Welcome back to the Healing Pain Podcast with Zachary Rethorn, PT, DPT
We have a new guest and a brand-new topic. You’ll be learning about how to address these social determinants of health in physical therapy practice. As physical therapists, we focus on alleviating pain, restoring physical function and teaching pain self-management as well as promoting healthy lifestyle behaviors to prevent chronic disease. As Doctoral-trained licensed health professionals, we have excellent skills, tools and technologies to address a variety of acute as well as chronic health conditions. Do you know how the social determinants of health, things like economics, education, neighborhood and other factors influence the lifestyle choices patients make and how it impacts their outcome in physical therapy?
Joining us to discuss the social determinants of health and physical therapy practice is Dr. Zachary Rethorn. He is a board-certified orthopedic physical therapist and a certified health coach with clinical and research expertise in musculoskeletal pain conditions, physical activity and health promotion. Zach is a PhD student in Health Promotion and Wellness at Rocky Mountain University, where his research focuses on how health professionals promote physical activity with their patients. On this episode, you’ll learn all about the social determinants of health, how to identify whether patients are impacted by the social determinants of health, what clinicians can do to address the social determinants of health and the role public and healthcare policy has in shaping the social determinants of health. Let’s begin and let’s meet Dr. Zachary Rethorn and learn all about the social determinants of health.
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Addressing Social Determinants Of Health In Physical Therapy Practice With Zachary D. Rethorn, PT, DPT
Zach, welcome to the show. It’s great to have you.
Joe, how are you? Thanks for having me on.
I came across a viewpoint of yours in the 2019 December edition of the Journal of Orthopedic and Sports Physical Therapy. The title of that viewpoint is the Social Determinants of Health. If you don’t measure them, you don’t see the big picture. The viewpoint is written concisely and it’s rapid to read for practitioners who don’t want to take a deep dive into social determinants of health. There are some things in there that are clinically applicable, which is great. I figured I need to connect with Zach and talk to him on the show. You and I have connected and you started telling me a little bit about the great things that you’re doing. Give us a 10,000-foot view of all the cool stuff you’ve got going on in your world.
I wear a lot of hats in my world. My day job is as a Faculty Development Resident at Duke University. The one-sentence summary of that is I’m a professor with training wheels. I am on a two-year appointment learning how to be a great educator and a great faculty member full-time one day in a PT program. I’m also a PhD student in Health Promotion and will be finishing that up in 2021. My work in that is looking at how PTs promote physical activity with their patients in an outpatient setting. The goal of my work is to try to move it more into practice through some implementation science frameworks. To figure out how we can move our profession toward considering health as an outcome and not rehabilitation as an outcome. The last hat I wear is as a solopreneur, which is a space I never thought I would get into. I started a digital-physical therapy practice. I still treat and see patients and do some health coaching on the side as well.
Lots of things are going on, which is awesome. Tell us what health promotion is. How do you define health promotion? What are a few of the important factors that are under that umbrella of health promotion?
Health promotion can mean a lot of different things depending on who you talk to. That’s why it’s a great question to bring up. The way I think of it is it’s anything that we’re doing to advance the health of individuals and populations that we serve as clinicians would be from a PT hat standpoint. There’s also the public health perspective that looks at the nation as a whole, states or groups in different factors and figures out how do we help our entire society even our world be healthier. There are many different layers at which you can view health promotion but the goal is how do you promote health? Whether that’s through healthcare, policy, or through collaborations. What does that look like? There can be many different ways that folks will use that to term and define that term depending on what space they’re in.
Tell us what the social determinants of health are and how that connects to health promotion. Because Health Promotion in the PT curriculum, they’re anywhere between 1 to 3 courses that are popping up in various schools specifically on health promotion. Social determinants of health are usually embedded within one of those courses.
When we talk about health promotion, you can’t talk about health promotion without considering where we live. What is the context in which we live our lives? The social determinants of health strictly defined by the World Health Organization are the conditions in which people are born, grow, live, work and age. That’s all-encompassing though. That is the entire context around which we live our lives. A few key areas that the Healthy People 2020 Initiative focused on were economic stability as a driver of health, educational attainment, social and community context. What does your relational web look like? The built environment around you. Are you in an area that has air pollution? Are you in an area that’s safe? What does the built environment look like for you? Finally, access to healthcare is a piece of the social context we need to consider. When we think about social determinants, they can be almost anything within that realm of where we live, work, play and pray is another way to think of it. Within that, there are some key areas that healthy people identify and that a lot of folks have been working toward over the last decade.
