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The Challenges and Limitations of Osteoporosis Diagnosis

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New Horizons in Osteoporosis Management

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Abstract

In September 2015, Paul Miller noted that, for those of us devoted to abolishing this disease, osteoporosis is the battle being lost on many faces of many hills. This was based on the consistent finding that osteoporosis is both an underdiagnosed and undertreated disease even though it is common and causes serious problems and even though effective treatments are available. On the other hand, most clinicians were taught directly or indirectly that bone density is the gauge for assessing bone strength and the response to anti-osteoporotic treatment. In recent years, however, the concept of bone strength has moved beyond density alone and has expanded to include a number of characteristics of bone that collectively are called quality. This chapter will discuss how the concept of quality has emerged and its impact on the patients’ management. It will also discuss the challenges to osteoporosis diagnosis and management including the challenges of underdiagnosis (even after fractures), the scanning process, patient awareness, as well as the missed falls risk assessment.

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References

  1. Burge R, Dawson-Hughes B, Solomon DH. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22:465–75.

    Article  PubMed  Google Scholar 

  2. US Department of Commerce, Economics and Statistics Administration, US Census Bureau. The next four decades. The older population in the United States: 2010 to 2050. Population estimates and projections. Washington (DC): US Department of Commerce; [cited 30 Jul 2018]. Available from: https://www.census.gov/prod/2010pubs/p25-1138.pdf (Accessed on 10th Nov 2019).

  3. International Osteoporosis Foundation. What is osteoporosis? https://www.iofbonehealth.org/what-is-osteoporosis (Accessed on 10th Nov 2019).

  4. Sambrook P, Cooper C. Osteoporosis. Lancet. 2006;367:2010–8.

    Article  CAS  PubMed  Google Scholar 

  5. Kim SH, Choi HS, Rhee Y, et al. Prevalent vertebral fractures predict subsequent radiographic vertebral fractures in postmenopausal Korean women receiving antiresorptive agent. Osteoporos Int. 2011;22:781–7.

    Article  CAS  PubMed  Google Scholar 

  6. MacIntyre NJ, Dewan N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. J Hand Ther. 2016;29:136–45.

    Article  PubMed  Google Scholar 

  7. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334:1519–25.

    Article  CAS  PubMed  Google Scholar 

  8. Haentjens P, Magaziner J, Colon-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152:380–90.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kannegaard PN, van der Mark S, Eiken P, et al. Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival. Age Ageing. 2010;39:203–9.

    Article  PubMed  Google Scholar 

  10. Sale JE, Beaton D, Posen J, Elliot-Gibson V, Bogoch E. Systematic review on interventions to improve osteoporosis investigation and treatment in fragility fracture patients. Osteoporos Int. 2011;22(7):2067–82.

    Article  CAS  PubMed  Google Scholar 

  11. Shepherd AJ, Cass AR, Ray LA, Tan A, Wilkinson GS. Treatment for older men with fractures. Osteoporos Int. 2012;23(3):1041–51.

    Article  CAS  PubMed  Google Scholar 

  12. Delmas PD, van de Langerijt L, Watts NB, IMPACT Study Group, et al. Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study. J Bone Miner Res. 2005;20(4):557–63.

    Article  PubMed  Google Scholar 

  13. Shibli-Rahhal A, Vaughan-Sarrazin MS, Richardson K, Cram P. Testing and treatment for osteoporosis following hip fracture in an integrated US. Healthcare delivery system. Osteoporos Int. 2011;22(12):2973–80.

    Article  CAS  PubMed  Google Scholar 

  14. Leslie WD, Giangregorio LM, Yogendran M, et al. A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving. Osteoporos Int. 2012;23(5):1623–9.

    Article  CAS  PubMed  Google Scholar 

  15. Johnell O, Kanis JA, Odén A, et al. Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004;15:175–9.

    Article  CAS  PubMed  Google Scholar 

  16. Curtis JR, Carbone L, Cheng H, et al. Longitudinal patterns in bone mass measurement among U.S. Medicare beneficiaries [abstract]. J Bone Miner Res. 2007;22(suppl 1):S193.

    Google Scholar 

  17. Baim S, Binkley N, Bilezikian JP, et al. Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD position development conference. J Clin Densitom. 2008;11:75–91.

