research paper in commerce and management

ISSN 0976 - 2183

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• VOLUME – XV (2024), ISSUE – IV (APRIL)
• ABSTRACTS OF XV (2024), ISSUE – IV (APRIL)
• RISE AND FALL OF A RETAIL GIANT: A CASE STUDY OF BIG BAZAR Dr. MANGESH MANNOHAR DASARE, DNYANESHWAR NARWADE & WASIM KHAN
• ARTIFICIAL INTELLIGENCE IN BUSINESS Dr. J FRANCIS MARY
• VOLUME – XV (2024), ISSUE – III (MARCH)
• ABSTRACTS OF XV (2024), ISSUE – III (MARCH)
• RESHAPING E-COMMERCE IN INDIA: PANDEMIC-DRIVEN GROWTH AND TRANSFORMATIONS Dr. V. DHIVYA KEERTHIGA & R. NIRMALA
• A DETAILED STUDY ON CSR ACTIVITIES OF LARGE LISTED COMPANIES IN INDIA Dr. K. B. RAVINDRA
• VOLUME – XV (2024), ISSUE – II (FEBRUARY)
• ABSTRACTS OF XV (2024), ISSUE – II (FEBRUARY)
• CONTRIBUTIONS OF RESILIENT EMPLOYEES IN BUILDING SUSTAINABLE HIGH PERFORMANCE IN ORGANIZATIONS PRIYANKA PRIYADARSHINI
• ADDRESSING CLIMATE RISKS IN BANGLADESHS FINANCIAL SYSTEM: EVALUATING THE GREEN FINANCING INITIATIVES OF BANGLADESH BANK Md. SERAJUL ISLAM
• VOLUME – XV (2024), ISSUE – I (JANUARY)
• ABSTRACTS OF XV (2024), ISSUE – I (JANUARY)
• A STUDY ON ATM CARDS AND MODES OF DIGITAL PAYMENTS IN BANKS Dr. NEERAJ KUMAR SADDY
• SPIRITUALITY IN ORGANISATIONS (A CASE STUDY OF BHAVAN’S VIVEKANANDA COLLEGE OF SCIENCE, HUMANITIES AND COMMERCE, SAINIKPURI) Dr. D SANJEEVA RAO & RACHANA SHARMA
• VOLUME – XIV (2023), ISSUE – XII (DECEMBER)
• ABSTRACTS OF XIV (2023), ISSUE – XII (DECEMBER)
• AN ANALYSIS OF PEOPLES PERCEPTION TOWARDS CASHLESS SYSTEM IN HIMACHAL PRADESH SUGREEV KUMAR & KULDEEP KUMAR
• A STUDY ON THE SOURCES OF INSPIRATION FOR PAINTINGS Dr. ROOPA BHATIA
• VOLUME – XIV (2023), ISSUE – XI (NOVEMBER)
• ABSTRACTS OF XIV (2023), ISSUE – XI (NOVEMBER)
• A STUDY ON COMMODITY TRADING WITH REFERENCE TO GOLD AND SILVER IN HYDERABAD CITY, TELANGANA STATE Dr. A. MADHAVI LATHA
• PRIVATIZATION OF PUBLIC SECTOR BANKS IN INDIA: A STUDY Dr. JYOTIRMOY KOLEY
• VOLUME – XIV (2023), ISSUE – X (OCTOBER)
• ABSTRACTS OF XIV (2023), ISSUE – X (OCTOBER)
• FIRMS FINANCIAL PERFORMANCE AND ENVIRONMENTAL IMPACT: EVIDENCE FROM NIGERIA ERETAN, GBENGA O. & ATOYEBI KEHINDE
• THE FAILED ECONOMIST AND A TALE OF THREE PROGRAMMES UNDER NEP 2020: A CASE STUDY OF CSTS GDC, JANGAREDDIGUDEM SRINIVASA RAO B
• VOLUME – XIV (2023), ISSUE – IX (SEPTEMBER)
• ABSTRACTS OF XIV (2023), ISSUE – IX (SEPTEMBER)
• CAREER AND SOCIO-ECONOMIC CONDITIONS OF FACULTIES WORKING IN FIRST GRADE COLLEGES: A STUDY WITH REFERENCE TO DAKSHINA KANNADA DISTRICT, KARNATAKA STATE Dr. GEETHA M L
• THE IMPACT OF DIGITAL MARKETING STRATEGIES ON PROMOTING NICHE TOURISM DESTINATIONS: A SPECIAL REFERENCE TO UTTARAKHAND RITISHA SHARMA & Dr. VIJAY KUMAR

CALL FOR MANUSCRIPTS

We invite unpublished novel, original, empirical and high quality research work pertaining to the recent developments & practices in the areas of Computer Science & Applications; Commerce; Business; Finance; Marketing; Human Resource Management; General Management; Banking; Economics; Tourism Administration & Management; Education; Law; Library & Information Science; Defence & Strategic Studies; Electronic Science; Corporate Governance; Industrial Relations; and emerging paradigms in allied subjects like Accounting; Accounting Information Systems; Accounting Theory & Practice; Auditing; Behavioral Accounting; Behavioral Economics; Corporate Finance; Cost Accounting; Economic Development; Economic History; Financial Institutions & Markets; Financial Services; Fiscal Policy; Government & Non Profit Accounting; Industrial Organization; International Economics & Trade; International Finance; Macro Economics; Micro Economics; Rural Economics; Co-operation; Demography: Development Planning; Development Studies; Econometrics; Applied Economics; Development Economics; Business Economics; Monetary Policy; Public Policy Economics; Real Estate; Regional Economics; Political Science; Continuing Education; Labour Welfare; Philosophy; Psychology; Sociology; Tax Accounting; Advertising & Promotion Management; Management Information Systems (MIS); Business Law; Public Responsibility & Ethics; Communication; Direct Marketing; E-Commerce; Global Business; Health Care Administration; Labour Relations & Human Resource Management; Marketing Research; Marketing Theory & Applications; Non-Profit Organizations; Office Administration/Management; Operations Research/Statistics; Organizational Behavior & Theory; Organizational Development; Production/Operations; International Relations; Human Rights & Duties; Public Administration; Population Studies; Purchasing/Materials Management; Retailing; Sales/Selling; Services; Small Business Entrepreneurship; Strategic Management Policy; Technology/Innovation; Tourism & Hospitality; Transportation Distribution; Algorithms; Artificial Intelligence; Compilers & Translation; Computer Aided Design (CAD); Computer Aided Manufacturing; Computer Graphics; Computer Organization & Architecture; Database Structures & Systems; Discrete Structures; Internet; Management Information Systems; Modeling & Simulation; Neural Systems/Neural Networks; Numerical Analysis/Scientific Computing; Object Oriented Programming; Operating Systems; Programming Languages; Robotics; Symbolic & Formal Logic; Web Design and emerging paradigms in allied subjects.

Anybody can submit the soft copy of unpublished novel; original; empirical and high quality research work / manuscript anytime in M.S. Word format after preparing the same as per our GUIDELINES FOR SUBMISSION ; at our email address i.e. [email protected] or online by clicking the link online submission as given on our website ( FOR ONLINE SUBMISSION, CLICK HERE ). 

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A Monthly Double-Blind Peer Reviewed (Refereed/Juried) Open Access International e-Journal - Included in the International Serial Directories Indexed & Listed at: Ulrich's Periodicals Directory ©, ProQuest, U.S.A., Indian Citation Index (ICI), Google Scholar, J-Gate [link of the same is duly available at Inflibnet of University Grants Commission (U.G.C.)], Cabell's Directories of Publishing Opportunities, U.S.A. & Index Copernicus Publishers Panel, Poland with IC Value of 5.09 (2012) as well as in number of libraries all around the world. Circulated all over the world & Google has verified that scholars of more than 7835 Cities in 197 countries/territories are visiting our journals on regular basis. Published 8528 quality Research Papers/Manuscripts, belonging to 14501 authors of different countries. Have more than 2135000 visits of researchers on our website, who have made more than 6000000 downloads. Copyright © 2010 IJRCM . All Rights Reserved..

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Hitotsubashi Journal of Commerce and Management

Aims and Scope

The Hitotsubashi Journal of Commerce and Management was established in 1960 for promoting scholarly research conducted at Hitotsubashi University. Published annually, the journal presents original contributions in various fields in social sciences, including accounting, business and economics, business management, culture and industry studies, innovation, marketing, money, and finance. The Hitotsubashi Journal of Commerce and Management publishes research regarding advances in commerce and management practices and is intended for academic researchers, business executives, and other influential leaders.

Table of contents for each issue is available from the university repository system (HERMES-IR). All the papers in Hitotsubashi Journal of Commerce and Management are downloadable in pdf format for free of charge from HERMES-IR.

*Available online only from 2020. Web page of Hitotsubashi Journal of Commerce and Management in HERMES-IR

Submission Guidelines

A. for faculty members and invited fellows.

Manuscripts should be written in English, German, or French.

For AY 2023-2024

• 『Manuscript Submission Guidelines and Application for Hitotsubashi Journal in AY 2023-2024』（in Japanese)
• 『Manuscript Submission Guidelines and Application for Hitotsubashi Journal in AY 2023-2024』（in English)

For AY 2021

• 『Manuscript Submission Guidelines and Application for Hitotsubashi Journal in AY 2021』（in Japanese)
• 『Manuscript Submission Guidelines and Application for Hitotsubashi Journal in AY 2021』（in English)

B. For Adjunct Assistant Professors and Students at the University

Manuscripts should be written in English, and must be reviewed.

*Please note that submissions will be accepted only from faculty members, invited fellows,  adjunct assistant professors and students at the University.

*All those considering submissions should consult Instructions to Authors.

Instructions to Authors

• Authors submitting a manuscript do so on the understanding that if it is accepted for publication, the copyrights in the submitted work, such as the right of reproduction or public transmission, including the copyrights protected under any applicable law of any foreign countries, shall be assigned exclusively to Hitotsubashi University in accordance with Hitotsubashi Journal Copyright Policy . When the author(s) reproduce or republish the work elsewhere, please notify Hitotsubashi Journal Editorial Office in advance.
• The editors do not accept responsibility for damage or loss of papers submitted.
• Manuscript should have margins of at least one inch on all sides, using double-spacing throughout. Number each page. The total number of pages should not exceed 40. Please send a single PDF file of the manuscript that includes references, tables and figures as an e-mail attachment to the Editor.
• The first page of the manuscript should contain the following information: (i) the title; (ii) the name(s) and complete affiliation(s) [including e-mail address(es)] of the author(s); (iii) an abstract of not more than 100 words.
• Acknowledgements and information on grants received should be given in footnote on the first page.
• Footnotes should be kept to a minimum and be numbered consecutively throughout the text with superscript in Arabic numerals. All graphs and diagrams should be referred to as figures and should be numbered consecutively in the text in Arabic numerals. Tables should be numbered consecutively in the text in Arabic numerals.
• Important formulae (displayed) should be numbered consecutively throughout the manuscript as (1), (2), etc. on the right-hand side of the page. Where the derivation of formulae has been abbreviated, it is of great help to referees if the full derivation can be presented on a separate sheet (not to be published).

Ara, K. (1958), “Capital Theory and Economic Growth,” Economic Journal 89, pp.511-527. Debreu, G. (1959), Theory of Value , New York, John Wiley and Sons. Fujino, S. (1965), Nihon no Keikijunkan [Japanese Trade Cycles], Tokyo, Keiso Shobo. Hildenbrand, W. and R. Radner (1979), “Stochastic Stability of Market Adjustment in Disequilibrium,” in: J. Green and J.A. Sheinkman, eds., General Equilibrium, Growth, and Trade: Essays in Honor of Lionel McKenzie , New York, Academic Press, pp.139-149. Kojima, K. (1958), “Shihon Chikuseki to Kokusai Bungyo [Capital Accumulation and the International Division of Labor],” in: Akamatsu Kaname Hakushi Kanreki Kinen Ronshu Kankokai, ed., Keizaiseisaku to Kokusaiboeki: Akamatsu Kaname Hakushi Kanreki Kinen Ronshu [ Economic Policy and International Trade ], pp.443-496. Masuda, S. (1958), “Chuseishoki Shuwaben no Kizoku Shihai [The Rule of Nobles in Schwaben in the Early Middle Ages],” Keizaigaku Kenkyu [ Hitotsubashi University Research Series;Economics ] 2, pp.87-178. Sumuelson, P. (1950a), “Probability and the Attempts to Measure Utility,” Keizai Kenkyu [ Economic Review ] 1, pp.167-173. Sumuelson, P. (1950b), “The Problem of Integrability in Utility Theory,” Economica 17, pp.355-385.

• A work already made public (such as graphs and illustrations) may be quoted appropriately, provided that their making is compatible with fair practice and their extent does not exceed that justified by purposes such as news reporting, criticism or research (Section 32 (1) of the Copyright Act of Japan). Approval of quotations is discussed by specialists. However, if the following three points apply, then the quotation will be approved: (1) the necessity of that quotation is obvious from your own words in your contribution, (2) the quotation is clearly distinguished from your own words and its source is clearly identified and (3) your own words exceed the quotation in quantity. If one of these points is not met, you have to obtain permission for the copyright of the work you use in your contribution.

