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• Research Paper Appendix | Example & Templates

Research Paper Appendix | Example & Templates

Published on August 4, 2022 by Tegan George and Kirsten Dingemanse. Revised on July 18, 2023.

An appendix is a supplementary document that facilitates your reader’s understanding of your research but is not essential to your core argument. Appendices are a useful tool for providing additional information or clarification in a research paper , dissertation , or thesis without making your final product too long.

Appendices help you provide more background information and nuance about your thesis or dissertation topic without disrupting your text with too many tables and figures or other distracting elements.

We’ve prepared some examples and templates for you, for inclusions such as research protocols, survey questions, and interview transcripts. All are worthy additions to an appendix. You can download these in the format of your choice below.

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Table of contents

What is an appendix in a research paper, what to include in an appendix, how to format an appendix, how to refer to an appendix, where to put your appendices, other components to consider, appendix checklist, other interesting articles, frequently asked questions about appendices.

In the main body of your research paper, it’s important to provide clear and concise information that supports your argument and conclusions . However, after doing all that research, you’ll often find that you have a lot of other interesting information that you want to share with your reader.

While including it all in the body would make your paper too long and unwieldy, this is exactly what an appendix is for.

As a rule of thumb, any detailed information that is not immediately needed to make your point can go in an appendix. This helps to keep your main text focused but still allows you to include the information you want to include somewhere in your paper.

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An appendix can be used for different types of information, such as:

• Supplementary results : Research findings  are often presented in different ways, but they don’t all need to go in your paper. The results most relevant to your research question should always appear in the main text, while less significant results (such as detailed descriptions of your sample or supplemental analyses that do not help answer your main question), can be put in an appendix.
• Statistical analyses : If you conducted statistical tests using software like Stata or R, you may also want to include the outputs of your analysis in an appendix.
• Further information on surveys or interviews : Written materials or transcripts related to things such as surveys and interviews can also be placed in an appendix.

You can opt to have one long appendix, but separating components (like interview transcripts, supplementary results, or surveys ) into different appendices makes the information simpler to navigate.

Here are a few tips to keep in mind:

• Always start each appendix on a new page.
• Assign it both a number (or letter) and a clear title, such as “Appendix A. Interview transcripts.” This makes it easier for your reader to find the appendix, as well as for you to refer back to it in your main text.
• Number and title the individual elements within each appendix (e.g., “Transcripts”) to make it clear what you are referring to. Restart the numbering in each appendix at 1.

It is important that you refer to each of your appendices at least once in the main body of your paper. This can be done by mentioning the appendix and its number or letter, either in parentheses or within the main part of a sentence. It’s also possible to refer to a particular component of an appendix.

Appendix B presents the correspondence exchanged with the fitness boutique. Example 2. Referring to an appendix component These results (see Appendix 2, Table 1) show that …

It is common to capitalize “Appendix” when referring to a specific appendix, but it is not mandatory. The key is just to make sure that you are consistent throughout your entire paper, similarly to consistency in  capitalizing headings and titles in academic writing .

However, note that lowercase should always be used if you are referring to appendices in general. For instance, “The appendices to this paper include additional information about both the survey and the interviews .”

The simplest option is to add your appendices after the main body of your text, after you finish citing your sources in the citation style of your choice. If this is what you choose to do, simply continue with the next page number. Another option is to put the appendices in a separate document that is delivered with your dissertation.

Remember that any appendices should be listed in your paper’s table of contents .

There are a few other supplementary components related to appendices that you may want to consider. These include:

• List of abbreviations : If you use a lot of abbreviations or field-specific symbols in your dissertation, it can be helpful to create a list of abbreviations .
• Glossary : If you utilize many specialized or technical terms, it can also be helpful to create a glossary .
• Tables, figures and other graphics : You may find you have too many tables, figures, and other graphics (such as charts and illustrations) to include in the main body of your dissertation. If this is the case, consider adding a figure and table list .

Checklist: Appendix

All appendices contain information that is relevant, but not essential, to the main text.

Each appendix starts on a new page.

I have given each appendix a number and clear title.

I have assigned any specific sub-components (e.g., tables and figures) their own numbers and titles.

My appendices are easy to follow and clearly formatted.

I have referred to each appendix at least once in the main text.

Your appendices look great! Use the other checklists to further improve your thesis.

If you want to know more about AI for academic writing, AI tools, or research bias, make sure to check out some of our other articles with explanations and examples or go directly to our tools!

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Yes, if relevant you can and should include APA in-text citations in your appendices . Use author-date citations as you do in the main text.

Any sources cited in your appendices should appear in your reference list . Do not create a separate reference list for your appendices.

An appendix contains information that supplements the reader’s understanding of your research but is not essential to it. For example:

• Interview transcripts
• Questionnaires
• Detailed descriptions of equipment

Something is only worth including as an appendix if you refer to information from it at some point in the text (e.g. quoting from an interview transcript). If you don’t, it should probably be removed.

When you include more than one appendix in an APA Style paper , they should be labeled “Appendix A,” “Appendix B,” and so on.

When you only include a single appendix, it is simply called “Appendix” and referred to as such in the main text.

Appendices in an APA Style paper appear right at the end, after the reference list and after your tables and figures if you’ve also included these at the end.

You may have seen both “appendices” or “appendixes” as pluralizations of “ appendix .” Either spelling can be used, but “appendices” is more common (including in APA Style ). Consistency is key here: make sure you use the same spelling throughout your paper.

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• How To Write A Research Paper Appendix: A Step-by-Step Guide

Think of appendices like bonus levels on your favorite video game. They are not a major part of the game, but they boost your points and they make the game worthwhile. 

Appendix are important facts, calculations, or data that don’t fit into the main body of your research paper. Having an appendix gives your research paper more details, making it easier for your readers to understand your main ideas.

Let’s dive into how to create an appendix and its best practices.

Understanding the Purpose of an Appendix

If you’re looking to add some extra depth to your research, appendices are a great way to do it.  They allow you to include extremely useful information that doesn’t fit neatly into the main body of your research paper, such as huge raw data, multiple charts, or very long explanations.

Think of your appendix as a treasure chest with different compartments. You can include different information including, extra data, surveys, graphs, or even detailed explanations of your methods. You can fit anything too big or detailed for the main paper in the appendix.

Planning Your Appendix

Before you dive into making your appendix, it’s a good idea to plan things out; think of it as drawing a map before going on an adventure. 

You want your appendix to be organized and provide more context to your research. Not planning it will make the process time-consuming and make the appendix confusing to people reading your research paper.

How to Decide What to Include in Your Research Paper

You have to sort through the content that you will include in your appendix. Think of what your readers need to know to understand your key points. Anything that’s overly detailed, off-topic, or clutters up your paper is a good candidate for your appendix.

Tips for Organizing Your Appendix

Once you’ve figured out what to put in your appendix, it’s time to organize it. Your appendix is a place to add extra information, but it shouldn’t be cluttered or confusing to your readers. Instead, it should make your research paper easier to understand.

Use clear headings, labels, and even page numbers to help your readers find the information they need in the appendix. This way, it’s not a jumbled mess, but a well-organized part of your research paper

Formatting Guidelines

Yes, your appendix must be formatted. Most of the time, you’ll want to keep the font and margin sizes consistent with your main paper. 

However, some universities and journals may have specific guidelines for appendix formatting. Verify if your institution has special guidelines, if they do, follow them, if they don’t use the same format as your main text.

Here’s a typical breakdown of how to format your appendix:

(1) Labeling and Titling 

If you have different types of information in your appendix, use letters to label them, such as “Appendix A” and “Appendix B”. Then, give each appendix a title that explains the information inside it. 

For example, if the first section of your appendix contains raw survey data, you could call it “Appendix A (Survey Data of People Living with Diabetes Under 18 in Texas)”. If the second section of your appendix contains charts, you could call it “Appendix B (The Effect of Sugar Tax in Curbing Diabetes in Children and Young Adults)”.

(2) Numbering Tables, Figures, and More 

If you have tables, figures, or other things in your appendix, number them like a list. For example, “Table A1,” “Figure A1,” and more. This numbering helps your readers know what they’re looking at, sort of like chapters in a book.

Creating Tables and Figures

Using tables and figures helps you organize your data neatly in your appendix. Here’s a step-by-step guide to creating tables and figures in your appendix:

Choose the Right Format for Your Appendix Data

Before creating tables or figures, you need to pick the right format to display the information. Think about what makes your data most clear and understandable. 

For example, a table is better for detailed numbers, while a graph is great for showing trends. The right format makes your information easy to grasp and makes your paper look organized.

How to Create Tables in Your Appendix

You can use a spreadsheet program (like Excel or Google Sheets) to create tables to arrange information neatly. Make sure to give your table a clear title so readers know what it’s about.

Here’s a step-by-step guide to creating tables with a spreadsheet program:

• Open Google Sheets/Excel : Access Google Sheets or Excel through the web or download the app
• Open a New Spreadsheet or Existing File : Create a new spreadsheet or open an existing one where you want to insert a table.
• Select Data : Click and drag to select the data you want to include in the table.
• Insert Table : Once your data is selected, go to the “Insert” menu, then select “Table.
• Create Table : A dialog box will appear, confirming the selected data range. Make sure the “Use the first row as headers” option is checked if your data has headers. Click “Insert .”
• Customize Your Table : After inserting the table, you can customize it by adjusting the style, format, and other table properties using the “Table” menu in Google Sheets or Excel.

You can use software like PowerPoint, Google Slides, or graphic design tools to create them. If you have a chart or graph, make sure it’s easy to understand and add a title or labels to explain it. 

You can use the editing tools for images to change the size and other aspects of the image.

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Including Raw Data

The major reasons for including raw data in your appendix are transparency and credibility. Raw data is like your research recipe; it shows exactly what you worked with to arrive at your conclusions.

Raw data also provides enough information to guide researchers in replicating your study or getting a deeper understanding of your research.

Formatting and Presenting Raw Data 

Formatting your raw data makes it easy for anyone to understand. You can use tables, charts, or even lists to display your data. For example, if you did a survey, you could put the survey responses in a table with clear headings.

When presenting your raw data, clear organization is your best friend. Use headings, labels, and consistent formatting to help your readers find and understand the data. This keeps your appendix from becoming a confusing puzzle.

Citing Your Appendix

Referencing your appendix in the main text gives readers a full picture of your research while they’re reading- They don’t have to wait until the end to figure out important details of your research.

Unlike actual references and citations, citing your appendix is a very straightforward process. You can simply say, “See Appendix A for more details.”

In-Text Citations for Appendix Content

If you would like to cite information in your appendix, you usually mention the author, year, and what exactly you’re citing. This allows you to give credit to the original creator of the content, so your readers know where it came from.

