Clinical Topic A-Z Clinical Speciality

Neck pain - non-specific

Neck pain - non-specific
D019547Neck Pain
Musculoskeletal
2013-09-01Last revised in September 2013

Neck pain - non-specific - Summary

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

The cause is usually multifactorial and includes poor posture, neck strain, sporting and occupational activities, anxiety, and depression.

Diagnosis of a person with neck pain involves:

Excluding 'red flags' features suggestive of a serious spinal or other abnormality, including compression of the spinal cord (myelopathy), cancer, severe trauma or skeletal injury.

Assessing for features of specific neck conditions for example whiplash injury, acute torticollis and radiculopathy.

Identifying typical features of non-specific neck pain.

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 abnormalities include:

Compression of the spinal cord (myelopathy) — neurological symptoms and signs, sensory changes.

Cancer, infection, or inflammation — malaise; fever; unexplained weight loss; unremitting pain affecting sleep; lymphadenopathy; bony tenderness.

Severe trauma or skeletal injury — a history of violent trauma, neck surgery, risk factors for osteoporosis.

For people with neck pain for less than 4 weeks, management includes:

Providing reassurance — non-specific neck pain is a common problem that usually resolves within a few weeks.

Encouraging activity and a return to a normal lifestyle.

Advising that a firm pillow may provide comfort at night.

Offering simple analgesia to relieve symptoms.

For people with neck pain for 4 to 12 weeks, in addition to the above measures, the following should be considered:

Referral to a physiotherapist.

Addressing any psychosocial factors.

Referral to Occupational Health for people with neck pain related to work.

Referral for acupuncture.

For people with neck pain for more than 12 weeks in addition to the above measures, the following should be considered:

A trial of therapy with amitriptyline, or pregabalin (or gabapentin).

Referral to a pain clinic.

Have I got the right topic?

192months3060monthsBoth

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

This CKS topic does not cover the management of other causes of neck pain including acute torticollis, cervical radiculopathy, or whiplash injury.

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 health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in September 2013

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.

Previous changes

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

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

August 2012 — minor update. Minor typographical error corrected.

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

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

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. Issued September 2008.

October 2005 — minor technical update. Issued in November 2005.

April 2005 — reviewed. Validated in June 2005 and issued in July 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

Guidelines published since the last revision of this topic:

Cryans, R., Decina, P., Descarreaux, M., et al. (2014) Evidence-based guidelines for the chiropractic treatment of adults with neck pain. Journal of Manipulative and Physiological Therapeutics 37(1), 42-63. [Abstract]

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2013.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2013.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses since 1 August 2013.

Primary evidence

No new randomized controlled trials published in the major journals since 1 August 2013.

New policies

No new national policies or guidelines since 1 August 2013.

New safety alerts

No new safety alerts since 1 August 2013.

Changes in product availability

No changes in product availability since 1 August 2013..

Goals and outcome measures

Goals

To make an accurate diagnosis

To refer urgently if serious pathology is suspected

To provide appropriate treatment in primary care

To appropriately refer to secondary care or other specialist services

To offer appropriate advice

QIPP — Options for local implementation

QIPP — Options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).

If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008].

Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008; NICE, 2009a; NICE, 2009b].

Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.

[NICE, 2013]

Background information

Definition

What is it?

Simple (or non-specific) neck pain is neck pain for which no specific cause can be found [Williams and Hoving, 2004; Binder, 2007a]:

Symptoms vary with physical activity and over time.

The cause is usually multifactorial and includes poor posture, neck strain, sporting and occupational activities, anxiety, and depression.

Risk factors

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

The following risk factors for the development of non-specific neck pain have been identified in three systematic reviews:

History of low back and neck problems.

Older age.

Female gender.

Low social /work support.

High job demand.

Job insecurity.

Poor work station design, poor work posture and sedentary work position.

Repetitive and precision work.

[Hogg-Johnson et al, 2008; McLean et al, 2010; Paksaichol et al, 2012]

Prognosis

What is the prognosis of non-specific neck pain?

