The Guide to Outpatient Occupational Therapy

The term “outpatient clinic” usually refers to those clinics which treat orthopedic diagnoses and post-operative procedures. Outpatient clinic can also refer to a community mental health setting or a sensory integration clinic for pediatric patients. This guide will focus on the most common outpatient setting for occupational therapists: outpatient orthopedic clinics.

This guide will cover the specific issues pertaining to outpatient occupational therapy, including details on:

1. Diagnoses
2. Evaluations
3. Interventions
4. Billing
5. Discharge planning
6. Continuing education for outpatient OT
7. Interview questions for OT jobs at outpatient clinics

Outpatient clinics typically address a local working population capable of arranging their own transportation to and from the clinic. An outpatient clinic is not to be confused with a hospital-based outpatient clinic, which is closely affiliated with a hospital and treats patients with more intensive problems more frequently each week.

Common diagnoses in outpatient occupational therapy

Common categories of diagnoses in outpatient clinics include chronic overuse injuries, acute injuries, and surgeries for fractures, joint replacements, muscle sprains and tears, along with other soft tissue injuries of the ligaments and tendons. Main diagnoses you will commonly see in outpatient clinics include:

Rheumatoid Arthritis

To hold a diagnosis of rheumatoid arthritis (RA), an individual must have definite clinical swelling in at least one joint. This swelling cannot be better explained by another diagnosis. Symptoms of rheumatoid arthritis may include one or more joints which are sore, warm, and swollen along with fatigue, fever, and changes in appetite. It is also common to have increased stiffness at rest or in the early mornings. The symptoms of rheumatoid arthritis mainly affect joints such as fingers, wrists, shoulders, and elbows. However, it is not uncommon to experience these symptoms in organs and structures such as the skin, lungs, heart, kidneys, eyes, and blood vessels.

Treatments provided by an occupational therapist will be highly dependent on the severity of symptoms. Symptoms of rheumatoid arthritis can increase (flares) and lessen (remission) depending on environment, activity levels, and the natural progression of the disease. Common therapeutic interventions for rheumatoid arthritis include: activity modification, therapeutic exercise, manual techniques, and modalities such as paraffin, ultrasound, hot/cold therapy.

Splinting: Depending on the severity of the diagnosis and the presenting symptoms, therapists may recommend resting hand splints, ulnar drift/ulnar deviation splints, or Oval-8 finger splints to maintain proper positioning and decrease pain.

Cubital Tunnel Syndrome

Someone with a diagnosis of cubital tunnel syndrome will experience symptoms including pain, numbness, and tingling in the elbow or extending down to the ring and pinky fingers. Additional symptoms may include weakness of the fingers, muscle wasting, and hand deformities in the shape of a claw. Cubital tunnel syndrome can be diagnosed by a physician through a physical examination followed by a nerve conduction study called electromyography. Cubital tunnel syndrome is often worsened at night by sleeping positions which compress the nerves.

Treatments provided by an occupational therapist will be dependent on symptoms and severity of the diagnosis. Common therapeutic interventions for cubital tunnel syndrome include activity modification, education, splinting, strengthening exercises, nerve gliding exercises, and modalities such as ultrasound, iontophoresis, and hot/cold therapy.

Splinting: Therapists may recommend an elbow immobilizer to minimize nerve compression when sleeping or during activity. This will reduce pain along with numbness and tingling someone may experience as a result of cubital tunnel syndrome.

Carpal Tunnel Syndrome

Symptoms of carpal tunnel syndrome (CTS) will experience muscle weakness along with numbness and tingling to the thumb, index, and middle fingers. Depending on the severity of the diagnosis, these symptoms may extend from the fingers to the wrist and elbow. These symptoms are due to compression of the nerve within the carpal tunnel, which is found at the wrist. Symptoms may come and go with activities which aggravate the nerve, including firmly grasping something, writing, typing, holding a phone, or anything done repetitively and with a specific grip or pinch pattern. These symptoms may be permanent due to irreversible nerve damage in those individuals who do not modify their activities or seek treatment.

Treatments provided by an occupational therapist will be dependent on the severity of symptoms and whether or not someone has had surgery. Often times, physicians recommend someone seek occupational therapy treatment as a conservative approach before attempting surgery. If occupational therapy relieves symptoms to an extent where the person is functional again, surgery can be avoided. Otherwise, a surgical approach to relieve the nerve compression will be used to treat carpal tunnel syndrome.

Common therapeutic interventions for conservative treatment of carpal tunnel syndrome include activity modification, education, splinting, strengthening exercises, nerve gliding exercises, and modalities such as ultrasound, iontophoresis, electrical stimulation, and hot/cold therapy. Early therapeutic interventions after someone has had carpal tunnel release surgery include scar massage, retrograde massage, education, nerve gliding exercises, activity modification, passive range of motion, and gentle strengthening exercises. Once a person is able to tolerate gentle strengthening exercises, weights can slowly be upgraded and most modalities used for pain relief can likely be discontinued. As always, a patient should check in with their doctor after surgery to ensure they are able to continue participating in a post-surgical rehabilitation protocol.

