Identifying Women with Low Bone Mass: A Systematic Review of Screening Tools

Screening for Osteoporosis Risk Among Community-Dwelling Older Adults: A Scoping Review

BACKGROUND AND PURPOSE

Due to potential health-related consequences of osteoporosis (OP), health care providers who do not order imaging, such as physical therapists, should be aware of OP screening tools that identify individuals who need medical and rehabilitation care. However, current knowledge and guidance on screening tools is limited. Therefore, we explored OP screening tools that are appropriate and feasible for physical therapy practice, and evaluated tools' effectiveness by examining their clinimetric properties.

METHODS

A systematic search of the following databases was performed: PubMed, PEDro, PsycINFO, CINAHL, and Web of Science. Articles were included if the study population was 50 years and older, had a diagnosis of OP, if the screening tool was within the scope of physical therapy practice, and was compared to either a known diagnosis of OP or bone densitometry scan results. Included articles underwent multiple reviews for inclusion and exclusion, with each review round having a different randomly selected pair of reviewers. Data were extracted from included articles for participant demographics, outcome measures, cut-off values, and clinimetric properties. Results were categorized with positive and negative likelihood ratios (+LR/-LR) based on the magnitude of change in the probability of having or not having OP.

RESULTS

+LRs ranged from 0.15 to 20.21, with the Fracture Risk Assessment Tool (FRAX) and Study of Osteoporotic Fractures (SOF) having a large shift in posttest probability. -LRs ranged from 0.03 to 1.00, with the FRAX, Male Osteoporosis Risk Estimation Scores, Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation having a large shift in posttest probability.

CONCLUSION

Tools with moderate-large shift for both +LR and -LR recommended for use are: (1) OST; (2) FRAX; and (3) SOF. The variability in cut-off scores and clinimetric properties based on gender, age, and race/ethnicities made it impossible to provide one specific recommendation for an OP screening tool. Future research should focus on OP risk prediction among males and racial and ethnic groups.

Prescreening for Osteoporosis With Quantitative Ultrasound in Postmenopausal White Women

OBJECTIVES

Calcaneal quantitative ultrasound (QUS) is a readily accessible and radiation-free alternative to dual-energy x-ray absorptiometry (DXA) for assessing bone mineral density (BMD). Results obtained from QUS measurement cannot directly be compared to DXA, since these techniques capture different bone-specific parameters. To identify individuals who are likely to have osteoporosis by DXA, device-specific thresholds have to be defined for QUS. This cross-sectional study evaluated the accuracy of QUS to identify postmenopausal women with osteoporosis, defined as a T score of -2.5 SDs or lower by DXA, and to calculate device-specific cutoff values for the QUS device investigated.

METHODS

We assessed BMD at the lumbar spine, bilateral femoral neck, and total hip sites with DXA and QUS parameters of the right and left calcanei in a cohort of 245 postmenopausal treatment-naïve women between 40 and 82 years. Correlation coefficients for BMD and QUS parameters were calculated. Receiver operating characteristic curves were generated, and areas under the curves (AUCs) were evaluated. Cutoff values for QUS were defined.

RESULTS

Calcaneal QUS had the ability to identify postmenopausal women with a T score of -2.5 or lower at the right hip (AUC, 0.887) and left femoral neck (AUC, 0.824). Cutoff values for the QUS T scores at the right (-1.455) and left (-1.480) calcanei were defined for screening purposes.

CONCLUSIONS

This study provides insights into the comparative performance of QUS with DXA. Considering the diagnostic accuracy of this modality in comparison to DXA, it can be recommended as a prescreening tool to reduce the number of DXA screenings.

