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Musculoskeletal

Neck pain - non-specific

Last revised in April 2023

Simple (or non-specific) neck pain is neck pain for which no specific cause can be found.

Neck pain - non-specific: Summary

  • Simple (or non-specific) neck pain is pain or discomfort in the neck and/or shoulder girdle with or without pain referred to the arms — in most cases no specific cause can be found. Symptoms vary with physical activity and over time.
  • The cause is usually multifactorial and includes; poor posture, neck strain, sporting or occupational activities, anxiety, and depression.
  • Assessment of people with neck pain should include:
    • Taking a detailed medical history and conducting a physical examination to distinguish neuropathic or other causes of pain from mechanical neck pain.
    • Assessing for features of specific neck conditions, for example whiplash injury, acute torticollis, and cervical radiculopathy.
    • Identifying typical features of non-specific neck pain.
    • Excluding red flags features suggestive of serious pathology.
  • If red flag features are present, referral (or admission) should be arranged, depending on the severity of the clinical findings. Signs of serious spinal or other conditions include:
    • Neurological symptoms and signs.
    • Malaise, fever, unexplained weight loss, or unremitting pain affecting sleep.
    • A history of violent trauma, cancer, neck surgery, or risk factors for osteoporosis.
  • For people with typical non-specific neck pain and no red flag features, management consists of:
    • Providing reassurance — non-specific neck pain is a common problem that usually resolves within a few weeks.
    • Providing education and lifestyle advice, particularly about remaining active and sleeping with a single, firm pillow.
    • Considering one or more of the following measures:
      • Oral analgesics (for example, ibuprofen, paracetamol or codeine) — the choice depends on the severity of pain, personal preferences, tolerability, and risk of adverse effects.
      • A topical nonsteroidal anti-inflammatory drug (NSAID).
      • Advice about exercise modalities which may be helpful.
      • Referral to physiotherapy for a multimodal treatment strategy that includes stretching and strengthening exercise, and some form of manual therapy.
      • Referral for psychological intervention, if appropriate. 
      • Referral to occupational health for people with neck pain related to their work. 
  • People with chronic neck pain (lasting more than 12 weeks) not responding to measures in primary care should be considered for referral to a pain clinic.

Have I got the right topic?

From age 16 years onwards.

This CKS topic is largely based on the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [APTA, 2017], a Danish guideline National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy [Kjaer, 2017], a Canadian guideline Management of neck pain and associated disorders [Cote, 2016], systematic reviews looking at recommendations for which there is consensus within international guidelines [Parikh, 2019; Lin, 2020; Corp, 2021], the BMJ Best Practice Guide Assessment of Neck Pain [BMJ, 2022], and narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [Binder, 2007a], Advances in the diagnosis and management of neck pain [Cohen, 2017], An approach to the patient with neck pain [Geiger, 2017], Neck pain: initial evaluation and management [Childress, 2020].

This CKS topic covers the diagnosis and management of non-specific neck pain.

This CKS topic does not cover the diagnosis or management of other causes of neck pain.  

There are separate CKS topics on Back pain - low (without radiculopathy), Neck pain - acute torticollis, Neck pain - cervical radiculopathy, Neck pain - whiplash injury and Sciatica (lumbar radiculopathy).

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2023 — minor update. Removed the recommendation on the use of diazepam to align with NICE guidance on the management of back pain. 

Previous changes

May 2022 — reviewed. A literature search was conducted in April 2022 to identify evidence-based guidelines, UK policy, systematic reviews and key randomized controlled trials published since the last revision of the topic. Some minor changes have been made to recommendations in line with international clinical guidelines and published expert opinion.

March 2022 — minor update. The section on red flags has been clarified and updated.

October 2018 — reviewed. A literature search was conducted in October 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Some minor changes have been made to the recommendations in line with national clinical guidelines.

April 2015 — minor update. Link inserted to the CKS topic on Analgesia - mild-to-moderate pain.

September 2013 — reviewed. A literature search was conducted in August 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made. The evidence sections on treatments with insufficient evidence and evidence supporting background information have been removed.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

August 2012 — minor update. Minor typographical error corrected.

February 2012 — minor update to clarify recommendations in the management section. 

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

October 2008 to January 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Together with the CKS topics on Neck pain - acute torticollis, Neck pain - cervical radiculopathy, and Neck pain - whiplash injury, this CKS topic replaces the former topic on Neck pain. There are no major changes to the recommendations.

September 2008 — minor correction to the Changes section. 

November 2005 — minor technical update. 

July 2005 — reviewed. Validated in June 2005.