Most cases of acute neck pain settle within a few weeks, however a proportion of cases develop chronic neck pain [Williams and Hoving, 2004].

Diagnosis

Diagnosis of non-specific neck pain

Diagnosis

How do I diagnose someone with non-specific neck pain?

Identify and urgently refer people with "red flags" indicative of serious spinal pathology including:

Spinal cord compression.

Cancer, infection or inflammation.

Spinal fracture.

Exclude specific neck conditions:

Neck pain symptoms that follow a recent sudden or excessive hyperextension, flexion, or rotation of the neck, see the CKS topic on Neck pain - whiplash injury.

Neck pain that is due to acute spasm with no obvious underlying cause, see the CKS topic on Neck pain - acute torticollis.

Unilateral neck, shoulder, or arm pain that approximates to a dermatome, suspect cervical radiculopathy, see the CKS topic on Neck pain - cervical radiculopathy. There may be altered sensation or numbness, or weakness in related muscles. 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.

Identify typical features of non-specific neck pain including:

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.

'Red flags'

'Red flags'

Identify and urgently refer people with serious spinal pathology including:

Spinal cord compression suggested by:

Insidious progression of neurological symptoms such as gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function.

Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs.

Upper motor neuron signs in the lower limbs (Babinski's sign — up-going plantar reflex, hyperreflexia, clonus, spasticity).

Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia).

Variable sensory changes, with loss of vibration and joint position sense more evident in the hands than in the feet.

Cancer, infection, or inflammation suggested by:

Malaise, fever, unexplained weight loss.

Pain that is increasing, is unremitting, or disturbs sleep.

History of inflammatory arthritis, cancer, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection.

Exquisite localized tenderness over a vertebral body.

Severe trauma or skeletal injury suggested by:

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 (especially post menopausal women).

Minor trauma may fracture the spine in people with osteoporosis.

[Williams and Hoving, 2004; Binder, 2007a; Binder, 2007b]

Basis for recommendation

Basis for recommendation

These recommendations are based on expert advice in a primary care textbook [Williams and Hoving, 2004] and in review articles [Binder, 2007a; Binder, 2007b].

Exclusion of 'red flags'

The negative predictive value of these 'red flag' 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 and Hoving, 2004].

In the absence of 'red flags', plain X-rays of the cervical spine are unlikely to help and may lead to false-positive findings [Williams and Hoving, 2004].

Radiographs of the cervical spine may suggest muscle spasm (loss of normal cervical lordosis).

Features of degenerative disease are also common in asymptomatic people older than 30 years of age and correlate poorly with clinical symptoms. The boundary between normal ageing and disease is very difficult to define [Binder, 2007b].

Cervical X-rays, and other imaging studies and investigations are not routinely required to diagnose or assess non-specific neck pain [Binder, 2007b].

Management

Management

Scenario: Management : covers the management of non-specific neck pain.

Scenario: Management

Scenario: Management of non-specific neck pain

192months3060monthsBoth

Management

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

If any red flags are present, refer urgently for investigations and further assessment.

For people with neck pain for less than 4 weeks:

Reassure them that neck pain is a common problem that usually resolves within a few weeks.

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.

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. Using two pillows may force the head into an unnatural position.

Offer analgesia to relieve symptoms. Choice of analgesia depends on pain severity, personal preferences, and risk of adverse effects (see Prescribing information on NSAIDs). Options include:

Paracetamol and/or ibuprofen taken regularly or as required.

Codeine taken in addition to regular paracetamol or ibuprofen. Prescribe codeine separately to allow flexibility of dosing and titration of analgesic effect. Combination products, such as co-codamol, are not recommended.

For people with neck pain for 4 to 12 weeks, in addition to the above measures:

Refer to a physiotherapist for a multimodal treatment strategy that includes stretching and strengthening exercise, and some form of manual therapy.

Address any psychosocial factors such as beliefs about avoiding activity, associated anxiety and depression, medico-legal issues, and family dynamics. Consider referral to a psychologist if appropriate.

Consider referral to Occupational Health for people with neck pain related to work.

Consider referral for acupuncture guided by person's preference and local availability.