Osteoprotective Effects of Polysaccharide-Enriched Hizikia fusiforme Processing Byproduct In Vitro and In Vivo Models

The traditional manufacturing method used to produce goods from Hizikia fusiforme, utilizes extraction steps with hot water. The byproduct (of hot water extraction) is rich in polysaccharide and is considered a waste. To evaluate the osteogenic effects of the byproduct of H. fusiforme (HFB), osteogenic cells and animal models were used to test it effects on osteogenesis. The HFB-treated mouse myoblast C2C12 cells exhibited significant dose dependently elevated alkaline phosphatase (ALP) activity and slightly increased bone morphogenetic protein-2 (BMP-2). HFB also suppressed the formation of tartrate-resistant acid phosphatase (TRAP) activity and TRAP staining in the bone marrow-derived macrophages (BMM) cells that had been stimulated with the receptor activator of the nuclear factor kB ligand/macrophage colony-stimulating factor kB ligand. In addition, HFB also increased the phosphorylation of extracellular signal-regulated protein kinase (p-ERK) level. Finally, osteogenic effects of HFB were clearly confirmed in the three in vivo models: zebrafish, ovariectomized mice, and mouse calvarial bones. HFB accelerated the rate of skeletal development in zebrafish and prevented much of the mouse femoral bone density loss of ovariectomized mice. Moreover, HFB enhanced woven bone formation over the periosteum of mouse calvarial bones. Our result showed that HFB functions as a bone resorption inhibitor as well as an activator of bone formation in vivo and in osteogenic in vitro cell systems.

A Description of How Advanced Practice Nurses Screen for Osteoporosis in Maryland

Osteoporosis is a major health problem in the United States, yet the evidence suggests that practitioners often fail to screen for osteoporosis risk and, as a result, underdiagnose and fail to treat the disease. Because little is known about how well advanced practice nurses (APNs) evaluate osteoporotic risk, determining the extent to which they screen may enhance our understanding of the scope of APN diagnostic practice. The purpose of this study was 3-fold: (a) to determine if APNs routinely screen for osteoporotic risks, (b) to ascertain how they screen, and (c) to identify barriers that influence osteoporosis screening. Survey methods were used to poll members of the Nurse Practitioner Association of Maryland (n = 357) who identified themselves as adult, family, geriatric, and women’s health nurse practitioners. The results suggest that master’s-prepared APNs screen for osteoporosis more so than APNs with doctor of nursing practice (DNP) degrees. In addition, adult APN screened more often than family APNs and APNs in urban areas screened more frequently than rural-based APNs. Logistic regression failed to predict which APNs were likely to screen for osteoporosis.

Performance of the Osteoporosis Self-Assessment Tool for Asians (OSTA) in Screening Osteoporosis Among Middle-Aged and Old Women in the Chengdu Region of China

The purpose of this study was to assess the performance of an osteoporosis self-assessment tool for Asians (OSTA) for screening middle-aged and old healthy women in the Chengdu region of China. OSTA scores were used to evaluate the effect of age on the development of osteoporosis. A total of 15,752 healthy women older than 40 yr, who reside in the Chengdu region, were assigned to 9 age groups divided by 5-yr intervals. Bone mineral density of the lumbar vertebrae, L1-L4, and the left hip was measured with a GE Lunar Prodigy advance dual-energy X-ray absorptiometry system (GE Healthcare, Cincinnati, OH). All subjects were classified into 3 categories according to OSTA cutoff values. The OSTA values used to define the categories were ≥-1, >-4 and <-1, and ≤-4. The accuracy of the OSTA index was compared with T-scores measured by dual-energy X-ray absorptiometry at various skeletal sites. All statistical analyses were performed using SPSS, version 17.0 (SPSS, Inc., Chicago, IL). The detection rate of osteoporosis and osteopenia at the lumbar vertebrae and the femur was found to increase with age. Furthermore, the sensitivity of OSTA value for detection of osteoporosis also gradually enhanced with subject age. In contrast, the specificity gradually decreased with age. The sensitivity and negative predictive value of the OSTA index for detecting osteoporosis gradually increased with higher OSTA cutoff values, and the specificity and positive predictive value appeared to gradually decline. It was concluded that the OSTA is a useful screening tool to detect osteoporosis in middle-aged and old women in the Chengdu region of China. Furthermore, specific OSTA cutoff values should be selected for screening individuals who belong to different age groups.

