INTRODUCTION
Osteoporosis is a systemic, metabolic bone disease that affects more than 10 million adults older than 50 years.1,2 Osteoporosis is characterized by impaired bone quality, increased susceptibility to low-trauma bone fracture, and bone mineral density (BMD) more than 2.5 standard deviations below that of sex- and race-matched young adults, as assessed using dual-energy x-ray absorptiometry.3,4 Aside from the biological processes that affect bone mass and quality, there are additional downstream effects on falls and fragility fractures. Fragility fractures are the result of low-force trauma that commonly would not result in injury. These fractures are quite frequent, occurring once every 3 seconds worldwide.5 Common fracture sites include the hip, spine, and distal radius.6 The significance of frailty fractures is demonstrated by increased morbidity and mortality, and reduced quality of life. Osteoporosis is a multifactorial disease process that requires management from multiple health care providers including physicians, nurses, and physical therapists.7,8
Physical therapy interventions directed at improving movement and mobility are of particular importance because physical inactivity is a cause of low bone mass, osteoporosis, and increased fall risk.9–12 Additionally, physical therapy interventions such as high-intensity resistive exercise targeted at improving strength and slowing decline in BMD are critical for fragility fracture prevention and recovery.13,14 However, further guidance is required regarding appropriate, specific physical therapy examination criteria and interventions for osteoporosis across clinical settings. Clinical guidance can be provided by evidence-based documents such as clinical practice guidelines (CPGs), adaptation of CPGs, and consensus-based documents. Clinical practice guidelines are the most rigorous and systematic of all evidence-based documents that promote consistent care for patients with a particular condition. Clinical practice guidelines are not protocols nor do they stifle clinical decision-making; rather, they reduce unwarranted variation in practice by directing clinicians and the public at large toward what should or should not be included in the management of a given condition. Valid CPGs rely on multiple systematic reviews composed of adequate numbers of high-quality, randomized clinical trials.15,16
There is a dearth of high-quality, well-controlled studies in the physical therapy literature. Therefore, CPGs related to physical therapist interventions are often based on moderate to weak evidence that may not provide direction in all aspects of physical therapist management including patient assessment.17,18 Consequently, such CPGs may have less value to for inquiring clinicians who want to know more about screening, assessment, and specific interventions. This is particularly true in the exploration of evidence concerning physical therapist management of patients with osteoporosis.19–21
Strong evidence regarding recommended screening tools, assessment techniques, and interventions including education and preventive strategies for patients with osteoporosis is nearly non-existent. One notable exception is exercise targeted at changing BMD.22,23 In the companion CPG,24 authors utilized the ADAPTE process to modify an existing CPG that now provides guidance for physical therapists practicing in the United States on optimizing bone health, specifically bone mass, in the stated population.25 The CPG did not address screening, assessment, or other interventions, as they pertain to physical therapy beyond those targeting bone mass. The lack of high-quality evidence to substantiate guidance across the full continuum of physical therapist management created a void for clinicians treating patients with confirmed or suspected osteoporosis. The absence of guidance beyond exercise for bone mass is due to a lack of primary and secondary sources in the area of osteoporosis and physical therapy examination, evaluation, and interventions. Therefore, the purpose of this Delphi study was to utilize expert consensus to provide some guidance across the full spectrum of physical therapist management of patients with osteoporosis.
A previously published Delphi study, “Too Fit to Fracture” (TFtF), provided health care providers with recommendations on exercise prescription, goal setting, and physical activity and exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture.26 Despite many beneficial aspects, the TFtF document did not specifically target the needs of physical therapists or include components that are unique to a patient with osteoporosis. The TFtF study focused on American College of Sports Medicine guidelines with very broad questions related to examination and very specific information on interventions that were largely directed toward exercise prescription/recommendations. It is not clear whether some of the recommendations were a component of the Delphi or whether they were represented by the authors' opinions. Thus, this Delphi study is intended to guide physical therapists' examination, evaluation, and intervention beyond specific exercise targeting bone mass as covered in the companion CPG.24 This document is based on the broad structure of the patient-client management model, as described in the Guide to Physical Therapist Practice.27 It is intended to fill the void in evidence-based documents on the topic of bone health and physical therapy and extend beyond exercise interventions.
