Essential Components of Physical Therapists’ Examination and Plan of Care for Patients with Osteoporosis: A Delphi Study

Abstract

Background and Purpose:

Osteoporosis is a systemic, metabolic bone disease that affects bone quality and increases the susceptibility of low-trauma fracture bone that has downstream effects of falls and fragility fractures. Osteoporosis is a multifactorial disease process that requires management from multiple healthcare providers including physicians, nurses, and physical therapists. However, the paucity of information regarding comprehensive physical therapy examination and assessment for patients with osteoporosis led to the need of an evidence-based document. A Delphi process was the foundation of this document sought to provide the best available expert guidance for clinicians in the selection of screening tools, essential tests and measures, treatment goals, and interventions for the patient with osteoporosis.

Methods:

The Delphi process targeted osteoporosis experts with a series of sequential surveys designed to build and reach agreement around the management of a patient with osteoporosis. Thirty-one physical therapists with expertise in the care of patients with osteoporosis were participated in a four round Delphi survey 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.

Results:

A clear consensus on the essential components of examination and interventions was achieved. In general, there were 4-6 retained items across history, tests and measures, education/goals and treatment.

Conclusions:

The prioritization of these management items will better direct clinicians working with adults who have osteoporosis.

INTRODUCTION

Osteoporosis is a systemic, metabolic bone disease that affects over 10 million adults over the age of 50 years old.^1,2 Osteoporosis is characterized by impaired bone quality, increased susceptibility of low-trauma fracture bone and bone mineral density (BMD) > 2.5 standard deviations below that of sex- and race-matched young adults, as assessed using dual-energy x-ray absorptiometry (DXA).^3,4 Aside from the biological processes that affect bone mass and quality, there are additional downstream effects of falls and fragility fractures. Fragility fractures are the result of low force trauma that commonly would not result in injury. These fractures are quite common, occurring every three seconds typically at the hip, spine, and distal radius fractures.⁵ 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 healthcare providers including physicians, nurses, and physical therapists.^6,7

Physical therapy is of particular importance first because physical inactivity is a cause of low bone mass, osteoporosis, and increased fall risk.^8-11 Secondly, physical therapy is critical for fragility fracture prevention and recovery.^12,13 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 a particular condition. CPGs are not protocols nor do they stifle clinical decision making, but rather attempt to reduce unwarranted variation in practice by directing clinicians and the public at large towards what should or should not be performed when managing a given condition. A requirement of CPGs is the need for multiple systematic reviews that are based upon adequate numbers of high quality, randomized clinical trials.^14,15

There is a dearth of high quality, well-controlled studies in the physical therapy literature for a number of reasons that are beyond the scope of this paper, but some of these reasons may include: funding, number of clinician scientists, difficulty properly blinding interventions, and varying degrees of specificity when describing interventions. Therefore, CPGs related to physical therapist interventions are often based on moderate to weak recommendations that may not provide direction in all aspects of physical therapist management including patient assessment.^16,17 Subsequently, CPGs can be less fulfilling for the inquiring clinician who wants to know more about screening, assessment, and specific interventions. We found this to be particularly true in the exploration of evidence concerning physical therapists’ management of patients with osteoporosis.^18-20

Strong evidence regarding recommended screening tools, assessment techniques, interventions including education and preventive strategies for patients with osteoporosis is nearly non-existent. One notable exception is exercise targeted at changing bone mineral density.^21,22 In the companion ADAPTE document (Physical Therapist Management of Patients with Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline from the Academy of Geriatric Physical Therapy), authors adapted an existing CPG that provided guidance on optimizing bone health, specifically bone mass. The adapted document does not address screening, assessment, or other interventions beyond those targeting bone mass. This document will expand upon overall management of the patient with osteoporosis by the physical therapist. The purpose of this document is to provide guidance across the full spectrum of physical therapist management of those with osteoporosis.

A previously published Delphi study, “Too Fit to Fracture” (TFtF), intended to direct health care providers with recommendations on exercise prescription, goal setting, and physical activity and exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture.²³ 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. For example, the body mechanics recommendations are generalizable to all patients, not simply those with osteoporosis. TFtF focused on American College of Sports Medicine (ACSM) guidelines with very broad questions related to examination and very specific information on interventions that were largely directed towards exercise prescription/recommendations. It is not clear how the modifications related to hip hinging, how to move a box, etc. were a component of the Delphi or if they were represented by the authors’ opinions. Our document is intended to guide PT examination, evaluation, and intervention based on the structure of the patient-client management model and the guide to PT practice.

Therefore, we are expanding upon the ADAPTE document filling a void in guidance documents on the topic of bone health and physical therapy. Authors implemented a Delphi process which provides a structured methodology centered around communication amongst a panel of experts. The Delphi process targets experts in a particular field of inquiry to answer questions through a series of sequential surveys designed to build and reach agreement. The result is a consensus-based document, developed by leading experts which is designed to guide practice when stronger evidence is either unavailable or unreasonable to perform.^23-26

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.²⁵ A panel of physical therapists with expertise in the care of patients with osteoporosis were identified and invited to participate 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 round 4 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, UT) 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 IRB oversight by the Advarra^® IRB (Columbia, MD).

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 by members of the research team with knowledge of national experts in the care of patients with osteoporosis. 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.²⁴

Round 1 – Identification of Important Examination and Plan of Care Components

In round 1, panelists were asked to review a 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 if they agree or disagree with the importance of the 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 one 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 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 (e.g., history, 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 (i.e. promoting to an essential status) by panelists in round 3. Operational definitions were then developed for all retained items, and 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 if 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 retained as potential saved items along with the corresponding operational definitions. Using a process of weighted recommendations, panelists were able to assign points to potential save items based on the strength of their recommendation for promoting the item to an 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 one item. Panelists could also choose to distribute all or a portion of the available points to a leftover points item indicating no further recommendations for promoting an item to an essential status.²⁶ The decision to promote an item to an 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

The targeted 30-member expert panel was achieved. One additional response was received due to timing of the participant opening the survey link prior to the 30th response being received and was therefore included, bringing the final number of panelists to 31. Panelists’ demographics and the scope of their education, leadership, and professional recognition are outlined in Table 1. It is notable that 58% of panelists possess 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 earned an advanced doctoral degree (PhD, EdD, DHSc). 58% 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

Gender	N=31 (%)
• Male	4 (13%)
• Female	27 (87%)
Highest Degree
• PhD/DSc/EdD	10 (32%)
• DPT	8 (26%)
• MSPT/MA/MS/MSc	7 (23%)
• BS	6 (19%)
Board Certified Specialists
• Geriatrics	9 (29%)
• Orthopaedics	2 (6%)
Other Certifications/Licenses
• Certified Exercise Expert for Aging Adults	5 (16%)
• Athletic Training	1 (3%)
• Occupational Therapy	1 (3%)
Fellow
• American Physical Therapy Association (FAPTA)	3 (10%)
• American Academy of Orthopaedic Manual Physical Therapist (FAAOMPT)	1 (3%)
• Geriatric Society of American (FGSA)	1 (3%)
• American College of Sports Medicine (FACSM)	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 (Table 2). All items pre-identified by the research team had at least one panelist indicating agreement (n = 66; 22.0% - 100%). Only 3 items (leg length, navicular to floor distance, and electrical modalities) received less than 50% agreement, supporting the quality of the items included in the initial list. A total of 11 additional items were added to the list based on panelists’ recommendations. The relatively low number of additional items supports the comprehensiveness of the pre-identified items, especially for the tests and measures, treatment goals, and interventions sections which had only 1 additional item each. All 77 items were advanced to round 2.

