A 76-year-old woman comes in with back pain that started « just like that », with no fall and no awkward movement. It hurts when she gets up from a chair, and eases when she lies down. The picture looks like ordinary mechanical thoracic spine pain, and in one case in two to one in three it is a vertebral fracture that has just happened and that nobody will name.1

This article deals with vertebral fracture as a reason for consulting : how to spot it when nothing points to it, what should interrupt the session, and what can be done next. For the bone disease itself (densitometry, T-score thresholds, anti-osteoporotic drugs, primary prevention), see Osteoporosis and the prevention of fragility fractures.

Clinical summary

Why are most of these fractures never diagnosed?

Because they have neither the noise nor the staging of a fracture. There is no spectacular fall, no sudden loss of function, no deformity visible under the skin. There is a back that hurts in someone whose back is expected to hurt.

The word « fracture » suggests an event. This one is not. The osteoporotic vertebral body does not break under an impact: it gives way under a load that healthy bone would have taken without flinching. Carrying a shopping bag, pulling a sheet, coughing, bending to lace a shoe, sitting down a little heavily, and the history often reports nothing more. In some patients there is not even that: the fracture is found months later on a radiograph taken for something else.

The reference figure comes from Schousboe's review published in the Journal of Clinical Densitometry : only a quarter to a third of vertebral fractures are recognised clinically at the time they occur, the others requiring lateral imaging of the spine to be detected.1 This is a wording that must be read exactly: it does not say that two thirds of fractures are asymptomatic, it says that they are not recognised. The nuance moves where the responsibility lies. Many of these patients were in pain. They did seek help. They were told it was their age.

The osteoporotic vertebral fracture is not silent: it is inaudible. It speaks the same language as ordinary thoracic spine pain, in a population where ordinary thoracic spine pain is the norm.

What the radiologist sees and what the radiologist writes

Under-diagnosis does not stop at the practice door. It runs through the imaging chain as well. An Irish study reviewed the chest CT angiograms performed in patients admitted for hip fracture between 2010 and 2017: of the 225 patients whose images were available, 40 % had at least one vertebral fracture and 20 % had several. Only one radiology report in five mentioned it. And only 24 % of patients left hospital on anti-osteoporotic treatment, with no difference between those who had a vertebral fracture and those who did not.2

In other words, in patients already admitted for a fragility fracture, whose vertebrae had already been photographed, whose fracture was already on the image, the chain did not conclude. That is the chain the physiotherapist can interrupt, because they are often the professional who sees these patients for the longest and the most often.

How often does this really happen?

The European prospective EPOS study remains the reference measure on this continent: 14,011 men and women aged 50 and over, recruited in 29 centres, radiographed and then re-radiographed on average 3.8 years later. The age-standardised incidence of morphometric fractures was 10.7 per 1,000 person-years in women and 5.7 in men, with a marked rise with age in both sexes.3

Two practical lessons hide in there. The first is that men are not spared: the ratio is about two to one, not ten to one. A 78-year-old man complaining of back pain deserves exactly the same vigilance as a woman of the same age. The second is that incidence climbs steeply with age, which shifts the pre-test probability with every decade: the same clinical picture does not mean the same thing at 60 and at 82.

How can a compression fracture be suspected behind ordinary thoracic or low back pain?

The honest answer is: not with a single sign. Twenty years of research have demolished the idea that one red flag on its own is enough. What remains, and what can be used in the clinic, is a way of counting.

The 2023 Cochrane review by Han and Hancock brought together fourteen diagnostic studies comparing history-taking and physical examination with reference imaging. Its conclusion is blunt: most red flags are not useful for screening for vertebral fracture in a patient with low back pain. Those that do inform, in primary care, are trauma (positive likelihood ratio 6.42; 95 % CI 2.94 to 14.02 for osteoporotic fracture specifically) and corticosteroid therapy (2.46; 1.13 to 5.34). Older age informs mainly for unspecified vertebral fracture. And above all: combinations of red flags do better than items taken on their own.8

Downie's review published in the BMJ in 2013 had already given the measure in post-test probabilities, which speak more plainly than likelihood ratios: in a patient with low back pain, prolonged corticosteroid therapy raises the probability of fracture to 33 % (CI 10 to 67), older age to 9 % (3 to 25), severe trauma to 11 % (8 to 16). And when several red flags are present at the same time, the probability of spinal fracture rises to 90 % (34–99).9 The intervals are wide, since these are small studies, but the direction is constant.

The Roman cluster: five questions the physiotherapist can ask

One tool deserves to be known, because it was built for and by manual therapists, and because the 2023 Cochrane review kept it as the most informative combination in its review. Roman and Cook analysed more than 1,400 patients from a spine surgery centre and isolated a cluster of five features:10

1. age over 52 years;
2. no pain radiating into the leg;
3. body mass index of 22 or less;
4. no regular physical activity;
5. female sex.

