Osteoporotic vertebral fractures can cause pain, increase thoracic kyphosis and fear, and impair the ability to perform activities of daily living.1 However, there is limited evidence on how to manage pain and other impairments in individuals with vertebral fractures, especially in the first 3 months after fracture. The purpose of this commentary is to highlight recent findings from an international consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.2 The international panel included physiotherapists, endocrinologists, geriatricians and exercise professionals from Asia, Europe, North America and Oceania.2 We present a summary of the evidence on exercise after vertebral fracture, provide practical recommendations on exercise and physical activity after vertebral fractures, and discuss persisting knowledge gaps and future research directions.

We performed a Cochrane review on exercise for people with vertebral fractures,3 which showed moderate certainty evidence that exercise can improve physical functioning (mean difference in the Timed Up and Go score was −1.09 s, 95% CI −1.78 to −0.40; 139 participants, 3 studies) and may improve quality of life, but the effects on outcomes such as falls, fractures and pain were uncertain. Many vertebral fractures happen as a result of a fall. While there is no direct evidence that exercise can prevent falls in people with vertebral fractures, there is high certainty evidence from a Cochrane review of randomised controlled trials in adults >50 years that training of balance, functional tasks, coordination or gait patterns reduces the rate of falls (rate ratio 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies) and the number of people who fall (risk ratio 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies).4 When balance and functional training were performed at least 3 hours per week, it reduced …