Vertebral Fractures

Our vertebral fractures research programme is led by Prof Emma Clark. The main aim is to improve the identification and management of older people with osteoporotic vertebral fractures.

A major component of this research programme is clear identification of the symptoms and impact of osteoporotic vertebral fractures. Our work has identified that the type of back pain and other symptoms described by women with vertebral fractures is different to that described by women with osteoarthritis of the back[1-3]. We have also identified that women with vertebral fractures have a reduced quality of life, mainly due to a reduction in physical functioning [4-6].


Using the differences in symptoms we have identified between those with and without vertebral fractures, we have studied the benefits of a screening programme aimed at older women in the community, utilising the Cohort for Skeletal Health in Bristol and Avon (COSHIBA)[7]. This work has been funded by Arthritis Research UK. Results were encouraging, but identified this was unlikely to be a cost-effective approach, and that screening needed to be targeted. Because of this we are currently developing a new screening tool called Vfrac[8], aimed at older women with back pain. Vfrac is funded by Versus Arthritis and is recruiting a new cohort of 1600 older women with back pain. The new screening tool should be available for testing in 2021.

Clinical Guidance for the Effective Identification of Vertebral Fractures

Another important area of work is focusing on diagnosis of osteoporotic vertebral fractures from spinal images such as X-ray or CT scan. This is important because a key component of improving the management of people with vertebral fractures is ensuring every spinal image where a vertebral fracture is present is reported clearly and correctly[9]. Dr Emma Clark has worked with the Royal Osteoporosis Society to develop the Clinical Guidance for the Effective Identification of Vertebral Fractures ( In collaboration with Dr Ken Poole from the University of Cambridge (, and funded by the NIHR, we are currently working on improving the opportunistic identification of vertebral fractures on CT scans performed for other clinical reasons.


Finally, we are also researching interventions to improve management of people with osteoporotic vertebral fractures. One important component is physiotherapy and we have identified this is safe[10], and that simple interventions such as taping may be helpful[11]. In collaboration with Dr Alex Ireland at Manchester University, we are currently researching the quantity and type of physical activity in people with back pain with and without vertebral fractures. This study is called PAVE and is funded by the Royal Osteoporosis Society.

In terms of medications to reduce risk of further fractures we have identified that poor adherence is often due to misunderstanding how to take the medication[12]. In collaboration with Dr Zoe Paskins from Keele University we are carrying out a study to optimise decision-making and communication about these medications during face-to-face consultations, ( This study is called iFRaP and is funded by the Royal Osteoporosis Society.


[1] Clark EM, Hutchinson AP, McCloskey EV, Stone MD, Martin JC, Bhalla AK, Tobias JH (2010) Lateral back pain identifies prevalent vertebral fractures in postmenopausal women: cross-sectional analysis of a primary-care based cohort. Rheumatology, 49(3): 505 – 512

[2] Clark EM, Gooberman-Hill R, Peters TJ (2016) Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes. Osteopor Int 27:1459-1467

[3] Drew S, Clark EM, Al-Sari U, Moore A, Gooberman-Hill R (2019) Neglected bodily senses in women living with vertebral fractures: a focus group study. Rheumatology doi:10.1093/rheumatology/kez249

[4] Al-Sari UA, Tobias JH, Clark EM (2016) Health related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis. Osteopor Int 27(10):2891-2900

[5] Al-Sari UA, Tobias JH, Clark EM (2017) Self-reported everyday physical activities in older people with vertebral fractures: a systematic review and meta-analysis. Osteop Int OSIN-D-17-00441R2.

[6] Al-Sari U, Tobias JH, Clark EM (2018). Impact of mild and moderate/severe vertebral fractures on physical activity: A prospective study of older women in the UK. Osteoporosis International OSIN-D-18-00421R1

[7] Clark EM, Gould VC, Morrison L, Ades AE, Dieppe P, Tobias JH (2012) Randomized controlled trial of a primary care-based screening programme to identify older women with prevalent osteoporotic vertebral fractures: Cohort for Skeletal Health in Bristol and Avon (COSHIBA). Journal of Bone and Mineral Research DOI: 10.1002/jbmr.1478

[8] Khera T, Burston A, Davis S, Drew S, Gooberman-Hill R, Paskins Z, Peters TJ, Tobias JH & Clark EM. (2019) An observational cohort study to produce and evaluate an improved tool to screen older women with back pain for osteoporotic vertebral fractures (Vfrac): Study protocol. Archives of Osteoporosis OSIN-D-18-00680R1

[9] Oei L, Koromani F, Breda SJ et al (2017) Osteoporotic vertebral fracture prevalence varies widely between radiological assessment methods: The Rotterdam Study. J Bone Miner Res DOI 10.1002/jbmr.3220

[10] Kunutsor SK, Leyland S, Skelton DA, James L, Cox M, Gibbons N, Whitney J, Clark EM (2018). Adverse events and safety issues associated with physical activity and exercise for adults with osteoporosis and osteopaenia: A systematic review of observational studies and an updated review of interventional studies. Journal of Frailty, Sarcopenia and Falls. 3(4):155-178.

11] Palmer S, Barnett S, Cramp M, Berry A, Thomas A, Clark EM (2018) Effects of postural taping on pain, function and quality of life following osteoporotic vertebral fractures – a feasibility trial. Musculoskeletal Care 16(3):345-352. doi: 10.1002/msc.1350.

[12] Clark EM, Gould VC, Tobias JH, Horne R (2016) Natural history, reasons for, and impact of low/non-adherence to medications for osteoporosis in a cohort of community dwelling older women already established on medication: a 2-year follow-up study. Osteopor Int 27:579-590

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