Osteoporos Int (2008) 19:895–903 DOI 10.1007/s00198-007-0530-x
REVIEW
Back pain in osteoporotic vertebral fractures R. M. Francis & T. J. Aspray & G. Hide & A. M. Sutcliffe & P. Wilkinson
Received: 1 August 2007 / Accepted: 9 November 2007 / Published online: 11 December 2007 # International Osteoporosis Foundation and National Osteoporosis Foundation 2007
Abstract Summary This review article examines the epidemiology and pathogenesis of back pain and vertebral fractures in osteoporosis, reviewing the management of pain in patients with vertebral fractures and the direct and indirect effect of osteoporosis treatments on back pain. Introduction The management of patients with vertebral fractures has largely concentrated on the prevention of further fractures by the treatment of underlying osteoporosis, with drug treatment for acute and chronic back pain and the non-pharmacological management of vertebral fractures receiving less attention. Discussion Emerging evidence suggests that, in addition to reducing the incidence of vertebral fractures, calcitonin, intravenous bisphosphonates and teriparatide may also have a direct effect on bone pain. Targeted analgesia, tailored to individual need is often required in both the
acute and chronic phases following vertebral fracture. Vertebroplasty and kyphoplasty have also been approved for use in the management of vertebral fractures and may prove useful in selected patients unresponsive to conventional pain relief. There is some evidence to support the use of individualised tailored exercise programmes aimed at strengthening back muscles to maintain bone density and reduce further fracture incidence. In addition the use of specific orthoses may help to reduce kyphosis, improve mobility and reduce pain. Conclusion Chronic back pain associated with vertebral fracture provides a great challenge to health care professionals and the patient. This demands a combination of options, including not only therapeutic interventions, but also physiotherapy, psychological support and patient education. Keywords Back pain . Exercise . Osteoporosis . Pain management . Spinal orthoses . Vertebral fractures
R. M. Francis School of Clinical Medical Sciences, University of Newcastle, Newcastle upon Tyne, UK T. J. Aspray Sunderland Royal Hospital, Sunderland, UK G. Hide Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK R. M. Francis (*) : A. M. Sutcliffe Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK e-mail:
[email protected] P. Wilkinson Pain Management Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
Introduction Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing a person to an increased risk of fracture [1]. Although vertebral fracture is the commonest fracture seen in patients with osteoporosis, only a third come to medical attention [2]. Even in symptomatic patients with back pain, the diagnosis of vertebral fractures is not always readily apparent. In a study of 1,042 patients with lower back pain unresponsive to conservative treatment examined using magnetic resonance imaging (MRI), 82 had osteoporotic vertebral fractures, of which 51 were recent and 31 had normal marrow signal indicating that they were old fractures [3]. Symptomatic
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vertebral fractures are associated with acute back pain, but chronic back pain may result from the associated skeletal deformity, joint incongruity and tension on muscles and tendons. Back pain in osteoporosis may also be due to other conditions, such as spondylosis, disc disease and skeletal metastases. The present article examines the epidemiology and pathogenesis of back pain and vertebral fractures in osteoporosis, reviews the management of pain in patients with vertebral fractures and the direct and indirect effect of osteoporosis treatments on back pain. Relevant papers were identified by the authors, all of whom are experts in their different specialties, supplemented by the use of Medline and Pubmed literature searches.