For instance, if you included a chart from a book in your appendix, you’d say something like (Author, Year, p. X). Keep in mind that there are different citation styles (APA, MLA, Chicago, and others), so your appendix may look a little different.

Proofreading and Editing

Proofreading and editing your appendix is just as important as proofreading and editing the main body of your paper. A poorly written or formatted appendix can leave a negative impression on your reader and detract from the overall quality of your work. 

Make sure that your appendix is consistent with the main text of your paper in terms of style and tone unless otherwise stated by your institution. Use the same font, font size, and line spacing in the appendix as you do in the main body of your paper. 

Your appendix should also be free of errors in grammar, spelling, punctuation, and formatting.

Tips for Checking for Errors in Formatting, Labeling, and Content

Here are some tips for checking for errors in formatting, labeling, and content in your appendix:

• Formatting : Make sure that all of the elements in your appendix are formatted correctly, including tables, figures, and equations. Check the margins, line spacing, and font size to make sure that they are consistent with the rest of your paper.
• Labeling : All of the tables, figures, and equations in your appendix should be labeled clearly and consistently. Use a consistent numbering system and make sure that the labels match the references in the main body of your paper.
• Content : Proofread your appendix carefully to catch any errors in grammar, spelling, punctuation, and content. You can use grammar editing tools such as Grammarly to help you automatically detect errors in your context.

Appendix Checklist

Having an appendix checklist guarantees a well-organized appendix and helps you spot and correct any overlooked mistakes.

Here’s a checklist of key points to review before finalizing your appendix:

• Is all of the information in the appendix relevant and necessary?
• Is the appendix well-organized and easy to understand?
• Are all the tables, numbers, and equations clearly labeled?
• Is the appendix formatted correctly and consistently with the main body of the paper?
• Is the appendix free of errors in grammar, spelling, punctuation, and content?

Sample Appendix

We have discussed what you should include in your appendix and how to organize it. Let’s take a look at what a well-formatted appendix looks like:

Appendix A. (Raw Data of Class Scores)

The following table shows the raw data collected for the study.

How the Sample Appendix Adheres to Best Practices

• The appendix is labeled clearly and concisely as “Appendix A. (Raw Data of Class Score).”
• The appendix begins on a new page.
• The appendix is formatted consistently with the rest of the paper, using the same font, font size, and line spacing.
• The table in the appendix is labeled clearly and concisely as “Table A1.”
• The table is formatted correctly, with consistent column widths and alignment.
• The table includes all of the necessary information, including the participant number, age, gender, and score.
• The appendix is free of grammar, spelling, and punctuation errors.

Having an appendix easily makes your research paper impressive to reviewers, and increases your likelihood of achieving high grades or journal publication.  It also makes it easier for other researchers to replicate your research, allowing you to make a significant contribution to your research field.

Ensure to use the best practices in this guide to create a well-structured and relevant appendix. Also, use the checklist provided in this article to help you carefully review your appendix before submitting it.

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How to Write an APA Appendix

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Amanda Tust is a fact-checker, researcher, and writer with a Master of Science in Journalism from Northwestern University's Medill School of Journalism.

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• When to Use an Appendix
• What to Include
• Basic Rules

If you are writing a psychology paper for a class or for publication, you may be required to include an appendix in APA format. An APA appendix is found at the end of a paper and contains information that supplements the text but that is too unwieldy or distracting to include in the main body of the paper. 

APA format is the official writing style used by the American Psychological Association . This format dictates how academic and professional papers should be structured and formatted. 

Does Your Paper Need an APA Appendix?

Some questions to ask about whether you should put information in the body of the paper or in an appendix:

• Is the material necessary for the reader to understand the research? If the answer is yes, it should be in your paper and not in an appendix.
• Would including the information interrupt the flow of the paper? If the answer is yes, then it should likely appear in the appendix.
• Would the information supplement what already appears in your paper? If yes, then it is a good candidate for including in an appendix.

Your appendix is not meant to become an information dump. While the information in your appendices is supplementary to your paper and research, it should still be useful and relevant. Only include what will help readers gain insight and understanding, not clutter or unnecessary confusion.

What to Include in an APA Appendix

The APA official stylebook suggests that the appendix should include information that would be distracting or inappropriate in the text of the paper.

Some examples of information you might include in an appendix include:

• Correspondence (if it pertains directly to your research)
• Demographic details about participants or groups
• Examples of participant responses
• Extended or detailed descriptions
• Lists that are too lengthy to include in the main text
• Large amounts of raw data
• Lists of supporting research and articles that are not directly referenced in-text
• Materials and instruments (if your research relied on special materials or instruments, you might want to include images and further information about how these items work or were used)
• Questionnaires that were used as part of your research
• Raw data (presented in an organized, readable format)
• Research surveys

While the content found in the appendix is too cumbersome to include in the main text of your paper, it should still be easily presented in print format.

The appendices should always act as a supplement to your paper. The body of your paper should be able to stand alone and fully describe your research or your arguments.

The body of your paper should not be dependent upon what is in the appendices. Instead, each appendix should act to supplement what is in the primary text, adding additional (but not essential) information that provides extra insight or information for the reader. 

Basic Rules for an APA Appendix

Here are some basic APA appendix rules to keep in mind when working on your paper:

• Your paper may have more than one appendix.
• Each item usually gets its own appendix section.
• Begin each appendix on a separate page.
• Each appendix must have a title.
• Use title case for your title and labels (the first letter of each word should be capitalized, while remaining letters should be lowercase).
• If your paper only has one appendix, simply title it Appendix. 
• If you have more than one appendix, each one should be labeled Appendix A, Appendix B, Appendix C, and so on.
• Put the appendix label centered at the top of the page.
• On the next line under the appendix label, place the centered title of the appendix. 
• If you refer to a source in your appendix, include an in-text citation just as you would in the main body of your paper and then include the source in your main reference section.
• Each appendix may contain headings, subheadings, figures, and tables. 
• Each figure or table in your appendix should include a brief but explanatory title, which should be italicized. 
• If you want to reference your appendix within the text of your paper, include a parenthetical note in the text. For example, you would write (See Appendix A).

Formatting an APA Appendix

How do you format an appendix in APA? An APA appendix should follow the overall rules on how to format text. Such rules specify what font and font size you should use, the size of your margins, and the spacing of the text.

Some of the APA format guidelines you need to observe:

• Use a consistent font, such as 12-point Times New Roman or 11-point Calibri
• Double-space your text
• All paragraphs should be indented on the first line
• Page numbering should be continuous with the rest of your paper

The appendix label should appear centered and bolded at the top of the page. A descriptive title should follow and should also be bolded and centered. As with other pages in your paper, your APA format appendix should be left-aligned and double-spaced. Each page should include a page number in the top right corner. You can also have more than one appendix, but each one should begin on a new page.

Data Displays in an APA Appendix

When presenting information in an appendix, use a logical layout for any data displays such as tables or figures. All tables and figures should be labeled with the words “Table” or “Figure” (sans quotation marks) and the letter of the appendix and then numbered.

For example, Table A1 would be the first table in an Appendix A. Data displays should be presented in the appendix following the same order that they first appear in the text of your paper.

In addition to following basic APA formatting rules, you should also check to see if there are additional guidelines you need to follow. Individual instructors or publications may have their own specific requirements.

Where to Include an APA Appendix

If your paper does require an appendix, it should be the very last pages of your finished paper. An APA format paper is usually structured in the following way:

Your paper may not necessarily include all of these sections. At a minimum, however, your paper may consist of a title page, abstract, main text, and reference section. Also, if your paper does not contain tables, figures, or footnotes, then the appendix would follow the references.

Never include an appendix containing information that is not referred to in your text. 

A Word From Verywell

Writing a paper for class or publication requires a great deal of research, but you should pay special attention to your APA formatting. Each section of your paper, including the appendix section, needs to follow the rules and guidelines provided in the American Psychological Association’s stylebook.

American Psychological Association. Publication Manual of the American Psychological Association (7th ed.). Washington DC: The American Psychological Association; 2020.

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APA Citation Style 7th Edition

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What goes into an Appendix?

Where is an appendix placed, labeling the appendix, formatting the appendix.

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"Material that supplements the content of the paper, but would be distracting or inappropriate to include in the body of the paper is to be placed in an appendix." This includes "materials that are relatively brief and that are easily presented in print format" ( Publication Manual of the APA: 6th edition , section 2.13; Publication Manual of the APA: 7th edition , section 2.14). Examples include "mathematical proofs, lists of words, a questionnaire used in the research, a detailed description of an apparatus used in the research, etc" ( Purdue OWL .)

An appendix (or appendices) follow the reference list. Use the following order for your paper:

• Abstract ( if required, start on a new page, numbered page 2)
• Text (start on a new page, numbered 3)
• References (start on a new page)
• Tables (start each on a new page)
• Figures (start each on a new page; include caption on page with figure)
• Appendices (start each on a new page)
• If only one appendix, label it Appendix
• If more than one appendix: label each one with a capital letter (Appendix A, Appendix B, etc.) in the order in which it is mentioned in the text
• Each appendix must have a title
• In the text, refer to appendices by their labels:

"produced the same results for both studies (see Appendices A and B for complete proofs)."

• Begin each appendix on a separate page
• At the top of the page, center the word Appendix and the identifying capital letters (A, B, etc.) in the order in which they are mentioned in the text.
• Center the title of the appendix using uppercase and lowercase letter on the next line
• Begin the text of the appendix flush left, followed by indented paragraphs.

A sample appendix is below:

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APA 7th edition - Paper Format: Appendices

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How to Format An Appendix - Tutorial

• APA Appendices - JIBC Tip Sheet All you need to know about appendices in APA Style.

Information in this section is as outlined in the APA Publication Manual (2020), sections 2.14, 2.17, 2.24, and 7.6.

Appendices are used to include information that supplement the paper’s content but are considered distracting or inappropriate for the overall topic. It is recommended to only include an appendix if it helps the reader comprehend the study or theoretical argument being made. It is best if the material included is brief and easily presented. The material can be text, tables, figures, or a combination of these three.

Placement :

Appendices should be placed on a separate page at the end of your paper after the references, footnotes, tables, and figure. The label and title should be centre aligned. The contents of the appendix and the note should be left-aligned.

• If you are choosing to include tables and figures in your appendix, then you can list each one on a separate page or you may include multiple tables/figures in one appendix, if there is no text and each table and/or figure has its own clear number and title within the appendix.
• Tables and figures in an appendix receive a number preceded by the letter of the appendix in which it appears, e.g. Table A1 is the first table in Appendix A or of a sole appendix that is not labeled with a letter.

