Don’t Break Your Back! Vertebral Fractures and How To Avoid Them

hello everyone Welcome to Spine Talks
I’m Dr Rita Roy CEO of the National
Spine Health Foundation and we are
delighted to bring you unparalleled
access to world-class experts like the
professionals who are joining me on the
panel today Today we’re going to be
talking about vertebral compression
fractures and prevention of fractures
And I’m going to start by introducing my
panelists Dr Paul Anderson from the
University of Wisconsin and Dr Laura
John Gregorio from Fragility Fracture
Network and the University of Wateroo in
Ontario Canada So I’m going to start out
today by asking Dr Anderson to give us a
background on what is a vertebral
compression fracture So this is a very
common injury In fact it’s the most
common fragility type fracture that we
see in older adults and it basically the
bone fails and instead of being shaped
like a rectangle it becomes much more
wedge-shaped Patient loses height and
also tends to bend forward slightly And
these fractures can cause considerable
pain and unfortunately also significant
disability especially when they’re acute
With treatment we do see recovery from
pain and improvement of function But
unfortunately many patients still have
loss of function after this fracture
That was a lot of information from Dr
Anderson about a fragility fracture in
the vertebral body Um that’s a a
vertebral compression fracture Fragility
Fracture Network is an organization that
focuses on these kinds of fractures What
does it mean to have a fragility
fracture Fragility fractures can cause
pain Uh they can also uh increase uh the
risk of disability and they can also
increase the risk of premature mortality
So we want to try to prevent fractures
uh to prevent that from happening So
we’re talking about fractures in your
back These are the bones of your back
your vertebral column And couple of big
concepts that come out as we begin to
think about why these fractures matter
As Dr Anderson mentioned um it’s a very
common occurrence for fractures to
happen bones to break in your
back When you break bones in your back
it can lead to as Dr John Gregorio said
an increased rate of mortality andor
loss of independence Um Dr Anderson
you’ve seen a lot of these cases and one
of the things that people worry the most
about is the limitations that they will
have in their life when they have a
vertebral fracture Can you share with us
some of that clinical experience Yeah So
one of the some of the consequences of
vertebral fractures are both
psychological and physical Some of the
psychological problems that we see is
patients begin to lose confidence in
their body They tend to start
restricting their activities which is
not really what we want in the uh in the
end we would like patients to resume
their lifestyle to the mo best
possibility possibility for them Uh so
the the psychological aspects is often
times overcoming this fear There’s a
concept called fear avoidance where
people really don’t do things because
they’re afraid they’re going to fracture
again in terms of performance or
function Uh it’s not uncommon for
patients not being able to take care of
themsel as well In other words do chores
around the house or those patients who
were still remain uh au active
athletically
uh we find that they aren’t quite as
good at uh being able to play tennis
nowadays pickle ball um or gardening and
other tasks that they’re used to doing
becomes much more difficult for them Uh
we do have ways to mitigate that and
that’s actually one of the major goals
of the treatment which we’ll talk about
is how to try to maintain your
independence in the future Mhm
One of the things that’s important to
talk about today is how you get one of
these fractures Where do they come from
How do people fracture their backs How
do you get a vertebral compression
fracture Dr Jean Gregorio can you talk
to us about who gets these fractures and
how they happen Yeah So a fracture
occurs when the load that’s applied to
bone is greater than the bone strength
So there’s two kind of things that
influence whether you’re going to
fracture your bone strength so how
strong your bones are and then the loads
that are applied to your bones So if as
we get uh older uh we lose bone and so
that can increase the risk So if you
have osteoporosis or low bone mineral
density um or low bone strength you can
that your fracture risk increase There’s
many other risk factors that can also
increase your risk of bone loss or a
factor of bone strength And then on the
other side of the equation the applied
load these are the the forces that are
applied to bone So the most common cause
of fractures generally um whether it be
hip fractures or wrist fractures but
even spine fractures is falls So uh
people who fall um say for example if
they fall backwards on their bum that
applies loads that can come up through
the spine and cause a fracture Um but
people can also fracture their spine um
if they’re lifting heavy furniture like
for example lifting a mattress uh while
trying to put sheets on the bed or uh
you know bending over to tie shoes if
your bones are really fragile um they
you you can actually cause a fracture So
it’s the forces uh on the bones that
increase the strength of the bones So