    Article  PubMed  Google Scholar 

  18. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.

    Google Scholar 

  19. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785–95.

    Article  Google Scholar 

  20. van Staa TP, Leufkens HG, Cooper C. Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int. 2002;13:624–9.

    Article  PubMed  Google Scholar 

  21. Cummings SR, Stone KL, Lui LL, et al. Are traumatic fractures osteoporotic? [abstract]. J Bone Miner Res. 2002;17(suppl 1):S175.

    Google Scholar 

  22. Delmas PD, van de Langerijt L, Watts NB, et al. Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study. J Bone Miner Res. 2005;20:557–63.

    Article  PubMed  Google Scholar 

  23. Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR. Recognition of vertebral fracture in a clinical setting. Osteoporos Int. 2000;11:577–82.

    Article  CAS  PubMed  Google Scholar 

  24. Cooper C, O’Neill T, Silman A. The epidemiology of vertebral fractures. European Vertebral Osteoporosis Study Group Bone. 1993;14(suppl 1):S89–97.

    Google Scholar 

  25. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22(3):465–75.

    Article  PubMed  Google Scholar 

  26. Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res. 2014;29(9):1929–37.

    Article  PubMed  Google Scholar 

  27. Singer A, Exuzides A, Spangler L, et al. Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States. Mayo Clin Proc. 2015;90(1):53–62.

    Article  PubMed  Google Scholar 

  28. Hopkins RB, Tarride JE, Leslie WD, et al. Estimating the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis. Osteoporos Int. 2013;24(2):581–93.

    Article  CAS  PubMed  Google Scholar 

  29. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly–a review. Osteoporos Int. 2013;24(3):747–62.

    Article  CAS  PubMed  Google Scholar 

  30. Eisman JA, Bogoch ER, Dell R, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012;27(10):2039–46.

    Article  PubMed  Google Scholar 

  31. Ambrose AF, Cruz L, Paul G. Falls and fractures: a systematic approach to screening and prevention. Maturitas. 2015;82(1):85–93.

    Article  PubMed  Google Scholar 

  32. Itself Miller P. Underdiagnoses and Undertreatment of osteoporosis: the Battle to be won. J Clin Endocrinology Metabolism. 2016;101(3):852–9.

    Article  Google Scholar 

  33. Foley KA, Foster SA, Meadows ES, Baser O, Long SR. Assessment of the clinical management of fragility fractures and implications for the new HEDIS osteoporosis measure. Med Care. 2007;45:902–6.

    Article  PubMed  Google Scholar 

  34. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326–8.

    Article  CAS  PubMed  Google Scholar 

  35. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;162:2217–22.

    Article  PubMed  Google Scholar 

  36. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721–39.

    Article  CAS  PubMed  Google Scholar 

  37. Quintos-Macasa AM, Quinet R, Spady M, et al. Implementation of a mandatory rheumatology osteoporosis consultation in patients with low-impact hip fracture. J Clin Rheumatol. 2007;13:70–2.

    Article  PubMed  Google Scholar 

  38. Streeten EA, Mohamed A, Gandhi A, et al. The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed? J Bone Joint Surg Am. 2006;88:1968–74.

    PubMed  Google Scholar 

  39. Yoo JW, Nakagawa S, Kim S. Effect of reimbursement reductions on bone mineral density testing for female Medicare beneficiaries. J Womens Health (Larchmt). 2012;21(11):1144–8.

    Article  Google Scholar 

  40. Jagla S, Hawker G, Croxford R, et al. Impact of a change in physician reimbursement on bone mineral density testing in Ontario, Canada: a population-based study. CMAJ Open. 2014;2(2):E45-SO.

    Google Scholar 

  41. Hayes BL, Curtis JR, Laster A, et al. Osteoporosis care in the United States after declines in reimbursements for DXA. J Clin Densitom. 2010;13(4):352–60.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Zhang J, Delzell E, Zhao H. Central DXA utilization shifts from office-based to hospital-based settings among Medicare beneficiaries in the wake of reimbursement changes. J Bone Miner Res. 2012;27(4):858–64.

