Osteoporosis posture: protecting your spine, and the signs of a fracture

What back exercises are safe with osteoporosis?

The muscles that run up either side of your spine, the erector spinae, are the ones this work is aimed at, and the direction is backward rather than forward. That is the whole principle, and it is the mirror image of the bending advice.

The UK consensus statement recommends exercises to improve the strength of the back muscles, to improve posture and support the spine, at 3 to 5 repetitions held for 3 to 5 seconds, at least twice a week. Your physio will adjust this (Brooke-Wavell 2022). The Too Fit To Fracture Delphi panel asks for more: endurance training for the spinal extensor muscles daily, for everyone with osteoporosis, alongside daily balance training (Giangregorio 2015). So twice a week is the floor, and daily is what the expert panel would prefer.

On this site the back extension on elbows is the usual starting point, the seated thoracic extension is the version that needs no floor, and the prone back extension is the harder one. All three are listed below with their starting ranges and their own precautions. The osteoporosis program puts them in stages with videos, and we are not rebuilding that here.

Two sets of numbers appear on this page and they are not the same prescription, so it is worth saying which is which before you pick one. The consensus figure is a held contraction, 3 to 5 lifts with each one held for 3 to 5 seconds. The ranges on the exercise cards go further than that, up to 8 to 12 lifts on the hardest of the three. Both load the back in the same direction and neither is heavy, so the smaller figure is the safer place to begin: start at 3 to 5 held lifts and let the range on the exercise page be where you are going rather than where you start. If you have had a fracture in your spine, or nobody has set your numbers for you, stay at the held version until they have.

A word on the floor, because two of the three need it. The back extension on elbows and the prone back extension are both done lying face down, and for many readers of this page getting down to the floor and back up is the risky part rather than the lift. If the floor is hard or unsafe for you, do the seated thoracic extension and leave the other two until your physio has watched you get down and up, or has given you a way of doing it that does not need the floor. Preventing falls at home covers getting up from the floor as a skill in its own right.

The commonest technique fault in all three is the same: pressing up as high as the arms will go, which bends the lower back rather than working the muscles beside the spine. A small lift you control beats a big one that happens somewhere else.

One check before any of them, and it is the reason for the second half of this page. If you have lost height, your upper back has become more rounded, or you have back pain or pain that wraps around to your ribs with no clear cause, see your doctor before you start. A broken bone in the spine can cause any of them, and it does not always announce itself.

Exercises that can help

Three back extension exercises, easiest first, and all three bend the upper back backward rather than forward. Seated thoracic extension needs no floor and often starts at 5 to 10 slow repetitions with a pause of a few seconds, once or several times a day, for example during breaks from sitting. Back extension on elbows often starts at 1 to 3 sets of 5 to 10 lifts, each held for about 5 seconds, building toward 10 seconds as it gets easier. The prone back extension is the hardest of the three and often starts at 1 to 3 sets of 8 to 12 slow lifts with a pause of a second or two at the top. Each one carries its own check-first line for anyone who has had a fracture in the spine or spine surgery in recent months, and the two you do lying down both add one for a narrowed spinal canal or a slipped vertebra, because bending backward often aggravates either, so open the line under an exercise and read it before you try that exercise. Where this paragraph and an exercise page differ, the exercise page wins. Your physio will adjust this.

The exercises below carry their own stop signs and precautions. Open the line under an exercise and read them before you try it.

How good is the evidence for the back work?

Worth knowing, because it is weaker than the strength recommendation and nobody says so.

The consensus prints a letter beside each recommendation: E where it rests on the evidence the group reviewed, C where it rests on expert agreement because research evidence was limited or absent. Every recommendation in its posture group is marked C, and the document states in its own words that those recommendations are consensus rather than evidence based. So the dose above is expert agreement about a reasonable thing to do, not a tested prescription. The two headline resistance training recommendations in the same document are marked E, which is why strength training for osteoporosis is the part of the advice with the firmer ground under it.

That is not an argument for skipping the back work. It costs a few minutes, it has no realistic downside in the direction it loads, and there is no competing advice telling you not to do it. It is an argument for knowing what you are buying.

What does posture training actually change?

A back that feels better and holds upright with less effort, mostly, and a small change in the measured curve.

The best known trial put adults aged 60 and over, all of whom already had a measured upper-back curve of 40 degrees or more, through physio-led group spine strengthening and posture training for an hour three times a week for six months. The curve on X-ray improved by a modest amount against a comparison group and the participants felt better about how they looked, while physical function did not differ between the groups (Katzman 2017). The figure itself, and what it means, are already set out on our page about a rounded upper back, so kyphosis exercises and physiotherapy is the place to read it rather than here.

