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This Web site is not providing medical advice.  The sole purpose of this section is to provide a general overview of bone densitometry for patients and individuals who wish to improve their understanding of this technology: what it is, how it’s done and what the results mean. You should discuss your individual needs with your doctor or other healthcare provider. All medical decisions should be made by your doctor in consultation with you and any other relevant parties.

Crisis in Osteoporosis Care

What is the ISCD?
What is osteoporosis?
How do I know if I have osteoporosis?
What is bone densitometry?
Are there different kinds of bone density tests?

What should I expect at that time of BMD testing?
Where should I go for a bone density test?
Who should have a bone density test?
When should a bone density test be repeated?
Who pays for a bone density test and how much does it cost?
Where can I get more information about osteoporosis?

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Author Information

Crisis in Osteopososis Care

Due to two separate Federal initiatives reimbursement for DXA testing have been cut by 40% and will be slashed by 60% in 2010. As a result 2/3rds of all DXA testing centers will likely shut down making access to this critical preventive health care measure scarce.

Join us in our fight to preserve quality osteoporosis testing.  Visit our ISCD Advocacy Web site for more information and to sign up to be part of the ISCD advocacy campaign.  Click here to go to the ISCD Advocacy Web site now. 

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What is the ISCD?

The International Society for Clinical Densitometry® (ISCD) was established in 1993 as a nonprofit professional medical society to:

• enhance knowledge about bone densitometry for healthcare professionals and the public;
• provide certification and continuing education in the field of bone densitometry;
• increase public awareness and access to bone densitometry; and
• support clinical advances in the field of bone densitometry.

ISCD members include clinicians, technologists and other healthcare professionals from over 50 countries. Clinicians of all medical specialties, densitometry technologists and others involved with bone densitometry may be members. The ISCD publishes the Journal of Clinical Densitometry® and a quarterly e-newsletter called SCAN®. It is governed by an elected President and Board of Directors and managed by full-time staff.  ISCD updates its Official Positions every other year following the Position Development Conference.

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What is Osteoporosis?

Note: Links to other sites that cover osteoporosis in more detail are available on the Patient Resources page.

Osteoporosis is a disease of the skeleton whereby the bones become brittle making them prone to break more easily, often with little or no trauma. This means that simple things like coughing, getting out of a chair, or falling from a standing height can result in a broken bone (what doctors call a fracture). Although osteoporosis can occur in both men and women of all ages and ethnicities, it is primarily a disease of older individuals, with women being more likely to develop it than men. Primary osteoporosis is mainly a result of an individual’s genetic background, but there are many other diseases, conditions, genetic disorders, medications, and lifestyle factors that can affect the skeleton and result in secondary osteoporosis.

Osteoporosis is a very big problem today, in part because people are living longer. Current estimates suggest that 200 million people or more worldwide have osteoporosis. In the United States there are greater than 1.5 million osteoporotic fractures annually, making it one of the most common diseases of the elderly. Unfortunately, despite recent advancements, studies show many people are not evaluated or treated for their disease, in part because they do not know they have it or understand the consequences.

There are no obvious symptoms of osteoporosis until someone has a fracture. A fracture is a medical term for a broken bone. Although any site in the skeleton can fracture, studies show this is more likely to occur at certain places such as the spine (vertebra), hip and forearm. If a fracture does occur, it can cause pain and disability. However not all fractures cause pain and studies show over half the people who suffer spinal (vertebral) fractures experience no pain at the time of their fracture. Other symptoms these people might notice are loss of height (shrinking 1 inch or more), stooping of their posture and shortness of breath. People who suffer osteoporosis related fractures are more likely to have another fracture than people who do not, and they also have a higher mortality rate.

Until recently, osteoporosis could not be easily diagnosed until a fracture occurred. However, today with new technology most people who are at risk can be identified before a fracture occurs, allowing them to start appropriate treatment programs, the goal of which is to prevent fractures occurring in the first place. Even if you have already suffered a fracture, lifestyle changes and medications today can significantly reduce the risk of further fractures.

The conclusion?  Discuss with your doctor or healthcare provider whether you are at risk for developing osteoporosis.

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How do I know if I have osteoporosis?

There are two ways of making a diagnosis of osteoporosis:

1.  One way is when a "fragility fracture" has occurred. This is a broken bone that has happened with no trauma or minimal trauma, such as if you were to cough or fall to the floor from a standing position.  The diagnosis in this case would be after you have experienced a fracture.  Clearly the better choice is to find out if you have osteoporosis by measuring your bone density BEFORE a fracture occurs so that treatment can be started to lower your risk of fracture. But even if you have already had an osteoporotic fracture, treatment can lower your risk of having another.  Sometimes other investigations such as blood tests are needed to diagnose other causes of osteoporosis or low bone mass.

