Osteoporosis – a very short historical perspective

Kaushik Chaudhuri, MD FRCP
Consultant Rheumatologist and Osteoporosis Lead, University Hospital, Coventry
President Rheumatology Section & Board
European Union of Medical Specialists

Chamith Rosa
Clinical Fellow in Rheumatology, University Hospital, Coventry

Two decades into the twenty-first century, Osteoporosis is described as a major public health problem worldwide. There are many reasons for this including an ageing global population, but also a consequence of a transformation of the understanding and definition of Osteoporosis in the latter half of the twentieth century. It would be interesting to look back on our understanding and management of this condition.

Archaeological sites in Egypt, offer evidence to suggest that osteoporosis was present around as long as 4000 years ago. An eminent eighteenth-century English surgeon John Hunter discovered that the bone underwent a process now known as remodelling, which played a critical role in osteoporosis. It was in the 1830s that a French pathologist called Jean Lobstein who has been credited with coming up with the term “osteoporosis” after he observed ‘porous bone’ in some patients. Another famous British surgeon, Sir Astley Cooper, in the 19th century, observed that the bones of older people were ‘thin in their shell’ and ‘spongy in their texture’.

In 1938, Fuller Albright of Massachusetts General Hospital discovered that frail bones were more common in postmenopausal women, particularly those who underwent early menopause, which made them more susceptible to osteoporosis. Albright advanced our understanding of osteoporosis by noting a deficiency of osteoblasts in the affected bone; described the predominant involvement of the spine, pelvis and long bones, and the association with disuse and senescence.

The evolution of diagnosis and treatment of Osteoporosis

In the late 19th century, measurements of bone opacity using dental X-rays were first described and plain radiographs were used to comment on bone quality for much of the first half of the 20th century.
Cameron and Sorensen significantly advanced the measurement of BMD by introducing the single-photon absorptiometry (SPA) technique in 1963.

In 1976, Madsen et al. in the USA developed dual-photon absorptiometry (DPA), a method using gamma rays of two different energies to measure BMD. With the introduction of dual-energy X-ray absorptiometry (DXA) in the late 1980s, acquisition time was dramatically shortened and the accuracy and precision of BMD measurement improved. DXA is now the gold standard for assessing bone density. Other technologies for assessing the strength of bone and the risk of fracture have been in development over the last two decades.

In 1994, the World Health Organization described the 4 diagnostic categories based on the bone mineral density of normal, osteopenia, osteoporosis and severe osteoporosis.

In 1969, Herbert Andre-Fleisch demonstrated in in-vitro and animal studies that bisphosphonates were strong inhibitors of bone resorption. However, it did take another 26 years for Alendronic acid to receive FDA approval. Bisphosphonates, oral and parenteral have been the mainstay of treatment for Osteoporosis.

In 2023, we have a better understanding of bone biology resulting in newer treatments like Denosumab, Teriparatide and Romosozumab; new fracture prediction tools like FRAX have helped stratify fracture risk and target therapy most likely to benefit; underpinned by fracture liaison services which have transformed secondary prevention of fragility fractures.

Historically, Osteoporosis has presented an epistemological challenge to medicine.

Our understanding has changed substantially in the past fifty years and that has led to a shift in our approach to the condition, and the current practice is not without its critics; public awareness and attitudes to Osteoporosis and its treatment are also evolving in this age of social media.