronic pain. He lives in Canada where he’s worked in an adult chronic pain service and now works with complex pediatric pain. Tom is also now leading a research project on how physiotherapists can be trained to utilize psychologically informed practice. On this episode, Tom will discuss ACT, psychological flexibility and how he uses ACT in his practice as a pain specialized physiotherapist.
I wanted to do a quick listen or shout out. Starting 2020, if you leave me a five-star review on iTunes, I’m going to read it at the beginning of the show and mention your name. Today’s listener shout-out is for Emma who lives in Canada. Emma says, “Dr. Joe, I want to let you know how useful your emails and podcasts are for me. My chronic pain from fibromyalgia has completely turned my life upside down. I’m someone who used to exercise regularly. I cannot endure any type of exercise after developing fibromyalgia, not even gentle yoga, not even a massage. The knowledge about pain from your podcast has provided me with such an understanding of the body, the mind and pain that for the first time I feel in control over my situation. Knowledge is power. I no longer feel like I’m damaged goods and I have less anxiety about where I’m going. I am by no way 100% pain free, but I cringe at the thought of how debilitating I would be now if I had never learned about pain from your podcast. I know your focus may be on health professionals, but I’m so thankful to hear about your discussions and learn from you each week.”
Emma, we’re thankful that you tune in each week to learn about pain. I’m so happy to hear that you’re empowering yourself with information because like you said, “Knowledge is power for chronic pain.” Emma, we wish you well and make sure to keep us up to date on all the steps you’re taking to overcome chronic pain each week. If you enjoy what you hear on the show, whether you’re a practitioner or someone who lives with pain, hop on over to iTunes and give us a five-star review, along with some comments about what you enjoy about the podcast. You never know, you may be my next listener shout-out. Let’s begin and dive into ACT and psychological flexibility with physiotherapist, Tom Young.
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Using ACT To Promote Psychological Flexibility In Physiotherapy With Physiotherapist Tom Young
Tom, welcome to the show. It’s great to have you here.
Thanks for inviting me. It’s a pleasure to be here.
Tom, you’re doing some interesting things in the world of physiotherapy or physical therapy. I wanted to have you on to share both of your history, the things you’ve learned and some of the new research and treatment that you’re involved in. A great place to start is if you can take us back a little bit and tell us how you got your start in physiotherapy and some of the things that you became interested in quite early in your career.
I absolutely fell into physiotherapy. You hear those people who they felt born to do it and they always knew. It was a total fluke for me. My background is that I was a Kung Fu teacher. I thought maybe I’d do a sports massage, something to supplement what I was doing. When I found out that was extortion and expensive, I was like, “I might as well go all in and do a degree.” I found physiotherapy. In terms of where I got to where I am now, one of my placements as a student physio was a national pain center in the UK where I trained. Those guys used a lot of Acceptance and Commitment Therapy. There was unlike any other physiotherapy I’d already seen.
At that point, it was quite bizarre to me. It was almost saying congruent with what I learned at school. I definitely wouldn’t have drunk any Kool-Aid if it was going around. It already got me interested in pain and what we do as physiotherapists. I’ve sought out opportunities in my career to move forward with that. I spoke with CRPS. I’ve worked in different pain environments in Canada now too. It’s always been something I’ve enjoyed.
You’re British, but you’re now working in Canada. You’ve been mostly in chronic pain throughout the entire time. You mentioned when you first were introduced to that pain service. It sounds like it was maybe a multidisciplinary service. All practitioners were trained in ACT. You said that it seemed a little almost incongruent to what you learned as a physiotherapist. Can you talk about that a little bit?
Some of the physios, I don’t think I’m doing them a disservice. They described themselves as not particularly physios. That was fair. A lot of what they did was that there was not a ton of investigation. For context, these are people who’ve been having pain for a very long time and they have been investigated until the cows come home. You’re safe to say there’s nothing necessarily dangerous with this population. It’s more straight to management. Even that, there was so much freedom. There was so much letting go of control as a therapist, which for me at the time was crazy.
