Purpose: To describe the results of bone mineral
density (BMD) screening in women with multiple sclerosis (MS) and to
identify risk factors for osteoporosis in women with MS and their use of
Methods: BMD screening was performed at the os calcis.
A self-administered survey, formatted as a checklist, asked women with MS
about their risk factors for osteoporosis and their use of osteoporosis
Findings: 142 women with MS completed the study.
Using a modified classification system suggested for use with peripheral
measurements of BMD, 44.4% of women in the sample were categorized as
having normal BMD, 35.2% were osteopenic, and 20.4% were osteoporotic. The
number of risk factors for osteoporosis reported by women with MS ranged
from zero to 10 with a mean of 4.6 ± 1.8. Relatively few women were using
strategies to minimize their risks for osteoporosis. Of those who did
employ a risk-minimization strategy, the lowest number of women in the
sample (4.3%) used raloxifene, and the highest number of women (38.6%)
used calcium supplementation.
Conclusions: Low BMD is common in women with MS,
increasing their risk for osteoporosis and osteoporotic fractures. Greater
awareness is needed among health care providers regarding the increased
risk and high incidence of osteoporosis in women with MS. Strategies to
detect and prevent osteoporosis are warranted in women with MS in order to
prevent further disability caused by osteoporosis-related fractures.
Suggested citation: Osteoporosis Risk Factors and Bone Mineral Density
in Women With MS. Smeltzer, SC, et al. Int J MS Care [Serial
on-line]. March 2002;4(1).
Osteoporosis is a skeletal disorder characterized by compromised bone
strength predisposing to an increased risk of fracture.1 It has
been referred to as a “silent” disease that is a major contributor to
morbidity and mortality in the United States and around the world.2,3
Osteoporosis is considered epidemic among women in the general population
and is a major risk factor for fracture.1 The costs of treating
fractures secondary to osteoporosis are estimated to exceed $15 billion
per year4; these costs are expected to rise exponentially and
to triple by 2040.3
Osteoporosis contributes to 90% of hip fractures in women. Most hip
fractures result from falls, which is an issue of heightened concern for
patients who are at increased risk for falling, such as those with MS.
Osteoporotic fractures have the potential for causing chronic pain,
disability, and loss of function and independence. All patients who
sustain hip fractures because of osteoporosis require hospitalization for
treatment, and two thirds of them fail to return to their baseline level
of functioning. Nearly one third of patients with osteoporosis-related hip
fractures are discharged to nursing homes within a year; one in five
patients die in the year following fracture.1,4
Osteoporosis and osteoporosis-related fractures are likely to increase
disability in women already disabled by the primary progressive neuronal
degeneration of MS. Few studies have investigated the risk and incidence
of osteoporosis in women with preexisting disability. As a result, little
is known about the risk and incidence of osteoporosis in women with
preexisting disabilities such as MS.
Inadequate physical activity, lack of weight bearing, sedentary
lifestyle, and chronic use of steroids are known risk factors for
osteoporosis. These factors are common among women affected by MS. Because
of impaired balance, lack of coordination, and lower extremity weakness,
falls in women with MS are more likely and increase the risk for fractures
in the presence of low bone mineral density (BMD) and osteoporosis.
Several investigators have found increased incidence of fractures in
persons with MS.5-7 Subjects in these studies have largely been
patients with significant disability because of MS or patients who have
been undergoing treatment with steroids for exacerbations or progression
of MS. Risk factors associated with fractures in these studies have
included low BMD, steroid use, and inadequate dietary intake of vitamin D.
Incidence of osteoporosis in persons with MS has not been well described.
Additionally, the relationship of osteoporosis to fracture in persons with
MS has not been investigated.
The purposes of this study were to: 1) describe the results of BMD
screening in women with MS, 2) identify risk factors for osteoporosis in
women with MS, 3) describe their use of osteoporosis prevention
strategies, and 4) examine the frequency of previous BMD testing in these
women and their compliance with recommendations for testing.