Discriminatory Performance of the Calcaneal Quantitative Ultrasound and Osteoporosis Self-Assessment Tool to Select Older Women for Dual-Energy X-ray Absorptiometry

The objective of this cross-sectional study was to evaluate the accuracy of the calcaneal quantitative ultrasound (QUS) and the Osteoporosis Self-Assessment Tool (OST) in identifying older women with osteoporosis as defined by dual-energy X-ray absorptiometry (DXA), and to establish optimal cutoffs to determine risk. We assessed bone mineral density of the femoral neck and lumbar spine using DXA and subsequent calcaneal QUS and OST measurements in 174 women aged 50-80 years. Pearson product correlation coefficients between QUS, OST, and DXA parameters were calculated. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) and optimal thresholds for QUS and OST were defined based on sensitivity, specificity, and likelihood ratio analysis. The ability of calcaneal QUS to identify women with a T-score ≤-2.5 at the femoral neck (AUC = 0.892) consistently outperformed a T-score ≤-2.5 at the lumbar spine (AUC = 0.696) and OST at both the femoral neck and lumbar spine (AUC = 0.706-0.807). Stiffness index cutoff values that fall between 65 and 78 were found to warrant DXA screening, with a cutoff <65 indicating high likelihood of osteoporosis. Further prospective research is needed to examine the gender-related differences of QUS and OST diagnostic performance and their usefulness in clinical practice.

Risk assessment tools to identify women with increased risk of osteoporotic fracture: complexity or simplicity? A systematic review

A huge number of risk assessment tools have been developed. Far from all have been validated in external studies, more of them have absence of methodological and transparent evidence, and few are integrated in national guidelines. Therefore, we performed a systematic review to provide an overview of existing valid and reliable risk assessment tools for prediction of osteoporotic fractures. Additionally, we aimed to determine if the performance of each tool was sufficient for practical use, and last, to examine whether the complexity of the tools influenced their discriminative power. We searched PubMed, Embase, and Cochrane databases for papers and evaluated these with respect to methodological quality using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist. A total of 48 tools were identified; 20 had been externally validated, however, only six tools had been tested more than once in a population-based setting with acceptable methodological quality. None of the tools performed consistently better than the others and simple tools (i.e., the Osteoporosis Self-assessment Tool [OST], Osteoporosis Risk Assessment Instrument [ORAI], and Garvan Fracture Risk Calculator [Garvan]) often did as well or better than more complex tools (i.e., Simple Calculated Risk Estimation Score [SCORE], WHO Fracture Risk Assessment Tool [FRAX], and Qfracture). No studies determined the effectiveness of tools in selecting patients for therapy and thus improving fracture outcomes. High-quality studies in randomized design with population-based cohorts with different case mixes are needed.

Integration of critically appraised topics into evidence-based physical therapist practice

Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies.

A clinical decision rule to enhance targeted bone mineral density testing in healthy mid-life women

SUMMARY

The rates of bone mineral density testing for osteoporosis among healthy mid-life women are high, although their osteoporosis or fracture risk is low. To reduce unnecessary testing, we created and evaluated a tool to guide bone density testing based on the woman's age, weight, fracture history, and menopausal status.

INTRODUCTION

This study aims to improve case finding of mid-life women with low bone mass on bone mineral density (BMD) assessment.

METHODS

Among healthy women aged 40-60 years having their first BMD test, osteoporosis risk factors were assessed by questionnaire and BMD by dual-energy X-ray absorptiometry. The combination of risk factors that best discriminated women with/without low bone mass (T-score ≤ -2.0) was determined from the logistic regression model area under the curve (AUC) and internally validated using bootstrapping. Using the model odds ratios, a clinical prediction rule was created and its discriminative properties assessed and compared with that of the osteoporosis self-assessment tool (OST). Sensitivity analyses examined results for pre-/peri- and post-menopausal women, separately.