the weaker your bones are the less force
it takes to to actually break them So
that makes sense that people want to
think about maintaining their optimal
bone strength so that some of these
activities like changing a mattress or
low um low energy activities that
shouldn’t cause a fracture in a normal
person’s body can be avoided and there
are things that people can do to
maintain their bone strength over time
Uh you mentioned Dr Jean Gregorio that
people lose bone over time and they lose
bone strength as we age We only have up
until about age 30 to build our maximum
amount of bone and from that time on it
begins to decrease So we think about
bone mineral density we think about
conditions like osteopenia and
osteoporosis that can lead to a
situation where your bones are weaker
and you’re more likely to
fracture Dr Anderson you mentioned the
word treatment for these fractures Let’s
talk a little bit about treatment for
vertebral compression fractures Yeah I
first of all just like to emphasize to
people that only onethird of the
vertebral fractures actually are
clinical That means that they’re
associated with pain that’s persisting
persistent or with some type of
functional loss And it’s not uncommon
for physicians to image a patient either
through bone density tests or just other
imaging that might be for other reasons
and find that there was a previous
fracture and they may ask you about a
previous fracture and you don’t know
anything about it It may have had pain
for a short period of time but you don’t
even remember anymore You might go in to
get a chest X-ray if you think you have
bronchitis or pneumonia and uh oh
there’s a bone fracture in there Does
that This is a a common scenario and
answers your question about what are our
treatments Uh as a spine surgeon it’s
rare that we would ever want to operate
on this kind of uh fracture Mostly
patients are going to heal well and do
not need any type of spine surgeries The
one exception would be someone who’s
developing nerve compression because you
remember inside the spine is your spinal
cord and in the lower part of your back
are your nerveies that are going down
your leg And so sometimes people get
compression because the bone is pushing
on those nerves and that might require
surgery but that’s usually the only
indication and 99% of the patients are
going to be treated with nonoperative
means There is a newer technique that’s
been around now for two decades called
vertebrallasty where we put cement in
the vertebrae to stepping it up and
that’s incredibly uh good for relieving
patients who are having very severe pain
and can’t mobilize out of bed because
their back pain is so bad or for someone
who doesn’t get better over time We
would consider though that again the
concept here is it’s rare that you’re
going to need surgery for an osteoprotic
fracture Um but these other techniques
such as vertebrallasty is another
technique called
kypoplasty done very similar are both
indicated for the severe pain or when
someone doesn’t get to better but the
majority of patients are going to be
treated with non-operative means Edison
thank you for taking us through those
surgical treatment options for patients
with vertebral fractures Um but you’ve
also mentioned that a lot of these
patients don’t need to have surgery
Others have worked on guidelines um for
how to handle these kinds of fractures
Could you speak to some of that work
that’s been done Dr John Gregorio Yes it
worked with the fragility fracture
network to come up with guidance on
management of spine fractures And we
kind of think of it under sort of three
pillars So one being uh managing pain uh
the other being improving physical
function and then the third being
preventing future falls of fracture so
we don’t have more fractures or more
fall related injuries and so uh in pain
management there are options or
medications that people can take uh for
pain um and that would be decided on
with their physician Some people um can
get by with certain medication some
people other types of medication Um we
also recommend that people avoid uh
prolonged bed rest and avoid using
braces because that can actually promote
immobility which uh over time may not be
helpful Um and then we also encourage
people to um you know work with other
health professionals to develop
strategies to improve their physical
function And that might be for example
using an assisted device or um getting
occupational therapists to um you know
give them advice on how to do movement
safely or um get groceries or they might
need to get help with groceries for a
little while while they’re recovering Um
but the important thing about pain
management is also understanding that
you know yes you may have pain for a
while after a vertible fracture but it
should get better over time and if it
doesn’t then you want to go back to your
doctor to have a conversation about how
to better manage that pain Um but
understanding that that it will probably
get better over um because we we don’t
want to create sear and we don’t want to
create anxiety about that pain And then
um thinking back again to physical
functioning also trying strategies of
eventually having a plan to do an
exercise program to improve physical
functioning So to improve your balance