The methods used in this study included BMD screening and a self-report
questionnaire. The study was approved by the appropriate institutional
review board prior to recruitment of subjects.
BMD screening was performed at the os calcis. A peripheral
instantaneous x-ray imager (PIXI), manufactured by Lunar Corporation, was
used to measure peripheral BMD. Measurements were obtained by a technician
skilled with this method of screening. PIXI employs dual-energy x-ray
absorptiometry (DEXA), considered the current gold standard and the most
accurate method of measuring BMD presently available.4
BMD is reported as a T-score, which represents the patient’s bone
mineral content in grams per square centimeter compared with the mean of a
population of young adults. An individual’s T-score refers to the number
of standard deviations (SD) above or below the mean BMD for young, healthy
of Peripheral DEXA as a Measure of BMD
Decreased BMD has been identified as the strongest predictor of
osteoporosis-related fractures.8-10 While DEXA measurements of
the hip are the most sensitive predictors of hip fractures, BMD
measurements obtained at the os calcis have also shown excellent
predictability for assessing risk for hip fractures.11
Sensitivity and specificity of peripheral DEXA at the os calcis for
identifying osteoporosis and osteopenia when compared with measurements
made at the femur have been reported to be 94% and 69%, respectively.12
The os calcis has been reported to be the optimal single site to use for
screening for potential fractures13; however, there are several
limitations of peripheral DEXA at the os calcis. First, it provides
measurement at a single site and does not directly assess risk for
fractures of the hip and spine,4 and second, the method may not
be sensitive in all situations. Thus, there may be false-negative results
suggesting normal BMD when in fact the person has low BMD.11
Despite these limitations, peripheral BMD screening can provide
information about the need for more definitive diagnostic testing.
Although there is less experience with measurement of peripheral bone
sites such as the os calcis as a predictor of hip fracture, such
measurements have been shown to be equivalent to more central sites, such
as the hip and the spine.11 The small size of the PIXI
apparatus, its lack of movable parts, and its speed of operation make it
ideal for BMD screening.12 It is a portable and less expensive
method of assessing BMD as compared with methods that assess hip and spine
BMD. Thus, peripheral BMD measurement by PIXI is appropriate for BMD
screening outside of imaging centers and is more accessible for screening
of physically disabled persons who are confined to wheelchairs or have
A self-administered survey was formatted as a checklist requiring
minimal effort to complete. It included questions about risk factors for
osteoporosis, use of osteoporosis prevention strategies, previous BMD
screening or testing, and recommendations for such testing by subjects’
health care providers. The risk factors listed were those widely
recognized as associated with osteoporosis; they included age, sex, race,
menopausal status, family history of osteoporosis, use of medications, use
of caffeine and alcohol, inadequate calcium intake, history of smoking,
thin frame, and lack of weight-bearing activity.3,4 Other
demographic data, including ambulatory status, educational level, and
employment status, were also obtained by questionnaire.
Descriptive statistics were used to report means; SDs; ranges of BMD
T-scores; frequencies of BMD T-scores that were categorized as normal,
osteopenic, and osteoporotic; osteoporosis risk factors; and preventive
strategies used by women with MS. Unpaired t-tests were used to compare
mean T-scores by nominal variables (menopausal status, history of BMD
testing, previous recommendation for BMD testing) where appropriate.
To be eligible for the study, women had to report a diagnosis of MS,
have no possibility of pregnancy, be willing and able to undergo BMD
screening, and attend one of four health fairs for persons with MS, since
these were the sites where bone density screening was provided without
cost to the participants. Women also had to be able to understand the
questions in the survey and give written informed consent. Consecutive
subjects who approached the screening site at the health fair and met the
eligibility criteria participated in the study; data were obtained from
each subject one time only.
The sample included 142 women with a self-reported diagnosis of MS. The
sample was largely composed of middle-aged women with a mean age of 49.3
years (SD = 9.6), with a range of 27 to 74 years. Nearly 90% of the sample
members identified themselves as white. Approximately three fourths of the
subjects reported having attained an educational level beyond high school.
