Scans and tests

and osteoporosis

What is osteoporosis?
Osteoporosis

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This leaflet covers specific information on

scans and tests. If you would like more
general information on osteoporosis, please
ask us for a copy of our publication
All About Osteoporosis.

Bone density
(DXA) scanning
Bone density scanning is the most commonly
used diagnostic technique for osteoporosis
but other scans and tests may be used to
help understand what is happening to your
bones. Most of these tests or scans help to
predict how likely it is you will break bones
and some are specifically used to diagnose
osteoporosis as it is currently defined.
Why measure bone density?
As osteoporosis causes no symptoms until
a bone is broken, it has traditionally been
difficult to pinpoint which individuals have
fragile bones prior to a fracture occurring.
With advances in technology and the
development of bone densitometry (the
measurement of bone density), it has
become possible to measure bone and
assess its density. This is particularly useful
because low bone density has been linked
to an increased risk of fracture. Osteoporosis
can now be diagnosed prior to bones

breaking, giving individuals, who have other

risk factors and are at high risk of fractures,
the opportunity to take treatments and adopt
lifestyle changes which will reduce their risk
of breaking their bones.
How is bone density measured?
The most common means of measuring
bone density involves a simple test called
dual energy x-ray absorptiometry (DXA). DXA
machines usually scan bones in the lower
spine and hip, two of the main areas at risk
from osteoporotic fractures. This is called
an axial or central scan. Other areas can
also be assessed including the forearm and
the heel using a peripheral scanner. These
techniques use a low radiation dose, which is
similar to natural background radiation less
than one tenth of the dosage of a chest x-ray.
A DXA scan will take between ten and twenty
minutes and is not in any way unpleasant. An
axial DXA scan involves lying on a firm couch
whilst a scanning arm passes over the body
taking an image of the spine and hips. It does
not involve being enclosed in a mechanical
tunnel or having an injection. Generally, clothing
does not have to be removed but clothes with
metal should be avoided.

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What will the results tell me?

A DXA scan produces a printout in which
your bone density is compared to a reference
range of young healthy adults with average
bone density. The difference between this
average and your bone density is then
calculated and expressed in terms of
standard deviations (SD) and you are given
a T score.
If the T score is:
Between +1 and -1 SD

this is normal

Between -1 and -2.5 SD

this is termed osteopenia

Below -2.5 SD

this is defined as
osteoporosis

Osteopenia is the name for the category

between normal and osteoporosis, when
bone is less dense than the average but not
low enough to be classed as osteoporosis.
Lifestyle changes such as the adoption
of a well-balanced, calcium-rich diet and
regular weight-bearing exercise are often
recommended for people in this category.
When a DXA scan is performed, a Z score
is also calculated. This is a comparison
between your bone density and that of a
reference range of people of your own age.
Although this is not used to diagnose

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osteoporosis, it is useful sometimes for the

doctor in the assessment of treatments in
older people or children, when a comparison
with a young adult reference range may not
be so relevant.
DXA scanning of the hip and spine is a very
useful tool to help assess an individuals
risk of fracture. However, there is more to
fracture risk than just bone density. Low bone
density, as diagnosed on a DXA scan, should
be considered as a risk factor for fracture
and not a perfect measure of bone strength,
i.e. there will be people who have low bone
density who never break a bone and vice
versa. Sometimes, if bones are breaking
very easily with an osteopenic result, bone
fragility is likely and drug treatments may be
appropriate. A referral to a specialist can be
helpful in this situation.

Who should be offered a scan?

Since 1999 The Royal College of Physicians
clinical guidelines for prevention and
treatment of osteoporosis (1999) have been
used to decide who needs a scan to help
with decisions about drug treatments. This
guidance recommends that bone density
measurements should be available to postmenopausal women over 45 years at high risk
of osteoporosis if results may influence the
doctors decision regarding treatment.
Recently, research has shown that although
measuring bone density and identifying
osteoporosis is useful, other risk factors for
fracture can also be used to identify who is at
greatest risk and who needs a treatment.
A fracture risk assessment tool called FRAX
has been developed by the World Health
Organisation (WHO). It has been incorporated
by a group of UK experts called the National
Osteoporosis Guideline Group (NOGG) into a
guideline to help health professionals identify
people at highest risk of fracture who would
benefit from treatment. These guidelines help
to identify those who need to have a bone
density scan.
Further information is available at
www.shef.ac.uk/FRAX and
www.shef.ac.uk/NOGG