Splinting: Therapists may recommend a wrist cock-up splint for use when sleeping or during activity. This will reduce nerve compression and promote appropriate positioning, serving to reduce pain along with numbness and tingling.

Upper extremity fractures

It is common to see a variety of fractures in an outpatient setting. Upper extremity fractures which an occupational therapist may see include: humerus fracture, wrist fracture (Colles fracture, Boxer’s fracture, or distal radius fracture are among the most common), elbow fracture, or fracture to any of the fingers. Depending on whether the fracture is open or closed, an upper extremity fracture may be treated with surgery.

Some fractures are treated through a closed reduction, in which the bones can be realigned without surgery. Other fractures, often those which cause a bone to break into multiple pieces, are treated with an open reduction and internal fixation (ORIF). Open reduction refers to a surgical incision necessary to realign the bones using internal fixators. Internal fixators refer to plates, screws, rods, and/or pins which may be used to join bone fragments into one piece to begin the healing process.

After this procedure, an individual is often temporarily placed in a cast or brace and cleared to begin light therapy. Some weight-bearing precautions may apply including instructions to stop working out, entering light duty restrictions at work, and seeking assistance in completing heavy household chores. This will allow the bone to properly heal and while remaining protected during therapy sessions.

Common therapeutic interventions for closed reduction fractures include light strengthening exercises, splinting, manual techniques, activity modification, maintenance of skin integrity, modalities such as ultrasound, iontophoresis, electrical stimulation, and hot/cold therapy. Light exercises can be upgraded once a splint or cast is removed and weight-bearing precautions are slowly lifted.

Early therapeutic interventions after someone has had an open reduction and internal fixation include scar massage, retrograde massage, education, activity modification, passive range of motion, and gentle strengthening exercises. Once a person is able to tolerate gentle strengthening exercises, weights can slowly be upgraded. Pain relief modalities are usually still indicated as pain levels may persist. As always, a patient should check in with their doctor after surgery to ensure they are able to continue participating in a post-surgical rehabilitation protocol.

Be sure to thoroughly read a patient’s chart before using ultrasound for pain relief. The use of ultrasound is contraindicated for patients who have internal hardware (e.g. plates, screws, rods, pins, etc.) as this heats the metal and can cause burns.

Splinting: Doctors typically provide hard casts following open or closed fractures, especially during the immobilization period. Some doctors opt for soft casts and slings, meaning therapists may assist with positioning and adjusting of these.

Lateral epicondylitis

Lateral epicondylitis, also known as tennis elbow, is a cumulative overuse injury in which the tendons in the elbow become weaker as more stress is placed on the area. Symptoms of tennis elbow include elbow pain which increases with activities such as lifting, gripping, or full range of motion, along with soreness to the elbow.

Therapeutic interventions for someone with lateral epicondylitis include activity modification, splinting/bracing, therapeutic exercise, manual techniques, modalities such as ultrasound, iontophoresis, electrical stimulation, and hot/cold therapy.

Doctors typically recommend conservative occupational therapy approaches as a first line of treatment for lateral epicondylitis. If this does not relieve pain and improve strength, steroid injections or autologous blood injections are often the next line of treatment to decrease inflammation and improve blood flow to the area.

Splinting: Therapists may recommend elbow immobilization splints to minimize the frequency of repetitive motions which aggravate symptoms. This will serve to reduce pain and inflammation associated with lateral epicondylitis.

Evaluations in outpatient OT

The evaluation process for orthopedic patients typically includes short, function-based assessments. Some common assessment tools include:

• Dynamometer - This is a standardized assessment which involves squeezing a grip tester to measure grip strength in the hand. This test is completed three times on each hand and values are then compared to the norms for age and sex, and used to track progress.
• Pinchmeter - This is a standardized assessment which involves pinching a small gauge using a variety of pinch patterns. This test is then compared to the norms for age and sex, and used to track progress.
• Range of Motion & Manual Muscle Testing (ROM/MMT) - These are typically tested together, as they are the ‘bread and butter’ of orthopedic therapy. Range of motion measurements often determine which areas of the body to perform manual muscle testing on.
• Disability of Arm, Shoulder, and Hand (DASH) - This is a self-report questionnaire used to determine the effect that upper extremity diagnoses or injuries have on activities such as sleep quality, leisure, work performance, and other integral daily tasks. Not only does this assessment identify functional areas of concern, but the DASH also identifies symptoms such as numbness and tingling along with greater issues such as quality-of-life.
• Functional Reach Test (FRT) - This simple test involves a person standing unsupported with their feet planted on the ground while reaching forward as far as they can. Their forward reach is then measured and used to determine their fall risk, with a measurement of less than 6 inches placing them at a high risk for falls.
• Timed Get Up and Go Test (TUG) - This simple test is often used by physical therapists to track progress in ambulation. However, occupational therapists who are addressing independence in functional mobility as it relates to orthopedic diagnoses may also use this test. The TUG is a timed test tracking how long it takes to get out of a chair, walk across the room and back, and sit in the same chair. While the emphasis is placed on decreasing the time this sequence takes, it also gives the chance to observe the safety and quality of this movement.
• Modified Barthel Index (MBI) - This rating scale is completed by therapists to assess level of assistance needed for each activity of daily living. Each level of assistance translates to a numerical rating for each functional activity. These numbers are added up to a total score. The higher the score, the less disability a person has. Scores below 15 indicate moderate disability while scores below 10 indicate severe disability.