Almost half of the women in the sample reported that they were unable to
work; 33.8% of them indicated that they received disability benefits.
Women reported their ambulatory status as fully ambulatory, ambulatory
with problems or requiring assistance, or wheelchair bound. More than 82%
of the sample members reported that they were able to ambulate, although
more than half of this group reported that they had difficulty walking.
Sixty-five percent of the ambulatory subjects reported use of some
assistive device (ie, canes or crutches), and 38.1% of those who described
themselves as able to walk reported use of a wheelchair part of the time.
Approximately 17% of the sample reported that they required a wheelchair
at all times. The demographic characteristics of the sample are summarized
in Table 1.
Results of BMD testing are reported as T-scores, which reflect the
number of SDs of subjects’ values from the population mean of young,
healthy white women.4 The World Health Organization (WHO)
defines normal BMD as a T-score greater than –1.0, osteopenia as a
T-score between –1.0 and –2.5, and osteoporosis as a T-score of –2.5
or less. Severe osteoporosis is defined as more than 2.5 SD below the mean
with fragility fractures.2
Demographic Characteristics of Sample (N = 142).
||49.3 + 9.6
||29 – 74
educational level completed:
(in/out of home)
(in/out of home)
to work because of MS
to work and on disability
with problems, require assistance or assistive devices, or
occasional wheelchair use
wheelchair at all times
The mean T-score of the sample of 142 women was –.69 ± 1.5; T-scores
ranged from a high of 2.9 to a low of –4.6. Using the WHO criteria for
normal BMD, osteopenia, and osteoporosis, 56.3% of the subjects had
T-scores indicating normal BMD, 33.1% had osteopenia, and 10.6% were
categorized as osteoporotic. Thus, 43.7% of the sample had BMD values
indicating either osteopenia or osteoporosis.
Method of Reporting BMD Results
Because of concern that the WHO categorization may not be sensitive
enough when applied to peripheral measurement of BMD and therefore may
yield false-negative results, another classification scheme has been
suggested.14 In this modified classification system, normal BMD
is indicated by a T-score greater than 0.6; osteopenia, by a score between
–0.6 and –1.6; and osteoporosis, by a score lower than –1.6. When
this modified classification system was used, 44.4% of the women in the
sample were categorized as having normal BMD, 35.2% demonstrated
osteopenia, and 20.4% had frank osteoporosis. Thus, 55.6% of the women had
T-scores indicative of osteopenia or osteoporosis. These results are
summarized in Table 2.
Bone Density Screening Results by Classification (N = 142).
M ± SD
(% of sample)
M ± SD
(% of sample)
||0.27 ± 0.99
|0.64 ± 0.87
||–1.6 ± 0.38
|–1.1 ± 0.29
||–3.6 ± 0.73
|–2.8 ± 0.96
Osteoporosis Risk Factors Among Women With MS
The number of risk factors reported by the sample ranged from zero to
10 with a mean of 4.6 ± 1.8. Table 3 identifies the percentage of women
reporting the presence of each risk factor. Menopausal status contributed
to the osteoporosis risk of women in this sample. Unpaired t-tests
demonstrated that there were significant differences (t = 2.4, df = 140, P
= .02) in the mean BMD T-score of the 62 women in the menopausal group (M
= –1.04, SD = 1.6) and the mean BMD T-score of the 80 women in the
premenopausal or the perimenopausal group (–.42, SD = 1.4). By WHO
criteria, 54.8% of menopausal women and 35% of premenopausal or
perimenopausal women were identified as having low BMD. By the alternate
classification scheme, 66.1% of menopausal and 47.5% of premenopausal or
perimenopausal women had low BMD values.
of Osteoporosis Prevention Strategies by Women With MS
Table 4 summarizes the subjects’ reported use of strategies
considered useful for reducing the risk for low BMD and osteoporosis. The
percentages of women reporting use of each of the preventive strategies
range from a low of 4.3% (for raloxifene use) to a high of 38.6% (for
calcium supplementation). Less than one quarter of the sample used hormone
replacement therapy (HRT) or participated in weight-bearing exercise. Less
than one tenth of the sample took raloxifene or alendronate, a
bisphosphonate used to prevent or treat osteoporosis.