The follow elements are required for appendices in APA Style:

Appendix Labels:

Each appendix that you place in your paper is labelled “Appendix.” If a paper has more than one appendix, then label each with a capital letter in the order the appendices are referred to in your paper (“Appendix A” is referred to first, “Appendix B” is referred to second, etc).

• The label of the appendix should be in bold font, centre-aligned, follow Title Casing, and is located at the top of the page.
• If your appendix only contains one table or figure (and no text), then the appendix label takes the place of the table/figure number, e.g. the table may be referred to as “Appendix B” rather than “Table B1.”

Appendix Titles:

Each appendix should have a title, that describes its contents. Titles should be brief, clear, and explanatory.

• The title of the appendix should be in bold font, centre-aligned, follow Title Casing, and is one double-spaced line down from the appendix label.
• If your appendix only contains one table or figure (and no text), then the appendix title takes the place of the table/figure title. 

Appendix Contents:

• Left aligned and indented; written the same as paragraphs within the body of the paper
• Double-spaced and with the same font as the rest of the paper
• If the appendix contains a table and/or figure, then the table/figure number must contain a letter to correlate the table and/or figure to the appendix and not the body of the paper, e.g. “Table A1” rather than “Table 1” to clarify that the table appears in the appendix and not in the body of the paper.
• All tables and figures in an appendix must be mentioned in the appendix and numbered in order of mention. 
• All tables and figures must be aligned to the left margin, (not center aligned), and positioned after a paragraph break, preferably the paragraph in which they are referred to, with a double-spaced blank line between the table and the text. 
• Each table and figure should include a note afterwards to further explain the supplement or clarify information in the table or figure to your paper/appendix and can be general, specific, and probability. See “Table Notes” in the section “Table and Figures” above for more details.

Referring to Appendices in the Text:

In your paper, refer to every appendix that you have inserted. Do not include an appendix in your work that you do not clearly explain in relation to the ideas in your paper.

• In general, only refer to the appendix by the label (“Appendix” or “Appendix A” etc.) and not the appendix title.

Reprinting or Adapting:

If you did not create the content in the appendix yourself, for instance if you found a figure on the internet, you must include a copyright attribution in a note below the figure. 

• A copyright attribution is used instead of an in-text citation. 
• Each work should also be listed in the reference list. 

Please see pages 390-391 in the Manual for example copyright attributions.

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An appendix contains supplementary material that is not an essential part of the text itself but which may be helpful in providing a more comprehensive understanding of the research problem or it is information that is too cumbersome to be included in the body of the paper. A separate appendix should be used for each distinct topic or set of data and always have a title descriptive of its contents.

Tables, Appendices, Footnotes and Endnotes. The Writing Lab and The OWL. Purdue University.

Importance of...

Appendices are always supplementary to the research paper. As such, your study must be able to stand alone without the appendices, and the paper must contain all information including tables, diagrams, and results necessary to understand the research problem. The key point to remember when including an appendix or appendices is that the information is non-essential; if it were removed, the reader would still be able to  comprehend the significance, validity , and implications of your research.

It is appropriate to include appendices for the following reasons:

• Including this material in the body of the paper that would render it poorly structured or interrupt the narrative flow;
• Information is too lengthy and detailed to be easily summarized in the body of the paper;
• Inclusion of helpful, supporting, or useful material would otherwise distract the reader from the main content of the paper;
• Provides relevant information or data that is more easily understood or analyzed in a self-contained section of the paper;
• Can be used when there are constraints placed on the length of your paper; and,
• Provides a place to further demonstrate your understanding of the research problem by giving additional details about a new or innovative method, technical details, or design protocols.

Appendices. Academic Skills Office, University of New England; Chapter 12, "Use of Appendices." In Guide to Effective Grant Writing: How to Write a Successful NIH Grant . Otto O. Yang. (New York: Kluwer Academic, 2005), pp. 55-57; Tables, Appendices, Footnotes and Endnotes. The Writing Lab and The OWL. Purdue University.

Structure and Writing Style

I.  General Points to Consider

When considering whether to include content in an appendix, keep in mind the following:

• It is usually good practice to include your raw data in an appendix, laying it out in a clear format so the reader can re-check your results. Another option if you have a large amount of raw data is to consider placing it online [e.g., on a Google drive] and note that this is the appendix to your research paper.
• Any tables and figures included in the appendix should be numbered as a separate sequence from the main paper . Remember that appendices contain non-essential information that, if removed, would not diminish a reader's ability to understand the research problem being investigated. This is why non-textual elements should not carry over the sequential numbering of non-textual elements in the body of your paper.
• If you have more than three appendices, consider listing them on a separate page in the table of contents . This will help the reader know what information is included in the appendices. Note that some works list appendices in the table of contents before the first chapter while other styles list the appendices after the conclusion but before your references. Consult with your professor to confirm if there is a preferred approach.
• The appendix can be a good place to put maps, photographs, diagrams, and other images , if you feel that it will help the reader to understand the content of your paper, while keeping in mind the study should be understood without them.
• An appendix should be streamlined and not loaded with a lot information . If you have a very long and complex appendix, it is a good idea to break it down into separate appendices, allowing the reader to find relevant information quickly as the information is covered in the body of the paper.

II.  Content

Never include an appendix that isn’t referred to in the text . All appendices should be summarized in your paper where it is relevant to the content. Appendices should also be arranged sequentially by the order they were first referenced in the text [i.e., Appendix 1 should not refer to text on page eight of your paper and Appendix 2 relate to text on page six].

There are very few rules regarding what type of material can be included in an appendix, but here are some common examples:

• Correspondence -- if your research included collaborations with others or outreach to others, then correspondence in the form of letters, memorandums, or copies of emails from those you interacted with could be included.
• Interview Transcripts -- in qualitative research, interviewing respondents is often used to gather information. The full transcript from an interview is important so the reader can read the entire dialog between researcher and respondent. The interview protocol [list of questions] should also be included.
• Non-textual elements -- as noted above, if there are a lot of non-textual items, such as, figures, tables, maps, charts, photographs, drawings, or graphs, think about highlighting examples in the text of the paper but include the remainder in an appendix.
• Questionnaires or surveys -- this is a common form of data gathering. Always include the survey instrument or questionnaires in an appendix so the reader understands not only the questions asked but the sequence in which they were asked. Include all variations of the instruments as well if different items were sent to different groups [e.g., those given to teachers and those given to administrators] .
• Raw statistical data – this can include any numerical data that is too lengthy to include in charts or tables in its entirety within the text. This is important because the entire source of data should be included even if you are referring to only certain parts of a chart or table in the text of your paper.
• Research instruments -- if you used a camera, or a recorder, or some other device to gather information and it is important for the reader to understand how, when, and/or where that device was used.
• Sample calculations – this can include quantitative research formulas or detailed descriptions of how calculations were used to determine relationships and significance.

NOTE:   Appendices should not be a dumping ground for information. Do not include vague or irrelevant information in an appendix; this additional information will not help the reader’s overall understanding and interpretation of your research and may only distract the reader from understanding the significance of your overall study.

ANOTHER NOTE :   Appendices are intended to provide supplementary information that you have gathered or created; it is not intended to replicate or provide a copy of the work of others. For example, if you need to contrast the techniques of analysis used by other authors with your own method of analysis, summarize that information, and cite to the original work. In this case, a citation to the original work is sufficient enough to lead the reader to where you got the information. You do not need to provide a copy of this in an appendix.

III.  Format

Here are some general guideline on how to format appendices . If needed, consult the writing style guide [e.g., APA, MLS, Chicago] your professor wants you to use for more detail:

• Appendices may precede or follow your list of references.
• Each appendix begins on a new page.
• The order they are presented is dictated by the order they are mentioned in the text of your research paper.
• The heading should be "Appendix," followed by a letter or number [e.g., "Appendix A" or "Appendix 1"], centered and written in bold type.
• If there is a table of contents, the appendices must be listed.
• The page number(s) of the appendix/appendices will continue on with the numbering from the last page of the text.

Appendices. The Structure, Format, Content, and Style of a Journal-Style Scientific Paper. Department of Biology. Bates College;  Appendices. Academic Skills Office, University of New England; Appendices. Writing Center, Walden University; Chapter 12, "Use of Appendices." In Guide to Effective Grant Writing: How to Write a Successful NIH Grant . Otto O. Yang. (New York: Kluwer Academic, 2005), pp. 55-57 ; Tables, Appendices, Footnotes and Endnotes. The Writing Lab and The OWL. Purdue University; Lunsford, Andrea A. and Robert Connors. The St. Martin's Handbook . New York: St. Martin's Press, 1989; What To Know About The Purpose And Format Of A Research Paper Appendix. LoyolaCollegeCulion.com.

Writing Tip

Consider Putting Your Appendices Online

Appendices are useful because they provide the reader with information that supports your study without breaking up the narrative or distracting from the main purpose of your paper. If you have a lot of raw data or information that is difficult to present in textual form, consider uploading it to an online site. This prevents your paper from having a large and unwieldy set of appendices and it supports a growing movement within academe to make data more freely available for re-analysis. If you do create an online portal to your data, note it prominently in your paper with the correct URL and access procedures if it is a secured site.

Piwowar, Heather A., Roger S. Day, and Douglas B. Fridsma. “Sharing Detailed Research Data Is Associated with Increased Citation Rate.” PloS ONE (March 21, 2007); Wicherts, Jelte M., Marjan Bakker, and Dylan Molenaar. “Willingness to Share Research Data Is Related to the Strength of the Evidence and the Quality of Reporting of Statistical Results.” PLoS ONE (November 2, 2011).

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Citations - APA: Formatting - Essay, Reference List, Appendix, & Sample Paper

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Sample Papers

• Diane Hacker APA Sample Paper

If you are adding an appendix to your paper there are a few rules to follow that comply with APA guidelines:

• The Appendix appears  after  the References list
• If you have more than one appendix you would name the first appendix Appendix A, the second Appendix B, etc.
• The appendices should appear in the order that the information is mentioned in your essay
• Each appendix begins on a new page
• APA Sample Paper - with Appendix (Purdue OWL example)

Quick Rules for an APA Reference List

Your research paper ends with a list of all the sources cited in the text of the paper. Here are nine quick rules for this Reference list.