Table 2.

Round 1 Results (n = 31)

Item
History		Agree n (%)	Unsure n (%)	Disagree n (%)	Total Responses n (%)
	Fracture history	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Bone-health related comorbidities (auto-immune disorders, medication-dependent depression, cancer, compromised pulmonary health, diabetes. seizure disorders)	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Current medications associated with fall risk	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Physical activity history (community ambulator, any changes related to pain or fatigue)	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Results from prior bone mineral density assessments (DEXA)	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Bone-friendly & bone-hazardous medication history	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Falls history	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Current exercise routine including type, duration, frequency, etc.	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Historical height loss	29 (93.5)	2 (6.5)	0 (0.0)	31 (100)
	Ergonomic risk factors (living/work situation)	29 (93.5)	1 (3.2)	1 (3.2)	31 (100)
	Family bone-health history	28 (90.3)	2 (6.5)	1 (3.2)	31 (100)
	Results from prior bone-related imaging studies (radiographs, CT)	25 (80.6)	5 (16.1)	1 (3.2)	31 (100)
†	Lab results (e.g., vitamin D levels, CTX, P1NP levels)	N/A	N/A	N/A	N/A
†	FRAX Risk	N/A	N/A	N/A	N/A
†	Absolute fracture risk scores	N/A	N/A	N/A	N/A
†	Nutrition status/Diet (e.g., Calcium intake, carbonated beverages)	N/A	N/A	N/A	N/A
†	Nutrition supplements (e.g., Calcium, vitamin D)	N/A	N/A	N/A	N/A
†	History of vestibular dysfunction	N/A	N/A	N/A	N/A
†	Menstrual history and periods of amenorrhea for females	N/A	N/A	N/A	N/A
†	Average time spent sitting each day	N/A	N/A	N/A	N/A
Tests and Measures		Agree n (%)	Unsure n (%)	Disagree n (%)	Total Responses n (%)
	Balance outcome measures (e.g., BERG Balance Scale, Performance Oriented Mobility Assessment, Dynamic Gait Index, BESTest)	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Current height and weight	30 (96.8)	0 (0.0)	1 (3.2)	31 (100)
	Functional lower extremity strength (e.g., 5x sit to stand, 30 second chair rise)	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Static standing balance (e.g., single leg stance, 4 stage balance)	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Dynamic standing balance (e.g., functional reach test)	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Quantification of thoracic kyphosis (e.g., flexicurve, inclinometer, tragus to wall)	29 (93.5)	0 (0.0)	2 (6.5)	31 (100)
	Observational gait analysis	29 (93.5)	0 (0.0)	1 (3.3)	30 (96.8)
	Relevant upper quarter range of motion/flexibility measurements (patient-specific)	28 (90.3)	2 (6.5)	0 (0.0)	30 (96.8)
	Relevant lower quarter range of motion/flexibility measurements (patient-specific)	28 (90.3)	2 (6.5)	0 (0.0)	30 (96.8)
	Pain (e.g., visual analogue scale, numeric rating scale)	28 (90.3)	3 (9.7)	0 (0.0)	31 (100)
	Confidence and mobility scales (e.g., Activities-specific Balance Scale)	28 (90.3)	2 (6.5)	0 (0.0)	30 (96.8)
	Lower quarter strength (e.g., manual muscle test, dynamometer)	27 (87.1)	4 (12.9)	0 (0.0)	31 (100)
	Rib to pelvis distance	26 (83.9)	2 (6.5)	2 (6.5)	30 (96.8)
	Trunk ROM (e.g., active and passive)	26 (83.9)	0 (0.0)	3 (9.7)	29 (93.5)
	Upper quarter strength (e.g., manual muscle test, dynamometer)	25 (80.6)	5 (16.1)	0 (0.0)	30 (96.8)
	Torso strength (e.g., manual muscle test, dynamometer)	24 (77.4)	5 (16.1)	2 (6.5)	31 (100)
	Two-joint flexibility (e.g., straight leg raise, Thomas test)	24 (77.4)	5 (16.1)	1 (3.2)	30 (96.8)
	Joint varus/valgus (e.g., hip, knee, rear foot)	22 (71.0)	6 (19.4)	1 (3.2)	29 (93.5)
	Spine joint mobility	22 (71.0)	6 (19.4)	2 (6.5)	30 (96.8)
	Endurance tests (e.g., 6-minute walk test)	22 (71.0)	4 (12.9)	1 (3.2)	27 (87.1)
	Body region specific functional outcome measures (e.g., Oswestry, Lower Extremity Functional Scale)	22 (71.0)	6 (19.4)	2 (6.5)	30 (96.8)
	Upper quarter joint mobility	21 (67.7)	4 (12.9)	4 (12.9)	29 (93.5)
	Lower quarter joint mobility	21 (67.7)	4 (12.9)	4 (12.9)	29 (93.5)
	Grip strength	21 (67.7)	7 (22.6)	2 (6.5)	30 (96.8)
	Timed loaded standing	21 (67.7)	7 (22.6)	0 (0.0)	28 (90.3)
	Palpation for trigger points, fibrotic tissue	18 (58.1)	8 (25.8)	2 (6.5)	28 (90.3)
	Quality of life scales	18 (58.1)	11 (35.5)	0 (0.0)	29 (93.5)
	Leg length	11 (35.5)	10 (32.3)	3 (9.7)	24 (77.4)
	Navicular to floor distance	10 (32.3)	12 (38.7)	5 (16.1)	27 (87.1)
†	Dynamic posture testing	N/A	N/A	N/A	N/A
Treatment Goals		Agree n (%)	Unsure n (%)	Disagree n (%)	Total Responses n (%)
	Patient understands fracture prevention strategies	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Patient understands and is engaged in a regular bone-safe resistance, aerobic, balance and flexibility exercise program	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Patient understands fall prevention strategies	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Patient understands safe and unsafe postures	30 (96.8)	0 (0.0)	1 (3.2)	31 (100)
	Patient understands safe and unsafe movements	30 (96.8)	0 (0.0)	1 (3.2)	31 (100)
	Patient understands strategies to slow the rate of bone loss	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Patient understands safe pain modulating activities	30 (96.8)	1 (3.2)	0 (0.0)	31 (100)
	Clinically important reduction in fall risk	28 (90.3)	3 (9.7)	0 (0.0)	31 (100)
	Patient's tissue mobility (e.g., joint capsules, muscles) is safely optimized	26 (83.9)	4 (12.9)	0 (0.0)	30 (96.8)
	Clinically important reduction in kyphosis	24 (77.4)	5 (16.1)	2 (6.5)	31 (100)
†	Patient demonstrates confidence in performing activities of daily living	N/A	N/A	N/A	N/A
Interventions		Agree n (%)	Unsure n (%)	Disagree n (%)	Total Responses n (%)
	Education on body mechanics to reduce fracture risk	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Balance training	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Resistance exercise	31 (100)	0 (0.0)	0 (0.0)	31 (100)
	Education on activity modifications to reduce fall risk	29 (93.5)	0 (0.0)	2 (6.5)	31 (100)
	Bone-healthy body mechanics patterns as exercise	29 (93.5)	2 (6.5)	0 (0.0)	31 (100)
	Flexibility/stretching exercises	29 (93.5)	2 (6.5)	0 (0.0)	31 (100)
	Education on activity modification to reduce fracture risk	28 (90.3)	1 (3.2)	2 (6.5)	31 (100)
	Education on body mechanics to reduce fall risk	28 (90.3)	2 (6.5)	1 (3.2)	31 (100)
	Education on posture to reduce fracture risk	27 (87.1)	2 (6.5)	2 (6.5)	31 (100)
	Education on posture to reduce fall risk	27 (87.1)	2 (6.5)	2 (6.5)	31 (100)
	Weight-bearing aerobics	26 (83.9)	4 (12.9)	1 (3.2)	31 (100)
	Soft tissue focused manual therapy techniques (e.g., muscle energy, deep tissue mobilization, trigger point release)	23 (74.2)	4 (12.9)	3 (9.7)	30 (96.8)
	Joint focused manual therapy techniques (e.g., joint mobilizations)	22 (71.0)	6 (19.4)	3 (9.7)	31 (100)
	Use of patient-specific external orthotic or supportive devices (e.g., spinal braces, plantar orthotics, taping)	21 (67.7)	8 (25.8)	2 (6.5)	31 (100)
	Electrical modalities	7 (22.6)	15 (48.4)	8 (25.8)	30 (96.8)
†	Referral to a dietitian	N/A	N/A	N/A	N/A

