FRAX Score Interpretation
In this blog (and the videos below) I provide a comprehensive explanation on how to use the FRAX Calculator and FRAX score interpretation. I also provide guidelines for Exercise for Better Bones users on how to select the appropriate weight bearing exercises with the FRAX tool app as your aid. The guidelines set out in this document can be used by both individuals concerned about their bone health and clinicians who treat patients with osteoporosis.
- Video Tutorial
- About the Tool
- Where to Find
- How to Use
- How to Interpret the Score for Exercise for Better Bones
- Relationship with WHO
- How to Adjust the Score
FRAX Tool App
The FRAX tool app was developed to assist clinicians determine the bone quality of a patient so that they could make a more informed decision regarding the appropriate therapeutic approach — whether that be pharmaceutical intervention, an exercise program or nutritional changes. The FRAX Calculator WHO is based on data from the World Health Organization (WHO) and is available online.
The video tutorial is about twelve minutes in duration and takes you step by step through the FRAX Calculator and provides the FRAX score interpretation so that you can understand your score results.
Please note that the tutorial was developed for health professionals. If you are not a health professional you are welcome to follow the tutorial and use the FRAX Calculator but keep in mind that some judgment is required as you go through it. I encourage you to consult a trained and qualified health professional after you get your results.
The data model in the FRAX Calculator is based on information gathered from a large number of different countries. The calculation tool takes into account more than just the results of the DXA test. It considers factors related to your medical and family history and computes a ten-year fracture risk.
Today we’re going to be talking about the FRAX calculator and FRAX score interpretation. FRAX is short for Fracture Risk Assessment and was developed to assist clinicians to predict the ten year probability of an osteoporosis fracture.
The FRAX risk assessment tool was developed by the University of Sheffield. It relies upon data from 34 countries within the World Health Organization. The FRAX calculator provides clinicians with a picture of an individual’s bone quality so that the clinician can decide, for their clients or with their clients, what is the best therapeutic approach to help them with reducing their fracture risk.
Before the FRAX calculator was available, people with relatively good bone mineral density scores were fracturing while people with poor bone mineral density scores were not fracturing. Researchers realized that there was more involved than just the density of the bone. The FRAX test for osteoporosis takes these additional variables into account when it computes your FRAX score.
The FRAX calculator gives clinicians a picture into the quality of your bones. We will go through the FRAX calculator together, but right now I’d like to just walk you through how to get to the FRAX calculator.
As Physical Therapists, we have more time than General Practitioner Physicians to go through the FRAX Calculator. I find a lot of my clients, both that see me in the clinic and from around the world that email me, will ask me questions about whether or not they should be on osteoporosis pharmaceuticals. My question to them is always, “Have you done your FRAX?” Or, “Has someone done your FRAX?” Usually, they have no idea what their FRAX is, and they have not had that information shared with them. So here we go, we’ll look at FRAX.
Enter in Google the term FRAX. That will take you to the first entry, which is “Welcome to FRAX.”
When you click on “Welcome to FRAX,” you will go to the University of Sheffield website and you’ll see a picture of Dr. John Kanis — the researcher behind FRAX.
Go to go to the top of the page and find the Calculation Tool. Follow the steps listed below to complete the FRAX calculator.
FRAX Score Calculator USA or Continent and Country Choice
Within the FRAX Score Calculator, there are choices of continents and then countries. For example you could choose FRAX Score Calculator USA if you live in North American and the USA. Let me explain further.
The continent that you choose, and then the country that you choose, should be either your place of birth or the place you’re living in. What you can actually do is do both and then do a comparison, because that is the most accurate way of getting a picture of your bone health.
Your country of birth will give you information on genetics leading up to your move. The place, where you’re living now, gives information on your bone health related to sun exposure and other variables such as diet. If you are in the United States, you should choose FRAX Score Calculator USA.
I want to choose North America (which is where I live and was born) and I choose Canada.