    Article  PubMed  Google Scholar 

  43. Kendler DL, Bauer DC, Davison KS, et al. Vertebral fractures: clinical importance and management. Am J Med. 2016;129(2):221–6.

    Article  PubMed  Google Scholar 

  44. Miller PD. Clinical management of vertebral compression fractures. J Clin Densitom. 2016;19(1):97–101.

    Article  PubMed  Google Scholar 

  45. Rosen HN, Vokes J, Malabanan AO, et al. The official positions of the International Society for Clinical Densitometry: vertebral fracture assessment. J Clin Densitom. 2013;16(4):482–8.

    Article  PubMed  Google Scholar 

  46. Kanis JA. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35(2):375–82.

    Article  CAS  PubMed  Google Scholar 

  47. Johne I, Kanis JA, Oden A, et al. Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004;15(3):175–9.

    Google Scholar 

  48. Akesson K, Marsh D, Mitchell PJ, et al. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24(8):2135–52.

    Google Scholar 

  49. Siris ES. 8ilezikian JP, Rubin MR, et al. pins and plaster aren't enough: a call for the evaluation and treatment of patients with osteopororic fractures. J Clin Endocrino/ Metab. 2003;88:3482–6.

    Article  CAS  Google Scholar 

  50. Khan AA, Morrison A, Hanley DA, et al. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consen8us. J Bone Miner Res. 2015;30(1):3–23.

    Article  PubMed  Google Scholar 

  51. Pazianas M, Kim SM, Yuen T, Sun L, Epstein S, Zaidi M. Questioning the association between bisphosphonates and atypical femoral fractures. Ann N Y Acad Sci. 2015;1335:1–9.

    Article  CAS  PubMed  Google Scholar 

  52. Paul D. Miller, Underdiagnoses and Undertreatment of Osteoporosis: The Battle to Be Won. J Clin Endocrinol Metabol. 2016;101(3):852–9.

    Article  Google Scholar 

  53. Laster AJ, Lewiecki EM. ISCD Board of Directors. Vertebral fracture assessment by dual-energy x-ray absorptiometry: insurance coverage issues in the United States. A white paper of the International Society for Clinical Densitometry. J Clin Densitom. 2007;10(3):227–38.

    Article  PubMed  Google Scholar 

  54. Kim SJ, Lee JH, Kim S, et al. Associations between the 2007 Medicare reimbursement reduction for bone mineral density testing and osteoporosis drug therapy patterns of female Medicare beneficiaries. Patient Prefer Adherence. 2014;8:909–15.

    Google Scholar 

  55. King AB, Fiorentino DM. Medicare payment cuts for osteoporosis testing reduced use despite tests' benefit in reducing fractures. Health Aff (Millwood). 2011;30(12):2362–70.

    Article  Google Scholar 

  56. Lewiecki E. Managing osteoporosis: challenges and strategies. Cleveland clinic J Medicine. 2009;76(8):457–66.

    Article  Google Scholar 

  57. Ewman ED, Ayoub WT, Starkey RH, Diehl JM, Wood GC. Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years. Osteoporos Int. 2003;14:146–51.

    Article  Google Scholar 

  58. Ayoub WT, Newman ED, Blosky MA, Stewart WF, Wood GC. Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments. Osteoporos Int. 2009;20:37–42.

    Article  CAS  PubMed  Google Scholar 

  59. Harrington JT, Barash HL, Day S, Lease J. Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum. 2005;53:198–204.

    Article  PubMed  Google Scholar 

  60. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int. 2003;14:1028–34.

    Article  PubMed  Google Scholar 

  61. Lewiecki EM, Baim S, Siris ES. Osteoporosis care at risk in the United States. Osteoporos Int. 2008;19:1505–9.

    Article  CAS  PubMed  Google Scholar 

  62. Childers L. ACR pushes for increased DXA reimbursement. Rheumatologist. https://www.the-rheumatologist.org/article/acr-supports-increased-dxa-medicare-reimbursement-for-the-private-practice-setting/.

  63. Kanis JA, on behalf of the World Health Organization Scientific Group (2007). Assessment of osteoporosis at the primary health-care level. Technical Report. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK; 2008.

    Google Scholar 

  64. World Health Organization. FRAX WHO Fracture Risk Assessment Tool. World Health Organization 2008. www.shef.ac.uk/FRAX/. Accessed 13 Nov 2019.