Note. †Additional items based on panelists' recommendations; N/A = not applicable

Round 2 – Essential Items Identified

Twenty five of the 31 (80.6%) panelists responded to round 2 with a range of 23-25 responses received per item. A total of 24 items achieved the a priori threshold of 75% of responding panelist rating an item as essential in order to retain the item for the next round (Table 3). 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 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.

Table 3.

Round 2 Results (n = 25)

History		Essential n (%)	Strongly Recommended n (%)	Recommended n (%)	Neutral n (%)	Not Recommended n (%)	Total Responses n (%)
*	Falls history	24 (96.0)	1 (4.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
*	Current medications associated with fall risk	22 (88.0)	2 (8.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
*	Fracture history	22 (88.0)	2 (8.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
*	Physical activity history (community ambulator, any changes related to pain or fatigue)	21 (84.0)	3 (12.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
*	Current exercise routine including type, duration, frequency, etc.	21 (84.0)	4 (16.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
*	Bone-health related comorbidities (auto-immune disorders, medication-dependent depression, cancer, compromised pulmonary health, diabetes. seizure disorders)	20 (80.0)	2 (8.0)	2 (8.0)	1 (4.0)	0 (0.0)	25 (100)
§	Bone-friendly & bone-hazardous medication history	17 (68.0)	6 (24.0)	0 (0.0)	2 (8.0)	0 (0.0)	25 (100)
§	Historical height loss	16 (64.0)	7 (28.0)	2 (8.0)	0 (0.0)	0 (0.0)	25 (100)
§	Results from prior bone mineral density assessments (DEXA)	14 (56.0)	8 (32.0)	2 (8.0)	1 (4.0)	0 (0.0)	25 (100)
§	Ergonomic risk factors (living/work situation)	13 (52.0)	11 (44.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
	FRAX® Risk	11 (44.0)	6 (24.0)	6 (24.0)	2 (8.0)	0 (0.0)	25 (100)
§	Nutrition supplements (e.g., calcium, vitamin D)	11 (44.0)	9 (36.0)	3 (12.0)	2 (8.0)	0 (0.0)	25 (100)
§	Nutrition status/diet (e.g., calcium intake, carbonated beverages)	10 (40.0)	10 (40.0)	5 (20.0)	0 (0.0)	0 (0.0)	25 (100)
§	History of vestibular dysfunction	10 (40.0)	9 (36.0)	4 (16.0)	2 (8.0)	0 (0.0)	25 (100)
§	Results from prior bone-related imaging studies (radiographs, CT)	9 (36.0)	10 (40.0)	4 (16.0)	2 (8.0)	0 (0.0)	25 (100)
	Average time spent sitting each day	8 (32.0)	10 (40.0)	7 (28.0)	0 (0.0)	0 (0.0)	25 (100)
	Absolute fracture risk score	5 (20.0)	9 (36.0)	8 (32.0)	1 (4.0)	0 (0.0)	23 (92.0)
	Family bone-health history	5 (20.0)	9 (36.0)	9 (36.0)	2 (8.0)	0 (0.0)	25 (100)
	Lab Results (e.g., vitamin D levels, CTX, P1NP levels)	4 (16.0)	5 (20.0)	13 (52.0)	1 (4.0)	0 (0.0)	23 (92.0)
	Menstrual history and periods of amenorrhea (for females)	3 (12.0)	7 (28.0)	7 (28.0)	6 (24.0)	0 (0.0)	23 (92.0)
Tests and Measures		Essential n (%)	Strongly Recommended n (%)	Recommended n (%)	Neutral n (%)	Not Recommended n (%)	Total Responses n (%)
*	Dynamic standing balance (e.g., functional reach test, Four Square Step Test)	23 (92.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
*	Balance outcome measures (e.g., BERG Balance Scale, Performance Oriented Mobility Assessment, Dynamic Gait Index, BESTest)	22 (88.0)	3 (12.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
*	Functional lower extremity strength (e.g., 5x sit to stand, 30 second chair rise)	22 (88.0)	2 (8.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
*	Static standing balance (e.g., single leg stance, 4 stage balance)	19 (76.0)	6 (24.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
*	Observational gait analysis	19 (76.0)	5 (20.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
§	Pain (e.g., visual analogue scale, numeric rating scale)	18 (72.0)	6 (24.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
§	Quantification of thoracic kyphosis (e.g., flexicurve, inclinometer, tragus or occiput to wall)	17 (68.0)	8 (32.0)	0 (0.0)	0 (0.0)	0 (0.0)	25 (100)
§	Current height and weight	16 (64.0)	5 (20.0)	4 (16.0)	0 (0.0)	0 (0.0)	25 (100)
§	Confidence and mobility scales (e.g., Activities-specific Balance Scale)	14 (56.0)	10 (40.0)	1 (4.0)	0 (0.0)	0 (0.0)	25 (100)
§	Rib to pelvis distance	13 (52.0)	6 (24.0)	4 (16.0)	1 (4.0)	0 (0.0)	24 (96.0)
§	Dynamic posture testing	12 (48.0)	10 (40.0)	2 (8.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Lower quarter strength (e.g., manual muscle test, dynamometer)	12 (48.0)	7 (28.0)	3 (12.0)	1 (4.0)	1 (4.0)	24 (96.0)
	Torso strength (e.g., manual muscle test, dynamometer)	12 (48.0)	5 (20.0)	4 (16.0)	0 (0.0)	3 (12.0)	24 (96.0)
§	Trunk range of motion (e.g., active and passive)	10 (40.0)	9 (36.0)	4 (16.0)	1 (4.0)	0 (0.0)	24 (96.0)
§	Relevant upper quarter range of motion/flexibility measurements (patient-specific)	10 (40.0)	11 (44.0)	4 (16.0)	0 (0.0)	0 (0.0)	25 (100)