I was still very much in the mindset of, “You’ve got to move a certain way. How are you moving this way?” Watching that lack of care about those smaller details and modeling the boldness of the patients took on was a very different experience. It was less of an expert delivered intervention. Not to say that they didn’t have expertise but it was less demonstrative and more explorative of therapeutic relationship and what the patients are seeking for and what’s important to them and allowing them to be the guidance of how they got there.
I love the word freedom you use. I’ve heard other physiotherapists who studied ACT and who used ACT use similar words around that topic. That topic of freedom interests me because from the feedback I’ve heard from other physiotherapists is that when they come out of school, they’re excited. They want to help people. In many ways, they want to fix and cure people. Especially if you start working with chronic pain populations, you realize that dream could be a little hazy and fuzzy at times depending on who you’re working with and where you’re working. If you can talk about freedom, both from your perspective as a clinician and maybe even for the patients as well?
Maybe if I can talk about the patients first and when I bring this to patients, there’s always maybe a fare on my end that I need to offer a solution, the Heifer effects. I’ve been more aware of my own urge to present them with the facts, even when I know that’s not necessarily an outcome I can realistically offer in chronic pain. I enjoyed the podcast you previously did with Dr. Steven Hayes. He was talking about after three years of chronic pain prognostically, it’s not great. You’re probably going to have some degree of pain moving forward.
Trying to fight that constantly can be exhausting for patients. It’s that sense of battle, but they pour so much energy into looking for effects, looking for a way out. As a therapist to say, “Let’s pull that energy somewhere else. Let’s chase things that make life more meaningful.” It’s already a big shift. Letting go of that fight is liberating for a lot of patients. It can be a difficult and painful process, but when they start to buy into that, it can be a frame as you’re saying.
Shifting that focus from pain control to the things they can do in their life. I call that putting the cart before the horse. Oftentimes, the rule is you have to be pain free and then you can return back to your life where so much of the research and things we’ve seen in clinical practice even before the research was created, was that when you return back to your life, that’s probably the quickest way for you to start living with less pain. As a physiotherapist, I’m wondering how that idea of freedom, how ACT has helped you access to more freedom as a practitioner?
Sometimes that’s been a little bit scary in a way. Some of what we do more traditionally, there’s something seductively complex about it like regional into dependent models, “I’m going to watch you walk. You’ve got shoulder pain, your ankles are pronating ten degrees. We need to fix that.” I’m accepting that maybe that A) That doesn’t have the best evidence to begin with and B) Letting go of that sense of maybe I’m not quite as clever as I am and that’s a challenge. You acknowledge your own sense of intellectual vanity almost. Letting go of that a little bit can be a challenge. Answering what you expect what a patient needs. When maybe you encourage a patient to do something and in the session they already buy it and they’re like, “This is so important to me. This is awesome.”
Then they have already a big pain fluff. There’s that sense of you can either swoop back in or try and save the day and say, “Here’s what we’re going to do. We’re going to control this and back off.” That rubs people of agencies. Part of that is trying to model a boldness about pain like, “You have pain, but what else came up for you? Was there some excitement when you did that thing? Was there some joy in the moment? What else was there for in that moment?” The more I’ve done that, the less of a wind loss there is as a frame for me. That’s what’s freeing. Trying to fix chronic pain is like banging your head against the wall. I talk a lot about patients letting go of that fight. Me as a practitioner also has to do that. If I’m still secretly like, “But all of this is to make you have less painful experience,” I keep on feeling of loss and that’s not a battle I’m winning. To truly let go of that control for myself as well and be willing to model a boldness. Pain is quite liberating too. Always bring it back to, “That happened, but what else? What’s important to you?”
That’s part of that therapeutic bond or relationship, patients are modeling your behavior. When they walk in the door, the first thing you say is, “How’s your pain? What was the pain intensity? Where is it over the weekend? Where did it travel or travel up and down, side and side?” Basically, you’re modeling the behavior. Your focus should be on pain. Where the complete opposite, which will probably lead us into the next topic of psychological flexibility, is that if you model other things as a practitioner, that eventually your patients will pick up on that and the focus will be less on pain and more on the things they can do, the things that they want to do in life.