Two positive items or fewer give a sensitivity of 0.95 (CI 0.83 to 0.99) and a negative likelihood ratio of 0.16 (0.04 to 0.51): fracture becomes unlikely, which is the most useful function day to day. Four items out of five give a positive likelihood ratio of 9.6 (3.7 to 14.9), recalculated to 9.62 (5.88 to 15.73) by the Cochrane review from the raw data.810

It must be said what this tool is not. It was derived in the population of a specialised surgical centre, where the prevalence of fracture is far higher than in a community practice, and the authors themselves write that prospective validation in a separate sample is still needed. It has not taken place. The cluster is therefore a structured aide-memoire, not an approved test: it organises doubt, it does not replace it.

The three measurements that cost thirty seconds

The clinical examination review published in JAMA by Green and colleagues assessed the physical manoeuvres for diagnosing osteoporosis and occult spinal fracture. Three of them need no equipment:11

• The wall-occiput distance. The patient stands, heels and back against the wall, gaze horizontal. If the occiput does not touch the wall, the distance is greater than zero: positive likelihood ratio 4.6 (CI 2.9 to 7.3) for an occult spinal fracture.11
• The rib-pelvis distance. Patient standing, arms abducted, the space between the lower costal margin and the iliac crest is measured laterally. Less than two finger breadths: positive likelihood ratio 3.8 (2.9 to 5.1).11
• Weight. Under 51 kg gives the highest ratio in the review, 7.3 (5.0 to 10.8)11 and that is for osteoporosis, not for fracture. It is not a sign of fracture, it is a sign of the underlying bone, and it is worth recording.

Documented height loss deserves a mention of its own, because it is often quoted without its figures. Mikula's study of 66,021 patients shows a specificity that climbs fast but a sensitivity that collapses : at 1, 2, 3 and 4 cm of height loss, the sensitivity for detecting a vertebral fracture is 42, 32, 19 and 14 % and the specificity 70, 82, 92 and 95 %.12 Clinical translation: a documented height loss of 3 or 4 cm justifies investigation, but the absence of height loss rules out nothing at all and even at the most sensitive threshold, 1 cm, close to six fractures in ten go undetected.

Which imaging to request, and to whom should the patient be referred?

The physiotherapist does not prescribe imaging, but is often the one who triggers the request. Knowing which examination answers which question avoids sending a patient away with a radiograph that will not say what you wanted to know.

Three questions, three examinations

« Is there a vertebral deformity? » The radiograph of the thoracic and lumbar spine lateral view answers that one. The lateral view is not a detail: it is the projection on which loss of vertebral body height is read, and it is precisely the imaging the literature names as necessary to recognise the fractures that escape clinical detection.1 Grading follows Genant's semiquantitative method, still the reference thirty years after its publication, and whose founding paper establishes above all its inter- and intra-observer reproducibility.13 In its working form it grades the loss of vertebral body height: grade 1 for about 20 to 25 %, grade 2 for 25 to 40 %, grade 3 beyond 40 %.

« Is this fracture recent? » The radiograph does not say. A grade 2 compression on a film carries no date: it may be six weeks or six years old. It is MRI that answers, through the presence of bone marrow oedema (high signal on STIR or fat-saturated T2, low signal on T1). It is the examination that separates the vertebra that has just given way from the one that gave way long ago, and it is that distinction that governs everything else: the first demands caution, the second allows progressive loading.

CT can settle the question in some cases when MRI is unavailable or contraindicated. A German study of 192 fractures measured the ability of multislice CT alone to separate recent or subacute fractures from old ones: the area under the curve reaches 0.854 and 0.861 depending on the reader, with a sensitivity of 97.2 and 94.5 % but a specificity of only 58.1 and 65.1 % when doubtful cases are classified as recent.14 In other words, CT misses few recent fractures but over-diagnoses many: it reassures badly. One sign is the exception, double trabecular compaction, present in about half of recent fractures but highly specific (93.2 and 88.6 %).14

« Does this patient have untreated osteoporosis? » That one is bone densitometry, and it is the general practitioner or the rheumatologist who requests it. The point the physiotherapist needs to know is that in France the updated recommendations of the Société française de rhumatologie and the GRIO recommend drug treatment in women with a severe fracture, vertebral fracture belonging to that category, without requiring a prior densitometric threshold.35 A patient coming out of a vertebral fracture with no bone treatment at all is not a borderline case: it is a departure from the recommendation, and flagging it is part of the job.

What looks like an osteoporotic compression fracture without being one?

The differential diagnosis works in both directions. You have to be able to recognise the compression fracture beneath thoracic pain you would have called mechanical, and to know that a compression fracture visible on imaging does not necessarily explain today's pain.

The commonest trap is not confusing the compression fracture with another disease: it is not thinking of it at all, because the picture fits something ordinary perfectly. Three spinal conditions, each covered in detail elsewhere on this site, occur in the same patient and sometimes on the same day.

The compression fracture that does not explain the pain

The reverse reasoning deserves just as much attention. In someone of 80, finding a vertebral deformity on a radiograph is nothing exceptional: it is even expected. Automatically attributing today's pain to that image is to repeat on the thoracic spine the mistake physiotherapy took twenty years to unlearn on the lumbar spine. An old deformity, with no marrow oedema on MRI, is not an active fracture: it is a scar.