§	Relevant lower quarter range of motion/flexibility measurements (patient-specific)	10 (40.0)	12 (48.0)	3 (12.0)	0 (0.0)	0 (0.0)	25 (100)
	Grip strength	10 (40.0)	6 (24.0)	6 (24.0)	2 (8.0)	0 (0.0)	24 (96.0)
	Two-joint flexibility (e.g., straight leg raise, Thomas test)	8 (32.0)	7 (28.0)	9 (36.0)	0 (0.0)	0 (0.0)	24 (96.0)
	Upper quarter strength (e.g., manual muscle test, dynamometer)	8 (32.0)	8 (32.0)	6 (24.0)	1 (4.0)	1 (4.0)	24 (96.0)
	Quality of life scales (e.g., ECOS-16)	7 (28.0)	9 (36.0)	6 (24.0)	2 (8.0)	0 (0.0)	24 (96.0)
§	Endurance tests (e.g., 6-minute walk test)	6 (24.0)	12 (48.0)	5 (20.0)	1 (4.0)	0 (0.0)	24 (96.0)
	Spine joint mobility	6 (24.0)	8 (32.0)	5 (20.0)	5 (20.0)	0 (0.0)	24 (96.0)
	Leg length	5 (20.0)	5 (20.0)	7 (28.0)	8 (32.0)	0 (0.0)	25 (100)
	Body region specific functional outcome measures (e.g., Oswestry, LEFS, QuickDASH)	5 (20.0)	6 (24.0)	12 (48.0)	2 (8.0)	0 (0.0)	25 (100)
	Joint varus/valgus (e.g., hip, knee, rear foot)	4 (16.0)	13 (52.0)	5 (20.0)	3 (12.0)	0 (0.0)	25 (100)
	Timed loaded standing	4 (16.0)	10 (40.0)	5 (20.0)	3 (12.0)	1 (4.0)	23 (92.0)
	Upper quarter joint mobility	4 (16.0)	6 (24.0)	10 (40.0)	3 (12.0)	1 (4.0)	24 (96.0)
	Lower quarter joint mobility	4 (16.0)	7 (28.0)	9 (36.0)	3 (12.0)	1 (4.0)	24 (96.0)
	Palpation for trigger points, fibrotic tissue	3 (12.0)	9 (36.0)	9 (36.0)	3 (12.0)	0 (0.0)	24 (96.0)
	Navicular to floor distance	0 (0.0)	5 (20.0)	10 (40.0)	9 (36.0)	0 (0.0)	24 (96.0)
Treatment Goals		Essential n (%)	Strongly Recommended n (%)	Recommended n (%)	Neutral n (%)	Not Recommended n (%)	Total Responses n (%)
*	Patient demonstrates knowledge of fall prevention strategies	24 (96.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Patient demonstrates knowledge and awareness of safe and unsafe movements	21 (84.0)	2 (8.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Clinically important reduction in fall risk	21 (84.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	23 (92.0)
*	Patient demonstrates knowledge of fracture prevention strategies	20 (80.0)	4 (16.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Patient demonstrates knowledge and awareness of safe and unsafe postures	19 (76.0)	4 (16.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Patient engagement in a regular bone-safe resistance, aerobic, balance and flexibility exercise program	18 (72.0)	6 (24.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Patient demonstrates confidence in performing activities of daily living	14 (56.0)	9 (36.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Patient demonstrates knowledge of strategies to slow the rate of bone loss	11 (44.0)	10 (40.0)	3 (12.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Patient demonstrates knowledge of safe pain modulating activities	11 (44.0)	12 (48.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
	Clinically important reduction in kyphosis	11 (44.0)	6 (24.0)	5 (20.0)	1 (4.0)	0 (0.0)	23 (92.0)
	Patient's tissue mobility (e.g., joint capsules, muscles) is safely optimized	6 (24.0)	11 (44.0)	6 (24.0)	0 (0.0)	0 (0.0)	23 (92.0)
Interventions		Essential n (%)	Strongly Recommended n (%)	Recommended n (%)	Neutral n (%)	Not Recommended n (%)	Total Responses n (%)
*	Education on activity modifications to reduce fall risk	24 (96.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Education on body mechanics to reduce fall risk	23 (92.0)	1 (4.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Education on body mechanics to reduce fracture risk	22 (88.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Education on activity modification to reduce fracture risk	22 (88.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Education on posture to reduce fracture risk	22 (88.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Resistance exercise	22 (88.0)	2 (8.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Balance training	21 (84.0)	3 (12.0)	0 (0.0)	0 (0.0)	0 (0.0)	24 (96.0)
*	Education on posture to reduce fall risk	19 (76.0)	4 (16.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Bone-healthy body mechanics patterns as exercise	16 (64.0)	7 (28.0)	1 (4.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Flexibility/stretching exercises	13 (52.0)	9 (36.0)	2 (8.0)	0 (0.0)	0 (0.0)	24 (96.0)
§	Aerobic exercise	9 (36.0)	11 (44.0)	4 (16.0)	0 (0.0)	0 (0.0)	24 (96.0)
	Management of patient-specific external orthotic or supportive devices (e.g., spinal orthotics, plantar orthotics, taping)	7 (28.0)	5 (20.0)	10 (40.0)	2 (8.0)	0 (0.0)	24 (96.0)
	Soft tissue focused manual therapy techniques (e.g., muscle energy, deep tissue mobilization, trigger point release)	5 (20.0)	9 (36.0)	8 (32.0)	2 (8.0)	0 (0.0)	24 (96.0)
	Joint focused manual therapy techniques (e.g., joint mobilizations)	5 (20.0)	4 (16.0)	11 (44.0)	4 (16.0)	0 (0.0)	24 (96.0)
	Referral to a dietitian	1 (4.0)	13 (52.0)	6 (24.0)	4 (16.0)	0 (0.0)	24 (96.0)
	Electrical modalities	0 (0.0)	1 (4.0)	6 (24.0)	11 (44.0)	6 (24.0)	24 (96.0)