  65. Hippisley-Cox J, Coupland C. Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ. 2012;344:e3427.

    Article  PubMed  Google Scholar 

  66. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.

    Google Scholar 

  67. NICE: Osteoporosis - prevention of fragility fractures 2016. https://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures [Accessed on 17th November 2019].

  68. Briota K, Rouxa C, Thomas T, Blainc H, Buchond D, Chapurlate R, Debiaisf F, Ferong JM, Gauvainh JB, Guggenbuhli P, Legrandl E, Lehr-Drylewiczm AM, Lespessaillesn E, Tremolliereso F, Weryhap G, Cortet B. 2018 update of French recommendations on the management of postmenopausal osteoporosis. Joint Bone Spine. 2018;85(5):519–30.

    Article  Google Scholar 

  69. Licata A. Bone density vs bone quality: what’s a clinician to do? Cleveland Clinic J Med. 2009;76(6):331–6.

    Article  Google Scholar 

  70. Choksi P, Jepsen KJ, Clines GA. The challenges of diagnosing osteoporosis and the limitations of currently available tools. Clin Diabetes Endocrinol. 2018;4:12.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Ralston SH, Uitterlinden AG. Genetics of osteoporosis. Endocr Rev. 2010;31(5):629–62.

    Article  CAS  PubMed  Google Scholar 

  72. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52:457–67.

    Article  CAS  PubMed  Google Scholar 

  73. Zebaze RM, Jones A, Knackstedt M, Maalouf G, Seeman E. Construction of the femoral neck during growth determines its strength in old age. J Bone Miner Res. 2007;22:1055–61.

    Article  PubMed  Google Scholar 

  74. Chen H, Zhou X, Shoumura S, Emura S, Bunai Y. Age- and gender-dependent changes in three-dimensional microstructure of cortical and trabecular bone at the human femoral neck. Osteoporos Int. 2010;21:627–36.

    Article  CAS  PubMed  Google Scholar 

  75. Bjornerem A, Bui QM, Ghasem-Zadeh A, Hopper JL, Zebaze R, Seeman E. Fracture risk and height: an association partly accounted for by cortical porosity of relatively thinner cortices. J Bone Miner Res. 2013;28:2017–26. https://doi.org/10.1002/jbmr.1934.

    Article  PubMed  Google Scholar 

  76. Shigdel R, Osima M, Ahmed LA, Joakimsen RM, Eriksen EF, Zebaze R, Bjornerem A. Bone turnover markers are associated with higher cortical porosity, thinner cortices, and larger size of the proximal femur and non-vertebral fractures. Bone. 2015;81:1–6.

    Article  PubMed  Google Scholar 

  77. Bjornerem A. The clinical contribution of cortical porosity to fragility fractures. Bonekey Rep. 2016;5:846.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Bala Y, Zebaze R, Ghasem-Zadeh A, Atkinson EJ, Iuliano S, Peterson JM, Amin S, Bjornerem A, Melton LJ 3rd, Johansson H, et al. Cortical porosity identifies women with osteopenia at increased risk for forearm fractures. J Bone Miner Res. 2014;29:1356–62. https://doi.org/10.1002/jbmr.2167.

    Article  PubMed  Google Scholar 

  79. Jepsen KJ, Silva MJ, Vashishth D, Guo XE, van der Meulen MC. Establishing biomechanical mechanisms in mouse models: practical guidelines for systematically evaluating phenotypic changes in the diaphyses of long bones. J Bone Miner Res. 2015;30:951–66.

    Article  PubMed  Google Scholar 

  80. Kleerekoper M, Balena R. Fluorides and osteoporosis. Annu Rev Nutr. 1991;11:309–24.

    Article  CAS  PubMed  Google Scholar 

  81. Riggs BL, Hodgson SF, O'Fallon WM, et al. Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. N Engl J Med. 1990;322:802–9.

    Article  CAS  PubMed  Google Scholar 

  82. Garnero P, Sornay-Rendu E, Duboeuf F, Delmas PD. Markers of bone turnover predict postmenopausal forearm bone loss over 4 years: the OFELY study. J Bone Miner Res. 1999;14:1614–21.