Previous BMD Screening or Testing
When asked if they had undergone previous BMD testing or screening,
23.2% of the sample (n = 33) reported that they had. The percentage of
women who reported having had testing recommended to them by a health care
provider was 31.2% (n = 44). Twenty-seven (61.4%) of those who had
received such recommendations had undergone BMD testing prior to
participating in this study. Significantly, 68.8% (n = 97) reported that
BMD testing had never been recommended by a health care provider. Of those
109 women who had not undergone previous testing, 37.6% had T-scores equal
to or less than –1.0, and 9.2% had T-scores of less than –2.5,
indicating osteopenia and osteoporosis, respectively.
The findings of this study demonstrate that low BMD is common in women
with MS; this was true whether the WHO criteria or the modified criteria
was used to categorize subjects’ T-scores. While the mean T-score of
–.69 would be indicative of normal BMD by WHO standards, according to
the modified classification system, this score would be indicative of
osteopenia. Diagnosis of osteopenia is important because it identifies
women at risk for osteoporosis and fractures if bone loss continues.15
While 44.4% of the sample in this study had normal BMD values using the
modified classification system, T-scores as low as –4.9 were obtained.
Each SD decrease in BMD is thought to represent a 12% decrease in bone15;
the risk for fractures increases approximately 1.5 to three times for
every decrease of 1 SD in BMD below the mean.10 A reduction of
the T-score to –2.0 has been used to define fracture threshold, the
value below which non-traumatic fractures begin to occur.3
Therefore, a T-score of –4.9 indicates very severe osteoporosis even in
the absence of non-traumatic fractures and represents almost a tenfold
increase in risk for fractures. In a recent two-year study in which
persons with MS and age- and sex-matched healthy control subjects were
compared, MS patients were found to have significantly more non-traumatic
fractures than were subjects in the control group.7 Fractures
occurred in 2% of control subjects and in 22% of MS patients over two
years (P < 0.002).
Risk for fractures is of particular concern because of the increased
risk for falls in patients with MS, because of impaired coordination,
ataxia, balance problems, and muscle weakness associated with the disease.
The cognitive impairment that occurs in some persons with MS has also been
suggested as a cause of falls.5 Therefore, women with MS and
low bone density have an increased susceptibility to falls and to bone
Osteoporosis Risk Factors Identified by Women With MS (N = 142).
history of osteoporosis
or previous smoker
use of caffeine
of steroid, thyroid, or anti-seizure medications
While others have reported a high prevalence of low bone density or a
high rate of fracture in persons with MS,5-7,16 previous
research has largely targeted persons with more advanced MS rather than
the type of women included in this study. Lack of regular physical
activity has been identified as a factor in bone loss and the progression
of osteoporosis.3,4,17,18 While inability to ambulate has been
identified as a risk factor in general and in persons with MS,16
in this study, ambulatory status alone was not a predictor of decreased
bone mass. In the present study, 17.3% of the subjects reported requiring
a wheelchair at all times. Although 82.7% were ambulatory with or without
assistive devices, only 18.7% of women reported participating in any
weight-bearing exercise. Their lack of participation in exercise despite
physical status that would permit some exercise may be due in part to fear
of falling, to fatigue, or to lack of awareness that exercise or activity
is needed to reduce the risk for osteoporosis. While the need for assuring
safety during exercise is essential, given the risk for falls and
fractures, the need for women with MS to participate in exercise within
their physical limitations needs to be addressed.
Other osteoporosis risk factors that have been identified for women
with MS include corticosteroid use, white race, inadequate calcium and
vitamin D intake, the absence of exposure to sunlight, and accelerated
bone loss.7,16,19,20 Menopause without use of HRT increases the
risks further, as is demonstrated by lower T-scores and higher incidence
of osteopenia and osteoporosis in study participants who are menopausal.