Note. Note. *Items retained as essential; §Items retained as potential save items; DEXA = dual-energy X-ray absorptiometry; CT = computed tomography; CTX = C-Terminal Cross-Linking Telopeptide; P1NP = Procollagen Type 1 Intact N-terminal Propeptide; BESTest = Balance Evaluation Systems Test; ECOS-16 = assessment of health-related quality of life in osteoporosis; LEFS = Lower Extremity Functional Scale; QuickDASH = Disabilities of the Arm, Shoulder and Hand Short Form.

Once identified, the study team used feedback from panelists to revise wording and create operational definitions for the retained essential and potential save items. During this process the research team identified opportunities to make the list more parsimonious by collapsing similar constructs into one item. For example, physical activity history and current exercise routine were collapsed into history of exercise and physical activity and an operational definition was developed to be inclusive of the concepts represented by each item. The category” treatment goals”, was also 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 lists of 17 essential items and 19 potential save items were advanced to round 3.

Round 3 – Consensus

Twenty-two of the 31 (71.0%) panelists responded to round 3 with a range of 20-22 responses received per item. The a priori threshold for consensus was achieved for all 17 items (Table 4). 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.

Table 4.

Round 3 Results (n = 22)

History		Agree as Written	Agree, but Recommend Revision	Disagree item is Essential	Total Responses	Final Level of Consensus Achieved
Item	Operational Definition	n (%)	n (%)	n (%)	n (%)	n (%)
Current medications associated with fall risk and bone loss	Use of chart review, medication list, patient report, and/or other means to identify current and prior use of medications that have known associations with fall risk and bone loss. - Selected Choice	21 (95.5)	1 (4.6)	0 (0.0)	22 (100)	100%
History of exercise and physical activity	Use of chart review, patient report, and/or other means to identify all physical activities including regular/typical walking distances, maximum walking distance/duration without a rest break, bicycling, swimming, use of any cardiovascular exercise equipment, strength training, gardening, yoga, Pilates, Tai Chi, Silver Sneakers, balance classes, etc. Reporting should include type, frequency, intensity, and duration including limiting factors (e.g., pain, exhaustion, motivation, etc.).	20 (90.9)	2 (9.1)	0 (0.0)	22 (100)	100%
History of falls, near falls, and fear of falling	Use of chart review, patient report, and/or other means to identify any falls within the past year, falls that resulted in a fracture or injury, and/or feeling of unsteadiness or worry about falling.	18 (81.8)	4 (18.2)	0 (0.0)	22 (100)	100%
Bone-health related comorbidities	Use of chart review, patient report, and/or other means to identify any disease that contributes to secondary osteoporosis, decreases bone mineral density, or requires medication that decreases bone mineral density (e.g., auto-immune disorders, medication-dependent depression, cancer, compromised pulmonary health, diabetes, seizure disorders)	18 (81.8)	4 (18.2)	0 (0.0)	22 (100)	100%
History of fracture	Use of chart review, patient report, and/or other means to identify all fractures sustained regardless of cause or age.	17 (77.3)	4 (18.2)	1 (4.6)	22 (100)	95.5%
Tests and Measures		Agree as Written	Agree, but Recommend Revision	Disagree item is Essential	Total Responses	Final Level of Consensus Achieved
Item	Operational Definition	n (%)	n (%)	n (%)	n (%)	n (%)
Assessment of static and dynamic balance	Use of tests and measures to examine a patient's ability to maintain center of gravity within the base of support in an upright posture (static balance) and ability to maintain stability during weight shifting, often while changing the base of support (dynamic balance)	19 (86.4)	2 (9.1)	1 (4.6)	22 (100)	95.5%
Functional lower extremity strength	Use of tests and measures that examine the strength and/or power in the lower extremities through performance of functional tasks (e.g., standing from sitting, going up a step, squatting).	19 (86.4)	2 (9.1)	1 (4.6)	22 (100)	95.5%
Observational gait analysis	Use of visual observation and/or recorded video to examine a patient's gait pattern for abnormalities that may increase risk for fall-related fractures or inhibit the safe performance of bone-protective/balance-improvement exercise programs.	18 (81.8)	4 (18.2)	0 (0.0)	22 (100)	100%
Balance-related outcomes	Use of tests and measures to examine of the impact of a patient's balance status on some meaningful outcome for the patient (e.g., falls, participation, quality of life) at a single time-point and/or over a period of time.	15 (68.2)	3 (13.6)	4 (18.2)	22 (100)	81.8%
Educational Goals		Agree as Written	Agree, but Recommend Revision	Disagree item is Essential	Total Responses	Final Level of Consensus Achieved
Item	Operational Definition	n (%)	n (%)	n (%)	n (%)	n (%)
Patient demonstrates knowledge and application of fall risk reduction strategies.	Confirmation that the patient has an understanding of physical, behavioral, environmental, and pharmaco-medical factors that contribute to falls and applies this knowledge during daily activities including exercise.	19 (86.4)	2 (9.1)	0 (0.0)	21 (95.5)	95.5%
Patient demonstrates knowledge and application of fracture prevention strategies including slowing the rate of bone loss.	Confirmation that the patient has an understanding of physical, behavioral, environmental, and compensatory strategies to reduce one's risk of fractures and slow bone loss and applies this knowledge during daily activities including exercise.	17 (77.3)	3 (13.6)	0 (0.0)	20 (90.9)	90.9%
Patient demonstrates knowledge and application of an exercise program that emphasizes bone-safe posture, resistance, aerobic, balance, and flexibility exercises.	Confirmation that the patient has an understanding of, and consistent ongoing participation in, an exercise program that promotes proper postural alignment, avoids bending forward at the waist and twisting of the spine to the point of strain, and consist of individually tailored resistance, aerobic, balance, and flexibility exercises.	17 (77.3)	3 (13.6)	0 (0.0)	20 (90.9)	90.9%
Patient demonstrates knowledge and application of safe and unsafe postures and movements.	Confirmation that the patient understands proper postural alignment and movements that avoid flexing the trunk or twisting to the point of strain and applies this knowledge during daily activities including exercise.	17 (77.3)	3 (13.6)	1 (4.6)	21 (95.5)	90.9%
Interventions		Agree as Written	Agree, but Recommend Revision	Disagree item is Essential	Total Responses	Final Level of Consensus Achieved
Item	Operational Definition	n (%)	n (%)	n (%)	n (%)	n (%)
Education on posture, body mechanics, and activity modification to reduce fracture risk during daily activities including exercise.	Use of live or recorded instruction, written or online materials, and/or other means to inform patients about postures, positions, and movements that predispose someone with osteoporosis to fracture (e.g., spinal compression fracture, fall-related fracture).	20 (90.9)	1 (4.6)	0 (0.0)	21 (95.5)	95.5%
Resistance exercise	Movements that require muscle force production beyond what is normally required to move a body segment or segments.	19 (86.4)	0 (0.0)	2 (9.1)	21 (95.5)	86.4%
Education on posture, body mechanics, and activity modification to reduce fall risk	Use of live or recorded instruction, written or online materials, and/or other means to inform patients about postures, positions, and movements that predispose someone with osteoporosis to sustaining fall-related spinal or extremity fractures and/or injury.	17 (77.3)	1 (4.6)	3 (13.6)	21 (95.5)	81.8%
Balance training	Activities aimed at improving or maintaining a patient's ability to remain upright and steady when standing or walking in order to avoid fall-related fractures and/or injury.	15 (68.2)	4 (18.2)	2 (9.1)	21 (95.5)	86.4%