A compression fracture on a radiograph dates from nothing. It is bone marrow oedema on MRI that separates the vertebra that is hurting from the one that has hurt.

This distinction has a direct consequence for what you allow yourself. Faced with a recent fracture, caution is required over loading and over flexion. Faced with an old, painless deformity in a patient whose pain comes from elsewhere, the same caution becomes an unjustified brake, and the international recommendations insist on exactly this point: do not turn a history of fracture into a list of lifelong bans.28

Why does a first vertebral fracture herald others?

Because the fracture is not an accident, it is a symptom. It reveals bone that gives way under ordinary stresses, and that bone does not become normal again because the pain has settled.

This is the figure to know by heart. Lindsay and colleagues analysed the 2,725 postmenopausal women randomised to the placebo arms of four large osteoporosis trials. Among the 381 participants who developed an incident vertebral fracture during the study, the incidence of a new vertebral fracture in the following year was 19.2 % (95 % CI 13.6 to 24.8). And the presence of at least one vertebral fracture at baseline multiplied by 5.1 the risk of fracturing during the first year of the study.4

One woman in five. Within the year. This figure circulates widely in distorted forms, « 20 % », « one in five », sometimes « 25 % », without the primary source ever being cited. Here it is, with its population: postmenopausal women of mean age 74, on placebo, in trials where fractures were detected radiographically, including those that had never shown themselves clinically.4

Klotzbuecher's statistical synthesis, published in the Journal of Bone and Mineral Research, gives the overall picture across all fracture sites. Its most striking result: the strongest association in the whole literature is the one between a previous vertebral fracture and a later vertebral fracture, with a risk about four times higher, which rises further with the number of fractures already present. For the other site combinations (hip, wrist, spine), the relative risk is around 2.5

What is at stake beyond the next vertebra

The vertebral fracture is not only a predictor of fracture. It is a marker of overall frailty. The Dubbo prospective cohort, published in JAMA, followed women and men aged 60 and over for nearly twenty years: the standardised mortality ratio after a clinical vertebral fracture is 1.82 in women (CI 1.52 to 2.17) and 2.12 in men (1.66 to 2.72), with excess mortality persisting five years after the event.6

This figure has to be read with the caution an association deserves: the vertebral fracture does not kill directly in most cases. It occurs in people who are frailer, more undernourished, more comorbid, and it then worsens what made it likely in the first place, through pain, immobilisation, loss of function, kyphosis, and the reduction in abdominal and thoracic volume. The chain is plausible and documented link by link, but overall causality is not demonstrated by this type of study, and this article will not pretend that it is.

What can the physiotherapist do against the fracture cascade?

Three things, and none of them consists of treating the bone. Spotting that the osteoporosis is untreated, reducing falls, and giving the patient back a spine that holds. The first two are the least spectacular and the best demonstrated.

First: check that someone is treating the bone

It is the simplest and most cost-effective contribution. It calls for no new skill: it calls for a question to be asked. Since your fracture, have you had a bone density scan? Are you taking any treatment for your bones?

The probability that the answer is no is high. In the Irish cohort already cited, only 24 % of patients admitted for hip fracture left on anti-osteoporotic treatment, with no difference between those who had a vertebral fracture on CT and those who did not.2 And the French recommendations of the Société française de rhumatologie and the GRIO are explicit: in women with a severe fracture (a category that includes vertebral fracture), drug treatment is recommended, all the available agents being usable.35

What this spotting produces is not hypothetical. Post-fracture care pathways, or fracture liaison services, have been the subject of a systematic review with meta-analysis covering 37 studies, 34 of them at low risk of bias: the risk of a secondary fragility fracture is reduced, relative risk 0.68 (CI 0.55 to 0.83) beyond two years, with moderate certainty of evidence according to GRADE.7 A one-third reduction in the risk of refracture, obtained through organisation and not through a technical procedure.

The physiotherapist does not prescribe bisphosphonates. But they are often the only clinician to see this patient twenty times in three months, and the only one in a position to notice that nobody has prescribed anything.

Second: reduce falls

This is the area where the evidence is the strongest in this whole article, and it does not bear specifically on vertebral fracture. Sherrington's Cochrane review, in the abridged version published in the British Journal of Sports Medicine, establishes on 59 studies and 12,981 participants that exercise reduces the rate of falls by 23 % (rate ratio 0.77; CI 0.71 to 0.83), with high certainty and that label is rare and deserves emphasis.30

The detail of the modalities matters as much as the overall result:

• Balance and functional exercise : a 24 % reduction in the rate of falls (0.76; 0.70 to 0.81), high certainty, across 39 studies.30
• Combined programmes, most often balance and functional work plus strengthening: a 34 % reduction (0.66; 0.50 to 0.88), moderate certainty.30
• Tai chi : a 19 % reduction (0.81; 0.67 to 0.99), low certainty.30
• Programmes centred on strengthening alone, on dance or on walking : the authors declare themselves uncertain.