Epidemiology of vertebral fractures
Fig. 1 The incidence of morphometric vertebral fractures in men and women. Figure drawn from data from the European Prospective Osteoporosis Study [5], with kind permission of the corresponding author and Springer Science and Business Media
Incidence/1000 person years
Musculoskeletal pain is common, with a Swedish study reporting an overall prevalence of 10–20%, with a higher prevalence in women than men [4]. Back pain (23%) was more common than shoulder (21%) or limb pain (16%). Nevertheless, the prevalence of back pain due to vertebral fracture is unknown. Vertebral fractures coming to medical attention are commonly described as clinical or symptomatic, whereas vertebral deformation identified radiographically is generally termed a morphometric fracture. The incidence of morphometric vertebral fractures approximately doubles in women every ten years, from less than 5/1,000 person years at age 50 to about 25/1,000 person years by the late 70s [5]. In men, the incidence also increases with age, but at a slower rate (Fig. 1). The overall prevalence of morphometric vertebral fractures in European men and women is 12% [6]. The prevalence is greater among middle-aged men (10%) than women (5%), but the converse is true after the age of 65 years, such that the prevalence in the eighth decade is 20–25% in women and 15–20% in men [6]. The
lifetime risk of a clinical vertebral fracture at the age of 50 years is 3.1% for women and 1.2% for men [7]. Clinical vertebral fractures are associated with substantial morbidity, causing back pain, kyphosis, loss of height and impaired quality of life [8]. In a study of men with symptomatic vertebral fractures, participants experienced more sleep disturbance, greater emotional problems and poorer mobility than age-matched male control subjects [9]. Patients with clinical vertebral fractures visit their primary care physician 14 times more often than control subjects in the year following a fracture [10]. In a study of women with either clinical or morphometric vertebral fractures, the relative risk of back pain and limitation of activity increased with the number of vertebral fractures [11]. Separate analyses of clinical and morphometric fractures showed similar relationships with pain and fracture risk, indicating that morphometric vertebral fractures cause substantial problems [11]. There is also an increased mortality associated with vertebral fractures, but this may be due to coexisting conditions associated with osteoporosis, rather than the fracture itself [12]. Data from the Study of Osteoporotic Fractures in the US show that mortality increases with the number of vertebral fractures [13]. In 1998 it was estimated that osteoporotic fractures cost £942 million annually in the UK, of which only £12 million was due to the acute cost of vertebral fractures [10]. The social and economic cost of vertebral fractures may be substantially higher than this, because of the associated long-term morbidity. Previous vertebral fracture increases the risk of further vertebral fractures and hip fracture [14, 15]. An incident vertebral fracture is associated with a 20% risk of further vertebral fracture in the next year [15]. Early intervention with treatments for osteoporosis may, therefore, prevent further vertebral fractures and the associated back pain.
30 25 20 Women Men
15 10 5 0 50-54
55-59
60-64
65-69
Age (Years)
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75-79
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Pathogenesis of back pain associated with vertebral fractures Back pain may arise directly from vertebral fracture or indirectly from the consequences of spinal deformity, secondary degenerative change and disc disease. In addition to changes to the vertebrae and annulae, back pain may also be derived from impact on associated muscles, posterior ligaments and facet joints. Nerve root compression may cause additional pain in the buttocks and legs. Vertebral fractures associated with osteoporosis rarely cause spinal cord compression, as this was demonstrated in only 2% of a series of 497 older patients admitted with acute vertebral fractures [16]. The manifestation of back pain is variable, as not all patients are affected and some experience more severe pain than others. Relatively little information has been published about the nature of pain associated with vertebral fracture. In a series of 210 patients with acute back pain associated with vertebral fracture, two groups were identified [17]. In the first group, severe pain was associated with obvious vertebral wedging and lasted for four to eight weeks. In the second group, the fracture was not readily apparent initially, but wedging developed over the next few months. Back pain was less severe and shorter-lived, but was followed by a second painful event 6–16 weeks later, with this pattern being repeated for 6– 18 months.
Imaging in patients with osteoporosis and back pain X-rays remain the main investigation to demonstrate vertebral fractures and may be sufficient in many cases. However some vertebral fractures are difficult to visualise on a plain X-ray, because bone anatomy is complex and there may be no visible break or displacement. Examples include sacral stress fracture and early vertebral fracture with central endplate depression. In such cases alternative methods of imaging may be appropriate. There is also a risk that pain associated with vertebral fracture may be wrongly attributed to another cause. Furthermore, when a patient with vertebral fracture does not experience a reduction in pain despite appropriate treatment, alternative methods of imaging may help to identify other causes of back pain, such as skeletal metastases. An isotope bone scan is very sensitive, but while refinements of this technique can offer more detailed imaging, isolated uptake of the isotope is not diagnostically specific, because it identifies both pathological and degenerative changes. However, widespread skeletal metastases and sacral stress fractures are associated with characteristic patterns, such as the ‘Honda’ sign in the latter. One of the advantages of isotope bone scanning is that imaging of the
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whole skeleton can be carried out without additional radiation exposure. It is important to appreciate that osteoporotic vertebral fractures are associated with increased uptake on isotope bone scan, which usually persists for over a year [18]. MRI is capable of imaging bone marrow oedema, which may help to identify early vertebral fractures. Routine spine MRI scan protocols do not include the oedema sensitive short tau inversion recovery (STIR) sequence and hence may not detect early fractures. It is, therefore, helpful to make imaging staff aware of the suspected diagnosis, so that a STIR sequence is included in the procedure. MRI is considered the most accurate imaging modality overall and offers greater diagnostic confidence than an isotope bone scan. Often the diagnosis of osteoporotic fracture is not suspected and a patient’s back pain raises concern about skeletal metastases. Radiologists must maintain an index of suspicion for osteoporotic fractures to avoid misinterpreting sacral stress fractures as metastases on routine lumbar spine MRI examinations. Computerised tomography (CT) is less useful for providing information about functional defects in bone. It may be a useful problem-solving measure to clarify the diagnosis in the event of uncertainty following an isotope bone scan. Imaging should be carried out at an early stage, because the clinical value of the scan declines as the patient's condition improves. Although open access to all imaging modalities is the ideal, there are currently insufficient resources in the UK and many other countries to meet such demand.
