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Understanding REMS: A New Era in Bone Health Assessment

egarrison@wte.net (Eric Garrison) — Fri, 12 Apr 2024 01:11:57 GMT

Are you concerned about your bone health and wondering if REMS is right for you?

Here's what you need to know:

Why should we reconsider how fracture risk is determined?

Wed, 06 Dec 2023 20:11:33 GMT

Bone Strength vs BMD

Historically, Bone Mineral Density (BMD) has been the default value for determining fracture risk. However, it is now recognized that, although low BMD values are associated with an increased risk of fracturing, BMD is not the absolute determinant of fracture risk. There are individuals with low BMD values that never fracture and conversely, a large percentage of individuals who sustain fragility fractures have BMD values that are above the osteoporotic range. There have been recent improvements in the understanding of bone structure and new capabilities are now available for quantitative measurements using novel technologies. Therefore, it is now universally accepted that multiple properties of bone need to be assessed to be able to correctly predict fracture risk. “Bone quality” is a term that is now ascribed to important structural properties of bone.

The “strength “of a material is a standard engineering term that describes the capacity of the material to withstand applied forces and not fail. Therefore, it is appropriate to use the term strength to describe the ability of a bone not to fracture due to an applied force. The strength of a material is a function of multiple physical properties of the material which include its microstructural properties. BMD and bone quality are two of the microstructural properties of bone. Infrared spectral analysis of bone biopsy specimens, determined that factors such as bone crystal size and collagen maturity, have a predictive value for fracture risk. It is now recognized that bone quality is a composite description of multiple microstructural properties of the bone which include the bone-mineral composition, the microarchitecture and the presence and the amount of micro fracturing present in addition to the amount and the integrity of the collagen components and the correct collagen-crosslinking. These properties are all integral components of the bone mineral crystal. BMD and bone quality are now considered to be the critical properties that determine bone strength. Consensus is growing that the term “bone strength” should replace “bone quality” when assessing bone structure.

In summary, the ability of a bone to withstand applied forces and not fracture should now be referred to as the bone strength. Bone strength is believed to be a composite property of the bone which consists of the density (BMD) and the bone quality. Recommendations are for both properties to be assessed to determine bone health and fracture risk.

Mobile Bone Health is a reality!

Tue, 21 Nov 2023 16:04:52 GMT

Bringing bone health to the patient

DXA densitometry has been the accepted standard for bone densitometry for over 30 years. It has helped healthcare providers include bone health as part of routine medical care. However, DXA has had limitations including a high error rate, lack of availability in many locations and repeated exposure to ionizing radiation during serial monitoring. It cannot be offered as an onsite service and requires a visit to an imaging center.

REMS densitometry is changing the bone heath landscape. REMS Radiofrequency Echographic Multi Spectrometry) is a newer method of performing standard densitometry which also offers the additional benefit of assessing microstructural properties of bone referred to as bone quality. The REMS bone quality assessment referred to as the Fragility Score provides the most accurate method currently available to assess fracture risk [ Paola Pisani , Francesco Conversano , Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years, Aging Clinical and Experimental Research volume 35, pages 763–773 (2023]. Because REMS is an ultrasound (pulsed echographic sonography) it is safe and portable!

Healthcare is preventative medicine – it is the core of fracture prevention. Early screening is essential. Many in the bone healthcare field recommend perimenopausal bone densitometric assessment around the age of 50 yo, not 65 yo as is the current recommendation. By 65 yo a woman may have lost 30% of her skeleton and by that time treatment choices are significantly limited. With early bone assessment, a baseline can be established and then routine yearly monitoring would be recommended. This recommendation for bone health monitoring is very much in line with other healthcare monitoring - blood pressure, cholesterol, and diabetes screening.

CCOA and BH@SOS would like you to consider offering a mobile REMS service to your patients. We would like the opportunity to discuss the potential that a bone health program can bring to the medical services that you provide. Too often, bone health gets forgotten in routine medical healthcare and patients only find out when it is too late that their bones are not healthy – by breaking a wrist, hip, vertebral body, pelvis, or shoulder. Or patients may be unnecessary prescribed medication based only on a BMD value without any reference to their bone quality measure which is the best measure of fracture risk.

Osteoporosis – a silent epidemic

Tue, 21 Nov 2023 16:01:31 GMT

If you ignore your bones, they will go away!

Rates of osteoporosis and fractures associated with poor bone quality, which are known as fragility fractures, are at epidemic levels. It is estimated that osteoporosis affects approximately 200 million people world-wide. Currently, it is also estimated that 10 million individuals over age 50 in the United States have osteoporosis. Each year an approximately 2 million individuals suffer a fracture due to osteoporosis. The risk of a fracture increases with age and is greatest in women. Approximately 1 in 2 women and 1 in 5 men age 50 or older will experience a hip, spine, or wrist fracture sometime during their lives. Approximately 40% of individuals are unable to return to their homes following a fragility fracture and require relocation to a nursing facility. As many as 20% of individuals will die within 6 - 12 months of a fragility fracture. Also, an additional 33.6 million individuals over age 50 have low bone density or “osteopenia” and thus are at risk of osteoporosis and fragility fracture.

Monitoring of the bone health is the foundation of fracture prevention in the way monitoring blood pressure is to stroke prevention and mammograms are to breast cancer prevention. The early detection of any of these conditions, allows for early treatment to be institutes to prevent the long-term consequences of the disease. Bone health assessment is looking for osteoporosis. Although, some may still consider developing osteoporosis an unfortunate part of growing older, it is now understood that fracturing due to idiopathic age-related bone loss is not an inevitable part of aging but a potentially preventable disease process. Nutrition and exercise fight against osteoporosis – monitoring makes sure that they are working.

The term for bone monitoring is known as bone densitometry – the measurement of bone density. Determining bone mineral density (BMD) has been the traditional method of diagnosing osteoporosis and predicting fracture risk. The most common way to measure BMD is by using Dual Energy X-ray Absorptiometry (DXA). DXA has been around for over 30 years and has been the backbone of Bone Healthcare. It is a method of measuring BMD by using low-energy x-ray and has been considered reasonably reliable for measuring BMD and diagnosing and treating osteoporosis.

There is another method of bone densitometry that not only determines BMD but also give a measure of the Bone Quality. Radiofrequency Echographic Multi Spectrometry (REMS) is a newer method of performing monitoring bone health that was developed and has been used in Europe for almost ten years and has replaced DXA as the official method of bone densitometry in Italy. REMS uses ultrasound to measure BMD. However, the ultrasound is also capable of measuring Bone Quality and therefore when REMS is used to assess bone, more information is obtained and there is a better way to predict fracture risk. REMS is still very new in the United States but its popularity is growing as more and more people are finding out about it.

In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you and poor bone health can affect anyone. So, bone healthcare is an issue for everyone and something that we all need to be aware of. Everyone has a skeleton and we need to pay attention to and take care of our skeletons because if you ignore your bones, they will go away!

