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Cost-effectiveness evaluation of manual physical therapy versus surgery for carpal tunnel syndrome: evidence from a randomized clinical trial [with consumer summary]
Fernandez-de-las-Penas C, Ortega-Santiago R, Diaz HF, Salom-Moreno J, Cleland JA, Pareja JA, Arias-Buria JL
The Journal of Orthopaedic and Sports Physical Therapy 2019 Feb;49(2):55-63
clinical trial
7/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

STUDY DESIGN: A randomized clinical trial. BACKGROUND: Carpal tunnel syndrome (CTS) results in substantial costs for the society and can be treated by either nonsurgical or surgical approaches. OBJECTIVE: To evaluate cost-effectiveness differences of manual physical therapy versus surgery in women with CTS. METHODS: One hundred and twenty women with clinical and electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery. Interventions consisted of 3 sessions of manual physical therapy including desensitization manoeuvres of the central nervous system, or decompression/release of the carpal tunnel. Societal costs and health-related quality of life (estimated by the EuroQol-5D) over 1-year were used to generate incremental cost per quality-adjusted life year (QALY) ratios for each treatment. RESULTS: The analysis was possible for 118 (98%) patients. Incremental QALYs showed greater cost-effectiveness in favor of manual physical therapy (difference 0.135, 95%CI 0.134 to 0.136). Manual therapy was significantly less costly (mean difference cost per patient: 2,576 Euro; p < 0.001) than surgery. Patients in the surgical group received a greater number of other treatments and made more visits to medical doctors than those receiving manual physical therapy (p = 0.02). Absenteeism from paid labour was sifnificantly higher in the surgery group (p < 0.001). The major contributors to societal costs were the treatment protocol (surgery versus manual therapy mean difference: 106,980 Euro) and absenteeism from paid labour (surgery versus manual physical therapy mean difference 42,224 Euro). CONCLUSION: Manual physical therapy including desensitization manoeuvres of the central nervous system has found to be equally effective but less costly, ie, more cost-effective, than surgery for women with CTS. From a cost-benefit perspective the proposed manual physical therapy intervention of CTS can be considered. LEVEL OF EVIDENCE: Economic and decision analyses, level 1b.

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