The useful conclusion from that trial is about expectations. Three supervised hours a week for six months bought a small change in the angle. So the reason to do the back work is the back, not the mirror, and nobody should judge the program by a photograph after a month.

One more limit belongs here, for the group most likely to be reading. The Cochrane review of exercise after osteoporotic vertebral fracture, covering 9 trials and 749 people, found it could not determine the effects on new fractures, falls or adverse events, and the one function measure that improved did so by an amount its own authors described as not clinically important (Gibbs 2019).

Is a change in posture a sign of a broken bone?

It can be, and often with nothing that felt like an injury behind it.

The Royal Osteoporosis Society lists the signs of a spinal fracture as unexplained back pain and muscle spasms, height loss, and a curved spine or change in posture, and says the symptoms become more noticeable the more broken bones you have. It adds two sentences that change how you should read your own back. You may not always be aware a spinal fracture has occurred. And the pain can be mistaken for a different condition, such as arthritis.

Think about what that means in practice. A broken bone in the spine from osteoporosis does not usually involve a snap and an ambulance. The bone squashes down on itself, sometimes after a cough, a sneeze or lifting a kettle, and sometimes after nothing anybody can name. Several of them add up to a back that is shorter and rounder than it was, which is the thing a reader notices in a photograph two years later and puts down to getting older.

So a new stoop is a symptom. If you have lost height, or your upper back has become more rounded and you are starting to stoop, or you have back pain or pain that wraps around to your ribs with no clear cause, book an appointment with your doctor. If the pain came on suddenly, get medical advice the same day. If the rounding seems to be getting worse over weeks or months, see your doctor within a few days. All three of those routes are in the warning signs at the end of this page, with the rest.

Height loss, and two numbers that are not the same thing

Two different measurements get quoted on this subject and they are routinely run together, which makes both of them useless. They are worth keeping apart.

The first is annual change. The Bone Health and Osteoporosis Foundation advises having your height measured once a year, at the same office each time, and says that height loss equal to or greater than half an inch (1.3 cm) in one year may be a cause for concern. That is a year-on-year comparison, and it depends on being measured the same way twice.

The second is total loss, measured against how tall you used to be. A larger figure is used for that in UK guidance as one of the signs of vertebral fracture, and the clinician-facing section of our osteoporosis program gives it with its source. It is a different measurement over a different period, so the two thresholds are not interchangeable and neither one can be read as the other.

What to do with either of them is the same, and it is simple. Get measured, properly, once a year, and keep the number. Your own height written down is worth more than any threshold, because the comparison is with you.

The reassurance, and what it does not cover

The Royal Osteoporosis Society offers a genuine reassurance about these fractures, and it holds for the ordinary case: spinal fractures caused by osteoporosis do not cause paralysis, because they are what it calls stable, meaning they are not going to move and damage the spinal cord.

That sentence is about one cause of back pain in one group of people, and it is worth saying plainly what it does not cover, because a true sentence is the easiest thing in the world to talk yourself out of an emergency with. Having osteoporosis does not stop you also having something else.

Three of those something elses are emergencies and they have nothing to do with a stable vertebral fracture. Numbness or altered feeling around your genitals, between your inner thighs or around your bottom, or new trouble peeing or controlling your bladder or bowels, can mean pressure on the bundle of nerves at the base of the spine. Back pain with a fever, or feeling hot, shivery or very unwell, together with new weakness, numbness or tingling in your legs, can mean an infection pressing on the nerves in the spine. And if you have had cancer, now or in the past, back or neck pain that feels like a tight band around your body, or new weakness, numbness or trouble walking, can mean cancer pressing on the spinal cord. New problems walking, or new numbness in a band around your chest or tummy, belong in the same category.

There is a fourth route, and this one does come from the fracture itself. Why most of these fractures are stable is a matter of where the bone gives way: the front of the vertebra crushes and shortens while the back of it, the part that forms the tunnel the spinal cord runs through, stays intact. That is how the American Academy of Orthopaedic Surgeons describes the usual pattern, and the same page says that if the fracture is a serious one it can press on nerves and cause symptoms in the legs, which is why surgeons use a CT scan to see whether the break has reached the spinal canal. A small number of these fractures keep collapsing over the weeks and months afterward, or leave a fragment sitting in that canal, and those can press on the spinal cord or a nerve root and need an operation to take the pressure off (Picazo 2014). It is uncommon. It is not impossible, and it does not announce itself as anything other than the symptoms in the next line.