For people with neck pain for more than 12 weeks in addition to the above measures, consider:

A trial of therapy with amitriptyline, or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin). For further information see the CKS topic on Neuropathic pain - drug treatment.

Referral to a pain clinic (following local referral guidelines where available) if the person has failed to respond to the above measures.

Basis for recommendation

Basis for recommendation

It is not possible to treat neck pain solely on the basis of current evidence, as few treatments have been assessed in high-quality randomized controlled trials [Binder, 2007b]. These recommendations are based on expert advice in a primary care textbook [Williams and Hoving, 2004].

Excluding 'red flags'

The negative predictive value of these 'red flag' 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 and Hoving, 2004].

For people with neck pain for less than 4 weeks:

Neck pain is very common and most cases of acute neck pain settle within a few weeks, however a proportion of cases develop chronic neck pain. Evidence suggests the risk of chronic neck pain increases once neck pain is established for 6 weeks [Williams and Hoving, 2004].

Although there is no trial evidence, expert opinion in review articles [Barry and Jenner, 1995; Binder, 2007b] 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.

Few randomized controlled trials have specifically tested drug treatments for neck pain. Although evidence is insufficient to assess the effects of drugs to treat neck pain, it is reasonable to extrapolate evidence from trials of these drugs for back pain and other painful musculoskeletal conditions:

Paracetamol is a good first-line choice for pain relief and is not associated with gastrointestinal toxicity [SIGN, 2011]. It is suitable for the treatment of mild-to-moderate pain, and it is well tolerated at the recommended daily dose. It is more likely to be effective for neck pain when used regularly rather than 'as required'.

Codeine 60 mg plus paracetamol has been shown to provide more pain relief than either codeine 60 mg alone or paracetamol 1000 mg alone [Moore et al, 1997].

Codeine can also be combined with an NSAID, or paracetamol can be combined with an NSAID, but there is less evidence to support this.

No evidence suggests that any particular NSAID is more effective than another for neck pain. Ibuprofen is generally preferred because of its lower risk of gastrointestinal adverse effects [CSM, 2002].

The evidence is insufficient to assess the effectiveness of other drug treatments, electrotherapy, massage, multidisciplinary biopsychosocial rehabilitation, education, physical treatment, special pillows, and traction.

For people with neck pain for 4 to 12 weeks:

Moderate evidence favours a multimodal care approach using strengthening and stretching exercise combined with mobilization or manipulation in people with subacute or chronic neck pain. The relative benefit of different exercise approaches and which subgroups may benefit is unclear. A best-evidence synthesis by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders concluded that the evidence suggests that manual and supervised exercise interventions are more effective than sham treatments, no treatment, or alternative treatments and that interventions that focussed on regaining function as soon as possible were more effective than interventions that did not have such a focus [Hurwitz et al, 2008].

The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders recommended that people with common neck pain (grade 1 neck pain with no signs of major abnormality and no or little interference with daily activities, or grade 2 neck pain with no signs of major abnormality but interference with usual daily activities) should be offered non-invasive treatments if short-term relief is needed [Guzman et al, 2008].

Experts in a review article suggests that referral to Occupational Health or a psychologist is reasonable in the presence of occupational or psychological factors [Williams and Hoving, 2004].

Moderate evidence indicates that acupuncture has a short-term clinical treatment benefits in sub acute and chronic non-specific neck pain.

For people with neck pain for more than 12 weeks:

Low-dose amitriptyline and anti-epileptics (gabapentin or pregabalin) are reasonable choices in chronic neck pain when the person failed to respond to conventional analgesics (paracetamol, non-steroidal anti-inflammatory drugs, or opioids) [Williams and Hoving, 2004; McQuay, 2010].

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 and Hoving, 2004].

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

NSAIDs

NSAIDs

When prescribing a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen:

Consider prescribing a gastroprotective agent (e.g. a proton pump inhibitor) for people with increased risk of gastrointestinal bleeding (e.g. elderly people). See Preventing and managing gastrointestinal adverse effects in the CKS topic on NSAIDs - prescribing issues.

