|Year : 2018 | Volume
| Issue : 1 | Page : 16-21
Screening for bone mineral density using distal radius ultrasound (quantitative ultrasound scan): A camp-based approach
Raju Sharma, Jaswant Kaur Sandhu, Priyank Sharda, Richa Sharma, Komaldeep Kaur
Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar, Punjab, India
|Date of Submission||02-Nov-2017|
|Date of Acceptance||28-Dec-2017|
|Date of Web Publication||19-Jun-2018|
Dr. Raju Sharma
Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar - 144 001, Punjab
Source of Support: None, Conflict of Interest: None
BACKGROUND: Bone mineral density (BMD) is an indirect measure of bone strength. As per WHO criteria of osteoporosis, osteoporosis and osteopenia are two subclinical states of low level of BMD. Osteoporosis is a major silent public health problem in India but epidemiological data are scanty in our country. Public awareness can play a crucial role to prevent the consequences of osteoporosis, which is based on the estimation of the BMD as osteoporosis is symptomless until person sustains fracture with a trivial trauma. The purpose of this study was to screen the people for their BMD levels using the quantitative ultrasound scan (QUS) method.
METHODOLOGY: A total of 215 individuals (125 males and 90 females) between 25 and 75 years of age were screened for their BMD levels in a camp held at Lyallpur Khalsa College of Jalandhar, Punjab. Their BMD was estimated using QUS on distal radius of dominating hand. Results were presented as distributive statistics.
RESULTS: As per WHO criteria of BMD, 11.2% participants were osteoporotic (T-score <−2.5), 32.6% were osteopenic (T-score <−1.0–2.5) whereas approximately 56% had normal bone density (T-score >−1.0) There was a significant trend of decreasing bone density with an increase in age in both the gender groups. A significant association (χ2 = 18.64, P < 0.005) was reported between the T-score and age of participants.
CONCLUSION: Although such as DEXA scan, QUS method is not considered to be a standard tool for estimation of BMD; however, it is effective and affordable in identification of subclinical cases having low level of BMD. In our country, a camp is the best setting to screen a large population and creating awareness about such health problem.
Keywords: Bone mineral density, camp, osteoporosis, screening
|How to cite this article:|
Sharma R, Sandhu JK, Sharda P, Sharma R, Kaur K. Screening for bone mineral density using distal radius ultrasound (quantitative ultrasound scan): A camp-based approach. Physiother - J Indian Assoc Physiother 2018;12:16-21
|How to cite this URL:|
Sharma R, Sandhu JK, Sharda P, Sharma R, Kaur K. Screening for bone mineral density using distal radius ultrasound (quantitative ultrasound scan): A camp-based approach. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2019 Mar 20];12:16-21. Available from: http://www.pjiap.org/text.asp?2018/12/1/16/229114
| Introduction|| |
Bone mineral density (BMD) is an indirect measure of bone strength. Bone strength in an individual is dependent on many qualities of bone, of which BMD which accounts for 70% of bone strength, is most commonly measured. It is an average concentration of mineral principally calcium hydroxyl apatite per unit area of the bone. Osteoporosis and osteopenia are two subclinical states of low level of BMD as per the WHO definitions of osteoporosis and osteoporosis is the greatest predictor of risk for bone fractures. An age-dependent decline in BMD is seen in both the genders over the age of 50 years.
Osteopenia refers to BMD that is lower than normal peak BMD but not low enough to be classified as osteoporosis. Osteopenia increases the risk of osteoporosis and osteoporotic fractures as the person advances to old age. Osteoporosis refers to a group of metabolic bone diseases that are characterized by decreased density (mass/volume) of normally mineralized bone. As the name implies, the bone becomes abnormally porous and thin. The reduced mass weakens the mechanical strength of the bone, thus making it much more likely to break, often with little or no trauma. Osteoporosis, the silent thief, usually remains asymptomatic until the weakened bone fractures. One out of eight males and one out of three females in India suffers from osteoporosis, making India one of the largest affected countries in the world. Two points worth noting about osteoporosis in India are the high incidence among men and the lower age of peak incidence compared to Western countries. Since osteoporosis affects the elderly population which is growing, it will put a bigger burden to the health-care system as treatment is expensive. Unless swift action is taken, it can escalate into an economic threat.
