A clinician's guide to the management of geriatric musculoskeletal disease: Part 1 - Osteoporosis

  • Jack Feehan
    Corresponding author. Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital, 176 Furlong Road, St Albans, VIC, 3021, Australia.
    Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne, Victoria University and Western Health, St Albans, VIC, Australia

    Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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  • Nicholas Tripodi
    Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne, Victoria University and Western Health, St Albans, VIC, Australia

    Institute for Health and Sport, Victoria University, VIC, Australia

    First Year College, Victoria University, VIC, Australia
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  • Michael Fleischmann
    Institute for Health and Sport, Victoria University, VIC, Australia

    College of Health and Biomedicine, Victoria University, VIC, Australia
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  • Jesse Zanker
    Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne, Victoria University and Western Health, St Albans, VIC, Australia

    Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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  • Gustavo Duque
    Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne, Victoria University and Western Health, St Albans, VIC, Australia

    Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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Published:December 20, 2021DOI:


      Osteoporosis is a condition of growing concern in all areas of healthcare, with osteopathic practice no exception. Allied health clinicians and other manual/physical practitioners are well placed to play a role in prevention, early detection and intervention in these patients, as well as in ongoing fall and fracture prevention. This masterclass aims to provide a clinical guide to the management of osteoporosis, with a focus on the role of the allied health clinician in its diagnosis and ongoing treatment. Specifically, it will cover key clinical risk factors, referral guidelines and recommendations for management, to allow for confident, evidence-informed management of these patients in practice. We propose that empowering clinicians with the clinical knowledge to provide support in the management of chronic musculoskeletal diseases such as osteoporosis will advance patient care and outcomes both now and into the future.