Is a bone density scan

useful for everyone?
As DXA scans are not a perfect measure of
bone strength or fragility, screening everyone,
even over the age of 50, would be very
expensive and would not always pick up
those at highest risk of breaking bones.
A DXA scan can tell if a bone is likely to be
fragile but other things about you will help
to predict your risk of fracture even more
accurately. Doctors have to take into account
all of their patients risk factors such as family
history or corticosteroid use, as a way of
identifying which people are at greatest risk
of breaking bones. For some people, a bone
density measurement will be necessary to
ensure they are at high enough risk to need a
drug treatment.
Sometimes your risk of fracture is so high
because of other risk factors, that a scan is
not necessary before treatment is prescribed.
This is particularly likely if you are over 75
years of age.
Interpretation of the results of bone density
measurements, especially of the spine,
may be more difficult after the age of 65
years. As we age, the spine can be affected
by other degenerative processes such as

osteoarthritis. Such changes can make bone

appear denser than it actually is when it is
scanned, therefore, affecting the accuracy
of the results. The presence of previous
fractures in the spine can also affect the
results of a bone density scan. It is generally
thought that scanning is most appropriate
if it is going to make a difference to the
management of a persons osteoporosis or
affect a decision with regards to treatment.
The evidence supporting the use of DXA
scanning as a means of diagnosing
osteoporosis is strongest in women after
the menopause. Although it can be useful
in younger women and men, it will require
specialist interpretation.

Should I have further scans in the future

to monitor my progress?
Bone density scanning is generally used to
help decide if a drug treatment is needed. If
bone density is not sufficiently low to require
treatment, a repeat scan might be performed
after two to five years to determine whether
a treatment is needed at a later date. As
more is understood about what influences
a persons risk of fracture and how the drug
treatments for osteoporosis work, repeat
scanning is now not so commonly used to
see if a treatment is working.
If a person is on a drug treatment that they
tolerate well and they have not had fractures
whilst on that treatment, then it is likely that
the drug is working (as shown in the drug
trials) and another scan is not necessary.
However, if a person does have problems
taking a treatment, or has fractures despite
being on a treatment, then the doctor may
decide that another scan to check bone
density would be useful to make an informed
decision about what to do next.
If scans are repeated it is important they are
performed on the same machine so that
comparisons can be made.

The National Osteoporosis Society Helpline

nurses are happy to discuss your bone
density scan results but there is no
facility for general scan interpretation.
This should take place at scanning centres,
with explanations and recommendations for
treatment sent to GPs.
How useful are DXA scans of the
forearm or other sites?
Peripheral DXA (pDXA) machines scan parts
of the body other than the hip and spine.
They might scan your forearm, heel or even
finger. These scans can be used to help
decide if you need a treatment. If a pDXA
scan shows that you have very low bone
density your doctor might decide to prescribe
a treatment. However, usually when a pDXA
scan shows that you have low bone density,
your doctor would refer you for a scan of the
hip or spine. Scanning these sites will allow
them to diagnose osteoporosis and make the
best treatment decision.

Ultrasound scanning
DXA of the hip and spine is a relatively
expensive procedure using a large, static
piece of equipment which is usually located
in a hospital. Research into less expensive,
more portable techniques that can predict
fracture risk has been carried out. Ultrasound
is one of these portable techniques.
What is ultrasound?
Ultrasound can be used to examine
structures inside the body. Sound waves
of extremely high frequency, inaudible to
the human ear, are beamed into the body.
The echoes of reflected sound, or the rate
and path of transmission of the sound,
are used to build up an electronic image
or measurement of the structure being
examined. Ultrasound does not use radiation.
What is ultrasound used for?
Ultrasound scanning has proved useful in
visualising many different parts of the body.
It can be used for scanning in pregnancy, or
imaging the liver, kidney, gallbladder, spleen,
ovaries, bladder, breasts and eyes.
Ultrasound waves may also be used to treat
soft tissue injuries, e.g. muscles, ligaments
and tendons. The treatment is thought to
improve blood flow, reduce inflammation
and speed up healing.

Portable and relatively inexpensive ultrasound

machines have been developed, which
are designed to look at bone structure and
strength, usually of the heel bone (calcaneus),
wrist or finger. They give a picture of the bone
and provide measurements of the speed of
the ultrasound wave through the bone or the
absorption of the beam. The measurement
is referred to as quantitative ultrasound
to distinguish it from ultrasound used for
imaging body structures.

