Acute-phase rehabilitation for osteoporotic vertebral fractures: current evidence from scoping review

Article information

Asian Spine J. 2026;20(4):805-816

Publication date (electronic) : 2026 August 5

doi : https://doi.org/10.31616/asj.2026.0333

Tomoyoshi Sakaguchi¹, Masato Tanaka², Ingrid Frances Dizon Ignacio², Tadashi Komatsubara², Ryo Ugawa², Yosuke Yasuda¹, Kazuhiko Takamatsu¹, Moeka Ueda¹, Kaoruko Ishihara¹, Yuka Hirose³

¹Department of Rehabilitation, Okayama Rosai Hospital, Okayama, Japan

²Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan

³Department of Rehabilitation, Watanabe Hospital, Okayama, Japan

Corresponding author: Masato Tanaka, Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-5 Chikkomidorimachi, Minami Ward, Okayama, Okayama, 702-8055, Japan, Tel: +81-86-262-0131, Fax: +81-86-262-3391, E-mail: tanaka0896@gmail.com

Received 2026 April 29; Revised 2026 July 15; Accepted 2026 July 15.

Abstract

Graphical Abstract

Introduction

Osteoporosis is a representative metabolic bone disease, with its prevalence increasing with age, and it has been identified by the World Health Organization as a major global health concern [1,2]. As populations continue to age worldwide, the burden of osteoporotic vertebral fractures (OVF) has also risen, increasing from 5.9 million cases in 1990 to 7.5 million cases in 2021 [3]. Age- and sex-adjusted estimates indicate that approximately 25% of females aged ≥50 years will experience at least one vertebral compression fracture during their lifetime [4]. OVFs typically result from low-energy mechanisms encountered in daily life, including turning in bed, coughing, or sneezing, although minor traumatic events such as falls may also precipitate these fractures [5]. OVFs significantly impact activities of daily living (ADL) and quality of life (QOL) in older adults, leading to progressive functional decline and poorer survival outcomes [6]. In addition, individuals with OVFs are at an increased risk of subsequent fractures and mortality, highlighting the broader clinical consequences of these injuries [1,7]. Collectively, these findings indicate that OVF is a systemic clinical problem that substantially impairs functional independence in older adults.

Conservative treatment remains the primary treatment approach for OVF [8]. Although several systematic reviews have examined conservative treatment strategies, most have focused on the effectiveness of pharmacological therapy and spinal bracing [9–11]. Exercise-based interventions have been reported to improve physical function, balance, and QOL in patients with vertebral fractures, particularly during the subacute and chronic phases [12]. However, the evidence regarding rehabilitation during the acute phase of OVF has not been well established.

Early initiation of rehabilitation, particularly within 48 hours after surgery, has been reported to improve functional outcomes such as independence in transfers and walking distance in osteoporotic fractures, particularly in older adults with hip fractures [13]. Similarly, in patients with OVF, appropriate rehabilitation during the acute phase is important not only for pain management but also for preventing disuse syndrome, maintaining and restoring physical function, and minimizing the risk of subsequent fractures. However, the current evidence regarding the timing, intensity, content, and outcome measures of physiotherapy interventions in the acute phase of OVF remains fragmented, and a comprehensive synthesis has not yet been established.

Therefore, this study aimed to comprehensively collect and map the existing evidence on physiotherapy interventions for patients with acute-phase OVF and to systematically summarize their characteristics, safety, and clinical effectiveness.

Materials and Methods

Results

A total of 1,034 records were identified through database search (Fig. 1). After eliminating the duplicates, 880 records underwent title and abstract screening. Of these, 31 articles were selected for full-text assessment. During the full text review, 24 studies were excluded, resulting in the inclusion of seven studies in the final review.

Fig. 1

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram describing the literature search/selection process. OVF, osteoporotic vertebral fracture.

The reasons for exclusion at the full-text stage were as follows: three studies evaluated postoperative rehabilitation for OVF, 13 did not target the acute phase, six did not investigate rehabilitation interventions (e.g., studies limited to physical modalities or bracing), and two studies were unavailable in full text.

Characteristics of included studies

Seven studies met the inclusion criteria in this scoping review (Table 1). The study designs were heterogeneous and comprised one retrospective cohort study, two observational studies using propensity score matching, one randomized controlled trial, one pre–post study, one prospective single-arm interventional study, and one prospective cohort study.

Table 1

Characteristics of included studies

Regarding the target population, four studies investigated patients with vertebral compression fractures (VCF), whereas three included patients with OVF. Sample sizes varied widely, ranging from 34 to 40,743 participants, reflecting large-scale database analyses and smaller clinical studies.

Across the included studies, rehabilitation interventions were typically initiated within 2 weeks, with several studies reporting initiation within 3 days of hospital admission. The primary outcomes assessed across the included studies were ADL, most commonly measured using the Barthel index (BI) and the Functional Independence Measure (FIM). Secondary outcomes were more heterogeneous and included the 6-minute walk test (6MWT), pain-related outcomes, and cognitive function measures.