You’re bringing in important topics such as the climate, for example, which some professionals have taken a stance on and other professional organizations have not taken a stance on. In my physical therapy mind, I think these are all important things but I feel like when I treat my patient, it’s the intervention, the mobilization, the specific exercise that’s “helping” someone or curing them, so to speak. Is that true? Is it more the social determinants of health that have an influence?
It’s not an either/or. It’s a both/and. It depends on the person in front of you. I’ll give you some anecdotal evidence from my own practice. I started working straight out of PT school in a clinic where a lot of folks I worked with had persistent pain. It’s your audience and what you’re about. What I realized was that when they were coming to me with this persistent low back pain or knee pain, I ended up realizing that I was already starting with an outcome. I had my own process of taking intake forms and using forms to track outcomes in my practice and seeing did my mobilization help? Did my specific rehabilitation plan help? Before that, they’re already coming to me with an outcome.
The fact that they even have this persistent pain is itself a process with things further upstream that are influencing that. A way to think of it is we see folks at the end of the line over here and by the time they need rehabilitation, my thought was, “How do I keep them healthy? How do I keep them from getting this?” What I saw was the same folks would come to me, they would seem to get better, and then I would see them again six months later. We work together, we change behaviors a little bit, they’d relapse, and I’d see them again six months later. I felt like I was running on a hamster wheel and my patients did too. They were looking for more permanent and long-term solutions.
That’s when I started looking upstream, if you will, and seeing what we can do to keep this from happening. What environment? How did the environment shape the choices that seem logical, reasonable, rational for my patients? I’ll give you one example. I had a patient I’ll never forget. I was working with her on physical activity. We know that helps and can help folks with persistent pain. I was encouraging her to start a walking program. When she came to me and said, “How am I going to do a walking program when I don’t have a sidewalk and when I hear gunshots on a regular basis on my street? I don’t feel safe going outside.” That’s when you look at, “If the walking program can’t be reasonable because of the social context around you, then that’s the barrier and that’s what needs to be addressed. We can’t do that within the four walls of our clinic.”
Many practitioners were in the moment with their patients in the clinic but they’re not necessarily going home with them in their mind and figuring out, “What’s happening in the social environment?” It reminds me the PT school I went to was in a bad neighborhood in Brooklyn that had a lot of gunshots and it was difficult for us to walk around, get exercise, and get out because of that. That story rings true. As a physical therapist or another health professional, how do you start to identify some of these social determinants of health? When you’re doing your patient intake and you’re starting to look upstream at, “There are things I have to do in the clinic,” but how do I start to identify these before we get the wheels moving?
There are a lot of tools that you can use to do this. You don’t have to reinvent the wheel. The work has already been done. There are folks in primary care that are working to see how we move this into clinical workflow. A colleague of mine here at Duke with a team of undergraduate students embed these screening tools for social needs within the local community health centers, workflow and intake. There are models and people that are doing this work. If you’re able to get access to the viewpoint, there’s a great compendium of different types of screening tools that you can use to begin to identify how is this working? What does this sound like to ask the questions of do you have violence in your community? What is your built environment like? Are you food insecure? Is your home environment safe? Are you concerned about heating? There are a lot of different areas that you could potentially ask questions but there are some great toolkits that have been developed.
The SIREN Network at UCSF has a great compendium of tools. The one I’ll highlight out of that that I personally think is a wonderful tool is the Health Leads Screening Toolkit. You can access it for free. You have to give your email address but they don’t spam you, I promise. They’ll send you a link to the PDF. What it is, it’s a validated screening ten-question toolkit. Yes-no, it’s simple. You can integrate it into your intake forms and begin to have an idea of what are the needs of the population that I’m working with. As we think about what this look likes, I would encourage folks if you’re going to do this, be systematic so do it with everybody. Don’t do it for people you think might have that social need because we can’t always tell on the surface. The ethics of that become gray and potentially black quickly if we don’t look at engaging our entire practice population but we try to target subgroups. I want to encourage folks to be careful of that. If you can integrate it with every patient, that’s a wonderful first way to begin to get a sense of what are the needs of my community.
Can you give us the website?
There are two websites. One of them is SIRENetwork.UCSF.edu. The other one is the Health Leads Toolkit.