Management of back pain Acute pain Although an episode of acute back pain in patients with documented osteoporosis is likely to be due to vertebral fracture, other causes may be excluded by the use of appropriate imaging techniques. Guidelines for the initial management of acute back pain recommend reassurance, physical therapies, non-opioid analgesia and exercise, before referral to secondary care [19]. Analgesics are usually prescribed in accordance with the principles of the World Health Organization (WHO) analgesic ladder [20]. Strong opioids are likely only to be considered where there is severe pain from a vertebral fracture, but the concomitant use of aperients may prevent the development of constipation. Chronic pain Identifying the causes and nature of chronic back pain is a complex process. Pain may be due to factors other than
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nociceptive input triggered by ongoing tissue damage. Neuroplastic changes are now recognised, with damaged nerves becoming “mini-pacemakers”, with signals amplified locally and centrally by neural and humoral mechanisms. Pain is more than “an unpleasant sensory sensation”, but an emotional experience linked to beliefs, behaviours defined within a social context. The development of chronic back pain after vertebral fracture may be influenced by these physical and behavioural changes. Muscle spasm, guarded movement and fear of increased pain may all lead to physical deconditioning and disability. The main determinants of the development of chronic back pain are psychosocial factors, including low mood, anxiety, catastrophic coping, poor physical health, previous physical abuse and passive coping [21–24]. This provides the rationale for using a biopsychosocial model in the management of chronic pain [25] (Fig. 2). Treatment should aim to reduce pain intensity, anxiety, emotional overlay and depression. Other objectives include reducing disability, improving sleep, optimising social function and supporting family members. Patients’ confidence in medical care may be reduced if osteoporosis is offered as an explanation of the cause of pain, without demonstration of fracture or other skeletal deformity. Furthermore, if patients perceive that they have a “weak” spine, they may develop avoidance behaviours that become maladaptive, leading to disuse and disability. The effectiveness of options for the long-term management of chronic back pain [26–39] is summarised in Table 1. The choice of drug treatment depends on the nature of the pain and the patient’s age, physical and mental health, with options including paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and centrally-acting agents, such as amitriptyline. There is also evidence that long-term treatment with a strong opioid is safe and effective [32].
Treatment failure Injury Pain
(Culture) (Spirituality) (Gender)
Focus +
Guarded movement and muscle spasm
Frustration, anxiety,anger Depression/ Learned Helplessness
Fear-avoidance Reduced physical activity
Family
Misattributions
Decreased participation (work, social, family)
Physical deconditioning
Fig. 2 Model of chronic pain. Adapted from Spanswick and Main [25]
Approaches to the management of back pain in osteoporosis Few studies have explored the impact of pain and its management on the life of women with osteoporosis. A study of postmenopausal women with vertebral fracture suggested that constant pain, coping with pain treatment and the perceived lack of control had a severe impact on the women’s ability to perform daily activities [40]. The authors suggested that intervention programmes incorporating education, pain management and techniques to reduce stress and isolation may increase self care ability in these women [40]. The association between new vertebral fractures, back pain and functional limitations was explored in another study, which indicated that time after fracture is an important determinant of quality of life [41]. The authors suggested that the teaching of coping strategies is an important measure in the management of osteoporotic pain. The need for psychological support with respect to pain control has also been highlighted in other studies [42, 43]. A small pilot study suggested that participating in an Osteoporotic Pain Program (OPP) helped patients to express their individual pain experiences, led to an improved understanding of their condition, reduced the intensity of pain and created greater levels of self efficacy [43]. Further research is needed to evaluate the effect of a structured pain programme as an integral part of the management of back pain in patients with osteoporosis.
