Phil Stevens, MEd, CPO, FAAOP

Building a Tower of Understanding

Phil Stevens, MEd, CPO, FAAOP, leads efforts to investigate O&P outcomes and devices to inform clinical decisions and benefit individual patients

O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.

Phil Stevens, MEd, CPO, FAAOP, presents at the annual meeting of the American Academy of Orthotists and Prosthetists.

ANEW STUDY ON PROSTHETIC feet provides important information for prosthetists across the United States, and could prove consequential for reimbursement purposes. Phil Stevens, MEd, CPO, FAAOP, a director of clinical and scientific affairs at Hanger, worked with a team to study the outcomes associated with some prosthetic feet after the Pricing, Data Analysis, and Coding (PDAC) reclassified several devices.

“The recent decisions by PDAC to categorize feet based on the presence or absence of distinct mechanical features, rather than observed performance and outcomes, has really impacted the field,” explains Stevens. “The result has been a reversion of sorts to taller, heavier feet that satisfied the PDAC requirement.” Team members examined the outcomes data to determine if the trends they saw in mobility correlated to features or functionality. Specifically, they studied L5987 feet that retained that coding profile, L5987 feet that were reclassified as L5981 feet, legacy L5981 feet, and L5987 feet that were never submitted to PDAC.

This landmark study is one of many undertaken by Stevens and his colleagues to take a closer look at important O&P topics. As an associate within the Hanger Institute for Clinical Research and Education, Stevens develops evidence-based clinical programs designed to help patients improve their orthotic and prosthetic outcomes. In collaboration with his associates, he is involved in outcomes implementation, groundbreaking research studies, and the establishment of Clinical Practice Guidelines and national standards of care. His interest in research dates back to his early days as a clinician—when he first sought to better understand why certain O&P devices are appropriate for specific patients.

Solving Clinical Problems

For Stevens, O&P research is key to improving clinical skills—and ultimately, patient outcomes. “Especially as a young clinician, I didn’t feel my experience was enough to provide the best care for my patients,” he recalls. “I saw research and literature as a way to augment my limited experience.”

Stevens, who graduated from the University of Washington’s O&P program, performed his first systematic review shortly after he finished his first round of board exams. “I remember being very frustrated with one of the

written simulation questions where I was answering the question according to my early experiences in a very pediatricbased facility, and I could tell my answers didn’t align with the treatment pathway that the exam wanted me to pursue,” he says. “The result was a deep dive into the literature associated with the orthotic management of muscular dystrophy. If there was a better way to manage those children, I wanted to understand what it was.”

Over the years, Stevens, who has a master’s degree in allied health education and administration from the University of Houston, has been involved in many impactful studies, in both orthotics and prosthetics. “This has included strategic discussions on how to examine some of our internal outcomes data and external collaborations with academic institutions and medical centers,” he explains.

For example, he studied the postoperative orthotic management of craniosynostosis—a relatively recent area of practice. “Prior to the proliferation of endoscopic surgical techniques, the various presentations of craniosynostosis were poorly understood within the orthotic community,” he explains. Stevens and the co-authors published their early experiences following total vault reconstruction surgeries—one of the first attempts to describe these clinical presentations and their orthotic management to O&P professionals. “One of the fair criticisms of that early publication was that the standard cranial measurements used in deformational plagiocephaly aren’t optimal for other cranial pathologies,” he says. “I’m happy to note that in recent years, we’ve published separate papers defining novel measurement indices specifically developed to track outcomes in certain presentations of craniosynostosis.”

Stevens also worked with a team to study the more common deformational plagiocephaly. “We used a Delphi consensus process to define care standards associated with deformational plagiocephaly,” he explains. “In an area that’s always had to contend with subjectivity, it’s been nice to have some guardrails and guidelines in place.” Patient families, clinicians, and referral partners have appreciated the clarity that comes with those types of standards, according to Stevens. “We’ve since produced similar guidelines in association with prosthetic foot and knee selection, transtibial interfaces, suspension and alignment, and the prosthetic management of unilateral transradial amputation.”

Demonstrating the Value of O&P

Stevens has played a part in several important large-scale investigations at Hanger Clinic that delve into patient data to demonstrate efficacy of O&P intervention.

The Mobility Analysis of AmpuTees (MAAT) series “has been quite significant, reporting upon study groups much larger than we have historically had in the field,” he explains. “MAAT I confirmed a strong correlation between prosthetic mobility and well-being. MAAT II confirmed that co-morbid health conditions do not innately compromise prosthetic mobility. MAAT III confirmed that microprocessor knees appear to compensate for roughly half of the mobility compromise that is observed between transtibial and transfemoral prosthesis use. MAAT V confirmed higher mobility levels with more advanced prosthetic feet. MAAT VI confirmed that both well-being and prosthetic mobility appear to remain stable as much as seven years following vascular amputation,” he says. He and his colleagues recently announced the publication of the seventh manuscript in the MAAT series, which further explores the theme of prosthetic mobility across amputation etiologies.

Hanger Clinic’s OASIS series, which focuses on outcomes assessment observed with specific prosthetic components, offers studies comparing the effectiveness of a variety of O&P components across different patient groups to enhance patient outcomes. “We are uniquely positioned to provide objective insights in the performance associated with certain prosthetic components,” Stevens explains. “For example, in OASIS 1, we were able to report on the injurious fall rates associated with several different makes and models of microprocessor knee.”