Alphabet Soup - Decoded

Tue, 21 Nov 2023 15:20:58 GMT

Medical Science is full of acronyms - here is a list of those commonly used on this site!

BMD - Bone Mineral Density - A measure of bone health that compares your bone density, or mass, to that of a healthy person who is the same age and sex as you are.
DXA - Dual Energy X-ray Absorptiometry - commonly used method of determining bone density using two x-ray beams of relatively low and differing energy levels to assess the capacity of the bone to attenuate the beams.
FS - Fragility Score - a measure of bone quality and fracture risk available through REMS
Osteopenia - low bone mass or decreased calcification of bone without the clinically increased risk of fracture.
Osteoporosis - "systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk' (National Institutes of Health and the National Osteoporosis Foundation)
QUS - Quantitative Ultrasound
REMS - Radiofrequency Echographic Multi Spectrometry - an ultrasound-based method of assessing bone density and quality.
ROI - Region of Interest - where the bone health is assessed - generally the spine and hips.

Bone Health is a Women's Healthcare Issue

Thu, 16 Nov 2023 18:55:45 GMT

If you ignore your bones, they will go away!

To stem the exponential rise in osteoporosis and fragility fractures and the associated human suffering and financial burden on society, it is important that our healthcare policy makers develop and implement public-wide screening and testing programs, and education programs to increase awareness of the public on the importance of bone health. Also, our leadership needs to show that it is serious in this endeavor by allocating sufficient resources to the front-line healthcare providers to appropriately address this crisis in their patient base. However, until that policy-shift happens, there are things that can be done on an individual basis to maximize bone health and to minimize the risk of fracture.

Bone health is not too different from heart health or gut health – we have to realize that all of our body systems work together in unison and often it is when that synergy gets interrupted and things are out-of-synch that we get sick. The basics of good health are pretty consistent – nutritious and balanced diet, active lifestyle, minimizing stress, appropriate exercise and plenty of rest. Also avoiding unhealthy lifestyle habits such as smoking and excessive alcohol consumption and eating low-nutrition and overly processed foods. These recommendations are pretty universal. However, there are some bone-specific recommendations.

Proper nutrition is extremely important for healthy bones throughout life but in particular during the years that bone is forming – up to approximately 30 years old. After that, the amount of bone that we have in our bodies will decrease as we get older. This bone loss happens in both men and women but it happens at much more rapidly and to a higher degree in women. There are some estimates that women may lose approximately 20-30% of their entire bone mass in the 10-15 years surrounding menopause. That is why the majority of fragility fractures happen in women. Now it is not inevitable that all that bone loss has to happen and things can be done to prevent or slow down bone loss. Although the main goal of a Bone Health program is to stop bone loss, it is just as important to address bone health early - early implementation of health nutritional habits twill help maximize the bone-building process and will optimize the amount of bone that we have throughout our lives.

An additional factor that is very important in both forming and maintaining healthy bone is activity and exercise. Bone development and remodeling is driven by the applied forces that the bone “feels”. Impact (light to medium) stimulates the bone cells called osteocytes that live in the bone matrix to send out signals to the bone building cells – the osteoblasts to start responding to those forces by building more bone. Also, bone health is maintained when muscles are strong so that the bone “feels” the pull of those muscles. Strong muscles come from living an active lifestyle and doing regular exercises. There is a theory that optimal bone building comes from additional exercises – the phrase “osteogenic loading” specifically refers to exercises where bone feel additional applied forces that stimulate bone to maintain its optimal composition. It is also known, that maintaining muscle strength helps maintain a good sense of balance – and when you have good sense of balance falls and therefore breaks are less likely!

If levels of nutrition and exercise were not enough to maintain a healthy skeleton, or other medical conditions are affecting bone quality, then there are specific medications that can help to prevent bone loss or even to reinvigorate the bone to build back a little. The decision to use any of these medications should be made in consultation with your bone healthcare provider. And if you are started on any of these medications you must be compliant with the directions of use and monitoring the effectiveness of the medications is also essential.

In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you and although we focused on bone health as a women’s health issue, poor bone health can affect anyone. So, bone healthcare is an issue for everyone and something that we all need to be aware of. Everyone has a skeleton and we need to pay attention to and take care of our skeletons because………...

If you ignore your bones, they will go away!

What is REMS in less technical terms

Sun, 05 Nov 2023 18:47:50 GMT

What is REMS?

REMS is a method of bone assessment the utilizes pulsed echographic ultrasonography – REMS is a technology developed by Echolight. REMS is utilized by the EchoS, an ultrasound unit that generates a sound wave that bounces off your bones creating echoes. REMS will then listen to the echoes to determine properties of your bones. REMS can do that because an echo from a strong bone will be different than an echo from a weak bone. The measurements obtained by REMS comply with the standards established by the World Health Organization for bone assessment. REMS assess your spine and left and right hips to generate two values that are critical to your bone health: These numbers are:

(1) Fragility Score - FS

(2) Bone Mineral Density - BMD

Historically, Bone Mineral Density (BMD) has been the number that was used to determine if you were at risk of sustaining a fragility fracture. However, it is now recognized that BMD is not the only important number because there are individuals with low BMD that never fracture and there are other individuals who sustain fragility fractures and have good BMD. Research is showing that there are other properties of bone that need to be measured. The important bone equation is:

Strength = Bone Quality & BMD

Fragility Score (FS) is a measure of bone quality that can help you have a better understanding of your risk of a fragility fracture. Also, there is a third bit of information that the REMS assessment will provide. This is:

(3) Body Composition and Estimated Activity Metabolism

The information provided by the Body Composition Analysis may provide useful information for a comprehensive weight loss program. The results obtained by REMS examinations are clinically valid and can be used in your bone health care.

REMS is an ultrasound-based technology and it does not generate x-rays like DXA does. It is a safe method of bone assessment and it can be done at OsteoStrong. REMS is free to travel all roads to reach those who are in search of quality bone health assessment and have the desire to maintain a healthy skeleton to best prevent life-altering and often life-threatening fragility fractures.

Clues in Interpreting Your REMS and DXA Reports- what data is important and how to look for patterns and consistency.

Tue, 18 Oct 2022 13:38:08 GMT

The goal of all of our REMS posts is for everyone to better understand what REMS is, what information REMS provides to you and the means by which REMS determines that information. Also, we want everyone to understand how REMS differs from DXA even though both methods of bone densitometry are equally valid and accepted means of diagnosing and monitoring osteoporosis. The fundamental difference between REMS and DXA is the type of energy that is used to perform the study - REMS is ultrasound-based and DXA is x-ray-based. Both methods of bone densitometry were developed utilizing the intrinsic properties of their relative energy sources to analyze bone and then provide information that is mathematically analyzed. And, although the information is obtained by different physical methods, the density that is determined by either REMS or DXA is reported according to established WHO standards in both methods. And it is also due to the physical properties of ultrasound, that REMS not only is less susceptible to some of the artifactual errors that can affect DXA results but is also capable of delivering information on the structural properties of bone that are related to bone quality. (DXA has that capability if the TBS software is available).