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International Journal of Research in Commerce and Management Studies (IJRCMS)

ISSN 2582-2292, An open access bi-monthly e-journal

International Journal of Research in Commerce and Management Studies (IJRCMS) ISSN 2582-2292

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Impact Factor: 5.07

Welcome to the International Journal of Research in Commerce and Management Studies (IJRCMS), your premier destination for cutting-edge research in the fields of management, economics, and commerce. With an ISSN 2582-2292, IJRCMS is a leading scholarly journal committed to advancing knowledge and fostering innovation in these critical disciplines.

Our journal publishes original research articles, reviews, and case studies that explore the latest trends and developments in management, economics, and commerce. Whether you’re a researcher, academician, or industry professional, IJRCMS provides a platform to share your insights and contribute to the global discourse in these fields.

At IJRCMS, we take pride in our rigorous peer-review process, which ensures the quality and integrity of the research we publish. Our editorial board comprises experts from diverse backgrounds in management, economics, and commerce, who provide valuable feedback to authors and help maintain the high standards of our publication.

As an indexed journal, IJRCMS is searchable in major databases, making your research easily discoverable to a wide audience of scholars, students, and professionals. By publishing with IJRCMS, you can enhance the visibility and impact of your work, while also contributing to the advancement of knowledge in your field.

We invite you to explore our website to learn more about IJRCMS, including our submission guidelines, editorial board, and past issues. Whether you’re interested in management, economics, or commerce, IJRCMS offers a platform for sharing and advancing research in these vital disciplines.

Thank you for visiting IJRCMS. We look forward to receiving your contributions and collaborating with you to drive innovation and excellence in management, economics, and commerce.

Anybody can submit the  soft copy  of an unpublished novel; original; empirical and high-quality  research work / manuscript   anytime  in  M.S. Word format  after preparing the same as per our  GUIDELINES FOR SUBMISSION ; at our email address i.e.  [email protected]  or online by clicking the link  online submission  as given on our website ( FOR ONLINE SUBMISSION, CLICK HERE ). 

Indian Journal of Commerce and Management Studies

About the journal.

For the past ten years, We, Educational Research Multimedia and Publications, India exhibited true commitment and excellence in inculcating high-quality research. We are a proud publisher of research contributions from global authors in the areas of Arts, Commerce, Management, Education and Social Sciences. Being headed by a team of Eminent Scientists, Professors, Professionals, Researchers, Key Opinion Leaders, Industrialists, our board of management holds 25+ years of collective experience in publishing research and educational materials. Our publications are open-access, double-blind peer-reviewed, plagiarism-free, updated and application-oriented that suit the current trends.

Indian Journal of Commerce & Management Studies  is owned and managed by  Educational Research Multimedia and Publications, India.  IJCMS is an open access peer review Tri-Annual research journal that publishes articles in the field of commerce & management. The journal serves as a bridge between worldwide scholars and commerce and management studies researchers. The journal publishes research articles and papers in all areas of commerce and management. The journal aims to provide the most complete and reliable source of information on recent developments in business studies. Each issue brings you critical perspectives and cogent analyses, serving as an outlet for the best theoretical and research work in the field. The purpose of the journal is to further the understanding of the theory and practice of business studies by publishing articles of interest to practitioners and scholars.

                                                     Call for Papers  - Volume XV, Issue 2, May 2024

                                  Please submit to [email protected] or   Click here     as per   Submission Guidelines

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Effectiveness of green entrepreneurship practices in driving the growth of indian small and medium-sized enterprises, role of entrepreneurship in bringing social change: a comparative analysis between maharashtra and bihar, corporate governance practices in south asia: a comparative study of india and nepal.

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Business Management Research Paper Topics

This page provides a comprehensive guide on business management research paper topics , designed to assist students in selecting areas that align with their interests and academic goals. The content is organized into several sections, offering an extensive list of topics divided into ten major categories, practical tips on choosing and writing on these topics, and information about iResearchNet’s customized writing services. The material aims to not only inspire and educate students but also support them in their academic journey, making the process of writing a research paper in business management more accessible and engaging. Whether you are new to the field or looking to explore new areas, this resource serves as a valuable starting point.

100 Business Management Research Paper Topics

Business management is a multifaceted field that touches various aspects of organizational functionality, leadership strategies, innovation, ethics, human resources, and much more. Here, we present a comprehensive list of business management research paper topics, categorized into ten distinct sections. These categories span the width and breadth of the field, giving students a wide range of topics to choose from.

Academic Writing, Editing, Proofreading, And Problem Solving Services

Get 10% off with 24start discount code, leadership and management.

• The Role of Transformational Leadership in Organizational Success
• Ethical Leadership and Corporate Social Responsibility
• Cross-Cultural Management: Leading Global Teams
• Women in Leadership: Challenges and Opportunities
• The Impact of Autocratic Management on Employee Satisfaction
• Emotional Intelligence in Leadership
• Leadership Styles and Organizational Culture
• Innovations in Management Practices
• The Relationship between Leadership and Motivation
• Agile Leadership: Adapting to Rapid Changes in Business

Human Resources Management

• Employee Retention Strategies in Competitive Markets
• The Role of HR in Diversity and Inclusion
• Talent Acquisition and Talent Management Strategies
• The Impact of Remote Work on Human Resources Practices
• Performance Appraisal Systems and Their Effectiveness
• Employee Wellness Programs and Their Impact on Productivity
• HR Analytics: Using Data to Drive Decision-making
• Labor Relations and Conflict Resolution
• Organizational Learning and Development
• Ethics in Human Resources Management

Strategic Management

• Competitive Advantage through Strategic Planning
• SWOT Analysis and Its Role in Business Strategy
• Mergers and Acquisitions: Strategies and Challenges
• Corporate Governance and Business Performance
• Strategic Management in Family-owned Businesses
• Sustainable Business Strategies
• The Role of Innovation in Strategic Management
• Risk Management in Business Strategy
• Strategic Alliances and Business Growth
• Strategy Implementation and Organizational Change

Marketing Management

• Digital Marketing Trends and Their Impact on Business
• Consumer Behavior and Market Segmentation
• Social Media Marketing Strategies
• Brand Management and Brand Loyalty
• Pricing Strategies in Competitive Markets
• Content Marketing and SEO Best Practices
• Relationship Marketing and Customer Retention
• Viral Marketing: Methods and Outcomes
• Influencer Marketing in the Age of Social Media
• Ethical Considerations in Marketing

Financial Management

• Financial Planning and Budgeting in Businesses
• Investment Strategies for Corporate Growth
• Risk Management in Financial Decision Making
• The Role of Financial Technology (FinTech) in Business
• Financial Ethics and Regulations
• Mergers, Acquisitions, and Financial Analysis
• Cash Flow Management for Small Businesses
• Corporate Finance and Capital Structure
• International Financial Management
• Impact of Economic Fluctuations on Financial Management

Operations Management

• Supply Chain Management: Strategies and Challenges
• Quality Control and Total Quality Management
• Lean Manufacturing and Efficiency in Operations
• Operations Strategy in E-commerce
• Inventory Management Techniques
• Process Improvement and Operational Excellence
• The Role of Information Technology in Operations Management
• Sustainability in Operations
• Project Management Best Practices
• Outsourcing and Global Operations

Innovation and Entrepreneurship

• Start-up Culture and Innovation
• Social Entrepreneurship and Sustainable Development
• Innovation Management and Organizational Growth
• The Entrepreneurial Mindset and Business Success
• Venture Capital and Financing Start-ups
• Women Entrepreneurs: Challenges and Opportunities
• Franchising as a Business Model
• Innovation in Product Development
• Disruptive Technologies and Business Transformation
• Creativity and Problem Solving in Entrepreneurship

Business Ethics and Social Responsibility

• Corporate Social Responsibility (CSR) and Stakeholder Engagement
• Ethical Dilemmas in Business Decision Making
• Sustainability and Business Ethics
• Transparency and Accountability in Business
• Ethical Leadership and Organizational Culture
• Business Ethics in Global Operations
• Corporate Philanthropy and Community Engagement
• Environmental Ethics in Business Practices
• Compliance, Regulations, and Business Ethics
• Social Impact of Business: Measuring and Reporting

International Business Management

• Globalization and its Impact on Business Management
• Cross-Border Mergers and Acquisitions
• International Business Strategy and Cultural Considerations
• Managing Multinational Corporations
• International Trade Regulations and Compliance
• Emerging Markets and Business Expansion
• International Marketing Strategies
• Global Supply Chain Management
• Foreign Direct Investment Strategies
• Leadership and Management in International Business

Technology Management

• The Role of Artificial Intelligence in Business Management
• Cybersecurity and Business Risk Management
• Technology Adoption and Organizational Transformation
• E-Business and Digital Transformation
• Technology Management in Healthcare
• Blockchain Technology in Business Operations
• Innovation in Mobile Technologies for Business
• Technology in Human Resources Management
• Internet of Things (IoT) and Smart Businesses
• Virtual Reality (VR) and Augmented Reality (AR) in Marketing

In conclusion, this comprehensive list of business management research paper topics offers students an expansive range of subjects to explore. These topics cater to various interests and can be further customized to align with specific research goals and academic requirements. Whether focusing on leadership, innovation, ethics, or technology, the options provided enable students to dive into meaningful inquiries that contribute to our understanding of the complex and dynamic field of business management.

Business Management and the Range of Research Paper Topics

Business management is an intricate and multifaceted discipline that encompasses various aspects of the modern corporate environment. It involves planning, organizing, directing, and controlling organizational resources to achieve specific goals. This vast field offers a plethora of research paper topics that span across leadership, strategy, marketing, human resources, technology, and more. In this article, we’ll explore the core areas of business management and the wide range of research topics they offer to students and scholars.

Leadership and management form the backbone of any successful organization. They involve setting visions, defining missions, developing strategies, and guiding the organization to achieve its objectives. Research in this area can focus on transformational leadership, ethical leadership, cross-cultural management, and various leadership styles. Investigating leadership theories and their practical application can shed light on how leaders influence organizational success and employee satisfaction.

Human resources management (HRM) plays a critical role in recruiting, training, motivating, and retaining employees. Research topics within HRM may include diversity and inclusion, talent management, performance appraisal systems, and employee wellness programs. The evolving nature of remote work has also opened new avenues for research in HR practices and its impact on organizational culture.

Strategic management involves the formulation and implementation of major goals and initiatives to ensure organizational growth and sustainability. Topics like competitive advantage, mergers and acquisitions, corporate governance, and risk management fall under this umbrella. Researching sustainable business strategies or innovation in strategic management can lead to valuable insights into long-term planning and decision-making.

Marketing management focuses on planning, executing, and monitoring marketing strategies. Research topics can cover digital marketing trends, consumer behavior, brand loyalty, pricing strategies, and ethical considerations in marketing. Investigating the effects of social media on marketing or exploring new methods of viral marketing can provide fresh perspectives on reaching modern audiences.

Financial management is vital for the financial health and stability of an organization. Research in this area may involve financial planning, investment strategies, risk management, financial technology, and corporate finance. Analyzing the effects of economic fluctuations or studying the role of FinTech in business can contribute to a deeper understanding of financial decisions and their consequences.

Operations management is concerned with designing, overseeing, and controlling production processes. Topics like supply chain management, quality control, lean manufacturing, and sustainability in operations are key areas of interest. Research in process improvement, project management best practices, or the role of IT in operations management can provide insights into efficiency and productivity.

Innovation and entrepreneurship are about fostering creativity, starting new ventures, and driving organizational growth. Research in this field can cover start-up culture, social entrepreneurship, venture capital, women entrepreneurs, and innovation in product development. Understanding disruptive technologies or exploring creativity in entrepreneurship can enrich the body of knowledge in business innovation.

Business ethics and social responsibility examine how organizations engage with stakeholders and the broader community. Topics include corporate social responsibility, ethical decision-making, transparency, and compliance. Research in this area can highlight the importance of ethics in global operations or explore the social impact of business practices.

International business management studies how organizations operate on a global scale. Research topics in this area may include globalization, cross-border mergers, international business strategy, and emerging markets. Investigating international marketing strategies or leadership in international business can offer unique insights into global commerce and cross-cultural interactions.

Technology management is an evolving field that integrates technology into business strategies. Research can explore artificial intelligence, cybersecurity, digital transformation, blockchain technology, and more. Investigating the role of technology in various business functions can lead to new ways of leveraging technology for growth and innovation.

Business management is a dynamic and complex field that intersects with various domains and specialties. The breadth of topics available for research reflects the multifaceted nature of the business world. Whether investigating leadership philosophies, diving into marketing strategies, exploring financial decision-making, or examining the ethical considerations of business practices, the field of business management offers a rich and varied landscape for intellectual inquiry.

For students looking to embark on a research paper, this wide array of topics provides opportunities to align academic interests with real-world applications. The continuous evolution of business practices, influenced by technological advancements, societal norms, global trends, and economic forces, ensures that business management will continue to be a fertile ground for research and exploration for years to come.

How to Choose Business Management Research Paper Topics

Choosing a topic for a research paper in business management can be a daunting task given the multifaceted nature of the field. Selecting the right topic is crucial as it lays the foundation for the entire research process. A well-chosen topic not only engages the reader but also aligns with the researcher’s interest, the study’s scope, and academic requirements. Here, we’ll explore some strategies and tips to help guide you through the process of choosing business management research paper topics that will resonate with your academic pursuits and curiosity.

