Just after a compression fracture, even turning over is painful in the acute pain stage. What many older people and carers most want to know is what can be done at home. They want to be active but fear doing the wrong movement, and want to rest more but have heard that long bed rest is not advisable. The standard answer is in fact not a fixed list of exercises but depends on which stage the older person is at. The content of training in the severe pain stage and in the stage when the person can already walk alone is quite different.
The core principle first: home rehabilitation for a compression fracture is a staged process that progresses level by level, and the direction of movement must be led by "backward extension" and not forward bending. A classic study found that the group of patients doing flexion (forward bending) exercise had a new fracture rate as high as 89%, against only 16% in the group doing extension exercise (Sinaki et al. 1984, an early small sample of n=59, whose direction is still useful as a reference). The key to a home programme is therefore to do movements in the right direction for the stage the patient is at and to raise the load step by step, and not to lie in bed resting all the time or train the core muscles blindly. The sections below start by working out "which stage the patient is at now".
Judging the present stage of recovery from symptoms
The first step in deciding what exercise to do at home and how much is to work out which stage of recovery the patient is in. The same movement can do harm if forced in the severe pain stage but is just right in the strengthening stage. The criterion is therefore not "how many days since the fracture" but the current level of pain and physical ability.
To judge accurately which stage the patient is in and when to move to the next, the safest approach is an on-site assessment by a physiotherapist. Going too fast brings on pain, and going too slowly wastes the period of recovery when bones and muscles respond best. To understand the biomechanics behind "extending backwards is safe and bending forwards is high-risk", first see the key differences between extension and flexion exercise after a compression fracture.
Home exercises in the four stages
The framework of the programme below needs no gym equipment, and at home only a sturdy chair and a small stretch of wall are needed. Each stage first sets out the core points and then describes the specific movements. Remember that the order of progression is posture and breathing as the base, then training the back extensors, and only last adding balance and weight-bearing training.
- 1Severe pain stage: safe movement + isometric groundworkThe patient first learns to roll onto the side (log roll) to get up and get out of bed, and to stand up by the strength of the legs and avoid bending over. Lying flat or sitting, the patient can gently tighten the transversus abdominis and buttock muscles (isometric contraction) while breathing deeply and slowly. Hold for a few seconds each time and repeat a few times a day, which stops the muscles stiffening and blood circulation slowing without increasing pain. Note that no forward bending movement of any kind may be done at this stage.
- 2Recovery stage: waking the back extensors + posture correctionThe patient can sit up straight leaning on the back of the chair and do light back extension, that is, lifting the chest and squeezing the shoulder blades back. The patient can also stand against a wall to improve a head and shoulders-forward posture. Weight-bearing practice using body weight can be added at this stage: hold a chair steady with both hands, sit down slowly and stand up again. Keep the range of movement small and the repetitions few, and the most basic rule is that it must not cause sharp pain.
- 3Strengthening stage: back extensor resistance + balance challengeThe patient can lie face down or sit to do back extensor resistance training, using a resistance band or a water bottle to add resistance. For balance, start by standing steadily with the feet together, then progress slowly to standing with one foot in front of the other, and then standing on one leg holding a chair. Sit-to-stand can be made harder too, going from holding the chair with both hands to standing up without using the hands. This stage is an important period for rebuilding the bones' ability to take load and improving the stooped posture.
- 4Maintenance stage: progressive weight bearing for the long termThe patient can fit strengthening exercise into a fixed weekly schedule and add weight step by step, for example wall squats, standing heel raises, and weight-bearing walking carrying a bag of rice. The load must be raised step by step. For the same movement, increase the repetitions first and only raise the resistance once the body has adapted, and never jump several levels at once. The aim is to maintain bone density and muscle strength over the long term and prevent the next vertebral fracture.
This four-pillar framework of "posture, back extensors, balance and progressive weight bearing" has not been put together at random. A UK consensus on exercise for osteoporosis called Strong, Steady and Straight states that weight-bearing, resistance and balance training are at the core of managing osteoporosis, and stresses that even patients who have had a spinal fracture should keep exercising, and only need to avoid uncontrolled repeated flexion movements (Brooke-Wavell et al. 2022). In other words, the point of a home rehabilitation programme is not "being so careful that the patient never moves" but "choosing the right direction and raising the load level by level".