We also want you to better understand how to look at and read the reports that you get when you have a bone densitometry study done. We want to emphasize that we are not trying to teach you how to interpret the report - interpretation of any medical report should be done by a provider that is trained and has experience in analyzing the data on a report, making sense of that data then making recommendations on how to apply that data to treatment recommendations. However, in order to have a better conversation with your provider, an understanding of what the numbers on a bone densitometry report mean would be very helpful.

There will be information on both REMS and DXA reports that are similar - BMD (g/cm2) T-score, Z-score and the diagnosis based on the T-score. Both systems have been determined to be a clinically valid means of determining BMD and T-score values and therefore in diagnosing and monitoring osteoporosis. T-scores are the method of using a statistical model to compare a measured BMD (bone density) value to an established “normal” value (please see our earlier FB post that explains all of these terms).

However, there will also be differences due to the differences in the technologies that are utilized by the systems. For example, REMS does not need to be routinely calibrated - the piezoelectric crystals in the transducer do not degrade and the occasional software and system upgrades that are done remotely are the only recommendations for unit maintenance. DXA however, uses an x-ray tube that, similar to any light bulb, will have a progressive degradation of its power and a resulting variability in the results and loss of accuracy. Therefore, a complete DXA report should include calibration parameters. Also, the Least Significant Change determined at 95% confidence (LSC) is a measure of the accuracy of a DXA and needs to be calculated at routine intervals (recommended monthly) for all of the examiners using the machine. The details of these calibration requirements are out of the scope of the REMS Discussion Group (thankfully, REMS users don’t have to worry about all that stuff) but all of you DXA users out there can (and should) be reviewing it on the ISCD website - www.iscd.org. Also, it is very important to have a copy of the DXA image page in order to make sure that the positioning of the ROIs and settings were done correctly. Either improper positioning of the ROI or improperly positioned capture boxes will affect the accuracy of the BMD measurement.

Now to get to the actual reports! A general and a very basic principle that applies to reviewing not only a densitometry report, but any medical report is that it needs to make sense. The numbers on a report should fall into certain groupings and have a logical consistency. An example of numbers that should cluster are the T-score values that are determined during bone density testing. Except in the situation of uncommon physiological conditions (i.e., transient osteoporosis of pregnancy and lactation) or the presence of pathological processes (disease conditions such as certain cancers, metastatic disease or metabolic bone diseases), the density of bone in an otherwise healthy individual will be relatively uniform and therefore, the T-score values should be concordant (similar) and not discordant (dissimilar) between the different Regions of Interest (ROIs). The average T-score value of the vertebral bodies (L1-L4) and the T-score values of the left and right hips should be close. The ISCD recommends that the T-score values of the spine and hips should be within one Standard Deviation of one another.

It has been our experience with REMS that the T-score values obtained at the spine and hips are usually concordant with the differences routinely in the 0.2 - 0.3 range, and usually no more than 0.3 - 0.5 Standard Deviations. It also has been anecdotally noted that when a DXA scan appears to have been well-performed (the image page is available and shows good positioning), and the spine and hip T-scores are concordant, then the REMS T-scores and DXA T-scores tend to also be relatively similar. Many times, it also has been noted that when the DXA hip and spine T-scores are discordant, the REMS measured T-scores will often be more similar to the DXA hip T-scores. In such a case, the DXA spine T-score should be considered an outlier and not considered as a valid measure (back to the basic concept that things should make sense). However, there are times that the REMS results and DXA results will just not match. In those cases, it is the responsibility of the provider to look at the numbers and see which ones make more sense. Also, it is always important to evaluate the other aspects of the reports including the bone quality measures (Fragility Score - we’re getting to that pretty soon), as well as all Relevant Clinical Factors in the medical history to determine treatment recommendations.

There are several other patterns that also should be evaluated. And, as with the T-scores, consistency of results is the general concept that applies. The individual T-score values of the vertebral bodies are not relevant to diagnosing or treating osteoporosis - it is the averaged T-score value of all of the vertebral bodies examined (Total). Also, at least two vertebral bodies must have been successfully examined for a clinical diagnosis to be made - the results of a single vertebral body cannot be used for establishing a diagnosis. Therefore, although one individual vertebral body may have a T-score that is “osteoporotic”, the diagnosis of osteoporosis is not correct unless the Total value is less than - 2.5. However, the BMD values of the vertebral bodies should be “looked at” with the expectation that the BMD values will increase from L1 through L4. There are some cases where that pattern does not happen - if the BMD values remain close then the overall results should not be affected by that situation. However, if one of the BMD values is way out of line with the others, it should not be included in the average (and your provider should consider a further diagnostic w/u to determine why the BMD value was out of sequence). Also, there are two BMD values of importance when evaluating the hips. The Femoral Neck (or Neck) BMD and the Total BMD. The Neck BMD should always be smaller than the Total BMD - if it is not, in the vast majority of DXA exams where this occurs it was the study was not done correctly, with an error in positioning being the most likely culprit for the discrepancy (only in a very small percentage of the cases there is the possibility that a physiologic problem with the bone would cause that finding and a w/u by your provider would be indicated). It is our anecdotal experience that we have not seen that situation occur in any of our REMS studies. Trochanteric BMD values are more of a historic relic and are not used in the determination of diagnoses.

There is one more clinical application of the BMD values - to determine whether or not there is any change between studies performed in a series. Quantitative analysis (mathematical averaging) is performed using BMD values of the Total spine and the Total hips (not the Neck). Although a qualitative “look” and T-scores between tests can be used as a quick and dirty way to compare studies, actual bone loss/gain calculations should only be done with BMD values. When using REMS, comparisons can be made without regard to where or who did the study - the documented rates between different users and between different EchoS units are extremely small. However, when comparing DXA results it is important to remember that only when the DXA was performed on the same machine and preferably by the same examiner will the quantitative analysis of BMD results really be meaningful. Also, the LSC of DXA is 5% - that means that there has to be at least a 5% change in the BMD in order for the change to be clinically meaningful. The LSC of REMS has been documented to be 0.5-1.0%. Therefore, a change in BMD greater than 1% may be clinically significant.

Unless the DXA study happens to include a TBS, then there is no more significant information on a DXA scan. However, the REMS test will provide a Fragility Score which is an assessment of Bone Quality.

The Fragility Score is determined from the sound waves that carry information on the structural properties of bone (please see our earlier posts). It is presented on a graph on the second page of the REMS report that depicts a database of individuals who have or who have not sustained a fragility fracture. The fragility score has been shown to be the most sensitive predictor of those individuals who are likely to fracture (true positives) as well as those individuals who are not likely to have a fracture (true negatives). If the FS that is determined by your REMS study places you in the “green zone” of the graph, then the likelihood of fracturing is very small. However, if you are in the FS “red zone” your risk of fracturing is high - the quality of your bone is similar to the quality of the bone of people who have sustained a fragility fracture. The FS is an independent predictor of fracture risk and is both more sensitive and specific than either the REMS-derived or DXA-derived BMD scores.