• Identify Your Area of Interest : Start by identifying the particular aspect of business management that intrigues you the most. Whether it’s human resources, marketing, finance, leadership, or any other area, focusing on your interest helps ensure that the research process will be engaging and rewarding.
• Analyze the Relevance : Consider the relevance of the topic to current trends and issues in the business world. Researching a relevant and timely subject allows your work to contribute to contemporary discourse and can make it more appealing to readers.
• Consider Academic and Practical Applications:  Think about the academic significance and real-world applications of the chosen topic. It’s essential to align the topic with academic theories while also considering how it can apply to real-world business scenarios.
• Evaluate the Scope:  Evaluate the scope of the topic to ensure that it’s neither too broad nor too narrow. A well-defined scope helps in focusing the research, developing a coherent argument, and ensuring that the research is manageable within the given timeframe.
• Check for Available Resources: Before finalizing a topic, ensure that there are enough resources and research materials available. Having access to relevant literature, data, and experts will facilitate a more thorough and credible research process.
• Consult with a Mentor or Advisor:  Consulting with a mentor, advisor, or faculty member can provide valuable insights and guidance in selecting the most suitable topic. They can offer expert advice based on your interests, academic requirements, and the field’s current trends.
• Analyze Previous Research:  Reviewing existing research in the desired field can highlight gaps in knowledge, emerging trends, and potential areas for further investigation. Analyzing previous works helps in building on existing knowledge and contributing something new to the field.
• Consider Ethical Implications:  It’s important to consider the ethical implications of the chosen research topic, especially if it involves human subjects, sensitive data, or controversial issues. Ensuring that the research adheres to ethical standards adds credibility to your work.
• Align with Learning Objectives : Make sure that the chosen topic aligns with your course’s learning objectives and your personal academic goals. A topic that complements your academic trajectory can enhance your understanding of the field and contribute to your professional development.
• Test the Topic : Before fully committing to a topic, consider writing a brief overview or outline to test if the topic resonates with your interests and if it can be explored in depth. This preliminary exercise can help in refining the topic and ensuring that it’s suitable for an extensive research paper.

Choosing the right business management research paper topic is a critical step that requires careful consideration and thoughtful planning. By following these tips, students can navigate the vast landscape of business management research and hone in on a topic that aligns with their interests, academic requirements, and the current trends in the field.

The chosen topic should not only reflect personal curiosity but also contribute to the broader understanding of business management. Engaging with mentors, analyzing existing research, considering practical applications, and evaluating the ethical and academic alignment of the topic will enable students to embark on a rewarding research journey that resonates with both academic scholars and business professionals.

How to Write a Business Management Research Paper

Writing a business management research paper involves meticulous planning, research, analysis, and composition. A well-crafted paper should reflect an in-depth understanding of business principles, theories, practices, and their application in the real world. In this section, we’ll guide you through the process of writing a compelling and insightful business management research paper, from the initial stages of planning to the final draft.

• Understand the Assignment Requirements : Before you begin, carefully read and understand the assignment guidelines and requirements. Pay attention to the expected length, format, style, and deadlines. Knowing what’s expected ensures that you meet the specific criteria and avoid unnecessary revisions.
• Start with a Strong Thesis Statement : Your thesis statement is the central argument or claim that you’ll be supporting throughout the paper. It should be clear, concise, and specific, guiding the reader on what to expect from your research.
• Conduct Thorough Research : Invest time in conducting thorough research. Utilize academic databases, scholarly articles, textbooks, and reputable online sources. Ensure that your sources are credible, recent, and relevant to your topic.
• Create a Detailed Outline : A well-structured outline helps in organizing your thoughts, arguments, and supporting evidence. Outline each section of your paper, including the introduction, methodology, analysis, conclusion, and bibliography.
• Write the Introduction : The introduction sets the stage for your research, providing background information, context, and the rationale for your study. Clearly state the problem you are addressing, your research questions, and your thesis statement.
• Develop the Methodology : In the methodology section, describe the research methods you used, such as surveys, interviews, or case studies. Explain why you chose these methods and how they helped you gather and analyze data.
• Analyze and Discuss Your Findings : Present and analyze your findings in a logical and coherent manner. Use charts, graphs, or tables to illustrate key points. Discuss how your findings support or challenge existing theories, and provide insights into the implications for business management.
• Craft a Thoughtful Conclusion : The conclusion should summarize the key findings, restate the thesis, and discuss the broader implications of your research. Highlight any limitations and suggest areas for future research.
• Cite Your Sources Properly : Proper citation is essential for academic integrity. Use the required citation style (APA, MLA, Chicago/Turabian, Harvard) consistently throughout the paper. Create a comprehensive bibliography to list all the sources you’ve referenced.
• Revise and Edit : Spend ample time revising and editing your paper. Check for clarity, coherence, grammatical errors, and stylistic issues. Consider seeking feedback from peers, tutors, or professional editors to ensure that your paper meets high standards.
• Consider the Practical Implications : Discuss the practical implications of your findings, linking theoretical concepts with real-world business applications. Demonstrating how your research can be applied in a business context adds value to your paper.
• Adhere to Ethical Standards : Ensure that your research complies with ethical standards, particularly if you’ve used human subjects or sensitive data. Obtain necessary permissions and be transparent about your research procedures.
• Add an Executive Summary (if required) : An executive summary provides a concise overview of the entire paper and is particularly useful for papers intended for a business audience. It should highlight the main points, findings, and implications in a brief and accessible manner.

Writing a business management research paper requires careful planning, critical thinking, and meticulous execution. By following these tips, you can craft a paper that is coherent, insightful, and engaging.

Remember that a successful business management research paper not only adheres to academic standards but also resonates with professionals in the field. Invest time in understanding the topic, conducting robust research, articulating your arguments, and reflecting on the broader implications of your findings. With dedication, attention to detail, and a thoughtful approach, you’ll be well on your way to producing a research paper that stands out in both academic and business communities.

iResearchNet Writing Services

iResearchNet is proud to offer students and professionals a comprehensive suite of writing services tailored to business management research papers. Whether you’re seeking guidance on a specific topic, need assistance with the entire research process, or want a fully custom-written paper, our team of expert degree-holding writers is here to assist you. This section outlines the 13 standout features that make our services the best choice for your next business management research paper.

• Expert Degree-Holding Writers : At iResearchNet, we boast a team of seasoned writers holding advanced degrees in business management and related fields. Their expertise ensures that your paper is not only well-written but also grounded in current theories, methodologies, and industry practices.
• Custom Written Works : Our writing services are tailored to meet your specific needs. From selecting a topic to finalizing the bibliography, every aspect of the paper is customized to your preferences, guidelines, and academic requirements.
• In-Depth Research : Thorough research is the backbone of a compelling research paper. Our writers have access to premium academic databases, scholarly journals, and industry reports, enabling them to provide well-researched, evidence-based arguments that support your thesis.
• Custom Formatting : We understand the importance of formatting in academic writing. Our writers are proficient in various citation styles, including APA, MLA, Chicago/Turabian, and Harvard. Rest assured that your paper will be formatted accurately and consistently according to your instructions.
• Top Quality : Quality is paramount at iResearchNet. Our quality assurance team carefully reviews each paper for clarity, coherence, originality, and adherence to guidelines. This rigorous process ensures that you receive a top-notch paper that exceeds your expectations.
• Customized Solutions : Whether you need assistance with a particular section of your paper, require revisions, or want a completely custom-written research paper, we offer flexible solutions that align with your goals and budget.
• Flexible Pricing : We believe that quality writing services should be accessible to everyone. Our pricing structure is flexible, transparent, and competitive, allowing you to choose the best option that fits your budget without compromising quality.
• Short Deadlines : Time constraints shouldn’t hinder your academic success. Our writers are skilled in handling tight deadlines, with the ability to deliver top-quality papers in as little as 3 hours for urgent requests.
• Timely Delivery : We take deadlines seriously. Our commitment to timely delivery ensures that you receive your paper well before the submission deadline, giving you ample time for review and revisions if needed.
• 24/7 Support : Our customer support team is available 24/7 to answer your questions, address concerns, and assist you at every stage of the writing process. Reach out to us via chat, email, or phone, and experience our commitment to exceptional service.
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iResearchNet’s writing services for custom business management research papers combine expertise, quality, flexibility, and value to provide a seamless and rewarding experience. With a team of highly qualified writers, cutting-edge research resources, personalized support, and unwavering commitment to excellence, we are the preferred choice for students and professionals seeking top-tier writing assistance.

Whether it’s a complex case study, a strategic analysis, or a comprehensive research paper, trust iResearchNet to deliver exceptional results that align with your academic or professional objectives. Reach out to us today and discover how we can make your next business management research paper not just an assignment but a significant contribution to your educational or career growth.

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International Journal of Commerce and Management: Volume 25 Issue 4

Table of contents, impact of personality on risk tolerance and investment decisions: a study on potential investors of kazakhstan.

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Personal values and entrepreneurial orientations in Malay entrepreneurs in Malaysia: Mediating role of self-efficacy

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Financial performance analysis of mergers and acquisitions: evidence from India

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Conceptualisation of the Balanced Scorecard (BSC) model: A critical review on its validity in Africa

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Trends and practices of consumers buying online and offline: An analysis of factors influencing consumer’s buying

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Using time to gain competitive advantage: a framework and analysis of propositions

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A framework for reverse logistics: the case of post-consumer carpet in the US

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Meaningful obstacles remain to standardization of international services advertising: New insights from a managerial survey

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IJECM, United Kingdom

International Journal of Economics, Commerce and Management (IJECM; ISSN 2348-0386) is a double blind peer reviewed journal from Rochester, United Kingdom, with a strong Editorial Board and a tested rapid peer review system.

IJECM intends to contribute to the development and propagation of knowledge on management, commerce & economics; thus feeding scholars, researchers and practitioners with valuable new insights from theory and practice.

In the same line IJECM invites authors to submit:

• empirical papers analyzing specific questions using qualitative or quantitative techniques
• conceptual papers developing propositions and outlining further research
• review articles/ perspectives summarizing and evaluating the stock of theoretical and applied knowledge
• epitomes and didactic articles on a specific issue of practical importance.

In all above cases, IJECM encourages quality papers by researchers. IJECM’s this quest for quality is reflected in the structure of journal’s editorial board as well as the strong network of reviewers, which allows the peer review process to be rigorous and constructive, helping to advance research work.

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Jcm - journal of commerce & management.

The IIS University Journal of Commerce & Management is a peer-reviewed academic journal (Print) dealing with issues pertaining to  various disciplines in trade, commerce, business and management, including:

General Management Human Resource Management Marketing Finance International Business Information Technology Emerging Paradigms in Commerce & Management

The IISU-JCM Editors would like to extend an invitation to academicians, scholars and research scholars to contribute Research Paper/Articles, Review Articles, General Articles, Comments/Research Notes, Case Studies and Book Reviews for the upcoming issue of The IIS University Journal of Commerce & Management, ISSN 2320-4907 .  Authors are requested to submit their manuscripts to the Editors at  [email protected] . Kindly note, that there are NO PUBLICATION CHARGES for publishing a paper/article in the journal. Once published, a complimentary copy of the journal is provided to the contributor. .

We would like to request you to bring this announcement to the notice of your colleagues and fellow researchers so that they may be aware of The IIS University Journal of Commerce & Management as a potential source for publication.

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The IIS University Journal of Commerce & Management , published by the The IIS University, provides a forum for an in-depth analysis of problems related to various disciplines in trade, commerce, business and management practices and also encourages scholarly dialogue on a broad range of topics within these disciplines: General Management, Human Resource Management, Marketing, Finance, International Business, Information Technology, and Emerging Paradigms in Commerce & Management. The journal encourages articles focusing on theoretical, applied and inter-disciplinary research that are accessible to a wider group of scholars. It also publishes Research Articles, Review Articles, General Articles, Case Studies and Book Reviews.

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International Journal of Research In Commerce and Management Studies is an open-access peer-reviewed bi-monthly research journal that publishes articles in commerce & management. The journal serves as a bridge between worldwide scholars and commerce and management studies researchers. The journal publishes research articles and papers in all areas of commerce and management. The journal aims to provide the most complete and reliable source of information on recent developments in business studies. Each issue brings you critical perspectives and cogent analyses, serving as an outlet for the best theoretical and research work in the field. The journal aims to further the understanding of the theory and practice of business studies by publishing articles of interest to practitioners and scholars. The Journal is published in English. The e-journal provides free and open access to all of its content on our website.

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Accepting articles for issue 2 march-april 2024.

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Journal of Commerce & Management

Journal of Commerce and Management (JCM) is a peer reviewed annual Journal issued by The IIS University, Jaipur. JCM is committed to maintain high academic standards by publishing scholarly articles, research papers and case studies in the field of commerce and management. JCM promotes new ideas or new perspectives on existing research.

Manuscripts that are suitable for publication in JCM cover various domains of commerce and management. The below mentioned domains are only indicative:

• Business and Commerce
• General Management
• Human Resource Management
• Information Technology
• Operations Management
• Emerging Paradigms in Commerce and Management

Each issue of JCM is divided into following categories:

• Research : It includes research papers focusing on contemporary issues in commerce and management. The research work done should exhibit its usability and practical application.
• Insight: Presents articles in the field of commerce and management practices, theories, and concepts.
• Case Study: It is an intensive analysis of a real-life situation faced and decisions taken by an individual or by an organization at different levels in the hierarchy.

Submission Guidelines for Research Papers

Papers of original work are invited both from academicians and Industry experts on commerce and management issues. Papers may be based on theoretical as well as empirical research and should exhibit practical application and usability of the work done.

Manuscript:  The author/s should send a soft copy of the manuscript in MS Word to The IIS University at [email protected] . Manuscript submitted is expected to contain original work, which has not been published elsewhere in any form - edited or otherwise. Each submitted paper should be in English and should be between 5000 - 8000 words, double spacing with 12 points Times New Roman font, justified, down load-able. The research paper should be accompanied with title page, Abstract of 100 - 150 words, list of key words included in the paper, write up of approximately 50 words about the author(s) and a declaration of the originality of the work done. The author's name (full name), designation and organization affiliation with content details should appear only on the first page and should not be repeated any where else in the paper. Tables, diagrams should also be duly provided with proper numbering and source mentioned below the table and diagram. The manuscript should have references, footnotes and endnotes. References should be complete in all respects and arranged in alphabetical order. In the text, the references should appear as follows: Kaplan (2000) has shown… or recent studies (Sen, 2004; Shrimal, 2005) specify...Journal references should be listed as follows: Last Name , First Name (Year). “Title of the paper,” name of the Journal, issue No., page no. Books should be referred to as follows: Last Name , First Name (Year). Book Title, Place: Publisher

Submission Guidelines for Articles: Conceptual articles focusing on the contemporary issues and challenges in the field of commerce and management will be preferred. Length of the article should range between 1500 to 3000 words. The article should be accompanied with title page, Abstract of 100 - 150 words, list of key words included in the paper and a declaration of the originality of the work done. The authors name (full name), designation and organization affiliation with content details should appear only on the first page and should not be repeated any where else in the article. Tables, diagrams should also be duly provided with proper numbering and source mentioned below the table and diagram. The manuscript should have references, footnotes and endnotes. References should be complete in all respects and arranged in alphabetical order. In the text, the references should appear as follows: Kaplan (2000) has shown… or recent studies (Sen, 2004; Shrimal,2005) specify... Journal references should be listed as follows: Last Name , First Name (Year). “Title of the paper,” name of the Journal, issue No., page no. Books should be referred to as follows: Last Name , First Name (Year). Book Title, Place: Publisher Submission Guidelines for writing case study: Management cases may be based on the information directly collected from an organization or publicly available data and information (such as from internet and/or business magazines). Cases will be evaluated based on the following features: Problem/issue identification Data reliability and adequacy. Focus and relevance of the issues identified. Citation of secondary resources. Overall framework of the presentation.

Cases submitted should be accompanied by teaching notes.  

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Manthan: journal of commerce and management.

Double-blind Peer-reviewed (Refereed) Journal Indexed in UGC-CARE List - no publication charges (Review process may take minimum 20-24 weeks)

Published by: journal press india.

Print ISSN: 2347-4440; e-ISSN: 2395-2601

Editor/s: prof. (dr.) raj k. kovid, frequency: bi-annual, indexation: indexed in ugc care list, index copernicus international, google scholar, ebsco, summon (proquest), indian citation index, cross-ref, cnki scholar, research gate, j-gate and scilit..

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Important Information for Authors It has been brought to our notice that some third parties are fraudulently charging Fees from authors for submission of manuscripts to JPI journals through their website. JPI categorically reiterates that authors don't have to pay any fee for submission/publication of manuscripts to JPI journals and the submission is valid only if made through JPI website following the given submission guidelines . Authors are requested not to use any other portal for submission and neither pay any amount whatsoever to anyone for submission. JPI will not be liable for the same.

To promote research and analytical thinking on various facets and dimensions of commerce and management for refinement and advancement of understanding of business environment and practices.

Aims and Scope

Manthan is a bi-annual double blind peer-reviewed   journal devoted to publication of research articles in all areas of commerce and management. It seeks to disseminate information and perspectives of scholars and practitioners regarding business systems, management practices and organizational performance.  The journal  publishes original, innovative research that focuses on emerging areas in commerce and management, and their implications for business. It provides a forum for exchange of ideas and techniques among scholars, professionals and practitioners of commercial and managerial practices.  The journal is intended to benefit academicians, corporate executives, professionals and researchers.

Current Issue: Volume 10, Issue 2 (July - December 2023)

Table of Contents

Research Papers

Effectuation and causation decision-making logics: scale development and validation.

Doi: 10.17492/jpi.manthan.v10i2.1022301

Pages: 1-27

Published Online: December 15, 2023

Intention to Purchase Organic Food among Indian Consumers: Role of Self-direction and Consumer Involvement

Doi: 10.17492/jpi.manthan.v10i2.1022302

Pages: 28-47

Identifying and Ranking Critical Factors for using Social Media as Health Information Source: An Analytic Hierarchy Process Approach

Doi: 10.17492/jpi.manthan.v10i2.1022303

Pages: 48-67

Assessing Purchase Intention of Consumers towards Fashion Products: Mediation and Moderation Analysis

Doi: 10.17492/jpi.manthan.v10i2.1022304

Pages: 68-90

Evaluating the Relative Role of Influencer Marketing and Celebrity Endorsements in Promotion of Electric Vehicles

Doi: 10.17492/jpi.manthan.v10i2.1022305

Pages: 91-106

Analyzing the Impact of Psychological Capital on Organisational Citizenship Behaviour

Doi: 10.17492/jpi.manthan.v10i2.1022306

Pages: 107-124

Influence of Work-Life Balance on Employee Engagement in Higher Education Institutions: Mediating Role of Quality of Life

Doi: 10.17492/jpi.manthan.v10i2.1022307

Pages: 125-144

Gendered Perception towards Financial Literacy and Fintech Security Risk: A Multi Method Analysis

Doi: 10.17492/jpi.manthan.v10i2.1022308

Pages: 145-163

Review papers

Thematic progression and emerging trends in online purchase intention research: a bibliometric analysis.

Doi: 10.17492/jpi.manthan.v10i2.1022309

Pages: 164-189

Mapping the Landscape of Research on Green Human Resource Management and Employee-level Outcomes: A Bibliometric Study using Biblioshiny

Doi: 10.17492/jpi.manthan.v10i2.1022310

Pages: 190-215

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Generative AI and Worker Voice

Apr 5, 2024

Much has been written about the potential impact of generative AI in the workplace, but the perspective of one set of key stakeholders has often been left out: workers themselves.  What’s more, research has found that incorporating the perspective of end users such as workers into the development and implementation of new technologies tends to produce better results than strictly top-down technology development approaches.

So argues a new working paper coauthored by an interdisciplinary team of  MIT researchers. The new paper, “Bringing Worker Voice into Generative AI,” was recently published online as part of a new collection called An MIT Exploration of Generative AI . This collection consists of 25 papers on the societal impact of generative AI that were authored by members of the MIT faculty, with support from seed grants from MIT .  “Bringing Worker Voice Into Generative AI” was coauthored by Thomas A. Kochan, the George M. Bunker Professor Emeritus at the MIT Sloan School of Management and a member of the faculty of the MIT Institute for Work and Employment Research (IWER) ; Ben Armstrong, Executive Director and Research Scientist at the MIT Industrial Performance Center; Julie Shah, the H.N. Slater Professor of Aeronautics and Astronautics at MIT and Director of the Interactive Robotics Group at the MIT Computer Science and Artificial Intelligence Laboratory (CSAIL); Emilio J. Castilla, the NTU Professor of Work and Organization Studies at MIT Sloan and Co-Director of IWER; Ben Likis, 2024 MBA Candidate at MIT Sloan; and Martha E. Mangelsdorf, Director of Strategic Communications at IWER.

The researchers conducted more than 50 interviews with a cross-section of stakeholders that included AI developers, business leaders, labor leaders, academic experts, and policymakers. In their interviews with AI developers, the authors learned that some factors weigh against incorporating worker input into the design of AI tools—including the pressure technology vendors feel to bring products to market quickly, without taking the time to incorporate worker input. “A number of our interviewees, along with the published works by scholars, suggest that there is a bias toward labor-displacing/replacing humans in the minds of many inventors or technology vendors,” Kochan, Armstrong, Shah, Castilla, Likis, and Mangelsdorf write.

But the authors also found examples of other approaches. They note, for instance, that Microsoft Corp. recently formed a partnership with the AFL-CIO labor federation to share information about how AI is impacting the workplace and to incorporate worker voice and experiences into the development of AI technology. Kochan et al. see this as an approach that might be a model.

In general, “the broader the set of stakeholders involved in defining the problems and opportunities that generative AI technologies can address, the more likely it is that these tools will be used to augment how workers do their jobs rather than displace them,” Kochan, Armstrong, Shah, Castilla, Likis, and Mangelsdorf write.

The authors also argue that, more than many previous new technologies, generative AI is particularly conducive to “bottom-up” innovation processes by workers and teams who use the tools. “This ‘democratization’ feature of generative AI opens up possibilities for the workforce to exert greater influence in how the technology evolves than was possible during many prior technological changes,” Kochan et al. observe. Moreover, the authors’ interviews with business leaders revealed that some companies are indeed incorporating “bottom-up” input from employees as one part of generating promising use cases for generative AI.

The research team also interviewed U.S. labor leaders, and the authors observe that unions have both an increasing interest and capacity to engage proactively with other stakeholders about the impact of AI. Examples include the partnership with Microsoft and collective bargaining agreements reached in 2023 between the Alliance of Motion Picture and Television Producers and the Writers Guild of America (WGA) and the Screen Actors Guild-American Federation of Television and Radio Artists (SAG-AFTRA); these new collective bargaining agreements incorporate protections for members of those unions regarding the use of generative AI in their professions.

The authors conclude with set of recommendations designed to encourage the incorporation of the perspective of the workforce into four phases of AI design and development: 1) defining the problems and opportunities to be addressed; 2) designing the technical and work process features that need to be integrated; 3) educating and training the workforce in the skills needed; and 4) ensuring a fair transition and compensation for those whose jobs are affected.

“We see this report as a first step in encouraging ongoing research, teaching, and outreach by MIT faculty and students to help bring the voices of the workforce into generative AI,” Kochan, Armstrong, Shah, Castilla, Likis, and Mangelsdorf conclude. “We hope this report serves as a catalyst for taking up this critical challenge and opportunity.”

  Read “Bringing Worker Voice into Generative AI.”

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Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging

• Position Paper
• Open access
• Published: 01 July 2023
• Volume 34 , pages 1501–1529, ( 2023 )

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• Enisa Shevroja   ORCID: orcid.org/0000-0001-6338-2948 1 ,
• Jean-Yves Reginster   ORCID: orcid.org/0000-0001-6290-752X 2 , 3 ,
• Olivier Lamy   ORCID: orcid.org/0000-0003-3684-2376 1 ,
• Nasser Al-Daghri   ORCID: orcid.org/0000-0001-5472-1725 4 ,
• Manju Chandran 5 ,
• Anne-Laurence Demoux-Baiada   ORCID: orcid.org/0000-0003-2616-839X 6 ,
• Lynn Kohlmeier 7 ,
• Marie-Paule Lecart 8 ,
• Daniel Messina   ORCID: orcid.org/0000-0002-7987-854X 9 ,
• Bruno Muzzi Camargos   ORCID: orcid.org/0000-0002-3132-6455 10 ,
• Juraj Payer   ORCID: orcid.org/0000-0002-4977-6817 11 , 12 ,
• Sansin Tuzun   ORCID: orcid.org/0000-0002-3300-2286 13 ,
• Nicola Veronese   ORCID: orcid.org/0000-0002-9328-289X 14 ,
• Cyrus Cooper   ORCID: orcid.org/0000-0003-3510-0709 15 , 16 , 17 ,
• Eugene V. McCloskey   ORCID: orcid.org/0000-0003-0177-8140 18 , 19 &
• Nicholas C. Harvey   ORCID: orcid.org/0000-0002-8194-2512 15 , 16  

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Trabecular bone score (TBS) is a grey-level textural measurement acquired from dual-energy X-ray absorptiometry lumbar spine images and is a validated index of bone microarchitecture. In 2015, a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) published a review of the TBS literature, concluding that TBS predicts hip and major osteoporotic fracture, at least partly independent of bone mineral density (BMD) and clinical risk factors. It was also concluded that TBS is potentially amenable to change as a result of pharmacological therapy. Further evidence on the utility of TBS has since accumulated in both primary and secondary osteoporosis, and the introduction of FRAX and BMD T-score adjustment for TBS has accelerated adoption. This position paper therefore presents a review of the updated scientific literature and provides expert consensus statements and corresponding operational guidelines for the use of TBS.

An Expert Working Group was convened by the ESCEO and a systematic review of the evidence undertaken, with defined search strategies for four key topics with respect to the potential use of TBS: (1) fracture prediction in men and women; (2) initiating and monitoring treatment in postmenopausal osteoporosis; (3) fracture prediction in secondary osteoporosis; and (4) treatment monitoring in secondary osteoporosis. Statements to guide the clinical use of TBS were derived from the review and graded by consensus using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

A total of 96 articles were reviewed and included data on the use of TBS for fracture prediction in men and women, from over 20 countries. The updated evidence shows that TBS enhances fracture risk prediction in both primary and secondary osteoporosis, and can, when taken with BMD and clinical risk factors, inform treatment initiation and the choice of antiosteoporosis treatment. Evidence also indicates that TBS provides useful adjunctive information in monitoring treatment with long-term denosumab and anabolic agents. All expert consensus statements were voted as strongly recommended.

The addition of TBS assessment to FRAX and/or BMD enhances fracture risk prediction in primary and secondary osteoporosis, adding useful information for treatment decision-making and monitoring. The expert consensus statements provided in this paper can be used to guide the integration of TBS in clinical practice for the assessment and management of osteoporosis. An example of an operational approach is provided in the appendix.