2.  Have a bone density test. A bone density test measures your bone density in grams/centimeter squared. The machine that does this then calculates a score based on this reading and other information. In general the lower the bone density, the weaker the bone, and the more likely they are to break. The resulting score is a mathematical method for comparing your bone density to that of a healthy person of the same sex in a particular age group.

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Bone densitometry is a non-surgical method of measuring bone density. Bone density (BMD) is a measurement used to estimate bone strength and the likelihood of bones to break (fracture) with simple trauma. Thus bone densitometry is a non-surgical method that can be used to assess fracture risk. However, it is only part of an overall assessment of fracture risk that your doctor or healthcare provider can perform.

A standard X-ray is not a good way to assess bone density.  There are different techniques for measuring bone density. The currently accepted "gold standard" method is called "Dual Energy X-ray Absorptiometry" - abbreviated DXA.  (The ISCD Official Position abbreviation is DXA, although you may also see it abbreviated DEXA.)

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Are there different kinds of bone density tests?

Yes. Bone density tests are divided into two types - central and peripheral.

Central Tests

Central DXA is a non-surgical and painless examination consisting of a very low dose X-ray.  Very low doses of X-ray (about 1/30 the radiation of a standard chest X-ray, less than radiation from an airplane trip, equivalent to two hours of direct sunshine) are used to rapidly scan your bones.  A computer converts this information to numbers indicating your bone density. This is a high technology test that takes only a few minutes and involves no shots, needles, enemas, or medicine. In fact, you don't even have to take off your clothes, provided what you are wearing does not contain any metal objects.

A central DXA test measures bone mineral density (BMD) at the spine and/or hip and/or radius and sometimes the whole body. Central DXA is generally considered the "gold standard" method of measuring BMD for diagnosing osteoporosis and monitoring the effects of osteoporosis therapy. 

Central testing can also be performed using quantitative computerized tomography (QCT) scanning. This is a specialized type of computerized tomography (CT scan or CAT scan) that requires use of much larger doses of X-ray radiation. However, this method is currently only used to measure the spine and is not directly comparable to other scanning techniques.

Peripheral Tests

Peripheral tests measure bone mineral density (BMD) at other skeletal sites, such as the heel, or finger.  This can be accomplished by several technologies today including peripheral DXA (pDXA), quantitative ultrasound (QUS), and peripheral QCT scanning (pQCT). Peripheral tests may be used to estimate fracture risk or SCREEN individuals for low bone mass, particularly when central DXA is not available.

However, currently the ISCD recommends that they not be used to diagnose osteoporosis or monitor the effects of therapy because they have less reliability and responsiveness.   If an individual has low bone mass using peripheral technology, the ISCD currently recommends they have a central DXA performed for diagnostic purposes.  Link to ISCD Official Positions.

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What should I expect at that time of BMD testing?

This depends on the type of bone density test you are having. However, all are non-surgical and involve a painless examination that does not involve injections or contrast materials.  You will likely have to wear a gown and have your height and weight measured. The lumbar spine/hips along with various other skeletal sites are usually examined. The time it takes to perform these tests varies depending on a number of factors.

Some items to consider as you prepare for your test include:

1.     Are you pregnant?  If so, tell the technologist.

2.     Eat a normal diet on the day of the test.

3.     Take your medications as you normally would.

4.     DO NOT take calcium supplements for 24 hours before the test.

5.     On the day of the test, leave valuables at home.

6.     Do not wear jewelry or body piercings to the examination.

7.     The test should be performed prior to oral, rectal or IV contrast studies, or at least 7 days after any of these studies.

For central DXA testing, you may be asked to wear a gown. You will need to lie on your back, on a table, in a comfortable position for several minutes. You should remain as still as possible during the procedure. Generally, you can resume your usual activities immediately.

For peripheral testing you may have to remove your shoe and sock and a harmless gel may be applied to the area being examined.

VFA (vertebral fracture assessment) is new technology used to assess the spine for fractures. This can be performed easily by some newer central DXA machines at the time of BMD examination.

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This depends on where you live. For some individuals there may be many options, while for others there may be few or none. Today bone density testing is much more widely available in many countries and performed in many settings including hospitals, other healthcare imaging facilities, doctors’ offices, screening health fairs, pharmacies and sometimes as part of a mobile health unit. It is estimated that there are about 18,000 DXA machines in the United States.  Some estimates show the number of DXA machines outside the United States to be about 18,000. Although travel, cost and convenience are important things to consider when making this decision, there are also technical issues to take into account so you get the best available value for your money.