A Delphi process targeted osteoporosis experts to answer questions posed in a series of sequential surveys designed to build and reach agreement. The result of this process provides a consensus-based document designed to guide practice when stronger evidence is either unavailable or unreasonable to obtain.26,28–30
METHODS
A modified Delphi process was used to reach expert consensus on the essential components of physical therapists' examination and plan of care for patients with osteoporosis.29 A panel of physical therapists with expertise in the care of patients with osteoporosis was identified and invited to participate initially in a 3-round, online Delphi process designed to: (1) identify the range of examination and plan of care components considered important to physical therapists' care for patients with osteoporosis, (2) determine which components should be considered essential, and (3) achieve consensus on the final list of essential components and related operational definitions. An optional fourth round was included in the study design to account for the potential need to confirm consensus if substantial changes were made to the operational definition or list of essential items from round 3. Surveys were conducted using the Qualtrics (Provo, Utah) online survey software and consent to participate was indicated by submission of a completed round 1 survey. The procedures for this study were reviewed and determined exempt from institutional review board (IRB) oversight by the Advarra IRB (Columbia, Maryland).
Expert Panel Selection
Eligibility criteria for panel membership included licensure as a physical therapist in the United States and at least one of the following criteria: (1) teaches osteoporosis-related coursework in a CAPTE/ABPTRFE accredited education program or of APTA credentialed continuing education course, (2) prior osteoporosis-related publication in a peer-reviewed journal or textbook, or (3) current or prior leadership role in a national osteoporosis organization. Preference was also given to individuals with current or recent (within the last 5 years) clinical practice treating patients with low bone density. A list of 60 potential panel members was identified based on their scholarly activity and their professional association involvement related to bone health, osteoporosis, and fragility fractures. The list was developed by members of the research team with knowledge of national experts in the care of patients with osteoporosis and who were blinded to consenting panelists' participation.28 Invitations to participate were emailed to potential panel members along with reminder emails every 2 weeks until the a priori target of 30 participating panelists was achieved. A panel of 15 to 30 members is appropriate when panel members are all from the same profession.28
Round 1: Identification of Important Examination and Plan of Care Components
In round 1, panelists were asked to review an initial list of items considered important to include in physical therapists' examination and plan of care for most patients with osteoporosis. The initial list was derived from the literature and clinical expertise of members of the research team. Panelists were asked to indicate whether they agree or disagree with the importance of each item, and to list any additional items missing from the list. Examination items were categorized as either “history” or “tests and measures” items, while plan of care items were categorized as either “treatment goals” or “intervention.” All items marked as agree by at least 1 panel member and unique items added by panelists were retained for the next round.
Round 2: Identification of Essential Items
In round 2, panelists were asked to review all items retained from round 1 and indicate the level of importance of each item on a 5-level scale from essential to not recommended. For the purposes of this study, essential was defined as an item that should be a standard part of physical therapists' examination and plan of care for almost all patients with osteoporosis. Other choices included strongly recommended, recommended, and neutral. As in round 1, items were grouped according to corresponding aspects of the examination and plan of care (eg, history and interventions). Panelists also had the opportunity to provide comments, which were used to inform the interpretation of results and prepare item wording and operational definitions for the following round. The percentage of responses indicating each level of importance was calculated for each item. Items identified as essential by an a priori threshold of 75% of responding panelists were advanced to round 3 as essential items. Items that did not achieve the 75% essential threshold but were identified as at least strongly recommended by 75% of the responding panelist were also retained as items eligible for saving (ie, promoting to an essential status) by panelists in round 3. Operational definitions were then developed for all retained items. All items that did not achieve the retention threshold were discarded.