How long does that take to fill out because practitioners are interested in not having too much paperwork and not adding too many things on? Is it something that’s relatively easy for them to tackle?
It’s ten questions, yes-no. They’re written below a sixth-grade reading level so they’re specifically designed to be accessible to the entire population. It shouldn’t take more than 1 or 2 minutes to fill out. It’s one of those things that can open conversations in your evaluation and can lead to some doors of avenues for further support and referrals for patients who may have some of these needs.
Some of these are big topics. When one shows up, what recommendations do you have for practitioners to either developing a network of professionals who can help out or other resources to help the patient when you identify these social determinants?
The screening by itself is good, but if all you’re doing is screening without having community partners and knowing what resources are available in your community, you may be doing more harm than good at that point. There are some tricky waters to navigate here because screening without the capacity to do something may make the patient feel, “You asked me these questions but there’s no follow-up. Why are you doing this?” You may lose trust and credibility with the patients if you don’t have these resources to refer them to. I would recommend even before you start screening, get to know your community, get to know the resources that you have in and around the areas that your patients tend to come from, and have those in place. Build those relationships now. As you build those relationships, integrate the screening and you’ll have no problem in connecting your patients. In my practice, it was a bit of an organic process.
When I started, I wasn’t aware of these toolkits. I wasn’t aware of what I needed to do. I started seeing the needs and reaching out to community partners as I was able to find them. Over time, I ended up building a robust network of community partners and stakeholders who trusted me and I trusted that I could say, “Let’s have a conversation. Is this something you’re willing to talk about? Is this something you’re open to seeing someone else, getting referred to someone else and see how they could assist you with this?” If the patient said yes, then I can talk up this person specifically, “Let me send you to Joe over here. He does great work. Here’s the process. When you call, you’re going to talk to this person. They’re going to get you set up with this and then this is going to happen.” I was able to have intimate knowledge of exactly the processes that the community partners that I had. That helps sell that, “I’m here to help and these people can help you too if you need it.” I will encourage you to take that approach if you’re interested at all in thinking about integrating this into your workflow.
Those community partners that you mentioned, what comes to mind for us as practitioners is potentially another licensed healthcare professional, maybe a social worker who can intervene. Are there other larger organizations, not-for-profits, that may be part of that community network that you’re leveraging?
In my practice, social workers were one piece of the puzzle and I got to know the community health clinics in my area well. I also got to know the system of what would you be qualified for and what wouldn’t you? If you’re not qualified for those kinds of services through the healthcare system, then what other resources are around me? For folks with food insecurity, what kinds of resources are there in my community? Is there a food bank? Are there churches or faith organizations? What else is out there? What’s the entire scope that I could potentially offer as resources for folks? From a mental health perspective, we had a graduate school in the area that had psychologists, counselors and training that would provide pro bono services.
I got to know them well for folks who were interested and payment was a barrier. I could refer them to the students who were learning the process, but also get services in a way that folks could afford. Finding avenues and partners like that was important for me. Depending on who you see in your practice population, your needs may vary. If you’re seeing a lot of patients screening positive, maybe food insecurity is a big issue, then that’s an area that you can say, “Let me take a little bit of time. Let me research my area. Let me see what’s out there. Build some partnerships because I see this come up again and again.” Other needs may or may not be as prevalent for you but that’s a reasonable model not to overwhelm clinicians who are extremely busy and have much to do outside of this.
Let’s take this to a different level. We have state physical therapy associations and then we have the national American Physical Therapy Association. What role do they have with regard to shaping policy or recommendations with regard to social determinants of health? On the national level, I’ve seen some information come out from the APTA. I haven’t seen so much at least in the states that surround me with regard to social determinants of health. Some physical therapists are behind this and want our professional organization to play more of a role in policy. Some professionals feel like, “I don’t know if those things are under our guy, so to speak.”
One that I think we can have a reasonable debate about the role of our professional associations in these challenges. For me, as I’ve learned more about what factors contribute to health. What affects at a community level of the health of a community? It’s those big picture policy-driven factors like what’s the educational system like in that area? What is the built environment like in that area? What are the economic opportunities available to people who live in that area? What is the built environment? Do they have public transit to get out of areas? That was part of the work I did was with the Department of Transportation to say, “I’ve got these folks and on paper they’re closed, but the public transit system doesn’t serve their needs in a way that gets them access to those economic opportunities that they’re looking for.”