So treat new weakness in a leg, new numbness in a band around your chest or tummy, new trouble walking, or new trouble controlling your bladder or bowels as urgent whether or not anybody has told you your fracture is stable. Every one of those is in the warning signs below, in full, with what to do and how fast. Read them once now. The reassurance stands for the ordinary case, and it is not a reason to wait out any of them.

How to bend, lift and reach in everyday life

The practical half. The exercise lasts ten minutes and the day lasts sixteen hours, so this is where most of the loading actually happens.

Bend from your hips, not your spine. Soft knees, back straight, bottom going backward as though you were pushing a drawer shut with it. Osteoporosis Canada puts it as bending with your hips and knees instead of your spine, and using slow, controlled movements. The osteoporosis program has the hip hinge and the full lifting technique, and exercises to avoid with osteoporosis covers how firm the evidence behind the restriction is.

For the floor, kneel or squat down to it rather than folding over at the waist. For shopping, split it between two bags so it is balanced and close to you, and keep one hand free. For getting out of bed, roll onto your side first and push up with your arms rather than curling straight up from flat. For the high shelf, move the things you use daily down to between hip and shoulder height and ask somebody to do the top cupboard, which is a better use of a visiting relative than letting them carry everything.

The cough and the sneeze catch people out, because neither gives you any notice. The US bone health foundation includes bending forward when coughing and sneezing in its list of movements to avoid, and suggests gently pressing one or both hands against the chest instead. A hand on a worktop or the back of a chair does the same job. It is worth rehearsing once, because a sneeze is not the moment to work out a technique.

Which of these instructions applies to you

This is a real disagreement between national bodies, not a difference of opinion here.

The three national bone bodies in our markets word this differently. The Royal Osteoporosis Society says bending forward and curving your back is normal movement, both in everyday life and when you are keeping active. The Bone Health and Osteoporosis Foundation says people with bone loss in the spine should not bend forward from the waist, and its list of six includes reaching for objects on a high shelf. Osteoporosis Canada applies its limits to a named group, people at high risk of fracture, and the movements on its list for them include repetitive bending and twisting, bending all the way forward, or all the way to the side, and bending or twisting while you hold something heavy.

The Canadian framing is the one that tells you how to use the other two. If you are at high risk of fracture, which usually means a previous fracture from a minor injury, several broken bones, or a very low bone density reading, the stricter version is written for you. If your bone density is low but you have never broken anything, the UK version is closer to your situation, and the Australian position statement's one restriction, that loaded spine flexion is not recommended, is the part everybody agrees on (Beck 2017).

Which group you are in is a question for your own doctor or physio, and it is a short question with a clear answer. It changes more of your daily life than anything else on this page.

Until you have that answer, use the strict version, which is the American one. Not knowing which group you are in is not the same as being in the safer one, and the cost of guessing runs only one way. What to bring to that appointment, and the Canadian advice on who to ask, are set out on exercises to avoid with osteoporosis. The short version: your fracture history, your last bone density reading, and any steroid tablets you take long term.

After a fracture in the spine, and after a procedure for one

Different reader again, and the advice for this group is both stricter and more encouraging than people expect.

The Royal Osteoporosis Society says that if you break a bone in your spine you will not usually need an operation, that it is recommended you aim to stay as active as possible, and that movement does not affect the healing process. Healing takes 6 to 12 weeks, and the bones do not go back to the shape they were before: they heal in their new, compressed shape. It advises waiting until the bone has healed, which can take up to three months, before you build up strength exercises.

For the back work specifically, the consensus keeps going but changes the emphasis. For a reader with a vertebral fracture it recommends daily exercises to strengthen the back muscles with a focus on endurance, exercising at low intensity, at 3 to 5 repetitions held for 3 to 5 seconds, and it recommends individual physiotherapy advice at the start of a new program for this group. Both of those are marked as expert consensus rather than evidence. So the dose is not the thing to take from a page: the person who sets it is.

Some people with a fracture that keeps hurting are offered a cement procedure. In a vertebroplasty the surgeon passes a needle into the broken vertebra under X-ray guidance and injects bone cement into it, with no attempt to change its shape. A balloon kyphoplasty adds a step before the cement: a small balloon goes in through the needle and is inflated to make the bone taller and rounder again, and the space it leaves is then filled. The American Academy of Orthopaedic Surgeons describes both as suited to people with severe pain from a recent fracture, says which one fits depends on the fracture, and sends that decision to your surgeon. If a procedure has been raised with you, the plan from your own surgical team comes first and nothing here replaces it.