It is important that the operator of DXA machine is well trained in its proper use and that the person interpreting the results is knowledgeable in the field of bone densitometry. One indicator that the technologist and clinician have received appropriate training in bone densitometry is to ask if they are ISCD Certified.  You can also search the online ISCD Certification Registry to find a certified technologist (CDT or CBDT) or certified clinician (CCD) in your area.  The ISCD Certification Registry lists participating certified individuals - Certified Clinical Densitometrist® (CCD), Certified Densitometry Technologist® (CDT) and Certified Bone Densitometry Technologist™ (CBDT).  Individuals may choose not to be displayed in this listing. Evaluation of the credentials, qualifications and competence of a physician or technologist is the responsibility of the person referencing the registry.

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Consult with your physician if you think you might benefit from knowing your bone density. The test is most often administered to those at highest risk of developing osteoporosis, or to monitor the effectiveness of treatment for osteoporosis. However, because osteoporosis is such a common disorder, many other persons may warrant this evaluation.

Although the testing procedure is generally very safe, because of cost concerns and inappropriate testing that may result in unnecessary treatment and worry, the test is most often administered for those with high risk of developing osteoporosis, or to monitor the effectiveness of treatment for osteoporosis.

Guidelines for who should undergo BMD testing differ between countries and societies. These guidelines continue to evolve as our technology and knowledge advances.

The ISCD currently recommends that a bone density test be done for:

• All women aged 65 and older.
• All men aged 70 and older.
• Anyone with a fragility fracture.
• Anyone with a disease, condition or medication associated with osteoporosis.
• Anyone who is considering therapy for osteoporosis, if bone density testing would facilitate the decision.
• Women who have been on hormone replacement therapy for prolonged periods.
• Anyone being treated for osteoporosis, to monitor the effects of therapy.

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This depends on why it is being recommended – whether as a follow-up to the results of previous testing, to monitor therapy, as a screening tool, or for some other reason. In addition, in order to determine the best time to repeat a bone density test, it is also necessary to know the expected rate of change in bone density and the precision of the instrument being used to perform the test. Lastly the precision of the technologist must be known in order to improve the accuracy of the report.

Guidelines for how often the test should be repeated, or will be covered by your insurance or health system, differ.  In some situations, such as starting high dose glucocorticoid therapy, like prednisone or prednisolone, a test may be done as often as every six months. After starting a medication for osteoporosis, it may take one or two years or longer before a significant change in bone density has occurred.

Remember you should discuss your individual needs with your physician.

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Like most things, it depends. At this time, most insurance companies and governments have a very specific list of diagnoses that will qualify you for coverage to have bone densitometry done. The list is different for each type of payor and sometimes a pre-authorization may be required before the test is scheduled. Your physician's office, local healthcare authority or insurance company can give you more information on whether or not you will be covered, and where you should go to have the test done in order to be covered. If you and your physician feel that the test should be performed, even if not covered by insurance, then arrangements may be possible for self-pay.  Although health fairs and screening tests may be available at a lower cost than central DXA, they have limitations.   

Out of pocket expenses for BMD differ between geographical areas and depend on a number of factors. Generally they range from $50-100 at a screening health fair to several hundred dollars or more in the United States. You should ask your local bone density center what you can expect to have to pay to get the most accurate information.

In the United States, Medicare (the primary government payor) has the following guidelines for who should have a BMD. They currently will cover a bone density test for the following situations:

• Estrogen deficient women at risk for Osteoporosis.
• Those with spinal abnormalities or X-ray evidence of bone loss.
• Anyone taking long-term corticosteroid treatment (such as prednisone).
• Primary hyperparathyroidism with no symptoms.
• Monitoring of therapy for osteoporosis.

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Author Information

Dr. John Joseph Carey

ISCD Web Site Content Committee Chair

Dr. Carey is a physician member since 2000 who is board certified in Internal Medicine and Rheumatology. Having graduated with his medical degree from the National University of Ireland, in Dublin, he completed his training in Internal Medicine and Rheumatology at Boston University Medical Center, MA, USA and The Cleveland Clinic, Ohio, USA. In addition Dr. Carey has a Masters Degree in Clinical Research and is an ISCD Certified Clinical Densitometrist (CCD).

Sharon Rae Wartenbee

ISCD Web Site Committee Member  

Sharon is a diagnostic radiologic technologist and bone densitometry technologist at McGreevy Clinic Avera in Sioux Falls, S.D.  She has credentials from the American Registry of Radiologic Technologists (ARRT) in both radiology and bone densitometry.  Sharon has also obtained bone densitometry certification from ISCD and has been a technologist member since 1999.

Web Content Committee Description and Committee Member List can be found on the Committees page of this Web site.  

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Page Last Updated: 10/23/2008

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