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Osteoporosis: Cathleen Colón-Emeric, MD, MHSc, MD, MPH, discusses the clinical examination for osteoporosis.
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Osteoporosis: Cathleen Colón-Emeric, MD, MHSc, MD, MPH, discusses the clinical examination for osteoporosis.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Cathleen Colon-Emeric about a disorder that affects many millions of people worldwide, osteoporosis. Dr. Colon-Emeric, why don't you introduce yourself to our listeners. >> Thank you very much. I'm Cathleen Colon-Emeric. I'm an Associate Professor at Duke University and the Durham VA Geriatric Research and Education and Clinical Center. >> And what do we know about the prevalence of osteoporosis?
Are there important demographic characteristics? >> There are. Osteoporosis affects more than ten million Americans. About one in two white women will have a fracture in their lifetime and about one in five white men will have a fracture in their lifetime. Although the disease is less common in African-Americans and other ethnic groups, those who do have osteoporotic fractures suffer a similar burden of disease. The incidence of osteoporosis increases greatly with advancing age and with certain medical conditions such as seizure disorders, Parkinson's disease, stroke, prostate cancers, rheumatoid arthritis, or any other condition that requires the use of steroids.
>> Which history and physical examination findings are helpful when diagnosing osteoporosis, and which findings are not so helpful? >> The most helpful physical exam findings in diagnosing osteoporosis are three The first is low body mass index or low weight, specifically a weight in a woman of less than 51 kilograms significantly increases the post-test probability that she has osteoporosis. The other two physical exam findings that are helpful actually are not so much aimed at diagnosing osteoporosis but at detecting occult vertebral fractures.
About two-thirds of vertebral fractures are silent and the patient doesn't actually know that they've suffered them. Those two physical exam findings are kyphosis, which can be detected either by a patient self-reporting that they've developed a humped back or by measuring a wall-occiput distance. This is done by having the patient stand next to a wall with their heels touching it and trying to touch the back of their head to the wall. If they can't do that, that's a wall-occiput distance of greater than zero and that also significantly increases the likelihood that they have had an occult vertebral fracture.
The last finding that's fairly helpful is the rib-pelvis distance. Again, this is detecting silent vertebral fractures. And to do this, the examiner stands behind the patient and sees how many fingers they can insert in the space between the top of the iliac crest and the bottom of the patient's ribs. If you can only insert two or fewer fingerbreadths, again that significantly increases the likelihood that they've had a vertebral fracture. If you can insert four fingerbreadths, that completely decreases the likelihood that they've had an occult vertebral fracture.
>> And are there certain findings that are not helpful? >> Yes. The most interesting one is the one we were all taught in medical school, the height loss. It turns out that the self-reported height loss isn't always a good predictor of osteoporosis or vertebral fracture. Although studies vary in the likelihood ratios that they report, overall it does not seem to be a terribly useful sign. Other things that have been proposed that don't seem to be terribly helpful in terms of the physical exam are hand-skin fold thickness, a tooth count, the patient's grip strength as measured by an in-clinic instrument, or the arm span-height difference.
None of those are terribly informative. >> The findings you mentioned are for patients who have occult fractures. Are there any findings from physical exam and history that help identify patients with osteoporosis before they have fractures? >> The only one that's really turned out to be useful is low weight. The cut-off for white women is a weight of less than 51 kilograms. The weight cut-offs haven't been as well established for men. >> Overall, how useful are the score and ORAI questionnaires in detecting the likelihood of osteoporosis?
>> Yes. These are questionnaires that use clinical risk factors, family history, other illnesses and so forth to try to predict the patient's likelihood of having osteoporosis. These are actually more useful in identifying people who are at low risk of having osteoporosis and whom you can probably delay testing with a DEXA. They're not as helpful in identifying patients who do have osteoporosis. However, a very low score in a patient would reassure you that they have a lower likelihood of having osteoporosis and you could potentially wait five or ten years before ordering their DEXA scan.
>> What do we know about the similarities or differences in using these questionnaires for osteoporosis between women and men? >> All of these questionnaires have been developed in women and there have not been questionnaires that have been extensively validated in men. However, the FRAX tool, the World Health Organization fracture risk assessment tool, has in fact been developed and validated in large cohorts of men of different ethnic and racial backgrounds and in different countries and that would be a more useful tool to use in them.
>> Would you please describe the reference standard tests for osteoporosis? >> There are two reference standards that have been used in these studies. The first is bone mineral density as measured by a DEXA scan. And generally, the authors have used a T-score of less than or equal to negative 2.5 as the definition of osteoporosis, which is consistent with the World Health Organization's definition of osteoporosis. Of course, the more clinically meaningful gold standard would be following patients forward in time until they have or don't have a fracture.
However, the cohort studies that have done this haven't always measured these physical examination findings. So really the only physical examination finding that has been validated in that way are the low body weight or low body mass index signs. >> Is there anything else that JAMAevidence users should know about osteoporosis? For example, is there an age which you start looking for evidence of osteoporosis or a patient perhaps being at risk? >> There are a variety of clinical practice guidelines that are available. There are relatively new osteoporosis guidelines available from the National Osteoporosis Foundation.
Recommendations currently suggest that all women be screened starting at age 65. There are not good recommendations available yet for men. Of note, though, the thinking about when to start initiating screening and treatment for osteoporosis is changing a little bit. We're moving from a screen everybody and treat based on their T-score threshold to a determine whether to start screening and treating based on their fracture risk.
And the FRAX tool that I mentioned earlier is the World Health Organization's way of trying to help clinicians in making some of these decisions. So the current recommendations would be to initiate treatment if the patient's ten-year fracture risk based on either their T-score or their clinical risk factors with more than 3% for a hip fracture or more than 20% for other major osteoporotic fractures. >> Is there anything else that you would care to add that our listeners should know about osteoporosis? >> I think about covers it.
>> Well, thank you very much. >> Thank you. I appreciate your time. >> This has been Joan Stephenson discussing osteoporosis as a part of the Rational Clinical Examination with Dr. Cathleen Colon-Emeric. Listeners interested in more information are encouraged to consult the osteoporosis chapter on the JAMAevidence website.
