A Comparison of Physical and Behavioural Characteristics Between Postmenopausal Women With Low Bone Mass on or Off Bone Medication

BACKGROUND: Identifying the relationships between physical and behavioural characteristics with the presence or absence of pharmacotherapy (on or off bone medication) for postmenopausal women with low bone mass could assist healthcare professionals to individualise bone health management plans and provide better patient-centred care. Linking patient characteristics with attitudes and motivations behind their decisions would be helpful for healthcare professionals in identifying what gaps in knowledge and types of therapy patients would most likely be open to initiating, adhering to and persisting. A cross-sectional study such as this has not previously been undertaken.

METHODS: A convenience sample of 349 postmenopausal women with low bone mass were recruited from participants of the Medication and Exercise for Osteoporosis (MEDEX-OP) trial, women who were excluded from the MEDEX-OP trial and clients of The Bone Clinic in Brisbane, Australia. The baseline data from participants of the MEDEX-OP trial and the data from a routine assessment from clients of The Bone Clinic were obtained for analysis. A questionnaire requesting demographic information as well as attitudes toward medication and motivations to be on or off bone medication was emailed or sent via mail to women who had been excluded from the MEDEX-OP trial. Data was analysed via univariable and multivariable logistic regression to identify physical or behavioural characteristics related to being on or off bone medication.

RESULTS: The majority of participants were aged in their early sixties, with 256 (73.4%) off bone medication and 93 (26.6%) currently taking antiresorptive bone medication. Age in years (OR 1.05, 95% CI 1.01-1.09), two or more fragility fractures (OR 5.08, 95% CI 2.60-9.94), previously took bone medication (OR 2.48, 95% CI 1.44-4.26), fracture risk calculated as a percentage using the Garvan Institute Fracture Risk Calculator (OR 1.03, 95% CI 1.01-1.06), back extensor strength measured in kilograms (OR 0.96, 95% CI 0.93-0.98), five times sit to stand measured in seconds (OR 1.16, 95% CI 1.04-1.30), and having a promedication attitude (OR 5.95, 95% CI 2.92-12.12) or ambivalent attitude toward medication in general (OR 1.51, 95% CI 0.73-3.09) were statistically significant variables that were found to be related to being on or off bone medication following the univariable logistic regression analyses. People with ambivalent attitudes were found to be just as likely as those with anti-medication attitudes to be on bone medication. At the adjusted multivariable level, having two or more fractures (OR 3.87, 95% CI 1.53-9.79), previous bone medication (OR 2.81, 95% CI 1.36-5.78), having poor back extension strength (OR 0.95, 95% CI 0.92-0.98), and having a pro-medication attitude (OR 6.41, 95% CI 2.73- 15.07) were associated with being on bone medication.

CONCLUSION: Fragility fracture history, previous use of bone medications, back extensor strength and attitudes toward medication in general were strongly related to being on or off bone medication among postmenopausal women with low bone mass. Healthcare professionals should consider these four characteristics when involving patients in the decision-making process of making a bone health management plan.

