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Osteoporosis is associated with increased fragility of bone and a subsequent increased risk of fracture. The diagnosis of osteoporosis is intimately linked with the imaging and quantification of bone and BMD. Scanning modalities, such as dual-energy X-ray absorptiometry or quantitative CT, have been developed and honed over the past half century to provide measures of BMD and bone microarchitecture for the purposes of clinical practice and research. Combined with fracture prediction tools such as Fracture Risk Assessment Tool (FRAX) (which use a combination of clinical risk factors for fracture to provide a measure of risk), these elements have led to a paradigm shift in the ability to diagnose osteoporosis and predict individuals who are at risk of fragility fracture. Despite these developments, a treatment gap exists between individuals who are at risk of osteoporotic fracture and those who are receiving therapy. In this Review, we summarize the epidemiology of osteoporosis, the history of scanning modalities, fracture prediction tools and future directions, including the most recent developments in prediction of fractures.

In 1970, there were no drugs under study for osteoporosis. Estrogen was used, but little was known about the correct dose for preventing bone loss. At that time, fractures were not even recognized as a disease, but regarded as part of normal aging. From 1970 to this year (2018), there have been extensive advances in the osteoporosis field ranging from fracture epidemiology to the remarkable invention of bone density measurements. There have been major advances in therapeutic options available for patients for prevention and treatment of osteoporosis. In parallel, the advances in the laboratory helped elucidate the process of bone remodeling, not only at the macroscopic level but also at the cellular level. This led to rapid advances in translational research from cellular biology to new therapies exemplified by the development of monoclonal antibodies for osteoporosis. Further understanding of the signaling pathways in bone cells will lead to new small molecules made for osteoporosis treatment, perhaps causing less adverse events. University-based research throughout the world has been a leader in most of these advances, and Pharma support for phase 1 to 4 studies helped bring these discoveries to patients. In the osteoporosis field alone, one sees the tremendous value of grant support for university research by National funding agencies such as the National Institute of Health in this country and similar agencies in other countries. There are clinical challenges that have to be solved with long-term compliance with osteoporosis medication if we want to reduce fracture incidence in the long term.

Osteoporosis is commonly perceived to be a disease confined to aging females, despite ongoing educational interventions. There are few data on the temporal change of dual-energy X-ray absorptiometry (DXA) use in aging males compared to females. Australian Medicare DXA claims between 1995 and 2015 were analyzed to investigate gender differences and temporal change of DXA use in males and females aged 45-85 yr. In females aged 45-54 and 55-64 yr, there was a progressive increase in DXA claims per capita between 1995 until 2002, with little subsequent change from 2002 to 2015 in the younger group, but a slow subsequent increase in females aged 55-64 yr. In males aged 45-54 and 55-64 yr, there was a progressive increase in DXA claims per capita between 1995 and 2002 with an ongoing slow increase from 2002 to 2015. In older females and males aged 65-74, 75-84, or ≥85 yr, there was a progressive increase in DXA claims per capita between 1995 and 2002, with a slow increase thereafter until 2007. After 2007, following the introduction of Medicare eligibility for age over 70, claims per capita increased sharply in all 3 age groups, with a subsequent ongoing increase. The male : female claim ratio in all groups demonstrates low relative male DXA use, with the ratio consistently below 1.0. Following the 2007 Medicare change, the male : female ratio improved in the 65-74, 75-84, and ≥85 age groups. The rate of increase in the male : female ratio in subjects ≥85 yr was significantly greater than that in the 65-74 (p < 0.001) and 75-84 (p < 0.001) age groups. DXA use in males is consistently lower than that in females. Government funding intervention appears to have been most effective in relation to very elderly males over 85 yr but less so in relation to the age group 65-84. There is a need for improved education of health professionals about the risk of osteoporosis in males aged 65-84 yr., (Copyright © 2016 International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

Background: Existing guidelines for repeat screening and treatment monitoring intervals regarding the use of dual-energy x-ray absorptiometry (DXA) scans are conflicting or lacking. The Choosing Wisely campaign recommends against repeating DXA scans within 2 years of initial screening. It is unclear how frequently physicians order repeat scans and what clinical factors contribute to their use., Objective: To estimate cumulative incidence and predictors of repeat DXA for screening or treatment monitoring in a regional health system., Design: Retrospective longitudinal cohort study PARTICIPANTS: A total of 5992 women aged 40-84 years who received initial DXA screening from 2006 to 2011 within a regional health system in Sacramento, CA., Main Measures: Two- and five-year cumulative incidence and hazard rations (HR) of repeat DXA by initial screening result (classified into three groups: low or high risk of progression to osteoporosis, or osteoporosis) and whether women were prescribed osteoporosis drugs after initial DXA., Key Results: Among women not treated after initial DXA, 2-year cumulative incidence for low-risk, high-risk, and osteoporotic women was 8.0%, 13.8%, and 19.6%, respectively, increasing to 42.9%, 60.4%, and 57.4% by 5 years after initial screening. For treated women, median time to repeat DXA was over 3 years for all groups. Relative to women with low-risk initial DXA, high-risk initial DXA significantly predicted repeat screening for untreated women [adjusted HR 1.67 (95% CI 1.40-2.00)] but not within the treated group [HR 1.09 (95% CI 0.91-1.30)]., Conclusions: Repeat DXA screening was common in women both at low and high risk of progression to osteoporosis, with a substantial proportion of women receiving repeat scans within 2 years of initial screening. Conversely, only 60% of those at high-risk of progression to osteoporosis were re-screened within 5 years. Interventions are needed to help clinicians make higher-value decisions regarding repeat use of DXA scans.

