FRAX®: a fracture risk-assessment tool

Use of a fracture prevention screening algorithm predicts self-reported falls in postmenopausal women

Background and Purpose: The prevention of falls and fall-related fractures following menopause is an important health initiative. The Fracture Prevention Screening Algorithm (FPSA) uniquely uses fracture risk to prompt fall risk assessment to classify both fall and fracture risk in individuals. The purpose of this study was to determine whether use of the FPSA accurately predicted self-reported falls in post-menopausal women over one year. Methods: 142 postmenopausal women were recruited. Based on Fracture Risk Assessment Tool (FRAX®) scores, women with a ≥3% 10-year probability of hip fracture (high risk), or who self-identified as having balance problems or a fall history, underwent the Functional Gait Assessment (FGA) to estimate fall risk (high risk = ≤22/30). This allowed classification on the FPSA into one of four risk categories: low fall/low fracture risk; low fall/high fracture risk; high fall/low fracture risk; high fall/high fracture risk. Participants were contacted monthly for one year to determine fall and injury occurrence. Results: Fall/injury surveillance was conducted with 136 subjects over one year. Compared to women in the low fall/low fracture risk group, both high fall risk groups demonstrated significantly greater fall rates. Falls were 81-89% more likely in women with FGA scores of 22/30 or less. All injuries were rare events across all risk strata and did not differ between risk groups. Conclusion: These findings support the use of fracture risk as a trigger for fall screening to comprehensively classify risk in post-menopausal women as proposed by the FPSA.

Screening postmenopausal women for fall and fracture prevention

Fragility fracture prevention has been historically associated with the diagnosis and treatment of osteoporosis. Given that the strongest determinant of fracture is falls, it is critical to add fall risk into clinical decision-making guidelines for fracture prevention. This special interest paper proposes an algorithm based on 2 validated tools: (1) World Health Organization's Fracture Risk Assessment Tool, which evaluates probability of fracture and (2) Functional Gait Assessment, which evaluates fall risk. Physical therapists can use this algorithm to better identify patients at greatest risk for fracture in order to customize interventions designed to promote bone health, minimize falls, and ultimately prevent fractures. Recommendations for referral, patient education, and exercise are provided for categories of varying fall and fracture risk.

Differences in adherence to osteoporosis regimens: a 2-year analysis of a population treated under specific guidelines

BACKGROUND

Patients' adherence to antiosteoporotic drug therapy is essential to prevent fracture and complications of osteoporosis over the long term. The guidance given in treating osteoporosis can potentially enhance adherence.

OBJECTIVE

This study was conducted to compare adherence to osteoporosis regimens by patients treated under specific guidelines in a medical center.

METHODS

This study used a database pertaining to the use of antiosteoporotic medication, including alendronate, raloxifene, and calcitonin, between 2001 and 2007. We selected patients who were being treated following the therapeutic recommendations of the National Osteoporosis Foundation or the guideline for glucocorticoid-induced osteoporosis recommended by the American College of Rheumatology. Adherence was determined by compliance and the persistence ratio (PR). Compliance was estimated by using the medication possession rate, and PR was determined by the percentage of patients with no medication refill gap for a period of ≥30 days.

RESULTS

A total of 2975 patients met the inclusion criteria. The patients were grouped according to treatment regimen: alendronate, n = 1745; raloxifene, n = 711; and calcitonin, n = 519. The good compliance rate (GCR; medication possession rate ≥80%) for alendronate, raloxifene, and calcitonin was 61.9%, 54.6%, and 36.4% at year 1 (P < 0.001), respectively. The GCR of alendronate was significantly higher than that for either raloxifene (P = 0.001) or calcitonin (P < 0.001). The GCR of the alendronate, raloxifene, and calcitonin groups at year 3 was 47.9%, 43.7%, and 36.4% of the included patients (P < 0.001). The PR of the alendronate, raloxifene, and calcitonin groups at year 1 was 57.1%, 50.2%, and 32.9% (P < 0.001) and 41.8%, 40.1%, and 23.5% (P < 0.001) at year 2.

CONCLUSIONS

Alendronate had a better adherence profile than raloxifene and calcitonin at the end of year 1 and a better adherence profile than calcitonin at the end of year 2.

Fracture risk and prevention: a multidimensional approach

Although physical therapists commonly manage neuromusculoskeletal disorders and injuries, their scope of practice also includes prevention and wellness. In particular, this perspective article proposes that physical therapists are well positioned to address the client's skeletal health by incorporating fracture prevention into clinical practice with all adults. Fracture prevention consists primarily of maximizing bone strength and preventing falls. Both of these initiatives require an evidence-based, multidimensional approach that customizes interventions based on an individual's medical history, risk factors, and personal goals. The purposes of this perspective article are: (1) to review the role of exercise and nutrition in bone health and disease; (2) to introduce the use of the Fracture Risk Assessment Tool (FRAX®) into physical therapist practice; (3) to review the causes and prevention of falls; and (4) to propose a role for the physical therapist in promotion of bone health for all adult clients, ideally to help prevent fractures and their potentially devastating sequelae.

Prevalence of risk factors for fractures and use of DXA scanning in Danish women. A regional population-based study

SUMMARY

To determine the relationship between risk factors and use of DXA scans. Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and socio-economic factors are associated with the use of DXA.

INTRODUCTION

To determine the relationship between risk factors for fracture and use of DXA scans in Danish women in relation to distance to DXA clinics and socio-economic factors.

METHODS

From the Danish National Civil Register we randomly selected 5,000 women aged 40-90 years living in the region of Southern Denmark to receive a mailed questionnaire concerning risk factors for fractures.

RESULTS

The respondents rate was 84% and 77% of the invited population were available for analysis. A total of 10.3% of the women without risk factors and only 36% of the women with three or more risk factors had a history of DXA. The likelihood of a history of DXA was higher with increasing FRAX(™) 10-year risk; i.e., 8.7% and 30.2% in patients with a 10-year fracture risk of 0-14.9% and 25-100%, respectively. In women with less than 10 km to nearest DXA facility, 20.2% had a history of DXA, while 11.5% of those with more than 40 km to the nearest scanner had a history of DXA. Logistic regression analysis showed that distance, fracture risk, oral glucocorticoids, low-energy fracture, conditions associated with secondary osteoporosis, low BMI, history of falls, age 65-79 years, spouse status, and income were significantly associated with having a history of DXA.

CONCLUSIONS

Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and a number of socio-economic factors are associated with the use of DXA.

Fracture risk assessment in postmenopausal women

Patients with osteoporosis have an increased risk of sustaining fractures because of the low bone mineral density (BMD) and altered bone micro-architecture which are characteristic features of the disease. Although a good correlation exists between BMD and fracture risks, many other factors influence this relationship. While there is consensus that patients with osteoporosis should be investigated and treated, the issue is much less clear for patients with osteopenia. Because osteopenia is so prevalent, it would be unrealistic to treat all patients with this condition. Therefore, there is a need to identify those patients who are at risk of sustaining a fracture and would benefit most from the available therapy. Providing treatment to the appropriate risk group would not only reduce the number of fractures, but could also reduce the adverse effects associated with treatment, as treating patients earlier could shorten the treatment time. The availability of tools to select patients at risk of fracture should change the impact of the disease.