Before I move towards more of a framework, I obviously looked into a lot of the pioneer education type work. That’s still something I find useful. The goal of that is to minimize the catastrophizing of pain. You can give the best explanation in the world, but if you come back to when they’re exercising, “I’m going to jump on you and you squat, your knees are a little bit too far beyond your toes and your pelvis.” The context is so important in pain and it might be that with good movement coaching, somebody moves in that context well, but they’re moving because a perceived expert is telling them it’s safe to do so. That’s the context you’re setting up. You give all that great education and you apply it practically in a narrow way. I don’t think it translates to a wider life that much. To let them go over a little bit of that context is as important.
Do you use a little bit of pain neuroscience education in practice?
Yeah, absolutely. I still think it’s important for people to understand why they’re having pain. People look for reasons. I definitely look at pain as the primary diagnosis as opposed to a secondary thing in all cases, where while you have some wear and tear or whatever else you might cut it down to. Offering good explanations and metaphor for peripheral adaptation, center adaptation and learn the complex nature of pain and all those things that tie into it and nothing that’s still useful.
It’s interesting to look at them side by side as treatment techniques, ACT and things like explain pain or pain neuroscience because they have some similarities. They use the metaphors in pain. In neuroscience, they are shorter and sweeter. The ones in ACT are much longer. The story that hopefully helps people change their behavior. There are some differences too because ultimately with explained pain or pain neuroscience education, you are trying to target maladaptive beliefs and change them, which in ACT, they don’t take that approach to it. That’s why I was curious to know if you have used both. Are you using them side by side at times? Is it like, “On the first visit, we’re going to do some explain pain. We’ll do a one-hour session on that so people have the baseline pain education they need. Going forward I take more of an ax stance when working with patients?”
It’s possibly more like the latter. I’d like to have a foundation of allowing people to move forward a little bit. Some of the explain pain certainly like the expectation is that your pain will decrease as a result of this intervention. It diverges a little bit because it’s more of that acceptance that, “What if it doesn’t? That’s okay. We can still move forward with life.” I’d like to help people understand that pain isn’t necessarily relating to an injury or tissue damage. That’s important to allow people the confidence to move forward. For as long as they’ve got quite that pain and an ongoing injury or harm, it is quite difficult to engage and move forward. Once you have that, I do shift more to a values-driven program.
Explaining pain and pain neuroscience, it’s a nice way to reassure people that they’re not going to hurt themselves. What’s interesting from an ACT perspective is that thoughts are going to come up and emotions are going to come up. Even if people understand, explain pain as good as Lorimer Moseley, that there is still these underlying thoughts that are going to pop up. We’re not necessarily going to change those. It’s very rarely do we ever change those thoughts in patients with long-term chronic pain. I know your background is in Kung Fu and Tai Chi. Do you see some similarities with perhaps the mindfulness aspects of that and the ACT work?
Yeah, absolutely. I’ve always been quite interested in Taoism. There are a lot of links between Taoism philosophy and ACT. What we described as values in an ACT framework to me is listening to your nature in Taoism. There’s a lot of overlap there. I certainly use a lot of more informal mindfulness. I don’t necessarily take people like a more formal route. I certainly use Tai-Chi as a movement strategy. I invite people to check in with themselves quite often. What’s coming up for you right now? In a class environment, do I felt like I’m not getting it as much as anybody else? What’s that like for you?
Can you notice that and still continue? We do a lot of where are you in space right now? Is your weight on your toes? Is it in your heels? Why are you moving in edge? The unpleasant body sensations, what’s that like? What does it make you do? What’s the narrative you’re attached to that? Trying to cue people to come into contact with that moment and notice what urges that brings for them. As you say, not trying to distract from that or not trying to change that narrative, but out of first step being more aware of it.
Tell us about where you’re working in, what that looks like and how all this is starting to play out in developing your practice?
I’ve changed roles, so I was working at the Calgary Chronic Pain Centre and that’s why a lot of these things have come into fruition a little bit. Whilst I was there, I developed a new exercise program with a colleague for people with long-term pain. We made it around the ACT methodology a little bit. It was a mix of education and exercise. Each session they would come twice a week for eight weeks. One of the introductory exercises we did was an ACT exercise called Creative Hopelessness. This is essentially, as you know, “What have you tried to control your pain thus far? What’s that been like for you? How’s that worked?”
More often than not, I think people go to extreme lengths because there doesn’t have real desperation with chronic pain. People try all kinds of things. You hear the waves, the wonderful and whole reams of drugs. “Are you still in pain?” “Yes, I am.” The next question is, “What does that cost you trying these things?” That was obvious costs. Financial, time and when we think about strategies to avoid pain, it’s often things that lead to us avoiding life too. Saying no to things, missing out. When we reflect on the cost there, the cost is quite often like sadness, regret, sometimes embarrassment, shame and it’s never just pain. It’s all this wealth of other things that come up.
From that we say, “Are you prepared to try something new, something different? Can we try something? We’re not trying these control strategies.” That lays the groundwork well with what the rest of the group is about. We do a week looking at values. I’m trying to get a sense of what’s important to people and what makes life fun and exciting. What are the things you’re missing out on? If you had low pain, what would you be doing? What would that look like? What would I say? Alongside this, we do some good general exercise education. Exercise is good for you. That in itself is interesting to me. We spend a lot of our careers telling this to people, but this is novel information to absolutely no one. A much more interesting question for me is, “Why aren’t you exercising?” That brings you more to barriers. “What’s come up for you? What’s come up to stop you doing these things that are important to you?” It doesn’t have to be exercise, “What is meaningful to you in life?” which is a shift for me as a therapist.
In many ways, all of the values in some way are going to promote people to be more active.
That’s the thing. I don’t care if you’re dead lifting and squatting. I’d like you to because that’s great. We’ve had lots of patients talking about they want to go play some crazy golf with their grandkids. I’m like, “That’s super cool. Let’s make that happen.” What do we need on a physical capacity level to make that happen and what do we need on the kind of acceptance and boldness level to make that happen?
It’s interesting you bring that up. I read a paper that was probably circulated around the internet somehow and I wish I had the resource right now, but it basically talks about how as physios, we need to do a better job at strength training and in general promoting exercise for our patients. In general, upon first glance, most of us who are physios and other healthcare practitioners would say, “This makes perfect sense.” The logic in our mind, as you mentioned that to a patient, it goes right over their head in so many different ways. There is one aspect there of, “We want to promote exercise,” and obviously health promotion exercise is important. If we were to do a long-term study in all the patients we’ve seen in our career, how many of them have said, “I’m going to do a basic yoga class. I’m going to work up to the gym. I’m going to go to CrossFit.” That almost never happens. We all have success stories, but the point of value is pointing them toward the things they already love and want to do is a lot easier arm wrestling than starting a completely new behavior that they’re potentially already adverse to.
What’s interesting with that as well I’ve found is the degree of the demands characteristics you see when like me as a physio talking to patients about their values, invariably they bring up exercise. I do think there’s a degree if I’m talking to a physio, that’s what he wants to hear. It’s important to you. What if I told you I don’t care about that? What makes you tick?
I live in New York City and people walk a lot. If your value is to spend more time with your daughter and go shopping on a Saturday, going shopping for four hours is enough. Potentially enough physical activity right there to get the needle moving in the directions of a positive mood, weight loss, more strength and better balance. You don’t necessarily need to go to the gym, which is what people think you need to involve yourself in an exercise program. As far as the shortcomings of the biomedical model, which most people reading understand the difference between the biomedical model and the biopsychosocial model. Where do you think we are as far as physio is in moving away from that biomedical model toward the biopsychosocial model?
