What is the initial treatment for spondylosis?

Initial Treatment for Spondylosis

The initial treatment for spondylosis combines patient education and regular exercise as the cornerstone, with NSAIDs as first-line pharmacological therapy for pain and stiffness. 1

Non-Pharmacological Treatment (Foundation of Therapy)

Patient education and regular exercise form the cornerstone of non-pharmacological treatment and should be initiated immediately. 1

Physical Therapy Approach

• Supervised physical therapy (land or water-based, individual or group) is more effective than home exercises alone and should be preferred when available 1
• Home exercises do improve function in the short term compared to no intervention, but patient global assessment is significantly better with group therapy 1
• Unsupervised back exercises can be advised as part of general physical activity recommendations, though they should not substitute for initial instruction by a physical therapist 1
• Gentle isometric muscle strengthening exercises that don't require significant joint movement are recommended for affected areas 2

Additional Non-Pharmacological Measures

• Patient associations and self-help groups may be useful 1
• Formal group or individual self-management education is conditionally recommended 1
• Fall evaluation and counseling should be considered 1

Pharmacological Treatment (First-Line)

NSAIDs (including COX-2 inhibitors) are recommended as first-line drug treatment for patients with pain and stiffness. 1

NSAID Prescribing Strategy

• There is Level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over 6 weeks 1, 2
• For patients with stable disease, on-demand NSAID treatment is conditionally recommended over continuous treatment 1
• For patients with persistently active, symptomatic disease, continuous NSAID treatment is preferred 1
• COX-2 inhibitors (Coxibs) are equally effective to traditional NSAIDs 1

Risk Mitigation

• Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing NSAIDs 1
• In patients with increased GI risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1, 2

Specific NSAID Dosing Example

For ankylosing spondylitis specifically, naproxen 250-500 mg twice daily is recommended as initial dosing, with the morning and evening doses not needing to be equal 3

Treatment Algorithm

1. Start immediately with patient education and exercise program (supervised when possible) 1
2. Initiate NSAIDs at lowest effective dose for patients with pain and stiffness, considering individual risk factors 1
3. Assess response after 6 weeks of combined non-pharmacological and pharmacological treatment 1
4. Continue or adjust based on clinical response, with activity modification and neck immobilization as needed for cervical involvement 4

Important Caveats

• Activity modification is essential - patients should avoid positions or activities that exacerbate symptoms 4
• Analgesics (paracetamol, opioids) should only be considered for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1
• Systemic glucocorticoids for axial disease are not supported by evidence, though local corticosteroid injections may be considered for specific sites of musculoskeletal inflammation 1
• DMARDs (including sulfasalazine and methotrexate) have no evidence for efficacy in axial disease and should not be used as initial treatment 1
• The majority of patients with spondylosis can be treated nonsurgically with this approach 5, 6