The Hanger team also recently published its first Stability and Falls Evaluations in AMPutees (SAFE-AMP) study, which will significantly impact clinical decision making and patient outcomes, according to Stevens: “We reported on the relationship between prosthetic knee selection and injurious falls among elderly K3 patients with unilateral transfemoral amputation of vascular etiology,” he says. “Fall risk is especially concerning in this group, with the overlapping risks of vascular disease, amputation, and advanced age.” Their data identified that individuals fit with a nonmicroprocessor

Stevens has spoken on a variety of important O&P topics at industry meetings over the years.

knee are 2.5 times more likely to experience an injurious fall during the preceding six months than their peers fit with a microprocessor knee.

Circling Back to Patients

Patient welfare should be the priority for collecting outcome data, according Stevens. “Each of those patient encounters constitutes a brick in whatever wall or tower of understanding we’re actively trying to build. But as the field migrates toward broader implementation of outcomes, it’s extremely important that we sit down with the patient who just provided us with these outcomes and place their responses in some sort of meaningful context for them.

“We should never exploit patients for outcomes without a commitment to use that data to improve their individual situations,” Stevens asserts. “Properly done, outcomes can help patients understand where they are in their own rehabilitation and what their next steps may look like. If we can leverage large-scale outcomes to produce data—that’s optimal. But individual outcomes should benefit individual patients, irrespective of what we do with those larger data sets.”

Beyond his dedication to research, Stevens is involved in furthering the O&P profession in other ways. A former president of the American Academy of Orthotists and Prosthetists, Stevens currently sits on the editorial board of the Journal of Prosthetics and Orthotics, is actively editing the fifth edition of the Atlas of Amputation and Limb Deficiencies, and holds adjunct faculty positions within the University of Utah’s Division of Physical Medicine and Rehabilitation and Concordia University’s O&P program. He also is an avid musician.

“I studied jazz piano in college and have continued to play since then,” Stevens says. His musical prowess inspired one of his sons to take up the piano and trumpet. “Throughout the pandemic, we would invite a few more musicians over, invite the neighborhood, and play concerts on our driveway,” he recalls. “Social distancing was always encouraged, but it gave the community an excuse to get out of their houses and interact with each other in a safe outdoor environment. Those driveway concerts were certainly my highlights throughout the pandemic.”

Now that the COVID-19 pandemic is easing and many clinical practices are at full capacity, Stevens has spent some time thinking about the future of O&P research. He believes it’s time to move away from simply studying “mechanisms and features” and shift the emphasis toward performance and outcomes. “I’m hoping we see less dialogue over whether a foot has 5 Stevens (second from right) plays keyboard degrees of motion or 7 degrees during a driveway concert with his son and of motion, or whether a waterneighbors during the COVID-19 pandemic. proof microprocessor knee is suitable for saltwater use or only freshwater use, and more research into how these components impact the larger concerns of our patient populations—things like mobility, activity levels, and stability,” Stevens says. Studying these larger issues will surely have beneficial repercussions on the patients who rely on orthoses and prostheses to improve their quality of life. NOTABLE WORKS Phil Stevens, MEd, CPO, FAAOP, has been involved in hundreds of impactful published studies, including the following: • Stevens, P.M., Hollier, L.H., Stal, S. “Postoperative Use of Remolding Orthoses Following Cranial Vault Remodeling: A Case Series.” Prosthet Orthot Int, 2007; 31(4): 327-341. • Ramsey, J.A., Stevens, P.M., Wurdeman, S.R., Bonfield, C.M. “Quantifying Orthotic Correction of Trigonocephaly Using Optical Surface Scanning.” J Craniofac Surg, 2021; 32(5): 1727-1733. • Lin, R.S., Stevens, P.M., Wininger, M., Castiglione, C.L. “Orthotic Management of Deformational Plagiocephaly: Consensus Clinical Standards of Care.” Cleft Pal Craniofac J, 2016; 53(4): 394-403. • Stevens, P., Wurdeman, S. “Prosthetic Knee Selection for Individuals With Unilateral Transfemoral Amputation: A Clinical Practice Guideline.” J Prosthet Orthot. 2019; 31:2-8. • Wurdeman, S.R., Stevens, P., Campbell, J.H. “Mobility Analysis of AmpuTees (MAAT) II: “Comorbidities and Mobility in Lower-Limb Prosthesis Users.” Am J Phys Med Rehabil, 2018; 97: 782-788. • Campbell, J.H., Stevens, P.M., Wurdeman, S.R. “OASIS I: Retrospective Analysis of Four Different Microprocessor Knee Types.” J Rehabil Assist Tech Engineer, 2020; 7: 1-10. • Wurdeman, S.R., Miller, T.A., Stevens, P.M., Campbell, J.H. “Stability and Falls Evaluations in AMPutees (SAFEAMP 1): Microprocessor Knee Technology Reduces Odds of Incurring an Injurious Fall for Individuals With Diabetic/ Dysvascular Amputation.” Assist Tech, published ahead of print.