European Spine Journal

, Volume 27, Supplement 6, pp 861–869 | Cite as

The Global Spine Care Initiative: a review of reviews and recommendations for the non-invasive management of acute osteoporotic vertebral compression fracture pain in low- and middle-income communities

  • Arthur AmeisEmail author
  • Kristi Randhawa
  • Hainan Yu
  • Pierre Côté
  • Scott Haldeman
  • Roger Chou
  • Eric L. Hurwitz
  • Margareta Nordin
  • Jessica J. Wong
  • Heather M. Shearer
  • Anne Taylor-Vaisey
Review Article



The purpose of this review was to develop recommendations for non-invasive management of pain due to osteoporotic vertebral compression fractures (OVCF) that could be applied in medically underserved areas and low- and middle-income countries.


We conducted a systematic review and best evidence synthesis of systematic reviews on the non-invasive management of OVCF. Eligible reviews were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Low risk of bias systematic reviews and high-quality primary studies that were identified in the reviews were used to develop recommendations.


From 6 low risk of bias systematic reviews and 14 high-quality primary studies we established that for acute pain management, in addition to rest and analgesic medication, orthoses may provide temporary pain relief, in addition to early mobilization. Calcitonin can be considered as a supplement to analgesics; however, cost is of concern. Once acute pain control is achieved, exercise can be effective for improving function and quality of life.


The findings from this study will help to inform the GSCI care pathway and model of care for use in medically underserved areas and low- and middle-income countries. Conservative management of acute pain and recovery of function in adults with OVCF should include early mobilization, exercise, spinal orthosis for pain relief, and calcitonin for analgesic-refractory acute pain.

Graphical Abstract

These slides can be retrieved under Electronic Supplementary Material.


Spine Review literature as topic Fractures Compression Osteoporosis Early medical intervention Conservative treatment 


Compliance with ethical standards


The Global Spine Care Initiative and this study were funded by grants from the Skoll Foundation and NCMIC Foundation. World Spine Care provided financial management for this project. The funders had no role in study design, analysis, or preparation of this paper.

Conflict of interest

AA declares no COI. KR declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. HY declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. PC declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care; Canadian Institutes of Health Research Canada. Research Chair Ontario Ministry of Finance; Financial Services Commission of Ontario; Ontario Trillium Foundation, ELIB Mitac; Fond de Recherche and Sante du Quebec. SH declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care; Clinical Policy Advisory Board and stock holder, Palladian Health; Advisory Board,; Book Royalties, McGraw Hill; Travel expense reimbursement—CMCC Board. RC declares funding from AHRQ to conduct systematic reviews on treatments for low back pain within last 2 years. Honoraria for speaking at numerous meetings of professional societies and non-profit groups on topics related to low back pain (no industry sponsored talks). EH declares he is a consultant for: RAND Corporation; EBSCO Information Services; Southern California University of Health Sciences; Western University of Health Sciences Data and Safety Monitoring Committee; Chair, Palmer Center for Chiropractic Research; Research Committee Co-chair, World Spine Care. MN declares funding from Skoll Foundation and NCMIC Foundation through World Spine Care; Co-Chair, World Spine Care Research Committee; Palladian Health, Clinical Policy Advisory Board member; Book Royalties Wolters Kluwer and Springer; Honoraria for speaking at research method courses. JJW declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. HR declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. ATV declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care.

Supplementary material

586_2017_5273_MOESM1_ESM.pdf (145 kb)
Supplementary material 1 (PDF 146 kb)
586_2017_5273_MOESM2_ESM.pptx (178 kb)
Supplementary material 1 (PPTX 179 kb)