One last important piece of information offered by the REMS assessment is 5-year fracture risk assessment. The Fracture Risk Score can help your provider advise you to fracture risk and recommendations for treatment based on a quantitative score. Please note - the fracture risk is presented as a per-thousand score, not as a percent!

Hopefully, this explanation on how the different measured values derived from a bone densitometry can be assessed and understood. Again, the purpose of this post was to provide some insight and education into how your provider may look at the numbers in either a DXA or REMS report - however, you still need your provider to help you interpret the results in order to determine the best bone health plan for you.

REMS and DXA and QUS - comparison of technologies

Tue, 30 Aug 2022 17:04:14 GMT

Here are some bullet point comparisons of the three technologies as a quick reference

We at the Bone Matrix accepted REMS technology early on - but not blindly and only after investigation and assessment of the available information. However, other providers may be slower in coming around to new technology for all of the above stated reasons. It goes back to knowing your provider, respecting their time, and understanding where they are coming from. However, your provider also has the responsibility of providing the best level of care that is available to you and so we recommend that you remain patient but be persistent and always, always respectful. Obviously, bone health is an important issue to all of you, so make sure that your provider understands that point and they should address it with you the same way that they address your weight or your blood pressure.

SHORT REMS LIST:

REMS is equivalent to DXA in determining Bone Mass Density according to the World Health Organization standards
REMS can be used to diagnose and to monitor osteoporosis
REMS is radiation free - it is ultrasound-based
REMS is done in a provider’s office and results are immediately available
REMS is portable (significant public health value)
REMS learning curve is not steep
REMS is not prone to user error
REMS is not prone to artifact error or patient positioning error
REMS has a low LSC (0.5-1.0% - error rate) can be used to monitor bone over short periods of time
REMS measures BMD and also provides a Fragility Score
Fragility Score is a measure of BONE QUALITY
FDA approved REMS in the US in 2018
REMS is used in the European Union and multiple other countries: Italy, Belgium. France. United Kingdom, Poland, Australia, Japan, India, Brazil, Canada, Spain, United States.
REMS was designated the Official method for bone densitometry in Italy in 2020.

Please feel free to copy this list!

Referenced DXA/REMS Fact Sheet - compiled by Andy Bush, MD, FAAOS, CWSP and Kim Zambito, MD, FAOA, FAAOS:

Other considerations and comparisons

Osteoporosis is diagnosed based on the WHO standard of measuring BMD at axial Regions of Interest (spine and hips) and then determining the T-score. A T-score of (-)2.5 or lower has been defined as threshold for the diagnosis of osteoporosis. (Tümay S, et al, An overview and management of osteoporosis, Eur J Rheumatol 2017; 4: 46-56).

Historical methods of performing densitometry:

DXA (Dual Energy X-ray Absorptiometry) has been historically the standard method to measure BMD at the appropriate Regions of Interest and it is the main method in the United States used to diagnose and monitor Osteoporosis per WHO standards. (Lewiecki, M, et al, Best Practices for Dual-Energy X-ray Absorptiometry Measurement and Reporting: International Society for Clinical Densitometry Guidance, Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, Volume 19, 2016, 127-140)

Error rates in DXA can be up to 90%! - that includes all errors.

The established error rate in BMD determination is 40-50%!

LSC for a calibrated DXA is 5%. - therefore, only if the change between two DXA bone BMD measurements is 5% or greater then should the results be considered clinically significant (Lecture #6, Can you Trust this DXA Report?, IOF/ISCD Clinician Course, US version December 2020).

Heel ultrasound (QUS) is another historical method to assess bone. QUS measurements were found to be predictive of fracture risk. However, because of technical issues, QUS could not provide axial BMD measurements; therefore, it could not be used to diagnose and/or monitor osteoporosis based on WHO standards. (Krieg D, Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD, Official Positions, J Clinical Densit, 2008 Jan-Mar;11(1):163-87).

REMS (Radiofrequency Echographic Multi Spectrometry) is a novel sonographic (ultrasound) method of determining BMD. REMS is echogenic - it analyzes the soundwaves that have been reflected from the bone (the echo). Therefore, it is technically different from QUS which analyzes transmitted sound waves. Because of the technological improvements over QUS, REMS can be used for axial bone assessment. REMS has been determined to be a method that is equivalent to DXA in determining BMD at axial Regions of Interest (spine and hips). Therefore, REMS is a clinically acceptable method to diagnose and monitor Osteoporosis per WHO standards. It has been used for almost ten years in the European Union to determine BMD. (Cortet B, et al, Radiofrequency Echographic Multi Spectrometry (REMS) for the diagnosis of osteoporosis in a European multicenter clinical context, Bone, (2021) 143:115786).

REMS is FDA approved for use in the US for the determination of osteoporosis and to monitor its treatment and to provide a FRAX-based fracture risk. (FDA 501(k) premarket notification of intent to market, October 19, 2018).

Sources of error in densitometry:

DXA accuracy is affected by arthritis or other artifacts including patient positioning all of which can affect and modify how x-rays penetrate tissues (attenuation differential) leading to inaccurate BMD determination.

REMS is not susceptible to the effects of artifacts or by patient positioning. In a REMS assessment, the sound waves will interact with the tissues (bone) that they insonify and the information about the properties of that tissue will be contained in the “echo”. The echographic waves are analyzed and only the waveforms that are determined to be quantitatively similar to bone will be used for BMD and Fragility Score determination. (Giovanni Adami, et al, Radiofrequency Echographic Multis Spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study, Bone, (2020) 134:115297).

The reported LSC, Intra-operator and inter-operator repeatability for REMS are significantly less than DXA (0.5 - 1.05%). (Marco Di Paola, et al, Radiofrequency Echographic Multi Spectrometry compared with Dual X-ray Absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck, Osteoporosis International, (2019) 30(2):391-402).

DXA testing requires uniformity of testing methods to minimize error rates. When performing a series of tests with DXA it is imperative that all DXA scans are performed on the same machine preferably by the same examiner. The results of DXA tests performed on different machines and by different examiners should not be considered diagnostically useful. (Lecture #6, Can you Trust this DXA Report?, IOF/ISCD Clinician Course, US version December 2020).

REMS testing is echogenic and that is the reason why REMS is not susceptible to artifact error. The basic physics of insonified bone and how the reflected sound waves are analyzed eliminates the effects of arthritis, bone pathology and the presence of foreign material on the results of the REMS assessment. This is in significant contrast to DXA. (Marco Di Paola, et al, Radiofrequency Echographic Multi Spectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck, Osteoporosis International, (2019) 30(2):391-402).

DXA-derived BMD is not a very accurate way to determine fracture risk:

DXA-derived BMD fracture risk determination is imperfect. The correlation of BMD to fracture risk can be best described as associative, and not determinative. Low BMD values are associated with an increase in fracture risk; however, it is estimated that approximately 50% of all fragility-type fractures occur in individuals with BMD values that are either normal or near-normal. It is now understood that the structural properties of bone other than just BMD, which are commonly referred to as the bone quality, factor into the determination of fracture risk. (Leslie W, et al, Why Does Rate of Bone Density Loss Not Predict Fracture Risk? J of Clin Endo & Metab, 2015, 100(2); 679–683).