    Article  CAS  PubMed  Google Scholar 

  83. Johnell O, Oden A, De Laet C, Garnero P, Delmas PD, Kanis JA. Biochemical indices of bone turnover and the assessment of fracture probability. Osteoporos Int. 2002;13:523–6.

    Article  CAS  PubMed  Google Scholar 

  84. Vasikaran S, Eastell R, Bruyere O, Foldes AJ, Garnero P, Griesmacher A, McClung M, Morris HA, Silverman S, Trenti T, et al. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int. 2011;22:391–420.

    Article  CAS  PubMed  Google Scholar 

  85. Mazess RB, Barden H, Mautalen C, Vega E. Normalization of spine densitometry. J Bone Miner Res. 1994;9(4):541–8.

    Article  CAS  PubMed  Google Scholar 

  86. Jepsen KJ, Kozminski A, Bigelow EM, Schlecht SH, Goulet RW, Harlow SD, Cauley JA. Karvonen-Gutierrez C femoral neck external size but not a BMD predicts structural and mass changes for women transitioning through menopause. J Bone Miner Res. 2017;32(6):1218–28.

    Article  CAS  PubMed  Google Scholar 

  87. Guyatt GH, Cranney A, Griffith L, et al. Summary of meta-analyses of therapies for postmenopausal osteoporosis and the relationship between bone density and fractures. Endocrinol Metab Clin N Am. 2002;31:659–79.

    Article  Google Scholar 

  88. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344:1434–41.

    Article  CAS  PubMed  Google Scholar 

  89. Cummings SR, Karpf DB, Harris F, et al. Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs. Am J Med. 2002;112:281–9.

    Article  CAS  PubMed  Google Scholar 

  90. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. 1996;348:1535–41.

    Article  CAS  PubMed  Google Scholar 

  91. Sarkar S, Mitlak BH, Wong M, Stock JL, Black DM, Harper KD. Relationships between bone mineral density and incident vertebral fracture risk with raloxifene therapy. J Bone Miner Res. 2002;17:1–10.

    Article  CAS  PubMed  Google Scholar 

  92. Qu Y, Wong M, Thiebaud D, Stock JL. The effect of raloxifene therapy on the risk of new clinical vertebral fractures at three and six months: a secondary analysis of the MORE trial. Curr Med Res Opin. 2005;21:1955–9.

    Article  CAS  PubMed  Google Scholar 

  93. Black DM, et al. J Clin Endocrinol Metab. 2000;85:4118–24.

    Article  CAS  PubMed  Google Scholar 

  94. Black D, et al. N Engl J Med. 2007;356:1809–22.

    Article  CAS  PubMed  Google Scholar 

  95. Chestnut CH, et al. J Bone Min Res. 2004;19:12410–1249.

    Google Scholar 

  96. Cummings SR, et al. N Engl J Med. 2009;361:756–65.

    Article  CAS  PubMed  Google Scholar 

  97. Harris ST, et al. JAMA. 1999;282:1341–52.

    Article  Google Scholar 

  98. Cummings SR, San Martin JA, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361:756–65.

    Article  CAS  PubMed  Google Scholar 

  99. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999;282:637–45.

    Article  CAS  PubMed  Google Scholar 

  100. Nakamura T, Sugimoto T, Nakano T, et al. Randomized teriparatide [human parathyroid hormone (PTH) 1-34] once-weekly efficacy research (TOWER) trial for examining the reduction in new vertebral fractures in subjects with primary osteoporosis and high fracture risk. J Clin Endocrinol Metab. 2012;97:3097–106.

    Article  CAS  PubMed  Google Scholar 

  101. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312(7041):1254–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. Watts NB. Fundamentals and pitfalls of bone densitometry using dual-energy x-ray absorptiometry (DXA). Osteoporos Int. 2004;15(11):847–54.

    Article  PubMed  Google Scholar 

  103. El Maghraoui A, Roux C. DXA scanning in clinical practice. QJM. 2008;101(8):605–17.

    Article  PubMed  Google Scholar 

  104. Dasher LG, Newton CD, Lenchik L. Dual x-ray absorptiometry in today’s clinical practice. Radiol Clin N Am. 2010;48(3):541–60.