This position paper presents an up-to-date review of the evidence base, synthesised through expert consensus statements, which informs the implementation of Trabecular Bone Score in clinical practice.

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Update on the utility of trabecular bone score (TBS) in clinical practice for the management of osteoporosis: a systematic review by the Egyptian Academy of Bone and Muscle Health

Yasser El Miedany, Walaa Elwakil, … Safaa Mahran

The Trabecular Bone Score (TBS) Complements DXA and the FRAX as a Fracture Risk Assessment Tool in Routine Clinical Practice

Didier Hans, Emőke Šteňová & Olivier Lamy

The Utility and Applicability of Risk Assessment Tools and Trabecular Bone Score

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Introduction

Osteoporosis is conceptually defined as a systemic skeletal disease characterized by low bone mass and deterioration of bone microarchitecture, leading to bone fragility and a consequent increase in fracture risk [ 1 , 2 ]. This definition encompasses the two pillars of bone resilience to fracture: bone mass (the amount of bone present) and bone microarchitecture (the material and organizational properties of bone). The densitometric assessment of osteoporosis is based on a bone mineral density (BMD) T-score of − 2.5 or less, which captures the bone mass element of fracture risk and is effective in identifying some, but not all individuals who go on to experience a fragility fracture [ 3 , 5 , 6 ]. An important clinical challenge is that most fragility fractures occur in individuals who have a BMD T-score in the osteopenic or normal range and therefore fall below the originally defined densitometric interventional threshold [ 3 , 4 , 5 , 6 ]. Ideally, the skeletal assessment of bone fragility should also capture bone microarchitecture as the second pillar of fracture resilience in order to improve the identification of individuals at high risk of fracture.

Trabecular bone score (TBS) is a grey-level textural measurement usually acquired from conventional lumbar spine dual-energy X-ray absorptiometry (DXA) BMD images, which provides a validated index of bone microarchitecture and correlates with mechanical properties of bone [ 7 , 8 , 9 , 10 , 11 , 12 ]. The score may be used as a continuous variable, by adjusting FRAX probability or BMD T-score, and has been interpreted clinically with cut-off values at thirds of the distribution [ 13 , 14 ]. In 2015, a review of the evidence for TBS in the assessment of osteoporosis was conducted by an Expert Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) [ 15 ]. The review concluded that TBS predicts hip and major osteoporotic fracture risk, at least partly independent of BMD and clinical risk factors and that TBS is potentially amenable to change as a result of pharmacological therapy [ 15 ]. Since then, the evidence base has rapidly expanded, with advances in the understanding of the role of TBS for fracture risk assessment in secondary as well as primary osteoporosis, for example in type 2 diabetes [ 16 , 17 , 18 ]. Evidence has also accumulated on the added value of TBS for decisions on treatment initiation and in understanding the effects of different antiosteoporosis therapies on bone microarchitecture in conjunction with known mechanisms of action [ 19 , 20 , 21 , 22 , 23 , 24 ]. It is estimated that over 2 million TBS assessments are performed annually (data extrapolated from Kanis et al., 2021) [ 25 ], with the clinical interpretation of results supported by FRAX® [ 13 , 26 ] and BMD T-score adjustments for TBS [ 14 ]. Given this rapid expansion of the scientific literature and the increasing clinical adoption of TBS, the ESCEO and International Osteoporosis Foundation (IOF) convened a Working Group to review the updated evidence base and provide guidance on the integration of TBS into clinical practice. The Appendix presents practical suggestions relating to clinical implementation and technical issues, derived from the Expert Working Group statements, technical information and clinical experience.

The international Expert Working Group included independent clinical scientists, physicians and researchers with expertise in the assessment, diagnosis and treatment of osteoporosis. Prior to the Working Group meeting, four topics were selected for review and systematic reviews of the evidence were undertaken: (1) use of TBS in fracture risk prediction; (2) use of TBS for treatment initiation and assessing response to pharmacological interventions in postmenopausal osteoporosis; (3) use of TBS for the assessment of fracture risk in secondary osteoporosis; and (4) use of TBS for assessing response to pharmacological therapies in secondary osteoporosis.

Systematic review search strategy

A comprehensive literature search was conducted using a similar approach to PRISMA guidelines, for articles published in MedLine via PubMed [ 27 ]. Fracture syntax (topics 1 and 3, Fig.  1 a) comprised ‘trabecular bone score’ OR ‘TBS’ [search term(Title/Abstract)], AND ‘fracture(s)’ [search term(Title/Abstract)]. Treatment syntax (topics 2 and 4, Fig.  1 b) comprised ‘trabecular bone score’ OR ‘TBS’ [search term(Title/Abstract)], AND ‘treatment(s)’ AND ‘effect’ [search term(Title/Abstract)], OR ‘therapy(ies)’ [search term(Title/Abstract)], OR ‘trial’ [search term(Title/Abstract)] AND ‘effect’ [search term(Title/Abstract)]. Articles were considered for review if they met the following general screening criteria: (i) an original, full-text study with TBS as a primary outcome, (ii) published or in-press (or known ‘accepted’ status and shared by a co-author) between March 2015 and 9 th February 2023, and (iii) available in the English language. Further eligibility criteria were specific to each of the four topics. A total of 96 papers were reviewed by 2 independent reviewers.

A PRISMA flow diagram of the literature search process for studies investigating trabecular bone score (TBS) and fracture prediction in primary and secondary osteoporosis. b PRISMA flow diagram of the literature search process for studies investigating trabecular bone score and treatment monitoring in postmenopausal and secondary osteoporosis

Expert consensus statements and operational guidelines

Expert consensus statements were developed in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach [ 28 ]. The GRADE approach is a widely used method for evaluating the quality of evidence and developing clinical recommendations. It provides a systematic and transparent process for assessing the certainty of the evidence, balancing the benefits and harms of interventions, and formulating recommendations. The GRADE approach involved several key steps:

Identifying the clinical questions: The first step involved defining the clinical questions regarding TBS, that the recommendations were to address. This included specifying the population and outcomes of interest.

Assessing the quality of evidence: the quality of evidence for each outcome was assessed using a systematic approach, with a defined study eligibility criteria, and considering methodological factors.

Rating the certainty of evidence: the certainty of evidence was characterized according to four levels: good, moderate, low, or very low. This rating reflects the confidence that the evidence accurately represented the true effect of TBS on a given outcome.

Formulating recommendations: a consensus process was followed to develop recommendations. The International Working Group, consisting of experts in the field, considered the quality and certainty of the evidence, the balance between benefits and harms, clinical experience, practical and resource implications, and other relevant factors.

Grading the strength of recommendations: a level of strength was assigned to each recommendation, indicating the extent to which the Working Group believes the benefits of the intervention outweigh the potential harms. Recommendations could be classified as either strong or weak.

The primary purpose of the GRADE approach is to help clinicians, researchers, and guideline developers make informed decisions based on the available evidence while considering various factors that may influence clinical practice. The process included a face-to-face meeting of the Working Group on 9 th February 2023 with presentations on each topic. Following the GRADE approach and based on the discussions and review outcomes, 22 corresponding statements were developed to inform guidance on the use of TBS in clinical practice. Thereafter, operational guidance to support the integration of TBS in clinical practice was developed.

Topic 1: Use of TBS in fracture risk prediction in postmenopausal and male osteoporosis

Eighteen studies met the eligibility criteria (prospective study design, conducted in men and/or women aged 40 years or over; Fig.  1 a). Of these, one study was conducted in Australia [ 29 ], five in Canada [ 14 , 30 , 31 , 32 , 33 ], two in China [ 34 , 35 ], two in Japan [ 36 , 37 ], one in Korea [ 38 ], one in Slovakia [ 39 ], three in Switzerland [ 40 , 41 , 42 ], one in Thailand [ 43 ], and two in the USA [ 44 , 45 ]. Cohort sizes from different ethnicities ranged from 115 to 45,185, and follow-up from 2.7 to 10 years. Ten studies were conducted in postmenopausal women, five in men, and three in both men and women, with mean age ranging from 58 to 76 years. The incident fracture rates for major osteoporotic fractures (MOF, including hip) ranged from 1.2 to 14%, and for vertebral fractures, 3.5 to 35% (Table 1 ). TBS was an independent predictor of incident fracture in 16 of 18 studies (Table 1 ). For each SD reduction in TBS, the increased risk of incident fracture ranged from 19% [ 14 ] to more than double [ 39 , 40 ]. The combination of TBS and BMD significantly enhanced the prediction of fracture risk compared to lumbar spine BMD in men and women [ 27 , 40 , 41 , 42 , 44 ], although, in one study, this was only significant in men [ 34 ].

TBS-adjusted FRAX

In 2016, a meta-analysis of 14 prospective population cohort studies showed that TBS is a significant predictor of fracture risk independent of FRAX and that the adjustment of FRAX for TBS resulted in a small but significant increase in fracture risk prediction, independent of gender and ethnicity [ 13 ]. The impact of TBS adjustment on FRAX probabilities is dependent on age, femoral neck BMD and the FRAX probability value [ 46 ]. Since 2016, four further prospective studies in women [ 14 , 30 , 37 , 41 ] and three in men [ 35 , 36 , 44 ] have since demonstrated that TBS combined with FRAX enhances the prediction of MOF, hip and vertebral fracture, compared with FRAX alone. Used together, the global assessment of fracture risk considers bone mass, bone microarchitecture and clinical risk factors (CRF). One recent study examined whether antiresorptive treatment affects fracture risk prediction from TBS using a large clinical registry ( n  = 76,810) that includes all DXA tests for the Province of Manitoba, Canada. Results showed that TBS was a robust predictor of fracture in models adjusted for clinical risk factors and BMD and that the use of antiresorptive treatment (mostly bisphosphonates) either in the year before or following TBS measurement (mean total use, 5.6 years) did not attenuate fracture risk prediction [ 33 ].

Over a 10-year follow-up period in 1541 Japanese women (mean age 58 y) [ 37 ], every SD increase in TBS-adjusted FRAX score equated to a 46% increased risk of fracture (OR: 1.46, 95%CI 1.08, 1.98) compared to 35% with FRAX alone (OR: 1.35, 95%CI 1.09, 1.67). Similar results were found in the Fujiwara-Kyo Osteoporosis Risk in Men (FORMEN) study [ 36 ], and in Chinese men from the MrOs. Hong Kong cohort [ 35 ]. In the latter, when applying the Taiwan Intervention Strategy treatment threshold of 12.5% [ 47 ], TBS-adjusted FRAX improved the net risk classification by 5.2% compared to FRAX without TBS [ 35 ]. These findings are consistent with those in Caucasian men and women [ 44 , 48 , 49 ].

In 5863 men (mean age 73.7 y) from the MrOS cohort, over 8.6 years [ 44 ], TBS significantly predicted incident MOF and hip fracture, independent of FRAX with BMD, and prevalent radiographic vertebral fracture. For each SD reduction in TBS, there was a 27% (HR: 1.27, 95%CI 1.17, 1.39) and 20% (HR: 1.20, 95%CI 1.05, 1.39) greater risk of MOF and hip fracture, respectively. Using the 20% National Osteoporosis Foundation (NOF, now the Bone Health Osteoporosis Foundation, BHOF) treatment threshold, [ 50 ] the addition of TBS to FRAX also increased the Net Reclassification Index (NRI) by 3.3%, and with TBS, FRAX and prevalent radiographic vertebral fracture, the NRI increased further to 6.2%.

Similar results were found in 34,316 women from the Manitoba cohort (mean age 63.5 y), over 8.7 years [ 30 ]. The NRI with TBS-adjusted FRAX was computed using treatment thresholds from three clinical guidelines: Bone Health and Osteoporosis Foundation (BHOF) [ 50 ], Osteoporosis Canada [ 51 ] and the UK National Osteoporosis Guideline Group [ 52 ]. For all thresholds, the TBS adjustment had a positive effect in identifying fracture cases. In the overall group, TBS-adjusted FRAX yielded a small but significant increase in the NRI (NRI = 3.5% p  = 0.002) compared with FRAX alone. Most reclassification occurred in individuals with a non-osteoporotic T-score (NRI = 3%), and there was also an age interaction, with reclassification more frequent in women under 65 years of age (NRI = 5.6%, p  < 0.001). Consistent with findings elsewhere reporting up to 25% reclassification [ 14 , 48 , 49 , 53 ] and as expected, most reclassification (> 90%) occurred for women close to an intervention cut-off (range 9 to 17.9%), suggesting that the clinical utility of TBS (i.e. altering risk classification and hence intervention decisions) is particularly enhanced when targeted to this segment of the population.

TBS-adjusted BMD T-score

The adjustment of BMD T-score for TBS represents a clinically relevant advancement in the field, deriving from the analysis of the Manitoba cohort of 45,185 women (mean age 63.5 y) on GE DXA systems [ 14 ] and confirmed in the OsteoLaus cohort using a Hologic DXA system [ 54 ]. In the Manitoba cohort at follow-up (mean 7.4 y), 3925 of women (8.7%) had sustained at least one incident MOF, and 1040 (2.3%) had sustained at least one incident hip fracture [ 14 ]. Each SD decrease in TBS was significantly associated with a 26%, 25% and 22% greater risk of MOF in models incorporating BMD at the lumbar spine, femoral neck and total hip, respectively, and the results were not attenuated after adjustment for age and BMI. Using risk estimates from the Cox proportional hazards models, the authors applied a risk-equivalent offset adjustment to BMD T-scores to derive TBS-adjusted BMD T-scores for each site (spine, neck and total hip). There were significant improvements in fracture risk prediction using the TBS-adjusted BMD T-scores, compared to the unadjusted T-scores. Of relevance when FRAX is the primary approach, the study also confirmed the strong agreement in fracture probability scores between the TBS-adjusted FRAX tool, and when using TBS-adjusted femoral neck BMD T-score as the BMD input to FRAX ( r 2  = 0.98, slope = 1.02, intercept =  − 0.3).