And one finding of direct use to the profession: the subgroup analysis shows a larger effect in the trials where the intervention was delivered by a health professional, most often a physiotherapist.30

The logic of this argument has to be named, because it is indirect. The evidence bears on falls, not on vertebral fractures, and a large share of vertebral fractures occur without a fall. Reducing falls by 23 % therefore does not reduce vertebral fractures by 23 %. But in a patient who has already fractured, fall prevention protects the hip, the wrist and the pelvis, whose risk is also doubled.5 It is a real benefit, on neighbouring targets, and it is better presented that way than over-interpreted.

Third: maintain the spinal extensors

This is the most specific line, and the most fragile in evidence. It rests on a prospective study by Sinaki carried out at the Mayo Clinic: 50 postmenopausal women followed for ten years after a two-year randomised trial, 27 of whom had performed progressive resistive strengthening of the spinal extensors. At ten years, the incidence of vertebral fracture was 1.6 % of the vertebral bodies examined in the exercise group against 4.3 % in the controls, a relative risk of 2.7 against the controls (p = 0.029). Extensor strength was still significantly higher eight years after the programme stopped.27

It is an encouraging result and it must be given its exact weight: fifty women, a single team, an outcome measured per vertebral body and not per patient, and observational follow-up after the randomised phase. This is not the demonstration that strengthening prevents fractures; it is the best signal available in favour of that hypothesis, and it has never been replicated on a large scale.

What are vertebroplasty and kyphoplasty really worth?

This is the subject on which it is most tempting to take a side, and the one where taking a side would be dishonest. Twenty years of trials have produced results that contradict one another, and the way they contradict one another is instructive.

The principle is simple: inject acrylic cement into the fractured vertebral body to stabilise it and relieve the pain. Kyphoplasty adds a balloon inflated before the injection, meant to restore part of the lost height. Both techniques are widely practised. Their evidence base is one of the most disputed in musculoskeletal medicine.

The story in five trials

2010, VERTOS II. Open-label Dutch and Belgian trial, 202 patients randomised, fractures less than six weeks old with oedema on MRI and pain of at least 5 out of 10. Vertebroplasty clearly beats conservative treatment: a difference of 2.6 points on the visual analogue scale at one month and 2.0 at one year, with no serious complication.18

But the trial contains a figure that its conclusions do not put forward and that deserves to be read: of the 431 eligible patients identified, 229, that is 53 %, saw their pain resolve spontaneously during the assessment phase, before randomisation.18 More than one patient in two got better on their own, within a few days. No open-label trial can separate the effect of the cement from that natural course plus the waiting.

2016, VAPOUR. Australian double-blind trial against a placebo procedure, 120 patients, restricted to fractures less than six weeks old with pain of at least 7 out of 10 and an optimised vertebral filling technique. Positive result: 44 % of treated patients against 21 % of controls had pain below 4 out of 10 at fourteen days (difference 23 percentage points, CI 6 to 39; p = 0.011).16

2018, VERTOS IV. Dutch double-blind trial against a sham procedure, 180 patients, acute fractures. Negative result: no statistically significant difference over twelve months of follow-up, not on pain, not on quality of life, not on disability, not on painkiller use, with both groups improving significantly.17

2018, the Cochrane review. Twenty-one trials, five of them against placebo. Verdict: high to moderate quality evidence that there is no important benefit on pain, disability, quality of life or treatment success. Mean pain was 5 out of 10 on placebo and improved by 0.7 points by vertebroplasty, against a minimal clinically important difference set at 15 %. The authors state that the subgroup analyses show no different effect according to the duration of pain, acute or subacute, and that the open-label trials comparing with usual care have probably overestimated the benefit.15

2023, VERTOS V. A change of ground: this time the fractures are chronic, pain for more than three months with persistent oedema on MRI, and the comparator is not a placebo but an anaesthetic injection. 80 patients. Positive but modest result: a difference of 1.3 points on the visual analogue scale at twelve months (CI 0.1 to 2.6), a significant difference on quality of life too, but not on disability.19

How to read this contradiction

Two readings compete, and neither is absurd.

The first: vertebroplasty does not work, and the positive trials are positive for reasons of method. That is the position of the Cochrane review. VERTOS II is open-label, therefore inflated by expectation; VAPOUR is small, single-centre for its main recruitment, and its outcome is a dichotomised threshold rather than a mean. Against placebo, across five trials, pain does not move in any clinically important way.15

The second: vertebroplasty does work, but for a population that the negative trials have diluted. That is the reading of the VAPOUR authors: fractures less than six weeks old in patients in severe pain, treated with sufficient filling, would be the target, and the negative trials would have included too many old or mildly painful fractures, in whom the natural course erases the difference.16 To which the Cochrane review replies that its subgroup analyses by duration of pain do not find that differential effect.15

A third element has been added recently, and it concerns the survival argument. Several observational studies had reported lower mortality after kyphoplasty. An analysis of 235,317 Medicare beneficiaries revisited the question with increasingly rigorous matching: the apparent advantage (hazard ratio 0.84) disappears and then reverses when matching is done on medical complications and on age and comorbidities, giving a hazard ratio of 1.32 and then 1.81 against kyphoplasty.20 The « survival gain » was an artefact of indication: the least ill patients were the ones being operated on.

