American Academy of Family Physicians Bone Density Test
Diagnosis and Management of Osteoporosis
Am Fam Physician. 2015 Aug 15;92(4):261-268.
This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.
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Article Sections
- Abstruse
- Diagnosis
- Screening
- Evaluation for Secondary Osteoporosis
- Handling
- References
Osteoporosis-related fractures affect approximately 1 in two white women and one in 5 white men in their lifetime. The impact of fractures includes loss of function, significant costs, and increased bloodshed. The U.South. Preventive Services Task Forcefulness recommends using dual free energy x-ray absorptiometry to screen all women 65 years and older, and younger women who have an increased fracture risk as determined past the FRAX Fracture Risk Assessment Tool. [corrected] Although guidelines are lacking for rescreening women who have normal bone mineral density on initial screening, intervals of at to the lowest degree iv years appear safe. The U.Due south. Preventive Services Task Force found bereft testify to recommend screening for osteoporosis in men; other organizations recommend screening all men lxx years and older. In patients with newly diagnosed osteoporosis, suggested laboratory tests to identify secondary causes include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone. Start-line treatment to prevent fractures consists of fall prevention, smoking abeyance, moderation of booze intake, and bisphosphonate therapy. Clinicians should consider discontinuing bisphosphonate therapy later 5 years in women without a personal history of vertebral fractures. Raloxifene, teriparatide, and denosumab are alternative effective treatments for certain subsets of patients and for those who are unable to take or whose status does not respond to bisphosphonates. The demand for follow-up bone mineral density testing in patients receiving handling for osteoporosis is uncertain.
More than x meg Americans accept osteoporosis, which is defined past the National Osteoporosis Foundation equally a chronic, progressive disease characterized by low os mass, microarchitecture deterioration of bone tissue, os fragility, and a consequent increase in fracture take chances.ane Roughly 50% of white women and twenty% of white men take a fracture related to osteoporosis in their lifetime; although black men and women are at lower risk of osteoporosis, those with osteoporosis take similar fracture risk.1 Osteoporotic fractures are associated with increased risk of inability, nursing dwelling placement, total wellness care costs, and mortality (Table i).i–3 Osteoporosis risk increases with historic period, and its bear on will increment as the U.S. population ages.3 Table two lists take chances factors for osteoporosis.ii
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| All women 65 years and older should exist screened for osteoporosis with dual free energy x-ray absorptiometry of the hip and lumbar spine. | B | 5 |
| Women younger than 65 years should be screened for osteoporosis if the estimated ten-year fracture risk equals or exceeds that of a 65-year-quondam white woman with no take a chance factors. | B | 1, 5 |
| The U.S. Preventive Services Job Force concludes that the current evidence is insufficient to appraise the balance of benefits and harms of screening for osteoporosis in men. | C | v |
| A fall take a chance assessment should be performed and a multicomponent practice program and smoking cessation should be recommended to decrease fracture gamble in individuals 65 years and older with osteoporosis or a history of vertebral fracture. | C | 17, xx, 22 |
| Bisphosphonates should be used as commencement-line pharmacologic treatment for osteoporosis. | A | xvi, 26 |
| In patients who cannot tolerate or whose symptoms practise not amend with bisphosphonate therapy, teriparatide (Forteo) and denosumab (Prolia) are effective culling medications to prevent osteoporotic fractures. | A | sixteen, 26, 44 |
BEST PRACTICES IN PREVENTIVE MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY Entrada
| Recommendation | Sponsoring organisation |
|---|---|
| Do non use dual energy 10-ray absorptiometry (DEXA) to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors.* | American Academy of Family Physicians |
| Do not routinely repeat dual energy 10-ray absorptiometry (DEXA) scans more often than once every ii years. | American College of Rheumatology |
Table 1.
Bear on of Osteoporosis
| Impact | Statistics |
|---|---|
| Disability (pain, disability, complications) |
|
| Bloodshed |
|
| Long-term nursing home intendance |
|
| Annualized health care costs (2002) |
|
Table ii.
