Does anyone have experience with this new type of bone scan that measures both bone density and bone quality? It has been used in Europe but is relatively new to the US. I am interested in this because I have very low DEXA scores in my spine -4.1 and hip -2.8. No fractures to date but my doctor would like me to start taking forteo (teriparatide). I am wondering (hoping) that if bone quality is good maybe I can manage things without meds. I am 68 and otherwise in good health. I’ve avoided taking meds of any kind and only take calcium, vitamin D, glucosamine and chondroitin supplements . Based on info here, I am adding vitamin k to this list. Appreciate any thoughts you might have.
Information about REMS Echolight scan... - Osteoporosis Support
Information about REMS Echolight scan for osteoporosis
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With such a large discrepancy between your spine and hip scores, you'll almost certainly find that REMS gives you 2 scores that are much more similar. I've had a REMS scan (in the UK a couple of years ago), 16 months after my last DEXA scan. DEXA gave me a spine score of -3.6, hip -2.5. REMS gave me both spine and hip at -2.6. Of course there's no guarantee that your spine score would be better with REMS, as it's possible that there was an error with your hip score rather than spine, but from those I know who've had REMS here, almost all of them had a better spine score with REMS than with DEXA. I think that's because there's more room for error with scanning the spine than with the hip. REMS technology is more fully automated, so makes such errors far less likely.
Thank you Met00!I’m trying to get as much information as I can before I decide about meds and your comments are very helpful. You inspired me to give the Echolight folks a call to find out where I can get a REMS scan in the US. It turns out there is one facility several hours drive from me. I made an appointment.
BTW - I noticed you posted research some time back about the different rate of fractures between Norwegians and Spaniards. Fascinating! I would be interested in knowing more about the relationship between ethnicity and bone quality.
Yes, I'd also like to know more about the link between ethnicity and bone quality. I've come across one or two other references to this, but haven't kept a record. You could google "ethnicity and fracture risk" if you want to do some reading!
This recent article courtesy of the IOF's Facebook page might be of interest: link.springer.com/article/1...
Thanks for your comments on REMS scans, Met00. May I ask why there's more room for error with scanning the spine than with the hip?
I'm not totally certain why the spine measurement is more likely to be inaccurate than the hip, but when people share their t-scores on the groups I'm in, if there's a large discordance, for the majority that's a much worse score for the spine than the hip. I know quite a number of people who've had REMS scans, and the majority have been given better spine scores from REMS compared to DEXA, but similar hip scores. This hasn't always been the case though, with one lady I know having been given a worse hip score together with a better spine score. There are a number of things that can affect the accuracy of DEXA scanning. From what I've read, it can be down to things like positioning errors, interpretation errors, curvature of the spine, size of the bones, amount of soft tissue, past fractures, arthritis.
I've seen various references to DXA's major error rate - from 40% to as high as 75%, the latter being from a densitometrist who is a volunteer moderator in another group. Dr. Neil Binkley, former ISCD president has referred to a 50% error rate and used the word 'rampant' in a recent presentation. An article on the topic: researchgate.net/publicatio...
Thanks, Met00. It's all very interesting, particularly as treatment recommendations are guided by these results. The error rate cited by lilo789 is concerning and underscores the need to repeat scans on the same machine. I'll have a read of that article you posted below, lilo789. Thank you.
Hello Met00,
Would you be able to let me know where it is possible in the UK to have the REMS Echolight scan? I suppose it is not available on the NHS? May I ask you how much this cost? Feel free to pm me if you prefer.
Were the results from such a scan different from a DEXA scan?
There are 2 companies that I know of that do the REMS scan, one based in Northamptonshire with clinics in various other places (osteoscanuk.com/ - clinics are listed on their website), the other has a clinic in Bedford (orchardclinicbedford.co.uk/.... I've used osteoscanuk.com, who for £150 give you a 1/2 hour appointment with a consultant, which includes the scan itself, the results and discussion over managing the condition. I don't know anything about the Bedford clinic, apart from the fact that it exists and uses the same technology. I was very impressed with my REMS scan and am booked for another one next month. When I had it done, it didn't include a bone strength measurement, but this has now been added and friends who've had the scan recently have found the bone strength score gives a much better indication of fracture risk. My own scores 18 months ago were -2.6 for both hip and spine, whereas 16 months prior to that my DEXA scores were -3.6 for spine and -2.5 for hip. I trust the REMS technology more than DEXA. Apart from anything else, you can't compare scores between different DEXA machines, so how can you know which one is giving accurate readings?! REMS scores on different machines are comparable, plus there is far less risk of operator error because REMS is more fully automated.