And is kyphoplasty any better?

The direct comparison exists. A meta-analysis of sixteen studies compared balloon kyphoplasty with percutaneous vertebroplasty: kyphoplasty reduces the wedge angle (standardised mean difference 0.98; CI 0.40 to 1.57), restores more vertebral height and reduces the risk of cement leakage (relative risk 0.62; 0.47 to 0.80). But these radiographic gains do not translate clinically : no significant difference on the visual analogue pain scale or on the Oswestry Disability Index.21

It is a textbook case of the gap between a surrogate outcome and the outcome that matters. The vertebra is straighter, cement leakage less frequent, and the patient has neither less pain nor less difficulty. For the physiotherapist the practical consequence is simple: the technique used beforehand does not change the rehabilitation they go on to deliver.

Should a brace be prescribed after a vertebral fracture?

The spinal brace is one of the most intuitive and least demonstrated moves in this whole area of management. It is prescribed very widely; the literature that supports it would fit in a pocket.

The systematic review by Newman, Minns Lowe and Barker brought together twelve studies, eight randomised or randomised pilot trials and four non-randomised studies, totalling 626 participants. Its result deserves to be quoted as it stands: only three studies, covering 153 people, evaluated bracing after an acute vertebral fracture, and none was of high quality. The data are lacking to say that a brace changes vertebral deformity, and it is with rigid braces that complications were the most numerous.22

The review does find more favourable signals in the subacute phase and in prolonged rehabilitation, across nine studies and 473 participants: three of them suggest that a semi-rigid backpack-type thoracolumbar brace can improve strength, pain, posture and quality of life; one study finds a balance benefit with a weighted kyphosis-correcting orthosis. The authors conclude that these leads « should be explored in studies of sufficient size and quality, including men ».22

The useful question is not « is a brace needed », it is « what is this one for, for how long, and what will replace its effect when it comes off ».

That wording is what makes the debate workable. A brace worn for a few weeks to let a patient get upright and walk during the most painful phase does a job that nothing else does. A brace worn for six months « to hold the back up » installs dependence and deprives the extensors of the stimulus they need, at exactly the moment when the literature suggests their strength counts.27

Which rehabilitation, and what does the evidence say for each modality?

You have to start with the bad news, because it is structuring: physiotherapy after vertebral fracture has not demonstrated much. Knowing this changes the way it is delivered, not the decision to deliver it.

What the Cochrane review says

The 2019 update of the Cochrane review, by Gibbs and Giangregorio, brought together nine trials and 749 participants, 68 of them men. Its conclusions, in order:23

• Incident fractures : a single trial, no difference, very low quality evidence (relative risk 0.54; CI 0.17 to 1.71).23
• Falls : a single trial, no difference, very low quality evidence (1.06; 0.53 to 2.10).23
• Physical performance : this is the only moderate-quality result. The Timed Up and Go improves by 1.13 seconds (0.42 to 1.85), and the authors themselves write that a one-second gain is not a clinically important improvement.23
• Pain, self-reported function, quality of life : uncertainty, very low quality evidence, differences that are not clinically important.
• Adverse effects : three trials report four exercise-related events, one costal cartilage fracture, one rib fracture, one knee pain, one skin irritation under adhesive tape.23

The authors conclude that a high-quality trial is still needed, and give the required sample size calculation: about 2,500 untreated participants, or 4,400 on anti-osteoporotic treatment.23 No trial of that size has been conducted since.

PROVE, the largest trial in the field

The PROVE trial, run in Oxford, is the largest ever carried out in the physiotherapy of vertebral fracture: 615 adults with back pain, osteoporosis and at least one vertebral fracture, randomised into three arms, seven individual manual therapy sessions over twelve weeks, seven home exercise sessions, or a single education session.24

At twelve months, on the two primary outcomes, quality of life measured by the QUALEFFO-41 and extensor endurance measured by the timed loaded standing, no statistically significant difference between the three groups. The endurance gain was 9.8 seconds in the exercise arm, 13.6 seconds in the manual therapy arm and 4.2 seconds in the single-session arm, with confidence intervals crossing zero for exercise.24

Two secondary results deserve attention. At four months, significant differences did exist: endurance and balance in the manual therapy arm; endurance in those under 70, balance, mobility and walking in the exercise arm. And the authors write it in black and white: « adherence was problematic », and « the benefits at four months were not sustained », while concluding that « short-term benefits are likely to be valuable ».24

At the other end of the size spectrum, Bennell's pilot trial, run in Melbourne on twenty participants, is clearly positive: compared with a no-treatment group, ten weeks of individual physiotherapy and daily exercise reduce pain on movement by 1.8 points (CI 0.1 to 3.5) and at rest by 2.0 points, improve QUALEFFO function by 4.8 points and endurance measured by the timed loaded standing by 46.7 seconds (16.1 to 77.3). Nine of the eleven participants in the treated group rated their pain « much better » against one of nine in the controls.25

Twenty patients, a comparator with no intervention, no blinding possible on the experience of pain: this pilot does not demonstrate, it suggests. But the juxtaposition with PROVE is illuminating. Bennell compares physiotherapy with nothing ; PROVE compares seven sessions with one education session. That is not the same question, and the fact that PROVE is negative means that seven sessions do no better than one well-conducted session, not that physiotherapy is useless.

