26.1 Introduction

VCFs due to osteoporosis are associated with pain, loss of function, impaired quality of life, and increased morbidity and mortality. ^{1 – 4} Multiple studies published over the past decades have provided insight into the population-level morbidity associated with VCF in the United States. ⁵ These include large reviews of the Nationwide Inpatient Sample, reviews of data from the Centers for Medicare and Medicaid Services, and data from the American College of Surgeons National Surgical Quality Improvement Program database. ^{6 – 10} These investigations have identified significant rates of deep vein thrombosis (0.7–6.6%), pulmonary embolism (0.4–1.9%), pneumonia (3.1–13.0%), and decubitus ulcers (1.1–4.4%), regardless of treatment type. Most of these complications are in part a result of prolonged periods of bed rest. Thus, the importance of mobilizing the patient is paramount and must not be overlooked.

The goals of management with vertebroplasty and balloon kyphoplasty are pain control, prevention of spinal deformity, and functional restoration. Vertebral augmentation reduces pain without reliance on narcotics alone, allowing for early and increased mobility. ^{11 , 12} It has been shown to reduce morbidity and mortality compared with conservative care. ^{1 , 6} Management does not cease here, as the patient still needs to improve strength, correct posture, and enhance balance to increase independence and prevent further progression. This is accomplished through physical therapy and rehabilitation.

26.2 Rehabilitation as Part of Routine Anti-Osteoporosis Care

The protective effects of stronger back muscles on the spine has been highlighted as necessary in a guideline on the management of osteoporosis and postmenopausal women at risk for osteoporosis. ¹³ Several studies have demonstrated that physical exercise programs maintain spine and hip bone mineral density (BMD) as well as decrease the frequency of falls. ^{14 – 16} Recent consensus guidelines recommend that individuals with vertebral osteoporosis should engage in a multicomponent exercise program that includes progressive resistance training, in combination with mobility and balance training, and guidance on safe movements. ^{15 , 17 , 18} High-risk individuals benefit from improved muscle strength in the back, legs, upper arms and core, and enhanced posture, balance, and coordination. ¹⁹ Exercises for lower extremity muscles should focus on every major group around each joint. Back strengthening and postural exercises will reduce forward head posture, improve shoulder range of motion and trunk stability, and reduce vertebral fractures over time. ²⁰ Elbow extensor strength also facilitates transfers by moving the body with their arms and is related to reduced risk of nursing home admission after hip fracture. ²¹

If an exercise program is to be prescribed for patients with spinal osteoporosis, a cautious approach is recommended. Regular weight-bearing exercise (e.g., walking 30–40 minutes per session, plus back and posture exercises for a few minutes, 3–4 days per week) should be advocated throughout life. ^{20 , 22 – 24} Extension or isometric back and abdominal strengthening exercises seem most appropriate. ²⁵ Fig. 26.1 demonstrates these exercises.

Not all types of exercise are appropriate for these patients because of the fragility of their vertebrae. Potential risks of prescribed exercise and preventive strategies are summarized in Table 26.1. Exercises that place flexion forces on the vertebrae tend to cause an increased number of vertebral fractures in these patients. Excess weight and side bending exercises similarly need to be avoided. Yoga exercises have become a concern due to the extreme spinal flexions performed, including several patients in whom VCFs developed as a direct result of participating in this activity. ²⁶ Similarly, rowing, lifting weights with a flexed spine, bowling, sit-ups, house and yard work must also be avoided due to increased risk of vertebral wedge fractures. ^{17 , 18} Additionally, high-impact activities and exercises that require rapid and/or loaded twisting, and explosive or abrupt actions, such as golf and racquet sports, are contraindicated for high-risk individuals.

Prolonged aerobic training, such as swimming and cycling, is beneficial to cardiovascular health but does not provide a stimulus to bone growth. Regular walking has also been shown in two meta-analyses as a single intervention having minimal or no effect on BMD in the lumbar spine. ^{27 , 28} Trials have also found that prescription of fast or brisk walking programs may actually increase the rate of falls. ²⁹ The inclusion of walking training may not be a crucial feature of program design and therefore recommend that walking training be included in a program as long as it is not at the expense of balance training. ³⁰ The addition of a weighted vest would seem to add a missing component to walking as an intervention; however, a study did not find significant improvement in strength, physical function, bone turn-over, or health-related quality of life. ³¹ Thus, despite the benefits of aerobic fitness, walking is insufficient to optimize bone health, has little or no effect on balance, and may increase risk of falls.

Studies on early postmenopausal women have shown that strength training leads to small yet significant changes in BMD. A meta-analysis of 16 trials including 699 subjects showed a 2% improvement in lumbar spine BMD in the group that exercised compared with the group that did not. ¹⁴ Effects of exercise on BMD are modest, but a meta-analysis estimated that exercise reduces the 20-year risk of osteoporotic fracture in the lumbar spine by 10%. ¹⁵ One study of the effect of strengthening exercises for back extensor muscles in healthy postmenopausal women demonstrated a significant increase in back extensor muscle strength and improvement of posture with reduction in kyphosis without association with BMD. ³² Others depicted improvement in muscle strength and BMD of the lumbar spine in estrogen-deficient women. ^{18 , 33}

Subject compliance with prescribed exercise interventions presents a challenge. In 2- to 3-year controlled, randomized studies, the dropout rate was 34 to 41% in the exercise groups. ^{29 , 34} Subjects who are not self-motivated may not continue with prescribed exercise programs. Sinaki et al ²⁰ looked at the long-term protective effect of stronger back muscles on the spine in 50 healthy white postmenopausal women, aged 58 to 75 years, 8 years after they had completed a 2-year randomized, controlled trial. In the trial, 27 subjects had performed progressive, resistive back-strengthening exercises for 2 years and 23 had served as controls. BMD, spine radiographs, back extensor strength, biochemical marker values, and level of physical activity were obtained for all subjects at baseline, at 2 years, and at 10 years. The difference in BMD, which was not significant between the two groups at baseline and 2-year follow-up, was significant at the 10-year follow-up. They also found that the relative risk for compression fracture was 2.7 times greater in the control group than in the back-exercise group at 10 years. This emphasizes the importance of life-long adherence to an exercise program.