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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 173-177

Determining prevalence of osteoporosis in health-seeking population of rural central India using singh's index: A resource optimization model to fight a silent epidemic

1 Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Radiology, Carondelet St. Joseph's Hospital, Tucson, Arizona

Date of Web Publication17-Jul-2018

Correspondence Address:
Deeptiman James
Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_35_18

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Context: To bring the prevalence of osteoporosis in rural India to the forefront of health care, to increase awareness and encourage proactive diagnosis of osteoporosis in a cost-effective manner. Settings: A retrospective observational study was designed to analyze a cohort of adult population attending outpatient clinic at a rural mission hospital. 350 patients with low back pain were evaluated for osteoporosis using the Singh's Index (SI). Methods: Sample size was calculated with 95% confidence level, with confidence interval of five. Three hundred and eighty-four radiographs were graded as per SI. Adult patients 40 years of age and above, with low back ache were included in the study. Patient data were retrieved using Doc 99 Hospaa3 HIMS software. Radiographs for all patients were evaluated using Medsynapse PACS software. Thirty-four radiographs were excluded from the study due to poor image quality. Results: Sample included 181 females and 169 males. Two hundred and eighty-five (84%) radiographs were graded as Grade 3 or below indicating definite osteoporosis. A total of 141 males (84%) and 144 females (80%) were graded as Singh's Grade 3 or less indicating definite osteoporosis. Conclusions: The rural physician must exercise a high clinical index of suspicion of osteoporosis and should encourage routine evaluation and diagnosis of osteoporosis using cost-effective means such as SI in resource-limited areas of the rural India. Limitations: This study highlights the prevalence of osteoporosis among healthcare-seeking adult population and cannot be extrapolated to the general population.

Keywords: Osteoporosis in rural population, Resource optimization, Singh's Index

How to cite this article:
James D, Williams S. Determining prevalence of osteoporosis in health-seeking population of rural central India using singh's index: A resource optimization model to fight a silent epidemic. CHRISMED J Health Res 2018;5:173-7

How to cite this URL:
James D, Williams S. Determining prevalence of osteoporosis in health-seeking population of rural central India using singh's index: A resource optimization model to fight a silent epidemic. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 5];5:173-7. Available from: http://www.cjhr.org/text.asp?2018/5/3/173/236896

  Introduction Top

Current rural medical practice demands perfect coupling of evidence-based practice and innovations to overcome limited resources.[1],[2],[3],[4] The rural practitioner must ensure prompt diagnosis and treatment of osteoporosis to minimize related morbidity.[5] This must be achieved within the boundaries of available resources.[4],[6] The rural physician has limited diagnostic tools available to evaluate osteoporosis, hence it is no surprise that osteoporosis is vastly under diagnosed in rural health-care practice. However, osteoporosis is as much a rural disease as it is an urban disease.[7],[8] Additional factors such as malnutrition, lack of health awareness, and limited accessibility to health care in rural areas compound the disease burden of osteoporosis in rural India.[9]

Unfortunately, adequate attention has not been given to osteoporosis prevention and treatment in rural health-care sector as of yet. With significant increase in life expectancy, both senile as well as postmenopausal osteoporosis are encountered more frequently than ever before.[8],[9] Thus, it is essential to identify and promptly treat osteoporosis in order to avoid associated morbidity such as fractures, disabling pain, and poor quality of life. This study attempts to highlight the existing disease burden of osteoporosis in a cohort of rural population, using cost-effective method to identify the disease. This study was carried out to identify the current prevalence of osteoporosis among patients presenting with low back pain at a rural orthopedic clinic in Chhattisgarh.

  Methods Top

Sample size was calculated with 95% confidence level, at confidence interval of 5. Outpatient registration data were analyzed using Aavanor Hospaa3 Doc 99 HIMS software. Three hundred and eighty-four adult patients aged 40 years and above, who underwent radiological evaluation for low back pain at the rural orthopedic clinic were included in the study [Figure 1]. All patients were evaluated for low back ache at the outpatient clinic from 2014 to 2016. Anterior–posterior radiograph of the pelvis of all patients was retrieved and assessed using Medsynapse PACS software (Medsynaptic Pvt Ltd). 34 patients who had poor quality radiographs with inadequate exposure of either hip joint were excluded from the study. Patient data such as name, age, and sex, were deleted from the radiograph screen before the analysis. Singh's grade was assigned to the radiographs by consensus of both authors. Singh's index (SI) for all patients was tabulated and analyzed using Microsoft Excel 2010 software.
Figure 1: Study population