PROVE does not say that rehabilitation is useless. It says that one well-conducted education session does almost as well as seven sessions, which is information about dosage, not about principle.

The table of modalities

The levels in this table are an editorial judgement applying the GRADE principles, and not a published GRADE assessment. Two rows repeat certainty judgements made by the authors of the reviews cited (exercise and falls; physical performance); the others are derived from the number of studies, their size, their risk of bias and the consistency of the results. No formal GRADE assessment exists on the rehabilitation of osteoporotic vertebral fracture.

Should spinal flexion really be banned?

This is the most asked and the most poorly handled question. The answer comes in two steps that seem to contradict each other and do not: loaded flexion is to be avoided in the early phase, and generic lifelong bans are counterproductive.

Where the rule comes from

From a single study, published in 1984 in the Archives of Physical Medicine and Rehabilitation. Sinaki and Mikkelsen followed 59 women with postmenopausal spinal osteoporosis and back pain, allocated to four exercise programmes. After one to six years of follow-up with radiographs before and after, the new fractures or wedge deformities were distributed as follows:26

This chart has to be looked at with both eyes. On one side, the gap is spectacular and the statistical significance is there: 16 % against 89 %, p < 0.001.26 On the other, the flexion group had nine patients. A study of nine people normally founds nothing. Yet it founds a rule taught throughout the world for forty years, for three reasons: the effect is very large, it is consistent with the mechanics of the vertebral body, since flexion transfers the load onto the anterior column, precisely where the wedge compression happens, and above all no study has ever contradicted it, for the obvious reason that no ethics committee would today allow osteoporotic patients to be randomised to a flexion programme.

This is a case where the strongest evidence that will ever exist is weak evidence, and where waiting for it would be unreasonable. The practical conclusion is therefore: in the early phase, loaded spinal flexion is not taught and is not used as an exercise. That does not mean immobilising the patient in extension.

Where the rule becomes harmful

The international consensus Too Fit To Fracture, from a two-round Delphi process bringing together researchers and clinicians, is explicit on this point. Its key conclusions:28

• the physical activity recommendations for the general population suit osteoporotic people without a vertebral fracture, but not those who have one;
• after a vertebral fracture, moderate intensity is preferred to vigorous intensity ;
• daily balance training and endurance of the spinal extensors are recommended for everyone ;
• and above all: teach spine-sparing techniques (the hip hinge, which the authors give as their example) rather than issuing generic restrictions of the « do not carry anything over five kilos » or « never turn round » kind;
• with one important caveat: in patients carrying a vertebral fracture, a fortiori in the presence of pain, of multiple fractures or of hyperkyphosis, the risks of many activities may outweigh the benefits, and physiotherapy advice is then recommended.

The central argument of the consensus is that a list of bans produces a patient who no longer moves, and that a patient who no longer moves loses strength, balance and bone mass, that is to say the three things that were protecting them. The right answer is not to ban flexion: it is to teach picking an object up by bending the hips and knees rather than the spine, and to repeat it until it becomes the default movement.

A ban protects today's vertebra. A technique protects every vertebra of the next ten years, because the patient takes it away with them.

And what about high-intensity exercise?

The question has been open since the LIFTMOR trial, run in Australia in 101 postmenopausal women with low bone mass (T-score below −1.0), randomised between eight months of high-intensity resistance and impact training (five sets of five repetitions at more than 85 % of maximum, twice thirty minutes a week, supervised) and a low-intensity home programme. The results are clear in favour of high intensity: lumbar spine bone mineral density +2.9 % against −1.2 %, femoral neck +0.3 % against −1.9 %, cortical thickness, height, and every functional test. A single adverse event was reported.29

This trial has circulated widely as proof that « you can lift heavy even with osteoporosis ». It has to be read for what it is. LIFTMOR included women with low bone mass, selected and screened for conditions and treatments interfering with bone and physical function; this was not a population of women with a recent vertebral fracture. The training was supervised in a gym by professionals, not prescribed to be done alone. Nothing in this trial permits heavy loading of a vertebra that still shows marrow oedema on MRI.

What LIFTMOR does establish, on the other hand, deserves to be kept in mind: in a well-supervised osteopenic and osteoporotic population, high intensity did not produce the wave of fractures that traditional caution had led people to fear. That moves the marker of what is reasonable, not what to do in the acute phase.

What do published clinical cases teach us?

Four case reports, chosen because they show the four trajectories this diagnosis can take: the one that goes well, the one discovered too late, the one that turns around, and the one that begins as ordinary low back pain.

How does all this work in practice?

Everything above comes down to four decisions: thinking of the fracture, knowing when to stop, knowing what to do next, and not letting a patient leave when nobody is treating their bone.