The combination of TBS with BMD for fracture prediction has been examined in the Swiss Evaluation of Methods of Measurement of Osteoporotic Fracture Risk (SEMOF) cohort study of 556 older women (mean age 76.1 y). Here, TBS significantly predicted incident fracture, independent of BMD (HR = 2.01, 95%CI 1.54, 2.63) [ 40 ]. The combination of TBS with lumbar spine BMD or the lowest BMD, significantly enhanced fracture prediction, with significantly different areas under the receiver operator curve (AUC) compared to models without TBS. Compared to osteoporosis (58%) or degraded TBS (60%) alone, the combination of osteoporosis and degraded TBS improved the classification of women with an osteoporotic fracture to 77%, confirming findings elsewhere in postmenopausal women [ 55 ] and non-osteoporotic patients [ 56 ]. Degraded TBS was categorized using data from a meta-analysis [ 13 ], where L1 to L4 TBS risk thresholds were established using a gender-independent tertile approach, with cut-off values for TBS of 1.23 and 1.31. Those with TBS values above 1.31 were characterised as being at low risk of fracture, those between 1.31 and 1.23 at intermediate risk and, finally, those below 1.23 at high risk of fracture. In subsequent studies, and in clinical usage, these tertiles have been termed normal TBS, partially degraded TBS and degraded TBS respectively.

Overall, whilst FRAX is widely available, and indeed is incorporated into over 100 guidelines internationally, some national guidelines predicate treatment on the basis of T-score rather than absolute fracture probability [ 57 ]. Furthermore, FRAX models are not available for all countries or territories. In these settings, the use of TBS-adjusted BMD T-score provides a practical method in which TBS information can be incorporated into risk assessment approaches.

Statements (GRADE outcome: strongly recommended)

The expert Working Group made the overall recommendation that TBS should be used in conjunction with BMD and clinical risk factors. Individual statements, all of which were strongly supported by the members of the Working Group, are itemized below:

TBS is predictive of fragility fractures in postmenopausal women and men above the age of 50 years.

TBS is predictive of fragility fractures independent of BMD and of clinical risk factors (including those in FRAX).

TBS adds predictive value when used in association with FRAX and BMD to adjust the FRAX probability of fracture in postmenopausal women and in men above the age of 50 years.

BMD adjusted for TBS is an alternative solution when FRAX is not available.

The greatest utility of TBS is for those individuals who lie close to a FRAX or BMD T-score intervention threshold.

TBS continues to add value to FRAX in patients previously receiving antiresorptive treatments.

Topic 2: Use of TBS for the initiation of treatment and monitoring of treatment effect in postmenopausal osteoporosis

Twenty studies met the eligibility criteria (prospective or intervention trial of an antiosteoporosis treatment in postmenopausal women, ≥ 6 months treatment duration; Fig.  1 b), and six were international multi-centre trials. Of those remaining, two were conducted in Canada, two in Japan, two in India, four in South Korea, one in Spain, one in Taiwan and two in the USA. Cohort sizes ranged from 28 to 6985 and treatment duration, from 6 months to 10 years. Studies included antiresorptive treatments anabolic treatments, and/or sequential treatment and/or treatment combinations (Table 2 ).

Antiresorptive agents

Antiresorptive treatment studies included bisphosphonates, menopausal hormone therapy (MHT), selective estrogen receptor modulators (SERMs) and denosumab (Table 3 ), which act in different ways to inhibit osteoclast activity [ 72 ], maintaining trabecular structure and increasing bone mass. Bisphosphonate treatment duration ranged from 12 to 49 months. Seven studies reported a preservation of TBS with bisphosphonates, SERMs and MHT [ 19 , 22 , 23 , 57 , 60 , 62 , 63 ] and three reported small, significant gains ranging from 0.7 to 1.4% over 12 months [ 57 , 59 , 71 ]. Seven reported significant gains in BMD, ranging from 1.5 to 4.9% over 12 months [ 19 , 22 , 57 , 59 , 60 , 62 , 63 ].

One recent study examined changes based on least significant change (LSC) in 6,985 adults (mean age 65 y, 94% women) treated primarily with bisphosphonates (78.3%), followed by SERMs (12%) then MHT (6.2%), over a mean treatment period of 38 months [ 69 ]. Consistent with findings from studies reporting on group mean treatment effects [ 18 , 22 , 57 , 59 , 60 , 61 , 62 ], the proportion of individuals with an increase in lumbar spine BMD (22%) and hip BMD (17.6%) was greater than those who had an increase in TBS (9.3%). The treatment effect on TBS was primarily one of preservation which aligns with the mechanisms of action (TBS: 76.9% within LSC, Table 2 ) [ 69 , 72 ]; indeed an increase in TBS would not necessarily be expected with antiresorptive treatment. An increase in TBS greater than the LSC should occasion consideration of potential technical factors, such as change in body weight, tissue thickness or scan mode, all of which also impact changes in BMD though to a somewhat lesser extent [ 69 ]. It is noteworthy that in the same study, 24.9% and 16.1% of patients had a decrease in hip and spine BMD which exceed LSC, which might also necessitate an investigation of clinical issues such as compliance or technical issues such as scan mode, weight change and DXA instrument.

Denosumab treatment durations ranged from 20 months to 10 years (Table 3 ). All studies reported significant increases in TBS with denosumab treatment, ranging from 0.4 to 1.8% /12 months, and increases in BMD ranging from 1.9 to 6%/12 months. One study included a comparison of TBS software versions for monitoring treatment with denosumab over 36 months [ 70 ]. Denosumab led to progressive increases in BMD and TBS over 36 months, with both TBS (version 3, BMI-adjusted) and TBS (version 4.0, tissue thickness adjusted) changes being significant compared to baseline and compared to placebo, from months 12 to 36 ( p  < 0.001). The mean percent changes from baseline with TBS version 3.0 were 1.4%, 1.5% and 1.9%, at months 12, 24, and 36 respectively, while for TBS (version 4.0), the mean increases were slightly better at 2.3%, 2.6% and 3.3%, respectively [ 70 ]. In a further study, the efficacy of long-term denosumab therapy was investigated in 279 postmenopausal women who were randomized to either long-term denosumab treatment for 10 years or placebo for 36 months followed by denosumab for 7 years [ 24 ]. Consistent increases in TBS to 4.7% and in BMD to 22.4% were observed in women on long-term denosumab treatment. For women in the cross-over denosumab group, there were significant increases in TBS to 3.2% for seven years following treatment initiation, and in BMD, to 17.2%. At the individual level, denosumab treatment over 10 years resulted in a reduction in the proportion of women with degraded TBS (from 48.6 to 29.1%) and an increase in the proportion of women with normal TBS (26.1 to 53.2%). Similarly, there was a reduction in the proportion of women classified at high risk of fracture according to the combination of TBS and BMD T-score (from 94 to 40%) [ 24 ]. Furthermore, consistent with TBS as a predictor of fracture, women with the greatest improvements in TBS experienced fewer new fractures or worsening fractures across the trial duration [ 24 ].

Collectively, the evidence indicates that bisphosphonates, SERMs and MHT are unlikely to result in TBS change as they act primarily to preserve bone microarchitecture, as confirmed by histomorphometric analyses [ 72 , 73 ]. On the other hand, denosumab, a more potent antiresorptive agent [ 72 , 74 ] with a potential bone-forming effect [ 74 ], results in sustained, modest to large gains in TBS with extended treatment durations up to 10 years [ 24 ].

Anabolic agents

Anabolic treatments studied included parathyroid hormone (PTH) analogues which act by increasing bone formation and resorption, and romosozumab, which through a novel, dual mode of action, rapidly increases bone formation and reduces bone resorption [ 75 ]. In histomorphometric analyses, both classes of treatment have been shown to significantly improve trabecular microarchitecture and bone volume [ 76 , 77 ]. Eight studies included PTH/PTHrP analogues (teriparatide and/or abaloparatide) and demonstrated mean increases in TBS from 1.3 to 4.8%/12 months and increases in BMD ranged from 2.0 to 8.3%/12 months (Table 2 ).

In a multi-national randomized controlled trial (RCT), 109 postmenopausal women (mean age 61.5 y) received abaloparatide (20, 60 or 80ug) or 20 ug teriparatide over 6 months [ 66 ]. Rapid increases in TBS were observed in all treatment groups, with the greatest increases observed with the higher 80ug dose of abaloparatide (4.2%). At the individual level, 52% of women on abaloparatide (80ug) and 30% of women on teriparatide, had a TBS increase which exceeded LSC. With a longer intervention duration, the ACTIVE and ACTIVExtend RCT demonstrated a mean TBS increase of 4% over 18 months in 457 postmenopausal women treated with abaloparatide [ 23 ]. This increase was sustained to 4.4% at 43 months, and 50% of women had a positive change which exceeded LSC. There was also a reduction in the proportion of women with degraded TBS (from 40 to 24%) while there was no change in the TBS category for women in the placebo group (from 43 to 45%). In the same trial, compared to those not having an increase in TBS greater than LSC (3.8%), the odds ratio of sustaining a new vertebral fracture over 43 months was lower in those with a greater than LSC increase at 6 months (OR: 0.19, 95%CI 0.04, 0.8) and at 43 months (OR: 0.3, 95% CI 0.11,0.79) [ 23 ].

Romosozumab rapidly increased lumbar spine and hip BMD with an effect size greater than that observed with PTH/PTHrP analogues [ 76 ]. Treatment with romosozumab results in significant reductions in vertebral fracture and MOF risk [ 77 ] and medication has been recommended as the first line of treatment in patients with very high fracture risk [ 78 , 79 ]. Two studies have investigated the effect of romosozumab on TBS [ 22 , 71 ]. The first, in a small sample of 10 women (mean age 66 y), demonstrated a 2.5% mean increase in TBS and an 8.3% increase in lumbar spine BMD with 6 months of romosozumab treatment [ 22 ]. Conversely, in this study, there were no changes in TBS following 12 months of antiresorptive treatment [ 22 ]. In the ARCH multi-centre RCT, TBS measurements were available in 378 women (mean age 73 y, ~ 9.3% of the study population) randomized to receive either romozosumab or alendronate [ 71 ]. Over 12 months, mean TBS increased significantly by 5.1% in women treated with romosozumab, compared to no significant change (mean + 1.5%) in those treated with alendronate [ 69 ]. Furthermore, treatment with romosozumab led to a reduction in the proportion of women with degraded TBS (from 52.6 to 33%) and an increase in the proportion of women with normal TBS (28.9 to 48.1%). In women treated with alendronate only, there was a smaller reduction in the proportion of those with degraded TBS (from 60.6 to 51.6%) and a smaller increase in those with normal TBS (from 26.1 to 33%) [ 71 ].

Sequential osteoporosis treatment regimens

The long-term management of osteoporosis, particularly in patients at very high fracture risk, may necessitate sequential treatment [ 79 ]. Recent recommendations suggest that this may require an anabolic-first treatment regimen with a bone-forming agent (such as romosozumab or PTH, PTH/PTHrP-analogue) for 1–2 years, followed by an antiresorptive (such as a bisphosphonate or denosumab) for a further 5–10 years [ 80 ]. In the DATA-Switch open-label trial, postmenopausal women were allocated to sequential treatment comprising teriparatide to denosumab, or denosumab to teriparatide [ 21 ]. After 24 months, TBS gains were greater in the anabolic first group (2.7% versus 1.8%), and continued to increase for a further 24 months, following the treatment switch (5.1% versus 3.6%). In the ARCH multi-center trial, the 5.1% increase in TBS with romosozumab at 12 months was maintained to 4.8% with alendronate, for a further 24 months [ 71 ]. In a comparison group of women treated only with alendronate, gains in TBS were lower (1.5% at 12 months, 2.5% at 36 months). This approach may also be useful in patients whose very high risk of fracture is driven by reduced bone density and/or degraded bone microarchitecture.

TBS and treatment decision-making

The initiation of treatment is increasingly driven by fracture risk, which may be assessed by a variety of risk assessment modalities, depending on the availability of densitometry and FRAX, and on country or regional-specific guidance. European guidelines recommend FRAX-based approaches [ 81 , 82 ] with age-dependent intervention thresholds [ 83 ]. The adjustment of FRAX for TBS provides a global risk assessment based on bone mass and bone microarchitecture, plus clinical risk factors. Alternatively, the adjustment of the lowest BMD for TBS captures fracture risk associated with reduced bone mass and degraded bone microarchitecture, and the adjusted T-score may be entered into fracture risk calculators, such as the Garvan fracture risk calculator [ 84 ]. At the conceptual level, the information that TBS conveys regarding bone microarchitecture suggests that this measure, taken with BMD and CRFs, might contribute to decisions about specific treatment strategies. For example, on this basis, a treatment regimen might be chosen to either increase BMD and preserve bone microarchitecture, or to increase both BMD and bone microarchitecture, with consolidation thereafter. While a conceptually appealing mechanism by which treatment could be chosen according to individual patient characteristics, it clearly requires further evidential underpinning in order to properly inform this suggested approach.