  1. 1.
    American Association of Neurological Surgeons (2016) Vertebral compression fractures. Accessed 1 Dec 2016
  2. 2.
    Denis F (1984) Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res (189):65–76Google Scholar
  3. 3.
    Cooper C, Melton LJ III (1992) Epidemiology of osteoporosis. Trends Endocrinol Metab 3:224–229. CrossRefPubMedGoogle Scholar
  4. 4.
    Hu R, Mustard CA, Burns C (1996) Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976) 21:492–499CrossRefGoogle Scholar
  5. 5.
    Handa R, Ali Kalla A, Maalouf G (2008) Osteoporosis in developing countries. Best Pract Res Clin Rheumatol 22:693–708. CrossRefPubMedGoogle Scholar
  6. 6.
    World Health Organization (2007) WHO scientific group on the assessment of osteoporosis at primary health care level. Accessed 27 Jan 2017
  7. 7.
    Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17:1726–1733. CrossRefPubMedGoogle Scholar
  8. 8.
    Felsenberg D, Silman AJ, Lunt M, Armbrecht G, Ismail AA, Finn JD, Cockerill WC, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Dequeker J, Eastell R, Felsch B, Gowin W, Havelka S, Hoszowski K, Jajic I, Janott J, Johnell O, Kanis JA, Kragl G, Lopes Vaz A, Lorenc R, Lyritis G, Masaryk P, Matthis C, Miazgowski T, Parisi G, Pols HA, Poor G, Raspe HH, Reid DM, Reisinger W, Schedit-Nave C, Stepan JJ, Todd CJ, Weber K, Woolf AD, Yershova OB, Reeve J, O’Neill TW (2002) Incidence of vertebral fracture in Europe: results from the European Prospective Osteoporosis Study (EPOS). J Bone Miner Res 17:716–724. CrossRefPubMedGoogle Scholar
  9. 9.
    Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jonsson B, Kanis JA (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8:137. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E (2001) Risk of new vertebral fracture in the year following a fracture. JAMA 285:320–323CrossRefGoogle Scholar
  11. 11.
    Al-Sari UA, Tobias J, Clark E (2016) Health-related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis. Osteoporos Int 27:2891–2900. CrossRefPubMedGoogle Scholar
  12. 12.
    Silverman SL (1992) The clinical consequences of vertebral compression fracture. Bone 13(Suppl 2):S27–S31CrossRefGoogle Scholar
  13. 13.
    Burger H, Van Daele PL, Grashuis K, Hofman A, Grobbee DE, Schutte HE, Birkenhager JC, Pols HA (1997) Vertebral deformities and functional impairment in men and women. J Bone Miner Res 12:152–157. CrossRefPubMedGoogle Scholar
  14. 14.
    Blau LA, Hoehns JD, Nazario M, Gagnon L (2003) Analgesic efficacy of calcitonin for vertebral fracture pain. Ann Pharmacother 37:564–570. CrossRefPubMedGoogle Scholar
  15. 15.
    Knopp-Sihota JA, Newburn-Cook CV, Homik J, Cummings GG, Voaklander D (2012) Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Osteoporos Int 23:17–38. CrossRefPubMedGoogle Scholar
  16. 16.
    Knopp JA, Diner BM, Blitz M, Lyritis GP, Rowe BH (2005) Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int 16:1281–1290CrossRefGoogle Scholar
  17. 17.
    Longo UG, Loppini M, Denaro L, Maffulli N, Denaro V (2012) Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature. J Bone Jt Surg Br 94:152–157. CrossRefGoogle Scholar
  18. 18.
    Dusdal K, Grundmanis J, Luttin K, Ritchie P, Rompre C, Sidhu R, Harris SR (2011) Effects of therapeutic exercise for persons with osteoporotic vertebral fractures: a systematic review. Osteoporos Int 22:755–769. CrossRefPubMedGoogle Scholar
  19. 19.
    Giangregorio LMM, Macintyre NJ, Thabane L, Skidmore CJ, Papaioannou A (2013) Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 1:CD008618. CrossRefGoogle Scholar
  20. 20.
    Giele BM, Wiertsema SH, Beelen A, van der Schaaf M, Lucas C, Been HD, Bramer JA (2009) No evidence for the effectiveness of bracing in patients with thoracolumbar fractures. Acta Orthop 80:226–232. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Chen LX, Li YL, Ning GZ, Li Y, Wu QL, Guo JX, Shi HY, Wang XB, Zhou Y, Feng SQ (2015) Comparative efficacy and tolerability of three treatments in old people with osteoporotic vertebral compression fracture: a network meta-analysis and systematic review. PLoS One 10:e0123153. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Rzewuska M, Ferreira M, McLachlan AJ, Machado GC, Maher CG (2015) The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis. Eur Spine J 24:702–714. CrossRefPubMedGoogle Scholar