Review NSAID treatment if the person has dyspepsia. For information on management, see Management with no alarm features, taking NSAID in the CKS topic on Dyspepsia - unidentified cause.

Amitriptyline, pregabalin and gabapentin

Amitriptyline, pregabalin and gabapentin

For further information on amitriptyline, pregabalin and gabapentin see the CKS topic on Neuropathic pain - drug treatment.

Evidence

Evidence

Supporting evidence

Treatments of non-specific neck pain

Evidence on treatments of non-specific neck pain

Evidence favours a multimodal approach which includes combined cervical, scapulothoracic stretching and strengthening exercise therapy for people with subacute or chronic neck pain. Manipulation and mobilization may reduce chronic pain in the short and intermediate term. Moderate evidence indicates that a acupuncture has important short term clinical benefits. Consistent evidence indicates that low-level laser treatment (LLLT) is beneficial.

Multimodal care approach:

A Cochrane review (search date: February 2012) aimed to assess the effectiveness of exercise therapy to relieve pain, improve function, disability, individual satisfaction, and global perceived effect in adults with mechanical neck disorders [Kay et al, 2012]:

Randomized controlled trials or quasi-randomized trials were included if they investigated exercise therapy as a treatment in adults with mechanical neck disorders with or without headache or radicular findings. Twenty-one trials were included.

There is moderate quality evidence that combined cervical, scapulothoracic stretching and strengthening exercises in people with chronic neck pain reduces pain immediately after treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60 to -0.10) and at follow-up (pooled SMD -0.31, 95% CI: -0.57 to -0.06). It has also been showed to improve function in the short and intermediate term (pooled SMD -0.45, 95% CI: -0.72 to -0.18).

One trial (n = 30) showed that general fitness training has no effect on pain with relation to chronic or subacute non-specific neck pain.

A best-evidence synthesis by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders suggested that treatment involving manual therapy and exercise is more effective that alternative strategies [Hurwitz et al, 2008].

Manipulation and mobilization:

A BMJ Clinical Evidence review concluded that manipulation and mobilization may reduce chronic pain more than usual care or less active exercise. The author of the review concluded that [Binder, 2008]:

They are as likely to be as effective as each other or as exercise.

They are more effective than heat treatment or pulsed electromagnetic field treatment.

A subsequent Cochrane systematic review (search date July 2009, n = 1522) examined the effect of manipulation and mobilization for neck pain. It found low to moderate quality evidence that cervical manipulation or mobilization are equally effective at relieving pain in the short- and intermediate-term. There is also low to moderate quality evidence that thoracic mobilization alone or in combination with electrothermal or individualized physiotherapy can provide immediate pain relief [Gross et al, 2010].

Acupuncture:

A Cochrane review aimed to determine the effects of acupuncture for people with neck pain [Trinh et al, 2006]:

The authors searched Central (2006, Issue 1) and Medline, Embase, Mantis, and Cinahl from their beginning to February 2006, plus reference lists and the acupuncture database TCMLARS in China.

The authors included any published study, either in full text or abstract form, that was a randomized controlled trial (RCT) or used quasi-RCT assignment to the intervention groups. Ten trials were found that studied acupuncture for chronic neck pain, but no trials were found in people with acute or subacute neck pain.

For chronic neck pain:

Acupuncture and pain relief: moderate evidence from two low-quality trials (n = 114) indicated that acupuncture was more effective for pain relief than some types of sham controls, measured immediately post-treatment.

Acupuncture compared with massage: one study (n = 177) provided limited evidence that acupuncture was more effective than massage at short-tem follow up.

Acupuncture compared with inactive treatment: moderate evidence from three trials (n = 338) indicated that acupuncture was more effective than inactive treatment measured immediately after treatment and at short-term follow up (pooled standardized mean difference –0.37, 95% CI –0.61 to –0.12).

The authors concluded that there was moderate evidence that acupuncture relieves pain better than some sham treatments and that people who receive acupuncture report less pain in the short term than people on a waiting list.