As with BMD, the monitoring of treatment effect at the individual level should apply LSC based on centre-specific precision error and acquired in accordance with ISCD guidelines [ 85 ]. Few studies to date have reported on the proportion of study participants exceeding TBS or BMD LSC [ 19 , 20 , 23 , 66 ], and it is recommended that future studies include this data to enable interpretation of treatment effect at the individual level. Precision errors for TBS using Hologic or GE DXA systems and different TBS software versions, are comparable to BMD precision [ 84 ] and have ranged from 0.8 to 2.1%CV with equivalent LSC ranging from 2.2 to 5.8%. The average precision error and LSC from studies to date are 1.4%CV and 3.8% respectively [ 9 , 36 , 40 , 63 , 68 , 86 , 87 , 88 , 89 , 90 , 91 ]. The corresponding LSC unit change in TBS has been reported to be 0.05 based on a precision of 1.4%CV [ 85 ].

The expert Working Group members made the general recommendation that TBS results should be interpreted within the clinical context of the patient. Individual statements, all of which were strongly supported by the members of the Working Group, are itemized below:

Patients with low TBS who lie below but near the treatment threshold should be considered for an earlier assessment and lifestyle advice.

TBS with BMD and FRAX probability contributes to the stratification of antiosteoporosis therapy according to fracture risk, directing very high-risk patients to anabolic-first approaches.

TBS in conjunction with BMD, is useful for monitoring individual response to long-term denosumab treatment (5 years or more).

TBS in conjunction with BMD is useful for monitoring individual response to PTH/PTHrP-analogue treatments such as teriparatide and abaloparatide.

TBS in conjunction with BMD is useful for monitoring the individual response to romosozumab.

A decrease in TBS more than LSC during treatment should prompt further clinical review.

TBS contributes useful information in the assessment of treatment response for patients receiving bone-forming agents or long-term denosumab.

Topic 3: Use of TBS in the prediction of fracture risk associated with secondary osteoporosis

Consistent with the growing clinical and research interest in this area, in 2015, four studies with fracture outcomes in secondary osteoporosis were reviewed [ 15 ], whereas, in the current review, 40 studies (seven prospective) met the eligibility criteria (prospective, retrospective or cross-sectional studies, fracture as the primary outcome, in men and/or women aged ≥ 18 years). Of these, three were conducted in Australia, one in Brazil, four in Canada, sixteen in Europe, two in India, three in Japan, four in South East Asia, seven in South Korea; 27 studies included men and 36 included women. Incident fragility fracture rates ranged from 8 to 31% and for prevalent fracture, from 10 to 45% (Table Sb, supplementary information). As would be expected, studies were often smaller, and more frequently cross-sectional rather than prospective, compared with those of TBS in the context of primary osteoporosis and risk assessment.

Type 2 diabetes

Type 2 diabetes (T2D) is associated with an increased risk of bone fragility and fractures, although the underlying mechanisms are not fully understood. Individuals with T2D have a higher risk of fractures despite in some cases, having higher BMD than non-diabetic individuals. This paradoxical relationship between BMD and fracture risk suggests that other factors, such as impaired bone quality (for example greater heterogeneity of trabecular bone microarchitecture and increased cortical porosity) and altered material properties (as a consequence of protein glycation), may be implicated [ 92 , 93 , 94 , 95 ]. Indeed, previous studies have suggested that the altered trabecular microarchitecture is at least in part due to the accumulation of advanced glycation end products in bone tissue which increases the propensity to fracture [ 96 , 97 ]. Accordingly, the risk appears to be greater in patients who have poorer glycemic control [ 94 , 95 , 98 ]. In the current review, eight studies with cohort sizes between 169 and 44,503, investigated the use of TBS for the prediction of fragility fracture in T2D patients (Table Sb, supplementary information). In seven studies, TBS was related to fragility fracture risk independent of BMD [ 16 , 17 , 18 , 99 , 100 , 101 , 103 ] and three reported enhanced fracture risk prediction with TBS-adjusted FRAX compared to FRAX alone [ 16 , 99 , 100 ]. In 44,543 men and women (mean age 63.9 y) from the Manitoba cohort, 3,946 (9%) sustained an incident MOF over a mean follow-up of 8.3 years [ 99 ]. Individuals with T2D ( n  = 4136) had significantly lower TBS but higher femoral neck BMD ( p  < 0.05). Diabetes was also a significant predictor of incident fragility fracture risk, supporting findings from earlier studies in both sexes [ 94 , 95 ] and of microarchitectural deterioration in T2D-related skeletal fragility [ 100 ]. The adjustment of FRAX for TBS in the diabetes sub-group resulted in an overall NRI of 3.9% for incident MOF and 2.5% for hip fracture. Most reclassification was upward, based on a fixed intervention threshold of 20% for MOF and 3% for hip fracture [ 100 ].

Hypercortisolism and glucocorticoid-induced fracture risk

Six cross-sectional studies examined associations between TBS and prevalent or recent fragility fracture in patients with Cushing’s syndrome [ 104 ] or treated with corticosteroids [ 105 , 106 , 107 , 108 , 109 ]. All reported that TBS was associated with fracture, independent of BMD. In 182 men and women with Cushing’s syndrome (mean age 37.8 y; 45% fractured), there were no associations between BMD and fracture [ 104 ]. However, 84% of fractured patients had either degraded (50%) or partially degraded (34%) TBS (compared to 40% with low BMD), suggesting an important role for TBS-detected parameters including degraded trabecular architecture in the elevated fracture risk associated with endogenous overproduction of cortisol [ 104 ]. Comparable skeletal profiles have also been observed in patients receiving long-term corticosteroid treatment [ 108 , 109 ]. In 127 Spanish patients treated with corticosteroids (mean duration, 47.7 months), 27% had sustained a recent fragility fracture [ 108 ]. The skeletal profiles of patients with vertebral or non-vertebral fragility fracture were predominantly characterized by degraded TBS (76% and 69% respectively) rather than densitometric osteoporosis (38% and 36% respectively).

Chronic kidney disease

Seven studies met the inclusion criteria and investigated the use of TBS for predicting fracture in patients with chronic kidney disease (CKD) [ 110 , 111 , 112 , 113 , 114 , 115 , 116 ]. Five studies showed that TBS predicted incidents or were associated with a prevalent fragility fracture, independent of BMD [ 110 , 111 , 112 , 113 , 114 ]. Whilst CKD metabolic bone disease represents several different histomorphometric phenotypes, the search did not identify studies specifically addressing this point. In 1426 men and women (mean age 67 y), reduced kidney function was associated with significantly lower TBS and a higher probability of fracture (18% vs. 6%, p  = 0.01) and low TBS predicted greater incidence of fragility fractures over 4.7 years, independent of BMD and CRFs [ 110 ]. Lower TBS also corresponds with increasing disease severity [ 111 , 112 ]. In hemodialysis patients (mean age 74 y), TBS and not BMD, was a significant, independent predictor of fracture [ 115 ]. Two studies did not report an association between TBS and fracture risk in CKD patients. First, a retrospective cohort study, found that neither TBS nor BMD were related to a history of fracture in men with moderate CKD (age 33 to 96 y) [ 113 ]. Second, in a prospective study of a modest sample of 59 CKD patients (mean age 68 y), FRAX-adjusted for TBS was higher in fracture compared to non-fracture cases (16.8% versus 10.6%), but the predictive model did not reach statistical significance [ 112 ].

Rheumatological conditions

Ten studies investigated TBS for fracture prediction/discrimination in rheumatological inflammatory conditions including rheumatoid arthritis [ 118 , 119 , 120 ], axial spondyloarthritis [ 121 ], ankylosing spondylitis [ 122 , 123 , 124 ], polymyalgia rheumatica [ 125 ], systemic lupus erythematosus [ 126 ] and systemic sclerosis [ 127 ]. The risk factors for skeletal fragility in these conditions include inflammatory disease mechanisms and cytokine-activation of bone resorption, in addition to the use of glucocorticoid and other immunosuppressive drugs, which are known to affect bone microarchitecture [ 128 ]. All studies showed that TBS was significantly associated with fracture, independent of BMD. In two studies of postmenopausal women with rheumatoid arthritis, TBS but not BMD was associated with a prevalent radiographic vertebral fracture [ 118 , 119 ], and adjustment of FRAX for TBS improved fracture risk prediction compared to FRAX alone [ 119 ]. In a separate study of 142 rheumatoid arthritis patients and 106 healthy controls, lower TBS was associated with vertebral fracture and of those with vertebral fracture, 26% had normal lumbar spine BMD and 12% had normal hip BMD [ 120 ].

Axial spondyloarthritis and ankylosing spondylitis are chronic inflammatory conditions that can lead to structural damage to bone tissue, degraded bone microarchitecture and increased fracture risk [ 129 ]. In all four studies reviewed, TBS was significantly associated with past or incident fracture [ 121 , 122 , 123 , 124 ], and in two studies femoral neck BMD, but not lumbar spine BMD, was lower in fracture cases [ 122 , 124 ]. In patients with axial spondylitis, those with fractures were more likely to have degraded TBS (29%) than low BMD (14%) [ 121 ]. It is also important to consider that lumbar spine BMD can be falsely elevated in degenerative noninflammatory arthropathy (due to sclerosis and osteophytes) and in certain inflammatory rheumatic diseases including ankylosing spondylitis (resulting from syndesmophyte formation). In a recent study of 63 spinal surgery patients, lumbar spine BMD was significantly increased with higher CT-derived degeneration scores ( p  < 0.001) whereas TBS and CT Hounsfield unit measurements were unaffected [ 130 ]. In the case of a patient who may have degraded TBS and normal or increased lumbar spine BMD, careful scrutiny of the DXA image is recommended to ensure that no vertebrae are affected by spinal artefacts.

Other causes of secondary osteoporosis

Ten studies investigated other causes of secondary osteoporosis including acromegaly, cirrhosis, hyperparathyroidism, pulmonary disease, HIV infection, and thalassemia [ 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 ]. These studies tended to be small and cross-sectional in nature. In one study of 106 men and women with acromegaly (mean age 56 y), despite lower TBS in vertebral fracture cases (1.18 vs. 1.202, p  < 0.05), TBS was not associated with prevalent vertebral fractures in a multivariate model [ 134 ]. In the other nine studies, TBS was associated with prevalent vertebral fractures, independent of BMD [ 131 , 132 , 133 , 135 , 137 , 138 , 139 , 140 ] or enhanced fracture prediction when combined with BMD [ 136 ]. In four of these studies, however, BMD did not differ between fracture and non-fracture cases [ 131 , 133 , 135 , 139 ].

Five studies examined TBS and hyperparathyroidism or hypoparathyroidism; conditions which are known to lead to alterations to trabecular bone microarchitecture [ 141 , 142 ]. In studies of patients with hyperparathyroidism or hypoparathyroidism, TBS was significantly lower in fracture compared to non-fracture cases [ 132 , 135 , 137 , 139 , 140 ]. In studies that examined the skeletal profiles of fracture cases, the prevalence of degraded TBS (35 to 57%) was greater than densitometric osteopenia or osteoporosis (11 to 21%) [ 137 , 139 ]. Similar skeletal profiles indicating a predominance of altered bone microarchitecture were also reported in chronic obstructive pulmonary disease [ 135 ] and thalassemia [ 136 ]. In patients with thalassemia, more fractured patients had degraded TBS (57%) than low BMD (20%) [ 136 ].

Reductions in TBS are observed in most secondary osteoporosis-related diseases.

TBS predicts fracture risk in type 2 diabetes, independently of BMD and FRAX probability.

TBS predicts fracture risk in chronic kidney disease, independently of BMD.

TBS predicts fracture risk in patients treated with glucocorticoid, independently of BMD.

TBS predicts fracture risk in rheumatological diseases, for example, rheumatoid arthritis, independently of BMD.

TBS is relatively unaffected by spinal changes such as osteophytes and syndesmophytes.

Topic 4: Use of TBS for treatment monitoring in secondary osteoporosis

Twenty-eight studies met the eligibility criteria (prospective, retrospective cohort or case–control cross-sectional design; treatments associated with secondary causes of osteoporosis, or antiosteoporosis therapies in secondary osteoporosis; men and/or women, age ≥ 18 years) and thirteen studies included men (Table 3 ). One study was conducted in China, one in Denmark, one in France, four in Italy, two in Japan, five in Korea, one in Norway, one in Poland, one in Slovakia, two in Spain, two in Switzerland, one in Taiwan and six in the USA. Fourteen studies investigated the effects of treatments associated with secondary osteoporosis, and fourteen investigated the efficacy of antiosteoporosis therapies (Table 3 ).

Aromatase inhibitors

Aromatase inhibitors (AI) are first-line therapies for reducing the risk of cancer recurrence in postmenopausal women with hormone-receptor-positive breast cancer, by inhibiting the conversion of androgens to estrogen. Given this mechanism of action, AI therapies accelerate bone turnover, increase bone resorption, reduce bone density and increase fragility fracture risk [ 143 ]. Four studies investigated the effect of AI therapy (duration from 18 to 48 months) on TBS in postmenopausal or early postmenopausal women with breast cancer [ 144 , 145 , 146 , 147 ]. Reductions in TBS ranged from − 0.5 to − 1.5%/12 months, with the greatest loss observed over 36 months (− 4.6%), unrelated to change in BMD [ 145 ]. In a retrospective, longitudinal study of 321 non-osteoporotic postmenopausal women with breast cancer (mean age 59 y), AI treatment for 3 years, negatively affected both BMD and TBS [ 147 ]. BMD significantly decreased by 6.1% and TBS by 2.1%, independent of BMD. The loss of TBS was more pronounced during the first year of treatment with a slowing thereafter, whereas the annual loss of BMD continued for up to 4 years.