Both radiologists as well as nonimaging physicians perform dual-energy X-ray absorptiometry (DXA) imaging in the United States. This study aims to compare provider distribution between these physician groups on the Medicare population, which is the predominant age group of patients evaluated by this imaging procedure. Using the 2 relevant Current Procedural Terminology, Fourth Edition codes for DXA scans, source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2003 through 2013. DXA scan procedure volumes for radiologists and nonradiologists on Medicare patients were tabulated. Utilization rates were calculated. From 2003 to 2013, the total number of DXA scans performed on Medicare patients decreased by 2%. However, over the same period, the number of scans performed by radiologists had increased by 25% over nonimaging specialists, whose utilization had declined by approximately the same amount. From 2003 to 2013, the rate of utilization of DXA scans in the Medicare fee-for-service population declined somewhat. However, radiologists continue to gain market share from other specialists and now predominate in this type of imaging by a substantial margin., (Copyright © 2016 International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

The prevalence of risk factors for osteoporosis in persons with epilepsy, patients' awareness of their risk, and their engagement in osteoprotective behaviors were assessed in this study. Two hundred and sixty patients with epilepsy (F=51.5%, average age=42) completed a survey tool. Of 106 patients with a dual energy X-ray absorptiometry (DXA) result, 52% had low bone mineral density, and 11% had osteoporosis. The results suggest that the majority of patients with epilepsy do not engage in bone-protective behaviors. Those who have undergone a DXA scan may be more likely to take calcium and vitamin D supplementation compared with those who did not undergo a DXA scan, but they do not engage in other osteoprotective behaviors. Many patients did not accurately report their DXA results, indicating that better patient education is warranted., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unlabelled: We examined the clinical characteristics of patients who underwent initial dual energy X-ray absorptiometry (DXA) testing at a primary care facility from 2000 to 2013, and whether these factors changed over time in accordance with Canadian clinical practice guidelines. The burden of osteoporosis remains high and largely unchanged and clinical practice guidelines are not being followed, overall., Purpose: This study examined the clinical risk factors, therapeutic health behaviors, and bone mineral density (BMD) status of patients who underwent initial DXA testing at a primary care facility in Saskatchewan, Canada, and whether these factors changed over time from 2000 to 2013 in accordance with Canadian clinical practice guidelines., Methods: We conducted a retrospective cross-sectional medical chart audit of 800 patients 50 years of age and older who underwent their first DXA test to assess BMD status. Data was extracted from 2000 to 2013 and further stratified into four periods (2000-2001, 2002-2006, 2007-2009, and 2010-2013; n = 200 each period) based on the years when practice guidelines were implemented. Extracted data included BMD outcomes, clinical risk factor indicators for DXA testing, and recommendations for therapeutic health behaviors outlined in the clinical practice guidelines., Results: There were no differences in BMD status across the four time stratas (p = 0.430). Overall, most clinical risk factors had little change over time. The number of males screened significantly increased over time (p < 0.05), and osteoporosis drug therapy use decreased from 2000-2001 to 2010-2013 (p < 0.001). Increasing age, body mass <60 kg, and history of adult fracture were significant independent predictors of osteoporosis diagnosis., Conclusions: The burden of osteoporosis remains high and largely unchanged in Saskatchewan, Canada. These results serve to inform strategies to enhance health-care provider awareness and compliance with practice guidelines, as well as improve screening rates and patient health behaviors.

The diagnosis of osteoporosis rests on areal bone mineral density (BMD) measurement using DXA. Cancellous bone microarchitecture is a key determinant of bone strength but cannot be measured using DXA. To meet the need for a clinical tool capable of assessing bone microarchitecture, the TBS was developed. The TBS is a texture parameter that evaluates pixel gray-level variations in DXA images of the lumbar spine. The TBS variations may reflect bone microarchitecture. We explain the general principles used to compute the TBS, and we report the correlations between TBS and microarchitectural parameters. Several limitations of the TBS as it is used now are pointed out. We discuss data from currently available clinical studies on the ability of the TBS to identify patients with fractures and to evaluate the fracture risk. We conclude that this new index emphasizes the failure of the BMD T-score to fully capture the fragility fracture risk. However, although microarchitecture may influence the TBS, today, to the best of our understanding, there is no sufficient evidence that a TBS measurement provides reliable information on the status of the bone microarchitecture for a given patient. The TBS depends on gray-level variations and in a projectional image obtained in vivo, these variations can have many causes. Nevertheless, as clinical studies suggest that the TBS predicts the risk of fracture even after adjustment for BMD, we are encouraged to learn more about this score. Additional studies will have to be performed to assess the advantages and limitations of the TBS, in order to ensure that it is used appropriately in clinical practice.

