How to maximise your management of osteoporotic vertebral fractures

Have you ever felt stuck managing an osteoporotic vertebral fracture? I know I have – as a physio, you want nothing more than to help your patient return to the activities they love, but pain, and restrictions on what they can and can’t do can leave you feeling powerless. Dr. Lora Giangregorio’s outstanding Masterclass gave me valuable strategies for these situations, along with expert insights into osteoporosis management and fracture prevention. In this blog, I’ll focus on practical approaches to managing vertebral fractures.

If you want to learn all-things osteoporosis management from an expert, watch Dr. Lora Giangregorio’s full Masterclass HERE.

Understanding load

The first step in the effective management of osteoporotic fractures starts with understanding the balance between load and bone strength. Key factors influencing spinal forces include:

• Body mechanics: Height, weight, and the positioning of the head, arms, and torso.
• Weight distribution: How weight is carried affects the strain on the spine.
• Muscle dynamics: Lengthened spinal extensors create shorter lever arms, increasing the forces applied to the spine.
• Shock absorption: Reduced capacity of local shock absorbers, such as intervertebral discs, further impacts spinal load.

Understanding these factors can help you to manage spinal load more effectively and help facilitate the healing process in those who have sustained an osteoporotic vertebral fracture. See Lora explain the balance between load and bone strength in the below snippet taken from her Masterclass:

Education

Managing vertebral fractures is different from treating non-specific, chronic back pain. Certain movements should be avoided, and some carry a risk of further damage. However, as with non-specific back pain, it’s crucial to avoid catastrophising the situation. The first step is to choose your words carefully, focus on activity pacing, and address anxiety and fear of falling. Education should then cover topics such as:

1- Pain relief

This may involve pain-relief strategies like unloading positions, using bolsters under the knees while sleeping, applying heat packs, or performing simple exercises like chin tucks. Providing your patient with a personalised “pain-relief toolkit” can empower them and enhance their confidence in managing their fracture.

2 – Pain expectations

It’s important to set realistic expectations for your patient regarding pain. While acute pain often decreases over time, fracture-related pain can persist for longer; sometimes, patients can experience persistent pain after healing has occurred. To minimise the risk of prolonged pain, educate your patient about avoiding heavy lifting for 12 weeks and emphasise a gradual, pain-guided return to exercises and daily activities. Teaching “spine-safe” movements is equally important to keep your patient mobile while supporting fracture recovery.

3- Things to include and avoid

After discussing pain-relief strategies, the next step is educating your patient on what to include and avoid—essentially, load management. For instance, advise against prolonged bed rest, extended sitting, and routine use of bracing. When it comes to the point your patient is ready to start some gentle exercise, educate them to avoid twisting and flexion-related movements. The later stages of fracture recovery can be particularly challenging, as patients may feel better but still face risks. In her Masterclass, Lora provides excellent examples of what to include and avoid in activities like yoga and Pilates:

1 – Yoga

Include = savasana, bridge, chair, warrior, mountain

Avoid = seated spinal twists, ragdoll, saw, pigeon, spinal rocking

2 – Pilates

Include = pilates breath, head nod, imprint and release, shoulder/scapula isolation, shoulder bridge, breaststroke, side leg work, plank

Avoid = abdominal prep, rolling like a ball, criss cross, spine twist, Pilates hundred

Additionally, a common question in osteoporosis and post-fracture management is about when it is appropriate to include impact exercise, Lora explains this in the below video from her Masterclass:

Therapeutic exercise prescription

So, your patient has recovered from a fracture and wants to prevent future ones, or you’re managing an osteoporotic patient at high fracture risk. What’s the best exercise approach? Lora highlights current clinical guidelines, emphasising that a combination of functional and balance training, with or without resistance training, is ideal for preventing falls—and potentially fractures. Resistance training, while not appropriate for all patients, may be used with those patients aiming to improve posture and bone mineral density.

Balance and functional training should be performed at least twice a week. Additionally, Lora recommends progressive resistance training two or more times weekly, with a focus on strengthening the back extensor and abdominal muscles. For patients recovering from vertebral fractures, simple exercises like supine isometric back extensions and supine abdominal bracing with feet on the floor can be effective. Watch Lora explain resistance exercise prescription in the video below, taken from her Masterclass:

Wrapping up

Managing osteoporotic vertebral fractures can feel daunting, and constrained at times. But with the right strategies, it’s possible to guide your patients toward recovery and long-term prevention. Understanding the delicate balance between load and bone strength is key, as is equipping your patients with pain-relief techniques, setting realistic expectations, and educating them on safe movements and activities, so you can keep them participating in life while minimising risks.

For a deeper dive into evidence-based osteoporosis management and fracture prevention, watch Dr. Lora Giangregorio’s full Masterclass HERE.