I am 67 years old and just want to mention why I think my t-scores are so different (I don't think one is wrong). I have had various back challenges since age 30 that keep me from lifting anything heavy or being able to do some of the spine strengthening exercises. But I walk every day and do have an exercise routine that includes squats and lunges for the hips. I just had a scan after not having one for many years and to my surprise my hips are in the normal range but my spine is at -3.2. It doesn't surprise me at all based on my history. I will be further improving my diet, adding in more K2 and asking my physical therapist to focus on some spine building exercises that I hopefully can tolerate. I am also not interested in taking any drugs (and in my case I question the decrease in bone building cycling as it is OK in my hips and not in my back ,again I think due to use ability). I will say that since the diagnosis I have found myself more nervous when I am out and about, afraid to fall even though my balance is good. I know with time that fear will diminish. I also would like to see tests associated with bone web strength vs. density. My mother who had osteoporosis fell frequently, I think due to the sleeping pills she was taking. She never broke or fractured anything. Neither have I.
There are measures of bone strength available now - the trabecular bone score that can be calculated by those DEXA scanners that have the additional software to make this possible, and the bone fragility score with REMS machines. You're certainly right that there's far more to fracture risk than simple bone density.
Having said that, although I understand what you're saying about being unable to do spine strengthening exercises, the orthopaedic consultant I see for my REMS scans, an expert on spine health, is confident that any impact exercise will benefit the spine as well as the hips. It may be that your spine score wouldn't be as good as your hips, but he wouldn't expect to see more than one standard deviation between the two (so if your hips are, say, -1.0, your spine shouldn't be worse than -2.0). REMS scans have been shown to be comparable to DEXA scans when done properly, but sadly DEXA scans are more prone to error; REMS scanners are more fully automated, making positioning and interpretation errors far less likely.
Thanks very much. What I would hope of course is that spine number is too inflated vs. the hip number being too low. I am curious what my doctor is going to say in terms of such a large gap. I know she wants me to take medication (all doctors generally do) but at this point I don't want to. I will look into the REMS scans. One addtl comment though, they did both of my hips with separate scans and I wouldn't expect both to be an error. These machines don't give me much faith. I just found all my old scans, 5 years worth at various ages and all came back with this very large gap. I think in my case it is my lack of physical ability with my spine.
My first DEXA scan gave -2.3 hip, -3.2 spine. Second one -2.5 hip, -3.6 spine. That made me believe the DEXA scan was probably right, as it seemed fairly consistent between the two scans. However, it could also mean that they simply make the same mistake every time. My first REMS scan, 15 months after my second DEXA, gave both hip and spine scores as -2.6. There's no reason why that should be wrong, as there aren't the same issues with positioning, interpretation, small bones etc as there are with REMS.
Entirely different machine, medical center and operator for latest scan.
I wonder whether your small frame size (which you mentioned in a separate comment) is giving an inaccurately low spine score? I'm also small framed according to wrist:height measurement, which seems to be the accepted way of calculating this.
Are you in the U.S. or U.K.? Recent guidelines suggest looking at other fracture risk factors besides low BMD.
I am Canadian and was interested in Dr. Aliya Khan's May 2022 presentation which provides insights into our new guidelines to be released shortly. "It doesn't matter what the bone density is....." The focus is on fracture risk.
Here is a link for the BHOF's guidelines to physicians. bonehealthandosteoporosis.o...
The U.K. version: osteoporosis.foundation/sit...
where did you get your rems scan. ..? I too am small boned. Many reasons why I don’t entirely believe my first dexa scan. I’m totally feeding and rehabbing my bones. I refuse to take meds at great kengtgs
Osteoscan UK Ltd do them -osteoscanuk.com - based in Daventry, but they have a number of clinics around the country.
Oh. I wish usa would get up to date
They are available in some states, but I don't know where
might also try adding melatonin 5 mg each night, and Turmeric 500 mg 2x/day. Both have been shown to help bone density in a few studies. And eat jello! Gelatin/Collagen has also been shown to help in actual clinical studies.
Interesting you should suggest turmeric- I had an OsteoScan on Monday and it was suggested that I take turmeric as well as the other supplements I take - I said I had tried it in the past and it gave me heartburn so I was told to try vegan capsules which I have done and which seem to be fine. I’ve also read that you should take turmeric curcumin root extract - which is what I have bought.
What I like about the OsteoScan is that it tells you your bone quality as well as bone density and also that it isn’t dependent on using the same machine every time, how you are positioned or the operator.
Thanks all for the articles and recommendations. Frightening to think that the DEXA error rate might be so high and women might be taking such serious meds based solely on those scores. Lack of confidence in DEXA scores may also keep people from taking meds when it might be critical. “Caught between a rock and a hard place. “ I will keep you posted on the REMS scan.