Bone density measurements are used to screen people for osteoporosis risk and to identify those who might benefit from measures to improve bone strength. Several quantitative techniques are available for the measurement of BMD. Dual-energy X-ray absorptiometry (DXA) and scans of axial skeletal sites are standard assessment tool to diagnose low BMD, but its use is limited due to high cost of scan, lack of portability, and deleterious effects of radiations. The ultrasound-based bone densitometer known as quantitative ultrasound scan (QUS) is relatively cheaper, portable, and widely available in India.,, Although calcaneal QUS is commonly used, but QUS of the radius has been shown to be more sensitive than the QUS of calcaneum when compared to a DEXA scan and has also been shown to be better predictor than clinical risk factors for women with low T-score; therefore, it can be useful for screening of osteopenia and osteoporosis at community level.,
However, available data about the prevalence of osteoporosis among both men and women is scanty both in developed as well as in developing countries. Moreover, very few Indian studies using QUS as a screening tool have been published till date. In India, different health issues have been addressed by different government and NGO's by organizing Camps since 1980. A camp approach increases the utilization of health-care services substantially and ensures greater community participation or delivery of services in the community itself. The present study was designed and planned with an objective of screening of participants between 25 and 75 years age groups for their BMD using ultrasound scan on distal radius in a camp.
| Methodology|| |
The present camp-based study was conducted in Physiotherapy Department of Lyallpur Khalsa College of Jalandhar city of Punjab in the month of June 2016. This study was conducted in the outpatient department of physiotherapy and has been approved by college ethical committee. The information regarding the camp was circulated to all the departments of the college as well as nearby local colonies of the area. For this purpose, pamphlets carrying the information regarding date, timings, and test were distributed in local areas through newspapers. A team comprising of a medical officer, four physiotherapy teachers, two clinical therapists, and nonteaching staff were involved in assessing and screening the subjects for their BMD level. On the camp day, each participant was registered, and their demographic information, history of illness (if any) was recorded by team members. The level of BMD of the distal radius of dominant hand of each participant was tested using quantitative ultrasound the Omnisense® 7000S (Sunlight Ultrasound Technologies, Rehovot, Israel). The BMD level was expressed as a T-score which was considered as the platform to categorize the participants according to WHO osteoporosis definitions based on T-score. [Table 4] The total 215 participants between 25 and 75 years of age were screened in this camp. The sample consisted of college teachers in majority.
|Table 4: Different levels of bone mineral density as per WHO criteria for osteoporotic|
Click here to view
Each participant was also given advice regarding diet, importance of exercise, and sunlight exposure by the concerned medical officer of the team. The data were analyzed using SPSS 16.0 version (Microsoft Corp., NY). The results were expressed as descriptive statistics. The probability level was set as 0.05%.
| Results|| |
A total of 215 participants were screened for their BMD in the present study. The mean age of sample was 46.93 (SD 13.31) with minimum age of 25 years and maximum age of 75 years. In the sample, there were 58.1% (n = 125) female subjects and 41.9% (n = 90) were male. The mean bone mass density of the sample was – 0.91 ± 1.27. The mean age of the participants (n = 24) with osteoporosis was 55.37 ± 11.90 with a minimum age of 32, and maximum age of 75 years. The mean age of participants with osteopenia (n = 121) was 48.67 ± 13.74 with a minimum age of 25 and maximum age of 75 years. The mean age of participants with normal bone density (n = 70) was 44.26 ± 12.53 with a minimum age of 25 and maximum age of 75 years [Table 1]. As per WHO criteria of BMD, 11.2% participants were osteoporotic (T-score <−2.5), 32.6% were osteopenic (T-score <-1.0-2.5) whereas approximately 56% had normal bone density (T-score >−1.0) [Figure 1].