Note. Final level of consensus represents the total number of panelists indicating agree as written or agree, but recommend revision divided by the total number of panelists participating in round 3. An a priori threshold of 75% was used to determine if consensus was achieved

In addition, no items from the potential save list were promoted to an 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 (Table 5). 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 4th 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. A summary of items consistently included in rounds 1-3 are provided in Table 6.

Table 5.

Points Awarded to Potential Saved Items

Items	Operational Definition	Total Points Possible	Points Received # (%)
History
Results from prior bone mineral density assessments and imaging studies	Use of radiology reports, chart review, patient report, and/or other means to obtain results of bone mineral density assessments (DEXA) and imaging studies (radiographs, CT).	660	305 (46.2)
Ergonomic risk factors (living/work/recreational settings)	Use of direct observation, pictures/video, patient report, and/or other means to identify aspects of a patient's physical work/living/recreational environment associated with fall risk and/or risk of mechanical spinal compression.	660	218 (33.0)
Historical height loss	Use of chart review, patient report, and/or other measures to determine the quantitative difference between current height and maximum height attained at any age.	660	197 (29.8)
Bone health-related nutritional status/diet	Use of food diaries, lists of supplements, chart review, and/or patient report to obtain average intake of key bone health-related nutrients such as calcium and vitamin D.	660	159 (24.1)
History of vestibular dysfunction	Use of chart review, patient report, and/or other means to identify any history of vertigo/dizziness/floating or confirmed medical conditions that predispose someone to vestibular dysfunction (e.g., Meniere's disease, acoustic neuroma, chronic ear infections)	660	136 (20.6)
Tests and Measures
Quantification of thoracic kyphosis	Measurement of erect posture sagittal spinal curve from C7 to L1 using direct (e.g., flexicurve, inclinometer) or indirect (e.g., tragus or occiput to wall) methods.	660	256 (38.8)
Dynamic posture testing	Use of tests and measures to examine a patient's ability to maintain postural control while reaching at various levels and/or performing functional activities.	660	177 (26.8)
Confidence and mobility scales	Use of standardized measures for the systematic assessment of confidence and self-efficacy as they relate to mobility and fear-avoidance (e.g., Activities-Specific Balance Scale).	660	135 (20.5)
Relevant range of motion/flexibility measurements	Use of tests and measures to quantify the ROM and/or flexibility of body segments relevant to the diagnosis, prognosis, and/or treatment plan of an individual patient (e.g., goniometry, distance, length).	660	115 (17.4)
Lower quarter strength	Use of tests and measures (e.g., manual muscle test, dynamometry) to measure force production of specific lower extremity muscles or muscle groups (e.g., quadriceps, triceps surae).	660	94 (14.2)
Current height & weight	Use of measurement devices (e.g., height rod, scale), chart review, and/or patient report to obtain a patient's current weight (in usual clothing) and height (no shoes).	660	82 (12.4)
Assessment of pain	Use of standardized measures for the systematic assessment of pain, pain response, and/or biopsychosocial aspects of pain (e.g., Numeric pain rating scales, Brief Pain Inventory, Pain Catastrophizing Scale).	660	75 (11.4)
Endurance tests	Use of tests and measures to assess the ability of the cardiovascular, pulmonary, and neuromuscular systems to resist fatigue and complete functional tasks (e.g., 6 min walk test, step test)	660	73 (11.1)
Rib to pelvis distance	Use of a measurement device (e.g., tape measure) to quantify the distance between the inferior margin of the ribs and the superior surface of the pelvis.	660	53 (8.0)
Educational Goals
Patient demonstrates knowledge and application of safe pain modulating activities	Confirmation that the patient has an understanding of physical activities, exercises, positions, modalities, and pharmaceutical agents to reduce pain intensity and applies this knowledge effectively when needed.	660	340 (51.5)
Patient demonstrates confidence in performing bone-safe daily activities including exercise	Confirmation the patient has attained an appropriate level of confidence in performing daily activities and exercise in a way that avoids fall risk and also reduces fracture risk by maintaining safe postures and movements.	660	300 (45.5)
Interventions
Bone-healthy (fracture preventive and bone mineral density preserving) body mechanics patterns as exercise	Exercises prescribed to reinforce safe movement patterns that prevent someone with osteoporosis from suffering fracture and/or pain from excessive appendicular torques.	660	345 (52.3)
Flexibility/stretching exercises	Exercises prescribed to restore range of motion in a joint or extremity	660	240 (36.4)
Aerobic exercise	Exercises prescribed to improve physical fitness and activity tolerance through physiologic mechanisms that promote the body's use of oxygen.	660	240 (36.4)

Table 6.