• Start a new page for your Reference list. Centre the title, References, at the top of the page.
• Double-space the list.
• Start the first line of each reference at the left margin; indent each subsequent line five spaces (a hanging indent).
• Put your list in alphabetical order. Alphabetize the list by the first word in the reference. In most cases, the first word will be the author’s last name. Where the author is unknown, alphabetize by the first word in the title, ignoring the words a, an, the.
• For each author, give the last name followed by a comma and the first (and middle, if listed) initials followed by periods.
• Italicize the titles of works: books, audiovisual material, internet documents and newspapers, and the title and volume number of journals and magazines.
• Do not italicize titles of parts of works, such as: articles from newspapers, magazines, or journals / essays, poems, short stories or chapter titles from a book / chapters or sections of an Internet document.
• In titles of non-periodicals (books, videotapes, websites, reports, poems, essays, chapters, etc), capitalize only the first letter of the first word of a title and subtitle, and all proper nouns (names of people, places, organizations, nationalities).
• If more than one place of publication is listed give the publisher's home office. If the home office is not given or known then choose the first location listed.
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How to Write a Research Paper Appendix

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Writing a research paper isn’t just a work of mere writing. Writing the perfect research paper takes a lot of research, analysis, framing, formatting, and much more. Correctly writing one of the most essential and academically popular segments of a research paper, the appendix, is one such effort that goes into a dissertation.  In this blog , we will discuss with you the functions of an appendix in-depth and give you some tried and tested tips to craft the perfect appendix section of a research paper! Let’s dive in! 

What is an Appendix?

The appendix on a research paper is a supplementary segment at the end of a dissertation or the research paper. This section isn’t considered a part of the main body text of the dissertation, but it is an important part of doing research. Appendices often feature raw data in the form of tables, figures, maps, diagrams and statistics and thus contribute to the credibility of the research and make it a perfect research paper . 

Using academic resources, books, and research tools can help frame an appendix better. Appendices are essential since they provide extra support to your research and make the dissertation seem more transparent regarding data. 

However, the appendix section of a research paper should only be supplementary; thus, you cannot depend on it to help the reader understand the main text. Your dissertation text should be detailed enough to be understandable without appendices, and they should only be placed to support your arguments presented in the research report. 

How to Write an Appendix for a Research Paper

Writing the perfect research paper appendix can be overwhelming if it’s your first time doing so. However, drafting the appendix section of a research paper can be quite fun if you know the basics and understand how exactly you should go about it. Here are our 5 tips on how to write the perfect appendix for your dissertation: 

Step 1: Organize the Appendix

With all the raw data, stats, and information, an appendix on a research paper can be difficult to go through and understand if they’re drafted disorganizedly. So, while writing your research paper appendix, make sure you are not just ramming all information into it but organising it well so the reader can utilise it. Structure it well, for it can very well come across as a reflection of your daily choices.

Step 2: Consider Accessibility

A research paper appendix can include non-textual information like tables, diagrams, graphs, images, illustrations, etc. If you’re adding such visual data elements to your appendices, ensure the material is clear and readable so the reader can comprehend the data. You should also ensure you are labelling these elements well and adding brief descriptions to each figure. 

Step 3: Review for Relevance

It is easy to lose track of the relevance of your data while preparing appendices since you have to work with many different types of data simultaneously. However, you have to remember that the goal is not to stuff your appendices with data. Rather, craft a precise, careful research paper appendix that can give your reader relevant and additional data that supports your research.

Step 4: Proofread and Revise

When it comes to dissertation writing, typos, grammatical errors, and spelling mistakes can cost you way more than just miscommunication. These seemingly harmless errors can make your work look casual and unprofessional, bringing in questions about the credibility of your work. It is a similar case when it comes to writing an appendix for a research paper. 

Step 5: Seek Guidance

It is important to remember that seeking guidance when you feel stuck is pretty normal, and there is nothing to be embarrassed about it. You may feel lost while writing an appendix for a research paper, and it is the perfect time to seek guidance from your peers, advisor or even dissertation committee members. 

How to Format an Appendix

Ensuring proper formatting is crucial for the seamless integration of the research paper appendix into the main body. Follow the guidelines below for a sharp-looking appendix:

Consistency with the Main Body

Formatting elements, fonts, font sizes and margins should have uniformity. Consistent and professional appearance gives your research paper a neat look.

Organisation and Structure

Use headings and subheadings to categorise your data logically. You can also use a well-structured numbering system to facilitate easy navigation.

Descriptive Elements

Introduce each content with short descriptions and paragraphs. Giving additional context makes the information more accessible and interpretable.

Consistent Formatting Style

Use a formatting style that goes well with the rest of your dissertation, along with font styles, sizes, and other formatting guidelines instructed by your academic institution.

Visual Accessibility

Any non-textual elements, such as tables, graphs, or images, should be clear and readable. Label these visual elements and add alternative texts for inclusivity in the digital appendix.

Where does the appendix go in your dissertation? 

Although the appendix section of a research paper is an essential part of your dissertation, it is not to be included in the main body of the dissertation. As a compilation of supplementary material and raw data, your research paper appendix should go at the end of the dissertation, typically inserted after the reference lists. Some even present appendices as separate supplementary documents, mostly done in specially requested cases. 

The format of the research paper appendix should be similar to the rest of your report for consistency. It should thus be drafted and formatted in the same style as the dissertation in terms of fonts, margins, and font sizes.

What to include in your appendix 

While drafting your research paper appendix, remember that it needs to be as precise as possible. Thus, there cannot be unnecessary information in it. Typically, appendices include raw data that supports your research and is referenced in the dissertation you have prepared. Here are some of the elements that you should include in your appendix: 

• Research results 
• Transcribed interviews 
• Survey/questionnaire details 
• Table and figures 
• Co-respondence 
• List of abbreviations used 
• Calculations and formulas 

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Referring appendix in-text 

Only adding your appendix to the research paper at the end of the dissertation would not make sense if there are no references to them in the main text. To justify its existence and inclusion in the research report, you should reference the appendix at least once in the whole report. A neatly labelled and properly referred research paper appendix can make your dissertation look more professional and supported. 

How to refer to an appendix

Referring to the research paper appendix within the main text is important in highlighting its relevance. Use these five methods for referencing:

In-text references

Specific references embedded in your sentences contextually shape your information. For example, "In Table 2 of Appendix B, the commonality between subjects A and B is illustrated.

Parenthetical references

You can use parentheses for concise references without disrupting the main text's flow. For instance, "The result [refer to Appendix C, Fig. 2] is not consistent with the previous findings."

Referring to the entire appendix

Refer to the entire research paper appendix in your text when appropriate. For example, "The data supporting this conclusion can be found in Appendix B."

Clarity and labelling

References should be clear and well-labelled. Proper labelling ensures easy identification of referenced material within the appendix, polishing your research paper professionally.

Cross-referencing

Cross-referencing helps you establish connections between the main text and the appendix. Phrases like "As discussed in Appendix A" guide readers to supporting material.

Crafting the perfect appendix section of a research paper involves meticulous attention to detail and adherence to formatting and referencing guidelines. As an integral part of your dissertation, the appendix contributes significantly to the transparency, credibility, and overall professionalism of your research. By following the comprehensive guidelines provided in this guide, you can ensure that your appendix not only complements your main text but also serves as a valuable resource for readers seeking additional insights. 

Frequently Asked Questions

What do i write in a research paper appendix, why is an appendix important for a dissertation, where is the appendix placed in the research paper, is writing a research paper appendix difficult, what are the basic guidelines for writing an appendix.

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Easy Guide on How to Write an Appendix

Understanding What Is an Appendix

Many students ask, 'What is an appendix in writing?'. Essentially, an appendix is a compilation of the references cited in an academic paper, prevalent in academic journals, which can be found in any academic publication, including books. Professors frequently require their students to include an appendix in their work.

Incorporating an appendix in your written piece can aid readers in comprehending the information presented. It is important to note that different professors may have varying guidelines on how to write an appendix. To learn more about how to write an appendix for a research paper according to APA, Chicago, and MLA styles, check out the following paragraphs prepared by our PRO nursing essay writing service !

Meanwhile, note that an appendix comprises all the information utilized in a paper, including references and statistics from several authors and sources (the number varies according to the type of academic paper). The purpose of the appendix is to prevent vague or irrelevant information and improve the reader's understanding of the paper.

The Purpose of an Appendix

To understand what an appendix tries to accomplish and how to write an appendix example, after all, we must first answer the key question, 'What is the purpose of an appendix?'. In short, an appendix is crucial for further explaining complex information that may be difficult to fully convey within the main text of an essay. It is intended to offer readers additional information about the topic addressed in the paper.

The material presented in an appendix has the potential to bolster the argument and sway the reader's opinion. Nonetheless, you should try to incorporate supporting material and examples toward the end of the paper to avoid disrupting the flow of the main text. Furthermore, the likelihood of including an appendix increases as a paper becomes more advanced. The use of an appendix is especially prevalent in the academic writing of a research document and journal-style scientific paper, in which extra information is usually needed to support a main point of view.

How to Structure an Appendix

While there are variations between formats, each one follows a basic structure. Thus, understanding the general structure is an essential first step in learning about this topic. No matter if you're tasked with 'how to write an appendix MLA or APA style?' - remember that both adhere to this structure, despite their differences:

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Every Appendix Should Contain:

• A clear title: The title of the appendix should be concise and descriptive, clearly indicating what information is contained within it. For example, 'Appendix A: Data Tables for Study Results or 'Appendix B: Images of Experimental Setup.'
• A list of contents: Including a table of contents in the appendix can be helpful for readers to navigate the information provided. For example:

Table of Contents:

A. Data Tables for Study Results

B. Images of Experimental Setup

C. Survey Questions and Responses

D. Sample Interview Transcripts

• Page numbers: The appendix should be a separate page, independently numbered from the main body of the paper, and specified uniformly (e.g., 'Appendix A,' 'Appendix B,' etc.). For example:

Page 1 of 5

• Relevant information: The appendix should contain all the relevant information supporting the main arguments of the document, including tables of data, raw statistical data, charts, or other documents. For example:

Figure 1: Experimental Results

[insert graph or chart here]

• Proper formatting: The appendix should be formatted in accordance with the specific requirements of the chosen citation style (e.g., APA, MLA, Chicago). For example:

Appendix B: Survey Questions and Responses

[insert survey questions and responses here, formatted following APA style guidelines]

• Clear labeling: Each element should have a clear appendix label so readers can easily understand its relevance to the paper. For example:

Table 1: Demographic Characteristics of Survey Respondents

• Concise explanation: It is important to provide short detailed descriptions of each element in the Appendix so that readers can understand its importance. For example:

Appendix C: Sample Interview Transcripts

Transcripts of the three interviews with the study participants shall be included for reference. These interviews provide further insights into the experiences of participants and their views on the subject addressed in this document.

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General Appendix Format

To ensure proper formatting, it is important to understand the basics of how to structure an appendix. Although it may seem overwhelming, the basic format is relatively easy to comprehend and serves as a foundation for understanding the APA and MLA formats. Additionally, mastering the basic format can be helpful when writing an appendix for a book or dissertation.