    Article  PubMed  Google Scholar 

  105. Guglielmi G, Muscarella S, Bazzocchi A. Integrated imaging approach to osteoporosis: state-of-the-art review and update. Radiographics. 2011;31:1343–64.

    Article  PubMed  Google Scholar 

  106. Gillespie CW, Morin PE. Osteoporosis-related health services utilization following first hip fracture among a cohort of privately insured women in the United States, 2008–2014: an observational study. J Bone Miner Res. 2017;32:1052–61.

    Article  PubMed  Google Scholar 

  107. Bone Health Policy Institute. https://www.bonehealthpolicyinstitute.org.

  108. de Iongh A, Fagan P, Fenner J, Kidd L. A practical guide to self-management support: key components for successful implementation. London: The Health Foundation; 2015.

    Google Scholar 

  109. Francis KL, Matthews BL, Van Mechelen W, Bennell KL, Osborne RH. Effectiveness of a community-based osteoporosis education and self-management course: a wait list controlled trial. Osteoporos Int. 2009;20(9):1563–70.

    Article  CAS  PubMed  Google Scholar 

  110. Kinghan D, Carson P, Flanagan A, Megaw M. Patient education / self management programmes for people with long term conditions (2016/17); 2017. https://www.health-ni.gov.uk/sites/default/files/publications/health/pesmp-ltc-ni-16-17_0.pdf. Accessed 11th Nov 2019.

  111. Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a metaanalytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Res. 1996;9(4):292–301.

    Article  CAS  PubMed  Google Scholar 

  112. Thompson B. In: Paskins Z, Jinks C, Mahmood W, Jayakumar P, Sangan CB, editors. Education and learning for people with ankylosing spondylitis. Newcastle, UK: Newcastle University; 2011. p. 7.

    Google Scholar 

  113. Belcher J, Gwilym S. Public priorities for osteoporosis and fracture research: results from a general population survey. Arch Osteoporos. 2017;12(1):45.

    Article  PubMed  PubMed Central  Google Scholar 

  114. Mahmood W, Jinks C, Jayakumar P, Gwilym S, Paskins Z. Public priority setting for research in osteoporosis. Rheumatology. 2016:115.

    Google Scholar 

  115. Gillespie CW, Morin PE. Trends and disparities in osteoporosis screening among women in the United States, 2008-2014. Am J Med. 2017;130:306–16.

    Article  PubMed  Google Scholar 

  116. Wluka AE, Chou L, Briggs A, Cicuttini F. Understanding the needs of consumers with musculoskeletal conditions: consumers’ perceived needs of health information, health services and other non-medical services: a systematic scoping review. Melbourne: MOVE muscle, bone & joint health; 2016.

    Google Scholar 

  117. Paskins Z, Sanders T, Croft PR, Hassell AB. The identity crisis of osteoarthritis in general practice: a qualitative study using video-stimulated recall. Ann Fam Med. 2015;13(6):537–44.

    Article  PubMed  PubMed Central  Google Scholar 

  118. Gregson CL, Dennison EM, Compston JE, Adami S, Adachi JD, Anderson FA, et al. Disease-specific perception of fracture risk and incident fracture rates: GLOW cohort study. Osteoporos Int. 2014;25(1):85–95.

    Article  CAS  PubMed  Google Scholar 

  119. Rowlands G, Protheroe J, Winkley J, Richardson M, Seed PT, Rudd R. A mismatch between population health literacy and the complexity of health information: an observational study. Br J Gen Pract. 2015;65(635):e379–86.

    Article  PubMed  PubMed Central  Google Scholar 

  120. Protheroe J, Estacio EV, Saidy-Khan S. Patient information materials in general practices and promotion of health literacy: an observational study of their effectiveness. Br J Gen Pract. 2015;65(632):e192–7.

    Article  PubMed  PubMed Central  Google Scholar 

  121. Otmar R, Reventlow SD, Nicholson GC, Kotowicz MA, Pasco JA. General medical practitioners’ knowledge and beliefs about osteoporosis and its investigation and management. Arch Osteoporos. 2012;7:107–14.