A best-evidence synthesis by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders considered six RCTs of people with subacute or chronic neck pain which included acupuncture arms and concluded that in people with neck pain not due to a whiplash injury, acupuncture is perhaps more effective than no treatment, sham treatment, or other interventions [Hurwitz et al, 2008].

A BMJ Clinical Evidence review considered five systematic reviews (which identified 16 RCTs) and two subsequent RCTs and concluded that acupuncture may be more effective in the short term than sham treatment or inactive treatment [Binder, 2008].

Low-level laser therapy (LLLT) uses a light source of a single wavelength. The effect is related to photochemical reactions in the cells and is not a heat (thermal) effect.

A best-evidence synthesis by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders considered four double-blind placebo-controlled RCTs in people with subacute or chronic neck or shoulder pain. These studies showed consistent evidence that LLLT was associated with improvements in pain and function in the short term (10 days to 12 weeks) [Hurwitz et al, 2008].

A subsequent systematic review and meta-analysis (16 trials included, n = 820) of RCTs or active-treatment controlled trials investigated the efficacy of LLLT in the management of neck pain [Chow et al, 2009]:

Two RCTs examined the effect of LLLT on acute neck pain and showed a significant improvement of pain when comparing immediate pre and post treatment pain scores (RR 1.69, 95% CI 1.22 to 2.33).

Five RCTs examined the effect of LLLT to treat chronic neck pain. They showed an improvement of pain with LLLT compared with placebo (RR 4.05, 95% CI 2.74 to 5.98).

Eleven RCTs used a visual analogue scale to assess the effect of LLLT on chronic neck pain. They showed a reduction in pain intensity by 19.86 mm (10.04 to 29.68) in favour of LLLT compared with placebo.

Search strategy

Scope of search

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

Search dates

January 2009 – August 2013

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

neck pain/, neck pain.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSH subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

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

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

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 guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Towards Optimal Practice

University of Michigan Medical School

Michigan Quality Improvement Consortium

Patient UK Guideline links

Driver and Vehicle Licensing Agency

Medline (with guideline filter)

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

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

NIHR Health Technology Assessment programme

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

Drug & Therapeutics Bulletin

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

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.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

Barry, M. and Jenner, J.R. (1995) Pain in neck, shoulder, and arm. British Medical Journal 310(6973), 183-186. [Free Full-text]

Binder, A.I. (2007a) Cervical spondylosis and neck pain. British Medical Journal 334(7592), 527-531. [Free Full-text]

Binder, A. (2007b) The diagnosis and treatment of nonspecific neck pain and whiplash. Europa Medicophysica 43(1), 79-89. [Abstract] [Free Full-text]

Binder, A. (2008) Neck pain. Clinical EvidenceBMJ Publishing Group Ltd. www.clinicalevidence.com [Free Full-text]

Chow, R.T., Johnson, M.I., Lopes-Martins, R.A. and Bjordal, J.M. (2009) Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. Lancet 374(9705), 1897-1908. [Abstract]

CSM (2002) Non-steroidal anti-inflammatory drugs (NSAIDs) and gastrointestinal (GI) safety. Current Problems in Pharmacovigilance 28(Apr), 5. [Free Full-text]

CSM (2005) Updated advice on the safety of selective COX-2 inhibitors. Committee on Safety of Medicines. www.mhra.gov.uk [Free Full-text]

Gross, A., Miller, J., D'Sylva, J. et al. (2010) Manipulation or mobilisation for neck pain (Cochrane Review). The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

Guzman, J., Haldeman, S., Carroll, L.J. et al. (2008) Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. European Spine Journal 17(Suppl 1), S199-S213. [Abstract]

Hogg-Johnson, S., van der Velde, G., Carroll, L.J. et al. (2008) The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. European Spine Journal 17(Suppl 1), S39-S51. [Free Full-text]

Hurwitz, E.L., Carragee, E.J., van der Velde, G. et al. (2008) Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. European Spine Journal 17(Suppl 1), S123-S152. [Abstract]

Kay, T.M., Gross, A., Goldsmith, C.H. et al. (2012) Exercises for mechanical neck disorders (Cochrane Review). The Cochrane Library. Issue 8. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]

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