• Heading “Appendix #” . Contains a number or letter, that could be 1 or A.
• Reference List.
• Index Table followed a list of appendices.
• Page Number.

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How to Write an Appendix in Different Styles

There are two distinct styles for creating an appendix, and it's important to familiarize yourself with both since a professor may request one or the other. Our expert writers have compiled guidelines and rules for both formats - the Appendix APA format and the Appendix MLA format. Although they share some similarities, they also have unique features and regulations that must be strictly followed.

Appendix APA

Many professors require students to write an appendix in a paper of this format. To master how to write an appendix APA format and get the structure correct, it's a good idea to follow these guidelines and rules:

The guidelines for Appendix APA:

• The appendix begins with the heading 'Appendix' followed by ABC.
• It should also be written on top of the appendix title.
• Every appendix follows the order of the stated information in the paper.
• Include the appendix after the reference list.
• Include page numbers for each appendix.
• Appendices are to have their own page, regardless of the size.
• Include Footnotes.

The general rules for Appendix APA are to be followed when writing. This is what professors look for when a paper is required when apprentices are to be written in this format. Learn the general rules to master how to write an appendix APA style and get you onto the right path to success. You may find it useful to memorize this information or keep a note of it.

Rules for APA:

• All appendices should include their own point.
• Include a title for each appendix.
• For multiple appendices, use ABC for tilting them.
• For reference within the body, include (see appendix a) after the text.
• The title should be centered.
• All appendices are to have their own page, regardless of the size.
• Paragraph One should be written without indents.
• The rest of the paragraphs should have the intended formatting.
• Include double spacing.

Whether you're tackling how to write an interview paper in APA appendix or any other type of academic work, the following example can serve as a valuable blueprint to guide you through the process.

Appendix Chicago Style

Writing an appendix Chicago style is rather similar to APA. Though, there are some minor differences. Take a look at these guidelines for this form of an appendix.

Guidelines for an Appendix Chicago Style

• More than one appendix is described as appendices.
• The font required for the appendix Chicago style is Times New Roman.
• The text size should be 12 points.
• The page numbers should be displayed on the top right of each page.
• The page numbers should also be labeled as 'Page 1,2,3'.
• Avoid including a page number on the front cover.
• The bibliography should be the final new page. It should not share a page with any other content.
• It is possible to include footnotes in the bibliography.

To better comprehend how to write an appendix in Chicago style, glance through the example below:

Appendix MLA Format

The guidelines and regulations for creating an appendix in MLA format are largely similar to those in APA format. However, there are some differences between the two, the most notable being that the MLA appendix is placed before the reference list.

The guidelines for MLA Format:

• The appendix is included before the list of references.

It may be useful to follow the example of an appendix to better understand how to write an appendix in MLA style. Doing so can increase the chances of getting a grasp of the MLA rules to fulfill the requirements of your professor on your academic paper.

Rules for MLA

• The title is to be centered.
• The list should be double-spaced.
• The first line should include each reference in the left margin. Every subsequent line is to be formatted so it's invented. This can be referred to as 'hanging indent' to make things easier.
• The reference list must be in alphabetical order. This can be done with the first letter of the title of the reference. Though, this is usually done if the writer is unknown. If the writer is known, you can also use the first letter of the surname.
• If you include the name of the known writer, use this order. SURNAME, FIRST NAME, YEAR.
• Italic fonts are required for the titles of complete writings, internet sites, books, and recordings.
• It is important not to use an italic font on reference titles that only refer to the part of a source. This includes poetry, short papers, tabloids, sections of a PDF, and scholarly entries.

Before we conclude, let's dive deeper into the world of appendix writing by exploring an example of how to write an appendix MLA style.

Let's wrap this up! It's safe to say that following the APA, Chicago, and MLA formats is crucial when crafting an appendix. As we've seen, starting with an APA appendix example can help ease you in mastering how to write an appendix of paper. Once you have a handle on the precise formats and guidelines, creating an appendix becomes a piece of cake. Also, memorizing the format can help you whip up accurate appendices for any type of paper, whether an essay or a dissertation. Trust us, mastering this topic is a must if you want to excel in knowing how to write an appendix in a report or any other academic work.

Moreover, if you ever find yourself in need of additional academic assistance, be sure to check out our resources on how to write an article review . Or, better yet, why not let us handle your most challenging tasks with ease by simply sending us a ' write my paper request? We are here to support you every step of the way.

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What is an appendix in a paper

What is an appendix?

What type of information includes an appendix, the format of an appendix, frequently asked questions about appendices in papers, related articles.

An appendix is a section of a paper that features supporting information not included in the main text.

The appendix of a paper consists of supporting information for the research that is not necessary to include in the text. This section provides further insight into the topic of research but happens to be too complex or too broad to add to the body of the paper. A paper can have more than one appendix, as it is recommended to divide them according to topic.

➡️ Read more about  what is a research paper?

An appendix can take many types of forms. Here are some examples:

• Surveys. Since many researchers base their methodology on surveys, these are commonly found attached as appendices. Surveys must be included exactly as they were presented to the respondents, and exactly how they were answered so the reader can get a real picture of the findings.
• Interviews . Whether it’s a transcript or a recording, interviews are usually included as an appendix. The list of questions and the real answers must be presented for complete transparency.
• Correspondence . All types of communication with collaborators regarding the research should be included as an appendix. These can be emails, text messages, letters, transcripts of audio messages, etc.
• Research tools . Any instrument used to perform the research should be acknowledged in an appendix to give the reader insight into the process. For instance, audio recorders, cameras, special software, etc.
• Non-textual items . If the research includes too many graphs, tables, figures, illustrations, photos or charts, these should be added as an appendix.
• Statistical data . When raw data is too long, it should be attached to the research as an appendix. Even if only one part of the data was used, the complete data must be given.

➡️ Learn more about surveys, interviews, and other research methodologies .

The format of an appendix will vary based on the type of citation style you’re using, as well as the guidelines of the journal or class for which the paper is being written. Here are some general appendix formatting rules:

• Appendices should be divided by topic or by set of data.
• Appendices are included in the table of contents.

The most common heading for an appendix is Appendix A or 1, centered, in bold, followed by a title describing its content.

• An appendix should be located before or after the list of references.
• Each appendix should start on a new page.
• Each page includes a page number.
• Appendices follow a sequential order, meaning they appear in the order in which they are referred to throughout the paper.

An appendix is usually added before or after the list of references.

There is no specific space limit to an appendix, but make sure to consult the guidelines of the citation format you are using.

Yes, all appendices must be included in the table of contents.

Appendices feature different types of material, for instance interviews, research tools, surveys, raw statistical data, etc.

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• Research Paper Appendix | Example & Templates

Research Paper Appendix | Example & Templates

Published on 15 August 2022 by Kirsten Dingemanse and Tegan George. Revised on 25 October 2022.

An appendix is a supplementary document that facilitates your reader’s understanding of your research but is not essential to your core argument. Appendices are a useful tool for providing additional information or clarification in a research paper , dissertation , or thesis without making your final product too long.

Appendices help you provide more background information and nuance about your topic without disrupting your text with too many tables and figures or other distracting elements.

We’ve prepared some examples and templates for you, for inclusions such as research protocols, survey questions, and interview transcripts. All are worthy additions to an appendix. You can download these in the format of your choice below.

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What is an appendix in a research paper, what to include in an appendix, how to format an appendix, how to refer to an appendix, where to put your appendices, other components to consider, appendix checklist.

In the main body of your research paper, it’s important to provide clear and concise information that supports your argument and conclusions . However, after doing all that research, you’ll often find that you have a lot of other interesting information that you want to share with your reader.

While including it all in the body would make your paper too long and unwieldy, this is exactly what an appendix is for.

As a rule of thumb, any detailed information that is not immediately needed to make your point can go in an appendix. This helps to keep your main text focused but still allows you to include the information you want to include somewhere in your paper.

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An appendix can be used for different types of information, such as:

• Supplementary results : Research findings  are often presented in different ways, but they don’t all need to go in your paper. The results most relevant to your research question should always appear in the main text, while less significant results (such as detailed descriptions of your sample or supplemental analyses that do not help answer your main question), can be put in an appendix.
• Statistical analyses : If you conducted statistical tests using software like Stata or R, you may also want to include the outputs of your analysis in an appendix.
• Further information on surveys or interviews : Written materials or transcripts related to things such as surveys and interviews can also be placed in an appendix.

You can opt to have one long appendix, but separating components (like interview transcripts, supplementary results, or surveys) into different appendices makes the information simpler to navigate.

Here are a few tips to keep in mind:

• Always start each appendix on a new page.
• Assign it both a number (or letter) and a clear title, such as ‘Appendix A. Interview transcripts’. This makes it easier for your reader to find the appendix, as well as for you to refer back to it in your main text.
• Number and title the individual elements within each appendix (e.g., ‘Transcripts’) to make it clear what you are referring to. Restart the numbering in each appendix at 1.

It is important that you refer to each of your appendices at least once in the main body of your paper. This can be done by mentioning the appendix and its number or letter, either in parentheses or within the main part of a sentence. It is also possible to refer to a particular component of an appendix.

Appendix B presents the correspondence exchanged with the fitness boutique. Example 2. Referring to an appendix component These results (see Appendix 2, Table 1) show that …

It is common to capitalise ‘Appendix’ when referring to a specific appendix, but it is not mandatory. The key is just to make sure that you are consistent throughout your entire paper, similarly to consistency in capitalising headings and titles in academic writing.

However, note that lowercase should always be used if you are referring to appendices in general. For instance, ‘The appendices to this paper include additional information about both the survey and the interviews.’

The simplest option is to add your appendices after the main body of your text, after you finish citing your sources in the citation style of your choice . If this is what you choose to do, simply continue with the next page number. Another option is to put the appendices in a separate document that is delivered with your dissertation.

Remember that any appendices should be listed in your paper’s table of contents .

There are a few other supplementary components related to appendices that you may want to consider. These include:

• List of abbreviations : If you use a lot of abbreviations or field-specific symbols in your dissertation, it can be helpful to create a list of abbreviations .
• Glossary : If you utilise many specialised or technical terms, it can also be helpful to create a glossary .
• Tables, figures and other graphics : You may find you have too many tables, figures, and other graphics (such as charts and illustrations) to include in the main body of your dissertation. If this is the case, consider adding a figure and table list .

Checklist: Appendix

All appendices contain information that is relevant, but not essential, to the main text.

Each appendix starts on a new page.

I have given each appendix a number and clear title.

I have assigned any specific sub-components (e.g., tables and figures) their own numbers and titles.

My appendices are easy to follow and clearly formatted.

I have referred to each appendix at least once in the main text.

Your appendices look great! Use the other checklists to further improve your thesis.