Your Age, Date of Birth, Sex, Weight and Height
We are going to use a fictitious client, Mary Smith. Mary is 50 years old (born June 1961). Second question is an easy one: Mary is female.
In Canada, we still tend to use pounds and inches when we do our measurements. If we go to the conversion box on the right-hand side, it will give us that information automatically. So Mary’s 130 pounds and she is five foot three, or 63 inches. Note, when you push the convert, it automatically brings the data in to the questionnaire.
Previous and Parent Fracture History
The next question is on previous fracture. Whether Mary had one previous fracture or seven previous fractures, she is to answer yes or no. Mary has had one previous fracture.
The next question is on the parent hip fracture. Neither her mother or her father have fractured a hip. The answer here is no.
Mary is no longer a smoker, so we’ll keep that as no.
Glucocorticoid Steroid Usage History
Mary is not taking glucocorticoid steroids currently. However, when Mary was in her 30s, she was on a course of glucocorticoid steroids for about two and a half months. We are going to keep the answer to be no, because the question is really about whether someone’s been on a dosage of greater than five milligrams per day, for three months or longer.
The researchers found that that dosage has significant negative impact on bones. Certainly if someone’s on a much higher dosage, that’s something that has to be weighed into the equation with the clinical decision-making at the end of the FRAX. Or if someone’s been on a very mild dose for longer period of time, although they might not fit into the yes answer, it is still something to be taken into account.
Next question, number nine, is rheumatoid arthritis. We will answer no, Mary does not.
Question number 10 is whether or not Mary has secondary osteoporosis.
Secondary osteoporosis is when you have been diagnosed with osteoporosis that is caused, not just by reaching menopause and a normal process of losing bone, but rather caused by an underlying disease process. An underlying disease process could be kidney disease, diabetes, intestinal absorption problems, celiac or long-term use of certain medications. So all of those things fall into secondary osteoporosis.
We’re going to click on Yes for Mary there.
Question number 11 is whether or not there is consumption of more than three units of alcohol per day, and that’s going to be a no.
Femoral Neck BMD (Bone Mineral Density) Question
Question number 12 relates to the femoral neck bone mineral density in grams per centimeter squared.
Many of my clients and many of you listening will be given just your T-score.
But the information that you need to make this calculation much more accurate is the machine that your bone mineral density was done on. So under the Select BMD, when you click and you have a pull-down bar, the different names of the machines are listed.
If you can get a copy of your client’s or your own bone mineral density test result, you will see on the sheet what machine it was done on. We’ll pick the Hologic as an example. And then you want the grams in centimeter squared. We’ll pick .5 kg/cm² and push Calculate.
Calculate Score Results
As it’s calculating, I’m going to just bring up a point.
Because Mary is a Caucasian and she’s a female, she is being compared against other female Caucasians. She doesn’t have to convert her T-score in any way. It’s been normalized for her.
If you are not female and you’re not Caucasian, then you do need to go and normalize the data if you’re using the T-score. There is a link to a website, Dr. Susan Ott’s website at the University of Washington, that we will provide for you that you can if you, again, are not Caucasian and you’re not female, that you can use your T-score, convert that over, then bring it back into the calculator.
When you have a choice of just the data that you’re entering and you choose T-score, use the T-score that is provided you by Dr. Susan Ott’s website.
Let us look at the FRAX score results in the red box.
Once you do the calculation, you will be given a red box score, and it has what the BMI is. It also lists the 10-year probability of a fracture.
For Mary, with the questions that we answered, her 10-year probability of a major osteoporotic fracture is 13%. Her 10-year probability of a hip fracture is 4.8%.
Within different countries, each country has chosen different guidelines as to recommendations for pharmaceuticals. Within Canada, we look at the major osteoporotic fracture percentage. Mary is sitting right in the middle. Her score of 13% is the percentage point, somewhere between 10 and 20, where it’s really wise to sit down with a clinician and ask, “What is the picture of my bone health?”
