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MusculoskeletalMay 16, 2022

Physiotherapists' guidance is needed when people with vertebral fractures start exercise regimes

People with osteoporosis should not be afraid to exercise regularly, according a consensus statement appearing in the latest issue of the British Journal of Sports Medicine.

But, while exercise may help people with vertebral fractures to feel less pain, and improve their mobility and quality of life, it should, ideally, be accompanied by guidance from a physiotherapist to ensure correct posture and encourage a return to normal activities. 

Katherine Brooke-Wavell from the National Centre for Sport and Exercise Medicine at Loughborough University is listed as the first of the paper’s authors, with physiotherapists Susanne Arnold, Karen Barker and Julie Whitney being named as three of the 12 co-authors.

Dr Arnold is a research fellow at the University of Warwick who also represented AGILE, the Chartered Society of Physiotherapy professional network for those working with older people. Karen Barker is based at the Nuffield Orthopaedic Centre, University of Oxford, while Julie Whitney is based at the department of physiotherapy at King’s College London.

Photo Credit: Shutterstock
Scottish dancing is one of the examples of impact exercise flagged up in the statement

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Royal Osteoporosis Society endorsement

The paper urges people with osteoporosis to follow regimes that include carrying out muscle strengthening exercises on two or three days a week. These exercises should be supplemented by brief bursts of moderate impact activities – such as jogging, aerobics or Zumba – on most days of the week.

The advice for those who already have a vertebral fracture, or who are frail/elderly, is to include lower impact exercise up to the level of brisk walking for 20 minutes every day.

The paper is based on the findings of a multidisciplinary expert panel that reviewed the existing evidence and drew on a wide range of expert clinical and patient opinion. Panel members reached agreement on recommendations designed to maximise the bone health of people with osteoporosis while minimising their fracture risk.

An estimated 137 million women and 21 million men have osteoporosis, with this prevalence expected to double within the next 40 years.

The consensus statement, which was endorsed by the Royal Osteoporosis Society, includes the following recommendations (summarised below):

  • progressive resistance training and impact exercise involving major muscle groups to maximise bone strength
  • resistance training ideally uses resistance machines or weights, building up gradually to heavy loads (the maximum that can be lifted from eight to 12 times). If this isn’t an option, circuit training; rowing; Pilates or yoga; stair climbing; sit-to-stands; heavy housework, gardening, DIY may be good muscle-strengthening alternatives
  • running, jumping, aerobics, Scottish dancing/Zumba and many ball games are examples of impact exercise 
  • activities to improve strength and balance to reduce fall risk, such as Tai chi, Pilates, and yoga; referral to recognised falls prevention programmes
  • spinal extension exercises to improve posture and potentially curb the risk of falls and vertebral fractures (examples are available from this site: https://theros.org.uk)
  • avoid postures involving a high degree of forwards bending of the spine, such as toe touches, curl-ups, or picking up heavy objects without bending at the knees and hips
  • for people with previous fractures, including of the vertebrae, or who are frail/elderly, exercise only up to an impact equivalent to brisk walking 
  • for those at risk of falls, start with targeted strength and balance training
  • breathing and pelvic floor exercises can help ease symptoms that may be worsened by severe curvature of the spine (spinal kyphosis)

Advice for clinicians

People with vertebral fractures may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with advice from a physiotherapist [Katherine Brooke-Wavell et al.]

Physical activity and exercise have a key role in promoting bone strength, reducing falls risk, and managing vertebral fracture symptoms, so should be part of a broad approach that includes other lifestyle changes – adequate calcium and vitamin D intake, not smoking, and cutting down on alcohol intake – combined with drug treatment, where appropriate. 

Health professionals should avoid restricting physical activity or exercise according to bone mineral density or fracture thresholds as this may put people off exercising. Those with painful vertebral fractures need clear and prompt guidance on how to adapt movements involved in day-to-day living. 

Katherine Brooke-Wavell and her co-authors conclude: ‘People with vertebral fractures may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with advice from a physiotherapist.

‘Most importantly, inactivity should be avoided, physical activity encouraged and reassurance provided to counter the fear of moving that could detrimentally affect bone strength and health/quality of life more broadly.’

Dawn Skelton, from the school of health and life sciences at Glasgow Caledonian University, chaired the expert panel. To coincide with the paper’s publication, she said: ‘Anyone who is new to regular physical activity or who is worried about their technique or unsure how to build their fitness, can seek advice from any trained exercise instructor.

Professor Skelton added: 'Those with a history of falls or serious concerns about their balance can contact their local falls service.'

To see the full version of the consensus statement, titled Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis, visit: https://bjsm.bmj.com/lookup/doi/10.1136/bjsports-2021-104634

Author: Ian A McMillan
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