REMS offers a novel way to determine fracture risk:

REMS provides the Fragility Score (FS). The FS is a value that is derived from the identification and analysis of a particular sound wave that contains information on structural properties of the bone. The analysis of this sound wave yields a measure of bone quality. Therefore, FS is a method to quantify fracture risk - this aspect of REMS is similar to the established capability of QUS. (Paola Pisani, et al, A quantitative ultrasound approach to estimate bone fragility: A first comparison with dual X-ray absorptiometry, Measurement (2017) 101: 243-249).

Hopefully, the information in this post will help at least some of you in your Bone Health journey. Remember that healthcare is a team effort and your provider is a member or YOUR team. They are there to give you advice and guidance but the person who makes the ultimate decision for your healthcare is YOU! Please feel free to copy and paste the above information into a Word Document of PDF and take it along to your appointment. Your provider may be willing to look at it and it may open the door to a REMS discussion with them.

Is it Possible to Educate Your Healthcare Provider About REMS?

Tue, 30 Aug 2022 13:38:08 GMT

Since REMS is an emerging technology, here are some reminders about communicating effectively with your healthcare provider:

The answer is ……a definite maybe! Obviously, all provider-patient relationships are different and depend not only on the provider and the patient, but the type of relationship you can have with your provider often depends on the setting where the healthcare is being delivered. In the body of this post we hope to provide insight into what we as providers consider when we review information that a patient has brought to us. We want to offer some suggestions on how to encourage and increase the likelihood that your provider will read what you have provided to them.

Know thy provider!!!!! - Everyone is different and you probably will already know whether or not your provider is amenable to receiving information from patients. If it is not your provider’s style to be receptive - don’t push the issue because it will not work and it may just set up feelings of frustration and possibly even unnecessary animosity which is counter-productive to any provider-patient relationship. Let it go and look for other options!

Respect your provider’s time!!!! - Even if your provider is willing to look at information that you bring in to help you determine if it is reasonable and even possibly beneficial for you it will take up time. Time is a problem in our modern health care system - modern medicine has had to become a “lean and mean fighting machine.” As insurance reimbursement levels continue to fall in order to stay open medical practices have to be “efficient”. Your provider has mandatory objectives that need to be completed during your visit in order to “close the loop” that include identifying your medical issue, addressing it and providing treatment all within in either 10, 15 or 20 minutes, whatever time your provider’s business overlords have allotted (very few providers are in their own practices). After they have completed your visit, they have 20-30 more visits to complete! You may have to book additional time (the question is whether insurance will pay for that time) to discuss an educational issue in any significant detail.

Understand that your provider may be skeptical of internet-based information that you bring in order to help keep you safe!!!!! - The internet is fantastic in many ways and there is a wealth of knowledge just a click away! However, there are also scams, misinformation and deceptive practices flourishing, often dressed up to look legitimate and wholesome. When your provider reviews something that you bring in, there should be a level of caution on their part. However, providing patients with education is a big part of the healing process so your provider should be willing to critically evaluate what you have brought them and realize that you are bringing to their attention because it is important to you. You may want to even point out how important it is to you for them to evaluate what you have brought to them and that you really respect their opinion - otherwise you wouldn’t be putting your health into their hands!

Understand what “standards of care” means and implies!!! - How a provider practices is based on her/his knowledge-base which is a composite of education/school, training and experience. However, “standards of care” are the region specific medical care standards practiced by surrounding providers in similar practice situations. Obviously, the “standards of care” will be different between a University Medical Center and a small community hospital. However, both “standards” should still deliver an acceptable level of health care. In order to maintain practice with an accepted “standard of care” a provider may stay with acceptable methods of providing care and not venture out of that “standard of care” comfort zone. Cutting edge is often what brings about innovation in health care but it is possibly a risky proposition - that goes back to the premise that it is your provider's responsibility to keep you safe. In regards to our topic - DXA is considered “standard of care”; REMS has not yet achieved that designation (but we are working on it!)

Show your provider that you respect their advice and recommendations, but if you disagree, tell them why you don’t agree and what alternative plan you would prefer that they consider. Be sure to be able to explain your opinion and having a valid reference at hand will go a long way!!!! Understand that your provider wants to keep you safe, but they also want to provide the highest level of healthcare that they can - in 10 minutes. Ultimately, your health care is your decision! Ask your physician to partner with you and offer their guidance. This is not an unreasonable request to make to your provider. For example, every so often there will be a patient in my ortho practice who declines a cast. If splinting is a reasonable alternative, then I will explain to the patient why I think that casting is a better treatment choice; discuss explicit instructions for splint use and document the patient’s preference in the medical record, as well as their statement of understanding of risks and declination of my recommendations, and then apply the splint and continue to monitor their progress. In most cases, it’s not a big deal - but sometimes it may be so it has to be case-by-case!

With REMS, since many providers know nothing about it, you will have to be knowledgeable. Make sure that you understand the results of your report and the specific information that REMS provides that DXA does not (Fragility Score). To assist you in this challenge, the second portion of this post is an outline of the major properties of REMS with included references. If your provider is willing to accept it, or better yet to look it over in your presence, that may be the first step in the process of breaking through their first line of defenses and possibly raising their curiosity. You can only hope!

SHORT REMS LIST:

REMS is equivalent to DXA in determining BMD according to the World Health Organization standards

REMS can be used to diagnose and to monitor osteoporosis

REMS is radiation free - it is ultrasound-based

REMS is done in a provider’s office and results are immediately available

REMS is portable (significant public health value)

REMS learning curve is not steep - REMS is not prone to user error

REMS is not prone to artifact error or patient positioning error

REMS has a low LSC (0.5-1.0% - error rate) can be used to monitor bone over short periods of time

REMS measures BMD and also provides a Fragility Score

Fragility Score is a measure of BONE QUALITY

FDA approved in the US in 2018

REMS is used in the European Union and multiple other countries: Italy, Belgium. France. United Kingdom, Poland, Australia, Japan, India, Brazil, Canada, Spain, United States.

REMS was designated the Official method for bone densitometry in Italy in 2020.

Please feel free to copy this list!

Referenced DXA/REMS Fact Sheet - compiled by Andy Bush, MD, FAAOS, CWSP and Kim Zambito, MD, FAOA, FAAOS:

Historical methods of performing densitometry:

DXA (Dual Energy Xray Absorptiometry) has been historically the standard method to measure BMD at the appropriate Regions of Interest and it is the main method in the United States used to diagnose and monitor Osteoporosis per WHO standards. (Lewiecki, M, et al, Best Practices for Dual-Energy X-ray Absorptiometry Measurement and Reporting: International Society for Clinical Densitometry Guidance, Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, Volume 19, 2016, 127-140)

Error rates in DXA can be up to 90%! - that includes all errors. The established error rate in BMD determination is 40-50%! LSC for a calibrated DXA is 5%. - therefore, only if the change between two DXA bone BMD measurements is 5% or greater then should the results be considered clinically significant (Lecture #6, Can you Trust this DXA Report?, IOF/ISCD Clinician Course, US version December 2020).