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        • Black D.M.
        • Rosen C.J.
        Postmenopausal osteoporosis.
        N Engl J Med. 2016; 374: 254-262
        • Steel A.
        • et al.
        Prevalence and profile of Australian osteopaths treating older people.
        Compl Ther Med. 2019; 43: 125-130
        • Drey M.
        • Sieber C.C.
        • Bertsch T.
        • Bauer J.M.
        • Schmidmaier R.
        Osteosarcopenia is more than sarcopenia and osteopenia alone.
        Aging Clin Exp Res. 2016; 28: 895-899
        • Hirschfeld H.
        • Kinsella R.
        • Duque G.
        Osteosarcopenia: where bone, muscle, and fat collide.
        Osteoporos Int. 2017; 28: 2781-2790
        • Zanker J.
        • Brennan-Olsen S.
        • Duque G.
        Osteosarcopenia: the modern geriatric giant.
        • Kirk B.
        • Zanker J.
        • Duque G.
        Osteosarcopenia: epidemiology, diagnosis, and treatment—facts and numbers.
        Journal of Cachexia, Sarcopenia and Muscle. 2020;
        • Kirk B.
        • Miller S.
        • Zanker J.
        • Duque G.
        A clinical guide to the pathophysiology, diagnosis and treatment of osteosarcopenia.
        Maturitas, 2020
        • Johnell O.
        • Kanis J.
        Epidemiology of osteoporotic fractures.
        Osteoporos Int. 2005; 16: S3-S7
        • Kanis J.
        • et al.
        Long-term risk of osteoporotic fracture in Malmö.
        Osteoporos Int. 2000; 11: 669-674
        • Nguyen N.D.
        • Ahlborg H.G.
        • Center J.R.
        • Eisman J.A.
        • Nguyen T.V.
        Residual lifetime risk of fractures in women and men.
        J Bone Miner Res. 2007; 22: 781-788
        • Cummings S.R.
        • Melton L.J.
        Epidemiology and outcomes of osteoporotic fractures.
        Lancet. 2002; 359: 1761-1767
        • Abrahamsen B.
        • Van Staa T.
        • Ariely R.
        • Olson M.
        • Cooper C.
        Excess mortality following hip fracture: a systematic epidemiological review.
        Osteoporos Int. 2009; 20: 1633-1650
        • Haentjens P.
        • et al.
        Meta-analysis: excess mortality after hip fracture among older women and men.
        Ann Intern Med. 2010; 152: 380-390
        • Hall S.
        • Williams J.
        • Senior J.A.
        • Goldswain P.
        • Criddle R.A.
        Hip fracture outcomes: quality of life and functional status in older adults living in the community.
        Aust N Z J Med. 2000; 30: 327-332
        • Borgström F.
        • et al.
        Fragility fractures in Europe: burden, management and opportunities.
        Archives of Osteoporosis. 2020; 15 (2020/04/19): 59
        • Johnell O.
        • Kanis J.A.
        An estimate of the worldwide prevalence and disability associated with osteoporotic fractures.
        Osteoporos Int. Dec 2006; 17: 1726-1733
        • Tatangelo G.
        • et al.
        The cost of osteoporosis, osteopenia, and associated fractures in Australia in 2017.
        J Bone Miner Res. 2019; 34: 616-625
        • National Osteoporosis Foundation
        The clinical and cost burden of fractures associated with osteoporosis.
        ([Online]. Available:)
        • Becker D.J.
        • Kilgore M.L.
        • Morrisey M.A.
        The societal burden of osteoporosis.
        Curr Rheumatol Rep. 2010; 12: 186-191
        • Miller P.D.
        Underdiagnoses and undertreatment of osteoporosis: the battle to Be won.
        J Clin Endocrinol Metabol. 2016; 101: 852-859
        • Dobbs M.B.
        • Buckwalter J.
        • Saltzman C.
        Osteoporosis: the increasing role of the orthopaedist.
        Iowa Orthop J. 1999; 19 (in eng) ([Online]. Available:): 43-52
        • Zanker J.
        • Duque G.
        Osteoporosis in older persons: old and new players.
        J Am Geriatr Soc. 2019; 67: 831-840
        • Eastell R.
        • et al.
        Postmenopausal osteoporosis.
        Nat Rev Dis Prim. 2016; 2: 1-16
        • Feehan J.
        • Al Saedi A.
        • Duque G.
        Targeting fundamental aging mechanisms to treat osteoporosis.
        Expert Opin Ther Targets. Dec 2019; 23 (in eng): 1031-1039
        • Duque G.
        • Troen B.R.
        Understanding the mechanisms of senile osteoporosis: new facts for a major geriatric syndrome.
        J Am Geriatr Soc. 2008; 56: 935-941
        • Mirza F.
        • Canalis E.
        Secondary osteoporosis: pathophysiology and management.
        European journal of endocrinology/European Federation of Endocrine Societies. 2015; 173: R131
        • Morgan S.L.
        • Prater G.L.
        Quality in dual-energy X-ray absorptiometry scans.
        Bone. 2017; 104: 13-28
        • Carey J.J.
        • Delaney M.F.
        T-scores and Z-scores.
        in: Clinical reviews in bone and mineral metabolism. vol. 8. 2010: 113-121 (3)
        • Kanis J.
        • Johnell O.
        • Oden A.
        • Dawson A.
        • De Laet C.
        • Jonsson B.
        Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds.
        Osteoporos Int. 2001; 12: 989-995
        • Licata A.A.
        Diagnosing primary osteoporosis: it's more than a T score.
        Cleve Clin J Med. 2006; 73: 473-476
        • Siris E.S.
        • et al.
        Bone mineral density thresholds for pharmacological intervention to prevent fractures.
        Arch Intern Med. 2004; 164: 1108-1112
        • Schuit S.
        • et al.
        Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study.
        Bone. 2004; 34: 195-202
        • Sornay‐Rendu E.
        • Munoz F.
        • Garnero P.
        • Duboeuf F.
        • Delmas P.D.
        Identification of osteopenic women at high risk of fracture: the OFELY study.
        J Bone Miner Res. 2005; 20: 1813-1819
        • Cosman F.
        • et al.
        Clinician's guide to prevention and treatment of osteoporosis.
        (in eng)in: Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. vol. 25. 2014: 2359-2381 (10)
      1. 2017). Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age, second ed. [Online] Available:

        • Donnelly S.
        • Doyle D.V.
        • Denton A.
        • Rolfe I.
        • McCloskey E.V.
        • Spector T.D.
        Bone mineral density and vertebral compression fracture rates in ankylosing spondylitis.
        Ann Rheum Dis. 1994; 53: 117-121
        • Epsley S.
        • Tadros S.
        • Farid A.
        • Kargilis D.
        • Mehta S.
        • Rajapakse C.S.
        The effect of inflammation on bone.
        Front. Physiol., Review. 2021; 11 (in English) (January-05 2021): 1695
      2. T. V. Nguyen, N. Pocock, and J. A. Eisman, "Interpretation of bone mineral density measurement and its change," (in eng), J Clin Densitom, vol. 3, no. 2, pp. 107-119, Summer 2000, doi: 10.1385/jcd:3:2:107.