The first appointment of an older patient with back pain

Nothing spectacular is being asked. Three minutes added to the history and two measurements are enough to change the probability.

1. Date the onset. Pain that began on a precise day, in someone over 65, does not have the same status as pain that has dragged on for ten years. « It started when I carried the shopping, three weeks ago » is information.
2. Look for corticosteroids. It is the most informative red flag in primary care, and patients almost never mention it spontaneously because they do not make the connection.89
3. Count the items of the Roman cluster. Age, no leg pain, BMI, physical inactivity, sex. Five questions, no equipment.10
4. Measure the wall-occiput distance, and if doubt persists the rib-pelvis distance. Thirty seconds and a wall.11
5. Ask for the height (the one on the driving licence, the one in the health record, the one the patient states), and compare it with the measured height. A documented loss of 3 cm or more justifies investigation; its absence rules out nothing.12
6. Percuss the spinous processes and note the exact level of any repeatable pain.

What you do, and when

The letter that changes something

This is the least technical and the most useful part. A letter to the general practitioner containing three precise lines does more than one extra session. What it must contain:

• What was observed, dated and measured: « thoracic pain of sudden onset on 12 March with no trauma, painful percussion over T11, wall-occiput distance 4 cm, reported height loss of 5 cm since the age of 60 ».
• The question asked : « does a lateral radiograph of the thoracolumbar spine seem indicated to you? »
• The position on the osteoporosis : « the patient reports never having had a bone density scan or any treatment for her bones. »

It is this third point that counts most over time. Three quarters of patients admitted for a fragility fracture leave with no treatment for the bone2, whereas the French recommendations provide for treating severe fractures35, and organising post-fracture pathways reduces the risk of refracture by about a third.7 The physiotherapist prescribes nothing. They can point out that something is missing.

Frequently asked questions

How long does a vertebral compression fracture take to heal?

There is no published standard time frame, and the round numbers in circulation deserve caution. What can be said from the data: in VERTOS II, 53 % of eligible patients saw their pain resolve spontaneously during the assessment phase, that is within a few days to a few weeks.18 The useful marker is therefore not a duration but a direction : the pain of a recent fracture should decrease. Pain that increases over the weeks raises the suspicion of non-union or of progressive collapse and calls for an opinion.33

Can the spine of an osteoporotic patient be manipulated?

Not until a recent fracture has been ruled out, and that is the cautious position this article supports. We should be honest about the nature of that recommendation: it does not rest on comparative trials, which do not exist and will not exist, but on mechanics and on potential severity. The reasoning is asymmetrical: the expected benefit of a manipulation on this terrain is modest, the cost of a mistake is one more vertebra.

My patient tells me their doctor has offered them a vertebroplasty. What do I say?

That the decision rests with the doctor, and that the literature is divided. Against placebo, the 2018 Cochrane review finds no clinically important benefit15 ; the VAPOUR trial, for its part, is positive but in very specific patients: a fracture less than six weeks old and pain of at least 7 out of 10.16 The question the patient can legitimately put to their doctor is: « am I in that situation? »

Should a corset be worn?

The evidence after an acute fracture is inconclusive, and it is with rigid braces that complications are most numerous.22 When a brace is prescribed, two questions must have an answer from day one: for how long, and what will take over. A brace that supports getting upright for three weeks has nothing to do with a brace worn for six months.

My patient is afraid to move. How should I answer?

By distinguishing what is risky from what is not, rather than by handing out a list of bans. That is exactly the position of the international consensus Too Fit To Fracture : provide spine-sparing techniques, the hip hinge for picking things up, the log roll for getting up, rather than generic restrictions of the « do not carry anything over five kilos » kind.28 The patient who knows how to do it moves; the patient who has been given a list stops.

Is height loss a good warning sign?

Good for confirming, bad for excluding. In 66,021 patients, a height loss of 3 cm has a specificity of 92 % but a sensitivity of 19 %; at 4 cm, specificity rises to 95 % and sensitivity falls to 14 %.12 In other words, a clear height loss justifies looking further, but the absence of height loss lets the great majority of fractures through.

Are men affected?

Yes, in a proportion that often comes as a surprise. The European EPOS study measures an incidence of 5.7 per 1,000 person-years in men against 10.7 in women: the ratio is about two to one.3 And the excess mortality after a clinical vertebral fracture is higher in men (standardised ratio 2.12) than in women (1.82).6 An older man with back pain should not receive any less vigilance.

Can exercise cause a fracture?

The available data are reassuring without being definitive. The 2019 Cochrane review reports four exercise-related adverse effects across nine trials and 749 participants: one costal cartilage fracture, one rib fracture, one knee pain, one skin irritation, and it rates the certainty of that information as very low.23 The LIFTMOR trial, with training at more than 85 % of maximum, reports only one adverse event in 101 women with low bone mass, but in a supervised setting and outside recent fracture.29

Where does walking fit into this picture?

It is indispensable for everything else (independence, morale, bowel function, preventing deconditioning), but it should not be credited with what it does not have. In the Cochrane review on fall prevention, the authors explicitly declare themselves uncertain as to the effect of programmes based mainly on walking, on dance or on strengthening alone; it is the balance and functional programmes, and the combined programmes, that carry the effect.30

Should imaging be repeated later on?