September 2001 — reviewed. Validated in November 2001 and issued in April 2002.

March 1999 — written. Validated in July 1999 and issued in August 1999.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 May 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 May 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 May 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 May 2022.

New policies

No new national policies or guidelines since 1 May 2022.

New safety alerts

No new safety alerts since 1 May 2022.

Changes in product availability

No changes in product availability since 1 May 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of non-specific neck pain.
  • Provide appropriate treatment in primary care.
  • Offer appropriate advice.
  • Refer to secondary care or other specialist services when appropriate.
  • Refer urgently if a serious underlying pathology is suspected.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Simple (or non-specific) neck pain is pain or discomfort in the neck and/or shoulder girdle with or without pain referred to the arms. In most cases no specific cause can be found. Non-specific neck pain usually relates to mechanical or postural factors, and the term excludes those where the cause is underlying fracture, malignancy or systemic pathology.
  • Symptoms vary with physical activity and over time.
  • It is defined as chronic if pain persists for three months or longer.

[Binder, 2007b; Kjaer, 2017; Parikh, 2019; Safiri, 2020]

How common is it?

  • Neck pain is common — up to 70% of the population will suffer neck pain at some point in their lives. 
  • Prevalence peaks between the ages of 45 and 54. It is more common in women. 
  • In Western Europe in 2017, age-standardized prevalence was around 4,636 per 100,000 population, incidence around 891 per 100, 000 population, and there were an estimated 461 years lived with disability due to neck pain per 100,000 population.

[De Zoete, 2020; Safiri, 2020]

What causes non-specific neck pain?

  • The cause of non-specific neck pain is usually multifactorial and contributing factors include poor posture, neck strain, sporting and occupational activities, anxiety, and depression.
  • Some people show degenerative changes (pre-dominantly in the cervical discs) with osteophyte formation and involvement of adjacent soft tissue structures.
    • However, many people aged over 30 years show similar changes, and the boundary between normal ageing and disease is difficult to define. Moreover, there is poor correlation between the degree of degeneration and severity, or even presence, of symptoms.
  • It may also be a result of whiplash, following a sudden acceleration-deceleration injury to the neck. For more information, see the CKS topic on Neck pain - whiplash injury.

[Binder, 2007a]  

What are the risk factors for developing non-specific neck pain?

  • Risk factors for non-specific neck pain include:
    • Female gender.
    • High job demand.
    • History of low back or neck disorders.
    • Job insecurity.
    • Low social/work support.
    • Older age.
    • Poor work station design, poor work posture and sedentary work position.
    • Repetitive, or precision work.
  • Additional risk factors for neck pain include:
    • Certain occupations (for example, clerical, industrial and agricultural workers).
    • History of mental stress.
    • Sleep disorders.
    • Sedentary lifestyle.
    • Smoking.
    • Trauma.
    • Obesity.

[McLean et al, 2010; Cohen, 2017; Jahre, 2020]

What is the prognosis for people with non-specific neck pain?

  • Most cases of acute neck pain resolve within 2 months.
    • However, around half of people continue to have low grade symptoms or recurrences for more than a year.
  • Non-specific neck pain usually resolves within days or weeks, but can recur or become chronic.
  • A less good prognosis is associated with:
    • Previous episodes of neck pain.
    • Poor general health.
    • Concurrent low back pain or headaches.
    • Psychological factors (for example, anxiety, depression, worry).
    • Work dissatisfaction.

[Binder, 2007a; Cohen, 2017; Verhagen, 2021]

Diagnosis of non-specific neck pain

How should I assess someone with non-specific neck pain?

  • The diagnosis of non-specific neck pain is clinical — further investigation is not normally required.  
  • Take a detailed medical history and conduct a physical examination to distinguish neuropathic or other causes of pain from mechanical neck pain, and to exclude red flags.
  • Ask about:
    • Onset - establish if acute, chronic, recurring, sudden.  Establish whether onset is related to trauma or a particular activity.
    • Nature of the pain - whether the pain is shooting or aching, severity, timing, and whether provoked or relieved by movement, position or certain activities. 
    • Location of the pain and any radiation.
    • Occupational history.
    • Medical history.
    • Symptoms of anxiety or depression.
    • Previous injury or infection.
    • History of cancer — in these people, assume the pain is related to the cancer until it is excluded.
    • Presence of fever — in these people, neck pain should be assumed to be secondary to an infection until proven otherwise.
    • Presence of symptoms of spinal cord compression - lower limb weakness or altered sensation, disturbance of bowel or bladder function.
  • Examination:
    • Assess the appearance of the neck and the range of motion. 
    • Inspect the skin — for example, for papulovesicular rash, petechiae or purpura.
    • Palpate the neck for tenderness. Significant specific bony tenderness or midline tenderness is suggestive of other pathology.
    • Check for cervical lymphadenopathy — which could suggest infection, malignancy, or an inflammatory cause.
    • Perform a neurological examination — check power, tone, reflexes, and sensation in the arms and legs.
      • A combination of tests can be used to help identify cervical radiculopathy, including the Spurling test. For more information, see the CKS topic on Neck pain - cervical radiculopathy. 
      • Consider examining for Kernig's sign (painful/resisted extension of leg bent at hip and knee) and Brudzinski's sign (reflective flexion of the knees when patient is on his/her back and the neck is bent forwards) to demonstrate nuchal rigidity if meningitis is suspected.
  • Cervical X-rays, and other imaging studies and investigations are not routinely required.
  • Identify and urgently refer people with red flags indicative of a serious spinal or alternative pathology.