Can quantitative ultrasound scanning

(QUS) measurements be used to
diagnose and monitor osteoporosis?
Osteoporosis is defined according to
World Health Organisation (WHO) criteria
in terms of bone density measured by DXA
scanning, when bone density is compared
to data collected from young, healthy adult
measurements. DXA scans of the hip and
spine are, therefore, the current preferred
method for diagnosing osteoporosis.
There is currently no established, accepted
definition of osteoporosis based on QUS
measurements, so QUS cannot currently
be used to confirm the diagnosis of
osteoporosis. Ultrasound cannot be used to
monitor rates of bone loss or bone gain with
treatment.
Who may benefit from heel ultrasound?
Large studies suggested that heel ultrasound
in older women (70+) may predict hip fracture
risk as well as DXA. Heel ultrasound is also
useful in predicting osteoporotic fracture risk
in women around the time of the menopause
and of Colles (wrist) fracture in women in
their early post-menopausal years. There is
no conclusive evidence that heel ultrasound
can accurately predict fracture at other sites
in women prior to the menopause, or in men.

There may also be problems using drug

treatments based on ultrasound readings
because research studies to determine the
benefits of osteoporosis drug treatments
were all based on DXA readings. Further
research is needed.
Some people are more at risk of osteoporosis
because of factors such as early menopause
(before age 45) or long-term tablet
corticosteroid use. Identification of these
high-risk groups may be useful in pinpointing
those who may benefit from a DXA scan.
QUS may sometimes be used as an improved
method of targeting women for hip and spine
DXA scanning to diagnose osteoporosis.
What does a heel ultrasound involve?
A heel ultrasound is a simple and painless
procedure, taking a few minutes. In some
machines, the heel is placed into a small
water bath machine. In others, gel is applied
to the heel, finger or wrist area and a dry
machine is used.
The test may be done at a unit that also does
DXA scanning as part of the research into
the usefulness of heel ultrasound, or within a
doctors surgery.

What about the advertised heel scans

which test anyone for a fee?
Due to the difficulties with using heel
ultrasound to diagnose and monitor
osteoporosis, and the lack of wellestablished, normal reference ranges,
heel scans are not generally used in the
same way as DXA scans. If someone is
concerned about their bone health and
osteoporosis risk and has a QUS heel
scan, it may still be appropriate to consider
bone density measurement by DXA scan
especially when decisions need to be made
about using drug treatments.
If I decide to have a heel ultrasound
scan I have seen advertised locally,
what questions would be helpful?
Does the company have
a medical practitioner with
responsibility for the service?
Will the company scan anyone or
just women after the menopause?
Is the operator a healthcare
professional with knowledge
of osteoporosis?
Is the service linked to the sale of
dietary supplements or other products?

Computerised tomography
(CT) scanning
Computerised tomography (CT) scanning
This type of scanning uses x-rays and a
computer to take pictures of bone and put
images together. CT scanners can be used
to measure bone density and may be useful
following compression fractures in the spine,
when getting an accurate result can be more
difficult. However, CT scans use higher levels
of radiation than a DXA scan, which is usually
considered preferable.

Magnetic resonance
imaging (MRI) scanning
This uses a strong magnetic field and radio
waves to produce detailed pictures of soft
tissue such as ligaments and muscles. It
does not provide information about bone
tissue so cannot diagnose osteoporosis or
measure bone density. However, sometimes
fractures might be identified using MRI,
especially hip or vertebral fractures not seen
on a normal x-ray. Often, MRI is used to
indicate if another disease is present.

X-rays
Normal x-rays are used to see if a hip, wrist
or other bone has broken. Your doctor will
also refer you for an x-ray if it is necessary to
confirm that a fracture has occurred in the
spine. Sometimes, identifying spinal fractures
on an x-ray is complex and it may be difficult
to determine how recent the fracture is. You
will need to tell your doctor of any previous
accident that might have resulted in damage
to the spine. Sometimes, other tests will be
carried out to ensure fractures have not been
caused by another disease.
A DXA scan might be useful after the x-ray
to see if bone density is low and confirm
that fractures are caused by osteoporosis.
A DXA scan may be able to identify a fracture
if it has occurred in the area being scanned.
Scanners are being further developed and
in the future may be used more widely to
diagnose compression or wedge fractures in
the spine.
Height loss and spinal curvature are not
always caused by osteoporotic fractures,
but may result from arthritis in the spine or
disc disease. Spine x-rays may, therefore, be
appropriate to investigate the cause of height
loss and curvature.

Bone (radioisotope)
scanning
Bone (radioisotope) scanning
These scans might be used to pick up
fractures that have been difficult to identify
on x-ray. You are given an injection of radio
active material which will show up ashot
spots on the image that is produced. Other
tests might then be necessary to ensure that
any fractures identified are not caused by
other conditions.

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Urine and blood tests

Bone marker tests:
what are bone markers?
Throughout life, the skeleton is continually
renewing itself through a process known
as remodelling or bone turnover. In healthy
bone, the rate of bone breakdown is linked
to the rate of bone formation so that bone
strength is maintained. As we get older, the
rate at which bone is broken down increases
and exceeds the rate at which bone is formed.
This results in loss of bone and may lead to
osteoporosis and an increased risk of fracture.
During the bone remodelling process
chemicals are produced which can be
detected in the blood and urine. These
products are known as biochemical markers
of bone turnover. An assessment of levels of
these markers can be used to measure the
rate of bone turnover, thus providing useful
information about factors that might affect
bone strength.