There are still lots to be done. We talk a pretty good talk about doing a biopsychosocial model like everyone knows what that is turning well. Maybe to an extent, but we still arbitrarily separate those things out of it. We very much keep bio in a box, very much keeps psycho in a box, very much keeps social in a box. It’s a complex model. Everything includes everything. Some of the research I’ve been looking into at the moment is how do we train physios to effectively deliver psychologically informed care? Doing a review around that, I’ve already seen how much we still train physios in a biomedical model. Much of our schooling is in that framework.
There was an editorial with Greg Layman and a bunch of other people looking at the model of SIJ management and talking about how we measure that is biologically implausible. That’s true and that’s how we’re trained. It’s difficult to overcome. As humans, we dislike uncertainty. We work pretty hard to convince ourselves that things are certain and from which certainly in pain they most certainly are not. Lots of great lines. For me, I’m trying to address more of an awareness at the very least of the complex nature of pain would be useful. A lot of what we do biomechanically doesn’t make tons of sense to me.
I don’t think it’s backed up by the literature either. SIJ dysfunction, how often do you read that on a chart or a referral? What does that mean? Most of our tests rely on pain provocation, but that only tells you something is mechanically sensitive. It doesn’t tell you about the structure. It doesn’t tell you about the mechanism. We make some inductive reasoning that this means this. There’s also data to show that can be quite harmful. That was a study. The author was Len in 2013 looking at the Aboriginal population of Australia when they came into a Western health camp model and suddenly pain and disability rocketed up. There was this massive iatrogenic effect of coming into contact with health practitioners and being told this is abnormal, you should do this differently. It’s quite alarming. Trying to move away from the structuralism where maybe it’s unjustified not warranted. It’s general good basic loading and being able to sit with that uncertainty. We know it responds to load and that should be the cornerstone of what we do more so than some more interventional things that maybe don’t have a good grounding and good science.
In that biopsychosocial model, because you’ve now worked in two different countries, have you noticed a difference between the UK versus Canada?
Yeah. What’s interesting to me is the UK has a largely public MSK sector versus Canada has a largely private. Obviously, there are good and bad practitioners in both. I would say Canada to me seems to be a little bit more treatment heavy and a little bit more modality heavy. Good or bad clinics and you can’t be generalized. Certainly, some of the private clinics I’ve worked in and it’s very much regardless of what walks through the door, slap on a heat pack intense, ultrasound for a while and on you go. It’s quite infuriating. Some of that leads to that idea of fragility. Certainly, the idea of come and see me for some maintenance. It might be that your alignment shifts a bit and we’ll do something to straighten that out. It reinforces that idea of a fragile body, which probably leads to more catastrophization and more pain avoidant behavior because if every time you fell a little niggle, which is part of human life, you attribute that to some crazy alignment problem. It’s probably going to be hurt more because your context is one of danger.
The UK obviously is a smaller country and it does have that national healthcare system, which it seems like as far as pain goes from what I’ve seen from interacting with people on this podcast is that it has helped physios and other people grasp on to a biopsychosocial model faster. You’re correct as you come across the pond into Canada and down into the US, people are eloquent at defining what the biopsychosocial model is. I’d love to be a fly on the wall at most people’s practice and figure out what’s happening here? Part of our challenge in the US especially is to try to roll that out. Talking to you and seeing how you’ve done it is going to be interesting for people and hopefully give them some confidence that they can go further into this and that it is within their scope of practice. Tell us about some of the research. I know you have some research coming down the pipe. You’re working on some exciting projects.
Myself and my group are looking at how we train physios to do this more. The specific thing we’re looking at is psychological flexibility. This is the cornerstone of ACT. “Are you able to do something different essentially?” is the crux of it for me. ACT is are very big undertaking. I wouldn’t claim to be an ACT practitioner. I’ve had some training. I’m ACT influenced and I think for physios, even working with that smaller concepts would be useful. I worked a little bit with a guy called Tim Gordon who did some of my training, who’s wonderful and I recommend them to everyone.