A member in another group has a low TBS score of 1.194 while the REMS score on her hips provided satisfactory fragility scores of 17.3 and 17.4. Her fragility score for the spine is 22.9. Another group member has DXA experience and is currently an Echolight employee. I asked her to explain the difference between TBS and REMS' fragility score.
"A few points on TBS: TBS is a textural index that evaluates pixel gray level variations in the lumbar spine DXA image (this tool only assesses spine, not the hip) , providing an indirect index of trabecular microarchitecture. TBS is not a direct physical measurement of bone microarchitecture, but rather an overall score computed by the projection of the 3D structure onto a 2D plane. Simply stated, TBS principles could be compared to an aerial view of a forest. An aerial view of the forest cannot discern individual elements of that forest (ie, trees); the DXA image cannot discern the individual elements of its components (trabeculae). Although both of these “low power” views do not have sufficient
resolution to identify individual trabeculae (by the spine DXA image) or trees (in the forest aerial view), the areas of missing bone in the trabecular compartment or clearings in the forest are quite clearly noticeable.
REMS technology provides an innovative diagnostic parameter called Fragility Score (FS) that investigates the quality of the bone and provides the estimate of the risk of fracture independently of the BMD by analyzing the micro-architecture of the bone (with both spine and hip). FS is a dimensionless parameter that derives from dedicated spectral and statistical analyzes carried out by an algorithm which compares the spectral characteristics of raw radiofrequency (RF) signals, acquired during a scan, with appropriate models of "fragile" or "non-fragile" bone structures, previously obtained from data collected from fractured and non-fractured patients."
Thanks, that's really interesting. I thought the REMS fragility score was the same as TBS, so have learnt something new!
TBS can also be assessed via proprietary software added to a DXA machine that analyzes the 2D image taken from a DXA scan. It is recommended to use the same DXA machine for both processes. A company called Medimaps Group is one vendor for this type of software.
(I should probably mention that both Echolight and Medimaps are members of American Bone Health's Corporate Advisory Board.)
Thanks.
The doctor at a local, major hospital ordered a TBS scan for me but it was used as a supplement to my DEXA scan from a different machine. I’m hearing that I should have had both done for the readings to be accurate.
That's correct. TBS is just a software that analyzes the image from your DXA. It gives more information than your DXA report alone. By looking at the bone microarchitecture (aka bone quality aka bone structure) in addition to your bone density, it helps your provider make decisions for your treatment.
It is advised to do DXA and TBS on the same machine. Incidentally, it's also advised to have follow-up DXA scans on the same machine. Doing this can cut down on the margin for error.
Read more about TBS here: americanbonehealth.org/bone...
Great info! Thanks for sharing it! I find the discussion re DXA accuracy and the REMS option to be very interesting, and exciting too; I want to have the most accurate information available to make these important choices regarding my health.
I am a member of two FB OP groups one of which is Dr. Lani Simpson's group. She has reservations about the accuracy of the REMS. When it comes to DXA I'll quote Dr. Susan Ott. At the 20.00 mark she discusses her 300 person experiment. "You have to take these measurements with a real grain of salt and not get overly concerned..." youtube.com/watch?v=BsDgxKk...
What are Dr Lani Simpson's reservations about the accuracy of REMS? Does she have evidence to support her concerns? It's been very well researched and proved to be more reliable than DEXA.
She has said she would make her findings available to all in the future - she had presented her views in her Master Class for which I am not a member.
Thank you for sharing this information with me! This conversation thread is so informative and I appreciate everyone's input immensely. Following this discussion, reading the posts, I found myself in a 4 month old conversation re DEXA scan accuracy and small boned women. I am uncertain how this is judged exactly, does it have to do with height, or simply bone size? Everytime I go to the doctor's office they measure me at a different height, from 5'4" to 5'5"! I even asked them to measure me again to make sure, I have concluded that they don't really care what my height and weight is...I weigh 125 and I am 64. My T score numbers are severe, but I do have over a point between my spine and my hip, and my forearm is crazy bad, but I have been a clinical massage therapist for 25 years (retired for just over a year), and I was also a potter, I know for a fact I have always been very strong. I am not confidant that my DEXA scan numbers are accurate, and I do believe that I have Osteoporosis. I live in the U.S., have contacted the REMS company, the only equipment is on the East coast while I live in Colorado.
The issue is bone size, pansies7 as this article explains. qct.com/Downloads/Whitepape...
Hi, where on the East coast is REMS available?