The emphasis of the four core types of training at different stages
- Posture correction: mainly practising standing against a wall, lifting the chest and squeezing the shoulder blades together. This practice is kept up through the whole of rehabilitation and is not limited to one stage.
- Back extensor training: strengthened step by step with the stage of recovery, starting with isometric tightening of the muscle, then light back extension, and finally adding resistance training.
- Balance training: starts from standing with the feet together and progresses step by step to standing with one foot in front of the other and standing on one leg holding a chair. Doing fall prevention training well helps prevent the next fracture.
- Progressive weight-bearing training: the load is raised level by level, first practising with body weight, then adding a resistance band or water bottle, and finally progressing to weight-bearing walking.
Using everyday objects at home to help with exercise
- A sturdy chair with a back: mainly used to practise sit-to-stand and back extension.
- A wall: used to practise standing against the wall to correct posture, and wall squats.
- A water bottle or a bag of rice: can stand in for dumbbells in resistance and weight-bearing training.
- A resistance band (not essential): can be used to add resistance to back extensor training.
Indicators for adjusting the amount of exercise, and warning signs to stop
The most dangerous thing in exercising at home is often not "not knowing how to do it" but "not being clear when to stop and when to do more". The practical self-check indicators below show that if any of them is crossed, a physiotherapist or doctor should be asked for help, and the patient should not push through.
- Sharp pain after exercise gets worse and lasts for more than one to two hours, or is bad enough to interfere with sleep
- New numbness or weakness in both legs, or loss of bladder or bowel control, which may be a warning sign of nerve compression
- A clear new loss of height, or the stoop clearly deepening, which may mean a new vertebral fracture
- Repeated sharp stabbing pain, and not ordinary muscle soreness, during back extension or weight-bearing exercise
- A recent fall, or clear unsteadiness when standing and walking together with great fear of falling
By contrast, positive indicators that it is safe to increase the load level by level include: no pain at rest or in daily activity, being able to sit or stand for 20 minutes continuously without tiring, and being able to complete the target repetitions without triggering sharp pain (only slight muscle soreness is normal). Once these conditions are met, the repetitions can be increased or the resistance raised in the order above. To get everyday movements such as getting out of bed, carrying things and bending over right as well, see everyday body mechanics and the movements to avoid after a compression fracture, which combines targeted exercise with the right everyday posture, so the two work together.
When is a therapist's help needed?If it is unclear which stage of recovery the older person is at, back extension hurts as soon as it is tried, or there has been no progress after practising for some time, the patient should stop working it out alone and adjusting the exercise by trial and error. Nova Health's registered physiotherapists can visit the home, assess directly the stage and physical ability of the older person using the bed, chairs and furniture heights actually used at home. The therapist demonstrates safe back extensor and weight-bearing movements on the spot, adjusts them step by step according to the older person's pain response and progress, and guides carers on how to help from beside the patient, so that the older person can exercise at home safely and steadily.
One last point on living conditions in Hong Kong: many older people live in small flats or even alone, and the home may have no space for standard rehabilitation equipment. In a home rehabilitation exercise assessment, the most common difficulty is that the older person does not dare to move for fear of pain, while family members do not dare to support the older person for fear of causing injury, so that the person ends up in bed all day, losing both muscle and bone. In fact, with a sturdy dining chair and a stretch of wall, together with proper staged guidance, the whole rehabilitation programme can be completed at home. For local community support, the Hong Kong osteoporosis society (香港骨質疏鬆學會) (tel. 2527 8898) can be called for information on fracture rehabilitation. In the public system, the patient can ask the doctor for a referral to physiotherapy at the Hospital Authority orthopaedic follow-up appointment. To learn about the overall strategy for preventing the next fracture (covering osteoporosis medication and fall prevention coordination), see the article on how to prevent the next vertebral fracture after a compression fracture.