Elizabeth A. Huntoon

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

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 Clinics 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.

The Role of Exercise in the Prevention and Treatment of Compression Fractures

To the Editor: We read with interest the excellent review article on osteoporosis by Mauck and Clarke in the May 2006 issue of Mayo Clinic Proceedings, which summarized current strategies for the diagnosis, screening, prevention, and treatment of this disorder. However, we found one area that we believe deserves further elaboration—the role of exercise in the prevention and treatment of osteoporotic compression fractures. In their article, Mauck and Clarke reported that “weightbearing exercise appears to be effective in maintaining or increasing bone density at the lumbar spine and hip in postmenopausal women, but currently, no evidence suggests that it decreases fractures.” They referenced the report by Bonaiuti et al in the 2002 Cochrane Database of Systematic Reviews, which included studies up to 2000. However, since that time evidence has accumulated that substantiates the use of targeted back extensor–strengthening (BES) exercise to reduce the risk of vertebral compression fractures in the postmenopausal population. For example, in 2002, Sinaki et al published the results of a prospective 10-year follow-up study showing a statistically significant reduction in vertebral compression fractures in a group of women who had participated in BES exercises compared to a control group of women who did not participate in such an exercise program (Figure 1). Stronger back extensors reduced the risk of vertebral fractures by 3-fold with no specific pharmacotherapy. In 2003, Turner and Robling noted that regular exercise can “effectively reduce fracture risk” while increasing bone strength. Pfeifer et al reviewed the literature in 2004 and concluded that exercise was associated with reduced risk of hip fracture. In a recent pilot study of the effects of BES exercise and refracture rates after vertebroplasty, we found not only a decreased refracture rate but an increased fracture-free interval when BES exercise was included. Bone mineral density accounts for less than 50% of fracture risk; the remaining risk depends on other factors such as muscle strength and risk of falls. Thus, given the safety of an appropriately designed exercise program in this population, we believe that targeted BES exercise should be considered for fracture prevention and as a treatment option for all osteoporotic individuals.