In Reply

Letters to the editor regarding the article Clinical Practice Guideline: Nonspecific Neck Pain by Ahmad El-Allawy, Nils Hecht, Kerstin Luedtke, Philipp Schleicher, Norbert Weidner, and Thomas Kötter in issue 20/2025

We thank Dr. Wörz for his important comments regarding our article (1). We agree with him that psychosomatic connections in neck pain are common. In the diagnostics chapter of the guideline—which was developed with participation from the German Pain Society and the German Society for Psychological Pain Therapy and Research—we therefore pointed out that yellow flags—risk factors for chronification of pain should be considered from the off (2). These include depression/distress, subjective concepts as regards the cause of neck pain and workplace related factors such as the type of job activity, the satisfaction with this activity, and possibly also the fear of losing one’s job.

Our relevant recommendation 2 (“Psychosocial and workplace-related factors should be considered from the onset of neck pain and over the course of treatment”) is a high-level recommendation. Recommendations for relaxation techniques as components of self-management (Recommendation 11), for patient education (Recommendation 40), and for cognitive behavioral therapy as components of a multimodal treatment concept in chronic course (Recommendation 41) take into account the psychosomatic associations in both directions.

Pain neuroscience education, which is explicitly recommended in the guideline, puts pain as a consciousness phenomenon at its center: the first key message of pain neuroscience education as regards chronic and/or non-specific pain says that pain is no sign of tissue injury (Chapter 8.7 in the guideline). What we perceive is uncoupled from this and is influenced by physical, mental/psychological, and social factors (3).

DOI: 10.3238/arztebl.m2025.0231

Prof. Dr. med. Thomas Kötter
Universitätsklinikum Schleswig-Holstein, Campus Lübeck,
Institut für Allgemeinmedizin, Lübeck

Conflict of interest statement
TK received an expense allowance in connection with the presentation of the guideline from GUAD-Netz e.V.

References

1. El-Allawy A, Hecht N, Luedtke K, Schleicher P, Weidner N, Kötter T: Clinical Practice Guideline: Nonspecific neck pain. Dtsch Arztebl Int. 2025; 122: 552–7.

2. Deutsche Gesellschaft für Allgemein- und Familienmedizin (eds.): S3-Leitlinie „Nicht-spezifische Nackenschmerzen“ (Version 3.0). 2025. https://register.awmf.org/de/leitlinien/detail/053-007 (last accessed on 22 November 2025).

3. Louw A, Zimney K, O’Hotto C, Hilton: The clinical application of teaching people about pain. Physiother Theory Pract 2016; 32: 385–95