RESULTS

Of 1,664 women referred for baseline BMD testing, 433 with conditions known to be associated with bone loss were excluded. Of 1,231 eligible women, 944 (77%) participated and 87 (9.2%) had low bone mass (35 pre-/peri- and 52 post-menopausal). Four risk factors for low bone mass were identified and incorporated into a clinical prediction rule. Selecting women for BMD testing with weight of ≤70 kg or any two of age >51, years' post-menopause of ≥1, and history of fragility fracture after age 40 was associated with 93% sensitivity to identify women with low bone mass, compared with 47% sensitivity for an OST score of ≤1 (AUC 0.75 versus OST AUC 0.69, p = 0.04). Results restricted to post-menopausal women were similar.

CONCLUSIONS

Among healthy mid-life women receiving a baseline BMD test, few had low bone mass, supporting the need for guidance about testing. A prediction rule with four risk factors had improved sensitivity over the OST. Further validation is warranted.

Criteria for the prescription of oral bisphosphonates for the treatment of osteoporosis in a series of women referred for tooth extraction

Objective: To evaluate the criteria for the prescription of oral bisphosphonates (OB) in a series of women with osteoporosis referred for tooth extraction. Study design: The study included 38 postmenopausal women on treatment with OBs. The following variables were analysed: age, weight, height, type of OB and duration of treatment, bone densitometry and risk factors for osteoporosis. In addition, the osteoporosis self-assessment tool (OST) was administered and collagen type I C-telopeptide (CTX) levels were measured. Results: Bone densitometry had only been performed in six patients (15.7%) before starting OB treatment. Based on the results of the OST, nine (23.6%) of the participants presented a low risk of osteoporosis. CTX levels were measured in 23 patients: 11 (47.8%) presented values below 150 pg/ml. Conclusion: Although all patients in the present series were on treatment with OBs, a large percentage did not satisfy the criteria for the initiation of treatment for postmenopausal osteoporosis.

Key words:Osteoporosis, oral bisphosphonates, osteonecrosis of the jaws.

Quinoxaline derivative of oleanolic acid inhibits osteoclastic bone resorption and prevents ovariectomy-induced bone loss

OBJECTIVE

Through bioassay-guided natural product research, it has been discovered that oleanolic acid and its glycosides possess an antibone resorption activity. Quinoxaline derivative of oleanolic acid (QOA-8a), a novel compound, is sourced from a structural modification of oleanolic acid. The aim of the present study was to evaluate the activities of QOA-8a on bone resorption in vitro and its osteoprotective effect in vivo.

METHODS

Osteoclast precursors and mature osteoclasts were used to assay antibone resorption activities in vitro. RAW264.7 cells cultured for 2 days in the presence of the receptor activator for nuclear factor κB ligand were used as osteoclast precursors. Mature osteoclasts were generated from either primary cultures of mouse bone marrow-derived macrophages or RAW264.7 cells. Eight-week-old female mice that underwent either ovariectomy or sham surgical operation were used for the evaluation of the osteoprotective effect of QOA-8a at doses of 0.1, 1, and 10 mg kg(-1) day(-1).

RESULTS

QOA-8a significantly inhibited the differentiation, formation, and bone resorptive activity of mature osteoclasts without cytotoxicity. QOA-8a selectively induced apoptosis at an early stage of mature osteoclasts at least via increasing the caspase-3 activity, but not osteoclast precursors. Furthermore, QOA-8a significantly prevented bone loss in ovariectomized mice without any hormone-like adverse effects, whereas the mice treated with 1 mg kg(-1) day(-1) kept the same bone mineral density level as that of the sham mice.

CONCLUSIONS

QOA-8a inhibits bone resorption without cytotoxicity and prevents bone loss without any hormone-like adverse effects. Although further investigations are necessary to elucidate the detailed molecular mechanisms, QOA-8a demonstrates great potential as a novel agent for the treatment of osteoporosis.

Developing a Malaysian Osteoporosis Screening Tool (MOST) for early osteoporosis detection in Malaysian women

BACKGROUND

Osteoporotic fracture is a major health burden. Early diagnosis and management would improve the quality of life and reduce costs to the society.