Selected Take a chance Factors for Osteoporosis
| Excessive booze intake (> four drinks per solar day for men; > 2 drinks per mean solar day for women), caffeine intake (> 2.5 units [e.g., cups of coffee] per twenty-four hours), and tobacco use (any smoking) |
| Family history of osteoporotic fracture |
| Gonadal hormone deficiency |
| Immobilization and inadequate action |
| Increasing age |
| Low body weight (< 58 kg [128 lb]) |
| Low calcium or vitamin D intake |
| Low level of physical activity |
| Personal history of fracture |
| Smoking |
| White or Asian race |
Diagnosis
- Abstruse
- Diagnosis
- Screening
- Evaluation for Secondary Osteoporosis
- Treatment
- References
Osteoporosis is diagnosed radiographically based on bone mineral density (BMD) determinations from dual free energy x-ray absorptiometry (DEXA) assessment.4 Although quantitative calcaneal ultrasonography and peripheral DEXA can besides predict fracture risk, these modalities practise not correlate well enough with central DEXA to exist used diagnostically.i,five,6 The World Health Organization (WHO) established normally accepted definitions of osteoporosis and osteopenia4 (Tabular array 36).
Table 3.
Diagnostic Criteria for Osteoporosis and Osteopenia in Postmenopausal Women and Men Older Than 50 Years
| Category | Bone mass (BMD derived from DEXA measurement) |
|---|---|
| Normal | Spinal or hip BMD inside 1.0 SD beneath the young adult female person reference hateful (T-score ≥ –1.0) |
| Low bone mass (osteopenia) | Spinal or hip BMD between 1.0 and 2.five SDs beneath the young adult female reference mean (T-score < –1.0 and > –2.5) |
| Osteoporosis | Spinal or hip BMD ≥ 2.5 SDs below the young adult female reference mean (T-score ≤ –2.5) |
| Severe/established osteoporosis | BMD ≥ 2.v SDs beneath the young adult female reference mean and the presence of 1 or more than fragility fractures |
The WHO criteria should not be practical to men younger than l years, children, or premenopausal women. For these groups, the International Society for Clinical Densitometry recommends use of the z score (age and sexual practice norms). Z scores of −2.0 or less are below the expected range for age. Osteoporosis in men younger than fifty years cannot be diagnosed based on BMD assessment alone.7
Screening
- Abstract
- Diagnosis
- Screening
- Evaluation for Secondary Osteoporosis
- Handling
- References
Published osteoporosis screening guidelines vary greatly (eTable A). The U.Southward. Preventive Services Job Force (USPSTF) recommends screening all women 65 years and older.v DEXA of the hip and lumbar spine is the preferred assessment method. The USPSTF also advises screening women younger than 65 years whose 10-twelvemonth fracture risk is greater than or equal to that of a 65-year-onetime white woman without additional risk factors.5 The FRAX Fracture Risk Assessment Tool (http://www.shef.ac.united kingdom/FRAX/) was used by the USPSTF as a method of determining increased fracture adventure for these women. [corrected] Although guidelines for rescreening women with normal initial screening results are lacking, recent prove suggests that intervals of at least four years appear prophylactic.viii,9
eTable A.
Osteoporosis Screening Recommendations
| Organization | Recommendation | |
|---|---|---|
| American Association of Clinical EndocrinologistsA1 (2010) | All women 65 years or older | |
| All postmenopausal women: | ||
| With a history of fracture(southward) without major trauma after 40 to 45 years of historic period | ||
| With osteopenia identified radiographically | ||
| Starting or taking long-term systemic glucocorticoid therapy (≥ 3 months) | ||
| Patients at increased risk of secondary osteoporosis (e.one thousand., rheumatoid arthritis) | ||
| Other perimenopausal or postmenopausal women with risk factors for osteoporosis if willing to consider pharmacologic interventions: | ||
| Current smoker | ||
| Early on menopause | ||
| Family unit history of osteoporotic fracture | ||
| Excessive consumption of alcohol (> ii drinks per mean solar day for women) | ||
| Low torso weight (< 58 kg [128 lb] or body mass alphabetize < 20 kg per m2) | ||
| Any history of long-term systemic glucocorticoid therapy (≥ 3 months) | ||
| American College of Obstetricians and GynecologistsA2 (2012) | Os density screening no more than than once every two years start at 65 years of age, unless new health risks develop | |
