Physical Therapy in Compression Fractures
Direct Recommendation
The evidence does not support mandatory physical therapy or supervised exercise programs for osteoporotic vertebral compression fractures, as current guidelines find insufficient data to recommend for or against these interventions. 1
Evidence Quality and Limitations
The American Academy of Orthopaedic Surgeons (AAOS) explicitly states an inconclusive recommendation regarding supervised or unsupervised exercise programs for neurologically intact patients with osteoporotic spinal compression fractures. 1 This inconclusive stance stems from:
- Only one Level II study examining home-based exercise programs, which was downgraded due to uncertainty about whether low back pain was directly attributable to the compression fracture itself 1
- The study showed some benefit in symptom and emotional domains at 6-12 months, but no improvement in physical function at either timepoint 1
- Activities of daily living showed benefit only at 12 months, not at 6 months 1
Clinical Approach to Physical Therapy
When Physical Therapy May Be Considered
Physical therapy can be incorporated as part of conservative management after the acute pain phase, typically combined with pain medications and bracing, though this represents standard practice rather than evidence-based mandate. 2, 3
Timing Considerations
- Acute phase (first 4 weeks): Focus on pain control with calcitonin and analgesics rather than aggressive physical therapy 4
- Subacute phase (4-12 weeks): Most vertebral compression fractures show gradual pain improvement during this period without specific interventions 5
- Chronic phase (>3 months): If conservative management including physical therapy fails, consider vertebral augmentation procedures 4, 5
What Physical Therapy Should NOT Include
Electrical stimulation lacks evidence for benefit - one Level I study found insufficient power to detect differences in pain relief or quality of life for chronic vertebral compression fractures treated with electrical stimulation. 1
Critical Red Flags Requiring Immediate Surgical Referral (NOT Physical Therapy)
- Any neurological deficits - requires immediate orthopedic or neurosurgical consultation 4
- Spinal instability on imaging - requires immediate surgical evaluation 4
- Spinal cord compression - requires urgent surgical decompression 6
- Progressive kyphosis or significant spinal deformity - refer to surgery 4
Conservative Management Algorithm
For neurologically intact patients with stable compression fractures:
- Initial 4 weeks: Calcitonin for pain, analgesics as needed, relative rest (not strict bed rest, as no evidence supports bed rest) 1, 4
- 4-6 week reassessment: Evaluate response to treatment 4
- If improving: Continue conservative approach with gradual mobilization; physical therapy may be added empirically though not evidence-mandated 2, 3
- If worsening at 3 months: Consider vertebral augmentation (kyphoplasty preferred over vertebroplasty) 4, 5
Important Caveats
- Bracing evidence is also inconclusive - only one Level II study exists, with unclear generalizability 1
- Vertebroplasty is strongly recommended AGAINST by AAOS based on Level I evidence showing no benefit over sham procedure 1
- Pathologic fractures must be ruled out with MRI, especially in patients with known malignancy or atypical presentations 4, 5
- The natural history is generally favorable - most patients improve over 2-12 weeks regardless of specific interventions 5
Bottom Line for Clinical Practice
Physical therapy is neither strongly recommended nor contraindicated for compression fractures. 1 When used, it should be part of a multimodal conservative approach after ruling out surgical indications, with realistic expectations that evidence for its specific benefit is lacking. 2, 3 The priority is identifying patients who need surgical intervention and managing pain appropriately while allowing natural healing to occur. 6, 4, 5