Treatment of Mild Spondylosis
For mild spondylosis, initiate NSAIDs at full therapeutic doses combined with regular exercise and patient education as first-line therapy, reserving physical therapy for patients who fail to improve with home exercises alone. 1
Initial Management Approach
Non-Pharmacological Treatment (Foundation of Care)
Start with patient education and a structured home exercise program, as this forms the cornerstone of spondylosis management and should continue throughout the disease course 1
Prescribe regular unsupervised back exercises as the initial approach, since home exercises have demonstrated functional improvement in short-term studies and are conditionally recommended by the American College of Rheumatology 1
Advance to supervised physical therapy (land-based preferred) only if home exercises prove insufficient, as supervised programs show better patient global assessment scores despite similar pain and function outcomes compared to home exercise 1
Prioritize active exercise interventions over passive modalities (massage, ultrasound, heat), as active interventions provide superior outcomes 1
Pharmacological Treatment
Prescribe NSAIDs (including COX-2 inhibitors) as first-line drug therapy for patients with pain and stiffness, as they have Level Ib evidence for improving spinal pain and function 1
Use on-demand (intermittent) NSAID dosing for mild disease rather than continuous daily dosing, as the American College of Rheumatology conditionally recommends this approach for stable disease 1
Select COX-2 inhibitors or non-selective NSAIDs with gastroprotective agents for patients with increased gastrointestinal risk factors, as COX-2 inhibitors have lower serious GI event rates while maintaining equivalent efficacy 1
Account for cardiovascular, gastrointestinal, and renal risk factors when selecting specific NSAIDs, as these toxicities are dose-dependent and patient-specific 1
Consider simple analgesics (paracetamol) or opioid-like drugs only for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1
Important Contraindications and Caveats
What NOT to Do
Never use systemic glucocorticoids for axial spinal symptoms, as they provide no proven benefit and are strongly recommended against by the American College of Rheumatology 1, 2, 3
Avoid spinal manipulation in patients with any degree of spinal fusion or osteoporosis, as this carries fracture risk 1, 2
Do not use conventional DMARDs (sulfasalazine, methotrexate) for purely axial disease, as there is no evidence for efficacy in axial symptoms 1, 3
Local Corticosteroid Injections
Consider corticosteroid injections directed to specific sites of musculoskeletal inflammation (sacroiliac joints, entheses, peripheral joints) if localized symptoms persist despite NSAIDs 1
Avoid peri-tendon injections of Achilles, patellar, and quadriceps tendons due to rupture risk 1
When to Escalate Treatment
Escalate to biologic therapy (TNF inhibitors) only if the patient develops persistently high disease activity despite adequate trials of NSAIDs and physical therapy, as this represents progression beyond mild disease 1, 3
Additional Supportive Measures
Recommend participation in patient associations and self-help groups, as these may provide benefit for motivation and anxiety, though they lack specific evidence for pain or functional outcomes 1
Advise fall evaluation and counseling as a conditional recommendation for safety 1
Encourage formal self-management education programs (group or individual), as these have moderate-quality evidence supporting their use 1