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  Results Top

The study population included 181 females and 169 males. Two hundred and eighty-five (84%) radiographs were graded as Singh's Grade 3 or below indicating definite osteoporosis [Table 1]. A total of 141 males (84%) and 144 females (80%) were graded as Singh's grade 3 or less indicating definite osteoporosis. One hundred and ninety-seven radiographs (54%) were grade 3, 72 radiographs (24%) were grade 4, and 16 radiographs (6%) were grade 1. Among male patients, 91 (54%) were grade 3, 40 (24%) were grade 2, and 10 (6%) were grade 1. Similarly among female patients, 106 (59%) were grade 3, 72 (18%) were grade 2, and 6 (3%) were grade 1. Two hundred and thirty-eight patients (68%) were below 60 years of age, remaining 112 patients (32%) were above 60 years of age. The group under 60 years included on 136 (57%) females and 102 (43%) males. In this group, 189 (81%) were graded as grade 3 or below indicating definite osteoporosis. The group with 60 years and above population had 45 (40%) female patients and 67 (60%) male patients. Ninety-six patients (82%) in this group were graded as grade 3 or below indicating definite osteoporosis.
Table 1: Singh's Index grading for different age groups

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  Discussion Top

Osteoporosis is a skeletal disease characterized by decreased bone mass per volume associated with microarchitectural deterioration of the bone tissue resulting in bone fragility and increased risk of fracture.[9],[10] It is a common condition of the skeleton where the amount of calcium present in the bones decreases to the point where the bones become less dense and are at higher risk of fracture. SI of grade 3 or below is indicative of definitive osteoporosis. Osteopenia refers to reduced bone mass of less severity then osteoporosis. Whereas, osteoporosis is primarily considered as disease of elderly with higher predilection for the female sex, osteopenia affects younger people of both genders. In some ways, osteopenia can be considered as a precursor to osteoporosis, however, not all people with osteopenia develop osteoporosis.

The disease burden of osteoporosis extends to nearly 40% of Indian population.[11],[12] Indians generally have lower bone mass index compared to their age- and sex-matched Western counterparts.[9] As the epidemic proportion of the disease dawns upon us, it is high time to take note of the condition, promptly identify and treat it in order to minimize associated morbidities. With the estimated proportion of the aging population, the prevalence of osteoporosis is likely to grow exponentially across the spectrum of the urban–rural population in India.[9],[12] Modern medical care while ensuring the longevity of human life have also increased the proportion of population at risk of osteoporosis-related morbidity. Chronic pain, disability and peritrochanteric and vertebral fractures, commonly associated with osteoporosis lead to severe limitations of function and deteriorate quality of life. Orthostatic pneumonia, nonhealing pressure sore, urinary tract infection, and increased risk of thromboembolic event worsen the prognosis. Chronic pain can lead to abuse of nonsteroidal analgesics with renal and hepatic impairment. Minimal rural medical insurance coverage, nonexistential rural pension scheme, and limited rural health-care amenities exert severe financial burden of expensive health care.[6],[9],[13],[14]

Trabecular bone pattern undergoes more rapid remodeling than cortical bone.[15] Inadequate osteoid leads to rapid bone loss in the trabecular bones, thus resulting in higher risk of fracture in sites such as vertebrae, distal radius, and peritrochanteric region of the femur.[16] These areas are the most common sites affected by osteoporosis.[17] Symptomatic osteoporosis commonly presents as vague, diffuse low back ache.[18] Diagnosis and treatment of osteoporosis is essential even with coexisting degenerative condition, which can present with similar symptoms. In this study, we have identified patients with symptomatic osteoporosis in a cohort of healthcare-seeking population.

Bone density gradually starts depleting after the person has attained peak bone density, but consensus eludes the exact age of peak bone mass index.[19] Contradictory reports have suggested that the second as well as early thrid decade of life as the period of peak bone mass.[20],[21] However, peak bone pass period is invariably followed by the phase of loss of bone mass. Maximum loss in bone density is observed in the fourth decade of life and in the early postmenopausal years and is associated with increased risk of osteoporotic fracture risk.[16],[21] It can be safely assumed that the phase of symptomatic osteoporosis begins from the fourth decade of life. Age and sex of patients are important contributory factors in the pathogenesis of osteoporosis.[5],[18],[19] In our study, we identified patients over 40 years of age with symptomatic back pain. This study successfully identified 280 patients (85%) symptomatic osteoporosis in the study population. Similar severity in loss of bone density was identified among both male as well as female patients. Severe kidney disease, severe liver impairment, eating disorders, rheumatoid arthritis, malabsorption syndromes, uncontrolled diabetes, hypercortisolism secondary to prolonged corticosteroid use, alcohol abuse, consumption of antacids containing aluminum, and barbiturates are some of the common conditions that lead to secondary osteoporosis. However, in our study population, we found unusually high incidence of surgical menopause secondary to hysterectomy. Twenty-three female patients in our study population had undergone either hysterectomy or hysterectomy with bilateral salpingooopherectomy before the age of 40 years. One patient had cervical cancer stage 1, seven patients had surgery for adenomyosis, and remaining patients did not have a biopsy proven diagnosis after surgery. High rates of hysterectomy from Chhattisgarh and other surrounding states have been often associated with universal health insurance and unscrupulous health-care practice.[22],[23] Despite the widespread practice of allopathy by alternative medical practitioners and AYUSH health-care practitioners, no data are available regarding osteoporosis secondary to corticosteroid abuse or usage of alternative medicine of uncertain nature in our population.[24]

Study population was classified into two age-based groups 40–60 years age group and over 60 years age group. Two hundred and thirty-eight patients (68%) were below the age of 60 years and remaining 112 patients (32%) were over the age of 60 years. On analysis of SI for both cohorts, similar prevalence of osteoporosis was recorded in both groups. In order to avoid selection bias, the age criteria were designated after completion of Singh's grading. Blinded analysis of the radiographs for SI also ensured that age-dependent bias was avoided. Multifactorial pathogenesis may be responsible for high prevalence of osteoporosis across the population groups.