Round 3: Determine Consensus on Essential Items and Operational Definitions
In round 3, panelists were asked to review the retained essential items along with corresponding operational definitions and indicate whether they agree with the item as written, agree with the item but recommend revision, or disagree with the item as an essential component. Panelists recommending revisions were asked to provide suggested changes in a comments field. The percentage of responding panelists indicating agree or agree with revision was calculated for each item with consensus represented by an a priori threshold of 75% agree or agree with revision. In addition, panelists were asked to review the items that had been retained as potential saved items along with the corresponding operational definitions. Using a process of weighted recommendations, panelists were able to assign points to a potential save item based on the strength of their recommendation for promoting that item to essential status. For each section, panelists could distribute a total of 50 points among the potential save items with 30 points being the maximum allowed for any 1 item. Panelists could also choose to distribute all or a portion of the available points to a leftover point item indicating no further recommendations for promoting an item to essential status.30 The decision to promote an item to essential status was based on the overall strength of recommendation as determined by the percentage of possible save points assigned to the item.
RESULTS
Panelists Characteristics
A final panel of 31 experts was convened. Panelists' demographics and the scope of their education, leadership, and professional recognition are outlined in Table 1. It is notable that 58% of panelists possessed at least a Doctor of Physical Therapy degree, 36% were Board-Certified as either a Geriatric or an Orthopaedic Clinical Specialist (by the American Board of Physical Therapy Specialties), and 32% of the expert panel members had earned an advanced doctoral degree (PhD, EdD, and DHSc). Fifty-eight percent of panelists teach osteoporosis-related courses to other physical therapists, and 26% hold (or have held) a leadership position in a national osteoporosis organization.
Table 1. -
Panel Demographics (n = 31)
Gender
Male
Female |
4 (13%)
27 (87%) |
Highest degree
PhD/DSc/EdD
DPT
MSPT/MA/MS/MSc
BS |
10 (32%)
8 (26%)
7 (23%)
6 (19%) |
Board-certified specialists
Geriatrics
Orthopedics |
9 (29%)
2 (6%) |
Other certifications/licenses
Certified exercise expert for aging adults
Athletic training
Occupational therapy |
5 (16%)
1 (3%)
1 (3%) |
Fellow
American Physical Therapy Association (APTA)
American Academy of Orthopaedic Manual Physical
Therapist (AAOMPT)
Geriatric Society of American (GSA)
American College of Sports Medicine (ACSM) |
3 (10%)
1 (3%)
1 (3%)
1 (3%) |
| Member of APTA Geriatrics Bone Health Special Interest Group |
24 (77%) |
| Leadership position in a national osteoporosis organization |
8 (26%) |
| Speaker at a state or national level on bone health/osteoporosis |
10 (32%) |
| Authored peer-reviewed publications related to bone health/osteoporosis |
10 (32%) |
| Teaches osteoporosis-related courses to physical therapists |
18 (58%) |
Round 1: Important Examination and Plan of Care Components
A total of 77 items considered important to the physical therapists' examination and plan of care for most patients with osteoporosis were identified in round 1 (see Supplemental Digital Content 1, available at: https://links.lww.com/JGPT/A99, which describes levels of agreement in round 1). All 66 items preidentified by the research team had at least 1 panelist indicating agreement (22.0%-100%). Only 3 of these items (leg, length, navicular to floor distance, and electrical modalities) received less than 50% agreement. Eleven additional items were added to the list based on panelists' recommendations. Thus, 77 items were advanced to round 2.
Round 2: Essential Items Identified
Twenty-five of the 31 (80.6%) panelists responded to round 2, with a range of 23 to 25 responses received per item. A total of 24 items (31%) achieved the a priori threshold of 75% of responding panelists rating an item as essential to retain the item for the next round (see Supplemental Digital Content 2 available at: https://links.lww.com/JGPT/A100, which describes levels of agreement in round 2). A relatively even distribution of items was achieved across categories such that 6 items were retained for history, 5 for tests and measures, 5 for treatment goals, and 8 for interventions. A total of 26 items (32%) were marked as strongly recommended or higher by at least 75% of the panelists but did not achieve the threshold for “essential.” These items were also retained for use as potential save items in round 3.
