An older person falls, or only bends over to pick something up, and is in so much pain that the back cannot be straightened. The X-ray then confirms a vertebral compression fracture. The first two questions many families put to the doctor are: “Do we need to buy a corset or back brace to wear?” and “Does the patient have to stay in bed for a while?” Instinct says a fracture should naturally be immobilised and rested, but in managing a vertebral compression fracture, neither instinct is entirely right.
First, a core principle: the role of a brace is to support and ease pain, and it is not the treatment for the fracture itself. Where pain can be controlled, getting active safely and early is also better than long bed rest. A recent systematic review of braces for stable vertebral fractures found that short-term wearing tends to help stabilise the spine and reduce worsening of the kyphosis angle, but because the studies differ greatly and are of mixed quality, there is no one-size-fits-all answer to whether to wear one, which type and for how long (Kweh et al. 2021). Below is a practical framework to help the family, the doctor and the physiotherapist work through these questions together.
Factors in deciding whether to wear a back brace
A brace is not an item where wearing one is always good and not wearing one always bad. It is a supporting tool that has a cost of its own. Whether it is worth wearing depends mainly on the following points, and a brace should not be bought at once on diagnosis of a fracture.
In other words, the value of a brace is to help the older person through the most painful stage and resume activity early, and not to speed up healing of the fracture or to prevent the next one. What really lowers the risk of refracture is back extensor strengthening and posture correction, which also explains why choosing the right direction of exercise matters so much. A classic study found that the group doing forward bending (flexion) exercise had a refracture rate as high as 89%, whereas the group doing back extension exercise had a refracture rate of only 16% (Sinaki & Mikkelsen 1984, an early small study, n=59, whose direction is still worth noting).
The different roles of a brace and exercise training
Many people see a brace and exercise as an either-or choice, but the targets they address are quite different, and the best approach is for them to work together and not replace each other.
- Deals with the moment: supports and eases pain in the acute painful period, so the patient can sit up and resume activity early
- Short-term wearing tends to help stabilise and reduce worsening of kyphosis (mixed evidence and quality, Kweh et al. 2021)
- Long-term reliance on a rigid brace has a cost: the trunk muscles weaken
- A transitional tool that does not reduce the risk of the next fracture
- Deals with the long term: back extensor strengthening, posture correction, balance and falls prevention
- Refracture 89% in the flexion exercise group and 16% in the extension group (Sinaki & Mikkelsen 1984, n=59)
- The more it is done, the stronger the patient, and it is the key to holding the spine upright and breaking the fracture cascade
- International consensus: people with vertebral fractures should still exercise (Brooke-Wavell et al. 2022)
The point is not to choose between wearing a brace and exercising. It is to use the brace to help the patient through the most painful stage so that exercise can begin earlier. After that, reliance on the brace should be reduced slowly and replaced by the patient’s own muscles and exercise for support. While the brace is worn, safe back extension and isometric exercises should be done, and the patient should not stay completely still because a brace is on.
Arranging how long to wear a brace and how long to rest in bed
Behind these two questions is the same principle: trade the shortest period of immobilisation and rest for the earliest possible start of safe activity. The direction of treatment is to move from protection to activity as soon as possible, and the longer the immobilisation or bed rest, the safer it is not.
How long to wear the brace
- Common practice: wear the brace as an aid in the first few weeks, when the pain is worst
- As the pain eases, slowly shorten the time the brace is worn each day
- The aim is to stop using it early, and it should not be worn indefinitely
- How long it needs to be worn differs from person to person and is adjusted by the doctor according to recovery progress
How long to stay in bed
- The number of days that really need complete rest in bed is usually very short
- Once pain is under control, the patient should start practising sitting at the bedside and getting out of bed slowly
- Long bed rest speeds up loss of bone and muscle, and does more harm than good
- Safe isometric exercises and posture improvement can already be done in the acute phase
The attitude of lying a bit longer and wearing it a bit longer for peace of mind is not advisable. Long bed rest speeds up the loss of bone and muscle, makes the spine more fragile and makes the next fracture more likely. In fact, in a person who has had one vertebral fracture, the cumulative risk of a new vertebral fracture in the following year is already as high as 19.2% (Lindsay et al. 2001). In other words, too much rest not only gives no protection but raises the risk of refracture. Getting active early and taking good measures against falls is real protection. Older people with cognitive impairment or an unsteady gait especially need good fall prevention, because a fall is often the trigger for the next fracture.
Many older people in Hong Kong live in old tenement buildings or small flats, with the bed against the wall and narrow corridors, so in the acute painful period how to get out of bed safely is often more pressing than whether to wear a brace. Going from lying to sitting and then from sitting to standing, a wrong effort can hurt so much that the patient dares not move again, and the less the body is moved, the weaker it gets. This transfer is best demonstrated once in person by a professional beside the older person’s own bed. If private physiotherapy cannot be arranged for the time being, the family can ask the ward physiotherapy department at discharge for a safe transfer and exercise guide, or the family doctor can refer the patient to the physiotherapy service of the Hospital Authority. In the community, the family can also contact the nearest District Elderly Community Centre (call the Social Welfare Department hotline 2343 2255 to find out which centre covers the area) to learn about resources for rehabilitation and fall prevention.
Some traps in the acute painful period where more protection does more harm, and avoiding them makes things go much better:
- Not moving at all because a brace is on—If the patient does not move at all, muscle is lost, and once the brace comes off the spine is actually more fragile. So while a brace is worn, safe exercise should be done all the more.
- Staying in bed all the time because of pain—Long bed rest does more harm than good. As soon as pain is controlled, the patient should start practising sitting at the bedside and getting out of bed.
- Wearing a rigid brace for a long time for peace of mind—If the muscles of the back are held up by an outside object for a long time, they weaken, and it becomes harder later to hold the spine upright. So there must be a plan for stopping the brace gradually.
- Buying a brace and wearing it without advice—If the type, tightness or method of wearing the brace is wrong, it is not only of no use but may even do harm, so it should be guided by a professional.
When to decide the next step and ask a therapist for help
Whether to wear a brace, for how long and how long to stay in bed must in the end return to the actual situation of this fracture, including the level of pain, whether the fracture is stable, whether there are neurological symptoms, and the home environment and the older person’s own ability to move. These decisions should not be made on the strength of information online or a neighbour’s experience. In any of the following situations the family should no longer grope along alone: a recent fall or clearly unsteady gait, pain that keeps getting worse at rest or on activity, numbness or weakness in both legs or loss of control of urine or stool (which may be red-flag signs of nerve compression), or pain and mobility that show no improvement after a period of wearing a brace and resting in bed.
In actual home assessments, the most common situation is that the family has already bought a corset but its method and timing of wear are not right. Some wear it upside down, some tie it so loosely that it gives no support at all, and more believe that wearing a corset is the same as having treatment, so for several weeks in a row not a single back extension exercise is done, and the back muscles waste away day by day. The home physiotherapy provided by Nova Health’s registered physiotherapists assesses the patient’s level of pain, the pattern of the fracture and the home environment in full, helps the patient and the doctor to find a sense of proportion between wearing a brace and resuming activity, demonstrates on the spot how to get out of bed, turn and extend the back safely, and teaches caregivers the right techniques for supporting the patient, so that a clear and workable route of rehabilitation is set between protecting the spine and resuming activity. Whether surgery is needed is a professional decision for the orthopaedic doctor. But whichever treatment is finally chosen, the basics of getting up and turning correctly and retraining the back muscles are an essential part.