        • Pouresmaeili F.
        • Kamalidehghan B.
        • Kamarehei M.
        • Goh Y.M.
        A comprehensive overview on osteoporosis and its risk factors.
        Therapeut Clin Risk Manag. 2018; 14: 2029
        • Kanis J.A.
        • Harvey N.C.
        • Johansson H.
        • Odén A.
        • McCloskey E.V.
        • Leslie W.D.
        Overview of fracture prediction tools.
        J Clin Densitom. 2017; 20: 444-450
        • Kanis J.A.
        • Johnell O.
        • Oden A.
        • Johansson H.
        • McCloskey E.
        FRAX and the assessment of fracture probability in men and women from the UK.
        (in eng)in: Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. vol. 19. 2008: 385-397 (4)
        • Imerci A.
        • Kılınç C.Y.
        • Aydogan N.H.
        • Karalezli M.N.
        • Savran A.
        Fracture Risk Assessment Tool (FRAX®) results calculated with and without bone mineral density values for the evaluation of fracture risk in postmenopausal women with osteopenia.
        J Clin Densitom. 2018; 21: 464-471
        • Center J.R.
        Fracture burden: what two and a half decades of Dubbo Osteoporosis Epidemiology Study data reveal about clinical outcomes of osteoporosis.
        Curr Osteoporos Rep. 2017; 15: 88-95
        • Cummings S.R.
        • et al.
        Goal‐directed treatment for osteoporosis: a progress report from the ASBMR‐NOF working group on goal‐directed treatment for osteoporosis.
        J Bone Miner Res. 2017; 32: 3-10
        • Zobi F.E.A.
        Effects of estrogen therapy for osteoporosis.
        • Lobo R.A.
        Hormone-replacement therapy: current thinking.
        Nat Rev Endocrinol. 2017/04/01 2017; 13: 220-231
        • Pickar J.H.
        • Komm B.S.
        Selective estrogen receptor modulators and the combination therapy conjugated estrogens/bazedoxifene: a review of effects on the breast.
        Post Reprod Health. Sep 2015; 21 (in eng): 112-121
        • Vignozzi L.
        • Malavolta N.
        • Villa P.
        • Mangili G.
        • Migliaccio S.
        • Lello S.
        Consensus statement on the use of HRT in postmenopausal women in the management of osteoporosis by SIE, SIOMMMS and SIGO.
        J Endocrinol Invest. 2019; 42 (2019/05/01): 609-618
        • Nancollas G.
        • et al.
        Novel insights into actions of bisphosphonates on bone: differences in interactions with hydroxyapatite.
        Bone. 2006; 38: 617-627
        • Rogers M.J.
        • Mönkkönen J.
        • Munoz M.A.
        Molecular mechanisms of actions of bisphosphonates and new insights into their effects outside the skeleton.
        Bone. 2020; : 115493
        • Bilezikian J.P.
        Efficacy of bisphosphonates in reducing fracture risk in postmenopausal osteoporosis.
        Am J Med. 2009; 122: S14-S21
        • Eastell R.
        • Walsh J.S.
        • Watts N.B.
        • Siris E.
        Bisphosphonates for postmenopausal osteoporosis.
        Bone. 2011; 49 (2011/07/01/): 82-88
        • Schilcher J.
        • Michaëlsson K.
        • Aspenberg P.
        Bisphosphonate use and atypical fractures of the femoral shaft.
        N Engl J Med. 2011; 364: 1728-1737
        • Mavrokokki T.
        • Cheng A.
        • Stein B.
        • Goss A.
        Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia.
        J Oral Maxillofac Surg. 2007; 65: 415-423
        • Beth‐Tasdogan N.H.
        • Mayer B.
        • Hussein H.
        • Zolk O.
        Interventions for managing medication‐related osteonecrosis of the jaw.
        Cochrane Database Syst Rev. 2017; 10
        • Makino A.
        • et al.
        Abaloparatide exerts bone anabolic effects with less stimulation of bone resorption-related factors: a comparison with teriparatide.
        Calcif Tissue Int. 2018; 103: 289-297
        • Gallagher J.C.
        • Genant H.K.
        • Crans G.G.
        • Vargas S.J.
        • Krege J.H.
        Teriparatide reduces the fracture risk associated with increasing number and severity of osteoporotic fractures.
        J Clin Endocrinol Metabol. 2005; 90: 1583-1587
        • Miller P.D.
        • et al.
        Effect of abaloparatide vs placebo on new vertebral fractures in postmenopausal women with osteoporosis: a randomized clinical trial.
        JAMA. 2016; 316: 722-733
        • Hanley D.
        • Adachi J.
        • Bell A.
        • Brown V.
        Denosumab: mechanism of action and clinical outcomes.
        Int J Clin Pract. 2012; 66: 1139-1146
        • Bandeira L.
        • Lewiecki E.M.
        • Bilezikian J.P.
        Romosozumab for the treatment of osteoporosis.
        Expet Opin Biol Ther. 2017; 17: 255-263
        • McClung M.R.
        • et al.
        Romosozumab in postmenopausal women with low bone mineral density.
        N Engl J Med. 2014; 370: 412-420
        • Bovijn J.
        • et al.
        Evaluating the cardiovascular safety of sclerostin inhibition using evidence from meta-analysis of clinical trials and human genetics.
        Sci Transl Med. 2020; 12 (eaay6570)
        • Tucker K.L.
        Osteoporosis prevention and nutrition.
        Curr Osteoporos Rep. 2009; 7: 111
        • Hill T.R.
        • Aspray T.J.
        The role of vitamin D in maintaining bone health in older people.
        Ther Adv Musculoskelet Dis. Apr 2017; 9: 89-95
        • Bischoff-Ferrari H.A.
        • Willett W.C.
        • Wong J.B.
        • Giovannucci E.
        • Dietrich T.
        • Dawson-Hughes B.
        Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials.
        JAMA. May 11 2005; 293: 2257-2264
        • Murad M.H.
        • et al.
        The effect of vitamin D on falls: a systematic review and meta-analysis.
        J Clin Endocrinol Metabol. 2011; 96: 2997-3006
        • Chiodini I.
        • Bolland M.J.
        Calcium supplementation in osteoporosis: useful or harmful?.
        Eur J Endocrinol. 2018; 178: D13-D25
        • Cano A.
        • et al.
        Calcium in the prevention of postmenopausal osteoporosis: EMAS clinical guide.
        Maturitas. 2018; 107: 7-12
        • Heaney R.P.
        • Layman D.K.
        Amount and type of protein influences bone health.
        Am J Clin Nutr. 2008; 87: 1567S-1570S
        • Rizzoli R.
        • et al.
        The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women: a consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).
        Maturitas. 2014; 79: 122-132
        • Bustins G.A.
        • Plaza P.-V.L.
        • Carvajal S.R.
        Profile of osteopathic practice in Spain: results from a standardized data collection study.
        BMC Compl Alternative Med. 2018; 18: 129
        • Deveugele M.
        • Derese A.
        • van den Brink-Muinen A.
        • Bensing J.
        • De Maeseneer J.
        Consultation length in general practice: cross sectional study in six European countries.
        BMJ. 2002; 325: 472
        • Gronholz M.J.
        Prevention, diagnosis, and management of osteoporosis-related fracture: a multifactoral osteopathic approach.
        J Am Osteopath Assoc. 2008; 108: 575-585
        • Bennell K.
        • Khan K.
        • McKay H.
        The role of physiotherapy in the prevention and treatment of osteoporosis.
        Man Ther. 2000; 5: 198-213
        • Konak H.E.
        • Kibar S.
        • Ergin E.S.
        The effect of single-task and dual-task balance exercise programs on balance performance in adults with osteoporosis: a randomized controlled preliminary trial.
        Osteoporos Int. 2016; 27: 3271-3278
        • Winger M.E.
        • et al.
        Associations between novel jump test measures, grip strength, and physical performance: the Osteoporotic Fractures in Men (MrOS) Study.
        Aging Clin Exp Res. 2019; : 1-9
        • Bohannon R.W.