Diagnosing osteoporosis in rural practice is a major challenge.[2],[9] Interpretation of bone density based on changes in the trabecular pattern of the upper end of the femur was developed by Singh et al. in 1970, after comparing the radiological parameters of bone quality with histological features noted in the iliac crest segments of respective patients who sustained neck of femur fracture. SI has been subjected to numerous studies, analyses, and comparisons to newer modalities of bone density assessment. Dual-energy X-ray absorptiometry (DEXA) scan is considered the gold standard for the diagnosis of osteoporosis [Table 2].[17],[25] However, it is available in few selected urban centers. High cost factor and radiation exposure are other deterrents against routine DEXA screening of all patients for osteoporosis.[9],[26] Questions have also been raised regarding validity of results of DEXA scan in the Indian population as they are interpreted using Western population baseline data.[10] Quantitative ultrasound of the calcaneus is an alternative method of measuring bone density. Ultrasonic waves are transmitted across the calcaneus and speed of sound through bone (ultrasound transit velocity) and attenuation of sound as it passes through bone (broadband ultrasound attenuation) is measured and quantitative ultrasound index is calculated. Studies have shown good correlation between quantitative ultrasound measurements and DEXA scan.[27] However, reproducibility, accuracy, and reliability of interdevice interpretation with this system has been questioned.[27] Limited access, cost factor, and involved logistics of ultrasonometric devices make evaluation of patients in rural centers for osteoporosis using such devices impractical. In contrast, X-ray machines are commonly available in secondary level centers.[6] High acceptance of radiological evaluation; relatively inexpensive as well easier accessibility makes routine radiological screening for osteoporosis easy. Albeit, SI assessment is plagued by low sensitivity and high interobserver variability regarding SI.[28] However, in a resource-limited setting, there can be no comparison between radiographic evaluation of SI vis-à -vis DEXA scan or ultrasonometric devices, which are nonexistent in rural sector. Very few selected privately owned urban centers in the state offer DEXA scan facility and ultrasonometric assessment facility. Occasional ultrasonometric mass screenings, which are carried out in rural areas are neither universally available nor accessible. Our study population had no access to either DEXA or ultrasonometric devices. Using the radiographic assessment of SI, we were able to perform a cost-effective evaluation for osteoporosis among adult symptomatic population in a resource area of rural Chhattisgarh.
Table 2: Modalities for assessment of bone density

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Diagnosing a disease is the first step of management. Hence, prompt diagnosis of this silent epidemic needs to be emphasized at the grass-root level of rural health care to avoid the morbidities and deterioration of quality of life as discussed earlier. Despite the alarming osteoporosis-related WHO epidemiological data, we lack a cohesive national osteoporosis prevention and screening policy and program. With limited rural centers with facility for managing peritrochanteric osteoporotic fractures and associated morbidities, it is imperative that the rural physician is alert, aware, and confident in diagnosing and treating osteoporosis. Our center is the sole rural orthopedic and trauma care facility that caters to nearly fifty thousand adult rural populations within a 50 km radius of central Chhattisgarh. Exciting newer modalities such as India specific FRAX tools is yet to gain a strong foothold in the subcontinent. A computer-based algorithm, FRAX tool, developed by University of Sheffield has gained worldwide popularity in predicting risk of 10-year probability of a major osteoporotic fracture.[29] This tool has been widely validated and has been modified to calculate country-specific risk of fractures. However, its dependence on DEXA BMD, poor dose–response relationship, inadequate coverage of secondary osteoporosis, especially in age group below 40 years of age, poor internet connectivity in rural areas and inability to include ethnic and racial factors of fracture risk and variability in fracture rates makes it a poor tool for administration in our study population.

  Conclusions Top

High prevalence of osteoporosis was identified in the patient cohort evaluated at the orthopedic clinic in the rural secondary hospital. Such high prevalence of osteoporosis among symptomatic adult population visiting the orthopedic clinic raises serious concern regarding the prevalence of osteoporosis among the general population. Osteoporosis must become an integral part of preventive medicine and not an afterthought in current rural medical practice. High prevalence of osteoporosis and prohibitive cost of health care for treatment of associated morbidities demand a radical change in our approach to management and treatment of osteoporosis. Cost-effective methods such as SI on plain radiograph are easily accessible for rural health sector and can be easily utilized to the augment secondary preventive management of osteoporosis among rural population.


Findings cannot be extrapolated to the general population as the incidence of osteoporosis was diagnosed among symptomatic patients. Due to nonavailability of qualified radiologist, all radiographs were evaluated by the orthopedic surgeon. As most rural centers are likely to lack radiologist, the attending physician/orthopedic surgeon have to interpret and diagnose osteoporosis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]


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