Mapping of Items through Delphi Process

	Round 1 Items	Round 2 Items	Round 3 Items	Round 3 Potential Save Items
History Items
	Bone-friendly & bone-hazardous medication history	Bone-friendly & bone-hazardous medication history	Current medications associated with fall risk and bone loss	Ergonomic risk factors (living/work/recreational settings)
	Bone-health related comorbidities (auto-immune disorders, medication-dependent depression, cancer, compromised pulmonary health, diabetes. seizure disorders)	Bone-health related comorbidities (auto-immune disorders, medication-dependent depression, cancer, compromised pulmonary health, diabetes. seizure disorders)	Bone-health related comorbidities	Bone health-related nutritional status/diet
	Current exercise routine including type, duration, frequency, etc.	Current exercise routine including type, duration, frequency, etc.	History of exercise and physical activity	Historical height loss
	Current medications associated with fall risk	Current medications associated with fall risk	History of falls, near falls, and fear of falling	History of vestibular dysfunction
	Ergonomic risk factors (living/work situation)	Ergonomic risk factors (living/work situation)	History of fracture	Results from prior bone mineral density assessments and imaging studies.
	Falls history	Falls history
	Family bone-health history	Family bone-health history
	Fracture history	Fracture history
	Historical height loss	Historical height loss
	Physical activity history (community ambulator, any changes related to pain or fatigue)	Physical activity history (community ambulator, any changes related to pain or fatigue)
	Results from prior bone mineral density assessments (DEXA)	Results from prior bone mineral density assessments (DEXA)
	Results from prior bone-related imaging studies (radiographs, CT)	Results from prior bone-related imaging studies (radiographs, CT)
		Absolute fracture risk score
		Average time spent sitting each day
		FRAX Risk
		History of vestibular dysfunction
		Lab Results (e.g., vitamin D levels, CTX, 1NP levels)
		Menstrual history and periods of amenorrhea (for females)
		Nutrition status/Diet (e.g., calcium intake, carbonated beverages)
		Nutrition supplements (e.g., calcium, vitamin D)
Tests and Measures Items
	Balance outcome measures (e.g., BERG, Tinetti, DGI, BESTest)	Balance outcome measures (e.g., BERG, Tinetti, DGI, BESTest)	Assessment of static and dynamic balance	Rib to pelvis distance
	Body region specific functional outcome measures (e.g., Oswestry, LEFS, QuickDASH)	Body region specific functional outcome measures (e.g., Oswestry, LEFS, QuickDASH)	Balance-related outcomes	Assessment of pain
	Confidence and mobility scales (e.g., Activities-specific Balance Scale)	Confidence and mobility scales (e.g., Activities-specific Balance Scale)	Functional lower extremity strength	Confidence and mobility scales
	Current height and weight	Current height and weight	Observational gait analysis	Current height & weight
	Dynamic standing balance (e.g., functional reach test)	Dynamic posture testing		Dynamic posture testing
	Endurance tests (e.g., 6-minute walk test)	Endurance tests (e.g., 6-minute walk test)		Endurance tests
	Functional lower extremity strength (e.g., 5x sit to stand, 30 second chair rise)	Functional lower extremity strength (e.g., 5x sit to stand, 30 second chair rise)		Lower quarter strength
	Grip strength	Grip strength		Quantification of thoracic kyphosis
	Joint varus/valgus (e.g., hip, knee, rear foot)	Joint varus/valgus (e.g., hip, knee, rear foot)		Relevant ROM/flexibility measurements
	Leg length	Leg length
	Lower quarter joint mobility	Lower quarter joint mobility
	Lower quarter strength (e.g., MMT, dynamometer)	Lower quarter strength (e.g., MMT, dynamometer)
	Navicular to floor distance	Navicular to floor distance
	Observational gait analysis	Observational gait analysis
	Pain (e.g., visual analogue scale, numeric rating scale)	Pain (e.g., visual analogue scale, numeric rating scale)
	Palpation for trigger points, fibrotic tissue	Palpation for trigger points, fibrotic tissue
	Quality of life scales (e.g., ECOS-16)	Quality of life scales (e.g., ECOS-16)
	Quantification of thoracic kyphosis (e.g., flexicurve, inclinometer, tragus to wall)	Quantification of thoracic kyphosis (e.g., flexicurve, inclinometer, tragus or occiput to wall)
	Relevant lower quarter ROM/flexibility measurements (patient-specific)	Relevant lower quarter ROM/flexibility measurements (patient-specific)
	Relevant upper quarter ROM/flexibility measurements (patient-specific)	Relevant upper quarter ROM/flexibility measurements (patient-specific)
	Rib to pelvis distance	Rib to pelvis distance
	Spine joint mobility	Spine joint mobility
	Static standing balance (e.g., single leg stance, 4 stage balance)	Static standing balance (e.g., single leg stance, 4 stage balance)
	Timed loaded standing	Timed loaded standing
	Torso strength (e.g., MMT, dynamometer)	Torso strength (e.g., MMT, dynamometer)
	Trunk ROM (e.g., active and passive)	Trunk ROM (e.g., active and passive)
	Two-joint flexibility (e.g., straight leg raise, Thomas test)	Two-joint flexibility (e.g., straight leg raise, Thomas test)
	Upper quarter joint mobility	Upper quarter joint mobility
	Upper quarter strength (e.g., MMT, dynamometer)	Upper quarter strength (e.g., MMT, dynamometer)
		Dynamic standing balance (e.g., functional reach test, Four Square Step Test)
Goals
	Clinically important reduction in fall risk	Clinically important reduction in fall risk	Patient demonstrates knowledge and application of an exercise program that emphasizes bone-safe posture, resistance, aerobic, balance, and flexibility exercises.	Patient demonstrates confidence in performing bone-safe daily activities including exercise.
	Clinically important reduction in kyphosis	Clinically important reduction in kyphosis	Patient demonstrates knowledge and application of fall risk reduction strategies	Patient demonstrates knowledge and application of safe pain modulating activities.
	Patient understands and is engaged in a regular bone-safe resistance, aerobic, balance and flexibility exercise program	Patient engagement in a regular bone-safe resistance, aerobic, balance and flexibility exercise program	Patient demonstrates knowledge and application of fracture prevention strategies including slowing the rate of bone loss.
	Patient understands fall prevention strategies	Patient demonstrates knowledge of fall prevention strategies	Patient demonstrates knowledge and application of safe and unsafe postures and movements
	Patient understands fracture prevention strategies	Patient demonstrates knowledge of fracture prevention strategies
	Patient understands safe and unsafe movements	Patient demonstrates knowledge and awareness of safe and unsafe movements
	Patient understands safe and unsafe postures	Patient demonstrates knowledge and awareness of safe and unsafe postures
	Patient understands safe pain modulating activities	Patient demonstrates knowledge of safe pain modulating activities
	Patient understands strategies to slow the rate of bone loss	Patient demonstrates knowledge of strategies to slow the rate of bone loss
	Patient's tissue mobility (e.g., joint capsules, muscles) is safely optimized	Patient's tissue mobility (e.g., joint capsules, muscles) is safely optimized
		Patient demonstrates confidence in performing ADLs
Interventions
	Education on body mechanics to reduce fracture risk	Education on body mechanics to reduce fracture risk	Education on posture, body mechanics, and activity modification to reduce fracture risk during daily activities including exercise.	Aerobic exercise
	Balance training	Balance training	Balance training	Bone-healthy (fracture preventive and bone mineral density preserving) body mechanics patterns as exercise
	Resistance exercise	Resistance exercise	Resistance exercise	Flexibility/stretching exercise
	Education on activity modifications to reduce fall risk	Education on activity modifications to reduce fall risk	Education on posture, body mechanics, and activity modification to reduce fall risk
	Bone-healthy body mechanics patterns as exercise	Bone-healthy body mechanics patterns as exercise
	Flexibility/stretching exercises	Flexibility/stretching exercises
	Education on activity modification to reduce fracture risk	Education on activity modification to reduce fracture risk
	Education on body mechanics to reduce fall risk	Education on body mechanics to reduce fall risk
	Education on posture to reduce fracture risk	Education on posture to reduce fracture risk
	Education on posture to reduce fall risk	Education on posture to reduce fall risk
	Weight-bearing aerobics	Aerobic exercise
	Soft tissue focused manual therapy techniques (e.g., muscle energy, deep tissue mobilization, trigger point release)	Soft tissue focused manual therapy techniques (e.g., muscle energy, deep tissue mobilization, trigger point release)
	Joint focused manual therapy techniques (e.g., joint mobilizations)	Joint focused manual therapy techniques (e.g., joint mobilizations)
	Use of patient-specific external orthotic or supportive devices (e.g., spinal orthotics, plantar orthotics, taping)	Management of patient-specific external orthotic or supportive devices (e.g., spinal orthotics, plantar orthotics, taping)
	Electrical modalities	Electrical modalities
		Referral to a dietitian