REMS - novel method of bone densitometry:

Sources of error in densitometry:

DXA-derived BMD is not a very accurate way to determine fracture risk:

REMS offers a novel way to determine fracture risk:

Dr. Andy Bush's backstory

Wed, 24 Aug 2022 14:51:03 GMT

Dr. Andy Bush shares how he got into medicine and bone health

My journey into bone health was not something that I can claim that I really planned on doing and was more a reaction to the changing medical landscape. So let me start off with something easier - how I decided to go into medicine.

My path into healthcare was pretty straight-forward. I went to medical school straight out of college planning to be a family doc. However, after doing an orthopedic surgery elective in my third year of med school and seeing that the ortho operating room looked a lot like the workshop in my garage, I was smitten. I was lucky enough to get into an orthopedic residency program and embarked on my 25+ year career as an orthopedic surgeon. To say that those 25 years were like a roller-coaster ride is an understatement! Coming out of residency I had planned on practicing as a general orthopedic surgeon in a community-based practice. I believed that I would not only practice in the community but that my family and I would live in that community and be part of it, and that I would stay my entire career in that community just like many of the surgeons that I trained with and that I wanted to emulate. However, my career turned out very different. It was after I weathered a practice closure, several consulting jobs and a stint as a surgeon in the prison system and as a locum tenens, that I finally had the opportunity to start my own practice in a small town in rural North Carolina. Things went well early on and my practice grew by referral and by word-of-mouth. It seemed that all would be well.

However, things began to change. The rising costs of healthcare became a hot political topic and dramatic changes to Medicine were instituted. Multiple unfunded mandates (expensive things that the government makes you do but doesn’t reimburse you for) hit medical practices. EHR, digital x-ray and data collecting and reporting started significantly increasing the cost to practice medicine. Also insurance companies began to put up incredible hurdles for docs to be able to properly care for patients requiring incredible amounts of paperwork for “pre-authorizations”. At the same time they started to significantly decrease payments for medical services including surgeries all in the name of cost savings. (As an aside - as many of you may have noticed, insurance premiums did not go down even as reimbursements for providers were dramatically cut - please refer to your EOBs - and denials for services became common-place and perversely, insurance company profits and insurance company executive compensation skyrocketed to obscene levels - and premiums continue to rise!) These dramatic changes put a tremendous amount of financial pressure on many independent practices.

Being faced with this financial pressure a lot of practices threw in the towel and were either taken over by larger hospital systems and groups (Medical monopolies? What could possibly go wrong?) or just disappeared. My situation as a solo-practitioner in private practice was not very different but, being incredibly stubborn, I was determined to stay independent. However, to do so required that I fundamentally change my orthopedic practice. Surgery would remain part of my practice, but due to unsustainably low reimbursement for surgery it could not remain the primary service that I provided.

This is when I began to investigate some other options, one of which was providing “Bone Healthcare” services. It wouldn’t be unreasonable to assume that bone healthcare should be part of the realm of orthopedics. However, in reality, orthopedic surgeons are taught to fix fractures, not keep them from occurring - prevention was never a Grand Rounds topic. However, there are a handful of Orthopedic Surgeons who committed at least a part of their careers to bone healthcare and fracture prevention. It was after I read several articles, in particular articles written by the late Dr. Andy Bunta who was a Professor of Orthopedic Surgery at Northwestern University that the idea of bone healthcare began to develop in my mind. Dr. Bunta urged us, his orthopedic surgeon colleagues, to take leadership roles in bone healthcare, not only through fracture fixation but with fracture prevention. I realized that much of what Dr. Bunta and others were promoting was correct - bone healthcare was not really considered a serious healthcare issue and no one was taking ownership of it in the community. After consulting with my medical colleagues in town who at first seemed surprised by what I wanted to do but soon were very supportive of my decision to provide bone healthcare, I started my personal “bone health retraining” program. Being an obsessive-compulsive surgeon I started my program with a structured and rigorous approach - hours reading and studying and listening to lectures, webinars and CMEs that resulted in my practice obtaining FLS (Fracture Liaison Service) designation and Bone FIt certification. Membership in the AOA Own-the-Bone registry and completion of the ISCD densitometry training course then gave me a foundation to get my bone health program going. But, the one thing that jump-started the development of my program happened through serendipity.

As I was clearing out my email folder one morning, right before I was about to download a whole bunch of emails into the trash, one email caught my eye. It was about some kind of ultrasound machine called Echolight REMS that could help predict if patients might be susceptible to periprosthetic fractures (nasty types of fractures above or below joint replacements - see previous FB posts). Instead of throwing it in the trash I read that email and I was hooked. After a couple of email exchanges, telephone calls, and Zoom meetings, the Echolight team was in my office installing an EchoS unit to trial. The Echolight team also recommended that I call an orthopedic surgeon up in NJ who had started using Echolight REMS just several months earlier. I called that surgeon - Dr. Kimberly Zambito, and as they say, the rest was history. With the Echolight REMS and a lot of good advice from Dr. Zambito, my bone healthcare program took off and the Bone Matrix and the Echolight REMS discussion group became a reality. Although the Echolight REMS group still remains a small group of doctors, we are committed to providing quality Bone Healthcare and understand the impact that a fracture can have on someone's life. Dr. Zambito and I have both fixed thousands of fragility fractures and have seen those effects first-hand. But the other aspect with which I agree with Dr. Zambito is that it is very evident is the fact that there are a lot of folks who are scared - not only scared of fracturing but also scared because of the uncertainty that often goes along with getting the diagnosis of osteoporosis and not knowing or understanding what that really means.

Often the diagnosis of osteoporosis follows a DXA test. To give credit where credit is due, DXA had basically created the current field of Bone Health Medicine by providing a method of quantitatively measuring bone density. But DXA is an imperfect test that is prone to errors, especially when it needs to be done in a manner that allows it to be “efficient”. Due to the same poor healthcare policy decisions and insurance company greed that have affected all physicians, docs who own DXA machines are often forced to sacrifice quality for efficiency and many times the DXA scans are poorly done. Unfortunately, it is the individual who is getting the test that is the casualty of that situation, having to make significant healthcare decisions based on a test whose results may be flawed. In our bone health programs, we feel that with REMS technology, that yields both a BMD and a fragility score (measure of bone quality) we can provide an accurate, reproducible and reliable method of determining bone densitometry and quality and therefore help give our patients the reassurance that the decisions that they are making are based on correct data.