| Selective screening in women younger than 65 years if they are postmenopausal and have other osteoporosis take chances factors or fracture | ||
| In the absence of new risk factors, DEXA monitoring of therapy should not be repeated after BMD is determined to be stable or improved | ||
| National Osteoporosis FoundationA3 (2014)* | BMD testing should exist performed: | |
| In women 65 years and older and in men 70 years and older | ||
| In postmenopausal women and men fifty to 69 years of age; recommended based on risk factor profile | ||
| With vertebral imaging in those who have had a fracture to determine degree of disease severity | ||
| At DEXA facilities using accepted quality assurance measures | ||
| Vertebral imaging should be performed: | ||
| In women 65 years and older and in men 70 years and older to diagnose vertebral fractures if T-score is ≤ –1.v | ||
| In women 70 years and older and in men 80 years and older to diagnose vertebral fractures, regardless of T-score | ||
| In postmenopausal women and men 50 years and older with a depression-trauma fracture | ||
| In postmenopausal women and men 50 to 69 years of age to diagnose vertebral fractures if there is meridian loss ≥ four cm (ane.5 in), or recent or ongoing long-term glucocorticoid therapy | ||
| To check for causes of secondary osteoporosis | ||
| Monitoring should include: | ||
| BMD testing one to 2 years later on initiating therapy to reduce fracture take chances and every two years thereafter | ||
| More frequent testing in certain clinical situations | ||
| Longer interval between repeat BMD tests for patients without major risk factors and who have an initial T-score in the normal or upper low–bone mass range | ||
| Osteoporosis CanadaA4 (2010)* | Younger adults (age < 50 years): | |
| Fragility fracture | ||
| Take chances factors: glucocorticoid use (> 3 months cumulative therapy in past year), high-take chances medication use, hypogonadism or premature menopause (historic period < 45 years), malabsorption syndrome, hyperparathyroidism, other associated disorders | ||
| Older adults (age > 50 years): | ||
| Fragility fracture | ||
| High alcohol intake | ||
| Low body weight (< 60 kg [132 lb]) or weight loss (> ten% of weight at 25 years of age) | ||
| Parental hip fracture | ||
| Rheumatoid arthritis | ||
| Smoking | ||
| Vertebral fracture or osteopenia on radiography | ||
| Men and women 65 years and older | ||
| Repeat BMD testing in 1 to iii years and reassess risk in moderate- and high-risk groups | ||
| United Kingdom National Osteoporosis Guideline GroupA5 (2009) | Population screening not recommended | |
| Case finding for BMD assessment is based on risk factor assessment and comparison of risk to age- and sex-specific fracture probabilities | ||
| U.S. Preventive Services Task ForceA6 (2011) | Screen for osteoporosis in women 65 years and older, and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional chance factors | |
| Current bear witness is insufficient to assess the residual of benefits and harms of screening for osteoporosis in men | ||
The USPSTF institute bereft evidence to recommend routine screening for osteoporosis in men.v Men with a minimal trauma fracture who are older than fifty years or those with secondary causes associated with os loss could be considered for screening. The National Osteoporosis Foundation also recommends screening all men 70 years and older, based on the assumption that this grouping has a similar osteoporotic fracture hazard and treatment effectiveness as 65-yr-old white women.1
Evaluation for Secondary Osteoporosis
- Abstruse
- Diagnosis
- Screening
- Evaluation for Secondary Osteoporosis
- Treatment
- References
Chief osteoporosis is related to aging and loss of gonadal function. Secondary osteoporosis is caused by other wellness weather condition (Table 4).ii Up to 30% of osteoporosis cases in postmenopausal women are estimated to exist from a secondary cause.10 The guess climbs to greater than 50% in men, premenopausal women, and perimenopausal women if vitamin D deficiency is included as a secondary cause.11–xiii In addition to performing a history and physical examination, expert consensus suggests a basic laboratory evaluation for all newly diagnosed patients to determine if there are contraindications for certain osteoporosis medications and to identify the more than common secondary causes. The well-nigh unremarkably recommended laboratory tests include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone levels.ane,14
Table 4.
Common Causes of Secondary Osteoporosis
| Medical atmospheric condition |
| Key nervous system disorders (e.yard., epilepsy, multiple sclerosis, Parkinson disease, spinal cord injury, stroke) |
| Chronic obstructive pulmonary disease |
| Endocrine/metabolic disorders (adrenal insufficiency, athletic amenorrhea, Cushing syndrome, hemochromatosis, homocystinuria, master hyperparathyroidism, hyperprolactinemia, hyperthyroidism, primary or secondary hypogonadism, premature menopause, thyrotoxicosis, type 1 diabetes mellitus) |
| Gastrointestinal disorders (celiac disease, gastric bypass, inflammatory bowel disease, malabsorption, pancreatic insufficiency, master biliary cirrhosis) |
| Hematologic disorders (hemophilia, leukemia and lymphomas, monoclonal gammopathies, multiple myeloma, sickle cell disease, thalassemia) |
| Homo immunodeficiency virus infection or AIDS |
| Liver disease (astringent) |
| Nutrition disorders (alcoholism, anorexia nervosa/bulimia, malnutrition, vitamin A excess, vitamin D deficiency) |
| Renal insufficiency or renal failure |
| Rheumatoid arthritis |
| Systemic lupus erythematosus |
| Medications |
| Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) |
| Chemotherapeutics |
| Cyclosporine (Sandimmune) |
| Depo-medroxyprogesterone (Depo-Provera) |
| Glucocorticoids |
| Gonadotropin-releasing hormone agonists and antagonists |
| Heparin |
| Lithium |
| Methotrexate |
| Proton pump inhibitors |
| Selective serotonin reuptake inhibitors |
| Tacrolimus (Prograf) |
| Tamoxifen |
| Thiazolidinediones (east.g., pioglitazone [Actos]) |
| Thyroid hormone excess |
Handling
- Abstract
- Diagnosis
- Screening
- Evaluation for Secondary Osteoporosis
- Treatment
- References
The National Osteoporosis Foundation recommends treatment of postmenopausal women and men with a personal history of hip or vertebral fracture, a T-score of −2.5 or less, or a combination of low bone mass (T-score between −1 and −2.v) and a 10-yr probability of hip fracture of at least iii% or any major fracture of at least 20% equally calculated by the FRAX Fracture Risk Assessment Tool.i [corrected] The WHO recommendations are less specific, stating that persons with or at take a chance of osteoporosis should exist considered for handling.15 Randomized controlled trials of handling have shown reduction of fractures for only ii groups: those with a T-score of less than –2.v and those who have already experienced a hip or vertebral fracture.16
NONPHARMACOLOGIC TREATMENT
Fall prevention is a priority for patients with osteoporosis because falls are more than closely associated with fracture take chances than is BMD.17 The USPSTF recommends practise or physical therapy and vitamin D supplementation to preclude falls in customs-dwelling adults 65 years or older who are at increased take a chance of falls.18 A multicomponent exercise program that consists of weight-begetting resistance and balance grooming should be recommended. Aerobic exercise programs that do not comprise force and remainder training should be avoided because of the clan with increased fracture risk.19 A thorough assessment of a patient'south risks of falling and mitigation of those adventure factors have stiff evidence of effectiveness in autumn prevention.20 A Cochrane review suggested that hip protectors subtract fracture take a chance.21
Patients should exist counseled to quit smoking because it has been shown to decrease BMD at all skeletal sites.22 Heavy alcohol consumption (defined as more than iv drinks per day for men or more than two drinks per day for women) is a major hazard factor for fracture and should exist discouraged.23
Dietary modifications may take a role in optimizing bone health. Consuming more than ii.5 units of caffeine daily (one unit = i cup of java or 2 cups of tea) may increment fracture risk.24 Diets with acceptable poly peptide intake are necessary for optimal bone wellness, but the proper amount or source (plant vs. animal) remains controversial. A balanced diet consisting of vitamin D, calcium, protein, vegetables, and fruits is recommended; mononutrient dietary supplementation is unlikely to exist helpful.24 Table 5 shows a comparing of nonpharmacologic therapies.17–25
Table 5.
Nonpharmacologic Therapy to Reduce Fractures
| Intervention | Comments |
|---|---|
| Alcohol moderation | ≤ iv drinks per mean solar day for men or ≤ two drinks per day for women |
| Decreased caffeine intake | ≤ two.five cups of coffee or ≤ 5 cups of tea per day |
| Multicomponent exercise with forcefulness and balance training | — |
| Multifactorial falls chance cess | — |
| Smoking abeyance | — |
| Sunlight/ultraviolet exposure | 30 minutes per day, five days per week |
| Vitamin D supplementation | 800 IU per day |
PHARMACOLOGIC Treatment
Table six summarizes pharmacologic treatments for osteoporosis, including bisphosphonates, raloxifene (Evista), teriparatide (Forteo), and denosumab (Prolia).sixteen,26–29
Table vi.