Glucocorticoids

Prolonged use of glucocorticoids increases fracture risk [ 148 ]. Previous studies have demonstrated that glucocorticoids can weaken bone microarchitecture, for example, through a major loss of trabecular connectivity [ 149 , 150 ], with disease mechanisms involving increased osteoclastogenesis and apoptosis of osteoblasts and osteocytes [ 151 ]. Three studies investigated the effect of glucocorticoid treatment on TBS, and all reported significant reductions ranging from − 3 to − 10%/12 months, with decreases in BMD ranging from − 1.7 to 18%/12 months [ 152 , 153 , 154 ]. The largest reduction in TBS was reported in men and women (mean age 38 y) with rheumatoid arthritis, treated with high-dose compared to lose-dose glucocorticoids over 12 months (− 10% vs. − 1.7%) indicating that the magnitude of the effect is dependent on treatment dose regimen [ 153 ].

Antiosteoporosis treatments in patients with secondary osteoporosis

Ten studies investigated the effects of antiresorptive treatments and five examined anabolic treatments. Of these studies, five included men. Collectively, the effects of treatment on TBS and BMD (Table 3 ), were comparable to those observed in postmenopausal osteoporosis (Table 2 ), reflecting the drug mechanisms of action and duration of treatment.

Antiresorptive agents included bisphosphonates, denosumab and testosterone therapy. One placebo-controlled RCT examined the effect of 12 months testosterone therapy in 197 androgen-deficient men (mean age 54 y) [ 166 ]. No significant differences in TBS were reported between the treatment and placebo groups (1.6% vs. 1.4%), although a significant effect on QCT-derived BMD was observed. In studies of bisphosphonates, the treatment effect, as in postmenopausal women, was one of preservation with no significant changes in either direction reported [ 62 , 162 , 163 , 164 , 167 ]. One RCT over 24 months included 109 women with breast cancer and treated with AI, who received either 35 mg/week risedronate or a placebo [ 164 ]. A significant loss of TBS (− 2.4%) and BMD (− 1.7%) was demonstrated in women receiving the placebo, whereas in women treated with risedronate, there was no change in TBS and an increase in BMD (2.3%). Similar findings were reported in osteopenic/osteoporotic men and women with liver cirrhosis [ 162 ], in women with T2D [ 168 , 169 ], and in corticosteroid-treated women [ 167 ]. On the other hand, TBS significantly increased by 4% in CKD patients treated with denosumab over 12 months [ 165 ].

Studies of anabolic agents included PTH/PTHrP analogues [ 62 , 65 , 168 , 169 , 170 ] and one extension RCT investigated the effects of a sequential anabolic-first treatment regimen [ 169 ]. Overall, anabolic treatments led to increases in TBS ranging from 0.5 to 2.5%/12 months. In the largest RCT and part of the ACTIVE trial, 198 postmenopausal osteoporotic women with T2D received either 80ug abaloparatide, 20ug teriparatide or placebo over 18 months [ 168 ]. The largest increases in TBS and BMD were observed in the abaloparatide group (3.7% and 8.9% respectively) although gains with teriparatide were also significant (2.4% and 2.7% respectively). A separate RCT investigated the efficacy of teriparatide in glucocorticoid-treated women and reported significant increases in TBS of 3.7% and increases in BMD of 10.3% [ 167 ], whereas treatment with alendronate led to increases in BMD (5.5%) and no change in TBS. One study investigated sequential therapy in 32 premenopausal women (mean age 39 y) with severe idiopathic osteoporosis and a history of fragility fractures [ 169 ]. Teriparatide for 12 to 24 months, followed by 24 months of treatment with denosumab led to a sustained mean increase of 5.8% in TBS, comparable to findings in postmenopausal women [ 21 ].

TBS adds value when used with BMD in monitoring skeletal effects of aromatase inhibitors.

TBS adds value when used with BMD in monitoring skeletal effects of glucocorticoids.

Evidence supporting the use of TBS in monitoring response to antiosteoporosis therapy is applicable across both primary and secondary osteoporosis.

Ongoing developments and future research

Recent and ongoing developments in TBS software include the updated TBS algorithm (version 4) that accounts for soft tissue thickness, as an improvement on the current algorithm which estimates tissue thickness using body mass index as a surrogate (version 3.1.2). The updated algorithm has been shown to perform similarly to previous versions of TBS in the prediction of fragility fracture [ 41 ] and be equally or more effective when monitoring changes in TBS in response to antiresorptive and anabolic osteoporosis therapies [ 23 , 24 , 64 , 70 , 71 ]. Given the incorporation of soft tissue adjustment, there is further potential for application in pediatric populations [ 171 ], in patients undergoing significant weight change and in patients with very high or very low BMI [ 172 ], although further studies are required. There are also several recent studies that demonstrate the versatility and expansion of TBS to other skeletal regions including the hip [ 173 ], the distal femur following knee arthroplasty [ 174 ] and lateral vertebral fracture assessment [ 175 ]. Further research in these areas is encouraged.

Conclusions

Evidence supporting the added value of TBS in the assessment and management of osteoporosis has rapidly accumulated since 2015. Collectively, data indicate that TBS enhances fracture risk prediction in both primary and secondary osteoporosis, and across diverse races and ethnicities. Together with FRAX, the inclusion of TBS in conjunction with BMD can provide an improved global assessment of fracture risk, which takes into account the two pillars of fracture resistance (bone mass and bone microarchitecture) and CRFs. Where FRAX is not available, TBS alongside BMD provides a dual skeletal assessment of fracture risk, and the lowest BMD T-score-adjusted for TBS can be input into other fracture risk assessment tools. Limited data suggest that TBS is less influenced by degenerative and inflammatory spinal disease than DXA BMD. Furthermore, TBS has the potential to help inform treatment initiation and the choice of treatment in light of the overall skeletal profile of an individual patient, taking into account both BMD and bone microarchitecture. Including TBS in the monitoring of treatment may be useful for denosumab and anabolic agents, while with bisphosphonates, MHT and SERMs, evidence demonstrates that the effect is mostly one of preservation. The expert consensus statements and operational approach, provided in this paper, can be used to guide the integration of TBS in clinical practice for the assessment and management of osteoporosis.

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Acknowledgements

We gratefully acknowledge information on technical considerations from Medimaps Group. The ESCEO Working Group was funded by the ESCEO. The ESCEO receives unrestricted educational grants to support its educational and scientific activities from non-governmental organisations, not-for-profit organisations, non-commercial or corporate partners. The choice of topics, participants, content and agenda of the Working Groups as well as the writing, editing, submission and reviewing of the manuscript are the sole responsibility of the ESCEO, without any influence from third parties.

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Enisa Shevroja & Olivier Lamy

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Jean-Yves Reginster

Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU Sart Tilman B23, 4000, Liège, Belgium

Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia

Nasser Al-Daghri

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J.Y.R. has received fees for lectures or advisory boards from IBSA-Genevrier, Mylan, Radius Health, Pierre Fabre, Faes Pharma, Rejuvinate Biomed, Teva, Theramex, Pfizer, Mithra Pharmaceuticals, CNIEL, Dairy Research Council, Nutricia, Danone and Agnovos, and industry grants (all through institution) from IBSA-Genevrier, Mylan, CNIEL, Radius Health and TRB, outside the submitted work.

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Appendix 1. operational considerations based on approved statements and expert opinion for the integration of tbs in clinical practice.

Trabecular bone score (TBS) is grey scale texture measure that correlates with bone microarchitecture, which can be used alongside FRAX and BMD to enhance the assessment of fracture risk and to inform treatment initiation and monitoring. The following guidance can be used to facilitate the integration of TBS in clinical practice in alignment with clinical workflow (see Appendix Fig. 2 ).

Integration of TBS into the clinical workflow

Indications for the use of TBS (adapted from ISCD, 2019; Kanis et al., 2019)

If FRAX (without BMD) indicates intermediate risk of fracture;

In women aged 65 years or over, and men aged 70 years or over, for routine bone health monitoring;

In women and men aged under 65 and 70 years respectively, TBS is recommended alongside BMD, if they have a risk factor for low bone mass such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss;

Adults with a fragility fracture;

Adults with a disease or condition associated with secondary osteoporosis;

Adults taking a medication associated with secondary osteoporosis;

Adults who are being considered for pharmacological treatment;

Adults receiving treatment, to monitor treatment effectiveness;

Adults not receiving osteoporosis treatment, when evidence of bone fragility would lead to treatment.

Image acquisition and quality assessment (technical considerations)

A DXA scanner calibration with a dedicated fractal phantom is required for TBS software installations and when there is a change in the DXA system, in order to clinically interpret the data;

When a DXA system is upgraded or replaced, it is strongly recommended that a new baseline TBS measurement is set for patients under treatment monitoring;

Change in scan mode may impact TBS outcomes. This can be mitigated by ensuring correct measurement and data entry of height and weight, and avoidance of change in scan mode for longitudinal monitoring, unless indicated by the DXA manufacturer;

Vertebrae affected by structural anomalies should be excluded from BMD analysis in accordance with ISCD protocol. Vertebrae excluded for BMD analysis are also excluded for TBS, e.g. sclerotic lesions, osteophytes, syndesmophytes, laminectomy and fracture;

Spinal degenerative changes minimally impact TBS, unlike BMD. As such, it is not unusual to observe discordance between spine TBS (lower) and BMD (higher);

If two or more vertebrae are excluded, neither BMD nor TBS can be used for diagnosis;

When a combination of vertebrae other than L1-L4 is used, combination-specific threshold adjustments are automatically applied in the current TBS iNsight version (3.1 and higher).

The currently available TBS software is valid for use in individuals within the BMI range of 15 to 37 kg.m −2 . Interpretation of TBS results outside of this range should be made with caution.

Bone health assessment

In the assessment of bone health, TBS can be used alongside BMD to provide additional information relating to bone microarchitecture;

The ‘Bone Resilience Index’ is an interpretive tool provided by the manufacturer, comprising combinations of categories of BMD (normal, osteopenic or osteoporosis) and TBS (normal, partially degraded or degraded);

Discordance between BMD and TBS (for example, normal BMD and degraded TBS), should prompt consideration of further clinical evaluation for possible causes of secondary osteoporosis;

Vertebral fracture assessment (VFA) should be considered for osteopenic patients with degraded TBS.

Fracture risk assessment

TBS can be used in the assessment of fracture risk using FRAX-adjusted for TBS directly OR indirectly by using the femoral neck BMD T-score-adjusted for TBS, but not both, to avoid over-adjustment for TBS;

FRAX-adjusted for TBS can be used to adjust the probability of MOF or hip fracture, for bone microarchitecture, in men and women aged 40 to 90 years. The adjusted FRAX probabilities can then be compared to local or national intervention thresholds;

In countries and regions where BMD T-score is the primary measure for assessment and reimbursement, BMD T-score-adjusted for TBS can be used;

BMD T-score-adjusted for TBS can be used in fracture prediction models other than FRAX;

The lowest adjusted T-score (lumbar spine, total hip or femoral neck) is used for diagnosis;

Other approaches might include BMD Z-score (age 20 to 49 years) and the risk threshold adjustment (or treatment threshold shift) referring to the lowest BMD T-score adjusted for TBS Z-score;

The selected approach should reflect patient age and country or region-specific guidelines.

Antiosteoporosis treatment initiation, decision-making and monitoring

FRAX-adjusted for TBS or BMD T-score adjusted for TBS can be used to inform treatment initiation, in conjunction with country or region-specific treatment intervention thresholds;

The greatest utility of either TBS adjustment is for individuals who are close to a FRAX or BMD T-score treatment intervention threshold;

Patients with low TBS who lie below but near the treatment threshold should be considered for an earlier assessment and lifestyle advice;

FRAX-adjusted for TBS can be used to guide the choice of anti-osteoporosis treatment in the framework of ESCEO-IOF recommendations on categorization to low, high or very high fracture risk (with the latter category directed to anabolic first regimens);

Since TBS captures elements of bone microarchitecture, conceptually, a low (degraded or partially degraded) TBS might support the use of treatments that impact both BMD and bone microarchitecture, for example, long-term denosumab or bone anabolic agents;

Conversely, bisphosphonates, SERMs and MHT might be considered if the treatment goal is preservation of TBS;

Least significant change (LSC) should be used to interpret treatment effect at the individual level, based on the center-specific precision error;

The average of published TBS precision errors and corresponding LSCs (Hologic and GE systems) are 1.37%CV and 3.79% respectively.

If a patient has a significant reduction (exceeding LSC) in TBS during treatment, consider causes of secondary osteoporosis and if an alternative treatment is required;

If a patient has a significant increase (exceeding LSC) in TBS and/or BMD during treatment while not expected given the given drugs and their associated mechanism of action, check for possible technical inaccuracies.

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Shevroja, E., Reginster, JY., Lamy, O. et al. Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporos Int 34 , 1501–1529 (2023). https://doi.org/10.1007/s00198-023-06817-4

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