to improve your uh muscular strength to
work on the muscles that support your
spine and uh potentially improve your
posture Uh so that would be important
and you can work with a physical
therapist or an exercise physiologist to
design an exercise program or find
resources uh to support you in
developing an exercise program And then
the last pillar being sort of preventing
falls and fractures And um there’s many
strategies we can do with that We want
to ensure that people have adequate
nutrition and that means adequate
calcium adequate vitamin D as well as
adequate calories We want to avoid
weight loss because weight loss losing
weight means you’re losing muscle and
bone Um uh we and that can increase the
risk of fractures Um so getting adequate
calories calcium vitamin D as well as
other other nutrients uh and then um
medication for bone strength and then uh
other strategies for preventing falls So
I mentioned already assistant device use
but maybe even a home hazard assessment
to to reduce the risk of falls in your
environment And then finally an exercise
program to prevent falls um to get your
muscles stronger how we prevent future
fractures And when you talk about
assistive devices you’re talking about
things like a cane or or a walker things
that can help you tools that can help
you with ear balance to prevent um a
fall But it can also mean things like
for example if I want to avoid bending
over to get laundry out of a laundry uh
machine I could get a grabber tool right
And that can help me so that I’m not
flexing my spine and creating pain or a
grabber tool to help reach things
overhead for example or having um you
know a a stool uh in a bathtub so that I
can sit if I’m finding my back is
getting fatigued or having a grabber bar
that I can hold on to to uh get my
balance when I’m getting in and out of
the tub or getting out of the shower So
assistant devices are basically anything
that can um compensate for um an
impairment or fear or concern that you
have right Yeah And so because a lot of
these fractures can heal on their own
what time frame does that encompass
where a person should decide whether or
not they’re not getting better Is it 2
weeks Is it 3 months What what time
period And I know that’s that’s
different for each person but but
generally what would be that um time
frame that people should should think
about So a fractural often in theory
should heal in around 12 weeks Um but if
a person is experiencing severe pain or
severe functional impairment they should
really talk to their doctor because
there may be other options that they can
consider Um so we kind of encourage
people to sort of return to physical
activity as tolerated but maybe avoid
really heavy exertion or really heavy
lifting for 12 weeks because that’s
probably around the time that it’s going
to take for a fracture to heal But again
if they are experiencing severe pain or
severe uh problems with viewing their
everyday activities because of um
weakness or fatigue or uh pain then they
should really uh consult their doctor
about other options When a patient finds
out that they have a fracture in their
back a compression fracture in their
vertebrae there’s typically a reason why
that happens and it may be a sign that
there is a problem with their bone
density or problem with their bones And
when this happens um it’s important to
talk about why it occurred And as Dr
Anderson has discussed about surgical
treatments Dr Jean Gregorio has talked
us about non-surgical ways that those
fractures are handled We want to think
about what is the likelihood that
another fracture will occur of Dr
Anderson can you speak to us about what
the likelihood could is of you getting
another fracture in your back if you’ve
already had one Yeah So we’ve talked
about treatment and we really talked
about treating the fracture and how to
reh rehabilitate after that The next
thing comes up is should we treat the
underlying disease process And if a
patient has a fragility type vertebral
fracture you by definition have a
condition we call osteoporosis And
osteoporosis is just a thinning of the
bone making it more brittle and
resulting in greater likelihood of
sustaining fractures And unfortunately
once you sustained a fracture of the
spine or could be other bones your risk
for another one goes way up in specific
to the spine about 15% of those patients
are going to sustain a new fracture
somewhere in their body uh 15% of the
time So the chance of getting another
fracture within the first year after a
spine fracture is at least 15%
So one of the goals of treatment is
secondary fracture prevention And what
we’re mean by that is now let’s treat
the underlying disease And this can
occur concently with rehabbing from the
original fracture We can start the the
diagnosing of it making sure we
understand what the cause is and then
defining a treatment program And once
you have a spine fracture most of the
time you’re it’s going to be indicated
to have some type of pharmaceutical
treatment uh of your osteoporosis That
means medication for the osteoporosis
And I would say the medication is quite
effective if used and timed
appropriately Another risk is that the
timing of the next fracture occurs much
closer to the original one So we need to
