Osteoporosis International

, Volume 15, Issue 5, pp 367–374 | Cite as

Can the WHO definition of osteoporosis be applied to multi-site axial transmission quantitative ultrasound?

  • K. M. Knapp
  • G. M. Blake
  • T. D. Spector
  • I. Fogelman
Original Article


Osteoporosis is a highly prevalent but preventable disease and, as such, it is important that there are appropriate diagnostic criteria to identify those at risk of low trauma fracture. In 1994 the World Health Organization (WHO) introduced definitions of osteoporosis and osteopenia using T-scores, which identified 30% of all Caucasian post-menopausal women as having osteoporosis. However, the use of the WHO T-score thresholds of −2.5 for osteoporosis and −1.0 for osteopenia may be inappropriate at skeletal sites other than the spine, hip and forearm or when other modalities, such as quantitative ultrasound (QUS) are used. The aim of this study was to evaluate the age-dependence of T-scores for speed of sound (SOS) measurements at the radius, tibia, phalanx and metatarsal by use of the Sunlight Omnisense, to evaluate the prevalence of osteoporosis and osteopenia at these sites by use of the WHO criteria, and calculate appropriate equivalent T-score thresholds. The study population consisted of 278 healthy pre-menopausal women, 194 healthy post-menopausal women and 115 women with atraumatic vertebral fractures. All women had SOS measurements at the radius, tibia, phalanx and metatarsal and bone mineral density (BMD) measurements at the lumbar spine and hip. A group of healthy pre-menopausal women aged 20–40 years from the pre-menopausal group were used to estimate the population mean and SD for each of the SOS and BMD measurement sites. Healthy post-menopausal women were classified into normal, osteopenic or osteoporotic, based upon the standard WHO definition of osteoporosis and expressed as a percentage. We investigated the age-related decline in T-scores from 20–79 by stratifying the healthy subjects into 10-year age groups and calculating the mean T-score for each of these groups. Finally, we estimated appropriate T-score thresholds, using five different approaches. The prevalence of osteoporosis in the post-menopausal women aged 50 years and over ranged from 1.4 to 12.7% for SOS and 1.3 to 5.2% for BMD. The age-related decline in T-scores ranged from −0.92 to −1.80 for SOS measurements in the 60 to 69-year age group and −0.60 to −1.19 for BMD measurements in the same age group. The WHO definition was not suitable for use with SOS measurements, and revised T-score thresholds for the diagnosis of osteoporosis of −2.6, −3.0, −3.0 and −2.2 and for osteopenia of −1.4, −1.6, −2.3, and −1.4, for the radius, tibia, phalanx and metatarsal, respectively, were recommended.


Axial transmission quantitative ultrasound Bone density Prevalence of osteoporosis WHO criteria 



The authors would like to thank the staff, volunteers, patients, twins, and the National Osteoporosis Society, UK for funding the study.