I know of two in NJ and I believe there is a new one in Maryland. For more information on where REMS scans are available in the US contact Vicki Baldwin vbaldwin@echolightmedical.com
I am reporting back on my experience with REMS versus DEXA scans.I just had my first REMS scan ( 4 months after my dexa) and the results were more in line with what Met00 mentioned. My hip and spine t scores were closer together with the REMS with the spine scores looking better.
DEXA - spine -4.1 total; hip -2.7 neck (-2.8 total)
REMS - spine - 2.1 total; hip -3.1 neck (-2.5 total)
Pretty confusing. Unfortunately, the machine where I had the scan did not measure bone quality. Next time I will visit a facility with a machine that measures quality. For now, I feel more comfortable choosing not to take some of the more “heavy duty” drugs and will continue with supplements and up the exercise. Will also lobby my doctor to explore REMS technology. Appreciate your thoughts....
Thanks very much for reporting back, osteo2021.
Two standard deviations in the spine T-score is quite a difference! Is this because you are petite and/or small-boned?
On the other hand, the DXA hip results are similar while there is a 0.6 SD with REMS. Dr. Susan Ott:
"It is worth checking that the neck, trochanteric, and intertrochanteric values are within 1/2 standard deviation from the total hip. Large discrepancies could mean technical error, or a maldistribution of cortical/trabecular bone."
courses.washington.edu/bone...
I am 5’2 and 110 lbs. I have heard that DEXA scans are less accurate for smaller bones...something related to lack of dimensionality in the scan. Is that what you are thinking? Is this issue more related to the spine than the hip?Thanks.
Yes, DXA provides smaller-boned individuals with low T-scores although our bone density may be identical to a larger-boned individual.
"DXA aBMD cannot differentiate between high density small bones and low density large bones. This results in a systematic overestimation of DXA aBMD in larger subjects and underestimation in smaller patients."
www-pub.iaea.org/MTCD/Publi...
I am 5'2 as well and weigh 130 lb. I ran my numbers through Dr. Susan Ott's BMAD calculator out of curiosity. BMD T-scores: L1-L4 -3.3 and hip at -1.8. BMAD T-scores -2.3 and -1.2. REMS has not received Health Canada's approval as yet - I am looking forward to its availability.
Thank you for sharing the link to that report! I too, have small bones and my T-scores are similar to yours. I unfortunately have started Tymlos out of fear, but am continuing to look for alternatives. (I see a new endocrinologist next week). Thanks again, I can't wait to read the report.
My mother and I are both small boned individuals, but her DEXA numbers are superlative while mine show osteoporosis.
She is 5’3” while I am nearly 5’5”. (However she has always been more active since childhood. )
I’m trying to reconcile this info with the concept that DEXA scans read petite people as having lower bone density. Hers show highly dense bones. I’m confused.
Maybe your bones are smaller in size? Your mother's L1-L4 T-score may be higher due to degenerative changes such as osteoarthritis. As American Bone Health points out low BMD is a single fracture risk factor. Have you used their Fracture Risk Calculator to determine your overall risk?
It’s possible my bones are smaller in size, but our forearm bones are similar diameter.
About the T scores: Her numbers are much better than mine in both spine and hip. Hers read like a 30 year old. Are you thinking that arthritis might make the scores look better than they really should be?
I would like to think my -2.8 scores are misleading because my bones are small -but then I would expect her numbers to be artificially poor too. I suspect she just has denser bones from being more active as a teenager.
It seems as if all these differences would have been washed out in the long term studies of fracture risk. Sigh.
Thanks for mentioning the calculator. My risk was in the green range when I used the tool just now without my t scores. (Yay!) But I’ll have to pull out my last DEXA scores to calculate it properly. I’m going from memory here.
Are you aware that according to former ISCD president, Dr. Neil Binkley major DXA errors are 'rampant'? I recommend his presentations in addition to those by densitometrist Larry Jankowski.
I am a little confused about small boned. I am almost 5'10" and 140 lbs but based on the frame test I am small framed. It is based on wrist size vs. height is what I understand. Am I getting this wrong?
It is wrist size. I have since learnt that even a volumetric bone density reading is no better than predicting fractures than BMD nor BMAD. Bone strength is complex as is fracture.
Thank you for sharing your updates. This is very curious about the differences in scores. It sounds like you can manage with proper diet, supplements, and weight bearing exercise. If you're interested, I have been listening to the Bone Coach podcast with Kevin Ellis. Several of the episodes provide excellent information from experts. Good luck with your journey!
Thank you all for your knowledge and support. You are all so amazing and brave to chart your own course.