    Article  PubMed  Google Scholar 

  122. Richardson JC, Hassell AB, Thomas E, Hay EM. GPs’ perceptions of the role of DEXA scanning: an exploratory study. Fam Pract. 2004;21(1):51–3.

    Article  PubMed  Google Scholar 

  123. Rizzoli R, Brandi M, Dreinhofer K, Thomas T, Wahl D, Cooper C. The gaps between participant and physician understanding of the emotional and physical impact of osteoporosis. Arch Osteoporos. 2010;5:145–53.

    Article  Google Scholar 

  124. Montori VM, Shah ND, Pencille LJ, Branda ME, Van Houten HK, Swiglo BA, et al. Use of a decision aid to improve treatment decisions in osteoporosis: the osteoporosis choice randomized trial. Am J Med. 2011;124(6):549–56.

    Article  PubMed  Google Scholar 

  125. Montori VM, Breslin M, Maleska M, Weymiller AJ. Creating a conversation: insights from the development of a decision aid. PLoS Med. 2007;4(8):e233.

    Article  PubMed  PubMed Central  Google Scholar 

  126. Guyatt G, Montori V, Devereaux PJ, Schünemann H, Bhandari M. Patients at the center: in our practice, and in our use of language. ACP J Club. 2004;140(1):A11–2.

    Article  PubMed  Google Scholar 

  127. Raybould G, Babatunde O, Evans AL, Jordan JL, Paskins Z. Expressed information needs of patients with osteoporosis and/or fragility fractures: a systematic review. Archiv Osteoporo. 2018;13:55.

    Article  Google Scholar 

  128. Stone KL, Seeley DG, Lui LY, et al. BMD at multiple sites and risk of fracture of multiple types: long-term results from the study of osteoporotic fractures. J Bone Miner Res. 2003;18:1947–54.

    Article  PubMed  Google Scholar 

  129. Jarvinen TL, Sievanen H, Khan KM, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008;336:124–6.

    Article  PubMed  PubMed Central  Google Scholar 

  130. Kanis JA, Johnell O, Oden A, et al. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone. 2000;27:585–90.

    Article  CAS  PubMed  Google Scholar 

  131. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  132. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348:42–9.

    Article  PubMed  Google Scholar 

  133. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337:1279–84.

    Article  CAS  PubMed  Google Scholar 

  134. Wagner H, Melhus H, Gedeborg R, et al. Simply ask them about their balance—future fracture risk in a nationwide cohort study of twins. Am J Epidemiol. 2009;169:143–9.

    Article  PubMed  Google Scholar 

  135. Sievanen H, Kannus P, Jarvinen TL. Bone quality: an empty term. PLoS Med. 2007;4:e27.

    Article  PubMed  PubMed Central  Google Scholar 

  136. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010;21(5):658–68.

    Article  PubMed  Google Scholar 

  137. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822–32.

    Article  PubMed  Google Scholar 

  138. Hill K, Schwarz J. Assessment and management of falls in older people. Intern Med J. 2004;34(9–10):557–64.

    Article  CAS  PubMed  Google Scholar 

  139. Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Lord SR. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1749–57.

    Article  Google Scholar 

  140. Mancini M, Horak FB. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Rehabil Med. 2009;45(3):391–401.

    Google Scholar 

  141. National Institute of Health and Care Excellence. Falls: assessment and prevention of falls in older people. 2013:161. https://doi.org/10.7748/nop.26.6.18.e586.

  142. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Stern A. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ (Clinical Research Ed). 2004;328(March):1–6. https://doi.org/10.1136/bmj.328.7449.1166.

    Article  Google Scholar 

  143. Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, Strifler L, Straus SE. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. J Am Med Assoc. 2017;318(17):1687–99.

    Article  Google Scholar 

  144. Ghahramani M, Naghdy F, Stirling D, Naghdy G, Potter J. Fall risk assessment in older people. Inter J Eng Sci. 2016;5(11):2319–1813.

    Article  Google Scholar 

  145. Goldie PA, Bach TM, Evans OM. Force platform measures for evaluating postural control: reliability and validity. Arch Phys Med Rehabil. 1989;70(7):510–7.

    CAS  PubMed  Google Scholar 

  146. Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41(6):304–11.