This article is an introduction to dual X-ray absorptiometry (DXA), the most widely used method today for diagnosis of osteoporosis. DXA can be used to assess projective bone mineral density at the lumbar spine, the proximal hip, and the whole body as well as the skeletal periphery at the forearm, the hand, and the heel. The prominent area of application of DXA is the diagnosis and monitoring of osteoporosis and its treatment. Because of its high accuracy, precision, and ability to predict osteoporotic fracture as well as its relatively low cost, DXA has prevailed over alternative methods. This article discusses the underlying X-ray physics and technological aspects, acquisition protocols, quality characteristics, and sources of error and their relevance. It also describes the various skeletal regions accessible to measurement, details on precision, nominal results, usability to predict fracture risk, and results of influential clinical trials.

During the lifetime of Physics in Medicine and Biology, osteoporosis has been recognized as the cause of a major health burden for societies, particularly within developed countries. The health detriment is associated with the consequences of bone fractures and the subsequent increases in morbidity and mortality. Much of the credit for the current availability of means for identifying groups of subjects at risk of fracture and the provision of means for the effective treatment of excessive bone loss can be attributed to the technique of dual photon absorptiometry. In this review, the history of the development of techniques based on the interactions of x- and gamma-rays with bone is considered and the ultimate dominance of x-ray based absorptiometry is described. The advantages and disadvantages of current absorptiometric techniques are presented and the likely future path for bone measurement is outlined.

Here a voice from the past suggests 28 changes that will affect how people study, manage, classify and think about "osteoporoses" today. Those changes depend mainly on two things: (i) "Connecting the dots" between diverse evidence and ideas from many fields and sources in order to find larger "messages" hidden in mountains of often poorly-organized lesser details, (ii) and features of the still-evolving Utah paradigm of skeletal physiology. That paradigm sums contributions from many people who worked in many fields for over 100 years. In one view it is the most important development in skeletal physiology since Rudolf Virchow and others realized approximately 150 years ago that cells provide the basis for human physiology and diseases. This article emphasizes the above messages instead of the details. The messages affect ideas about the nature, pathogenesis, diagnosis, classification, study and management of osteopenias and osteoporoses, as well as some roles of muscle, drugs, hormones, other agents and fatigue damage, in those disorders. Those larger messages also concern how to classify "osteoporosis fractures", how to define bone health, the choice of absorptiometric methods for noninvasive evaluations of bones, osteopenias and muscle strength, and new criteria for selecting patient cohorts for "risk-of-fracture" analyses and in searches for genetic roles in "osteoporoses". Finally, those larger messages identify many new targets for research that should prove unusually useful in clinical and pharmaceutical domains and work.

Introduction: Osteoporosis and fragility fractures are problems which will increase in significance as the population of the elderly in many countries increases. The availability of bone mineral density (BMD) measurements, which can define osteoporosis, allows the implementation of effective therapeutic interventions to those at risk for fractures before they occur. Because of the increasing at-risk population and the relatively high cost of these measurements and interventions, a case-finding strategy to detecting osteoporosis has been widely recommended. This review highlights the approach to detecting and diagnosing osteoporosis., Methods: A non-systematic review of English-language literature on the diagnosis and assessment of osteoporosis was conducted., Results: Many risk factors have been found to be associated with osteoporosis and fractures. These risk factors may be utilised for case finding in deciding who should be evaluated for osteoporosis. Clinical self-assessment tools have been developed to identify women likely to have low BMD who might be recommended for BMD. Several techniques are available for BMD measurement, but the technique of choice for the diagnosis of osteoporosis is dual-energy X-ray absorptiometry (DXA) measured at the hip. BMD thresholds have been widely used to guide osteoporosis treatment. However, recent research has been directed at using risk factor assessment and self-assessment tools to derive medium-term fracture risk as a guide to therapeutic intervention., Conclusions: Proper selection of individuals for evaluation and treatment for osteoporosis would include risk factor assessment and appropriate BMD measurement to determine the risk of fracture and the need for intervention.

Over the past decade, growing awareness of the impact of osteoporosis on the elderly population and the consequent costs of healthcare have stimulated development of new treatments to prevent fractures, together with new imaging technologies to assist in diagnosis. With its ability to perform high-precision measurements of bone mineral density (BMD) in the spine and hip, dual X-ray absorptiometry (DXA) is well suited to meet this latter need. However, there is continuing interest in smaller, less expensive, systems for assessing the peripheral skeleton. These include peripheral DXA scanning of the distal forearm and a variety of devices for performing quantitative ultrasound (QUS) measurements of broad-band ultrasonic attenuation (BUA) and speed of sound (SOS) in bone. Pivotal to all these developments is the demonstration in prospective studies that new technologies can reliably identify patients at risk of osteoporotic fractures. Whether DXA technology can meet the anticipated need for wider provision of diagnostic services is uncertain at present. The likely alternative is bone ultrasound. Although QUS technology is substantially cheaper than DXA and has proved its ability to predict fracture risk in the elderly, it is less precise, there is a lack of appropriate phantoms for quality control and there are doubts about how to interpret results in younger women.