What are the expectations of resolution, management options, and suggested exercises for a patient with spondylitis or arthritis?

Patient Education Handout: Spondylitis vs Arthritis

What's the Difference?

Spondylitis (specifically ankylosing spondylitis) is an inflammatory disease primarily affecting your spine and sacroiliac joints, typically starting before age 45, while osteoarthritis is a degenerative "wear-and-tear" condition that can affect any joint and usually occurs later in life. 1

Key Distinguishing Features:

Spondylitis:

• Inflammatory back pain that improves with exercise and worsens with rest 1
• Morning stiffness lasting >30 minutes 1
• Night pain that improves when you get up and move 2
• Often associated with HLA-B27 genetic marker (positive in ~90% of cases) 1
• Can cause eye inflammation (uveitis), inflammatory bowel disease 3

Osteoarthritis:

• Pain that worsens with activity and improves with rest 4
• Brief morning stiffness (<30 minutes) 4
• Affects hands, hips, and knees most commonly 4
• Related to age, prior joint injury, or obesity 4

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What to Expect: Will This Get Better?

For Spondylitis:

This is a chronic, progressive condition that cannot be cured, but symptoms can be well-controlled with proper treatment. 5, 6

• Without treatment, the spine can gradually fuse over many years 4
• With modern treatment (especially if started early), most patients maintain good function and quality of life 6
• Disease activity fluctuates—you'll have flares and periods of lower symptoms 4
• Radiographic progression is very slow in most patients; monitoring X-rays more than once every 2 years is unnecessary 4

For Osteoarthritis:

Osteoarthritis is also chronic and progressive, but symptoms can be significantly improved with weight loss, exercise, and appropriate medications. 4

• Joint damage is permanent, but pain and function can improve substantially 4
• Weight loss of 5-10% produces meaningful symptom improvement 4
• Exercise consistently improves pain and function despite the joint damage 4

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Treatment Plan

For Spondylitis:

Step 1: NSAIDs + Physical Therapy (Start Immediately)

• NSAIDs are your first-line medication and should be taken at maximum tolerated doses continuously if you have active symptoms 4
• Approximately 75% of patients show good response within 48 hours of full-dose NSAID therapy 1
• Common options: naproxen 500mg twice daily, ibuprofen 800mg three times daily, or diclofenac 7, 2
• If you have stomach problems: take a proton pump inhibitor (like omeprazole) with your NSAID, or use a COX-2 selective NSAID 7

Physical therapy and exercise are NOT optional—they are as important as medication. 4

Step 2: Biologic Medications (If NSAIDs + PT Insufficient After 3 Months)

• If you still have persistently high disease activity despite maximum NSAID doses and regular exercise, you need a TNF inhibitor (like adalimumab, etanercept, or infliximab) 4, 1
• These are injectable medications given weekly or every 2 weeks 1
• If TNF inhibitors don't work or cause side effects, IL-17 inhibitors (secukinumab, ixekizumab) are the next option 4, 1

What NOT to Use:

• Traditional disease-modifying drugs (methotrexate, sulfasalazine) do NOT work for spinal symptoms in spondylitis 4
• Long-term oral steroids should be avoided 4
• Opioid pain medications are only for breakthrough pain when other treatments have failed 4

For Osteoarthritis:

Step 1: Weight Loss + Exercise (Most Important)

• If you are overweight, losing 5-10% of your body weight will produce more benefit than any medication. 4
• Weight loss combined with exercise produces the best results 4

Step 2: NSAIDs (As Needed or Daily)

• NSAIDs can be used on-demand for pain flares or continuously if needed 4
• Same dosing and stomach protection as described above 7

Step 3: Other Options

• Acetaminophen (Tylenol) 1000mg three times daily for mild pain 4
• Topical NSAIDs (diclofenac gel) for hand or knee arthritis 4
• Steroid injections into severely painful joints (provides 4-12 weeks of relief) 4

What NOT to Use:

• Glucosamine and chondroitin have minimal to no benefit 4

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Exercise Program

For Spondylitis:

You must exercise regularly—this is non-negotiable for maintaining spinal mobility. 4

Recommended Exercises (Do Daily):

1. Spinal extension exercises (lying on stomach, lifting chest off floor) 4, 8
2. Deep breathing exercises (expand chest fully, hold 5 seconds) 4
3. Neck range of motion (chin tucks, looking over each shoulder, ear to shoulder) 7
4. Posture exercises (stand against wall, shoulders back) 8
5. Swimming or water aerobics (excellent for maintaining flexibility without joint stress) 4

Exercise Guidelines:

• Supervised physical therapy is more effective than home exercise alone, especially when starting 4
• Active exercises (you moving yourself) are better than passive treatments (massage, heat) 4
• Land-based therapy is preferred over aquatic therapy due to better access, though both work 4
• Exercise should be done even when you have pain—it will improve your symptoms 4

What to Avoid:

• Contact sports or activities with high fall risk (increased fracture risk with spinal fusion) 3
• Prolonged sitting or static positions 8

For Osteoarthritis:

Exercise improves pain and function even though you have joint damage—this is proven in clinical trials. 4

Recommended Exercises (Do 3-5 Times Weekly):

1. Low-impact aerobic exercise: walking, cycling, swimming (30-45 minutes) 4
2. Strengthening exercises: resistance bands, light weights, body weight exercises 4
3. Balance exercises: single-leg stands, heel-to-toe walking (reduces fall risk) 4
4. Tai chi: combines strength, balance, and meditation (strongly recommended) 4
5. Yoga: gentle stretching and strengthening (conditionally recommended for knee OA) 4

Exercise Guidelines:

• Supervised programs (with physical therapist or in group classes) are more effective than exercising alone 4
• Programs combined with self-management education work better than exercise alone 4
• Some pain during exercise is acceptable—use common sense about when to push through vs. when to stop 4

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When to Seek Urgent Care

For Spondylitis:

• New weakness, numbness, or loss of bowel/bladder control (possible spinal cord compression) 7
• Sudden severe back pain after minor trauma (high fracture risk with fused spine) 4, 3
• Red, painful eye with vision changes (uveitis—needs same-day ophthalmology) 3
• Persistent severe pain despite 3 months of proper treatment (may need biologics or specialist referral) 7

For Osteoarthritis:

• Joint becomes hot, red, and swollen (possible infection) 4
• Inability to bear weight or perform daily activities despite treatment (may need joint replacement) 8

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Lifestyle Modifications

For Both Conditions:

• Stop smoking immediately—smoking worsens spondylitis progression and increases surgical complications 4
• Maintain healthy weight (critical for osteoarthritis, helpful for spondylitis) 4, 9
• Participate in self-management programs (group education sessions improve outcomes) 4

For Spondylitis Specifically:

• Sleep on a firm mattress without a pillow (or thin pillow) to maintain spinal alignment 8
• Maintain good posture throughout the day 8
• Monitor for cardiovascular disease (increased risk with chronic inflammation) 3

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Monitoring Your Condition

For Spondylitis:

• Track your morning stiffness duration, night pain, and overall pain levels 4
• See your rheumatologist every 3-6 months when stable, every 4-6 weeks when adjusting medications 1
• Blood tests (ESR, CRP) help monitor inflammation 1
• Spine X-rays only needed every 2+ years unless symptoms change dramatically 4

For Osteoarthritis:

• Monitor your pain levels, function, and ability to perform daily activities 4
• Regular follow-up with primary care or rheumatology as symptoms dictate 4