  23. 23.
    Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C (2009) An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol 62(9):944–952CrossRefGoogle Scholar
  24. 24.
    McGowan JSM, Lefebvre C (2010) An evidence based checklist for the peer review of electronic search strategies. Evid Based Libr Inf Pract 5(1):149–154CrossRefGoogle Scholar
  25. 25.
    Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Slavin RE (1995) Best evidence synthesis: an intelligent alternative to meta-analysis. J Clin Epidemiol 48:9–18CrossRefGoogle Scholar
  27. 27.
    Viera AJ, Garrett JM (2005) Understanding interobserver agreement: the kappa statistic. Fam Med 37:360–363PubMedGoogle Scholar
  28. 28.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ (Clinical research ed) 339:b2535. CrossRefGoogle Scholar
  29. 29.
    Chou R, Hashimoto R, Friedly J, Fu R, Dana T, Sullivan S, Bougatsos C, Jarvik J (2015) AHRQ Technology assessments. In: Pain management injection therapies for low back Pain. Agency for Healthcare Research and Quality (US), Rockville (MD)Google Scholar
  30. 30.
    National Institute for Health and Care Excellence (NICE) (2012) The guidelines manual. Accessed 16 May 2016
  31. 31.
    de Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BC (2009) Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int 20:2111–2125. CrossRefPubMedGoogle Scholar
  32. 32.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778. CrossRefPubMedGoogle Scholar
  33. 33.
    Bajaj S, Saag KG (2003) Osteoporosis: evaluation and treatment. Curr Womens Health Rep 3:418–424PubMedGoogle Scholar
  34. 34.
    Anonymous (2000) Osteoporosis prevention, diagnosis, and therapy. NIH Consens Statement 17:1–45Google Scholar
  35. 35.
    Hough SM, Mahlati MP (2000) Diagnosis and management of osteoporosis-full guideline. S Afr Med J 90:907–944PubMedGoogle Scholar
  36. 36.
    Coggins ME (1995) Nonunions and malunions of thoracolumbar spine injuries. Semin Spine Surg 7:137–140Google Scholar
  37. 37.
    Consoli V, Alfieri P, Giuntini C, Mancia M, Avaldi F, Soncini R (1991) A double blind placebo-controlled trial of the efficacy and tolerability of intranasal elcatonin administered to patients suffering from senile and postmenopausal osteoporosis. Curr Ther Res 50:369–378Google Scholar
  38. 38.
    Vorsanger GJ, Farrell J, Xiang J, Chow W, Moskovitz BL, Rosenthal NR (2013) Tapentadol, oxycodone or placebo for acute pain of vertebral compression fractures: a randomized Phase IIIb study. Pain Manag 3:109–118. CrossRefPubMedGoogle Scholar
  39. 39.
    Zhang THD, YH, Yu SM, Zhnag C, Ya B (2013) Analgesics osteoporotic fracture healing. J Clin Rehabil Tissue Eng Res 17:6364-6374Google Scholar
  40. 40.
    World Health Organization WHO’s cancer pain ladder for adults. Accessed 5 Feb 2017
  41. 41.
    Lyritis GP, Ioannidis GV, Karachalios T, Roidis N, Kataxaki E, Papaioannou N, Kaloudis J, Galanos A (1991) Analgesic effect of salmon calcitonin in osteoporotic vertebral fractures: a double-blind placebo-controlled clinical study. Calcif Tissue Int 49:369–372CrossRefGoogle Scholar
  42. 42.
    Lyritis GP, Paspati I, Karachalios T, Ioakimidis D, Skarantavos G, Lyritis PG (1997) Pain relief from nasal salmon calcitonin in osteoporotic vertebral crush fractures. A double blind, placebo-controlled clinical study. Acta Orthop Scand Suppl 275:112–114CrossRefGoogle Scholar
  43. 43.
    Lyritis GP, Ioannidis GV, Karachalios T, Roidis N, Kataxaki E, Papaioannou N, Kaloudis J, Galanos A (1999) Analgesic effect of salmon calcitonin suppositories in patients with acute pain due to recent osteoporotic vertebral crush fractures: a prospective double-blind, randomized, placebo-controlled clinical study. Clin J Pain 15:284–289CrossRefGoogle Scholar