OBJECTIVE

We aimed to identify risk factors associated with osteoporosis followed by development and validation of a screening tool in the hope of providing an appropriate regime to detect low bone density (BMD) in Malaysia.

METHODOLOGY

Between November 1999 and November 2002, 514 healthy women aged ≥ 45 with intact uterus, non-HRT users were recruited. Following BMD testing, a screening tool was developed. For validation, 72 women were recruited from June 2003 to December 2003.

RESULTS

Age and a longer duration postmenopause were negatively linked to BMD. Higher family income, BMI, waist and hip circumference were positively correlated. A score of ≥ 4, the screening tool had a sensitivity of 73.2%, a specificity of 61.6% for identifying women with low BMD (T score ≤ -2) plus a sensitivity of 80.2% in selecting women with osteoporosis. The tool enabled a 45.9% reduction in unnecessary DEXA testing. Validation of the screening tool showed a negative predictive value of 97.8%, sensitivity and specificity of 87.5% and 70.3%, respectively.

CONCLUSION

The Malaysian Osteoporosis Screening Tool (MOST) is relatively simple. Its usage may reduce unnecessary DEXA test.

A gel-based proteomic analysis of the effects of green tea polyphenols on ovariectomized rats

OBJECTIVE

Our recent study demonstrated the protective action of green tea polyphenols (GTPs) against bone loss in ovariectomized (OVX) rats through their antioxidant capacities to scavenge reactive oxygen species. The objective of the present study was to evaluate the alterations of liver protein profiles in estrogen-deficient middle-aged rats after GTP treatment by a gel-based proteomic approach. This may lead to understanding the mechanisms of GTPs in promoting bone health.

METHODS

Liver samples were obtained from 14-mo-old female OVX rats treated with no GTPs (OVX) or 0.5% (w/v) GTPs (OVX + GTP) in drinking water for 16 wk (n = 10/group). Two-dimensional difference gel electrophoresis combined with mass spectrometry was used to compare the liver protein profiles of pooled samples from the OVX and OVX + GTP groups. Liver proteins were labeled in duplicate by reversing the fluorescent dyes.

RESULTS

Approximately 800 protein spots were detected. The expression levels of superoxide dismutase-1 and adenosine triphosphate synthase were 2.0-fold and 1.5-fold higher in the OVX + GTP group versus the OVX group, respectively, whereas the expression level of catechol-O-methyltransferase was 1.5-fold lower in the OVX + GTP group versus the OVX group. The changes of superoxide dismutase-1 and catechol-O-methyltransferase in individual liver samples were confirmed by western blots.

CONCLUSION

Our data provide further evidence for the antioxidant role of GTPs by increasing superoxide dismutase-1 and adenosine triphosphate synthase and the estrogen-associated effect of GTPs by decreasing catechol-O-methyltransferase.

Review of osteoporosis pharmacotherapy for geriatric patients

BACKGROUND

Fractures are a significant problem in geriatric patients, and understanding the evidence for benefit and possible harm of osteoporosis treatments is critical to appropriate management of this patient population.

OBJECTIVE

The purpose of this article was to review the evidence and treatment considerations related to use of the approved osteoporosis treatments in the United States across the continuum of ages in the geriatric population.

METHODS

MEDLINE and the Web of Science were searched to find English-language articles published from 2000 through July 2009. Search terms included: practice guideline, osteoporosis, calcium, vitamin D, pharmacoeconomics, ethnicity, and treatment. The generic names of each of the osteoporosis treatments approved in the United States were searched to find relevant clinical trials and randomized controlled trials (RCTs). Pivotal trials that included fracture data or focused specifically on elderly patients (> or = 60 years of age) were selected. Bibliographies in the identified articles were searched for additional articles, and the prescribing information for each of the approved treatments was reviewed.

