IntroductionChronic pain, defined as pain persisting for more than 3 months, affects a significant portion of the adult population in the United Kingdom (UK), with estimates ranging from one-third to one-half of adults experiencing it (Cohen, Vase, and Hooten 2021; Fayaz et al. 2016). Low back pain (LBP) is the leading cause of years of healthy life lost due to disability (YLD) globally and in the UK, affecting both sexes across all age groups (Institute for Health Metrics Evaluation 2024). Approximately 619 million people worldwide experience LBP annually, with females disproportionately affected at a rate of 9,300 cases per 100,000, compared to 5,520 per 100,000 for males (Ferreira et al. 2023). Similarly, neck pain is also a major contributor to YLD, ranked 15th globally and 11th in the UK, affecting an estimated 203 million people per year globally (Institute for Health Metrics Evaluation 2024; Kazeminasab et al. 2022; Wu et al. 2024), with 2,890 cases per 100,000 females versus 2,000 per 100,000 males (Wu et al. 2024). Given these significant differences in how musculoskeletal conditions, like neck and back pain, affect males and females, understanding the biological and social factors contributing to this disparity is crucial. This understanding is necessary to develop tailored, sex- and gender-considered management strategies that improve healthcare (International Association for the Study of Pain 2024; Zheng et al. 2022). For clarity, sex refers to biological characteristics that define individuals as male or female (Walker and Cook 1998), such as chromosomal makeup, hormone levels, genetic factors, and anatomical structure, whilst gender refers to socially constructed roles and identities (Walker and Cook 1998; International Association for the Study of Pain 2024). Biological sex differences include variations in skeletal structure, hormone regulations, and reproductive anatomy, all of which can influence health and pain experience (Goymann, Brumm, and Kappeler 2023). For example, males have broader shoulders and narrower pelvises, while females have wider pelvises to facilitate childbirth, alongside other distinct skeletal and hormonal variations (Weiss 2024; Huang et al. 2012). In forensic settings, sex is typically determined by the morphology of the pelvis or skull, as well as long bone measurements, with the pelvis being a key indicator due to its distinct differences between males and females (Spradley 2016). Male and female hormones also affect the development of the skeletal system, as bone growth and development are partly controlled by hormones such as testosterone and oestrogen (Baustian, Crandall, and Martin 2015). Intersex individuals, who possess biological characteristics that do not fit typical definitions of male or female, are often excluded from these binary categories, and their specific needs must also be considered in clinical guidelines (International Association for the Study of Pain 2024; Rosenwohl-Mack et al. 2020). Despite the importance of accounting for sex diversity, much of current research and healthcare practice continues to overlook these nuances (Biz et al. 2024). Current healthcare frameworks often fail to sufficiently consider the unique needs of gender-diverse populations, including intersex individuals, leading to significant disparities in healthcare (Biz et al. 2024). Sex-based biological differences may influence the development and experience of pain (International Association for the Study of Pain 2024). For instance, skeletal differences such as a wider pelvis in females can alter biomechanics and posture, potentially affecting how stress and strain are distributed across the spine (Sizer and James 2014; Grechenig et al. 2021). Additionally, hormonal fluctuations, particularly oestrogen and progesterone, which vary throughout the menstrual cycle and life stages, like pregnancy and menopause, may impact pain perception and sensitivity (Tommaso 2011; Chen et al. 2024; McCarthy and Raval 2020). Thus, these sex-based factors can result in differences in how neck and back pain develop and are experienced by females. The need to consider sex-specific differences is further supported by initiatives like the UK’s National Health Service (NHS)“Universal Personalised Care”, which advocates for individualised care based on patient’s preferences, needs, and values (NHS England 2019). However, it remains unclear to what extent sex-specific factors are considered within this personalised approach when managing chronic conditions, such as neck and back pain. The recent publication of the Women’s Health Strategy for England (Department of Health & Social Care 2022) recognises the need to address health inequalities, and highlights the need for healthcare systems to move away from a "male as default" approach (Department of Health & Social Care 2022). Historically, healthcare research, training, and education have often focused on males, leading to gaps in knowledge about how conditions like chronic musculoskeletal pain affect females differently (International Association for the Study of Pain 2024; Barlek et al. 2022; Zucker and Prendergast 2020). This male-centric bias could result in less effective treatment and management of these conditions in females. The Women’s Health Strategy aims to provide better information, education, and resources to ensure that healthcare professionals are equipped to deliver sex-sensitive, person-centred care (Department of Health & Social Care 2022). This highlights the urgent need to assess current clinical guidance to determine whether they adequately consider sex-specific factors in the management of general health conditions, like neck and back pain. This study undertakes a documentary analysis of UK-based Clinical Practice Guidelines (CPGs) and Clinical Guidance Documents (CGDs) for chronic neck and back pain, aiming to identify whether female-specific factors are included, examine the focus of these factors, and pinpoint gaps that need to be addressed to improve the management of neck and back pain for female patients specifically.
