Unveiling ExploreLearning Reflex and FRAX: Transforming Math Education and Fracture Risk Assessment

Basic math facts might seem elementary, but in Concho, Arizona, District Administrator Billie Bell and special education teacher Maria Lopez-Haffke know that addition, subtraction, multiplication, and division facts can transform an entire math program. This article delves into how ExploreLearning Reflex and FRAX are revolutionizing their respective fields: math education and fracture risk assessment. We'll explore how Concho Elementary School leveraged Reflex to boost math fact fluency and how FRAX aids clinicians in preventing osteoporosis-related fractures.

ExploreLearning Reflex: Igniting Math Fact Fluency

Concho Elementary School serves grades Pre-K through 8th grade in eastern Arizona. Committed to changing math scores, they sought a solution to address their "abysmal" math performance. Grade 3-7 students at Concho Elementary School District No. 6 used ExploreLearning Reflex, an adaptive and game-based math fact fluency program, to host a school-wide math competition.

Pinpointing the Problem: Math Fact Fluency

Maria Lopez-Haffke, a special education teacher, partnered with her school’s instructional coach to go deeper into the problem. The instructional coach explained to her that the problem was the facts and that the students didn’t know their facts that well. The fluency was lost. As much as they can solve an equation or you solve whatever math problem they have in front of you, if students incorrectly say that 7 X 5 = 25 because they are miscounting, that’s the problem. They’ll get the answers wrong, lose points, and that’s why the scores were low.

Searching for Trusted Math Solutions

As with most things, word of mouth is often the most trustworthy form of recommendation. Lopez-Haffke turned to neighboring school districts in that state with strong math scores to learn more about the math programs they were using with students. Three schools recommended Reflex. Reflex helps students develop crucial math fact fluency skills with adaptive and individualized practice, making it an ideal solution for all levels of learners.

Boosting Student Engagement with Math Fact Fluency Competitions

Bell had previously brainstormed a school-wide math competition, and the Reflex trial period was the perfect opportunity to put things into action. Lopez-Haffke organized a three-week math fact fluency challenge between the 3rd, 4th, 5th, 6th, and 7th grade classrooms. This Ready, Set, Reflex competition sparked friendly rivalry between the classes to earn prizes like ice cream with the principal and Concho Bucks, the school’s motivational currency system that students can use to purchase prizes. Concho teachers implemented Reflex into their daily classroom routines for roughly 30 minutes per day, ensuring students achieved the Green Light in each session. Reflex uses the Green Light as a key motivator for students, signifying the completion of a successful day of math fact practice. Lopez-Haffke reported Green Light and classroom fluency progress to the school using numbers from the built-in Reflex data reports.

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Measuring Student Growth

To accurately measure growth, teachers administered a 5-minute paper-and-pencil multiplication and division pre-test to students. After the three-week competition ended, teachers gave students the same questions on a post-test. Teachers measured the average number of problems (out of 100) that students answered correctly on the pre- and post-tests. All classrooms began to experience growth after implementing Reflex during the free trial period.

The growth was incredible. The ones that were playing Reflex 30 minutes a day, they grew, even if it was a minimum of five points. Reflex is going to be something that will really, really help our students. When kids are excited about learning, they learn.

Improved Student Confidence and Math Fact Fluency

As students began to grow stronger with their math facts, teachers began to notice changes in students’ everyday math work. Even though they are easy, they are easily confused by the SPED students. For example, you have a student saying that 5 x 1 = 6 because they automatically add. I’m seeing changes that they aren’t doing that anymore. There’s no adding, and they know pretty much when an answer is zero, even if it’s a high number, it’s zero. District Administrator Bell also noticed positive changes. After about the second week [of Reflex], my husband would ask him questions, and boom, boom, boom, he knew his facts. We were really impressed on a personal level, not just in the school, so I’ve seen it from both angles.

Continuing the Math Momentum

After the free trial ended, students at Concho Elementary School have continued to use Reflex with a pilot. While Reflex is still new on campus, Bell is confident it will continue to help students develop math fact fluency over the coming months. We did try it, we liked it, and the students liked it. We’re really looking forward to it next year. We’re looking forward to Frax. We haven’t tried that yet, but I’m sure if it’s anything like Reflex we will be very happy with it.

Reflex Competitions

Student and teacher engagement is crucial, and nothing drives motivation like some healthy competition. Available with any full Reflex subscription, the new Reflex Competitions feature allows teachers to host competitions among different classrooms in the same school building. The class with the greatest average number of Green Light Days wins! Arizona students began to experience math fact fluency in just three weeks.

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FRAX: Assessing Fracture Risk in Osteoporosis Management

FRAX®, a simple-to-use fracture risk calculator, was first released in 2008 and since then has been used increasingly worldwide. By calculating the 10-year probabilities of a major osteoporotic fracture and hip fracture, it assists clinicians when deciding whether further investigation, for example a bone mineral density measurement (BMD), and/or treatment is needed to prevent future fractures.

The Evolution of Osteoporosis Definition

Osteoporosis, although first used to characterise post-mortem bones with hollow spaces in 1820, was first defined from a consensus group in 1993 as ‘a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture’. Dual-energy X-ray absorptiometry (DXA) was approved for the measurement of bone mineral density (BMD) by the Food and Drug Administration (FDA) in 1988. A few years later, osteoporosis was defined by a WHO Working Group in densitometric terms as a BMD that was 2.5 standard deviations (SD) or more below the mean value of young healthy women, i.e., a T-score <− 2.5 SD. This threshold would classify 30% of all postmenopausal women as having osteoporosis. Osteopenia was defined as a T-score between − 1.0 and − 2.5. The recommended reference range is the Third National Health and Nutrition Examination Survey (NHANES III) database for femoral neck in white women aged 20-29 years.