Once identified, feedback from panelists was used to revise wording and create operational definitions for the 48 retained essential and potential save items. During this process the list was shortened by collapsing items with similar constructs into a single item. For example, “physical activity history” and “current exercise routine” were collapsed into “history of exercise and physical activity,” and an operational definition inclusive of the concepts represented by each item was developed. The category “treatment goals” was changed to “educational goals” due to all retained items having an education focus, and comments from panelists indicating that essential treatment goals might be confused with recommendations for documentation of goals on a plan of care. The resulting list of 17 essential items and 19 potential save items was advanced to round 3.
Round 3: Consensus
Twenty-two of the 31 (71.0%) panelists responded to round 3 with, a range of 20 to 22 responses received per item. The a priori threshold for consensus (75%) was achieved for all 17 essential items (see Supplemental Digital Content 3 available at: https://links.lww.com/JGPT/A101, which describes levels of agreement in round 3). The percentage of agreement ranged from 81.8% to 100% indicating strong agreement among the expert panelists on the items deemed essential to physical therapists' examination and plan of care for patients with osteoporosis. A review of the comments and suggested revisions revealed no oversights or consistent themes that would warrant substantive changes to the essential items.
No items from the potential save list were promoted to essential status. The maximum number of save points any item could receive was 660 based on 22 panelists responding and a maximum of 30 points awardable to any item. The highest number of save points received by any item was 345, representing only 52.3% of the maximum possible (see Supplemental Digital Content 4, available at: https://links.lww.com/JGPT/A102, which describes save items based upon points awarded following round 3). As such, there was no evidence indicating broad agreement among panelists that an essential item had inadvertently fallen below the threshold in the prior round. The research team determined that a fourth round to confirm consensus was unnecessary based on the high level of consensus achieved, the lack of substantive revisions, and the absence of any save items being promoted to essential status. See Supplemental Digital Content 5, available at: https://links.lww.com/JGPT/A103, for a summary of items consistently included in rounds 1 to 3 plus potential saved items.
DISCUSSION
The positive impact of physical activity on individuals with low bone density is irrefutable. However, variability that exists in clinical practice can lead to inefficient use of health resources and negatively impact health outcomes.31,32 Researchers and clinicians have a collective duty to reduce unwarranted variation in practice that exists at regional, national, and international levels. Evidence-based documents help to reduce such variation. Therefore, the overarching goal of this investigation was to develop expert consensus regarding the essential components of physical therapist examination, evaluation, and management of individuals with osteoporosis given the absence of clear evidence sufficient to address these aspects of patient care. The prioritization of these items will better direct clinicians working with adults who have osteoporosis.
Some items that were suggested and retained in this document could be deemed generalizable to the management of the older adult. Authors differentiated items that are considered specific to osteoporosis from other items deemed generalizable to all patients seeking physical therapist services (eg, pain history/assessment) regardless of diagnosis (see Table 2). It is noted that the current research question targeted only patients with diagnosed osteoporosis or osteopenia. Therefore, screening items such as rib to pelvis and FRAX tool may not have been retained by this panel since osteoporosis was assumed known or already suspected. Although these items were not retained in the final round, it may be useful to utilize them with those at risk for bone loss, as postural and fracture history information is variable between individual patients.
