What is the initial management for patients with spondylosis?

Initial Management of Spondylosis

The initial management of spondylosis should include a combination of non-pharmacological approaches with regular exercise and physical therapy as the cornerstone treatment, along with NSAIDs as first-line pharmacological therapy for pain and stiffness. 1, 2

Assessment Considerations

• Treatment should be tailored according to current disease manifestations (axial, peripheral, entheseal, extra-articular symptoms) 2
• Assessment should include evaluation of disease activity/inflammation, pain levels, function, disability, and structural damage 2, 1
• Disease monitoring should incorporate patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation 1
• Radiographic monitoring is generally not needed more often than once every 2 years, though exceptions exist for rapidly progressing cases 1

Non-Pharmacological Management

• Regular exercise and physical therapy are fundamental components of spondylosis management 1, 2
• Home exercises are effective but supervised physical therapy (land or water-based, individual or group) is preferred as it shows better outcomes 2
• Aquatic exercises in warm water provide buoyancy to reduce joint loading and pain while offering resistance for gentle strengthening 3
• Patient education about the condition and self-management strategies is essential for long-term management 1
• Patient associations and self-help groups may provide additional support and improve adherence to treatment 2, 1

Pharmacological Management

• NSAIDs are the first-line drug treatment for patients with pain and stiffness 1, 4
• There is convincing evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over short periods 1
• For patients with increased gastrointestinal risk, consider either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor 1
• Analgesics such as paracetamol and opioids might be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 4
• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial for symptom relief 1, 5

Exercise Approach

• Start with gentle, isometric exercises that don't require significant movement of the spine 3
• Begin with light intensity (40-50% of capacity) and gradually progress as tolerated 3
• Use pain response as a guide to appropriate exercise intensity and duration 3
• Incorporate rest periods between exercise sessions to allow recovery 3
• Consider mind-body practices such as gentle tai chi or modified yoga that emphasize controlled movement and breathing 3

Common Pitfalls to Avoid

• Overreliance on imaging findings without correlation to clinical symptoms can lead to unnecessary interventions 1
• Failure to incorporate both pharmacological and non-pharmacological approaches limits treatment effectiveness 1, 2
• Systemic corticosteroids should be avoided for axial disease due to lack of evidence and potential side effects 1
• Spinal manipulation is contraindicated in conditions with spinal fusion or advanced spinal osteoporosis 3
• Delaying appropriate conservative management may lead to prolonged symptoms and disability 4, 6

When to Consider Advanced Interventions

• Surgical intervention should only be considered for patients with persistent severe symptoms despite conservative management 4, 7
• Epidural or transforaminal injections may be helpful for leg pain and neurogenic intermittent claudication 4, 7
• Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage 1
• Spinal surgery may be valuable in selected patients with progressive neurological deficits 6