Physiotherapy Management of Osteoporosis
Core Principle: Multidisciplinary Coordination Within Fracture Liaison Services
Physiotherapy for osteoporosis must be integrated into a structured Fracture Liaison Service (FLS) model, which is the most effective organizational approach for secondary fracture prevention, improving appropriate management rates from 26% to 45% within 6 months post-fracture. 1
The physiotherapist functions as part of a coordinated team under supervision of an orthopaedic surgeon, endocrinologist, or rheumatologist, with a dedicated coordinator (often a specialized nurse) managing the overall care pathway. 1
Immediate Post-Fracture Phase (Days 1-14)
Avoid Prolonged Bed Rest
- Begin gentle range-of-motion exercises within the first few days to prevent accelerated bone loss, muscle weakness, deep venous thrombosis, and pressure ulcers. 2
- Prolonged immobilization is contraindicated as it worsens outcomes and increases comorbidity risk. 2
Early Mobilization Protocol
- Initiate early finger motion for distal radius fractures immediately after casting or surgery to prevent edema and stiffness. 1
- For shoulder fractures, begin range-of-motion exercises including shoulder, elbow, wrist, and hand motion within the first postoperative days, restricting above-chest activities until fracture healing is evident. 1
- Focus on maintaining mobility while avoiding activities that increase spinal flexion in vertebral fractures. 2
Rehabilitation Goals and Phases
Primary Objectives
The most critical aim is regaining pre-fracture mobility and independence levels, requiring early identification of individual patient goals before developing the rehabilitation plan. 1
Three-Phase Approach for Vertebral Fractures
- Phase 1 (Acute): Achieve bone union and avoid complications 3
- Phase 2 (Subacute): Increase physical fitness and teach proper, safe everyday activities 3
- Phase 3 (Maintenance): Improve and maintain skills learned in previous phases 3
Exercise Prescription
Muscle Strengthening and Balance Training
Implement early postfracture physical training focusing on muscle strengthening combined with balance training, which reduces fall frequency by approximately 20% and is essential for both early recovery and long-term fracture prevention. 1, 2
Weight-Bearing Exercise
- Prescribe 30 minutes of weight-bearing exercise (jogging or walking) at least 3 days per week to improve bone mineral density. 1
- High-impact activities should be encouraged in younger patients to maximize peak bone mass. 4
- In older adults with established osteoporosis, structured weight-training and weight-bearing exercise conserve bone mass while reducing fall risk. 4
Evidence Limitations
A Cochrane Review found inconclusive results for exercise interventions specifically in vertebral fracture patients, with only moderate evidence for improvement in walking speed, highlighting the need for individualized assessment. 1
Fall Prevention Strategies
Comprehensive Assessment
Evaluate fall risk starting with history of falls during the past year, followed by specific functional tests when indicated. 1
Multidimensional Interventions
Implement long-term continuation of balance training and multidimensional fall prevention programs, which are critical components alongside early physical training. 1
Patient Education Components
Essential Teaching Points
- Educate about osteoporosis burden, fracture risk factors, medication adherence importance, and expected treatment duration. 2
- Provide instruction on adequate calcium intake (1000-1200 mg/day) and vitamin D (800 IU/day), which reduces non-vertebral fractures by 15-20% and falls by 20%. 1, 2
- Emphasize smoking cessation and alcohol limitation, as these negatively affect bone mineral density, bone quality, and fall risk. 1, 2
Activity Modification
Teach safe performance of activities of daily living to prevent subsequent fractures, with specific attention to avoiding spinal flexion in vertebral fracture patients. 3
Pain Management Support
Non-Pharmacological Approaches
Physiotherapy assists with passive, active-assisted, and active therapies to reduce pain and increase mobility following osteoporotic fractures. 5
Functional Restoration
The goal after distal radius fracture is restoring normal hand function and preventing complications from limb immobilization through aggressive finger and hand motion once immobilization is discontinued. 1, 3
Monitoring and Follow-Up
Systematic Assessment
Regular monitoring for treatment tolerance and adherence should be established as part of systematic follow-up within the FLS model. 2
Reassessment Timing
Fracture risk should be reassessed every 1-3 years with repeat DXA scanning, with earlier reassessment (within 1 year) for patients with fragility fracture history. 2
Special Considerations for Frail Elderly
Orthogeriatric Approach
An orthogeriatric and multidisciplinary approach is warranted for frail elderly patients with major fractures, particularly hip or pelvic insufficiency fractures. 1
Comorbidity Management
Optimal care in preoperative, operative, and postoperative phases significantly affects clinical outcomes, as limited mobility and poor quality of life postoperatively associate with elevated future fracture risk. 1
Critical Pitfalls to Avoid
- Never allow prolonged immobilization – this accelerates bone loss and increases complications 2
- Never delay early mobilization – begin range-of-motion exercises within days, not weeks 1, 2
- Never ignore uninjured joints – maintain motion in all non-immobilized areas to prevent stiffness 1
- Never prescribe exercise in isolation – physiotherapy must be integrated with pharmacological treatment (bisphosphonates reduce vertebral fractures by 47-48%) and calcium/vitamin D supplementation 2
- Never overlook fall risk assessment – this is mandatory for all patients over 50 with fragility fractures 1