Hi, welcome to MelioGuide. I'm Margaret Martin, and today we're going to be talking about
FRAX, which is short for Fracture Risk Assessment. And this is a tool that was developed in conjunction
with many countries. So there's 34 countries involved in total, within the World Health
Organization, to provide clinicians with a picture of an individual's bone quality in
order to help clinicians make a decision, for their clients or with their clients, as
to what is the best therapeutic approach to help them with reducing their fracture risk.
And so what was happening was people were fracturing, and they had relatively good bone
mineral density scores, and yet people with poor bone mineral density scores were not
fracturing. And so they said, "Well, you know, there's more involved than just the density
of the bone.
And so the FRAX, as we go through the questions, these are all things that give clinicians
a picture into the quality of someone's bones. So we will go through the questionnaire together,
but right now I'd like to just walk you through how to get to your FRAX. And so as physical
therapists, we have a lot more time than the GPs to be going through FRAX. And I find a
lot of my clients, both that see me in the clinic and from around the world that email
me or connect with me, will ask me questions about whether or not they should be on pharmaceuticals.
And my question to them is always, "Have you done your FRAX?" Or, "Has someone done your
FRAX?" And usually, they have no idea what their FRAX is, and they have not had that
information shared with them. So here we go, we'll look at FRAX.
And so in order to start, what I suggest you do at home is to enter, in Google, upper case
F-R-A-X. And that will take you to the first entry, which is "Welcome to FRAX." And you
can click on your "Welcome to FRAX," which is from the University of Sheffield, and you'll
see a picture of Dr. John Kanis. We're now going to go to the top and find the Calculation
Tool. Within the Calculation Tool, there are choices of continents. And the continent that
you choose, and then the country that you choose, should be either your place of birth
or the place you're living in. And so what you can actually do is do both and then do
a comparison, because that is the most accurate way of getting a picture of your bone health.
Your country of birth will give you information on genetics leading up to your move. And then
your place, where you're living now, gives information on your bone health related to
sun exposure and those kinds of things, diet.
So I want to choose North America, easy for me, which is where I live and was born in.
I want to go right into Canada. And we're going to use a fictitious client, so Mary
Smith. And Mary is 50, 1961 and June, 50. Now, second question is an easy one. So Mary
is female. Now, in Canada, we still tend to use pounds and inches when we do our measurements.
And so if we go to the conversion box on the right-hand side, it will give us that information
automatically. So Mary's 130 pounds and she is five foot three, or 63 inches. And note,
when you push the convert, it automatically brings the data in to the questionnaire.
Next, the question is on previous fracture. So whether Mary had one previous fracture
or seven previous fractures, she is to answer yes or no. And so Mary has had one previous
fracture. The next question is on the parent hip fracture, and neither her mother or her
father have fractured a hip. Mary is no longer a smoker, so we'll keep that as no. Mary is
not taking glucocorticoid steroids currently. However, when Mary was in her 30s, she was
on a course of glucocorticoid steroids for about two and a half months. And so we're
going to keep that as no, because the question is really about whether someone's been on
a dosage of greater than five milligrams per day, for three months or longer. And so they
found that that dosage has, you know, significant negative impact on bones. And so certainly
if someone's on a much higher dosage, that's something that has to be weighed into the
equation with the clinical decision-making at the end of the FRAX. Or if someone's been
on, you know, a very mild dose for longer period of time, although they might not fit
into, you know, the yes answer, it is still something to be taken into account.
Next question, number nine, is rheumatoid arthritis, whether or not she has it, if no,
she does not. And then number 10 is whether or not Mary has secondary osteoporosis. Secondary
osteoporosis is when you have been diagnosed with osteoporosis that is caused, not just
by reaching menopause and a normal process of losing bone, but rather caused by an underlying
disease process. Whether it be kidney disease, diabetes, intestinal absorption problems,
celiac or long-term use of certain medications. So all of those things fall into secondary
osteoporosis. And we're going to click on Yes for Mary there. And then number 11 is
whether or not there is consumption of more than three units of alcohol per day, and that's
going to be a no.