We were looking at how we can maybe almost script or manualize a little bit of that. For instance, a conversation like, “What’s important to you? What would that look like? What might stop you from doing that? What would that be like?” It’s something as simple as that to get that conversation and that ball rolling. Where we are right now is maybe taking even a step back from that and trying to get a better needs assessment of the environment. There have been some good work done in the UK looking at all the physios using ACT and they’ve looked at the barriers that are. Some of them are what I’ve mentioned, that sense of loss of expertise, that feeling of, “This is out of my realm. I can’t do this. I’m not a psychologist,” which we’re not, to be clear. You can still be informed by these things. We’re now looking at our local environment of Calgary and Alberta and what would be the barriers and facilitators to adopting that approach and all that to a degree in a private setting, all the business barriers to that. Is that a sustainable model in business practice? How much willingness is that to try this? How much belief in that is that? We’re trying to get a sense of what might help with that so that we can develop a good testable teaching protocol subsequently to look at, one, to feel confident engaging in psychological support for their patients. Two is that good treatment fidelity to an ACT methodology or at the very least psychological flexibility techniques if they do.
I’ve read some of the ACT research when they train physiotherapists in using ACT and some of the challenges and the pros and cons to it. It’s a little bit similar to almost any psychologically informed intervention, whether it’s explaining pain or traditional Cognitive Behavioral Therapy or mindfulness. It’s taking practitioners that are rooted in that biomedical model. We’re so good at asking our patients to change their behavior, but we’re not so good at asking ourselves to change our behavior. It’s interesting on a large scale.
I find that funny. I’m thinking essentially how do we get people doing something? You have to do ACT on the individual to get them to do it is what I keep on coming back to.
You start to embody it before you can use it.
We spent some time in focus groups talking to physios as a pilot and trial and stuff to try things. When they come out, they’re like, “What was that like for you? What came up?” You had some funny things. It’s an interesting one.
As you mentioned, we’re not psychologists. Any physical therapists or physiotherapists across the world who’s using any type of psychologic informed practice are not psychologists. If you’re working with people, you’re working with psychology. That’s the important take home for all of the psychologically informed approaches that not just PTs but OTs and even personal trainers, fitness instructors, yoga instructors, Pilates instructors, all using certain types of psychological informed care and practice. Tom, the work you’re doing is awesome. You’re a big inspiration for lots of practitioners who are starting to dip their toe in the water of these topics who want to change and want to make that change for themselves and their practice. Let everyone know how they can learn more about you and keep up on the great work you’re doing.
I’m mainly on Twitter. You can find me at Basic Physio. If anyone has any ideas about this or any interest, I’d love to hear from you. I’m always keen to learn.
I want to thank Tom for joining us on the show. Make sure to follow him on Twitter, which is Basic Physio. If you are a physical therapist or a physiotherapist interested in ACT, Tom is a great resource and you can ask him some questions, reach out to him with regard to some of his new and latest research. As I asked you at the end of every podcast, make sure to share this out with your friends and family. Share it on Facebook, Twitter, LinkedIn or in Facebook group where people are all hanging out, talking about pain, physiotherapy, ACT or the combination of all. I’ll see you again soon.
Important Links:
- Tom Young
- The Healing Pain Podcast on iTunes
- Dr. Steven Hayes – previous episode
- Basic Physio on Twitter
- https://integrativepainscienceinstitute.com/act-for-chronic-pain-waitlist/
About Tom Young
Tom has worked in both the UK and Canada as a physiotherapist with a specialism in chronic pain. Having trained in the UK, he worked at a national specialist CRPS service and was also involved in pain programming in rheumatology. In Canada, he worked at an adult chronic pain service and now works in complex pediatric pain. He is currently leading a research project in how physiotherapists can be trained to utilize psychologically informed practice. He is part of a working group for both, the Bone and Joint Strategic Care Network reviewing shoulder assessment in Alberta and Alberta Pain Society tasked with improving interdisciplinary access, and is supporting knowledge translation work for the pain science division of the Canadian Physiotherapy Association. Prior to physiotherapy Tom was a Kung Fu teacher and has a special interest in using Kung Fu and Tai Chi as movement strategies for chronic pain patients.
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