Osteoporosis treatments in patients with vertebral fractures and back pain Treatments such as hormone replacement therapy, raloxifene, bisphosphonates, strontium ranelate, teriparatide and calcitonin may decrease back pain by reducing the risk of vertebral fractures, but calcitonin, intravenous bisphosphonates, teriparatide and alfacalcidol, may also have a direct effect on bone pain in patients with vertebral fractures. Calcitonin Calcitonin has been used to treat bone pain associated with acute vertebral fracture, Paget’s disease of bone, skeletal malignancy and other pain of musculoskeletal origin. In two small randomised double-blind placebo-controlled trials, calcitonin 100–200 IU significantly relieved pain and improved early mobility in patients admitted with vertebral crush fracture [44, 45]. A recent systematic review identified five randomised double-blind placebo-controlled trials involving a total of 246 patients with acute pain due to recent osteoporotic vertebral fracture [46]. Calcitonin significantly reduced pain, with onset of effect in the first
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Table 1 Evidence for the effectiveness of interventions for back pain in general Intervention
Evidence of benefit
References/Comments
Acupuncture
Trials with greater validity were more likely to have negative outcomes Acupuncture superior to control interventions (NNT=13), but insufficient evidence of superiority over placebo Might be effective for short-term relief of lower back pain
Systematic review of 13 randomised controlled trials [26] Meta-analysis of 9 randomised controlled trials [27]
Non-steroidal anti-inflammatory drugs (NSAIDs) Capsaicin
Tricyclic antidepressants (TCA) and selective serotonergic inhibitors (SSRI) Transcutaneous electrical nerve stimulation (TENS) Anticonvulsants Strong opioids Epidural steroids Facet joint radiofrequency lesioning Dorsal column stimulation
Intrathecal therapy
May help some people with musculoskeletal conditions. Relative benefit compared with placebo of 1.5 (95% confidence intervals 1.1 to 2.0) Moderate symptomatic improvement in chronic lower back pain with TCAs, independent of depression status. No apparent benefit with SSRIs Clinical experience suggests benefit. Trials equivocal but difficult to perform Possibly useful in back pain. Generally used for radicular neuropathic pain 33% reduction in mean pain intensity. NNT=2.2 Odds ratio of >75% improvement in back pain of 2.6 (95% confidence intervals 1.90 to 3.77) Yes Possibly
Cognitive behavioural therapy Exercise
Not clear
Expert patient programmes
Specific exercises ineffective in acute back pain, but may be useful in chronic low back pain Clinical experience suggests benefit Yes
Yes
Systematic review of 7 randomised controlled trials [30] Technology assessment of TENS in Canada [31]
Randomised controlled trial in 49 patients with chronic pain unresponsive to other treatments [32] Meta-analysis of 11 randomised controlled trials in sciatica [33] Multiple case series Systematic literature synthesis [34]. At one year, 14 out of 29 studies had outcome of >50% pain relief
Clinical experience suggests benefit. Limited trial data Positive across various outcome measures
Specialist pain physiotherapy Pain management programme combining specialist physiotherapy and psychological interventions Back-to-work interventions/ programmes
Systematic review of 26 randomised trials, but authors highlight flawed design in most studies [28] Systematic review of 6 randomised controlled trials, 3 in musculoskeletal conditions [29]
Systematic review and meta-analysis of 25 trials [35] Blinded review of 16 randomised controlled trials, most considered to be of poor quality [36] Systematic review of 39 randomised controlled trials [37] Evidence increasing
Randomised trial of three programmes with different levels of intensity [38]. Early extensive intervention beneficial in group with poor prognosis Observational study of factors predicting return to work [39]. Return to work possible in selected patients with chronic pain
Under evaluation
week and continuing for at least four weeks; improvement occurred in pain scores at rest, sitting, standing and walking. Adverse effects, which predominantly involved the gastrointestinal system, were considered minor and self-limiting.
Other analgesic mechanisms for agents influencing the bones are becoming increasingly apparent. In animals and humans, similarities have been reported between calcitonin and morphine-induced analgesia, with elevation of plasma beta-endorphin levels, suggesting possible involvements of
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the endogenous opiate system peripherally. In animal studies, calcitonin binding sites in areas of the brain involved in pain perception have raised the possibility that calcitonin may directly modulate nociception in the central nervous system, with some observations of analgesic effect in humans on direct epidural or subarachnoidal injection of calcitonin [47].