So when we go down to number 12, the femoral neck bone mineral density, this is in grams
per centimeter squared. So I know many of my clients and many of you listening will
be given just your T-score. But the information that you want to make this calculation much
more accurate is the machine that your bone mineral density was done on. So under the
DXA, when you click and you have a pull-down bar, the different names of the machines are
listed. So if you can get a copy of your client's or your own bone mineral density test result,
you will see on the sheet what machine it was done on. And so we'll pick the Hologic
as an example. And then you want the grams in centimeter squared. And so we'll pick .5
kg/cm² and push Calculate.
Now, as it's calculating, I'm going to just bring up a point. If you only have the T-score,
then what happens with that is that you are then having... For Mary, because she's Caucasian
and she's a female, she is being compared against other female Caucasians. And so she
doesn't have to convert her T-score in any way. It's, you know, been normalized for her.
If you are not female and you're not Caucasian, then you do need to go and normalize the data
if you're using the T-score. And so there is a link to a website, Dr. Susan Ott's website
at the University of Washington, that we will provide for you that you can if you, again,
are not Caucasian and you're not female, that you can use your T-score, convert that over,
then bring it back into the FRAX box. And when you have a choice of just the data that
you're entering and you choose T-score, use the T-score that is provided you by Dr. Susan
Ott's website.
All right, so let's just look now in the red box. Once you do the calculation, you will
be given a red box score, and it has what the BMI is. It then has listed the 10-year
probability of a fracture. So for Mary, with the questions that we answered, her 10-year
probability of a fracture, major osteoporotic fracture is 13%. And her 10-year probability
of a hip fracture is 4.8%. Now, within different countries, each country has chosen different
guidelines as to recommendations for pharmaceuticals. Within Canada, we look at the major osteoporotic
fracture percentage. And Mary is sitting right in the middle. So 13% is the percentage point,
somewhere between 10 and 20, where it's really wise to sit down with a clinician and go,
you know, "What is the picture of my bone health?" You know, if we went back and...although
Mary put in "No" for smoking, if she had been a two-pack-a-day smoker for 20 years, although
she's not currently smoking, we might be thinking that her bone quality is not as high as the
fracture risk assessment tool is giving us. So those kinds of things. And if Mary had
had, you know, seven previous fractures, although the datas entered is the same as whether she
had only one, again, we might be weighing, you know, looking at, "Maybe Mary's bone health
isn't quite as good as we're seeing in this little answer picture here."
And so it was a very complex tool to develop. And so they couldn't allow for, you know,
one fracture, two fractures, all of the different variables. Nor could they allow for all the
different variables' smoking patterns. And so it is really just a clinical tool giving
us a picture of bone health that is stable. So that's important as well, when the clinical
judgment is being made is as to whether or not pharmaceuticals are warranted and/or,
you know, how aggressive to be on an exercise program. That picture is for someone who is
stable at this time. And so if I knew that Mary was recently diagnosed with cancer, and
that Mary was going to be on some strong medication that would also be affecting her bone health,
or she had had, you know, an epileptic seizure and she was going to be put on medication
for her epilepsy, medications that are going to negatively affect here bone health, then
those things are telling me that her bone health is no longer stable, and actually being
affected by other medical conditions that she's having to deal with. And so those are
things that allow us then to make a better decision, and help the medical doctors and
specialists in the area make a better decision as to the best treatment approach for an individual.
So I hope that this tutorial has given you a little window into how FRAX is used and
the questions that are asked, and the parameters that are taken into consideration when looking
both at bone quality and bone density in order to determine the fracture risk for an individual,
and in order to help clinicians make the best decision for a better quality of life. So
that's all today on MelioGuide, and we look forward to talking to you again.