  44. 44.
    Pontiroli AE, Pajetta E, Scaglia L, Rubinacci A, Resmini G, Arrigoni M, Pozza G (1994) Analgesic effect of intranasal and intramuscular salmon calcitonin in post-menopausal osteoporosis: a double-blind, double-placebo study. Aging (Milan, Italy) 6:459–463Google Scholar
  45. 45.
    Flynn JA, Choi MJ, Wooster LD (2013) Oxford American handbook of clinical medicine. Oxford University Press, New YorkGoogle Scholar
  46. 46.
    Carroll R, Matfin G (2010) Endocrine and metabolic emergencies: hypercalcaemia. Ther Adv Endocrinol Metab 1:225–234. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Giangregorio LM, Macintyre NJ, Thabane L, Skidmore CJ, Papaioannou A (2013) Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev. CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Bergland A, Thorsen H, Karesen R (2011) Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial. Osteoporos Int 22:1863–1871. CrossRefPubMedGoogle Scholar
  49. 49.
    Malmros B, Mortensen L, Jensen MB, Charles P (1998) Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporos Int 8:215–221. CrossRefPubMedGoogle Scholar
  50. 50.
    Papaioannou A, Adachi JD, Winegard K, Ferko N, Parkinson W, Cook RJ, Webber C, McCartney N (2003) Efficacy of home-based exercise for improving quality of life among elderly women with symptomatic osteoporosis-related vertebral fractures. Osteoporos Int 14:677–682. CrossRefPubMedGoogle Scholar
  51. 51.
    Yang LH, Cheng-qi H, Lei Z, Xie W, Lan Q (2007) Effect of pain-free exercises on female osteoporosis patients with spinal compressive fracture. J Clin Rehabil Tissue Eng Res 11:9108–9111Google Scholar
  52. 52.
    Pfeifer M, Kohlwey L, Begerow B, Minne HW (2011) Effects of two newly developed spinal orthoses on trunk muscle strength, posture, and quality-of-life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil 90:805–815. CrossRefPubMedGoogle Scholar
  53. 53.
    Bautmans I, Van Arken J, Van Mackelenberg M, Mets T (2010) Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis. J Rehabil Med 42:129–135. CrossRefPubMedGoogle Scholar
  54. 54.
    Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, Larsen J, Wark J (2010) Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 11:36. CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Gold DT, Shipp KM, Pieper CF, Duncan PW, Martinez S, Lyles KW (2004) Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial. J Am Geriatr Soc 52:1471–1478. CrossRefPubMedGoogle Scholar
  56. 56.
    World Health Organization (2012) Scoping document for WHO guidelines for the pharmacological treatment of persisting pain in adults with medical illnesses. In: Pain TGo (ed). Accessed 5 Feb 2017
  57. 57.
    Morrison A, Polisena J, Husereau D, Moulton K, Clark M, Fiander M, Mierzwinski-Urban M, Clifford T, Hutton B, Rabb D (2012) The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies. Int J Technol Assess Health Care 28:138–144. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2018

Authors and Affiliations

  1. 1.University of Montreal Faculty of Medicine Certification Program in Insurance Medicine and MedicoLegal ExpertiseMontrealCanada
  2. 2.Canadian Society of Medical EvaluatorsTorontoCanada
  3. 3.University of Ontario Institute of Technology (UOIT)-Canadian Memorial Chiropractic College (CMCC) Centre for Disability Prevention and RehabilitationTorontoCanada
  4. 4.Department of Epidemiology, School of Public HealthUniversity of California Los AngelesLos AngelesUSA
  5. 5.Department of NeurologyUniversity of CaliforniaIrvineUSA
  6. 6.World Spine CareSanta AnaUSA
  7. 7.Department of Medical Informatics and Clinical Epidemiology and Department of MedicineOregon Health and Science UniversityPortlandUSA
  8. 8.Office of Public Health StudiesUniversity of HawaiiHonoluluUSA
  9. 9.Department of Orthopedic Surgery and Environmental MedicineNew York UniversityNew YorkUSA
  10. 10.World Spine Care EuropeHolmfirthUK

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