Because of recent emphasis on the use of medications (eg, alendronate,
raloxifene, estrogen, calcium supplements) to prevent and reverse bone
loss, osteoporosis is no longer a disease that is inevitable and
untreatable.3,4,21 The National Osteoporosis Foundation and
National Institutes of Health Consensus Conference have recommended that
treatment be initiated when the patient’s T-score is lower than –2.0
if no other risk factors are present and less than –1.5 if the patient
has other risk factors.3,4 Although therapy is now available to
treat low bone mass,22 few women in this study reported use of
medications or other strategies to prevent or slow the loss of bone mass.
Because not all women are eligible, able, or willing to take medications
with demonstrated effectiveness in treatment or prevention of
osteoporosis, other prevention strategies are of interest. Not all women
in the sample, notably those who are premenopausal, are candidates for
medications such as HRT; nevertheless, few of them use other prevention or
treatment strategies such as calcium supplementation.
Osteoporosis Prevention Strategies Used by Women With MS (N =
of prevention strategies
The findings of this study strongly suggest that additional strategies
to prevent osteoporosis or reduce its severity are warranted in women with
MS. This includes educating women who have MS about the importance of
adequate calcium intake, weight-bearing exercise within their physical
limitations, consideration of appropriate medications, and avoidance of
smoking, caffeine, and alcohol. Although only 29.5% of women in the sample
reported consumption of a diet low in calcium, it is likely that the
incidence of low calcium intake is far greater than reported, since the
calcium intake of most people in this country is far below the recommended
Although the decreased bone mineral screening values reported in this
study are a measure of peripheral BMD rather than a measurement of BMD of
the hip and spine, the values do suggest the need for diagnostic testing
using DEXA or quantitative computerized tomography. Such testing of these
more crucial central sites is needed to determine if treatment is
warranted. Despite the high incidence of low BMD and the presence of a
number of osteoporosis risk factors in this sample, few women (23.2%)
reported having undergone BMD screening or testing prior to this study,
and only 31.2% reported having received a recommendation for testing from
their health care provider. While one might argue that there is inadequate
justification for BMD testing, the mean number of osteoporosis risk
factors identified by the women in this sample (4.6 ± 1.8) and the number
of women with low BMD upon screening suggest that risk factors were not
assessed or recognized in these women by their health care providers or by
the women themselves. More women with low BMD reported that they had
undergone previous BMD testing or had had it recommended than did those
with normal BMD. However, of the 79 who had T-scores indicative of low
bone mass, 64.6% reported no previous BMD testing and 58.2% had received
no recommendations for testing. While the value of universal screening,
especially in premenopausal women, has not been established, the findings
of this study suggest that there is adequate justification for considering
screening in women who have MS with several osteoporosis risk factors.
Thirty-one percent of the sample members reported that they had
received recommendations from their health care providers for BMD testing;
however, 38.6% of these women had failed to comply with the
recommendations. Clearly, recommending testing once without following up
is inadequate to convince many women to undergo testing or to persuade
them of its importance. Their failure to follow through with
recommendations for testing may be due in part to lack of understanding of
the significance of their osteoporosis risks and to limited access for
testing. Following up recommendations for testing is needed, given the
concomitant health problems and barriers to access encountered by women
with MS and other disabilities that may keep them from complying with
these recommendations. It is more likely than not that follow-up on
recommendations by their health care providers will increase women’s
understanding of the importance of testing. Access to screening and
reimbursement for BMD testing may be an issue for some women with MS
because of their disability and should be addressed with them.
Many women in this study were unaware of their risks for osteoporosis
or their low BMD and, consequently, few were implementing strategies to
reduce their risks for osteoporosis. Though one potential limitation of
this study rests in the fact that it employed only self-reported data, its
findings are consistent with the results of other studies.23 A
recent report revealed that only 7% of women with osteoporosis were aware
of their condition.24 If women with MS and their health care
providers were aware of the women’s BMD value and their osteoporosis
risk profile, there is a greater likelihood that strategies to prevent and
treat osteoporosis would be implemented.