Pharmacologic Therapies for Osteoporosis
| Course/medication | FDA indication | Fracture blazon | Typical dosage and monthly cost 27,28 | Agin effects and contraindications | NNT (to prevent 1 fracture) 29 | ||
|---|---|---|---|---|---|---|---|
| Bisphosphonates | Consider drug discontinuation after 5 years in low-risk patients | Minor risk of atypical femoral shaft fractures; osteonecrosis of the jaw | |||||
| Alendronate (Fosamax) | Prevention | Hip, vertebral, nonvertebral |
|
| Hip: 91 (2 to five years) | ||
| Treatment | Hip, vertebral, nonvertebral |
| |||||
| Alendronate/cholecalciferol (Fosamax Plus D) | Handling | Hip, vertebral, nonvertebral |
| Same as alendronate | — | ||
| Ibandronate (Boniva) | Prevention and treatment | Vertebral only |
| Same equally alendronate | Spine: xx (three years) | ||
| Handling | Vertebral merely |
| Same as alendronate | — | |||
| Risedronate (Actonel) | Prevention and handling | Hip, vertebral, nonvertebral |
| Same as alendronate | Hip: 77 (3 years) | ||
| Risedronate, delayed release (Atelvia) | Treatment | Hip, vertebral, nonvertebral |
| Same equally alendronate | — | ||
| Risedronate with calcium | Prevention and treatment | Hip, vertebral, nonvertebral |
| Same as alendronate | — | ||
| Zoledronic acid (Reclast) | Prevention | Hip, vertebral, nonvertebral |
|
|
| ||
| Treatment | Hip, vertebral, nonvertebral |
| |||||
| Raloxifene (Evista) | Prevention and treatment | Vertebral only |
|
| Spine: 29 (three years) | ||
| Teriparatide (Forteo) | Treatment (loftier take chances*) | Vertebral, nonvertebral |
|
| Spine: 11 (1.five years) | ||
| Denosumab (Prolia) | Treatment (loftier risk*) | Hip, vertebral, nonvertebral |
| Muscular and articulation pains; small risk of osteonecrosis of the jaw (particularly older women with poor dental hygiene or cancer) Contraindications: hypocalcemia; pregnancy | Spine: 21 (3 years) | ||
Bisphosphonates. Oral bisphosphonates inhibit osteoclastic activity and are antiresorptive agents. They are considered first-line pharmacologic therapy. Randomized clinical trials demonstrate a reduction of vertebral and hip fractures with alendronate (Fosamax) and risedronate (Actonel).sixteen,26 Alendronate and risedronate also decrease vertebral fractures in men30,31 and in patients with glucocorticoid-induced osteoporosis.32,33 Daily and intermittent use of ibandronate (Boniva) take demonstrated effectiveness in reducing fractures of the spine only.34 Weekly and monthly dosing formulations improve adherence.35 Oral bisphosphonates should be taken only with water and a await of at least 30 minutes before reclining or ingesting other medication or food. This decreases upper gastrointestinal agin effects and allows for advisable absorption.
The intravenous bisphosphonates approved by the U.S. Nutrient and Drug Administration for the treatment of postmenopausal osteoporosis are zoledronic acrid (Reclast), 5 mg yearly (shown to subtract vertebral and hip fractures),16,26,36 and ibandronate, 3 mg every 3 months.37 Although these medications are expensive, they are useful for high-run a risk patients who are unable to tolerate or adhere to oral therapy.
The optimal length of oral bisphosphonate therapy is unknown. I report plant that women who take alendronate for five years followed by five years of placebo have no increased incidence of nonvertebral or hip fractures compared with women who take alendronate for 10 years. There is, however, an increment in vertebral fractures.38 Osteonecrosis of the jaw and atypical femoral fractures are rare complications of bisphosphonate therapy that are associated with longer elapsing of use.39,40 Clinicians should consider discontinuing bisphosphonate therapy afterward 5 years in women without a personal history of vertebral fractures.