Common interventions in outpatient orthopedic clinics

The main method of treatment in outpatient clinics are individual sessions or double-booked sessions. Some clinics and insurance payers have restrictions which prevent double-booking, or seeing two patients at the same time. For example, Medicare regulations restrict a therapist from double-booking a Medicare patient with any other patient. Interventions include:

• Physical agent modalities (ultrasound, iontophoresis, phonophoresis, paraffin, electrical stimulation, neuromuscular electrical stimulation, hot/cold therapy)
• Complementary and alternative modalities (deep breathing, guided imagery, reiki)
• Activity modification
• Health education
• Instrumental activities of daily living (IADLs)
• Therapeutic exercises, strengthening protocols
• Therapeutic activities to improve strength, fine and gross motor coordination, range of motion
• Neuromuscular re-education to improve active movement, cognition, balance
• Manual techniques (soft tissue massage, retrograde massage, scar massage, passive range of motion, instrument-assisted manual soft tissue massage)
• Kinesiotape application

A mix of any of these treatments may be indicated for any diagnosis. This is to be determined after screening or evaluating the patient and determining goals based on their deficits. Many treatment plans developed for post-operative orthopedic conditions follow surgical protocols which account for weight-bearing restrictions and other precautions.

Outpatient billing procedures

Billing can be one of the most complicated parts of being an occupational therapist. However, billing is simply another way to demonstrate the findings of your evaluations and treatments. For each session (including evaluations, re-assessments, and discharge visits), therapists must assign patients CPT (Current Procedural Terminology) codes based on the treatment completed. Common CPT codes include:

• Low complexity OT evaluation - 97165
• Moderate complexity OT evaluation - 97166
• High complexity OT evaluation - 97167
• Therapeutic exercise - 97110
• Neuromuscular re-education - 97112
• Manual therapy - 97140
• Therapeutic activities - 97530
• Self-care training - 97535
• Cognitive skills - 97127
• Prosthetic training - 97761

Starting in 2017, the ‘grading’ of evaluations as low, moderate, or high complexity has come into effect. This grading can be determined once a therapist has a full view of a patient’s presenting situation. Full views include standardized assessments, occupational profiles, projected goals, prior level of function, and current level of assistance.

A low complexity OT evaluation requires:

• Low clinical decision making
• A brief chart review and medical history
• Treatment of one to three performance deficits (physical, cognitive, or psychosocial)
• Around 30 minutes for an evaluation with patient and family members, if applicable

A moderate complexity OT evaluation requires:

• Moderate clinical decision making
• An expanded chart review and medical history
• Treatment of three to five performance deficits (physical, cognitive, or psychosocial)
• Around 45 minutes for an evaluation with patient and family members, if applicable

A high complexity OT evaluation requires:

• High clinical decision making
• An extensive review of charting and medical history
• Treatment of five or more performance deficits (physical, cognitive, or psychosocial)
• Around 60 minutes for an evaluation with patient and family members, if applicable

Discharge planning in outpatient OT

Discharge planning in an outpatient setting is often much simpler than in inpatient settings. Outpatient occupational therapists typically focus on recommendations for diet changes, exercise programs, activity modifications, stress management techniques, and sleeping positions. If applicable, recommendations are also made for the ordering and use of splints, braces, orthotics, prostheses, and adaptive equipment. The use of these devices is also accompanied by training, education, information on wearing schedules, along with what to expect and what is cause for concern.

Another major component to community living and integration is symptom management. Occupational therapists may educate their patients to track their symptoms such as pain, loss of strength, numbness and tingling, swelling, and loss of motion. These symptoms will be important to monitor in order to track progress and adjust the treatment plan as needed.

Continuing education requirements and opportunities

There are many continuing education courses available for therapists who work with an orthopedic population. MedBridge is a great resource with a wide range of topics in all areas of OT. Specifically, there are pre-recorded webinars and other educational content on hand, elbow, shoulder, and other bodily regions. Additional online continuing education sources with various formats are Home CEU Connection and Summit Professional Education.

Some therapists opt for in-person continuing education courses, especially if they are looking to learn specific manual therapy techniques. This gives hands-on practice with trained professionals who can provide feedback in real-time to ensure competence. Hands-on continuing education can be sought out through organizations such as IAOM and Evidence in Motion.

Looking for your first OT job? Or maybe just a new one? We can help with that!