RESULTS

Many osteoporosis studies have a mean patient age >60 years, but data for older patients are limited. Subanalyses of older patient groups have found risedronate to be beneficial for vertebral fractures in patients aged 70 to 79 years (absolute risk reduction [ARR], 8.4%; P < 0.001) and teriparatide to be beneficial for both vertebral (ARR, 6.4%; P < 0.05) and new nonvertebral fragility fractures (ARR, 9.9%; P < 0.05) in women aged > or = 75 years. However, no RCTs of geriatric patients who were either nonambulatory or had multiple comorbidities were identified in the literature.

CONCLUSIONS

Evidence indicates that the osteoporosis treatments currently available in the United States are beneficial for treating osteoporosis in geriatric patients. However, data are limited for the oldest patients (> or = 80 years) and those with significant comorbidities. Because of the limited availability of data for geriatric patients with significant comorbidities, the properties of the various agents, including efficacy, tolerability, and potential contraindications, should be considered carefully for each geriatric patient.

The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity

The clinical diagnosis of an osteoporotic vertebral compression fracture (OVCF) is challenging and requires detailed assessment using comprehensive imaging methods. Further complicating matter is that the clinical sequelae associated with OVCF typically involves asymptomatic findings and variable pain patterns. The purpose of this study was to identify clinical characteristics and assessment findings that were associated with a diagnosis of OVCF. The study evaluated routine clinical findings in over 1400 subjects seen at an adult spine surgery clinic for thoracolumbar spine-related conditions within the years 2005-2009. All patients underwent a standardized clinical examination that included a self-report, observational, physical examination and imaging assessment. The diagnosis of OVCF was made after assessment of radiographic findings in sagittal alignment, vertebral body compression, and spinal canal dimensions. Data from the patient history and observational findings were then statistically analyzed and compared between those patients with a diagnosis of OVCF and those with an alternative diagnosis. Based on the results, a diagnostic support tool was created to predict the likelihood of OVCF. The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index ⩽ 22; (4) does not exercise regularly; and (5) female gender. A finding of two of five positive tests or less demonstrated high sensitivity of 0.95 (95% CI  =  0.83-0.99) and low negative likelihood ratio of 0.16 (95% CI  =  0.04-0.51), providing moderate value to rule out OVCF. Four of five yielded a positive likelihood ratio (LR+) of 9.6 (95% CI  =  3.7-14.9) providing moderate value in ruling in the diagnosis of OVCF. Further validation is necessary prospectively to determine the value of these findings on a disparate sample of patients in other unique environments.

Osteoprotective effect of extract from Achyranthes bidentata in ovariectomized rats

AIM OF THE STUDY

A Chinese herbal drug, root of Achyranthes bidentata showed a potent inhibitory activity on bone resorption induced by parathyroid hormone (PTH) in a bone organ culture using neonatal mouse parietal bones. The present study is to clarify the fractions responsible for the activity and further explore the osteoprotective effect of the fraction in vivo.

MATERIALS AND METHODS

The hexane, ethyl acetate (EtOAc), n-butanol (n-BuOH) and water soluble fractions of methanol extract of the root of Achyranthes bidentata were prepared and screened for their anti-bone resorption activity using the bone organ culture system. The n-BuOH soluble fraction was further administered orally at doses of 25, 50 and 100mg/(kgday) to ovariectomized (OVX) rats. The analyses of the rat body weight, serum estradiol (E2), total cholesterol and triglyceride levels, uteri weight and measurement of bone mineral density (BMD) were conducted.

RESULTS

The EtOAc and n-BuOH fractions showed the most potent inhibitory activity on PTH-induced bone resorption. Further research using OVX rat model revealed that the n-BuOH fraction significantly prevented BMD loss due to OVX operation. While, the uteri weight and serum estradiol (E2), total cholesterol and triglyceride levels displayed no differences compared with those of control group (OVX rats), suggesting the n-BuOH fraction should have no estrogen-like side effects.

CONCLUSIONS

The results reveal that the n-BuOH soluble fraction of the root of Achyranthes bidentata is effective at preventing bone loss in OVX rats and has a great potential as an alternative tool for the treatment of osteoporosis.