|Figure 1: Distribution of participants according to their bone mineral density|
Click here to view
There was a significant trend of decreasing bone density with an increase in age in both the gender groups. The percentage of osteoporotic female participants (58.8%) was more than male participants in the age group of <55 years whereas in the same age group, the percentage of osteopenic participants was more among males (46.7%) than females (27.5%). One case of osteoporosis was also reported in the age group of 25–35 years among female participants [Table 2]. A significant association (χ2 = 18.64, P < 0.005) was reported between the T-score and different age groups. Whereas, a nonsignificant association exists between gender and the T-score [Table 3].
|Table 2: Age-wise distribution of bone mass density (T score) of participants|
Click here to view
|Table 3: Association between the bone mineral density (T score) and age of participants|
Click here to view
[Figure 2] shows a clear increasing trend in the frequency of osteopenic and osteoporotic participants with age of 35 years onward. In addition, on comparison between the gender groups, the frequency of osteopenic and osteoporotic was higher in female group [Figure 3].
|Figure 2: Distribution of bone mineral density according to different age groups|
Click here to view
|Figure 3: Distribution of bone mineral density according to gender of the participants|
Click here to view
| Discussion|| |
The results of the present camp-based study showed that among total 215 screened participants, 11% were osteoporotic (T-score <−2.5), 33% were osteopenic (T-score <−1.0–2.5), and 56% had normal BMD (T-score >−1.0). Among osteoporotic population, 13.6% were female, and 7.7% were male participants. Out of total osteoporotic female population (n = 34), approximately 59% participants were in the age groups of 55–75 years, similarly out of total osteoporotic male population, 43% were above the age of 55 years. The findings are inconsistent with other Indian studies on prevalence of osteoporosis using QUS method.,,,,,, Other studies report a higher prevalence rate of osteoporosis too , However, most of them were carried out on population comprising pre- and post-menopausal women. The present study finds a significant association of age with BMD which is in accordance with other studies carried out time-to-time. Higher prevalence of low BMD level could lead to more falls, fractures, and subsequent disability.
In literature, in the group of different risk factors for osteoporosis, female gender has been identified as a nonmodifiable risk factor, whereas nutritional factors, nutritional status, lifestyle, and use of medications are modifiable risk factors. Indian women have a small body stature, are more prone to have a less portion of calcium-rich foods and for ethnocentric reasons are likely to have poor sun exposure. Moreover, estrogen being vital for the formation and growth of bone in women, decrease level of estrogen during women's lifetime may also lead to osteoporosis. Although the average, age of menarche in Indian girls is 12.5 years, age at menopause is often earlier than that seen in Caucasian women., This has been accounted as an important risk factor for the generation of osteoporosis in Indian female., Numerous studies have proclaimed that the incidence of osteoporosis surges with age, this drift had been perceived to a higher level among Indian females than males.
Further, numerous studies indicate that information about bone status is quite scant among Indian women. Therefore, low calcium intake, substantial occurrence of Vitamin D deficiency, less information about osteoporosis, and difficulty in the detection of osteoporosis in Indian conditions are some of the reasons that have resulted in osteoporosis becoming a major public health problem in Indians, predominantly in Indian women.
In the present study, the incidence of osteoporosis and osteopenia was also reported in 8% and 33% male participants, respectively. According to the International osteoporosis foundation reports, there is higher prevalence of osteoporosis among Indian men and lesser age of peak incidence as compared to Western countries. In men, one of the possible causes of lower BMD could be smoking, systemic diseases, intake of drugs, bowel disease, and immobilization. Males with raised parathyroid hormone, less testosterone, and low estrogen levels in blood and may have elevated bone turn over and depressed bone mass with age. Hence, determining BMD in males is equally important.