Grading of neck pain

  • Neck pain can be considered in four categories:
    • Grade 1 — No signs of major pathology and little interference with daily activities.
    • Grade 2 — No signs of major pathology but may impact daily activities.
    • Grade 3 — Neck pain with neurological signs or symptoms (radiculopathy).
    • Grade 4 — Neck pain with signs of major pathology.

Basis for recommendation

These recommendations are based on the British Medical Journal (BMJ) best practice guide Assessment of neck pain [BMJ, 2022], and expert opinion in narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [Binder, 2007a], An approach to the patient with neck pain [Geiger, 2017], Neck pain: initial evaluation and management [Childress, 2020]. 

The classification system was originally proposed by the Task Force on Neck Pain in 2008 and it's use is recommended in many current guidelines [Haldeman, 2008; Parikh, 2019; Lin, 2020].

What are the signs and symptoms of non-specific neck pain?

  • The clinical features of non-specific neck pain include: 
    • Pain that is aggravated by particular movements, posture, and activities.
    • Pain that radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae.
    • Pain associated with paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength.
    • Positional asymmetry, limited range of movements often asymmetrically.
    • Tenderness in intervertebral joints and/or hypertonic muscles that may be palpable as nodules or tender bands.

What signs and symptoms may indicate a more serious pathology?

  • Be aware of signs and symptoms that may indicate a more serious pathology in people with neck pain, such as:  
    • Malignancy, infection, or inflammation 
      • Fever, night sweats, unexplained weight loss.
      • Excruciating pain, intractable night pain, pain that is increasing, exquisite tenderness over vertebral body, generalised neck stiffness.
      • Pain and stiffness that is worse in the morning.
      • Cervical lymphadenopathy.
      • Nausea or vomiting.
      • New or severe headache.
      • Photophobia or phonophobia.
      • Visual loss.
      • Skin erythema, wounds or exudate. 
    • Cervical myelopathy 
      • Paresis.
      • Sensory changes or loss of sensation.
      • Altered muscle tone.
      • Clumsy or weak hands. 
      • Gait disturbance.
      • Babinski's sign: up-going plantar reflex, hyper-reflexia, clonus, spasticity.
      • Hoffman's sign: involuntary flexion and adduction of the thumb and flexion of the index finger when the nail of the middle finger is flicked downwards. (Not reliable in isolation as may be present normally).
      • Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs.
      • More severe symptoms may include profound weakness of the hands, bowel or bladder dysfunction, and severe gait ataxia. Rarely there is loss of proximal muscle strength in the arms or legs.
  • Other red flag features include: 
    • Other neurological signs and symptoms, such as altered cognitive state, weakness involving more than one myotome or loss of sensation involving more than one dermatome.
    • A history of immunosuppression, tuberculosis, or intravenous drug abuse (consider spinal abscess, discitis, or osteomyelitis).
    • A history of violent trauma (for example, a road traffic accident) or a fall from a height or minor trauma in a person at risk of osteoporosis, for example, post–menopausal women. Consider possible fractures. Even minor trauma may result in fractures of the spine in people with osteoporosis.
    • Risk factors for osteoporosis. For more information, see the CKS topic on Osteoporosis - prevention of fragility fractures.
    • A history of neck surgery.
    • A history of inflammatory arthritis.
    • A history of cancer — assume metastases until excluded.
    • A history or features of vascular disease, such as blackouts, dizziness, or a pulsatile mass in the neck.
    • Presence of congenital disorders which may rarely predispose to atlanto-axial subluxation (such as Down's syndrome), or lead to spinal or soft tissue abnormalities.