The question arises mainly if the pain does not follow the expected trajectory, or if a new episode occurs: the risk of a new vertebral fracture in the following year is 19.2 %4, which makes a new painful episode anything but trivial. It is a medical decision, but the physiotherapist is often the one who notices the change of trajectory and who has to flag it.

References

Thirty-five references, each resolved through its PubMed identifier and read before citation. The figures in the text point to the source that establishes them, at the place where they are written.

1. Schousboe JT. Epidemiology of vertebral fractures. J Clin Densitom 2016;19(1):8-22. DOI 10.1016/j.jocd.2015.08.004: PMID 26349789
2. Kelly MA, McCabe E, Bergin D, Kearns SR, McCabe JP, Armstrong C, Heaney F, Carey JJ. Osteoporotic vertebral fractures are common in hip fracture patients and are under-recognized. J Clin Densitom 2021;24(2):183-189. DOI 10.1016/j.jocd.2020.05.007: PMID 32546345
3. European Prospective Osteoporosis Study (EPOS) Group; Felsenberg D, Silman AJ, Lunt M et al. Incidence of vertebral fracture in Europe: results from the European Prospective Osteoporosis Study (EPOS). J Bone Miner Res 2002;17(4):716-724. DOI 10.1359/jbmr.2002.17.4.716: PMID 11918229
4. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285(3):320-323. DOI 10.1001/jama.285.3.320: PMID 11176842
5. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000;15(4):721-739. DOI 10.1359/jbmr.2000.15.4.721: PMID 10780864
6. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301(5):513-521. DOI 10.1001/jama.2009.50: PMID 19190316
7. Danazumi MS, Lightbody N, Dermody G. Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis. Osteoporos Int 2024;35(7):1133-1151. DOI 10.1007/s00198-024-07052-1: PMID 38536447
8. Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev 2023;8(8):CD014461. DOI 10.1002/14651858.CD014461.pub2: PMID 37615643
9. Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f7095. DOI 10.1136/bmj.f7095: PMID 24335669
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16. Clark W, Bird P, Gonski P, Diamond TH, Smerdely P, McNeil HP, Schlaphoff G, Bryant C, Barnes E, Gebski V. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2016;388(10052):1408-1416. DOI 10.1016/S0140-6736(16)31341-1: PMID 27544377
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24. Barker KL, Newman M, Stallard N, Leal J, Lowe CM, Javaid MK, Noufaily A, Hughes T, Smith D, Gandhi V, Cooper C, Lamb SE; PROVE trial group. Physiotherapy rehabilitation for osteoporotic vertebral fracture: a randomised controlled trial and economic evaluation (PROVE trial). Osteoporos Int 2020;31(2):277-289. DOI 10.1007/s00198-019-05133-0: PMID 31720722
25. Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, Larsen J, Wark J. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010;11:36. DOI 10.1186/1471-2474-11-36: PMID 20163739
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28. Giangregorio LM, McGill S, Wark JD, Laprade J, Heinonen A, Ashe MC, MacIntyre NJ, Cheung AM, Shipp K, Keller H, Jain R, Papaioannou A. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int 2015;26(3):891-910. DOI 10.1007/s00198-014-2881-4: PMID 25510579
29. Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res 2018;33(2):211-220. DOI 10.1002/jbmr.3284: PMID 28975661
30. Sherrington C, Fairhall N, Wallbank G, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb S. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med 2020;54(15):885-891. DOI 10.1136/bjsports-2019-101512: PMID 31792067
31. Papa JA. Conservative management of a lumbar compression fracture in an osteoporotic patient: a case report. J Can Chiropr Assoc 2012;56(1):29-39., PMID 22457539, PMC3280116
32. Massoud NA, Alashkar AH. When minor falls are overlooked in the elderly: a case report of vertebral compression fractures and chronic diaphragmatic hernia. Cureus 2026;18(3):e104527. DOI 10.7759/cureus.104527: PMID 41783551
33. Kuppan N, Muthu S, Parthasarathy S, Mohanen P. Strategies in the management of osteoporotic Kummell's disease. J Orthop Case Rep 2022;12(10):34-38. DOI 10.13107/jocr.2022.v12.i10.3356: PMID 36874888
34. Picazo DR, Villaescusa JR, Martínez EP, Pérez FD. Late collapse osteoporotic vertebral fracture in an elderly patient with neurological compromise. Eur Spine J 2014;23(12):2696-2702. DOI 10.1007/s00586-013-2751-3: PMID 23778750
35. Briot K, Roux C, Thomas T, Blain H, Buchon D, Chapurlat R, Debiais F, Feron JM, Gauvain JB, Guggenbuhl P, Legrand E, Lehr-Drylewicz AM, Lespessailles E, Tremollieres F, Weryha G, Cortet B. 2018 update of French recommendations on the management of postmenopausal osteoporosis. Joint Bone Spine 2018;85(5):519-530. DOI 10.1016/j.jbspin.2018.02.009: PMID 29654947