Table 2. -
Items Considered Specific to Osteoporosis Versus Items Deemed Generalizable to All Patients Seeking Physical Therapist Services
| History items |
| Specific to osteoporosis |
Current medications associated with fall risk and bone loss |
| Bone health–related comorbidities |
| History of fracture |
| Results from prior bone mineral density assessments and imaging studies |
| Generalizable to all |
History of falls, near falls, and fear of falling |
| History of exercise and physical activity |
| Tests and measures items |
| Specific to osteoporosis |
Quantification of thoracic kyphosis |
| Generalizable to all |
Assessment of static and dynamic balance |
| Balance-related outcomes |
| Observational gait analysis |
| Functional lower extremity strength |
| Education items |
| Specific to osteoporosis |
Patient demonstrates knowledge and application of fracture prevention strategies including slowing the rate of bone loss |
| Patient demonstrates knowledge and application of an exercise program that emphasizes bone-safe posture, as well as resistance, aerobic, balance, and flexibility exercises |
| Patient demonstrates knowledge and application of safe and unsafe postures and movements |
| Generalizable to all |
Patient demonstrates knowledge and application of fall risk reduction strategies |
| Patient demonstrates knowledge and application of safe pain modulating activities |
| Intervention items |
| Specific to osteoporosis |
Education on posture, body mechanics, and activity modification to reduce fracture risk during daily activities including exercise |
| Bone-healthy (fracture preventive and bone mineral density preserving) body mechanics patterns as exercise |
| Generalizable to all |
Education on posture, body mechanics, and activity modification to reduce fall risk |
| Resistance exercise |
| Balance training |
Surprisingly, 2 items within the history section were not retained: historical height loss and bone health–related nutritional status/diet. Patient history is intended to identify risk for bone loss and falls-related fracture; therefore, questions included in the survey covered topics from medications to comorbidities to exercise history. The survey included items that may not directly impact osteoporosis but rather a sequela of events such as fall and fracture history. There are no standardized tests or measures utilized by physical therapists to directly assess bone health. Therefore, items included in this section of the survey are likely similar tests and measures employed by physical therapists in a variety of clinical scenarios. The education/goals and intervention sections were consistent with expectations of the study team except for interventions such as manual therapy, self-mobilization, and dynamic bracing. The omission of these items may reflect a focus on strategies to slow the rate of bone loss and mitigate safety risks, and does not preclude clinical implementation. Lastly, the lack of inclusion of referrals to interprofessional consultants such as dieticians or other health professionals who could prescribe and interpret BMD results or serum vitamin D levels was unexpected. The inclusion of resistance exercise as an intervention met authors' expectations, but there are nuances of exercise prescription that warrant further attention.24
The outcomes from each round and the cumulative Delphi process highlight the consistency among the panel of experts, and the consensus results were clear. The methods employed (>75% items rated as essential) confirm the strength of conclusions among our large panel of experts (n = 31). Because the literature regarding nonpharmacological management of individuals with or suspected of having osteoporosis is relatively scant, the results of this Delphi investigation could have an immediate impact on clinical practice. The authors and contributors to this Delphi process respect the expression of knowledge, experience, and science, and encourage patient/client-centered approaches to physical therapy services for individuals and populations. However, outcomes from systematic reviews, CPGs, and consensus documents such as this, for example, confirm what should be done rather than what could be done. Despite strict methodology and a relatively strong number of content experts (n = 31, 25, 22), Delphi studies represent lower levels of evidence as mentioned in the introduction. However, expert opinion documents such as this will help to fill the void in the absence of systematic reviews and randomized clinical trials. Potential limitations of this investigation may have stemmed from misunderstandings about the research question, and that some items were not specific to osteoporosis or specific to physical therapists. Furthermore, panelists may have made some assumptions about tests and measures, for example, that they assumed had already been completed or were not necessary if a patient was already diagnosed with a low bone mass disorder. An additional limitation noted was the decision to limit the expert pool to US trained physical therapists.
SUMMARY
This Delphi study provides expert consensus opinion in the physical therapist management of older adults with osteoporosis. Given the current lack of sufficient clinical trials and meta-analyses required to develop comprehensive CPGs that guide all components of the patient management inclusive of examination, evaluation, intervention and outcomes, this document provides broad, yet low-level evidence. The overarching intent is to reduce unwarranted variation in practice and provide a framework for professional clinical development. Clinicians can utilize this Delphi consensus to inform their clinical decision-making in the care and management of patients with low bone density.
ACKNOWLEDGMENTS
The authors wish to thank the members of the Delphi panel and the Academy of Geriatric Physical Therapy (APTA Geriatrics) who made this work possible.
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