Physical Therapy Guide to Spinal Compression Fractures
A compression fracture in the spine occurs when the vertebrae (small cylinder-shaped bones) that form the spine collapse or break. The most common cause of spinal compression fractures is osteoporosis. Trauma (e.g., car or skiing accidents), infection, and cancer can also cause spinal fractures.
Both men and women over age 60 are at risk. Those who are at greater risk for spinal compression fractures include:
- Women over age 50 who are postmenopausal. This is due to hormonal changes.
- People with excessive kyphosis (rounded upper-back posture).
About 1.5 million spinal compression fractures occur each year in the U.S. due to osteoporosis. About 25% of women who are past menopause have had a spinal compression fracture due to weakening of the bones. Physical therapists help people with spinal compression fractures reduce their pain and improve their overall function.
What Are Spinal Compression Fractures?
Twenty-four bones, called vertebrae, make up the entire spine. There are seven cervical (neck) vertebrae, 12 thoracic (upper and middle back) vertebrae, and five lumbar (lower back) vertebrae.
A simple activity like bending to lift an object or twisting can cause a compression fracture. Even coughing, laughing, or sneezing can cause a compression fracture in someone with weakened bones. These small compression fractures can cause the spine to lose height and stability over time. Fractures can weaken the entire spine.
Compression fractures often cause the bone in the front of a vertebra to break down. The back portion of the vertebra remains solid. This frontal breakdown causes the upper spine to round forward. This rounded posture is a condition known as thoracic hyperkyphosis, or “dowager’s hump.”
A spinal compression fracture also may be caused by trauma to the spine. Events that may cause trauma to the spine can include:
- A car accident.
- A hard fall or a fall from a height of more than 15 feet, landing on the feet.
- A blow to the head.
Any fall from a standing height that results in a spinal compression fracture or any other fracture most likely indicates weak bones due to osteoporosis.
Physical therapy begins as soon as possible after the compression fracture is stable (as determined by a physician). Physical therapists help people with spinal compression fractures:
- Reduce their back pain.
- Improve their flexibility and strength.
- Improve their posture.
- Increase their overall function.
- Reduce their risk of falling to help lessen the chance of future fractures.
How Does It Feel?
The symptoms of a spinal compression fracture are often overlooked. They can be dismissed as common back pain that occurs with a muscle strain or with aging. About two-thirds of nontraumatic compression fractures of the spine go untreated. If you have a spinal compression fracture, you may experience:
- Back pain that occurs suddenly or worsens over time.
- Pain or numbness in the legs.
- Back pain that gets worse with standing and walking.
- Pain felt with coughing, sneezing, laughing, or breathing deeply.
- Back pain that improves with lying down.
- Pain and difficulty with bending or twisting.
- Tenderness over a specific area of the spine.
- A stooped-over posture.
- Loss of overall height.
In severe cases people with spinal compression fractures may have:
- Difficulty walking.
- Loss of bowel and/or bladder control.
- Inability to move the legs (paralysis).
How Is It Diagnosed?
A physician may order one or more tests to determine if a spinal compression fracture has occurred. They may include:
- Spinal X-rays.
- A special side-view X-ray (Vertebral Fracture Assessment).
- Bone density testing to measure the thickness of the bone.
- CT scan or MRI imagery (in severe traumatic cases).
How Can a Physical Therapist Help?
Your physical therapist will perform a complete evaluation. They will gather information about your past medical history, medications you may be taking, and your current symptoms. Your regular daily activities and exercise regimen will be discussed. Your physical therapist will use this information to design a treatment plan specific to your personal needs and goals.
When you experience a spinal compression fracture, it is very important to start physical therapy immediately. If you are in too much pain to travel to an outpatient clinic, you can receive home care or start physical therapy in the hospital. Your physical therapist will immediately teach you safety measures to protect your spine. This information can help prevent more fractures of nearby bones. If needed, they will also fit you for a brace for additional support.
Your physical therapist also will perform a physical examination of your spine. They may touch places along your spine to locate any areas of pain or tenderness, and check your spinal movements. They will test the strength in your spine, legs, and shoulders, and check your balance.
A compression fracture rarely requires surgery. In more severe cases, a surgeon may perform a procedure (vertebroplasty) injecting medical cement into the collapsed vertebra to give it support.
It may take weeks or months for a spinal compression fracture to heal. During the healing process, your doctor may recommend that you:
- Wear a back brace.
- Take bone-healing medications.
- Reduce your overall activity level for a short time.
- Avoid intense activities, depending on the severity of the fracture
While you heal and your activity is limited, muscles in the core, hips, and back can become weak. This weakness can make it difficult to resume your regular activities. It may also increase your risk for falls. It is important to help the muscles of the trunk and legs stay strong as you heal. Your physical therapist can help.
Your physical therapy treatment may include:
Pain reduction. Your physical therapist may use different treatments, technologies, and manual (hands-on) therapy to control and reduce your pain. These treatments can help you avoid the need for pain medications, including opioids.
Movement guidance. Your physical therapist will teach you what movements and exercises to gently perform, and not to perform. Avoiding certain movements will promote healing and help prevent future fractures or collapse of the vertebrae.
