Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Common mistakes in the clinical use of bone mineral density testing

Nature Clinical Practice Rheumatology volume 4, pages 667–674 (2008)Cite this article

Abstract

Bone mineral density (BMD) testing is used to diagnose osteoporosis, assess fracture risk and monitor changes in BMD over time. A variety of devices and technologies are used to measure BMD or other surrogate markers of bone strength. Measurements obtained with these devices are often reported according to different proprietary standards, and the comparability of values obtained with different instruments is often poor. In addition, there is a high degree of variability in the skills of the technologists performing the tests and the clinicians interpreting the results. Heterogeneity in the guidelines for using BMD measurements together with poor-quality BMD testing and reporting can result in inappropriate clinical decisions, causing unnecessary worry and expense for the patient and possible harm due to unnecessary treatment or treatment being withheld. This Review describes and discusses the mistakes commonly made in BMD testing, and emphasizes the importance of maintaining high-quality standards in order to optimize patient management.

Key Points

  • Dual-energy X-ray absorptiometry (DXA) can be used to diagnose osteoporosis, assess fracture risk and monitor changes in bone mineral density (BMD) over time

  • Quality control, acquisition, analysis, interpretation and reporting of DXA studies require training and experience for the DXA technologist and interpreter

  • Quantitative comparison of BMD values on the same instrument cannot be made unless precision assessment has been done and the least significant change calculated

  • Quantitative comparison of BMD values obtained on different instruments cannot be made unless a cross-calibration study has been done

  • Poor-quality DXA reports may result in inappropriate patient care decisions that can be costly and sometimes harmful to patients

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: DXA of the lumbar spine with poor positioning.
Figure 2: Differences in vertebral body labeling.
Figure 3: Femoral neck box placement.

Similar content being viewed by others

References

  1. US Department of Health and Human Services (2004) Bone health and osteoporosis: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General

  2. Shepherd JA et al. (2006) Cross-calibration and minimum precision standards for dual-energy X-ray absorptiometry: the 2005 ISCD Official Positions. J Clin Densitom 9: 31–36

    Article  Google Scholar 

  3. Bonnick SL et al. (2001) Importance of precision in bone density measurements. J Clin Densitom 4: 105–110

    Article  CAS  Google Scholar 

  4. Lewiecki EM et al. (2006) DXA quality matters. J Clin Densitom 9: 388–392

    Article  Google Scholar 

  5. Lewiecki EM (2005) Update on bone density testing. Curr Osteoporos Rep 3: 136–142

    Article  Google Scholar 

  6. Lotz JC et al. (1991) Fracture prediction for the proximal femur using finite element models: part I—linear analysis. J Biomechan Eng 113: 353–360

    Article  CAS  Google Scholar 

  7. Marshall D et al. (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312: 1254–1259

    Article  CAS  Google Scholar 

  8. World Health Organisation (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Geneva: WHO

  9. Cranney A et al. (2002) Systematic reviews of randomized trials in osteoporosis: introduction and methodology. Endocr Rev 23: 497–507

    CAS  Google Scholar 

  10. Wasnich RD and Miller PD (2000) Antifracture efficacy of antiresorptive agents are related to changes in bone density. J Clin Endocrinol Metab 85: 231–236

    Article  CAS  Google Scholar 

  11. Mazess R et al. (1992) Enhanced precision with dual-energy X-ray absorptiometry. Calcif Tissue Int 51: 14–17

    Article  CAS  Google Scholar 

  12. Njeh CF et al. (1999) Radiation exposure in bone mineral density assessment. Appl Radiat Isot 50: 215–236

    Article  CAS  Google Scholar 

  13. Siris ES et al. (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286: 2815–2822

    Article  CAS  Google Scholar 

  14. Lewiecki EM et al. (2006) Uses and misuses of quantitative ultrasonography in managing osteoporosis. Cleve Clin J Med 73: 742–752

    Article  Google Scholar 

  15. Krieg MA et al. (2008) Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions. J Clin Densitom 11: 163–187

    Article  Google Scholar 

  16. Faulkner KG et al. (1999) Discordance in patient classification using T-scores. J Clin Densitom 2: 343–350

    Article  CAS  Google Scholar 

  17. Hans DB et al. (2008) Peripheral dual-energy X-ray absorptiometry in the management of osteoporosis: the 2007 ISCD Official Positions. J Clin Densitom 11: 188–206

    Article  Google Scholar 

  18. Engelke K et al. (2008) Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD Official Positions. J Clin Densitom 11: 123–162

    Article  Google Scholar 

  19. Baim S et al. (2008) Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 Position Development Conference. J Clin Densitom 11: 75–91

    Article  Google Scholar 

  20. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheum 44: 1496–1503

  21. Bonnick SL (2004) Bone Densitometry in Clinical Practice—Application and Interpretation, edn 2. Totowa, NJ: Humana Press

    Google Scholar 

  22. Binkley NC et al. (2002) What are the criteria by which a densitometric diagnosis of osteoporosis can be made in males and non-Caucasians? J Clin Densitom 5 (Suppl): S19–S28

    Article  Google Scholar 

  23. Lenchik L et al. (2002) What is the role of serial bone mineral density measurements in patient management? J Clin Densitom 5 (Suppl): S29–S38

    Article  Google Scholar 

  24. Leslie WD et al. (2006) Application of the 1994 WHO classification to populations other than postmenopausal Caucasian women: the 2005 ISCD Official Positions. J Clin Densitom 9: 22–30

    Article  Google Scholar 

  25. Lewiecki EM (2005) Premenopausal bone health assessment. Curr Rheumatol Rep 7: 46–52

    Article  Google Scholar 

  26. Kanis JA (2007) Assessment of osteoporosis at the primary health-care level. Technical report. Sheffield: WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield

  27. National Osteoporosis Foundation (2008) Clinician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation

Download references

Author information

Authors and Affiliations

  1. EM Lewiecki is a Clinical Assistant Professor of Medicine at the University of New Mexico School of Medicine and Osteoporosis Director of the New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM.,

    E Michael Lewiecki

  2. NE Lane is Endowed Professor of Medicine and Rheumatology and Director of the Center for Aging at the University of California at Davis Medical School, Sacramento, CA, USA.,

    Nancy E Lane

Authors
  1. E Michael Lewiecki
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nancy E Lane
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to E Michael Lewiecki.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lewiecki, E., Lane, N. Common mistakes in the clinical use of bone mineral density testing. Nat Rev Rheumatol 4, 667–674 (2008). https://doi.org/10.1038/ncprheum0928

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0928

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing