Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor-strengthening exercises. (2008)

Abstract
OBJECTIVE:
To determine whether patients with osteoporotic compression fractures would have decreased fracture recurrence or a longer time before refracture after percutaneous vertebroplasty (PVP) if they also participated in the Rehabilitation of Osteoporosis Program-Exercise (ROPE) instruction, which includes back-strengthening exercises.

PATIENTS AND METHODS:
We reviewed and collected data from the medical records of 507 patients with osteoporosis who were treated at Mayo Clinic’s site in Rochester, MN, from July 1, 1998, through August 31, 2005. Patients older than 55 years with at least 1 radiographically confirmed nontraumatic vertebral compression fracture (VCF) were identified, and those with evidence of secondary osteoporosis, traumatically induced VCF, long-term oral corticosteroid use, or bone malignancy were excluded. The remaining 57 patients were categorized into 3 groups: those receiving treatment with ROPE only (n=20), PVP only (n=20), or both PVP and ROPE (n=17). The end point was the refracture date or date of the last recorded follow-up if no refracture occurred. Statistical analysis of time-to-recurrence data was performed using the Kaplan-Meier method and the log-rank test (P less than .05).

RESULTS:
The median time before refracture for patients treated with PVP was 4.5 months (95% confidence interval [CI]), 1.4-9.3 months; for patients treated with ROPE only, 60.4 months (95% CI, 27.6 months-upper limit undefined); and for patients treated with PVP-ROPE, 20.4 months (95% CI, 2.8 months-upper limit undefined) (P <001).

CONCLUSION:
This retrospective study showed that a targeted exercise program after PVP significantly decreased fracture recurrence. Refracture rates also were lower in the ROPE-only group vs the PVP-only group.

My comments:

Vertebroplasty is a relatively non-invasive procedure.  A person with a painful vertebral compression fracture, most often resulting from osteoporosis, has that vertebra stabilized and if lucky decompressed to some degree with the injection of bone cement.  Kyphoplasty is largely the same procedure with a small differences. Rather than decompressing the vertebra with bone cement, the vertebra is decompressed with a balloon first, the balloon is removed and the cement is injected into the cavity. Outcomes thus far appear similar as  both procedures have been shown to be effective in rapidly reducing back pain in those with painful vertebral compression fractures. There is still debate among physicians as to whether one procedure is safer or better at restoring vertebral height.

One complication, however, is a high incidence of additional compression fractures above and below the one being stabilized. There is some debate remaining as to whether this additional fracture rate is secondary to the stiffness of the treated vertebra after being stabilized or if it is resultant from the ongoing osteoporotic changes in the spine.

This study found that by adding back extensor muscle training they were able to significantly reduce the refracture rate. They used exercises begun in sitting and progressing to back extensions and bird dog type exercises in prone or quadruped.  Unfortunately they did not give much in the way of details as to when the exercises were started after the procedure, frequency, sets or repetitions performed. However, so far it’s the only study that addresses exercise after vertebroplasty so sometimes you just have to take what you get and develop your physical therapy programs with less than perfect data.  Did I say sometimes?  Actually rehabilitation being an infant science it’s pretty much all the time, which is what keeps the job interesting, and also illustrates the importance of continued research, reading and implementing said research.

The good news was that the back extensor exercises had significant beneficial effects at reducing additional fractures. The incidence of additional compression fractures within 12 months was reduced from 75% in the control group to 35% in the exercise group. This makes sense. If patients’ spine extensors are strong enough to hold their spines neutral during daily activities, that would take pressure of the anterior vertebral bodies, which is increased primarily due to spine flexion. Based on this, and a lot of other spine research, I would think it prudent as well to add abdominal exercises (performed with the spine neutral and perhaps with a bias into extension) as well as hip and lower extremity strength exercises. These make it easier for those with osteoporosis to lift with their legs as opposed to their backs.  Not to mention that those with osteoporosis need the weight bearing through their hips to increase bone mineral density there and lessen the risk of hip fractures. If it were me I would stay away from “conventional” yoga.