Basis for recommendation

These recommendations are based on expert opinion in narrative reviews Cervical spondylosis and neck pain [Binder, 2007b], Nonoperative management of cervical radiculopathy [Childress, 2016], Advances in the diagnosis and management of neck pain [Cohen, 2017], An approach to the patient with neck pain [Geiger, 2017], and the British Medical Journal (BMJ) Best Practice guides Assessment of neck pain [BMJ, 2022] and Spinal cord compression [BMJ, 2019]. 

Red flags

  • The negative predictive value of these red flags clinical findings is high — if no red flags are present, then it is unlikely that a serious spinal abnormality has been missed. Individual positive findings must be interpreted with care, as their positive predictive value for diagnosing serious disease is poor [Williams, 2004]. 

What else might it be?

  • The differential diagnosis of neck pain is broad, but includes trauma and a wide range of musculoskeletal and systemic disease processes. For example: 
    • Acute disc prolapse.
    • Acute torticollis — neck pain that is due to acute spasm with no obvious underlying cause. For more information, see the CKS topic on Neck pain - acute torticollis. 
    • Acute trauma (for example, whiplash type injury) — neck pain symptoms that follow a recent sudden or excessive hyperextension, flexion, or rotation of the neck. For more information, see the CKS topic on Neck pain - whiplash injury.
    • Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, cocaine).
    • Osteoarthritis of the cervical spine.
    • Inflammatory arthritis - rheumatoid arthritis, polymyalgia rheumatica.
    • Cervical strain, fracture, dislocation, or myelopathy.
    • Cervical radiculopathy — unilateral neck, shoulder, or arm pain that approximates to a dermatome, suspect cervical radiculopathy. There may be altered sensation or numbness, or weakness in related muscles. For more information, see the CKS topic on Neck pain - cervical radiculopathy.
      • However, the presence of pain or paraesthesia radiating into the arm is not specific for nerve root pain and may be present in people with non-specific neck pain.
    • Fibromyalgia.
    • Infections (for example, meningitis, herpes zoster, osteomyelitis).
    • Malignancy (primary or metastatic).
    • Carotid or vertebral artery dissection.

Basis for recommendation

This information is based on the British Medical Journal (BMJ) best practice guide Assessment of neck pain [BMJ, 2022], expert opinion in narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [Binder, 2007a], Advances in the diagnosis and management of neck pain [Cohen, 2017], and a chapter on neck pain in the Oxford textbook of primary medical care [Williams, 2004]. 

Management

Scenario: Management

From age 16 years onwards.

Management

  • If any red flags (suggesting a serious spinal abnormality or other concerning pathology) are present, refer urgently or arrange further investigation or immediate assessment, depending on clinical judgement. 
  • For people with non-specific neck pain and no red flag features:
    • Provide reassurance — neck pain is a common problem that usually resolves within a few weeks. 
    • Provide advice and education:
      • Advise that a firm pillow may provide comfort at night. It should provide lateral support and support the hollow of the neck and the position should be comfortable. Advise against sleeping with more than one pillow.
      • Encourage activity and a return to a normal lifestyle (including work) as soon as possible. 
        • However, advise the person not to drive if the range of motion of the neck is restricted.
        • Discourage the use of cervical collars because this restricts mobility and may prolong symptoms.
      • Signpost to information sites such as Versus Arthritis.
    • Consider offering one or more of the following management options:
      • Oral analgesics (for example, ibuprofen, paracetamol, or codeine) — the choice depends on the severity of pain, personal preferences, tolerability, and risk of adverse effects.
      • A topical NSAID. 
      • Referral to a physiotherapist for a multimodal treatment strategy — this may include stretching and strengthening exercises, range of motion exercises, and some form of manual therapy. 
      • Advice on exercise options. Depending on patient preference and availability, exercise such as yoga, Pilates, Tai Chi, or Qigong can be useful. Information on simple neck exercises is available from sites such as Versus Arthritis and the Chartered Society of Physiotherapy.
    • Further options in specific situations:
      • Consider referral for psychological therapy if there are psychological symptoms or risk factors or if pain is chronic. 
      • Consider referral to occupational health for people with neck pain related to their work. 
      • Consider medication for neuropathic pain if there is radiation without features suggesting the need for further investigation. For information about prescribing drugs for neuropathic pain, see the CKS topic on Neuropathic pain - drug treatment.
  • For people with neck pain for more than 12 weeks — consider referral to a pain clinic (following local referral guidelines where available) if the person has not improved in response to treatment.