What the evidence says is less encouraging than the offer usually sounds, and it is worth knowing before that conversation. The academy also puts most people at feeling better within three months with no surgery at all. For vertebroplasty, the Cochrane review of the five trials that compared it against a dummy procedure, 541 people randomized, found high to moderate quality evidence of no clinically important benefit at one month: pain was 0.7 points better out of 10, where the review took 1.5 points as the smallest difference that matters to a patient (Buchbinder 2018). The orthopaedic surgeons' own clinical practice guideline on these fractures, published in 2011, made a strong recommendation against vertebroplasty, and listed kyphoplasty as a weakly supported option for people with no nerve involvement (Esses 2011). The counterweight came later. The VAPOUR trial took a much narrower group, fractures less than six weeks old with pain of at least 7 out of 10, and found 44 percent got their pain below 4 out of 10 by two weeks against 21 percent after a dummy procedure (Clark 2016).

Surgeons genuinely disagree about this, and the page cannot settle it for you. A 2023 review in the academy's own journal describes exactly that split: historically the data showed no difference between treating these fractures conservatively and injecting cement, while more recent work has shown better outcomes and more mobility after cement (Hoffmann 2023). So the fair summary is that it may help if the fracture is recent and the pain is severe, that the average result across routine practice has been close to nothing, and that your own surgeon is the one who weighs your fracture, your pain and your other conditions against that. Ask what this procedure is expected to change for you, and by when, in those words.

Neither procedure treats the osteoporosis. Neither improves bone strength or lowers your risk of breaking another bone, which is why the bone medicine, the calcium and vitamin D and the exercise all carry on afterward. Side effects are uncommon. The Royal Osteoporosis Society lists cement leaking out, infection, cement blocking the blood vessels in the lungs, allergic reactions, injury to the spinal cord or a nerve root, and the balloon rupturing in a kyphoplasty. The lung one has a mechanism worth understanding, because it is not a clot: a vertebra drains into large veins, and cement that escapes into one while it is still liquid can be carried to the arteries of the lung and set there. A meta-analysis of 13 studies and 6,251 patients found it in 2.3 percent, more often where cement had leaked into a vein, at levels in the upper back, where more cement went into each level, and where more than three vertebrae were done in one sitting (Sun 2022). Much of it turns up on a scan in someone with no symptoms and is only followed up, while a symptomatic one is treated like any other blood clot in the lungs (Krueger 2009). So new breathlessness or chest pain after one of these procedures is an emergency, not something to raise at the follow-up appointment. The trials in the Cochrane review also reported bone infection, pressure on the spinal cord, injury to the lining around the cord and respiratory failure among their serious harms.

The longer-term worry is about the neighbors. The Royal Osteoporosis Society puts it as the treated bone putting pressure on the bones around it and raising the chance of those breaking, and the thinking behind it is that set cement is stiffer than the bone it sits in. The evidence is thinner than that sounds, in both directions. Six trials in the Cochrane review counted new vertebral fractures with symptoms in 95 of every 1,000 people after vertebroplasty against 73 of every 1,000 in the comparison groups, a difference whose range runs from less than half the risk to more than three times it, so the review graded it low quality and said it could not be certain either way (Buchbinder 2018). What is not in doubt is that breaking one vertebra already makes the next one more likely whatever is done about the first. That is an argument for treating the osteoporosis itself, not a score for or against the cement, and it is why the osteoporosis treatment carries on whichever way the procedure decision goes.

One more group, and the one most likely to be handed the wrong number by a page like this one: if you have had screws, rods or a fusion in your spine, or an operation to take pressure off the nerves, do not take your starting point from here. Your limits on bending, lifting and arching backward, and the date each of them lifts, come from the team that operated, and they differ between surgeons and between operations. Ask them, or the physio they refer you to. After a cement procedure the advice is usually the opposite of restrictive, with normal daily activity encouraged as soon as you feel able, but the level for strengthening work still comes from your own team rather than from this page.

The Royal Osteoporosis Society also lists what can follow spinal fractures in the longer term, and it does not make comfortable reading: nerve pain, muscle spasms, pain in the joints and ligaments, arthritis, loss of height and a curved spine. None of that is a reason to stop moving, and the exercise evidence for this group, thin as it is, points toward staying active with the right level set for you. The after-a-fracture section of the osteoporosis program has the sequence, preventing falls at home covers the house, and your own physio sets the starting point.

Related exercise programs

• Osteoporosis
• Kyphosis
• Balance and falls prevention
• Strength training for older adults

Common questions

References

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Written and checked by the PocketPhysio editorial team. Last updated 2026-11-06.

This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.