get the medical treatment if we’re going
to do it on board fairly acutely We’re
not talking the next day or anything but
hopefully within four to six weeks that
kind of therapy would start Dr Anderson
thank you so much for helping us
understand when it is appropriate and
why it is appropriate to start
medication for treating the underlying
bone disease that can result in
fractures Um Dr Dr Jung Goyo can you
tell us some other techniques that um
patients are often advised uh to to
undergo to to help prevent more
fractures Yeah So I think one thing
that’s really important is to screen for
malnutrition and um and whether or not
they’re getting adequate healthy
immunity Um and if uh available a
referral to a dietitian if if that might
be an issue So if someone um uh is
experiencing malnutrition they should um
get some guidance on uh eating properly
eating enough calories eating enough
calcium uh vitamin D protein So that
would be an example The other thing
would be um a clinician or a physician
understanding kind of what resources are
available in terms of occupational
therapy physical therapy or community
program Patients can also become aware
of what’s available in their community
so that they can um find exercise
programs that meet their needs or uh
reach out to a exercise physiologist or
physical therapist for an exercise
program Um and there may be also
resources that can help get them
education on how to recover after a
spine fat So we do uh advise that people
avoid uh bed rest or lying in bed and we
avoid people use braces So we want to
encourage people to be as physically
active as they can or as their pain will
tolerate uh and and maybe get advice uh
from their healthcare provider from an
occupational therapist or physical
therapist or their physician about the
types of movements they might want to
modify or avoid So the types of
movements that are often considered
risky are those that involve bending
forward all the way uh or uh twisting
all the way like to the side or uh doing
bending or twisting rapidly or
repetitively or bending or twisting
while you’re lifting heavy weight Um so
uh maybe considering modifying some of
those activities or getting help with
some of those activities So Dr Sean
Gregorio what are some of the exercises
that people with vertebral fractures can
think about doing Yeah So many fractures
occur due to falls and that is true for
vertebral fractures and it’s really
important to talk to your health care
provider if you are having a fall
because there are things that you can do
and in fact there’s really strong
evidence that certain types of exercise
can prevent falls as well as doing
things like a home hazard assessment
where you have an occupational therapist
come into your home and and reduce risky
things So it’s really important to
communicate um if you are having falls
or you are concerned about falling so
that you can come up with a plan for
preventing falls So the types of
exercise that are effective for
preventing falls are exercise programs
that include um balance training and you
know functional strengthening exercises
and even Tai Chi So you can find a
community program that offers Tai Chi or
offers exercises that challenge your
balance and challenge your strength if
you prefer to go out into the community
and do exercise or you can uh talk to
your healthcare prom
uh give you an exercise program that you
can do at your home that will challenge
your uh balance or uh challenge your
strength or you can even find YouTube
videos that teach Taichi and you know uh
follow those as well So it’s it’s trying
to do exercises that um challenge your
balance So like for example you’re in a
position where you feel a little
unstable but you’re able to maintain
that position So you don’t want to do an
exercise that’s so difficult that’s
going to cause you to fall but it should
feel challenging to try to maintain your
balance And similarly when we’re trying
to challenge our strength we want to do
exercises that feel like work They feel
like they’re high effort so that we’re
challenging our muscles to get stronger
And so those are the types of exercises
usually that we recommend when we want
to try to prevent falls and potentially
try to prevent uh further bone loss and
further muscle loss and fractures Yeah
that’s fantastic And I think one of the
things about the community programs
that’s nice is is it can be motivating
because so much of what you’ve said is
that you need to do these exercises
They’re exercises you can do but they
don’t work if you don’t do them right
and and and many of them are are simple
things that don’t require um a gym or
fancy equipment There are simple things
you can do right at home Um and there
are resources uh that are available to
people to do them Yeah So I think a lot
of it is figuring out what’s available
to you in your community or what’s
available to you online that you have
access to You know osteoporosis Canada
develops uh lots of education materials
uh under our two foot to fracture web
page where we talk about the different
types of exercise that people can do Um
but I think it’s it’s really figuring
out what is um uh something that’s sort
of tailored to your ability So everybody
needs to kind of start where they’re at