Raloxifene. Raloxifene, a selective estrogen receptor modulator, is canonical for treating postmenopausal osteoporosis, and is effective at reducing vertebral fractures only.xvi,26 Raloxifene is ordinarily associated with increased vasomotor symptoms. It is associated with an increased risk of venous thromboembolism and a decreased adventure of invasive breast cancer.xvi The best candidates for raloxifene are postmenopausal women with osteoporosis who are unable to tolerate bisphosphonates, take no vasomotor symptoms or history of venous thromboembolism, and accept a loftier chest cancer risk score.16,27 Bazedoxifene is a selective estrogen receptor modulator more than recently approved for apply in the United States for the prevention of osteoporosis equally part of a combination therapy with conjugated estrogen (Duavee).
Calcitonin. Calcitonin nasal spray is an antiresorptive amanuensis approved for the treatment of postmenopausal osteoporosis. It has been shown to decrease the occurrence of vertebral compression fractures only.16,26 Although calcitonin has minor analgesic properties in the setting of acute and chronic vertebral compression fracture, it is not considered first-line treatment for osteoporosis considering more effective medications are bachelor.xvi,41 There take also been reports of increased cancer rates associated with use of calcitonin.42
Teriparatide. Teriparatide is a recombinant man parathyroid hormone with os anabolic activity. In a dosage of 20 mcg per day given subcutaneously for up to two years, teriparatide decreases vertebral and nonvertebral fractures.xvi,26 Teriparatide is approved for the handling of postmenopausal women with astringent bone loss, men with osteoporosis who have loftier risk of fracture, and individuals whose condition has not improved with bisphosphonate therapy. One study suggests that it is advisable to follow teriparatide therapy with bisphosphonate therapy to maintain BMD gains.43
Denosumab. Denosumab is a human monoclonal antibody that inhibits the formation and action of osteoclasts past blocking receptor activator of nuclear factor kappa B ligand. In a dose of 60 mg given subcutaneously every six months for three years, information technology significantly increased BMD in postmenopausal women compared with weekly dosing of alendronate.44 Denosumab has been shown to decrease hip, vertebral, and nonvertebral fractures compared with low doses of calcium and vitamin D. It appears to be a reasonable alternative for persons whose condition does non improve with bisphosphonates. Renal insufficiency is a listed caution, only denosumab appears to be safe for patients with chronic kidney disease stages 1 to 3.45
Hormone Therapy. The Women'southward Health Initiative study confirmed that estrogen, with or without progesterone, slightly reduced the chance of hip and vertebral fractures; yet, this benefit did not outweigh the increased risk of stroke, venous thromboembolism, coronary centre illness, and breast cancer, even for women at loftier risk of fracture.46 Lower doses of conjugated equine estrogens and estradiol have been shown to improve BMD, but a reduced chance of fracture has not been demonstrated and the safe is unknown.47
Combination Therapy. There has been no demonstrated effectiveness of combination therapy in reducing fractures. Although research continues, in that location is currently a limited role for combination therapy beyond clinical trials.
FOLLOW-Upward
After initiation of treatment, the need for follow-up bone density testing is uncertain. A decrease in BMD could suggest treatment nonadherence, inadequate calcium or vitamin D intake, an unidentified secondary cause of osteoporosis, or treatment failure.48 All the same, a single-establishment study found that although follow-up DEXA scanning for patients with osteoporosis was performed often, this rarely led to changes in treatment, even in patients plant to have decreased BMD.49
Data Sources: We reviewed all cited references from the original 2009 review article, and so performed a PubMed search using the following fundamental words: osteoporosis, osteopenia, screening, diagnosis, treatment, prevention, secondary, and vitamin D. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Additional searches included Essential Evidence Plus, the U.S. Preventive Services Job Strength, the Institute for Clinical Systems Comeback, the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews, and the National Osteoporosis Foundation website. Search dates: April and July 2014, and May 2015.
The opinions or assertions independent herein are the individual views of the authors and are non to exist construed equally official or as reflecting the views of the Department of Defense, the U.S. Army Medical Corps, or the U.S. Army at large.
note: This review updates a previous article on this topic by Sweet, Sweet, Jeremiah, and Galazka.29
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