  1. 1 Anonymous WHO Study Group (1994) Assessment of fracture risk and its application to screening for post-menopausal osteoporosis. WHO, GenevaGoogle Scholar
  2. 2 Faulkner KG, Roberts LA, McClung MR (1996) Discrepancies in normative data between lunar and hologic DXA systems. Osteoporos Int 6:432–436PubMedGoogle Scholar
  3. 3 Genant HK, Grman ME, Hangartner T, et al (1995) Standardisation of measurements for assessing BMD by DXA. Calcif Tissue Int 57:469PubMedGoogle Scholar
  4. 4 Hanson J (1997) Standardisation of femur BMD. J Bone Miner Res 12:1316–1317PubMedGoogle Scholar
  5. 5 Looker AC, Wahner HW, Dunn WL, et al (1995) Proximal femur bone mineral levels of US adults. Osteoporos Int 5:389–409PubMedGoogle Scholar
  6. 6 Faulker KG, von Stetten E, Steiger P, et al (1998) Discrepancies in osteoporosis prevalence at different skeletal sites: impact on the WHO criteria. Bone 23: s194Google Scholar
  7. 7 Hans D, Schott A-M, Dargent-Molina P, et al (1998) Is the WHO criteria applicable to quantitative ultrasound measurement? The EPIDOS prospective study. Bone 23:s238Google Scholar
  8. 8 Frost ML, Blake GM, Fogelman I (2000) Can the WHO criteria for diagnosing osteoporosis be applied to calcaneal quantitative ultrasound? Osteoporos Int 11:321–330CrossRefPubMedGoogle Scholar
  9. 9 Ish-Shalom S, Yaniv I, Singal C, et al (1999) Can the WHO osteoporosis criteria be applied to ultrasound measurements? 11th International Workshop on Calcified Tissues. Abstracts:34Google Scholar
  10. 10 Delmas PD (2000) Do we need to change the WHO definition of osteoporosis? Osteoporos Int 11:189–191CrossRefPubMedGoogle Scholar
  11. 11 Barkmann R, Kantorovich E, Singal C, et al (2000) A new method for quantitative ultrasound measurements at multiple skeletal sites. J Clin Densitom 3:1–7Google Scholar
  12. 12 Sunlight Ultrasound Technologies Ltd (1998) Sunlight Omnisense User ManualGoogle Scholar
  13. 13 Ryan PJ, Blake GM, Fogelman I (1992) Post-menopausal screening for osteopenia. Br J Rheumatol 31:823–828PubMedGoogle Scholar
  14. 14 Knapp KM, Blake GM, Spector TD, et al (2001) Multisite quantitative ultrasound: precision, age- and menopause-related changes, fracture discrimination, and T-score equivalence with dual energy absorptiometry. Osteoporos Int 12:456–464PubMedGoogle Scholar
  15. 15 Weiss M, Ben-Shlomo A, Hagag P, et al (2000) Reference database for bone speed of sound measurements by a novel quantitative multi-site ultrasound device. Osteoporos Int 11:688–696PubMedGoogle Scholar
  16. 16 Dennison E, Eastell R, Fall CHD, et al (1999) Determinants of bone loss in elderly men and women: a prospective population-based study. Osteoporos Int 10:384–391CrossRefPubMedGoogle Scholar
  17. 17 Kontulainen S, Kannus P, Haapasalo H, et al (2001) Good maintenance of exercise-induced bone gain with decreased training of female tennis and squash players: a prospective 5-year follow-up study of young and old starters and controls. J Bone Miner Res 16:195–201PubMedGoogle Scholar
  18. 18 Maddalozzo GF, Snow CM (2000) High intensity resistance training: effects on bone in older men and women. Calcif Tissue Int 66:399–404CrossRefGoogle Scholar
  19. 19 Coupland CAC, Grainge MJ, Cliffe SJ, et al (2000) Occupational activity and bone mineral density in post-menopausal women in England. Osteoporos Int 11:310–315CrossRefPubMedGoogle Scholar
  20. 20 Mulder JE, Michaeli D, Flaster ER, et al (2000) Comparison of bone mineral density of the phalanges, lumbar spine, hip and forearm for assessment of osteoporosis in post-menopausal women. J Clin Densitom 3:373–381PubMedGoogle Scholar
  21. 21 Gürlek A, Bayraktar M, Ariyurek M (2000) Inappropriate reference range for peak bone mineral density in dual energy X-ray absorptiometry: implications for the interpretation of T-score. Osteoporos Int 11:809–813PubMedGoogle Scholar
  22. 22 Kim K II, Han I-K, Kim H, et al (2001) How reliable is the ultrasound densitometer for community screening to diagnose osteoporosis in spine, femur and forearm? J Clin Densitom 4:159–165CrossRefPubMedGoogle Scholar
  23. 23 Woodson G (2000) Dual X-ray absorptiometry T-score concordance and discordance between hip and spine measurement sites. J Clin Densitom 3:319–324Google Scholar
  24. 24 Melton LJ (1995) How many women have osteoporosis now? J Bone Miner Res 10:175–177PubMedGoogle Scholar
  25. 25 Looker AC, Orwell ES, Johnston CC Jr, et al (1997) Prevalence of low femoral bone density in older US adults from NHANES III. J Bone Miner Res 12:1761–1768PubMedGoogle Scholar
  26. 26 Ballard PA, Purdie DW, Langton CM, et al (1998) Prevalence of osteoporosis and related risk factors in UK women in the seventh decade: osteoporosis case finding by clinical referral criteria or predictive model? Osteoporos Int 8:535–539CrossRefPubMedGoogle Scholar
  27. 27 Ahmed AIH, Ilic D, Blake GM, et al (1998) Review of 3,530 referrals for bone density measurements of spine and femur: evidence that radiographic osteopenia predicts low bone mass. Radiology 207:619–624PubMedGoogle Scholar
  28. 28 Meyer HE, Tverdal A, Falch JA, et al (2000) Factors associated with mortality after hip fracture. Osteoporos Int 11:228–232CrossRefPubMedGoogle Scholar
  29. 29 National Osteoporosis Society (2001). Position statement on the use of quantitative ultrasound in the management of osteoporosis. NOS, UKGoogle Scholar
  30. 30 Ryan PJ, Spector TD, Blake GM, et al (1993) A comparison of reference bone mineral density measurements derived from two sources: referred and population based. Br J Radiol 66:1138–1141PubMedGoogle Scholar
  31. 31 Andrew T, Hart DJ, Sneider H, de Lange M, et al (2001) Are twins and singletons comparable? A study of disease-related and lifestyle characteristics in adult women. Twin Res 4:464–77CrossRefPubMedGoogle Scholar
  32. 32 Black D, Nevitt M, Palermo L, et al (1993) Prediction of new vertebral deformities. J Bone Miner Res 8 [Suppl 1]:S135Google Scholar
  33. 33 Melton LJ (1993)Long-term fracture prediction by bone mineral assessment at different skeletal sites. J Bone Miner Res 8:1227–1233PubMedGoogle Scholar
  34. 34 Blake GM (2001) Peripheral or central densitometry: does it matter which technique we use? J Clin Densitom 4:83–96Google Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2003

Authors and Affiliations

  • K. M. Knapp
    • 1
    • 2
    • 3
  • G. M. Blake
    • 2
  • T. D. Spector
    • 3
  • I. Fogelman
    • 2
  1. 1.Osteoporosis Screening and Research UnitGuy’s HospitalLondonUK
  2. 2.Imaging SciencesGuy’s, Kings and St. Thomas’ School of Medicine, Guy’s CampusLondonUK
  3. 3.The Twin Research and Genetic Epidemiology UnitSt Thomas’ HospitalLondonUK

Personalised recommendations