It wasn’t reasonable. I lived within a mile of three health systems and to get to one of the health systems, it took 40 minutes on the bus lines. It was crazy. You had to go all the way back to Central Station and then take a different bus all the way down to get a mile away. There are all kinds of issues related to that. At a local level and a community level, it makes sense to advocate for that policy. We’re in a polarized moment and whenever we talk about social issues, inevitably we’re talking about politics because they’re intertwined. We can’t talk about one without talking about the other. Keeping it at a community level helps disentangle a lot of those polarizing topics.
At the end of the day, don’t we want all of our community members to have the opportunity to live healthy, productive, long lives? Everybody wins when we have more access to economic opportunity, when we have better access for people to have healthy nutrition. We see the costs in healthcare associated with these long-term chronic conditions. The evidence is clear. I don’t know how familiar you are with Michael Marmot and his work in social determinants of health but you look at the gap. There’s a gap between the best and the worst and it can range between 10 to 15 years depending on what zip code you live in the city. We see that there’s a social gradient that the more income, the more education, the better situation from a social standpoint you have, the better your health and life expectancy is going to be.
It’s a clear gradient and it’s all the way to the top. It should affect all of us. If we’re not in the 0.001% of people of earners and education and whatever else, there’s somebody above you who’s doing better on the health perspective. Even from a self-interested viewpoint, you should care because other people are doing better than you because of this inequality and opportunities. There are a number of reasons that we should consider getting involved. The way that we do that and what role our professional organizations play is going to play out over the next decade. With our vision statement and APTA of transforming society, we have a lot of opportunities to be outward-facing and the APTA’s mission is now aligned with that in outward-facing language. What that looks like and how do we be strategic? Where can we pull on these policy levers to make a real impact for the patients that we serve? That is going to take a bit more figuring out among people who are at much higher levels than I am within the organization to see where we can make an impact.
Is this something that’s sprinkled throughout all of our chapters and SIGs? Do we need to develop a new chapter, a new SIG, or have some committee? We can get marred down in committees, but I’m wondering how do we bring this message? It’s in school a little bit. If you’ve been at a school, you may not be as open and aware of all this which is why I’m doing a show episode on this. Looking at the national level, APTA-national, we have a health promotion part which is slowly growing. There’s some talk there and that’s similar to this, but not quite the same.
There are some linkages there between health promotion and social determinants of health because whenever you look at health as the goal and not rehabilitation, you have to consider these social factors because they play such a huge role. I know that the APTA is working on several population health initiatives, which that’s another word you might hear that’s related to social determinants and health promotion. Population health is looking at not the health of individuals but zooming out and looking at the health of groups. How can we influence the health of groups of people? That’s one way that I see the national organization beginning to get on board with this and look at this. You may not see that social determinants language used, but anytime you’re looking beyond an individual level, you’re going to have to be addressing these concerns and these issues.
Within the Council on Prevention, Health Promotion and Wellness at the APTA, I know that there’s some work going on of developing some population health resources and strategies. That council is designed to connect people from across sections and chapters. It’s designed to be a meeting place and a clearinghouse, if you will, rather than a SIG within one chapter, which is a bit siloed. The idea with the council is it can be open to everybody and provide access to anybody who needs it or wants it. I know that the APTA has a Population Health Task Force as well. There’s some movement within the state and national organizations. In my mind, there’s still a lot of awareness that needs to happen within our profession. It’s a relatively small group of people who are invested in this and are working in this. If you’re interested, feel free to contact me and I’d be happy to connect you with others who might be in similar situations. It’s a relatively small group of people who are trying to move this forward.
Let me play devil’s advocate for a moment and flip the coin on this topic a little bit. I finished watching a series on Netflix called The Pharmacist. Check it out when you can. I’ll give you the overarching one-two of it is that during the opioid crisis in the early 2000s, pharmaceutical companies and some prescribers of opioids targeted areas that I would identify as areas with challenges to those determinants of health. You have a large publicly-traded company that we hope is doing well, but in essence they sent hundreds and thousands of drug representatives into those communities that they know had health challenges. Many of the social terms of health you’re talking about and push these drugs there. We know what the outcome of that was. It wasn’t good. Do you want to say something about that? How do we become aware of someone using the data and the information for purposes that are not ethical?