Year	Entry
2005	Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J Clin Invest. December 2005;115(12):3318-3325.
2002	Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C; The Osteoporosis Methodology Group; The Osteoporosis Research Advisory Group. Meta-analyses of therapies for postmenopausal osteoporosis, IX: summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev. August 2002;23(4):570-578.
2010	Nikander R, Sievänen H, Heinonen A, Daly RM, Uusi-Rasi K, Kannus P. Targeted exercise against osteoporosis: a systematic review and meta-analysis for optimising bone strength throughout life. BMC Med. 2010;8:47.
2005	De Laet C, Kanis JA, Odén A, Johanson H, Johnell O, Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D, Melton LJ III, Meunier PJ, Pols HAP, Reeve J, Silman A, Tenenhouse A. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. November 2005;16(11):1330-1338.
2020	Cornelissen D, Kunder Sd, Si L, Reginster J-Y, Evers S, Boonen A, Hiligsmann M; European Society for Clinical and Economic Aspect of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Interventions to improve adherence to anti-osteoporosis medications: an updated systematic review. Osteoporos Int. September 2020;31(9):1645-1669.
2006	Pasco JA, Seeman E, Henry MJ, Merriman EN, Nicholson GC, Kotowicz MA. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int. September 2006;17(9):1404-1409.
1993	Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med. June 1993;94(6):646-650.
2010	Eriksen EF. Cellular mechanisms of bone remodeling. Rev Endocr Metab Disord. December 2010;11(4):219-227.
2014	Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson‐Hughes B. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. November 2014;29(11):2520-2526.
2016	Langdahl B, Ferrari S, Dempster DW. Bone modeling and remodeling: potential as therapeutic targets for the treatment of osteoporosis. Ther Adv Musculoskel Dis. December 2016;8(6):225-235.
2016	Weaver CM, Gordon CM, Janz KF, Kalkwarf HJ, Lappe JM, Lewis R, O’Karma M, Wallace TC, Zemel BS. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporos Int. April 2016;27(4):1281-1386.
2019	Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. May 2019;104(5):1595-1622.
2008	Weeks BK, Beck BR. The BPAQ: a bone-specific physical activity assessment instrument. Osteoporos Int. November 2008;19(11):1567-1577.
2017	Harvey NCW, McCloskey EV, Mitchell PJ, Dawson-Hughes B, Pierroz DD, Reginster J-Y, Rizzoli R, Cooper C, Kanis JA. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int. May 2017;28(5):1507-1529.
1982	Lanyon LE, Goodship AE, Pye CJ, MacFie JH. Mechanically adaptive bone remodelling. J Biomech. 1982;15(3):141-154.
2017	Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N; The National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. December 2017;12(1):1-24.
2014	Bellido T. Osteocyte-driven bone remodeling. Calcif Tiss Int. January 2014;94(1):25-34.
2019	Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. January 26, 2019;393(10169):364-376.
2000	Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. April 2000;15(4):721-739.
2018	Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. February 2018;33(2):211-220.
1982	Rubin CT, Lanyon LE. Limb mechanics as a function of speed and gait: a study of functional strains in the radius and tibia of horse and dog. J Exp Biol. December 1982;101:187-211.
2010	Chen J-H, Liu C, You L, Simmons CA. Boning up on Wolff's Law: mechanical regulation of the cells that make and maintain bone. J Biomech. January 5, 2010;43(1):108-118.
2003	Albrand G, Munoz F, Sornay-Rendu E, DuBoeuf F, Delmas P. Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. Bone. January 2003;32(1):78-85.
2006	Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. December 2006;17(12):1726-1733.
2017	Bone HG, Wagman RB, Brandi ML, Brown JP, Chapurlat R, Cummings SR, Czerwiński E, Fahrleitner-Pammer A, Kendler DL, Lippuner K, Reginster J-Y, Roux C, Malouf J, Bradley MN, Daizadeh NS, Wang A, Dakin P, Pannacciulli N, Dempster DW, Papapoulos S. 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension. Lancet Diabetes Endocrinol. July 2017;5(7):513-523.
2004	Kanis J, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey E, Mellstrom D, Melton L, Pols H, Reeve J, Silman A, Tenenhouse A. A meta-analysis of previous fracture and subsequent fracture risk. Bone. August 2004;35(2):375-382.
2009	Riddle RC, Donahue HJ. From streaming-potentials to shear stress: 25 years of bone cell mechanotransduction. J Orthop Res. February 2009;27(2):143-149.
2002	Robling AG, Hinant FM, Burr DB, Turner CH. Improved bone structure and strength after long‐term mechanical loading is greatest if loading is separated into short bouts. J Bone Miner Res. August 2002;17(8):1545-1554.
2006	Ruff C, Holt B, Trinkaus E. Who's afraid of the big bad Wolff? "Wolff's law" and bone functional adaptation. Am J Phys Anthropol. April 2006;129(4):484-498.
1995	Burger EH, Klein-Nulend J, Van Der Plas A, Nijweide PJ. Function of osteocytes in bone: their role in mechanotransduction. J Nutr. July 1995;125(7)(suppl):S2020-S2023.
2006	Zhang K, Barragan-Adjemian C, Ye L, Kotha S, Dallas M, Lu Y, Zhao S, Harris M, Harris SE, Feng JQ, Bonewald LF. E11/gp38 selective expression in osteocytes: regulation by mechanical strain and role in dendrite elongation. Mol Cell Biol. June 2006;26(12):4539-4552.

Year

Entry

2005

Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J Clin Invest. December 2005;115(12):3318-3325.

2002

Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C; The Osteoporosis Methodology Group; The Osteoporosis Research Advisory Group. Meta-analyses of therapies for postmenopausal osteoporosis, IX: summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev. August 2002;23(4):570-578.

2010

Nikander R, Sievänen H, Heinonen A, Daly RM, Uusi-Rasi K, Kannus P. Targeted exercise against osteoporosis: a systematic review and meta-analysis for optimising bone strength throughout life. BMC Med. 2010;8:47.

2005

De Laet C, Kanis JA, Odén A, Johanson H, Johnell O, Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D, Melton LJ III, Meunier PJ, Pols HAP, Reeve J, Silman A, Tenenhouse A. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. November 2005;16(11):1330-1338.

2020

Cornelissen D, Kunder Sd, Si L, Reginster J-Y, Evers S, Boonen A, Hiligsmann M; European Society for Clinical and Economic Aspect of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Interventions to improve adherence to anti-osteoporosis medications: an updated systematic review. Osteoporos Int. September 2020;31(9):1645-1669.