Cost-Effectiveness of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome

by Leah Flamm, PT,

César Fernández-de-las-Peñas, PT, PhD, DMSc, Ricardo Ortega-Santiago, PT, PhD, Homid Fahandezh-Saddi Díaz, MD, PhD, Jaime Salom-Moreno, PT, PhD, Joshua A. Cleland, PT, PhD, Juan A. Pareja, MD, PhD, José L. Arias-Buría, PT, MSc, PhD.


Carpal tunnel syndrome (CTS) costs more than $2 billion annually in the United States. Considered the most common nerve entrapment in the arm, CTS results in less work productivity and other healthcare costs. Surgery is most often recommended to treat CTS, perhaps because of limited evidence supporting nonsurgical treatments such as exercise and mobilization. A recent study found that compared to surgery, manual therapy (such as desensitization of the central nervous system) resulted in better short-term outcomes and similar long-term effects on pain intensity and function. This study compares healthcare costs between manual therapy and surgery in women with CTS.


Women younger than 65

Diagnosed with CTS based on clinical and electrophysiological findings

Must have had symptoms for at least 12 months


Alongside a randomized clinical trial in a hospital in Madrid, Spain, the researchers performed an economic evaluation to determine the cost-effectiveness of surgery versus manual physical therapy. Patients were randomly assigned to receive either manual physical therapy or a surgical procedure. Those in the manual physical therapy group received three 30-minute sessions once a week, with soft tissue mobilization at areas where the median nerve may be entrapped, lateral glides to the neck, and tendon- and nerve-glide exercises (which patients were also taught to do at home). Those in the surgery group had open or endoscopic release of the carpal tunnel and the same home exercises on tendon- and nerve-glides the manual physical therapy group received.

Economic Evaluation

For the economic evaluation, the researchers looked at direct healthcare costs, direct non-healthcare costs, and indirect costs due to CTS. For direct healthcare costs, they looked at the costs of each treatment (such as the number of sessions, number of visits to manual physical therapists), additional visits to healthcare providers, additional treatments received, prescribed medications, and professional home care. For direct non-healthcare costs, they looked at costs of over-the-counter medications, time spent visiting a healthcare provider, and travel expenses. They also looked at indirect costs of lost productivity due to CTS-related absence from work.


The researchers also measured health-related quality of life at baseline and at each follow-up period.


The researchers found the surgery group was significantly more expensive than the manual physical therapy group. Additionally, patients in the surgery group also received a greater number of other treatments, mostly complementary manual physical therapy, and also made more visits to their orthopaedic surgeon and/or neurologist than those in the manual physical therapy group.

Missing paid work was significantly higher within the surgery group than in the manual physical therapy group, both in terms of the number of people missing work (86.7% vs. 6.9%) and the number of days off from work (mean, 65 versus 28 days; total, 3360 vs. 112 days).

Mean cost (including work absence) was €12,147 for manual physical therapy and €167,143 for surgery. Similarly, mean cost per participant (including work absence) was statistically higher in the surgery group than in the manual physical therapy group (€2785 versus €209, P<.001).


The researchers found that manual physical therapy group was less costly (€−154,996) and more effective (5.844 Quality-Adjusted Life Years) than the surgery group.


The results showed that manual physical therapy was more cost-effective than surgery, and healthcare costs and missed work within the surgery group were significantly greater than in the manual physical therapy group.

The generalizability of the results may be limited, as only women from a single hospital in Spain were included and the study was conducted in a particular health system. However, the study suggests that manual physical therapy, including desensitization of the central nervous system, may be an intervention option for patients with carpal tunnel syndrome as a first line of management prior to, or instead of, surgery.

Here at Physical Therapy First, we perform a complete evaluation to try to figure out what is the underlying cause of every patient’s symptoms. We may examine any or all of the following: range of motion, strength, muscle imbalances, joint mobility, functional movement, posture, and more. Based on those findings, we create custom treatment plans to reduce symptoms and help our patients return to living a full and healthy life. Just as the study suggests, some of our treatments may include soft tissue mobilization and neural desensitization, as well as other interventions such as muscle strengthening and stretching, improving posture, and creating a home exercise program.

Original article:

Fernández-De-Las-Peñas, C., Ortega-Santiago, R., Díaz, H. F., Salom-Moreno, J., Cleland, J. A., Pareja, J. A., & Arias-Buría, J. L. (2019). Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy,49(2), 55-63. doi:10.2519/jospt.2019.8483

Peñas, C. F., Ortega-Santiago, R., Llave-Rincón, A. I., Martínez-Perez, A., Díaz, H. F., Martínez-Martín, J., . . . Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain,16(11), 1087-1094. doi:10.1016/j.jpain.2015.07.012