I’m not aware of that series. That doesn’t surprise me though because I worked in one of those areas as a clinician. When I would meet with the primary care physicians and the folks who were prescribing medications, I would say there’s one physician, in particular, I remember that we saw a lot of referrals from in that outpatient clinic. Every single one of his patients came in with an opioid referral and they would visit him every 28 days to get a refill on this opioid referral. That was his whole practice. When we would go to do marketing lunches, there would always be a pharmaceutical rep there. That doesn’t surprise me to hear that wasn’t happenstance, but was, in fact, a coordinated strategy. On some level, I despair a little bit that you can do that. A company can look at that data and target vulnerable populations and say, “I see money here. I don’t see people, I see the money.”
I don’t know that there’s any way we can move around that in our current system but when we look at addressing the social determinants of health, there are a few layers. I’ve been talking about layers a lot but we can do that from an individual level. We can look at social needs, we can screen for them in our clinical practice and we can refer to resources as they’re available. That’s good. That’s something we can do but that’s not enough. That’s not solving the big picture problem. We can work on our community level and work with our boards of education to integrate physical activity into schools because we know the beneficial effect that has on grades. We can work with our boards of education to talk about the inequity in education and how schools are still segregated, at least where I was in Chattanooga, extremely segregated. The impacts that have and the impact the inequity in education has on the whole community because everybody loses.
That’s what the epidemiology tells us. Everybody loses when we live in a society where those inequities persist. We can also think about the policy level. That’s where we’re going to have to get to as a society, as professionals, we have a voice to play at this policy level to say what the causes of the causes are. If boards of education are not dealing with the inequities, what are the policies that they’re following that are allowing this to persist? What are the policies with zoning that we’re allowing to persist? There are a lot of different areas that we can look at upstream to say, “What can we do here? How can we make things more equitable? How can we make things better for our entire society?” Does that make sense to you? There are three levels. Each of them is good. When we get to that policy level that most removed from the individual, that’s where we start to see the most impact potentially.
That’s when you do look at things like what does Congress do? You look at things like what does your Senate state representatives, whatever your state legislative system is, what are they doing? That’s where you look at. That’s where policies are made. That’s where decisions that are impacting the entire population get made and are influenced. That could be a realm for physical therapists to advocate for. In our climate, we all have Political Action Committees. At least the states I’ve lived in have PACs. What are we lobbying for? Who are we lobbying for? Are we lobbying for our own interests? I have some intention there. Is there a room? Do we have the ability to lobby for the health of our populations in policies that follow the evidence, epidemiology, and research? That’s an area where I would push our associations to move a little bit further into saying, “Where do we have strong evidence?” There are plenty of policies. We have strong research evidence that policies can work. Do we have the political will? Can we have the messaging to convince people that this is truly what’s going to be best for all of us?
As a profession, we’re a large profession as far as the health professions go but our representation in Congress is small. I’d love to see more PTs get involved, PTPAC and policies on the local level, a community level, a state level and national level. I do think physical therapists have a lot to say, have a lot of great information to share. Both information that they’ve experienced on the job as well as people like yourself who are doing research that can start to open people’s eyes to what’s happening in the communities where your senator or congressman is working. Zach, I know you’re close to finishing your PhD. This is a big topic that you’ve started to chew on. Where do you see yourself going with this information in the future? You mentioned you want to be a full-time professor potentially. Is there something bigger there for you?
Who knows what the future holds at this point? My contract and my appointment ends at the end of 2020. I’m not sure what’s coming next for me quite yet. Whatever I do, this is definitely what drives me. My experiences in that clinic for those three years that I worked there, and then in-home health for another year working with the same group of folks. That’s been the professional catalyst that’s driven me to care about this and to want to see changes. From a research perspective, there’s a lot of room that we can still work in this area. There’s little work that’s been done that specifically delineates the pathways by which the social determinants of health impact musculoskeletal disorders specifically. It’s what we work with primarily as PTs. There have been lots of work done for cardiovascular disease, diabetes, and endocrinological disorders.
There has been little work done with musculoskeletal disorders. That’s a missing piece within the research base that we need to have if we’re going to make this argument that, “We serve people who primarily have musculoskeletal conditions and this impacts them in clear ways. Therefore, we do have a stake in this. We do have a voice in this. This is something we should be doing.” In the viewpoint, that’s one of the limitations I address almost immediately is we don’t have one pathway that links these things together. Anecdotally, I’ve seen the evidence, we see applications to others so we can infer, but we don’t have that direct pathway to low back pain, neck pain or knee pain. That’s one area that I’m extremely interested in pursuing from a research perspective to draw that out and give us the impetus to move this forward from advocacy and a policy perspective.