Limitations of BMD-Based Diagnosis

The BMD-based threshold for osteoporosis, while serving a critical role in clinical diagnosis and management of osteoporosis, has several limitations which compromise its utility in identifying patients who go on to experience an incident fracture. The most important one is that although BMD has a high specificity, its sensitivity is low and the majority of fractures (60-70%) occur in individuals without osteoporosis. BMD might not be available or not reliable, either due to limited access to facilities or due to individual patient issues (degenerative changes at the spine, hip replacements etc.). Moreover, the significance of any given T-score threshold differs by age. Furthermore, many clinical risk factors do not act solely via BMD, and thus may provide further independent contribution to risk stratification. Finally, fracture rates differ between countries, and the variations cannot be explained by BMD alone.

FRAX: A Comprehensive Risk Assessment Tool

In an effort to address the insensitivity of BMD for the identification of individuals who go on to experience a fracture, risk calculators have been developed which use clinical risk factors plus/minus BMD to generate a risk of fracture over a defined period. FRAX is a computer-based algorithm that calculates the 10-year probability of a major osteoporotic fracture and a hip fracture. Through a series of extensive meta-analyses [from 12 prospective population-based studies from North America, Europe, Asia, and Australia: Rotterdam, EVOS/EPOS, CaMos, Rochester, Sheffield, Dubbo, EPIDOS, OFELY, Kuopio, Hiroshima, and two cohorts from Gothenburg, with a total of 60,000 men and women (75%) and a total follow-up of over 250,000 person years], several risk factors for fractures were identified and incorporated into the tool. One of the main aims for the tool was for it to be easily accessible and simple-to-use in primary care. Thus, FRAX uses seven readily available dichotomous clinical risk factors (inserted as yes or no into the calculator): prior fragility fracture, parental hip fracture, smoking, systemic glucocorticoid use, excess alcohol intake, rheumatoid arthritis, and other causes of secondary osteoporosis. Other factors included in FRAX are age, sex, and body mass index (BMI).

FRAX vs. Other Assessment Tools

There are other well-validated assessment tools available, including the Garvan fracture calculator and QFracture. Similar to FRAX, it takes into account the history of smoking, alcohol, previous fracture, parental history, and glucocorticoid use. It asks specifically about several causes of secondary osteoporosis and also includes a history of falls and whether oestrogen or hormone replacement therapy (HRT) is used. BMD is not included in this tool, and it is only applicable in the UK. A big difference of FRAX from these other tools is that FRAX calculates the probability of fracture by also considering the competing risk of mortality. This is because some risk factors (female sex, age, BMI, BMD, glucocorticoids, and smoking) affect both these outcomes. Based on that, the model integrates the hazard ratios of fracture and death.

Validation and Implementation of FRAX

To develop a country-specific model, which is necessary because age-specific rates of fracture and death differ, data on the number of hip fractures from national sources and mortality rates from United Nation sources need to be carefully collected. Therefore, the model is as reliable as the data collected and its validation depend on the representativeness of the population. The FRAX tool was validated in the UK in a prospective cohort of 454,499 women aged 40-85 years and 424,336 men from 357 general practices and was found to be well calibrated, as the incidences of fractures predicted by FRAX were similar to those observed in the cohort. The area under the receiver-operating characteristic curve (ROC) for FRAX in hip fracture prediction was 0.85 for women and 0.82 for men. The importance of FRAX is reflected by its inclusion in many international guidelines. There are more than 150 guidelines published and FRAX is the tool used in more than half of them. However, the way this tool is used for deciding whether to treat a patient or not varies among countries.

Intervention Thresholds

In general, there are two main approaches. Thus, many guidelines use fixed probability thresholds as intervention thresholds, applied to both sexes and irrespective of age. This approach used in USA and Canada incorporates a 20% FRAX 10-year probability of a major osteoporotic fracture as the intervention threshold. The second approach is to use age-dependent thresholds, as espoused by European guidance from the International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, and incorporated in other country-specific recommendations. Finally, there are countries that used hybrid thresholds, i.e., a combination of age-dependent thresholds and fixed thresholds.

Age-Dependent Thresholds

Age-dependent thresholds, as espoused by the European guidance, are incorporated in recommendations from the UK National Osteoporosis Guideline Group (NOGG), representing the first national guideline to adopt this approach shortly after FRAX was introduced. Prior to the NOGG guidance, the Royal College of Physicians (RCP) guidance recommended the use of BMD as the basis for intervention in postmenopausal women without fracture. The notion that postmenopausal women with a prior fragility fracture should be considered for treatment without the need for a BMD measurement remains a key recommendation. Indeed, the probability of future fracture at any particular age conferred by a prior fracture, with average body mass index and no other risk factors considered, is set as the intervention threshold in the NOGG approach, as proposed through the European guidance. The intervention threshold for women was also applied to men, since the effectiveness and cost-effectiveness of interventions are generally similar to that in women for equivalent risk. Definition of the intervention threshold also informs the setting of assessment thresholds.

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