Note: Items in bold indicate new items added based on panel responses; Items in italics indicate revised wording based on panel response; DEXA = dual energy x-ray absorptiometry; CT = computerized tomography; FRAX = fracture risk assessment tool; CTX = beta-C-terminal telopeptide; 1NP = 1-Nitropyrene; BERG = Berg balance scale; DGI = dynamic gait index; BESTest = balance evaluation systems test; LEFS = lower extremity functional scale; QuickDASH = quick disabilities of arm, shoulder, and hand questionnaire; MMT = manual muscle test; ECOS-16 = assessment of quality of life in osteoporosis questionnaire; ROM = range of motion; ADLs = activities of daily living.

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 impact health outcomes.^27,28 Researchers and clinicians have a collective duty to reduce unwarranted variation in practice that exists at regional, national, and international levels, which can be achieved via evidence-based documents. Therefore, the overarching goal of this investigation was to develop consensus of the essential components of patient/client examination, evaluation, and plan of care in the absence of clear evidence-based documents that address these aspects of patient/client management. The first objective established a range of potential examination and intervention items that experts believed to be integral to care for patients with osteoporosis. From there, clear consensus on the essential components of examination and interventions were achieved through two additional rounds as described in the study procedure section. In general, there were 4-6 retained items across history, tests and measures, education/goals and treatment (see Tables 2-4, 6). The prioritization of these management items will better direct clinicians working with adults who have osteoporosis.

Authors left the Delphi process open to the panel experts regarding which items to retain, exclude, and save. Panelists were provided an overall objective to identify components of physical therapists’ management specific to osteoporosis. The study team utilized the survey feedback and interpreted the results from the surveys to guide revisions in subsequent survey rounds. Based upon survey results we collapsed items and created operational definitions. Upon completion of the Delphi, the authors examined the retained and saved items to identify which items that supplement the essential components of management and plan of care for those patients with osteoporosis. Some items could be deemed generalizable to the management of the older adult that were suggested and retained in this document. Authors differentiated items that are considered specific to osteoporosis from other items deemed generalizable to all patients seeking physical therapist services (e.g., pain history/assessment) regardless of diagnosis (see Table 7). 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 7.

Items considered specific to osteoporosis vs. 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, 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.
	Resistance 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
	Balance training

The authors were surprised that two 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 authors were surprised by the lack of inclusion of referrals to interprofessional consultants such as dieticians or other health professionals who could prescribe and interpret bone mineral density results or serum Vit D levels. The inclusion of resistance exercise as an intervention met authors’ expectations, but there are nuances of exercise prescription that warrant further attention. See the clinical practice guideline companion document (Physical Therapist Management of Patients with Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline from the Academy of Geriatric Physical Therapy).

The outcomes from each round and the cumulative Delphi process highlights the consistency among the panel of experts, and the results are 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 is relatively scant of non-pharmacological management of individuals with or suspected of having osteoporosis, this investigation should have an immediate impact on clinical practice. The results should not be interpreted as a cookie-cutter approach to examination, evaluation, and plans of care. 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, clinical practice guidelines, 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 misunderstanding 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 United States trained physical therapists.

SUMMARY

The intent of a Delphi study is to provide consensus opinion from experts in a content area that lacks sufficient clinical trials and meta-analyses to develop clinical practice guidelines. The intent is to reduce unwarranted variation in practice and provide a framework for clinicians developing their skillset in a given area. The retained items are specific to those with osteoporosis. Therefore, a lack of inclusion in this study may simply reflect the perspective that an item is common to all, but still appropriate for a patient with osteoporosis. Clinicians can utilize this Delphi consensus to inform their examination and intervention in patients / clients with low bone density prioritizing incident and secondary fracture prevention with education on safely performing activities of daily living followed by appropriate exercise and direct treatment selections. As technology makes information more accessible, clinicians should be mindful of potential patient biases and seek to educate their patients/clients to make choices based on the best available evidence and their clinical judgement.

CLINICAL HIGHLIGHTS.

• There is a paucity of evidence-based documents that guides physical therapists for the management of osteoporosis.

• This Delphi study provides guidance across the patient-client management model based upon expert feedback.

• This document is meant to provide the best available expert guidance for physical therapists in the selection of screening tools, essential tests and measures, treatment goals, and interventions for the patient with suspected or confirmed osteoporosis.