Basis for recommendation

These recommendations are based on the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [APTA, 2017], a Danish guideline National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy [Kjaer, 2017], a Canadian guideline Management of neck pain and associated disorders [Cote, 2016], recent systematic reviews of available guidelines[Parikh, 2019; Lin, 2020; Corp, 2021], narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [Binder, 2007a], Advances in the diagnosis and management of neck pain [Cohen, 2017], and what CKS considers good clinical practice. 

Analgesics 
  • Few clinical trials have evaluated drugs for neck pain, so treatment is often based on generalization from studies performed for back pain [Cohen, 2017]. 
    • Two moderately sized placebo controlled trials established short term (2-8 days) benefit for topical diclofenac in people with neck and upper back pain secondary to suspected muscle and joint disease.  
  • Although evidence is insufficient to assess the effects of drugs to treat neck pain, expert narrative reviews and available guidelines continue to recommend these relatively consistently [Parikh, 2019; Corp, 2021].
Advice and education
  • Guidelines consistently recommend education and advice about physical activity and remaining active [Corp, 2021; Parikh, 2019].
  • Although there is no trial evidence, expert opinion in review articles [Barry, 1995; Binder, 2007a] recommends that:
    • Postural aspects in daily activities, work, and sport should be identified and corrected where possible.
    • A reduction from several pillows at night to one pillow will help many people.
Referral for physiotherapy
  • Recent systematic reviews of available guidelines shows there is consistent recommendation for manual therapy as an option for management, in combination with other treatment strategies [Parikh, 2019; Lin, 2020; Corp, 2021]. 
  • The APTA recommends that people with acute neck pain and mobility deficits, should receive thoracic manipulation, a program of neck range of motion exercises, scapulothoracic and upper extremity stretching and strengthening exercises, and that cervical manipulation and/or mobilization may also be considered [APTA, 2017]. 
  • A Danish guideline recommends that for people with recent onset neck pain, supervised exercise therapy and spinal manual therapy can be considered, either alone or in combination, in addition to other treatments [Kjaer, 2017]. 
  • A Canadian guideline recommends that for [Cote, 2016]: 
    • Grade I–II neck pain of 3 months duration or less, structured patient education in combination with range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants may be considered.
    • Grade III neck pain of 3 months duration or less, supervised strengthening exercises in addition to structured patient education may be considered. 
Exercise interventions
  • A systematic review suggests no physical exercise strategy is significantly superior to another [De Zoete, 2020]. As guidelines recommend a multi-modal approach and recommend a broad range of mostly non-pharmacological management options, CKS considers it pragmatic to consider patient preference and availability when discussing treatment with the patient.
Referral to occupational health 
  • Experts in a review article suggest that referral to occupational health is reasonable in the presence of occupational factors [Williams, 2004]. 
Psychological interventions
  • The advice to consider psychological treatments in those patient with persistent neck pain or with psychological risk factors is based on a systematic review of European guidelines [Corp, 2021]. 
Chronic neck pain 
  • Referral to a pain clinic for a multidisciplinary pain management programme is reasonable in people with neck pain for more than 12 weeks who fails to respond to management in primary care [Williams, 2004]. 

Prescribing information

Supporting evidence

This CKS topic is largely based on the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [APTA, 2017], a Danish guideline National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy [Kjaer, 2017], a Canadian guideline Management of neck pain and associated disorders [Cote, 2016], recent systematic reviews of available guidelines [Parikh, 2019; Lin, 2020; Corp, 2021], the BMJ Best Practice Guide Assessment of Neck pain [BMJ, 2022], and narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [Binder, 2007a], Advances in the diagnosis and management of neck pain [Cohen, 2017], An approach to the patient with neck pain [Geiger, 2017], Neck pain: initial evaluation and management [Childress, 2020]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of nonspecific neck pain.

Search dates

August 2018 - April 2022

Key search terms

The terms listed immediately below are the core search terms that were used for EBSCO MEDLINE (searched 28th August 2018) to identify references for both the Neck pain - non-specific and Neck pain - cervical radiculopathy topics. 

  • S6 S1 or S2 or S3 or S4 or S5
  • S5 AB cervicalgia OR TI cervicalgia 
  • S4 AB ( ((neck or cervical) N2 radiculopath*) ) OR TI ( ((neck or cervical) N2 radiculopath*) ) 
  • S3 AB (neck N2 pain*) OR TI (neck N2 pain*) 
  • S2 (MH "Radiculopathy") 
  • S1 (MH "Neck Pain") 
  • The terms listed thereafter were added April 2022 using OVID MEDLINE
  • Exp neck pain// or Exp whiplash injuries/ or Exp neck injuries/
  • (Cervical adj (pain or neckache or cervicodynia or cervicalgia).ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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