While there has been a growing recognition of the importance of
prevention, detection, and treatment of osteoporosis in otherwise healthy
men and women, the matter has greater urgency for women with MS. However,
Shabas and Weinreb report that osteoporosis in women with MS is rarely if
ever addressed by their health care providers.23 Fifty percent
of the 200 women with MS who participated in their study of the adequacy
of preventive health care services reported that they did not have regular
medical checkups; they reported seeing a primary care or family health
care provider only when a problem occurred. Yet, in their visits with
neurologists, women with MS reported that their MS-related issues—such
as progression of MS and disability, treatment of MS, and management of
MS-related signs and symptoms—often take precedence; as a result, little
attention is given to health promotion issues, including risk for
osteoporosis.23 As a consequence, the risk for osteoporosis in
MS is often not addressed. Because many women with MS have a normal or
near-normal life span, it is incumbent on health care providers to assist
them in prevention of osteoporosis and osteoporotic fractures that may
lead to secondary disabilities. The findings of this study strongly
suggest the need for considerably greater attention to osteoporosis risk
and BMD testing in women with MS. The consequences of secondary
disabilities related to fracture, in addition to preexisting disability as
a result of MS, mandate further attention to these issues.
For women with MS, the need to prevent additional disability caused by
low BMD is a high priority. Because of the increased risk for fractures
and the potentially devastating consequences of fractures in patients with
MS, greater attention should be given to reducing risks for osteoporosis
in women with MS, particularly in those with impaired balance, impaired
coordination, and lower-extremity weakness. The women who participated in
this study were active enough to attend a health fair. Thus, their BMD
values are likely to be higher than those of women with more severe
disability due to MS who are less active and unable to participate in such
Health care providers need to become more aware of the increased risk
of osteoporosis in women with MS, and they need to implement proactive
strategies, including pharmacologic treatment, to prevent osteoporosis in
this population. BMD testing is critical in women with MS, regardless of
their menopausal status, because of their increased risk for low bone
mass. Osteoporosis-related fractures would increase the severity of
disability in women with MS. Interventions to prevent bone loss and
osteoporosis-related fracture in women with MS are needed. Currently,
there is a lack of adequate BMD testing of women with MS. BMD testing
followed by treatment, if warranted, is a simple health promotion strategy
to prevent further disability in women with MS. Health care providers of
women with MS need to be aware of these clients’ increased risk of
osteoporosis and their critical need for BMD testing.
This study was carried out as part of the Health Promotion for Women
with Disabilities Project at Villanova University College of Nursing, and
was funded by the Bristol-Myers Squibb Foundation. The authors also thank
John Demas of UltraMed Imaging Services, Inc. for his assistance with this
study and his commitment to women with disabilities.
- Healthy People 2010 (Group), US Department of Health and Human
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- WHO Work Group. Assessment of Fracture Risk and Its Application to
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- National Osteoporosis Foundation. Physician’s Guide to
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- National Institutes of Health Consensus Development Panel on
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- Stenager E, Jensen K. Fractures in multiple sclerosis. Acta
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- Troiano RA, Jotkowitz A, Cook SD, et al. Rate and type of fractures
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- Cosman F, Nieves J, Komar L, et al. Fracture history and bone loss
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- Cummings SR, Black DM, Nevitt MC, et al. Bone density at various
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- Melton LJ 3rd, Atkinson EJ, O’Fallon WM, et al. Long-term fracture
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- Wasnich RD, Ross PD, Heilbrun LK, Vogel JM. Selection of the optimal
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- Herndon RM, Mohandas N. Osteoporosis in multiple sclerosis: a
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- Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip
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- Kelley G. Aerobic exercise and lumbar spine bone mineral density in
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- Nieves J, Cosman F, Herbert J, et al. High prevalence of vitamin D
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