If we went back and (although Mary put in “No” for smoking) if she had been a two-pack-a-day smoker for 20 years, although she’s not currently smoking, we might be thinking that her bone quality is not as high as the fracture risk assessment tool is giving us.
If Mary had had seven previous fractures, although the data entered is the same as whether she had only one, again, we might be weighing, and considering, “Maybe Mary’s bone health isn’t quite as good as we’re seeing in this little answer picture here.”
Now that you have your FRAX score, how do you interpret the FRAX score to determine the weight bearing exercises in your MelioGuide Exercise for Better Bones program level?
This can get a bit complicated because the interpretation varies from country to country. Let’s work through this slowly so you can get what you need to start the exercise program right for you. Please note that I will only cover the major countries we serve: Canada, the US, the UK and Australia.
Finally, if your fracture risk is high or if you have had either a spinal compression fracture or hip fracture, we recommend you omit the hopping and jumping exercises found in the Balance and Strength sections in the Athletic and Elite sections.
How to Interpret FRAX Score for Canada
The following is the interpretation of the FRAX score for Canadian users who want to know what weight bearing exercises (to stimulate bone) is appropriate for them from Exercise for Better Bones.
Once you complete the FRAX tool app, you will see several score results — as illustrated in the image of the red box above. The FRAX score we want to use is the “Major osteoporotic” result (5.8 in the case above). This represents the ten year probability of a major osteoporotic fracture.
In Exercise for Better Bones, the cardiovascular (or weight bearing) exercise recommendations fall into three categories:
- Low Fracture Risk.
- Moderate Fracture Risk.
- High Fracture Risk.
If you are in Canada and your ten year probability of a major osteoporotic fracture (“Major osteoporotic”) is below 10%, then you are in the Low Fracture Risk category of Exercise for Better Bones. If your score is greater than 10% but less than 20%, you are in the Moderate Fracture Risk category. Finally, if your score is greater than 20% or more, then you are in the High Fracture Risk group.
How to Interpret FRAX Score for United States
The following is the interpretation of the FRAX score for users in the United States who want to know what weight bearing exercises (to stimulate bone) is appropriate for them from Exercise for Better Bones.
Unlike other countries, clinicians in the United States classify individuals with ten year probability of a hip fracture (“Hip Fracture”) scores above 3% as high risk of fracture. Clinicians are advised to recommend intervention (principally pharmaceutical intervention) when they see scores like that for their patients.
We are not in a position to prescribe pharmaceutical intervention. Our preferred modality is exercise prescription for our clients.
For our Exercise for Better Bones clients in the United States we recommend following the same guidelines for choice of weight bearing exercise level as our Canadian clients. Read the section above and follow those recommendations.
How to Interpret FRAX Score for United Kingdom (UK)
Clinical guidelines for how to interpret FRAX score for users in the UK differ from those in Canada or the United States. Clinicians in the UK consider the patient’s age as well as the ten year probability of a major osteoporotic fracture (“Major osteoporotic”) score.
The following table provides more detail on FRAX score interpretation by age grouping. Note that the “Lower” and Upper” range refer to the assessment thresholds for the ten year probability of a major osteoporotic fracture (“Major osteoporotic”) score.
|Age (Years)||Lower Threshold||Upper Threshold|
|40 to 44||2.6||7.1|
|45 to 49||2.7||7.2|
|50 to 54||3.4||8.6|
|55 to 59||4.5||11|
|60 to 64||5.9||14|
|65 to 69||8.4||19|
|70 and above||11||24|
Exercise for Better Bones clients in the UK should follow these guidelines when selecting the weigh bearing exercises from the program. Review the table above, find your age range and compare your ten year probability of a major osteoporotic fracture (“Major osteoporotic”) score to the Lower and Upper Threshold scores provided. If your FRAX major osteoporotic fracture (“Major osteoporotic”) score falls at or:
- Below the lower threshold you are at low risk.
