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 of non-pharmacological management, with NSAIDs as first-line pharmacological therapy for patients experiencing pain and stiffness. 1, 2

Non-Pharmacological Treatment (Foundation of Therapy)

Physical therapy and regular exercise are strongly recommended and should be initiated immediately. 1, 2

• Supervised exercise programs (land or water-based, individual or group) are more effective than home exercises alone and should be preferred when available 1
• Home exercise programs do improve function in the short term compared to no intervention, though patient global assessment is significantly better with group therapy 1, 2
• Patient education about the condition and self-management strategies is essential and has been shown to improve motivation, reduce anxiety, and is cost-effective over 12 months 1

Important caveat: In patients with spinal fusion or advanced spinal osteoporosis, spinal manipulation with high-velocity thrusts is strongly contraindicated due to case reports of spine fractures, spinal cord injury, and paraplegia 1

Pharmacological Treatment (First-Line)

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

• There is Level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over a 6-week period 1, 2
• For ankylosing spondylitis specifically, the recommended naproxen dose is 250 mg, 375 mg, or 500 mg twice daily 3
• Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease rather than on-demand dosing 1

Risk mitigation is critical: 1

• In patients with increased gastrointestinal risk: use non-selective NSAIDs plus a gastroprotective agent, OR use a selective COX-2 inhibitor
• Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing
• Naproxen-containing products are not recommended in patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 3
• Lower doses should be considered in elderly patients and those with hepatic impairment 3

Treatment Algorithm

Step 1: Initiate patient education and supervised exercise program (physical therapy) 1, 2

Step 2: Start NSAIDs for symptomatic relief of pain and stiffness, with appropriate risk assessment and gastroprotection as needed 1, 2

Step 3: Monitor response using validated disease activity measures (such as Bath AS Disease Activity Index or AS Disease Activity Score) and acute-phase reactants (CRP or ESR) at regular intervals 1, 2

Step 4: If inadequate response after appropriate trial of NSAIDs and physical therapy, consider escalation to anti-TNF therapy for persistently high disease activity 1, 2

Additional Considerations

Analgesics (paracetamol and opioid-like drugs) may be considered only for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1

Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered, but systemic glucocorticoids for axial disease are not supported by evidence 1

Disease-modifying antirheumatic drugs (DMARDs) including sulfasalazine and methotrexate have no evidence for efficacy in treating axial disease, though sulfasalazine may be considered for peripheral arthritis 1

The treatment approach must account for: 1

• Current manifestations (axial, peripheral, entheseal, extra-articular symptoms)
• Level of current symptoms and prognostic indicators
• General clinical status including age, comorbidities, and concomitant medications