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reduced risk of any back pain (Fig. 3), moderate or severe back pain, and severe back pain. Although the reduction in back pain with teriparatide may be due to prevention of vertebral fractures, animal models suggest that it accelerates fracture healing, so it may also heal and stabilise preexisting vertebral fractures [52]. Alfacalcidol
Bisphosphonates The bisphosphonates have been used to treat bone pain associated with acute vertebral fracture, Paget's disease of bone, metastatic bone pain and complex regional pain syndrome. There are few published reports of bisphosphonates specifically to relieve pain associated with vertebral fracture. In one study involving 30 patients with acute fracture, disodium clodronate was superior to paracetamol in relieving pain at rest, on pressure and on motion [48]. In a series of five patients rendered immobile by pain despite treatment with analgesics including opioids and supplemented by TENS, three days’ treatment with intravenous pamidronate was associated with pain reduction and recovery of mobility and ability to carry out normal daily activities [49]. For bisphosphonates, although their potent action on osteoclast activity is believed to cause analgesia by directly promoting osteoclast apoptosis, newer evidence is emerging for alternative mechanisms, seen in rat models of allodynia (painful sensations in response to non-noxious stimuli). In these studies, bisphosphonates have suppressed arthritic pain and the mechanism is hypothesised to be due to modulation of K+ ATP channels [50].
Although there is little evidence to support the use of alfacalcidol as a treatment for back pain associated with osteoporosis, a three-year study comparing alfacalcidol with vitamin D in the treatment of glucocorticoid-induced osteoporosis showed fewer new vertebral fractures and greater reduction in back pain [53].
Vertebroplasty and kyphoplasty Vertebroplasty involves percutaneous injection of cement, such as methylmethacrylate, into a vertebral body fractured by osteoporosis or a tumour. The needle may be inserted via the transpedicular and intercostovertebral routes for thoracic vertebrae, the transpedicular and posterolateral routes for lumbar vertebrae and the anterolateral route for cervical vertebrae. Kyphoplasty is performed in a similar manner, except that prior to cement injection, a balloon tamp is passed down the needle and into the vertebral body. The balloon is then inflated, creating a space within the vertebra, which may be then filled with cement under low pressure, restoring some of the vertebral body height lost as a result of the fracture. In the UK, the National Institute of Health and Clinical Excellence (NICE) has issued guidance
Teriparatide A secondary analysis of the Fracture Prevention trial compared teriparatide 20 μg/day with placebo in 1,085 women with vertebral fracture treated for 19 months [51]. Teriparatide was associated with a 31% relative risk reduction of moderate or severe back and a 57% reduced risk of severe back pain. Pain reduction was associated with fewer new vertebral fractures, suggesting this may be the mechanism of action in relieving pain. Compared with alendronate 10 mg/day, teriparatide 20 or 40 μg/day was associated with a 66% reduction in back pain and an 80% reduction in moderate or severe back pain [51]. In a meta-analysis of five double-blind trials in men and women with osteoporosis, the incidence of back pain (defined as new or worsened back pain after starting treatment) was estimated from adverse events databases [52] Teriparatide was compared with pooled data from patients randomised to placebo, alendronate and hormone replacement therapy. Teriparatide was associated with a
Fig. 3 Survival analysis: incidence of any back pain as an adverse event in randomised trials of teriparatide vs. pooled comparators (placebo, hormone replacement therapy, alendronate). Reproduced from Nevitt et al. [52], with kind permission of the corresponding author and Springer Science and Business Media
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on the use of these techniques [54, 55]. Both procedures may be administered under a local or general anaesthetic, by a clinician who has received appropriate training. Facilities for good imaging and access to a spinal surgeon are also required [54, 55]. Vertebroplasty and kyphoplasty should only be considered, when conventional medical management has failed and there is continuing severe back pain or progressive vertebral deformation [54, 55]. Vertebroplasty may be helpful in patients with refractory back pain due to vertebral fracture and an uncontrolled study suggests that the benefits may persist for up to four years [56]. Prospective controlled cohort studies also demonstrate significant improvements in pain and function after vertebroplasty [57, 58] and a small, short-term randomised controlled trial suggests that it is more effective than conservative management [59]. Kyphoplasty also improves back pain in patients with recent vertebral fractures and a small controlled trial suggests improvement in pain and physical activity one year after fracture [60, 61]. There is some controversy in the literature regarding the magnitude of height restoration achieved with kyphoplasty [62, 63]. Vertebroplasty and kyphoplasty are contraindicated in patients with a clotting abnormality or infection over the puncture site. Complications associated with the needle insertion include local trauma or haemorrhage, fracture of the pedicle, encroachment on neural structures or dura and needle fracture. Complications resulting from cement injection include local leakage, pulmonary embolism and extra-osseous cement casts. Cement leakage is less common in kyphoplasty, as this is injected under lower pressure than vertebroplasty. There is some evidence that there may be an increased risk of fractures in vertebrae adjacent to the site of vertebroplasty and kyphoplasty [64, 65], which may offset or outweigh the benefits of these techniques. Until the results of head to head comparisons are available, it is difficult to compare the outcome of the two techniques, but the resources and cost required are considerably higher in kyphoplasty.