- Between the lower and the upper threshold you are at a moderate risk.
- Above the upper threshold you are at a high risk.
This table was published by McCloskey (1). You can learn more about this here.
How to Interpret FRAX Score for Australia
Osteoporosis Australia is unable to recommend the use of FRAX for intervention recommendations. They do not explain why.
Data for FRAX is available for Australia so it is unclear what is causing them to hesitate. If you are user of Exercise for Better Bones and reside in Australia, our recommendation is to follow the guidelines we set above for Canadian users.
The FRAX calculator was a very complex tool to develop. They couldn’t allow for one fracture, two fractures, all of the different variables. Nor could they allow for all the different variables’ smoking patterns.
It is a clinical tool giving us a picture of bone health that is stable. The FRAX score interpretation plays a key role in the clinical judgment as to whether or not pharmaceuticals are warranted and/or how aggressive to be on an exercise program.
Medications Are Not Considered
If I knew that Mary was recently diagnosed with cancer and that Mary was going to be on some strong medication that would also be affecting her bone health, or she had had an epileptic seizure and she was going to be put on medication for her epilepsy, medications that are going to negatively affect here bone health, then those things are telling me that her bone health is no longer stable, and actually being affected by other medical conditions that she’s having to deal with.
Calcium, Vitamin D, Vitamin K Levels Not Considered
In addition, the FRAX does not take into account calcium, Vitamin K, Vitamin D and other nutrient levels. These play an important role in bone health and fracture risk.
As mentioned at the beginning of this blog post, FRAX leverages data from the World Health Organization (WHO). In 2016, representatives of WHO clarified their position on FRAX (2) and seemed to want to distance themselves from the makers of FRAX. In 2018, they reiterated their position in the New England Journal of Medicine (3).
The FRAX calculator is often based on specific populations in certain geographic areas. For example, if you use the calculator for the United States the results could be skewed to white females. If you are non-white, you may need to adjust (or normalize) your T Score and enter that adjusted score in the calculator.
I have prepared a second video tutorial on how to do this. You will locate the adjustment tool online at the following location.
Normalize Your Score
If you want to normalize your T-score, click on the URL. That’s going to bring you to the Washington State University site.
At the top, you’re going to see T and Z scores. Here I’ve gone down to the third bullet point where it says, “Convert T-scores for men and non-white races.”
I’m going to click on this one.
(Note that the website is a bit dated and the tool you will use is based on Adobe Flash. You might need to install this software into your browser to get the normalization tool to work.)
I want you to pay attention to the smaller box of the two boxes. In the smaller box, all the calculations that you see in the big box are done for you automatically. In the little box, choose the ethnicity and the sex that best describes you.
I’m going to choose Hispanic woman as an example, and then in the little box above T-score, place the T-score that appeared in your bone density test results.
Convert by clicking on the convert arrow. You will receive the T-score that is most representative of a white-referenced female.
That is a T-score.
The -2.18 if you were a Hispanic woman, you’d now take the -2.18 and bring that into your FRAX calculator tool. You place that in the box asking you for your T-score. Then complete your FRAX calculator to get your score.
Usage of FRAX Calculator
Usage of the FRAX score interpretation and online tool presented in this article has been generously provided by the International Osteoporosis Foundation. I would like to thank the IOF for allowing me to present this important information to clinicians worldwide.
- McCloskey et al. (2015) FRAX-based assessment and intervention thresholds – an exploration of thresholds in women aged 50 years and older in the UK. Osteoporosis International 26 (8), 2091–9
- Ford, et al, Clarifying WHO’s position on the FRAX® tool for fracture prediction, Bull World Health Organization, 2016 Dec
- Letter to the Editor by Nathan Ford, et al, Correcting the Record on a Fracture Risk Assessment Tool, The New England Journal of Medicine, March 1, 2018
For more information, check out my Osteoporosis Guidelines.