Throughout my career specializing in bone health, I've witnessed countless clients arrive at my office clutching their DXA scan results, eyes wide with fear after being told they have osteoporosis. Many were immediately prescribed powerful medications based solely on these scans. But here's what many doctors aren't telling you: DXA scans, while long considered the gold standard for bone health assessment, have significant limitations that can lead to misdiagnosis, unnecessary anxiety, and potentially harmful overtreatment.

The Silent Crisis in Bone Health Assessment

According to the U.S. Department of Health and Human Services, approximately 10 million Americans over age 50 have osteoporosis, with another 43 million having low bone mineral density. These numbers are concerning, but what's more troubling is how we're diagnosing and treating these individuals.

DXA (Dual-Energy X-ray Absorptiometry) scans measure bone mineral density (BMD) at specific sites, typically the hip and spine. While this technology has served us for decades, emerging research reveals critical shortcomings that every patient should understand before making treatment decisions.

Why DXA Falls Short: The Technical Limitations

DXA's most fundamental flaw is its two-dimensional nature. When examining the complex three-dimensional structure of bone, DXA essentially flattens everything into a single plane, creating several problems:

1. Limited Resolution: DXA's pixel size is approximately four times larger than the average trabecular thickness in bone. This means the fine microarchitecture that significantly contributes to bone strength is literally invisible to DXA.

2. Misleading Artifacts: Spinal calcifications, arthritis, and even obesity can artificially inflate BMD readings. One patient might appear to have healthy bone density when in fact they have significant structural weakness, while another might be diagnosed with osteoporosis despite having functionally strong bones.

3. One-Dimensional Assessment: Bone strength isn't just about mineral quantity—quality matters tremendously. DXA focuses almost entirely on density, missing critical factors like collagen quality, bone turnover rate, and microdamage that determine how bones will perform under stress.

As one review noted, "many skeletal features other than BMD escape DXA's grasp," yet treatment decisions are frequently made based on this limited data point.

The Consequences of Misdiagnosis

When DXA results are interpreted uncritically, the consequences can be serious:

Psychological Impact: Being labeled with osteoporosis can trigger what researchers call "fear-based medicine." Studies have documented patients becoming afraid of normal activities, seeing themselves as fragile "like glass." This fear can lead to reduced physical activity—ironically, one of the best ways to build bone strength.

Medication Overuse: Bisphosphonates, commonly prescribed after a concerning DXA scan, work by inhibiting bone resorption. While these medications can help those with genuine high fracture risk, they carry side effects including severe musculoskeletal pain. More concerning, long-term use can actually lead to compromised bone quality by preserving "old bone" rather than promoting healthy bone formation.

An investigation by BMJ Journal stated bluntly that drug treatment of at-risk bone patients "can achieve at best a marginal reduction in hip fractures at the cost of unnecessary harms." For patients with borderline or artificially low readings, these risks often outweigh the benefits.

The REMS Revolution: A Better Approach

Fortunately, newer technologies are emerging that address DXA's limitations. Radiofrequency Echographic Multi Spectrometry (REMS) represents a significant advancement, using ultrasound to evaluate both bone density and quality without radiation exposure.

REMS provides several advantages:

• Three-Dimensional Insight: By analyzing the full spectrum of ultrasound signals, REMS can differentiate between cortical (outer) and trabecular (inner) bone, providing crucial information about bone structure.

• Superior Precision: Clinical studies have demonstrated excellent repeatability with precision error under 0.5% at both spine and femur sites—better than typical DXA scans.

• Radiation-Free Safety: Unlike DXA, REMS uses harmless sound waves, allowing more frequent monitoring without radiation concerns, particularly beneficial for women of childbearing age, children, and adolescents.

• Quality Assessment: Perhaps most importantly, REMS provides a qualitative evaluation of bone microstructure through measures like the "Fragility Score," helping distinguish between patients with similar BMD but very different fracture risks.

A Comprehensive Approach to Bone Health

Rather than relying solely on DXA or any single test, I advocate for a comprehensive approach that may include:

• Confirming questionable DXA results with REMS scans

• Evaluating bone turnover markers through blood tests

• Conducting thorough risk factor assessments including diet, exercise habits, and fall risk

• Prioritizing lifestyle modifications like targeted exercise programs and nutritional optimization

• Using medications judiciously only for those with genuine high fracture risk

This multifaceted strategy provides a more accurate picture of bone health and focuses interventions where they'll truly benefit patients.

Taking Control of Your Bone Health

If you're concerned about osteoporosis or have been diagnosed based solely on a DXA scan, consider these steps:

1. Ask your doctor about additional assessment methods like REMS

2. Discuss bone turnover markers and other lab tests

3. Evaluate your overall fracture risk beyond just your T-score

4. Consider a second opinion before starting long-term medication

5. Focus on bone-building nutrition and weight-bearing exercise

Remember, bone strength involves much more than density alone. By taking a more comprehensive approach to assessment, you can avoid unnecessary anxiety and treatment while taking truly effective steps to protect your bone health.

The future of bone health assessment lies beyond DXA's limitations. By embracing newer technologies like REMS and more holistic evaluation methods, we can provide patients with more accurate diagnoses and truly personalized treatment plans that strengthen not just their bones, but their confidence in managing their health.

Collier County residents now have REMS technology available in their community and anyone interested in a more comprehensive bone assessment can receive a REMS scan without requiring a doctor's referral. 

Dr. Krystyna Shepetiuk is a Doctor of Pharmacy, a bone health specialist and co-owner of Strength Labs, located at 3441 Tamiami Trail N., in Naples. To learn more or schedule an assessment, call 239-544-4114. Visit ScreenMyBones.us.