Dr. Kimberly Zambito backstory

Tue, 09 Aug 2022 14:55:38 GMT

Dr. Kimberly Zambito shares show she got interested in bone health

Greetings, Bone Babes! This is Dr. Kimberly Zambito. I’m happy to share my story about Bone Health and the Echolight REMS technology. I am an orthopaedic surgeon with a subspecialty in hand surgery. My interest in bone health began when I was a medical student. During 3rd year of medical school, students choose specialty pathways to guide their clinical rotations in the 4th year of medical school. I chose to combine two pathways- orthopaedic surgery and women’s health. Some people did not understand why, since orthopaedic surgery is such a male dominated field, and really, what does women’s health have to do with ortho? I listened to what critics had to say and I listened to advice from the few supporters who thought I had an interesting idea. I chose to follow my heart, my gut, and some great advice from women advisors who believed I could combine the two. To make a long story short, I completed a 5 year residency training in orthopaedic surgery, a one year fellowship in hand surgery, then embarked on my career in orthopaedic surgery/hand surgery and military service in the US Army Reserves. I absolutely loved serving our country. Caring for the men and women who have made incredible sacrifices on our behalf was an incredible honor. I deployed multiple times over the first 9 years of my career. The multiple deployments made continuity of care for my patients challenging. As a result, I developed relationships with colleagues (rheumatologists, endocrinologists, OB/Gyns, etc) who were able to serve patients in need of bone health optimization following orthopaedic surgery. Once my military career ended, I decided it was time for me to really engage my patients regarding their bone health. Yes, I fix broken bones. As much as I like fixing broken bones, I feel I have not provided complete care for my patients unless I can help my patients prevent the next fracture.

As I began to build a bone health program to engage my patients, I thought about the things I want. After all, I am at the magic time in life when a gal wakes up in the morning and ask, “what is going on…ugh…what’s starting to sag today…why aren’t my arms long enough to read the menu anymore…and man, now I understand why my grandparents cherished conversations about bowel movements?” I apologize for getting off track. What do I want for myself? I want to live life well- grateful for every blessing bestowed upon me. I want to age well with an appreciation that aging is a normal part of life and it is okay to evolve and grow on many levels. I want to optimize the things I can optimize…without medications.

Then I listened to the bone health community…just listened and read and learned from patients, from people who took a different approach to bone health, and to professional organizations.

Common themes surfaced. One theme was that no one really likes DXA because it has been fraught with errors. I researched different options including REMS technology. REMS technology has been available in Europe for many years. It was approved for use in the United States in late 2018. Echolight established a team in the US in 2019, then in March 2020, life was changed by COVID-19. For those individuals who want to know why there aren’t many REMS units in use in the US and why more doctors don’t know about it…here is your one simple answer. For those of you who have been living under a rock, there was a pandemic which crushed the world for two years. Trying to move forward with anything has been a challenge- no travel, no professional meetings to offer face-to-face engagement with other professionals, etc.

When I learned about the technology, I contacted the Echolight US team. In March 2021, I acquired the unit. I have performed scans on over 200 patients who come from all over the US and Canada. The information about bone quality as reflected in the Fragility Score is information patients cannot obtain from any other type of technology available. Someone may mention TBS, but that is a topic for another discussion. The technical aspects of REMS are for other posts. For this post, I really want to share two things. When I scan a patient, I get to spend time with my patient talking about whatever comes to mind- sometimes questions about REMS, sometimes about kids and life events, sometimes we have a good laugh about the last time we had “goo” on our bellies for ultrasound, sometimes we talk about gardening. I. Get. Time. With. A. Patient. Let that sink in. As a physician, that time is not valued by administrators or insurance carriers who would rather I cut and cure and see a patient every 5 minutes, then spend quality time with a patient. This is a criticism of healthcare in the US, not a criticism of former employment structures. The Echolight REMS technology allows me to engage patients. Its portability will allow me to reach out to underserved people who may not be able to get a DXA for various reasons.

The second thing I want to share is this- women with small bone structure who have lived healthy lives have been told they have osteoporosis and need to go on medication. Women who have never broken a bone. They have been scared…and I mean SCARED…that they are going to crumble and become disabled because a physician scared them. The REMS Fragility Score is a reflection of the QUALITY of bone. There are many women with low bone density and NORMAL quality of bone. Acquiring this information gives these women peace of mind that they will not disintegrate or crumble. In fact, it opens their minds and hearts to develop a relationship with their doctor and engage their doctor to develop a comprehensive plan for their bone health, rather than just simply taking medication. While some patients will benefit from medication; there is so much more to bone health- nutrition, exercise, balance, fall prevention, etc. Those are topics for The Bone Matrix group.

I believe REMS is ground-breaking technology that will change bone health conversations from a “you’re going to fall apart because your T-score is negative infinity” to “yeah, you have low bone density, but your bone quality is normal…and you’ve never broken a bone, let’s talk about how we can help you age well and prevent fractures…and no, you don’t need a medication at this point in time.”

That’s my story, Bone Babes. As for the nay-sayers, I’ve dealt with nay-sayers before…and in the sage words of Forest Gump, “That’s all I have to say about that.”

What Kind of Errors Can Happen With REMS and How Can They be Prevented?

Mon, 28 Mar 2022 13:38:08 GMT

Let us start off by first stating the obvious - that we are unabashed proponents of REMS technology. We are building successful bone health programs based on REMS. What started off as curiosity with a new and innovative technology led to an “a-ha!” moment - understanding the underlying principles of how sound waves interact with bone to provide an accurate measurement of BMD and an assessment of Bone Quality. Those out there who really understand the unique physical properties of sound will not only comprehend the fantastic capabilities of the current REMS technology but will also anticipate the incredible and yet-to-be discovered potential applications of acoustics science to the human body. This stuff is just amazing, and we are just starting to see the future of its use in all types of medical screening applications. The individuals who have chosen to use REMS are building solid bone health programs on a technology that is growing and developing!

While I am known in some circles to enjoy hat ing on DXA, I still am willing to give credit where credit is due. DXA is truly amazing technology. Period. The only reason why we are even writing this post and discussing osteoporosis these days is because of the advent of DXA. DXA was the first method with the necessary accuracy to determine BMD. I would stake the claim that all of the social media REMS-haters/DXA-lovers out there really don’t have the slightest clue about how complex DXA really is - the complex physics and mathematics that are behind every DXA scan and the true marvel of technology that it really is. The people who came up with DXA were obviously brilliant. As Bone Healthcare providers, we owe a lot to the developers of DXA and to those medical practitioners who initially started applying DXA to their Bone Health practices when it was a brand-new technology and not widely used or understood and not accepted by the general medical community. Those individuals have persisted and persevered and to this day they continue to promote the need for public awareness of Bone Health. DXA has been the foundation of their treatment of this crippling disease for over thirty years. And thirty years without change is a really long time! Maybe too long?