The present study was conducted in the city of Jalandhar in Doaba region of Punjab, and all the participants belonged to Punjabi community only. This region of Punjab receives adequate sunlight and has proper middle-class society with a blend of agricultural practices, business, and servicemen. Economic upswing has showed about modification in the standard of living as regards the eating habits, work category, and schedules. A high prevalence of vitamin D deficiency was observed in a study conducted in the year 2015 on North West population of Punjab., Recently published data have clearly displayed widespread vitamin D deficiency across India at all ages and in both genders peculiarly in urban areas. The prevention of sun exposure due to sociocultural reasons, less intake of dietary calcium, atmospheric pollution and increased 25(OH)-d-24-hydroxylase enzyme in Asian Indians are some of the reasons for hypovitaminosis D. The same result was detected in another study by Singh et al. (2013) on prevalence of osteoporosis among general population in Amritsar city using QUS calcaneal ultra sonometer method.
The occupation also has influenced on the level of BMD.,, In the present study, majority of the participants screened were from the teaching profession and were in 25–45 years of age group. Percentage of osteopenic male as well as female population also falls in the above age group. However, in the present study, data have not been categorized according to the occupation or educational status of the participants. However, it reflects the significant low BMD level of the participants of teaching profession. In a South Indian study, a homogenous osteoporosis prevalence proportion was observed among white-collar jobs and manual laborers. However, prevalence was high among homemaker. The association between different types of occupation, educational status of people and their BMD levels needs to be explored further.
The number of elderly in the developing countries has been growing at a phenomenal rate. The two major population giants of Asia are India and China, because they are sharing a significant proportion of this growing elderly population. The Indian aged population is currently the second largest in the world to that of China with 100 million of the aged. The absolute number of the over 60 population in India will increase from 77 million 2001 to 137 million by 2021., Conservative estimates in a study suggest that 20% women and about 10%–15% men are osteoporotic in India. This would place a stress on health care and public care systems in the country. However, the Government of India does not recognize osteoporosis as a major health problem. However, the Indian Society of Bone and Mineral Research and some other societies such as arthritis formation of India are engrossed in conducting public progress for the elimination of osteoporosis.
The preliminary data from India (published and unpublished) indicated a high occurrence rate of postmenopausal osteoporosis) making it as a major health problem which make it absolutely imperative for more population-based studies of new hip fractures and related morality. Measuring BMD remains the only important tool in the diagnosis of osteoporosis. So that, effective preventive and therapeutic measures be started at the earliest. Dual-energy X-ray absorption-metry, an advanced bone densitometer is presently considered as the “gold standard” for measuring BMD since its use from the year 1997. There are approximately 250 DXA machine available in the country (about 0.2 DXA machines per million) at present. A large proportion of this is available in metropolitan areas only. Whereas, the number of ultrasound machines is several folds higher. The cost of each DXA-BMD is expensive in comparison to ultrasound BMD Scan. Although useful, QUS cannot replace DXA, although it can be used as a cost-effective tool to assess bone density in developing countries like ours for ruling out osteoporosis and osteopenia. QUS of radius has been shown to be more sensitive than QUS of calcaneus when compared to a DXA Scan and has also been displayed to be better allocator than clinical speculator for women with low T-score.
In India, from early 1980, autonomous and various government agencies have looked into health problems by organizing camps such as eye camps, family planning, immunization camps, etc., Similarly, BMD assessment camps could be effective means to report subclinical cases using the cost-effective QUS method. It creates the awareness about the problem which is easy in a camp where a large number of persons can be attended in a single session.
| Conclusion|| |
Osteoporosis is an important cause of morbidity and mortality in elderly population of India which is aging at a faster rate. A database of the issue is lacking which is crucial for the policy formulation for effective intervention. The present study is part of a series of prevalence studies conducted on this issue across the country. A camp-based approach can help to identify subclinical cases of osteopenia in the community. In addition, it can help in increasing awareness about bone health in developing countries where a large section of population cannot afford expensive investigation such as DXA–BMD scan.