Flexibility exercises. Your physical therapist may teach you gentle spinal range-of-motion exercises for the neck, middle, and low back, and the hip and shoulder areas.
Strengthening exercises. Your physical therapist will prescribe gentle exercises to help stimulate your bone strength and straighten the curve of your middle back. These may include upper- and lower-body, stomach, and back muscle-strengthening activities.
Posture and spine sparing. Your physical therapist will teach you how to maintain safe posture and spinal positions. This will protect the vertebrae from undue stress when you sit, stand, walk – and even while you sleep. You also will learn proper ways to perform tasks at home, such as bending and lifting.
Fall prevention. Your physical therapist will teach you exercises to improve your balance and steady your walking to prevent falls. You may be instructed in the use of a walker or cane for temporary support as you recover. You may learn how to do gentle exercises on a variety of surfaces. You also will learn ways to make changes to your home to make it safer and reduce the risk of a fall.
Home-exercise program. Your physical therapist will design a personalized home-exercise program just for you. Continuing the program at home after you have completed your formal physical therapy sessions will help you stay strong and avoid further injury.
Can This Injury or Condition Be Prevented?
There are several ways to prevent spinal compression fractures. Physical therapists recommend that you:
- Maintain proper posture and body mechanics when performing activities of daily living.
- Avoid forward bending and deep or rapid twisting of the spine in daily activities and exercises. Your physical therapist will teach you the right movements and exercises to perform to help keep you safe.
- Reduce your risk of falls. Your physical therapist may recommend home modifications and balance exercises.
- Exercise regularly. Include weight-bearing activities, such as walking and using light weights.
- Stop smoking. It slows down the healing process.
- Keep alcohol consumption moderate, as it impairs balance.
- Eat a well-balanced diet to promote bone health.
- Take calcium and vitamin D supplements as recommended by your doctor or dietitian.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of spinal conditions and injuries. However, you may want to consider:
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or geriatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist who is experienced in treating people with spinal conditions and trauma. Some physical therapists have a practice with an orthopedic or geriatric focus.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have spinal conditions and injuries.
- During your first visit with the physical therapist, you will be asked to describe your symptoms in as much detail as possible, and say what makes your symptoms worse. Here are some tips to prepare for your visit.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of spinal compression fractures. Wendy Katzman, PT, DPTSc, is a world-renowned researcher on the topic of exercise for the stability and reduction of thoracic kyphosis. You will find several references below regarding her work. The other articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Katzman WB, Parimi N, Gladin A, et al. Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. BMC Musculoskelet Disord. 2017;18(1):509. Article Summary in PubMed.
US National Library of Medicine, Medline Plus. Compression fractures of the back. https://medlineplus.gov/ency/article/000443.htm. Updated July 9, 2018. Accessed January 21, 2020.
Katzman WB, Vittinghoff E, Lin F, et al. Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Osteoporos Int. 2017;28(10):2831-2841. Article Summary in PubMed.
Katzman WB, Vittinghoff E, Kado DM, et al. Study of hyperkyphosis, exercise and function (SHEAF) protocol of a randomized controlled trial of multimodal spine-strengthening exercise in older adults with hyperkyphosis. Phys Ther. 2016;96(3):371-381. Article Summary in PubMed.
Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil. 2014;95(1):129-140. Article Summary in PubMed.
Sinaki M. Exercise for patients with osteoporosis: management of vertebral compression fractures and trunk strengthening for fall prevention. PM R. 2012;4(11):882-888. Article Summary in PubMed.
Shipp KM, Gold DT, Pieper CF, Lyles KW. Improving trunk strength and endurance in older women with vertebral fractures. J Bone Miner Res. 2010;22:S463.
Pawlowsky SB, Hamel KA, Katzman WB. Stability of kyphosis, strength, and physical performance gains 1 year after a group exercise program in community-dwelling hyperkyphotic older women. Arch Phys Med Rehabil. 2009;90(2):358-361. Article Summary in PubMed.
Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA. Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil. 2007;88(2)192-199. Article Summary in PubMed.
Huang MH, Barrett-Connor E, Greendale GA, Kado DM. Hyperkyphotic posture and risk of future osteoporotic fractures: the Rancho Bernardo Study. J Bone Miner Res. 2006;21:419-423. Article Summary in PubMed.
Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine: current options and considerations for treatment. Spine J. 2006;6(5):479-487. Article Summary in PubMed.
Pfeifer M, Sinaki M, Geusens P, et al. Musculoskeletal rehabilitation in osteoporosis: a review. J Bone Miner Res. 2004;19(8):1208-1214. Article Summary in PubMed.
Old JL. Calvert M. Vertebral compression fractures in the elderly. Am Fam Physician. 2004;69(1):111-116. Article Summary in PubMed.
National Osteoporosis Foundation. Health Professional’s Guide to Rehabilitation of the Patient With Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2003.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Andrea Avruskin, PT, DPT. Revised and reviewed by Sherri R. Betz, PT, DPT, a certified exercise expert for aging adults and board-certified clinical specialist in geriatric physical therapy, on behalf of the Academy of Geriatric Physical Therapy and the Bone Health Special Interest Group.