        Reference values for the timed up and go test: a descriptive meta-analysis.
        J Geriatr Phys Ther. 2006; 29 (in eng): 64-68
        • Rikkonen T.
        • et al.
        Muscle strength and body composition are clinical indicators of osteoporosis.
        Calcif Tissue Int. 2012; 91: 131-138
        • Dixon W.
        • et al.
        Low grip strength is associated with bone mineral density and vertebral fracture in women.
        Rheumatology. 2005; 44: 642-646
        • Taniguchi Y.
        • et al.
        The association between osteoporosis and grip strength and skeletal muscle mass in community-dwelling older women.
        Int J Environ Res Publ Health. 2019; 16: 1228
        • Bhasin S.
        • et al.
        Sarcopenia definition: the position statements of the sarcopenia definition and outcomes consortium.
        J Am Geriatr Soc. 2020; 68: 1410-1418
        • Von Berens Å.
        • et al.
        Physical performance and serum 25 (OH) vitamin D status in community dwelling old mobility limited adults: a cross-sectional study.
        J Nutr Health Aging. 2018; 22: 1-7
        • McCarthy E.K.
        • Horvat M.A.
        • Holtsberg P.A.
        • Wisenbaker J.M.
        Repeated chair stands as a measure of lower limb strength in sexagenarian women.
        The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2004; 59: 1207-1212
        • Bohannon R.W.
        Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders.
        Percept Mot Skills. 2006; 103: 215-222
        • Finucane L.M.
        • et al.
        International framework for red flags for potential serious spinal pathologies.
        J Orthop Sports Phys Ther. 2020; (0): 1-23
        • Adams J.
        • Sibbritt D.
        • Steel A.
        • Peng W.
        A workforce survey of Australian osteopathy: analysis of a nationally-representative sample of osteopaths from the Osteopathy Research and Innovation Network (ORION) project.
        BMC Health Serv Res. 2018; 18 (2018/05/10): 352
        • Catalano A.
        • et al.
        Pain in osteoporosis: from pathophysiology to therapeutic approach.
        Drugs Aging. 2017; 34: 755-765
        • Bottai V.
        • et al.
        Underdiagnosis of osteoporotic vertebral fractures in patients with fragility fractures: retrospective analysis of over 300 patients.
        Clin Cases Miner Bone Metab. 2016; 13 (in eng) (May-Aug): 119-122
        • Kim D.H.
        • Vaccaro A.R.
        Osteoporotic compression fractures of the spine; current options and considerations for treatment.
        Spine J. 2006; 6: 479-487
        • Khan A.A.
        • Kaiser S.
        Atypical femoral fracture.
        CMAJ (Can Med Assoc J) : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2017; 189 (in eng) (E542-E542)
        • Mahjoub Z.
        • et al.
        Incidence and characteristics of atypical femoral fractures: clinical and geometrical data.
        J Bone Miner Res. 2016; 31: 767-776
        • Benedetti M.G.
        • Furlini G.
        • Zati A.
        • Letizia Mauro G.
        The effectiveness of physical exercise on bone density in osteoporotic patients.
        BioMed Res Int. 2018; 2018
        • Compston J.
        • et al.
        UK clinical guideline for the prevention and treatment of osteoporosis.
        Archives of osteoporosis. 2017; 12: 43
        • The Royal Osteoporosis Society
        Exercise and physical activity for osteoporosis and bone health.
        • The National Health Service
        Exercises for healthy bones.
        • Beck B.R.
        • Daly R.M.
        • Singh M.A.F.
        • Taaffe D.R.
        Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis.
        J Sci Med Sport. 2017; 20: 438-445
        • Fryer G.
        Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. Part 2: clinical approach.
        Int J Osteopath Med. 2017; 26: 36-43