    Article  Google Scholar 

  147. Chiu AYY, Au-Yeung SSY, Lo SK. A comparison of four functional tests in discriminating fallers from non-fallers in older people. Disabil Rehabil. 2003;25(1):45–50.

    Article  CAS  PubMed  Google Scholar 

  148. Hartikainen S, Lönnroos E, Louhivuori K. Medication as a risk factor for falls: systematic review. J Gerontol Ser A Biol Sci Med Sci. 2007;62(10):1172–81.

    Article  Google Scholar 

  149. Gnjidic D, Hilmer SN, Blyth FM, Naganathan V, Waite L, Seibel MJ, Le Couteur DG. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012;65(9):989–95.

    Article  PubMed  Google Scholar 

  150. El Miedany Y, El Gaffary M, Toth M, Youssef S, Ahmed I. Falls risk assessment score (FRAS): time to rethink. J Clin Gerontol Geriat. 2(1):21–6.

    Google Scholar 

  151. Cattelani L, Palumbo P, Palmerini L, Bandinelli S, Becker C, Chesani F, Chiari L. FRAT-up, a web-based fall-risk assessment tool for elderly people living in the community. J Med Internet Res. 2015;17(2):e41.

    Article  PubMed  PubMed Central  Google Scholar 

  152. Palumbo P, Palmerini L, Bandinelli S, Chiari L. Fall risk assessment tools for elderly living in the community: can we do better? PLoS One. 2015;10(12):1–13.

    Article  Google Scholar 

  153. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45(6):239–43.

    Article  Google Scholar 

  154. Camargos FFO, Dias RC, Dias JMD, Freire MTF. Adaptação transcultural e avaliação das propriedades psicométricas da Falls Efficacy Scale – International emidosos brasileiros (FES-I-BRASIL). Rev Bras Fisioter. 2010;14(3):237–43.

    Article  PubMed  Google Scholar 

  155. Clark RA, Mentiplay BF, Pua YH, Bower KJ. Reliability and validity of the Wii balance board for assessment of standing balance: a systematic review. Gait Posture. 2018;61(December):40–54.

    Article  PubMed  Google Scholar 

  156. Scoppa F, Capra R, Gallamini M, Shiffer R. Clinical stabilometry standardization. Basic definitions – acquisition interval - sampling frequency. Gait Posture. 2013;37(2):290–2.

    Article  PubMed  Google Scholar 

  157. Audiffren J, Contal E. Preprocessing the Nintendo wii board signal to derive more accurate descriptors of statokinesigrams. Sensors (Switzerland). 2016;16(8):1208.

    Article  Google Scholar 

  158. Van Parys JAP, Njiokiktjien CJJ. Romberg’s sign expressed in a quotient. Agressologie. 1976;17(3):95–100, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1008169.

  159. Howcroft J, Lemaire ED, Kofman J, McIlroy WE. Elderly fall risk prediction using static posturography. PLoS One. 2017;12(2):1–13.

    Article  Google Scholar 

  160. Woolf AD, Akesson K. Preventing fractures in elderly people. BMJ. 2003;327:89–95.

    Article  PubMed  PubMed Central  Google Scholar 

  161. Stalenhoef PA, Crebolder HFJM, Knottnerus A, Van der Horst FGEM. Incidence, risk factors and consequences of falls among elderly subjects living in the community. Eur J Publ Health. 1997;7:328–34.

    Article  Google Scholar 

  162. Department of Health. National service framework for older people. London: DoH; 2001.

    Google Scholar 

  163. Durward G, Pugh CN, Ogunremi L, Wills R, Cottee M, Patel S. Detection of risk of falling and hip fracture in women referred for bone densitometry. Lancet. 1999;354:220–1.

    Article  CAS  PubMed  Google Scholar 

  164. El Miedany Y, Toth M, Youssef S, El Gaafary M. Predictors of falls risk among patients referred for dxa scanning: a prediction model. Rheumatology (Oxford). 2010;49(Suppl 1):i85.

    Google Scholar 

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    Yasser El Miedany

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El Miedany, Y. (2022). The Challenges and Limitations of Osteoporosis Diagnosis. In: El Miedany, Y. (eds) New Horizons in Osteoporosis Management. Springer, Cham. https://doi.org/10.1007/978-3-030-87950-1_9

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