We would like to thank all the members of Cipla Pharmaceutical Co. for providing technical support in conducting this camp.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Multani NK, Kaur H, Chahal A. Impact of sporting activities on bone mineral density. J Exerc Sci Physiother 2016;7:103-9.
Bates DW, Black DM, Cummings SR. Clinical use of bone densitometry: Clinical applications. JAMA 2002;288:1898-900.
Follin SL, Hansen LB. Current approaches to the prevention and treatment of postmenopausal osteoporosis. Am J Health Syst Pharm 2003;60:883-901.
Pande KC, Veeraji E, Pande SK. Normative reference database for bone mineral density in Indian men and women using digital X-ray radiogrammetry. J Indian Med Assoc 2006;104:288-91.
Benu GD, Animesh D, Amitabha C, Madhumita B, Jashodip B. Prevalence and risk factors of osteopenia and osteoporosis in Indian women. IOSR J Dent Med Sci 2016;15:15-8.
Makker A, Mishra G, Singh MM, Singh BP, Tripathi A. Normative bone mineral density data at multiple skeletal sites in Indian subjects. Arch Osteoporos 2008;3:25-37.
Rudani S. Prevalence of osteopenia and osteoporosis among women in Bhuj, Gujarat, India – A cross-sectional study. Paripex Indian J Res 2016;5:83-4.
Kung AW, Ho AY, Ross PD, Reginster JY. Development of a clinical assessment tool in identifying Asian men with low bone mineral density and comparison of its usefulness to quantitative bone ultrasound. Osteoporos Int 2005;16:849-55.
Mohr A, Barkmann R, Mohr C, Römer FW, Schmidt C, Heller M,et al
. Quantitative ultrasound for the diagnosis of osteoporosis. Rofo 2004;176:610-7.
Planning Commission of India: Food and Nutrition Security, 10th
Five Year Plan. Vol. 2. Ch. 3.3. 2002-2007. p. 329.
Babu AS, Ikbal FM, Noone MS, Joseph AN, Samuel P. Osteoporosis and osteopenia in India: A few more observations. Indian J Med Sci 2009;63:76-7.
] [Full text]
Stewart A, Reid DM. Quantitative ultrasound or clinical risk factors – Which best identifies women at risk of osteoporosis? Br J Radiol 2000;73:165-71.
Kannan R, Prasanna Karthik S, Lal DV, Lokesh R, Mahendrakumar K, Magesh Kumar S. Evaluation of osteoporosis using calcaneal QUS and FRAX score as a screening tool in a semi urban tertiary care hospital of South India. Int J Adv Med 2015;2:341-5.
Ranganathan S. The manjakkudi experience: A camp approach towards treating alcoholics. Addiction 1994;89:1071-5.
WHO Scientific Group. Prevention and Management of Osteoporosis. WHO Technical Report Series 921. Geneva: WHO Scientific Group; 2003. p. 35-6.
Hemalata, Reeba MM, Sreekala VK. The prevalence of osteoporosis and osteopenia in persons above 50 years attending a tertiary care hospital in South India. J Med Sci Clin Res 2016;12:14458-62.
Dutta N, Saikia AM, Saikia AM, Das AK. Status of bone mineral density in adult population using calcaneal ultrasound bone densitometer: A study from Assam, India. Indian J Basic Appl Med Res 2015;4:150-8.
Khadilkar AV, Mandlik RM. Epidemiology and treatment of osteoporosis in women: An Indian perspective. Int J Womens Health 2015;7:841-50.
Unni J, Garg R, Pawar R. Bone mineral density in women above 40 years. J Midlife Health 2010;1:19-22.
Agrawal T, Verma AK. Cross sectional study of osteoporosis among women. Med J Armed Forces India 2013;69:168-71.
Gandhi AB, Shukla AK. Evaluation of BMD of women above 40 years of age. J Obstet Gynecol India 2005;55:265-7.