Other treatment options: spinal orthoses, exercise and supplementary therapies Spinal orthoses Traditionally, rigid spinal orthoses have been used in the management of thoracolumbar injuries, including vertebral fractures. In the acute stage supporting the spine reduces motion of the apophyseal vertebral joints as well as flexion and extension of the spine. The subsequent decrease in the patient’s pain helps to reduce overguarding of the spine and immobility. It is, however, recognised that ongoing use of
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rigid spinal orthoses will lead to atrophy of supported back muscles and therefore their use should be discontinued as soon as pain subsides. Although the use of rigid spinal orthoses has rarely been tested under standardised conditions, Spinomed is an example of a more recently developed orthosis that has been subjected to more rigorous research. Based on the concept of biofeedback as the underlying principle of efficacy, this type of orthosis has been shown to increase abdominal flexor and back extensor muscle strength, decrease the kyphotic angle, reduce pain and improve quality of life [66]. The correction of the centre of gravity and reduced body sway, might be expected to lead to a reduction in falls. A variety of orthoses may be used for the relief of back pain, but there is a lack of controlled trials to evaluate these appliances. Exercise In the acute phase following vertebral fracture, there will be pain induced reflex inhibition resulting in overuse of spinal flexors. Performing isometric contractions of paraspinal muscles can help to decrease post fracture pain and oedema. Ongoing chronic pain may be caused by vertebral fractures or may result from postural deformities, such as hyperkyphotic changes in the spine with inappropriate stretching of ligaments. In addition, vertebral fractures, severe kyphosis and height loss may lead to iliocostal contact, resulting in iliocostal friction syndrome and flank pain. Although the mechanism by which exercise decreases chronic back pain is not totally understood there is some evidence to support the use of back strengthening exercises. The recruitment of back extensors may decrease kyphosis, lead to better dynamic static posturing, reduce pain and subsequently increase mobility and improve the patient’s quality of life. Exercises to improve muscle strength need to focus on the back extensors and flexion exercises should be largely avoided. In one study of postmenopausal women, 89% of those who performed spinal flexion and bending exercises increased the number of vertebral fractures. In contrast only 16% of the group that performed back extension exercises developed further compression fractures [67]. It is widely recognised that one vertebral fracture increases the risk of further fractures and back strengthening exercises may help to reduce this risk. One randomised ten-year follow-up study of postmenopausal women demonstrated an improvement in axial muscle strength in the resistance exercise group associated with a reduction of bone loss and incidence of vertebral fractures. The relative risk of fracture was 2.7-fold higher in the control group than in the resistance exercise group [68].
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In conclusion, chronic back pain associated with vertebral fracture provides a great challenge to health care professionals and the patient. This demands a combination of options, including not only therapeutic interventions, but also physiotherapy, psychological support and patient education.
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16. Disclosures of interest Roger Francis has served as an adviser and/ or received speakers’ honoraria from Procter & Gamble, Merck Sharp & Dohme, Roche/GSK, Novartis, Pfizer, Lilly, Servier, Nycomed and Wyeth. Terry Aspray has served as an adviser and received speakers’ honoraria from Roche/GSK. Anne Sutcliffe has served as an adviser and/or received speakers’ honoraria from Procter & Gamble, Roche/ GSK, Lilly and Servier. Geoff Hide and Paul Wilkinson have no potential conflicts of interests to declare. This review article resulted from a roundtable meeting arranged by Lilly, but the authors were solely responsible for the content of the meeting and paper. None of the authors received an honorarium for taking part in the meeting or preparing the manuscript.
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