Characteristics of rehabilitation interventions

The characteristics of rehabilitation interventions reported in the seven included studies, including the timing of rehabilitation initiation, exercise components, mobilization strategies, treatment intensity, and orthotic management, are summarized in Table 2. Acute-phase rehabilitation generally involved a combination of early mobilization, gait training, and ADL practice, tailored to the patient’s pain level and overall clinical condition.

Table 2

Characteristics of rehabilitation interventions in included studies

Regarding the timing of intervention initiation, Ikeda et al. [16] examined the number of days from hospital admission to the start of rehabilitation as an exposure variable and examined its relationship with outcomes. In contrast, Kobata et al. [17] compared patients who received rehabilitation within 3 days of admission with those who did not. Funayama et al. [18] employed a conservative management strategy consisting of 2 weeks of bed rest and compared outcomes between delayed and early mobilization. Similarly, Ikumi et al. [19] conducted a pre–post comparison following 2 weeks of strict bed rest. In the remaining studies, the timing of rehabilitation initiation was not explicitly reported.

With respect to intervention content, most studies incorporated spinal orthoses (either rigid or soft braces) as part of conservative management during rehabilitation and provided conventional inpatient rehabilitation. In studies by Ikeda et al. [16] and Asahi et al. [20], physiotherapy interventions consisted primarily of gait training and ADL training. Kataoka et al. [21] reported interventions that included strength training, stretching, and balance and postural exercises; however, no standardized rehabilitation protocol was described. Kataoka et al. [21] incorporated cognitive behavioral therapy (CBT)-based pain management in addition to conventional gait and ADL training. Fujiwara et al. [22] conducted a single-arm interventional study combining conventional rehabilitation with abdominal electrical muscle stimulation (EMS). In the studies by Ikumi et al. [19] and Funayama et al. [18], rehabilitation was primarily implemented within a bed rest–based conservative treatment regimen and included range-of-motion exercises and basic therapeutic exercises.

Overall, rehabilitation protocols varied substantially with respect to the timing of mobilization, exercise components, orthotic management, and pain management strategies. Moreover, only a limited number of studies described standardized protocols for acute-phase rehabilitation.

Outcomes of acute-phase rehabilitation

The overall outcomes reported across the included studies are summarized in Table 3. Earlier rehabilitation initiation was consistently associated with better functional outcomes, while structural improvements (e.g., vertebral morphology) did not necessarily translate into functional gains.

Table 3

Summary of outcomes across included studies

Discussion

In this scoping review, we synthesized the available evidence on acute-phase rehabilitation for patients with VCF and OVFs from seven included studies. Despite heterogeneity in the study design and sample size, the findings consistently suggest that acute-phase rehabilitation is safe and may contribute to improvements in ADL.

In the present review, rehabilitation was initiated within 2 weeks of onset in most included studies, underscoring the potential importance of early mobilization in the acute management of OVF. However, conservative management has often emphasized bed rest or activity restriction to alleviate pain and protect the fractured vertebra [23]. Traditionally, strict bed rest in patients with OVFs has involved maintaining a supine position during the acute painful phase, minimizing trunk loading and permitting only limited positional changes. In the studies by Ikumi et al. [19] and Funayama et al. [18], patients underwent approximately 2 weeks of strict bed rest before the initiation of progressive mobilization and walking rehabilitation, although bedside range-of-motion and non-weight-bearing exercises were permitted to prevent disuse syndrome.

Prolonged bed rest has been associated with adverse effects on the musculoskeletal, cardiovascular, respiratory, and cognitive systems [24], including a decrease in muscle mass and bone mineral density [25–27]. Moreover, shorter periods of bed rest (e.g., 3 days) have been reported to be associated with lower rates of complications such as pneumonia, deep vein thrombosis, and delirium compared with longer periods (e.g., 7 days) [28]. Although no definitive criteria for early mobilization have been established, recent evidence suggests that restricting bed rest to no more than 3 days, followed by early mobilization, may represent a reasonable management strategy [28,29]. In this context, appropriate pain management plays a crucial role in facilitating early mobilization in patients who might otherwise remain immobilized due to pain. Commonly used analgesics for OVF include non-steroidal anti-inflammatory drugs, opioids removed anti-osteoporotic agents such as teriparatide. Although each has potential limitations, adequate pain control may facilitate early mobilization and help prevent functional decline [30]. Beyond pain control, optimization of bone health is a key component of conservative management for OVF. Anabolic agents, such as teriparatide, may promote fracture healing and alleviate pain, whereas anti-resorptive therapies, including bisphosphonates and denosumab, contribute to secondary fracture prevention [31–33]. These pharmacological interventions may complement rehabilitation by enabling safe mobilization and preserving vertebral integrity. However, because the included studies did not consistently report standardized pharmacological protocols, their influence on rehabilitation outcomes could not be evaluated in the present review.

