After a vertebral compression fracture, what many patients ask first is not when they will heal but whether they can later bend over, carry things or hold a grandchild. Common advice goes to two extremes: either that bending is bound to cause trouble and is banned for life, or that nothing is wrong and the usual activities can carry on. Neither approach is correct.
Whether bending is safe for a patient with a compression fracture does not depend on "bending or not bending" alone but on four factors: excessive (bending all the way), repeated (bending again and again), sustained (staying bent for a long time) and loaded(lifting something heavy while bent). The more of these occur together, the more easily the front of the spinal bone (the anterior vertebral body) is compressed again. Rather than memorising a long list of prohibitions, learn one core movement: use a "hip hinge" instead of bending. Once this movement is mastered, nine in ten of the needs of daily life can already be met safely.
This distinction is not nit-picking. For a patient who has had one vertebral fracture, the chance of a new vertebral fracture in the following year is about 19.2%, far higher than in the general population (Lindsay et al. 2001). The more severe the baseline fracture, the higher the later risk too: the three-year new vertebral fracture rate rises from 10.5% for a mild one to 23.6% for a moderate one and 38.1% for a severe one (Delmas et al. 2003). One wrong effort in daily life can be the spark for the next vertebral fracture. During recovery, "knowing how to move" is therefore just as important as "which exercise to do".
Which bending movement is the most dangerous?
The same "bending" movement can be completely harmless or extremely dangerous, depending entirely on the four factors above. Dividing everyday movements by these four lines makes it easy to tell which habits must change and which can carry on as usual.
The clinical direction that "flexion is more dangerous than extension" is not a new finding. An old small study (n=59, 1984) already showed that the proportion with later fractures was clearly higher with flexion-based exercise than in the group doing mainly extension exercise (Sinaki & Mikkelsen 1984). The study is early and the sample small, but its direction of conclusion matches later clinical consensus. Drawing these lines, however, is not meant to make patients stop activity altogether. The international consensus on exercise for osteoporosis (Strong, Steady and Straight) states clearly that patients with vertebral fractures should still keep up weight-bearing, resistance and balance exercise, but must avoid uncontrolled repeated spinal flexion(Brooke-Wavell et al. 2022). In other words, the main direction is not "keep still" but "move in the right way". The debate between flexion and extension in the exercise prescription itself is covered in the article in this series on whether to do flexion or extension exercise after a compression fracture.
The hip hinge: bending at the hip instead of the waist
Avoiding high-risk flexion movements does not mean giving up all everyday activity near the floor. It only requires changing where the body folds. This core technique is called the hip hinge: the body folds at the hip joint and not at the lumbar spine, while the back stays straight and neutral throughout.
- Stand with the feet as wide apart as the shoulders, steady, and the knees slightly relaxed and not locked
- Move the buttocks backwards, folding back at the hip joint, imagining a chair behind and getting ready to sit down on it gently
- Keep the back straight throughout, and feel that the folding is at the hip and knees and not at the waist
- When the hands need to reach near the floor, bend the knees and squat down at the same time, and then stand up by the strength of the legs and buttocks
- When lifting an object, hold it close to the body and abdomen, and never straighten the arms to pick it up from far away
- Never twist the waist at any point. If you need to turn, move the feet and do not turn by twisting the spine
On a physiotherapist's home assessment, the most common situation is a patient who is quite careful but uses the wrong place to exert force. For example, when picking up a shopping bag from the floor, the patient keeps both knees fully straight and lifts by arching the back. Bent like this, all the force falls directly on the most fragile front of the vertebra. If the patient bends the hips and knees and squats down to pick it up, the load the same movement puts on the vertebra is very different. The hip hinge sounds simple, but making it a natural reaction through repeated practice usually needs a professional to watch and correct several times before the movement really becomes steady.
There is a detail in daily life that is easily overlooked: when coughing or sneezing hard, if the body bends forward with it, the pressure at that instant is concentrated on the front of the spinal bone (the anterior vertebral body). The right way is to support one hand on the thigh or table when coughing or sneezing and lean the upper body slightly back, and not forward. By the same principle, slow down when sitting, hold the armrests firmly with both hands, and avoid dropping suddenly into the chair, which puts sudden pressure on the spine.
How to do everyday movements, and how to improve them
Applying these principles to the everyday movements most common in Hong Kong homes makes the safety lines quite concrete. The movements in the left column can be done safely with a good hip hinge, while those in the right column must be done differently or left to family members.
- Washing the face, tying shoelaces: lean forward lightly, bending slightly at the hip, for a short time and with no load
- Picking up light things from the floor: squat down by bending hips and knees to pick them up, and not just arch the back
- Holding a grandchild: squat down first, bring the child close to the body and then stand up, and never bend over to hold the child from a distance
- Carrying shopping bags / moving flower pots: hold them close to the body and use the strength of the legs and buttocks; if too heavy, make several trips or ask family
- Bending while lifting a heavy load: excessive plus loaded flexion adds up and hurts the front of the vertebra most
- Housework done bent over for long periods: washing dishes bent over, scrubbing the bath, watering plants, so use a high stool or long-handled tools instead
- Repeated bending in a row: clearing a floor full of clutter in one go, building up load with each bend and rise
- Deep-flexion yoga postures: seated forward fold, standing toe touch pressing the chest towards the thighs
Flats in tenement buildings and public housing in Hong Kong are generally small, and the kitchen and bathroom worktops are often low, forcing residents to work bent over for a long time. This is the source of sustained flexion that is the easiest to overlook. Practical improvements include: sitting half-perched on a high stool when washing dishes, and using long-handled brooms and cleaning brushes; and using a height-adjustable clothes drying rack for hanging clothes, to avoid bending over each time to take things in and out of the washing machine. Raising the working surfaces at home by a notch is far more lasting and effective than memorising a list of prohibitions. As for yoga and stretching, the point is to screen out deep-flexion postures and keep extension-oriented movements, and it is best to have a physiotherapist check the list of movements once before a class.
Three principles for lifting objects
- Close to the body: the closer the object is to the body, the less pressure the front of the vertebra takes
- Bend the hips and knees: use the strength of the legs and buttocks, and never the strength of the lower back
- Do not twist the waist: when turning, move the feet and do not turn by twisting the spine
Three adjustments to the home environment
- Raise the working surface: make good use of high stools and long-handled tools to cut down on bending over
- Keep commonly used things at a height between the waist and shoulders: so there is no need to bend over or raise both arms each time to reach them
- Clear the floor to prevent falls: when the bone is fragile, a fall easily leads to another fracture
When should a physiotherapist be asked to help?
Body mechanics are easy to read about in words but not easy to do accurately, especially the hip hinge and lifting technique. Looking in a mirror alone, it is hard to notice whether the lower back is arching without being aware of it. If any of the following occurs, do not keep trying alone: new severe pain or a sudden worsening of existing pain, a sharp pain at one point of the spine during daily activity, a clearly deeper stoop, or lasting aching in the back after housework. The home physiotherapyprovided by Nova Health's registered physiotherapists can assess the patient's stage of fracture recovery at home, demonstrate and correct the hip hinge and lifting techniques on the spot, and then draw up an improvement plan to suit the real layout of the home (such as the height of the kitchen worktop and the design of the bathroom and stairs), so that the patient can cope with daily living and protect the vertebra well.
One last point: mastering body mechanics is only one part of rehabilitation after a compression fracture. To keep the spine stable over the long term, regular back extensor strengthening and posture training are still needed. To learn how to build an exercise habit safely at home, see the article on a home exercise programme for compression fractures. For the overall direction of conservative rehabilitation, return to the overview of physiotherapy for spinal compression fractures.