If we have that research, I’m wondering, does CAPTE, the Commission on Accreditation in Physical Therapy Education, have any language on social determinants of health being embedded in the PT curriculum?
I will preface my answer by saying I am by no means a CAPTE expert. I am a CAPTE novice and I’m learning more. To the best of my knowledge, we do not have any language in the CAPTE standards specific to social determinants of health. We do have some broader language related to our responsibility to society but nothing specific to social determinants of health. That’s a program-by-program basis.
If that’s what’s going to drive education which will start to plant some seeds and new professionals as they are entering into the workforce.
That’s one of the barriers we face is that programs can choose to present this or not choose to present this. Here at Duke, we have a wonderful course that we’ve been partnering with the med school to deliver cultural determinants of health and health disparities where they get a lot of this information. They get actionable information about what they can do as students to help be in to drive change. They get information about what they can do at that community level and policy level from their position of privilege as a healthcare professional and how you can use your professional voice to help better the lives of your patients. Also, learning the history of why we are where we are because there’s a long history throughout our nation of why these inequities exist at a local level, at a community level and at a national level.
Learning history is an important part as well. That’s been something that I’ve been involved with and have been excited about. I would hope to see more programs picking up models like this because it’s important. At the Education Leadership Conference, the keynote speaker closed his keynote with this great quote that I don’t think I’ll ever forget. It’s a quote from Ernest Boyle who is a sociologist, I believe. I’m looking at undergraduate education but this applies to PT education as well. He said, “The great crisis of our time is not from a lack of technical competence. We are great at producing graduates who have technical competence. The great crisis of our time is due to a divorce between competence and conscience.”
What I would love to see is how we help students, whatever their passions are to improving the health of populations or people, because everybody I believe in PT school is there because they want to help people. That’s who we are as a profession. We’re like the golden retrievers of healthcare. We want to help. We want to be there and do things. How can we empower our students not to divorce their competence from their conscience and connect them to resources and ways to move this forward?
I love that quote. That will hit home with a lot of people and give them some good things to think about. Hopefully, the schools are reading your viewpoint and coming across some of your research which would be nice for you and they’re starting to take some of that information and reflecting back on their curriculum and starting to make some changes. We’ll certainly follow your work. If you have anything new, please let us know. In the meantime, let us know how we can find more information out about you.
The main platform you can keep up-to-date with me is Twitter. You can follow me, it’s @ZacharyRethorn. If you’re interested in reaching out, you can feel free to reach out through my website, RethornPT.com. You can also reach out through my Duke email address, [email protected]. The social media platform I’m on the most is Twitter. I have met tons of great people through that platform and it has been an immense joy as crazy as social media can be.
I want to thank Zach for being on the show talking about the social determinants of health. You can reach out to him at RethornPT.com. This is a new topic so make sure you share it out with your friends and family on social media. It’s an important topic for both health professionals as well as people who are interested in policy and healthcare. We’ll see you next time.
Important Links
- Social Determinants of Health
- Healthy People 2020 Initiative
- SIRENetwork.UCSF.edu
- Health Leads Toolkit
- American Physical Therapy Association
- Council on Prevention, Health Promotion and Wellness
- PTPAC
- CAPTE
- [email protected]
- http://www.RethornPT.com
- @ZacharyRethorn on Twitter
About Zachary Rethorn, PT, DPT
Dr. Zachary D. Rethorn is a board-certified orthopedic physical therapist and certified health coach with clinical and research expertise in musculoskeletal pain conditions, physical activity, and health promotion. He earned his undergraduate degree in Exercise Science from Belmont University followed by his DPT degree from the University of Tennessee at Chattanooga. Dr. Rethorn has completed a residency in orthopedic physical therapy through Benchmark Rehab Institute and is a PhD student in health promotion and wellness at Rocky Mountain University of Health Professions where his research focuses on how health professionals promote physical activity with their patients. He is a faculty development resident at Duke University in the Doctor of Physical Therapy Division and owner of Rethorn Physical Therapy and Wellness, a digital physical therapy practice. He has presented at national and international conferences on topics related to orthopedic physical therapy and health promotion.
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