So some people might start with an
easier exercise and some people might
start with a harder exercise but there’s
always a version that you can do uh to
start with and then uh progress over And
people should talk to their doctor about
what the right exercise is for them or
get a referral to an exercise
physiologist or a physical therapist or
at least start with something that they
feel comfortable with Right I want to
ask Dr Anderson this question about um
what you’ve seen in your clinic with
patients who are experiencing falls and
how they talk about that with you when
they come to see you Yeah So I I would
say it’s very important if you have had
a fall within the last six months you
should tell your physician about that
because there are many underlying
treatable modifiable processes that
could be going on uh that that can help
prevent another fall where you may
sustain a fracture So the first thing is
to disclose to the doctor who may not
ask you about how often you have had a
fall Uh that’s very important It it’s a
difficult discussion with patients They
tend to want to hide that they’re
falling They’re afraid to let see or
embarrass that they’re falling But don’t
be You need to let this let the
physician know This is going to help
empower you in taking control of your
life and trying to maintain your
independence For instance there’s a lot
of drug
uh interaction between different
medicines such as blood pressure
medicines
uh that can cause uh temporary low blood
pressure you pass out Uh people have a
poorly controlled diabetes You can get
low blood sugar that can cause you to
faint Uh so there are a lot of causes
that we can deal with but you have to
let the the physician know and then uh
assuming there aren’t any other
treatable causes uh based on your
medicals then you would be referred to
uh a therapy to go through this fall
prevention exercise program to try to
prevent it One thing you have to realize
is that your bones and your muscles are
very linked together and that if you
have osteoporosis you generally also
have uh weakened muscles Both the
muscles are atrophied In other words
there’s not as much muscle mass as there
used to be But even worse there’s often
times fatty substitution of the red
muscle uh with bad and that also
considerably weakens it And some of that
is reversible with exercise It’s a
little more difficult than actually
treating the ball which is actually a
little bit easier But you have to start
the conversation with a position about
falls how often you’ve had them uh and
whether they are harmful or not These
are big predictors of future falls and
future fractures I’d like to to talk a
little bit about um why having fractures
impacts your life your ability to live
independently and your ability to live
longer This has been an amazing
conversation with these worldclass
experts who are talking to us about
fractures in your back fractures in your
vertebrae and why they matter and what
to do about them Dr Anderson what are
your final comments and words of wisdom
for our audience today that you can
recover from this fracture Her aim or
goal would be to restore a functional
lifestyle for you What you you want to
do Uh secondly I want to reassure you
that
uh we do have treatments that are
effective in preventing additional
fractures and that is very important to
you not only for pain and uh your mor
morbidity uh from the fracture or
functional loss but also even mortality
So it’s really important for you to be
engaged with your providers that you’re
going to get some type of secondary
fracture prevention
Thank you Dr Changorio Final comments
Yeah I think it’s important to recognize
that having a fracture is a sign that
you’re at risk for future fractures So
um in the short term you want to have a
strategy to um support your recovery
reduce pain prevent any additional uh
weight loss or bone loss Uh and then in
the long term you want to have a
strategy to prevent future falls or
fractures and so and also prevent uh
disability So that might mean doing
things like um building muscle strength
improving your balance doing some
exercise um maybe thinking about um
changing your nutrition to support um
you know uh healthy aging as well as
considering medications for fracture
risk Yeah And I would add that the
medications
uh are very effective but they actually
work a lot better if you are also
exercising your muscoskeleton
uh because these drugs do act to a
greater degree give you more bone
density improvement when you’re
exercising So just being sedentary
um is not the best strategy We really
want people to get out and move and be
as active as they can be Well I want to
thank Dr John Gregorio and Dr Anderson
for joining us today to bring this
really important information to our
audience At the National Spine Health
Foundation one of the things we believe
in most is providing hope for recovery
and helping people find the tools to
advocate for themselves to be able to
get back to their lives and live life on
their own terms And the way that we do
that is by partnering with experts like
the the professionals who are joining me
today to give you this insight to help
you live your best life Thank you so
much for your time Thank you Dr Chung
Gregorio Thank you Dr Anderson