Cite this Scribbr article

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Dingemanse, K. & George, T. (2022, October 25). Research Paper Appendix | Example & Templates. Scribbr. Retrieved 2 April 2024, from https://www.scribbr.co.uk/thesis-dissertation/appendix/

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Appendices – Writing Guide, Types and Examples

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Definition:

Appendices refer to supplementary materials or documents that are attached to the end of a Book, Report , Research Paper , Thesis or other written work. These materials can include charts, graphs, tables, images, or other data that support the main content of the work.

Types of Appendices

Types of appendices that can be used depending on the content and purpose of the document. These types of Appendices are as follows:

Statistical Appendices

Statistical appendices are used to present raw data or statistical analysis that is relevant to the main text but would be too bulky to include in the main body of the document. These appendices may include tables, graphs, charts, or other types of visual aids that help to illustrate the data.

Technical Appendices

Technical appendices are used to provide detailed technical information that is relevant to the main text but would be too complex or lengthy to include in the main body of the document. These appendices may include equations, formulas, diagrams, or other technical details that are important for understanding the subject matter.

Bibliographical Appendices

Bibliographical appendices are used to provide additional references or sources that are relevant to the main text but were not cited in the main body of the document. These appendices may include lists of books, articles, or other resources that the author consulted in the course of their research.

Historical Appendices

Historical appendices are used to provide background information or historical context that is relevant to the main text but would be too lengthy or distracting to include in the main body of the document. These appendices may include timelines, maps, biographical sketches, or other historical details that help to contextualize the subject matter.

Supplemental Appendices

Supplemental appendices are used to provide additional material that is relevant to the main text but does not fit into any of the other categories. These appendices may include interviews, surveys, case studies, or other types of supplemental material that help to further illustrate the subject matter.

Applications of Appendices

Some applications of appendices are:

• Providing detailed data and statistics: Appendices are often used to include detailed data and statistics that support the findings presented in the main body of the document. For example, in a research paper, an appendix might include raw data tables or graphs that were used to support the study’s conclusions.
• Including technical details: Appendices can be used to include technical details that may be of interest to a specialized audience. For example, in a technical report, an appendix might include detailed calculations or equations that were used to develop the report’s recommendations.
• Presenting supplementary information: Appendices can be used to present supplementary information that is related to the main content but doesn’t fit well within the main body of the document. For example, in a business proposal, an appendix might include a list of references or a glossary of terms.
• Providing supporting documentation: Appendices can be used to provide supporting documentation that is required by the document’s audience. For example, in a legal document, an appendix might include copies of contracts or agreements that were referenced in the main body of the document.
• Including multimedia materials : Appendices can be used to include multimedia materials that supplement the main content. For example, in a book, an appendix might include photographs, maps, or illustrations that help to clarify the text.

Importance of Appendices

Appendices are important components of research papers, reports, Thesis, and other academic papers. They are supplementary materials that provide additional information and data that support the main text. Here are some reasons why appendices are important:

• Additional Information : Appendices provide additional information that is too detailed or too lengthy to include in the main text. This information includes raw data, graphs, tables, and charts that support the research findings.
• Clarity and Conciseness : Appendices help to maintain the clarity and conciseness of the main text. By placing detailed information and data in appendices, writers can avoid cluttering the main text with lengthy descriptions and technical details.
• Transparency : Appendices increase the transparency of research by providing readers with access to the data and information used in the research process. This transparency increases the credibility of the research and allows readers to verify the findings.
• Accessibility : Appendices make it easier for readers to access the data and information that supports the research. This is particularly important in cases where readers want to replicate the research or use the data for their own research.
• Compliance : Appendices can be used to comply with specific requirements of the research project or institution. For example, some institutions may require researchers to include certain types of data or information in the appendices.

Appendices Structure

Here is an outline of a typical structure for an appendix:

I. Introduction

• A. Explanation of the purpose of the appendix
• B. Brief overview of the contents

II. Main Body

• A. Section headings or subheadings for different types of content
• B. Detailed descriptions, tables, charts, graphs, or images that support the main content
• C. Labels and captions for each item to help readers navigate and understand the content

III. Conclusion

• A. Summary of the key points covered in the appendix
• B. Suggestions for further reading or resources

IV. Appendices

• A. List of all the appendices included in the document
• B. Table of contents for the appendices

V. References

• A. List of all the sources cited in the appendix
• B. Proper citation format for each source

Example of Appendices

here’s an example of what appendices might look like for a survey:

Appendix A:

Survey Questionnaire

This section contains a copy of the survey questionnaire used for the study.

• What is your age?
• What is your gender?
• What is your highest level of education?
• How often do you use social media?
• Which social media platforms do you use most frequently?
• How much time do you typically spend on social media each day?
• Do you feel that social media has had a positive or negative impact on your life?
• Have you ever experienced cyberbullying or harassment on social media?
• Have you ever been influenced by social media to make a purchase or try a new product?
• In your opinion, what are the biggest advantages and disadvantages of social media?

Appendix B:

Participant Demographics

This section includes a table with demographic information about the survey participants, such as age, gender, and education level.

Age Gender Education Level

• 20 Female Bachelor’s Degree
• 32 Male Master’s Degree
• 45 Female High School Diploma
• 28 Non-binary Associate’s Degree

Appendix C:

Statistical Analysis

This section provides details about the statistical analysis performed on the survey data, including tables or graphs that illustrate the results of the analysis.

Table 1: Frequency of Social Media Platforms

Use Platform Frequency

• Facebook 35%
• Instagram 28%
• Twitter 15%
• Snapchat 12%

Figure 1: Impact of Social Media on Life Satisfaction

Appendix D:

Survey Results

This section presents the raw data collected from the survey, such as participant responses to each question.

Question 1: What is your age?

Question 2: What is your gender?

And so on for each question in the survey.

How to Write Appendices

Here are the steps to follow to write appendices:

• Determine what information to include: Before you start writing your appendices, decide what information you want to include. This may include tables, figures, graphs, charts, photographs, or other types of data that support the main content of your paper.
• Organize the material: Once you have decided what to include, organize the material in a logical manner that follows the sequence of the main content. Use clear headings and subheadings to make it easy for readers to navigate through the appendices.
• Label the appendices: Label each appendix with a capital letter (e.g., “Appendix A,” “Appendix B,” etc.) and provide a brief descriptive title that summarizes the content.
• F ormat the appendices: Follow the same formatting style as the rest of your paper or report. Use the same font, margins, and spacing to maintain consistency.
• Provide detailed explanations: Make sure to provide detailed explanations of any data, charts, graphs, or other information included in the appendices so that readers can understand the significance of the material.
• Cross-reference the appendices: In the main text, cross-reference the appendices where appropriate by referring to the appendix letter and title (e.g., “see Appendix A for more information”).
• Review and revise: Review and revise the appendices just as you would any other part of your paper or report to ensure that the information is accurate, clear, and relevant.

When to Write Appendices

Appendices are typically included in a document when additional information needs to be provided that is not essential to the main text, but still useful for readers who want to delve deeper into a topic. Here are some common situations where you might want to include appendices:

• Supporting data: If you have a lot of data that you want to include in your document, but it would make the main text too lengthy or confusing, you can include it in an appendix. This is especially useful for academic papers or reports.
• Additional examples: I f you want to include additional examples or case studies to support your argument or research, but they are not essential to the main text, you can include them in an appendix.
• Technical details: I f your document contains technical information that may be difficult for some readers to understand, you can include detailed explanations or diagrams in an appendix.
• Background information : If you want to provide background information on a topic that is not directly related to the main text, but may be helpful for readers, you can include it in an appendix.

Purpose of Appendices

The purposes of appendices include:

• Providing additional details: Appendices can be used to provide additional information that is too detailed or bulky to include in the main body of the document. For example, technical specifications, data tables, or lengthy survey results.
• Supporting evidence: Appendices can be used to provide supporting evidence for the arguments or claims made in the main body of the document. This can include supplementary graphs, charts, or other visual aids that help to clarify or support the text.
• Including legal documents: Appendices can be used to include legal documents that are referred to in the main body of the document, such as contracts, leases, or patent applications.
• Providing additional context: Appendices can be used to provide additional context or background information that is relevant to the main body of the document. For example, historical or cultural information, or a glossary of technical terms.
• Facilitating replication: In research papers, appendices are used to provide detailed information about the research methodology, raw data, or analysis procedures to facilitate replication of the study.

Advantages of Appendices

Some Advantages of Appendices are as follows:

• Saving Space: Including lengthy or detailed information in the main text of a document can make it appear cluttered and overwhelming. By placing this information in an appendix, it can be included without taking up valuable space in the main text.
• Convenience: Appendices can be used to provide supplementary information that is not essential to the main argument or discussion but may be of interest to some readers. By including this information in an appendix, readers can choose to read it or skip it, depending on their needs and interests.
• Organization: Appendices can be used to organize and present complex information in a clear and logical manner. This can make it easier for readers to understand and follow the main argument or discussion of the document.
• Compliance : In some cases, appendices may be required to comply with specific document formatting or regulatory requirements. For example, research papers may require appendices to provide detailed information on research methodology, data analysis, or technical procedures.

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How to Write an Appendix: Step-by-Step Guide & Examples

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While composing your work, you may stumble upon a question on how to write an appendix.

An appendix is a supplemental section of a research paper that provides additional information, data, or materials to support the main content. The appendix is usually placed at the end of the document and is numbered with letters or numbers, such as "Appendix A," "Appendix B," etc. The purpose of an appendix is to provide readers with supplementary details that are not included in the main text but are relevant to the topic.

Once you decide on writing appendices, you should collect additional information and format your text as required. Here, we will talk about how you can work with appendices. We will also show some nuances of their preparation process using a real example. Is the deadline around the corner? Consider using professional research paper help from expert scholars.

What Is an Appendix: Definition

Experienced researchers know what an appendix in a paper is. But aspiring authors often have problems with this section of the work. First of all, you should understand that appendices are an additional section of a dissertation or any other scientific paper that includes additional information. Main points are not placed in an appendix meanwhile at the end of your work it can expand on some context or clarify author’s position on a particular issue. Also, an appendix is ​​often placed after the citation page of a work. It is indicated with the help of references in a main text.

What Is the Purpose of an Appendix

Quite often, authors don’t understand the purpose of an appendix. This usually looks like a table and is not included in a main text. Remember that content of your dissertation should be concise and clear. It is also undesirable if you deviate from your theme so as not to confuse readers. Therefore, you can provide a reference, which will lead a reader to an appendix of a thesis. Typically, the purpose of an appendix is to extra information that is usually not included in the text's body. It expresses author's point of view, and provides additional information. It may not address the immediate topic of your dissertation or expand on current research. As a reminder, your work should be clear even without studying an appendix. So make sure you don't put important details there.