REMS is a completely different technology from DXA, based on a completely different manner in how the information on the properties of bone is collected (sound vs. ionizing radiation). Sound is a form of mechanical energy and therefore it can be modified by the physical properties of what it interacts with. REMS is an examination of bone with ultrasound - a single frequency soundwave is used to insonify the target bone (3.5MHz). The properties of the bone will alter the sound wave and the backscatter radio frequency wave (the echo) carries information on the physical properties of the bone that it just interacted with - just like the physical properties of a canyon will modify your voice when you yell into it and listen for your echo (see our second FB post). What that means is that a bone that has “good” density and “good” quality will alter the index sound wave differently than a bone with “bad” density and/or “bad” quality. REMS is then capable of analyzing the sound wave to generate the BMD value and Fragility Score. However, it is also important to realize that during this process, bone isn’t the only structure or tissue in our body that will interact with the sound wave and generate an echo. Therefore, the echo generated during a REMS study is an extremely complex soundwave and is actually composed of many different soundwaves coming from many different structures (bone, disc, cartilage, bone spurs, intestines, car keys). However, REMS isn’t confused by this complex soundwave. Utilizing a mathematical analysis (Fast Fourier Transformation) the complex sound wave is broken down into its component sound waves. The first level of filtering then analyzes the component soundwaves - artifacts that would be caused by non-bone sources are removed at this point because bone structure will have a specific spectral signature (fingerprint) that can be compared to a standard spectral database. Only the waveforms that meet the spectral requirements of bone are selected for the next level of analysis. If, for some reason, REMS was not able to detect and isolate enough sound waves that have the spectral criteria of bone then REMS does not proceed to the next step of analysis and requests that the examiner repeat the study. This eliminates the well known artifact error that plagues DXA scans (I couldn’t help myself).

In the case where there are a sufficient number of acceptable waveforms isolated during the scan, REMS will continue to process the information to generate an Osteoporosis Score (OS) and a Fragility score (FS). The Osteoporosis Score is derived from a sound wave that is significantly modified by bone density. This sound wave is then analyzed and is used to generate the OS. The OS is converted to a BMD value utilizing databases of bone ranging from normal to osteoporotic. The BMD value then is used to determine the T-score using the NHANES database. At this stage, limitations in REMS are due to the fact that all databases are based on the process of averaging a large group of individuals. Even though the process of REMS assessment of bone is not affected by the size of a bone that is being analyzed (soundwaves are not affected by bone size), the results of the REMS studies are constrained to the databases that are developed on population averages that tend to skew the results of individuals who may not be an “average” size. Unfortunately, DXA is also affected by the “averaging effects” of the available databases. However, the DXA issue is compounded by an intrinsic bone size error artifact due to the properties of x-ray and the method by which the bone is analyzed during a DXA scan (there I go again!). Back to REMS!

The FS is derived in a similar manner to the OS. A single sound wave that is affected by structural components of the bone is isolated and analyzed. It is then compared to a database of individuals who are fragile (have sustained a fragility-type fracture) or non-fragile (have not sustained a fragility-type fracture). The FS will then represent the probability of fracturing. The FS measurement has been shown in a recent study to be more sensitive and more specific in fracture prediction than either REMS or DXA BMD measured in the same study.

So, up to this point there really weren’t a lot of places where REMS could give a “wrong” result. If a study is determined by REMS to have insufficient data for analysis - it was found to be “noisy” REMS will automatically discard the study and there will be no data reported. Therefore, an incorrect report will not be generated! So where do the errors come from? Why then, were there a number of REMS assessments determined to be “erroneous” and therefore discarded from the large multi-center studies from Italy and the European Union that were published in the peer-reviewed literature and established that REMS was an equivalent method of bone densitometry as compared to DXA? Is this the REMS scandal that social media has been waiting for?

Well not really. In the largest multi-center study performed in the EU where 4307 patients were initially recruited, an average (hip and spine) 348 of the patients were excluded due to REMS errors - about 8.2%! Wow! Is that a lot? Probably not, because in the same study, an average 374 (hip and spine) patients were excluded due to DXA errors. About 8.8%! (the numbers were averaged in order to save space - this post is already long enough!). Although this may not be as dramatic as some may have hoped for, it actually does show that there can be “erroneous” REMS reports. Now, unfortunately this is the point where some of the other social media posts stopped and didn’t ask the next appropriate question - where do the REMS errors come from? But that's why we’re here! To make sure that all the facts are presented!

In general, errors can be made in the acquisition of any type of data. Obviously, that can also occur during a REMS scan. Every technology also has a learning-curve and if the individual doing the scan is not experienced, then errors in method and settings can be made. In REMS method errors will usually result in an ND (non-diagnostic) will not generate a report (unlike DXA - that will still provide a report). However, during REMS examinations, if appropriate technique is utilized when performing an examination but the settings are inappropriate, a report may be generated that is suboptimal (or just plain wrong). And in some cases those results will be reported. So where are the mistakes made? The Focal Setting (where REMS is supposed to focus the sound wave) and the Depth Setting (how deep is the bone that needs to be analyzed) are parameters that are chosen by the examiner. These parameters have optimal settings and if they are not optimized resulting data may not be correct. This tends to be a “newbie” mistake that is eliminated with experience. Noted in the above cited paper “ Concerning REMS errors, they were typically associated with wrong settings at acquisition parameters or with incomplete adherence to indications provided by the software and/or the user guide.” Also, several other papers recommended that REMS examiners performing research work have “at least 3 months of experience.”

It has been our experience, that experience solves the majority of REMS issues (not all, but the vast majority). Several articles also describe difficulty with obtaining satisfactory results with very large individuals (DXA has the same issue). This has been our experience and we have learned how to deal with not only issues of some folks being big, but also individuals who are very small. Now, REMS does not have an issue with bone size like DXA does - however, very small and thin individuals also present an examining challenge. We have learned through experience (and with Vicki’s help) that the maximum and minimum settings on the EchoS, if used during the spine examination, tend to give suboptimal or even incorrect results. How do we know that? If the spine results are very discordant from (do not match) the hip examinations that are performed, then there is something wrong (please refer to our previous post on how to understand REMS results). By re-performing the examination utilizing the next level of settings which often makes the examination more technically challenging to perform, the results will be much more concordant and more likely to truly reflect the true condition of the bone.

So, there are some challenges to performing a REMS assessment and it is important for someone performing a REMS to adhere to the basic principles while performing the examination. Pretty much, as long as the image is centered on the viewing screen and minimum or maximum settings are not used, the error rate of any REMS will match industry standards. The REMS report generated can be trusted to provide an accurate assessment of the condition of the bone being examined!

P.S. - one more REMS challenge. Gas! Although part of a healthy digestive tract, gas will make a REMS examination very difficult. That is why we perform our REMS in the mornings and ask our patients to skip breakfast. It’s not impossible to do the test after eating but it just makes the test a little harder to do!

Hopefully, this post has answered some of your additional questions about REMS. And, as much as I had managed to restrain myself and not hate-on DXA, logically, the next post will have to discuss errors associated with DXA. All kidding aside, the intent is to provide a little more of an explanation behind some of the errors that are notorious to DXA and that we love to point out. With the intent to help anyone who had a DXA why the DXA results may not be considered to be correct.