Consistent with the recommendation to limit bed rest to within 3 days, multiple studies have demonstrated that the timing of rehabilitation is associated with functional outcomes. Ikeda et al. [16] reported that delayed initiation of rehabilitation was associated with poorer functional outcomes, and together with the findings of Kobata et al. [17], these results suggest that commencing rehabilitation within 3 days of admission may play a crucial role in functional recovery. Furthermore, a study evaluating the Cumulated Ambulation Scoree in patients with OVF revealed that early recovery of mobility was a significant predictor of discharge to home [34]. These findings support the association between early rehabilitation and favorable clinical outcomes observed in the present review and highlight the importance of maintaining physical activity and walking ability in the acute phase. Therefore, rehabilitation should be initiated as early as clinically feasible to optimize functional recovery.

Most studies included in this review used ADL measures, such as BI or FIM, as primary outcomes, emphasizing the clinical importance of functional recovery in patients with OVF. Improvements in ADL reflect not only recovery of physical function but also the ability to return to independent living, which is a principal treatment goal in older adults [35]. Several studies also evaluated secondary outcomes such as walking endurance, pain, and muscle strength [19,21], thereby providing complementary perspectives on patient recovery. Because falls are a major cause of OVF, the assessment of mobility and balance is of considerable clinical importance. A Cochrane review reported that the Timed Up and Go test (TUG) is a useful tool for evaluating mobility and balance in patients with OVF [36]. While ADL measures are primarily used in the acute phase, functional assessments, such as the TUG, are more frequently emphasized in the subacute and recovery phases. Therefore, incorporating TUG as a secondary outcome in the acute phase may facilitate early identification of fall risk and optimization of rehabilitation strategies.

Exercise therapy is recommended in clinical guidelines for VCFs, particularly progressive resistance and endurance training targeting the back extensor muscles [37]. However, these recommendations are largely based on evidence from the subacute and chronic phases of recovery. During the acute phase, severe pain may limit the feasibility of resistance exercises, making early mobilization and gait training more practical rehabilitation priorities. In this setting, spinal orthoses are commonly employed to stabilize fractures, mitigate pain, and limit excessive forward flexion, thereby facilitating early mobilization [38,39]. Systematic review evidence indicates that rigid and semirigid spinal orthoses improve biomechanical stability, decrease kyphotic deformity, enhance postural stability, and contribute to superior pain and functional outcomes in older adults with OVFs [40]. Rigid orthoses, such as the Jewett brace, may provide greater restriction of spinal flexion and improved fracture stabilization during the acute phase, whereas soft orthoses and lumbosacral corsets may offer greater comfort and patient adherence, thereby facilitating early mobilization. However, current evidence does not clearly support the superiority of one type of orthosis over another, and brace selection should be individualized based on fracture characteristics, pain severity, and patient tolerance. Previous studies have reported improvements in posture, muscle strength, ADL, and QOL following rehabilitation interventions, and systematic reviews have demonstrated beneficial effects on functional outcomes and kyphotic alignment [40,41]. Accordingly, most studies predominantly implemented conventional inpatient rehabilitation focused on these activities, while clearly defined protocols for back extensor strengthening were limited.

Regarding the safety of early rehabilitation, most of the included studies reported no serious adverse events related to rehabilitation interventions, indicating that acute-phase rehabilitation is generally safe in this population. However, Funayama et al. [18] reported that, among high-risk patients, the rate of conversion to surgical treatment was higher in the early mobilization group. Recent reviews have indicated that approximately 15%–35% of patients with OVFs may develop progressive vertebral collapse and eventually require surgical intervention, despite conservative management. Several imaging-based risk factors for fracture progression have been identified, including the presence of an intravertebral cleft, severe initial vertebral collapse, involvement of the thoracolumbar junction, and posterior wall injury [30,42].

This review has several limitations. First, the number of included studies was relatively small. Second, all included studies were conducted in Japan, which may limit the generalizability of the findings, possibly reflecting the country’s rapidly aging population, high prevalence of osteoporosis, and a healthcare system that supports the implementation of early rehabilitation in acute care settings [43,44]. Third, the search was limited to English-language studies published within the past 10 years, which may have led to the exclusion of relevant studies. Fourth, fracture diagnosis was heterogeneous across the included studies. Although most studies included hospitalized symptomatic patients, details regarding diagnostic imaging modalities and the distinction between incidentally identified and clinically symptomatic fractures were not consistently reported, which may have affected the reported functional outcomes.

Conclusions

This scoping review suggests that acute-phase rehabilitation for patients with OVFs, particularly when initiated within 2 weeks of onset, and ideally within the first 3 days, may contribute to improved functional recovery and favorable clinical outcomes. Functional outcomes were primarily evaluated using ADL measures such as the BI and FIM. Few rehabilitation-related adverse events were reported, suggesting that these interventions demonstrated a favorable safety profile. However, standardized protocols defining specific exercise components and intervention strategies have not yet been established. Further prospective studies are needed to establish the optimal rehabilitation program in the acute phase.

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