What Can You Include in an Appendix

An appendix in a paper is a supplement to a main text, not a replacement. You can put different elements there. It is better if you separate appendices, highlighting one element in each of them. Don’t forget about separate references in your text. Otherwise it will be difficult for a reader to understand your information better. Thus, the following information can be added:

• diagrams with illustrative figures;
• abbreviations ;
• interviews;
• statistics, and much more.

There are no restrictions on content added to your dissertation's appendices. Theoretically, you can attach absolutely any information that is relevant to your topic. Thus, possibilities for evidence base are almost unlimited. All you need to do is add tables or any other information.

How to Write an Appendix: Full Guide

If you already have experience working on dissertations and other scientific texts, you will not wonder how to make an appendix. However, it is still important that you get some advice on how to properly structure an appendices section. This will help add information that may be redundant in the main part of your paper. We offer 4 simple steps to create an informative and readable appendix block.

Step 1. Make an Appendix: Include Your Data

When creating an appendix, include extra data in their raw form. That is, you might not have used some details in your main paper. But you want a reader to know more information. For example, it can be calculations, some results of which are mentioned in your main text. Or maybe, you can add some statistics that clearly demonstrate your research paper conclusion . You can also include facts from other scientific sources that support your position. One thing is important — information should complement your text but not contradict it.

Step 2. Include Visual Supporting Documents in an Appendix 

When you are writing an appendix, you can’t avoid visual additions that clearly demonstrate an information and save an author from lengthy descriptions in the text. Should you need to support your conclusions drawn in the scientific text, these can be used:

Don’t forget: you should quote and indicate the authorship of graphics used in your work. If you took it from any third-party sources, of course. Thus, a reader will be able to find additional data that explains the content of your text. It is good if you personally put results of your research in a graphic form. To do this, you can use Office programs, graphic editors and other programs available to PC users.

Step 3. Describe the Instruments of Your Research in Your Appendices

It is good if your appendix in the research paper has a section for indicating tools that were used during the preparation of your dissertation writing . This way, your reader will understand how you collected information and do it themselves. For example, it could be a dictaphone or tape recorder on which an interview with your expert was recorded. Or you might have used a video camera for recording facts and interviews. In such case, it is advisable to indicate these instruments in your appendix. Specialized equipment for measuring, calculating and making graphics should also be added at the beginning of the appendix. This way, you will demonstrate your skills and knowledge. Research units don’t require extra tools, so make sure they are listed. You can do it even in a short format.

Step 4. Include an Interview and Transcripts in an Appendix

When conducting interviews and surveys for collecting information, make an appendix with photocopies of handwritten materials or electronic copies of digital surveys. Their order is not important. The main thing is that your research text contains references. This will allow you to quickly study the sources. You should not only show that the source contains important data but also explain it. So, even additional content, including questions and answers, needs to be listed. But if you originally had a readable format, you don’t need to do this. In addition to interviews, also add screenshots or photos of correspondences used for surveys. For example, you can refer to a significant researcher with whom you exchanged letters. Or maybe you studied subject, together with this researcher, and they gave some comments on a particular issue. Do not know how to write a discussion section of a research paper ? Do not worry, we have the whole article dedicated to this topic.

Formatting an Appendix: Main Rules

Formatting of appendices is required in any case. First of all, provide correct citations. APA, MLA, and Chicago are the most commonly used standards. Although, you should clarify what formatting requirements your institution has. Correct formatting includes:

• Appendix title. Write it at the top of the content page, indicate its title, using letters or numbers for ordering.
• Sorted by mention. Don’t add appendices randomly, it is better to do it in chronological order. That is, as information from it is given in main text.
• Location after bibliography. This is a general requirement that cannot always be met. For example, if your professor wants the appendices to be put before the bibliography, this will have to be done.
• Page numbers. All dissertation pages should be numbered, even if they are blank. This will make the appendix block the part of main text.

Also, review your appendix before approval. Make sure that its content is clear, error-free, and correctly quoted.

Appendix Example

To do the job successfully, it is recommended to have an example of an appendix at hand. Without it, there are usually problems with a choice of font and mentions that appear in main text. We will show you what the appendix itself looks like at the end of the dissertation using a short interview as an example.

We have one more blog in case you wonder what is an abstract in a paper  or need some examples and writing tips.

How to Make an Appendix: Final Thoughts

Thus, we talked about how to write an appendix. It allows you to include additional details, while avoiding writing them in the body of your text. To do this, one can use graphics, transcriptions of conversations, tables and statistics — anything that complements your research. Be sure to clarify formatting requirements of your university. Arrange appendices in an order in which they appear in your text. Try to use your own materials and not take other people's work. In case of unique findings, they can be used in your work.

Please contact us if you have any difficulties preparing an academic work! Our professional paper writers guarantee high quality and loyal prices. Just choose a writer to your liking, send your requirements and you're good to go!

Frequently Asked Questions About Appendix Writing

1. how do you add an appendix to an essay.

The inclusion of appendix to an essay is the same as to any other paper. You need to provide references in your text of an essay itself, as well as submit attachments after a bibliography. Don't forget to specify name of an appendix for easy navigation.

2. Do I add references to the appendix?

Yes, this is not only recommended but must be done. In this case the appendix will allow your reader to check the reliability of sources you used. Moreover, if you took any information from third-party sources, this protect you from plagiarism charges.

4. How do you create an appendix in Word?

It is not difficult to prepare an appendix in Word, because this Office program contains all the necessary tools. To get started, choose the same font, font size and indentation that were used in the main text, so as not to visually break away from it. We also recommend that you apply title formatting with built-in Word tools. Place the appendix titles at the top in the center of a page. In this case it will be much easier to navigate the paper.

3. What is an appendix in a report example?

You can include a wide range of information into an appendix in a report. It is better to opt for descriptive formats, though. For example, it can be graphical or mathematical research results, statistics of a certain phenomenon, and questionnaires filled in by other people.

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APA Appendix – Construction, Rules & Examples

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While an appendix is fairly self-explanatory, academic writing styles have their own conventions on how to create and use this section of a paper. The APA appendix comes at the end of your paper and provides supplementary material not present within the main body with the purpose of complementing the primary text. It typically offers deeper insight into the research and results. Master the task of creating and formatting an APA appendix below.

Inhaltsverzeichnis

• 1 APA Appendix – In a Nutshell
• 2 Definition: APA appendix
• 3 When is it relevant to create an APA appendix?
• 4 APA appendix format
• 5 Naming and structuring an APA appendix

APA Appendix – In a Nutshell

• An APA appendix isn’t mandatory.
• An APA appendix contains supplementary material that is too detailed or distracting if included in your main text.
• Do not use an APA appendix as an info dump – appendix information should be included for value and research transparency, and only if it is referenced within your research.
• An APA appendix appears as the last section of your paper, clearly labelled with APA style conventions.
• Refer to tables and figures within your main text just as they appear in your appendix.

Definition: APA appendix

An appendix is derived from the Latin “appendere” (“to add”).

In academic terminology, an appendix is the end section of a paper where extra information is provided for the reader. The plural of appendix is appendices. Appendices often consist of research materials in the form of tables and figures, but textual appendices are also permitted. The APA style advocates for the APA appendix to be placed very last, after references, in a paper’s order.

When is it relevant to create an APA appendix?

Appendices aren’t mandatory and should only be included if they help the reader understand, interpret or evaluate your main argument. As all essential information is included within the text, including figures and tables, only supplementary material appears in appendices. However, appendices can be useful for listing the following:

• Interview transcripts that are partially quoted within your main argument. This is for transparency.
• Complete and detailed statistical data. You can provide supplementary tables for figures, like charts, used in your main body.
• Detailed descriptions of items or complex equipment used in your research.
• Full documents or forms used in your research, whether test group questionnaires or scales.

An APA appendix doesn’t just appear without any reference. Each APA appendix must be mentioned at least once within your paper’s main body. If you don’t actually refer to an appendix, do not include it.

When you reference or discuss information found in an appendix, you don’t need to repeat the appendix name each time you discuss the general topic.

“Interviewee C described her experiences growing up in Holmes County, Ohio as “formative” (see Appendix C for full interview transcripts) .”

APA appendix format

An APA appendix section follows similar formatting conventions to other sections in the APA style:

• The title appears bold and centered at the top of the page.
• Underneath the main appendix title you’ll provide a descriptive title for the content. (similarly formatted)
• The rest of the appendix follows the APA style with a left-aligned and double-spaced text layout .
• Page numbers should be listed in the top right header .

Note: Always start a new appendix on a separate page , not underneath another.

Naming and structuring an APA appendix

You should present your appendices in alphabetical order that relates to their reference position within your text. Appendix A will be the first appendix mentioned, and so on.

An APA appendix must be titled and referenced correctly. If you have just one appendix, this is simply titled “Appendix” and appears as “see Appendix” in the text. However, if you’re using multiple appendices, follow the titling convention of “Appendix A”, “Appendix B” and so on.

You can include additional tables and figures within your APA appendix. However, unlike their use within your main text, appendix-based tables and figures follow different labeling conventions.

Each appendix has its own alphabetical label followed by a numerical reference for each table/figure included.

Refer to individual tables and figures within your main text with the above conventions, e.g., (see Fig C1). However, if an appendix consists of just one figure or table, you can refer to it by the appendix name, like “Appendix C”.

What is an appendix?

An appendix is a section of your paper that includes additional information to supplement your research. Examples of content include interview transcripts and raw data.

Can I cite external sources in my APA appendix?

Yes. Follow APA in-text citation guidelines by treating your appendix like the main text. Any sources must be included in the Reference List section.

Do I need to include an APA appendix?

An appendix is not mandatory but should be used where appropriate. If in doubt, consult your professor or subject guidelines.

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How to Write an Appendix

Last Updated: October 4, 2023 Approved

This article was co-authored by Stephanie Wong Ken, MFA . Stephanie Wong Ken is a writer based in Canada. Stephanie's writing has appeared in Joyland, Catapult, Pithead Chapel, Cosmonaut's Avenue, and other publications. She holds an MFA in Fiction and Creative Writing from Portland State University. wikiHow marks an article as reader-approved once it receives enough positive feedback. This article has 16 testimonials from our readers, earning it our reader-approved status. This article has been viewed 1,700,817 times.

Like the appendix in a human body, an appendix contains information that is supplementary and not strictly necessary to the main body of the writing. An appendix may include a reference section for the reader, a summary of the raw data or extra details on the method behind the work. You may be required to write an appendix for school or you may decide to write an appendix for a personal project you are working on. You should start by collecting content for the appendix and by formatting the appendix properly. You should then polish the appendix so it is accessible, useful, and engaging for your reader.