Sharma S, Tandon VR, Mahajan A, Kour A, Kumar D. Preliminary screening of osteoporosis and osteopenia in urban women from Jammu using calcaneal QUS. Indian J Med Sci 2006;60:183-9.
] [Full text]
Thokchom S, Chhugani M. A Study to find out the prevalence for osteoporosis and osteopenia in pre and post menopausal women in India: A cross sectional study. Int J Sci Res 2015;10:270.
Bachhel R, Singh NR, Sidhu JS. Prevalence of vitamin D deficiency in North-West Punjab population: A cross-sectional study. Int J Appl Basic Med Res 2015;5:7-11.
Khadilkar AV. Vitamin D deficiency in Indian adolescents. Indian Pediatr 2010;47:755-6.
Parker SE, Troisi R, Wise LA, Palmer JR, Titus-Ernstoff L, Strohsnitter WC,et al
. Menarche, menopause, years of menstruation, and the incidence of osteoporosis: The influence of prenatal exposure to diethylstilbestrol. J Clin Endocrinol Metab 2014;99:594-601.
Bharadwaj JA, Kendurkar SM, Vaidya PR. Age and symptomatology of menopause in Indian women. J Postgrad Med 1983;29:218-22.
] [Full text]
Palacios S, Henderson VW, Siseles N, Tan D, Villaseca P. Age of menopause and impact of climacteric symptoms by geographical region. Climacteric 2010;13:419-28.
Keramat A, Patwardhan B, Larijani B, Chopra A, Mithal A, Chakravarty D,et al
. The assessment of osteoporosis risk factors in Iranian women compared with Indian women. BMC Musculoskelet Disord 2008;9:28.
Marwaha RK, Tandon N, Garg MK, Kanwar R, Narang A, Sastry A,et al
. Bone health in healthy Indian population aged 50 years and above. Osteoporos Int 2011;22:2829-36.
Pande K, Pande S, Tripathi S, Kanoi R, Thakur A, Patle S,et al
. Poor knowledge about osteoporosis in learned Indian women. J Assoc Physicians India 2005;53:433-6.
Naheed T, Akbar N, Akbar N, Chaudhry M. A bone mineral density measurement in a medical camp to identify osteopenic and osteoporotic subjects. Pak J Med Sci 2005;21:74-7.
Gopal KM, Gowdhaman N, Meganathan M, Balamurugan K, Mohan J, Vijayalakshmi D. Fight and prevent osteoporosis – Bone mineral density: A report in a multicenter hospital survey, need a time for action. Sch J Appl Med Sci 2015;3:1954-7.
Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N. Bone status of Indian women from a low-income group and its relationship to the nutritional status. Osteoporos Int 2005;16:1827-35.
Central Statistics Office. Ministry of Statistics and Programme Implementation. Government of India. Elderly in India; 2016. Available from: http://www.mospi.gov.in
. [Last assessed on 2017 May 31].
Government of India: Ministry of Home Affairs. Office of the Registrar General and Census Commissioner, India; 2011. Available from: http://www.censusindia.gov.in/
. [Last accessed on 2017 May 31].
Munshi R, Kochhar A. Nutritional implication of osteoporosis among post menopausal women in India. Int J Health Sci Res 2014;4:157-65.
Silvanus V, Ghosal K, Behera A, Subramanian P. Screening for osteopenia and osteoporosis in an urban community in India. Nepal Med Coll J 2012;14:247-50.
Díez-Pérez A, Marín F, Vila J, Abizanda M, Cervera A, Carbonell C,et al
. Evaluation of calcaneal quantitative ultrasound in a primary care setting as a screening tool for osteoporosis in postmenopausal women. J Clin Densitom 2003;6:237-45.
Chavan BS, Gupta N, Raj K, Arun P, Chanderbala. Camp approach – An effective, alternate inpatient treatment setting for substance dependence: A report from India. German J Psychiatry 2003;6:17-22.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]