How useful is the test?

The bone marker test is simple and requires
a sample of urine or blood, which is then sent
off to the laboratory for testing. Although the
test can assess the rate at which bone is
being broken down or formed, it cannot be
used to diagnose osteoporosis or determine
bone strength. Bone density scanning is
more useful to help work out how likely
fractures or broken bones are.
Bone markers may be able to assess the
effectiveness of treatment. Most treatments
for osteoporosis work by reducing the rate of
bone turnover, so monitoring bone loss using
this technique may allow adjustment of the
dosage of a treatment or change to another
therapy if bone turnover is not reduced or
back to normal within six months.

Where can I obtain the test?

The test is only currently available in specialist
centres when it is felt that the additional
information provided could affect the type of
treatment offered. They are also often used
in the research field. Bone marker tests are
not generally available from GPs as a tool to
monitor treatment. This is because outside
of the specialist setting it is difficult to avoid
inaccuracies.
A referral to a specialist centre to see a
consultant is by GP referral only. The GP
will be able to advise whether a consultant
referral is required, as routine treatment of
osteoporosis is usually managed by the GP.

Other blood and urine tests

Sometimes, especially at a hospital
appointment, levels of calcium in the blood
might be checked. Low blood calcium levels
do not indicate that you have osteoporosis,
but may be due to vitamin D deficiency
which can be treated with supplements. High
calcium levels in the blood can mean you
have other medical conditions that might be
causing osteoporosis or fractures.
Other blood tests may also help to check
for other diseases that cause pain or bone
fragility. Vitamin D levels may be checked
by a blood test. Low levels can indicate you
have a related condition called osteomalacia
(soft bones) that can be treated with
supplements of vitamin D.

A blood test (and occasionally a urine test)

might be used to check that your kidneys are
working well. This is not a routine procedure,
but if there is concern about your kidney
function your doctor might ask for this test
before prescribing some of the osteoporosis
drug treatments.
If you are unsure about whether you are
at risk of osteoporosis and the benefits of
available tests, you may want to discuss this
with your doctor or telephone the National
Osteoporosis Society Helpline to speak to
one of the nurses.

Factors which can help to maintain healthy

Factors which can help to maintain healthy
bones are a well-balanced diet with
adequate calcium-rich foods; regular weightbearing exercise; avoiding smoking and
keeping alcohol consumption within the
recommended limits.

Join the National Osteoporosis

Society today
Become a member and support the only
UK-wide charity dedicated to improving
the diagnosis, prevention and treatment
of osteoporosis.
You can join today, either call us or visit
our website:

01761 473287
www.nos.org.uk
Our publications are free of charge
but we would welcome a donation
You can support the work of the National
Osteoporosis Society by making a single
or regular donation:

01761 473111
www.nos.org.uk
For osteoporosis information and
support contact our Helpline:
0845 450 0230
nurses@nos.org.uk

Other leaflets and factsheets

in this range:
Anorexia nervosa and osteoporosis
Anti-epileptic drugs and osteoporosis
Breast cancer treatments and osteoporosis
Clothing, body image and osteoporosis
Coeliac disease and osteoporosis
Complementary and alternative therapies
and osteoporosis
Complex regional pain syndrome and osteoporosis
Drug treatments and osteoporosis
Exercise and osteoporosis
Glucocorticoids and osteoporosis
Further Food Facts and bone - beyond calcium and
vitamin D
Healthy living for strong bones
Hip protectors and osteoporosis
Hormone therapy in men and women and osteoporosis
Hyperparathyroid disease and osteoporosis
Osteoarthritis and osteoporosis
Osteogenesis imperfecta and osteoporosis
Osteoporosis in children
Percutaneous vertebroplasty and balloon
kyphoplasty and osteoporosis
Pregnancy and osteoporosis
The contraceptive injection (Depo Provera)
and osteoporosis
Thyroid disease and osteoporosis
Transsexual people and osteoporosis
Vibration therapy and osteoporosis

0845 130 3076 (General Enquiries)

0845 450 0230 (Helpline)
www.nos.org.uk
Camerton, Bath BA2 0PJ

President: HRH The Duchess of Cornwall

National Osteoporosis Society is a registered charity no. 1102712 in England and Wales
and no. SC039755 in Scotland. Registered as a company limited by guarantee in England
and Wales no. 4995013
Last reviewed October 2014 NOS/00147

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