Collecting Content for the Appendix

• Raw data may include sample calculations that you refer to in the body of the paper as well as specialized data that expands on data or information you discuss in the paper. Raw statistical data can also be included in the appendix.
• You may also include contributory facts from other sources that will help to support your findings in the paper. Make sure you properly cite any information you are pulling from other sources.

• You may include graphs or charts you have created yourself or graphs or charts from another source. Make sure you properly cite any visuals that are not your own in the appendix.

• For example, you may note in the appendix: “All interviews and surveys were conducted in person in a private setting and were recorded with a tape recorder.”

• You should also include any correspondences you had with subjects in your research, such as copies of emails, letters, or notes written to or from your research subjects.

Formatting the Appendix

• If you have more than one appendix, order them by letter or number and be consistent about the ordering. For example, if you are using letters, make sure the appendices are titled “Appendix A,” “Appendix B,” etc. If you are using numbers, make sure the appendices are titled “Appendix 1,” “Appendix 2,” etc.
• If you have more than one appendix, make sure each appendix begins on a new page. This will ensure the reader is not confused as to where one appendix ends and another begins.

• For example, if raw data is mentioned in the first line of your paper, place that raw data first in your appendix. Or if you mention interview questions at the very end of your paper, make sure the interview questions appear as the last point in your appendix.

• You should also make sure you list the appendix in your table of contents for the paper, if you have one. You can list it based on title, for example, “Appendix”, or “Appendix A” if you have more than one appendix.

• For example, if the text ends on page 17, continue numbering from page 17 when you put in the page numbers for the appendix.

Polishing the Appendix

• You may find it helpful to have someone else read through the appendix, such as a peer or a mentor. Ask them if they feel all the included information is relevant to the paper and remove any information they deem unnecessary.

• Read through the appendix backwards so you can make sure there are no spelling errors. You want the appendix to appear as professional as possible.

• For example, you may note an appendix in the text with: “My research produced the same results in both cases (see Appendix for raw data)” or “I feel my research was conclusive (see Appendix A for interview notes).”

Sample Appendices

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• ↑ https://libguides.usc.edu/writingguide/appendices
• ↑ http://libguides.usc.edu/writingguide/appendices
• ↑ https://askus.library.wwu.edu/faq/116707

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To write an appendix, start by writing “Appendix” at the top of the document, using the same font you used for your chapter headings. Then, order the contents, such as graphs, surveys, or interview transcripts, based on the order in which they appear in your paper. Next, number the pages so they follow sequentially, coming after your paper and your reference list or list of sources. Finally, make sure to check for spelling and grammar errors, so everything will look polished and professional. For more tips from our English co-author, including how to refer to the appendix in your paper, keep reading! Did this summary help you? Yes No

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How do I format an appendix and style its heads?

Note: This post relates to content in the eighth edition of the MLA Handbook . For up-to-date guidance, see the ninth edition of the MLA Handbook .

There are many possible ways to format an appendix. A rule of thumb is to let the content guide the choice of format. Types of appendix content include the following: prose explanations that supplement the main text, numbered and unnumbered lists, bibliographies and suggestions for further reading, samples of questionnaires and surveys, and charts and tables.

An appendix that consists mainly of prose requires no special formatting. Use paragraphs, as in your main text, and consider adding titled subheads if the appendix is long.

Appendix 1: An Introduction to the Language of the C Text The language in the C text of William Langland’s Piers Plowman can be strikingly different from present-day English and even from Chaucer’s English. The manuscript on which Pearsall’s annotated edition, Piers Plowman : A New Annotated Edition of the C-Text , is written in a South West Midlands dialect, which frequently varies from Chaucer’s London dialect. This introduction provides students with the basic knowledge necessary to smoothly read Pearsall’s edition. Since difficult lines in the poem are explained in its footnotes and annotations, this guide provides only a rudimentary working knowledge of the most pressing grammatical and lexical issues. No specific linguistic knowledge is assumed. Pronunciation and Spelling Reading Langland’s text aloud is the key to comprehending it. The letters i , e , a , o , u are usually pronounced closer to the Spanish or French pronunciations. Normally, i sounds like the vowel in American English beat , e like that in bait , a like in bot , o like in boat , and u like in boot . All consonants are pronounced, even when clustered together like in knowe (pronounced kuh-no ). Sometimes gg is pronounced like the y in year , for example, in Middle English segge (“say”). The letter y sometimes interchanges with the letter i , for example, mornyng (“morning”). The letters v and u can interchange, for example vp (“up”) and haue (“have”). Nouns Plural nouns normally end in -es , as in thynges (“things”). Possessive nouns also end in -es , as in goddes loue (“God’s love”). Adjectives Sometimes, but not always, adjectives have an – e on the end, as in gode seyntes (“good saints”), especially if the noun is plural.

For an appendix that consists of a list of items, decide if the items should be numbered or not. (Hint: Are the numbers meaningful to the content? If not, consider omitting numbers.) If the list is unnumbered, ensure that each item is clearly distinct from the others. For items with multiple components, style each component consistently. For example, in the following annotated list of web resources, the annotation appears indented on a line below the site name and URL.  

Appendix Asclepio , asclepio.revistas.csic.es The journal of the history of medicine published by Spain’s National Research Council offers free access to all of their issues. Colección Historicomédica de la Universitat de València , hicido.uv.es/Expo_medicina The website of the University of Valencia’s History of Medicine Collection offers well-curated links to exhibitions, including online images, texts, and clinical studies. Diccionario de la Real Academia Española , www.rae.es The Royal Academy’s Diccionario de la lengua española is the essential starting point for exploring general vocabulary. It contains links to historical dictionaries as well. Diccionario médico-biológico, histórico y etimológico , www.dicciomed.eusal.es This online medical dictionary is a valuable resource for technical words and historical usages.

Bibliographies

An appendix that takes the form of a list of sources or recommended readings can be formatted much like a works-cited list: alphabetize the items, follow a consistent format for the entries, and use a hanging indentation.

Appendix 1 The following editions were consulted for this volume: Bercot, Martine, et al., editors. Anthologie de la poésie française: XVIII e , XIX e , XX e siècles. Vol. 2, Gallimard/Pléiade, 2000. Boucher, Gwenaëlle, editor. Poètes créoles du XVIII e siècle: Parny, Bertin, Léonard . Vol. 1, L’Harmattan, 2009. Parny, Évariste. Œuvres complètes . Edited by Gwenaëlle Boucher, L’Harmattan, 2010. 4 vols. ———. Œuvres complètes d’Évariste de Parny . Edited by Pierre-Jean de Béranger, 1831. ———. Œuvres inédites d’Evariste Parny precédées d’une notice sur sa vie et ses ouvrages par P. F. Tissot . A. Dupont, 1827. ———. La guerre des dieux . Edited by J. C. Lemaire, Champion, 2002. Seth, Catriona. Les poètes créoles du XVIII e siècle: Parny-Bertin-Leonard . Memini, 1998.  

Questionnaires and Surveys

An appendix may reproduce a questionnaire or survey used by a researcher. It is usually not necessary to reproduce the exact format of the questionnaire.

Appendix A What were your preconceived notions for this study abroad trip prior to arrival? How do those compare with your actual experiences thus far in Honduras? In what ways, if at all, have your thoughts on what it means to be a teacher changed since your time in Honduras? What sort of teaching strategies did you find teachers use in the classroom in Honduras? How do they compare and contrast with the instructional practices you have witnessed in the United States? How have you managed to communicate without knowing much Spanish? How does it feel to be in a country where the majority of the people are Latino and Latina and speak Spanish, not English? What has been your reaction to the poverty you have seen in Honduras? Has your perception of English-language learners changed? What is your perception of bilingual classrooms? Are there any experiences on this trip that you feel have helped prepare you to be a teacher?  

Charts and Tables

Sometimes a chart or table is the best way to convey information in an appendix. However, don’t use a chart or table to present information that can be shared in a simpler format, such as a list.

Appendix: Sample Fieldwork Schedule   Morning Afternoon  Day 1 Breakfast; depart for Bolʹshie Koty  Settle in at Bolʹshie Koty; tour of biostation with Evgenii Zilov Day 2 Hike to Chernaia Creek; work at biostation Collect samples at Chernaia Creek; discuss student hypotheses Day 3 Trip to Listvianka; visit Museum of Baikal, Limnological Institute Dry suit divers collect benthic samples; discussion of samples Day 4 Guided tour of Kadilʹnaia Valley Preserve with ISU botanists Discussion with Svetlana Sizykh and other botanists from ISU Botanical Garden Day 5 Guided tour of Bolʹshie Koty valley with botanists Collection of samples; discussion Day 6 Visit site of Great Baikal Trail; discussion with trail leader Ecotourism discussion with Tatʹiana Klepikova, Great Baikal Trail  

Heads in Appendixes

Structuring and styling the heads in an appendix follow the same principles as using heads in your main text . Short appendixes may need only a title and no heads, while longer, more complex appendixes may benefit from the structure that heads can provide. The styling and size of heads should be used to signal prominence and subordination of head levels: larger, boldface fonts indicate the most prominent head levels, while a smaller or italic font indicates subordinate head levels.

Titles of Appendixes

If your work has more than one appendix, label the appendixes numerically or alphabetically. Appendixes may also bear titles, which should be short and descriptive.

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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

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• Published: 01 July 2023
• Volume 34 , pages 1501–1529, ( 2023 )

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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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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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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.

C.C. reports personal fees from ABBH, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier and Takeda, outside the submitted work.

N.C.H. reports personal fees, consultancy, lecture fees and honoraria from Alliance for Better Bone Health, AMGEN, MSD, Eli Lilly, UCB, Kyowa Kirin, Servier, Shire, Theramex, Consilient Healthcare and Internis Pharma, outside the submitted work.

L.K. reports lecture fees and honoraria from Alexion, Amgen, Ascendis, Medimaps (2 single presentations), and Radius, outside the submitted work.

E.V.M reports consultancy, advisory boards and or lecture fees from Amgen, AstraZeneca, Consilient Healthcare, Fresenius Kabi, GSK, Hologic, Internis, Lilly, ObsEva, Pfizer, UCB. Additional research support from Versus Arthritis, I3 Innovus, MRC and IOF.

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N.A-D., D.M.C., M.C., A-L.D., O.L., D.M., J.P., M-P.L., S.T. declare no conflicts of interest.

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Supplementary file1 (DOCX 28 KB)

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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Received : 04 April 2023

Accepted : 31 May 2023

Published : 01 July 2023

Issue Date : September 2023

DOI : https://doi.org/10.1007/s00198-023-06817-4

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