Oscarbuddy- if you are comfortable sharing, I would be interested in how it goes with the new endocrinologist. I still need to meet with my primary and explain to her why I am not taking the osteologist’s advice. The journal articles you all have shared will help.
Will check out the Bone Coach !
Yes, I will let you know. We are in the Chicago area. She is supposed to be an osteoporosis specialist.
FWIW Expertscape's website. If you click on a person's name you get information on their published papers etc. expertscape.com/ex/osteopor...
Hi Oscarbuddy , how did your session with the new specialist go? I hope you’ve found hope or help or both.
Sorry, I forgot about sharing while reading other comments! She is VERY knowledgeable about osteoporosis. After reviewing my test results, she said the major cause is menopause, ((low estrogen). She said most bone loss in women occurs within 5 years of menopause. After that, it is normal to lose bone density but not at such a high rate.
She did order blood tests (bone markers, CTx and P1NP) since I have been on Tymlos for about 1 month. She also ordered 24-hour urine Calcium, as Tymlos will increase the Calcium in your urine. All results are "normal" for someone on Tymlos, and indicate that it is working as it should. After 3 months on Tymlos, I will get another DEXA scan and they will compute the TBS to show my bone quality. She indicated that if it is much improved, she may take me off the Tymlos, but I will need to take a bisphosphonate like Reclast so I don't lose any bone I may have gained. We are also going to test for celiac disease again, because I had cut gluten out of my diet for 6 months when another doctor had it tested. You need to have at least some gluten in your diet in order for the test to show any antibodies. Let me know if you have any other questions about the tests I have mentioned and I am more than happy to share what I have learned. Thank you for reaching out.
Thanks so much for the update and for providing all that information. It’s so helpful to hear from your expert and that you feel good about your program. 🙏
It sounds like you found a great doctor! I started getting emails from The Bone Coach, and he seems like he knows what he is talking about. I haven't joined his team, but am hoping for new advice on where to go from here. I would like to get a REMS scan, but can't find a location in my area. How did you find one? Thanks for your info on prior posts.
Hi there, I did not get a REMS scan, but I got a DEXA scan with a TBS score. (TBS is trabecular bone score, indicating bone strength/microarchitecture) The TBS score is "calculated" from the DEXA scan. The clinic where you have your DEXA scan needs to have the software to compute and image the TBS.
There is a website that will tell you where you can get a DEXA with the TBS. I'm at work right now, but when I'm home later, I'll pull up and share the site from my home computer.
I’m very interested in how your TBS score related to your T-score. REMS provides what they call a fragility score that takes into account bone quality as well as density. My REMS fragility scores indicated far less risk of fracture over the next five years than what the REMS T-scores alone indicated. Does the TBS allow for a similar calculation?
I'm not sure. I do know that my TBS scores were in the "good" range, indicating that I may have low bone density, but my bone strength and microarchitecture are good. Of course, I have been on Tymlos for the last 5 months so that has helped T scores. I never had a TBS prior to the Tymlos, so I don't know if that was affected. (my spine and hip T-scores are in the osteopenia category now)
Sorry I can't be of more help.
I can say, that the clinician at my latest DEXA/TBS was VERY careful with my positioning. This did not happen at my primary care office when I had the DEXA scan that resulted in T-scores in the -4 range. I still think that the results at my primary care were lower than reality. Which is why I pushed for another DEXA test at my new endocrinologist. But out of fear of the earlier low T-scores, I had already agreed to taking the Tymlos.
Here is the website to find a clinic that offers TBS along with DEXA scan: medimapsgroup.com/find-a-cl...
Thank you!
At this point, I think there is not a lot of data. It's one of several interesting new technologies that are coming on the market. At the moment, DXA is still the "gold standard" for osteoporosis diagnosis.
DEXA is still the gold standard, in that it's the preferred approach, but there's a growing body of evidence that REMS gives more reliable results. It's more fully automated, therefore is less open to operator error with both positioning and interpretation of results.
I think we'll see more use of these new technologies in a few years. I don't think insurance is covering their use at the moment.
I'm in the UK, and it's only available here if we pay for it, not on the NHS.
Agreed, insurance doesn’t risk paying for newer technologies until there’s more track record to show the tool helps prevent more costs later. I’m happy to see innovation, though, because DEXA is valuable but measures just one aspect of data.
I am also wondering if anyone has had an REMS scan. How do I find out availability in my area?
Watercolors. I’ve had several REMS scans in the last year on two different machines with very similar results—one in NJ and another in DC at a menopause convention 
where the Echolight folks were demonstrating the machine to practitioners. For information on where REMS scans are available in the US contact Vicki Baldwin [vbaldwin@echolightmedical.com]. Hope this helps.
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