Is the Gold Standard
Fool's Gold?

Two kinds of patients walk into my clinic, and they arrive with very different fears. The first has a DEXA report showing a T-score of −2.5 and a physician who communicated, with the best of intentions, that her bones are fragile and medication is the next step. She is frightened. She feels breakable. She is often moving more carefully than she should be, afraid that exertion will somehow make things worse. The second patient arrives with that same score — or one not far from it — and says something like: "My doctor wants me on bisphosphonates, and I'm not ready to accept that as my first option." She is not in denial. She is asking whether there is another way.

Both patients deserve a more complete picture than a single number provides. Both are asking the right questions. And both — when we complete a REMS scan as part of their intake — sometimes discover that the story is more nuanced than the DEXA suggested. Sometimes REMS confirms the concern entirely. Sometimes it reveals a fragility score that is better than expected, offering a more accurate baseline and a clearer starting point for intervention. Occasionally it reveals worse. In every case, we have learned something we didn't know before — and that knowledge changes the conversation.

I am not writing this to dismantle DEXA. It has served medicine well for decades, and it remains a clinically useful tool. I'm writing this because the patients arriving at my door deserve a more honest conversation about what bone density testing can and cannot tell us, and because a technology called REMS — Radiofrequency Echographic Multi-Spectrometry — is changing what that conversation can include.

As a physical therapist, a licensed Onero™ provider, and the operator of a dedicated bone health clinic, I use REMS as the baseline assessment for every single client who walks through my door. Here's why — and why I think every physician managing patients with bone health concerns should know about it too.

The Problem With "Good Enough"

DEXA — dual-energy X-ray absorptiometry — has been the gold standard for osteoporosis diagnosis since the early 1990s. It measures bone mineral density (BMD) at the lumbar spine and hip and produces a T-score comparing you to a young adult reference population. If your T-score is −2.5 or lower, you have osteoporosis. Between −1.0 and −2.5, you have osteopenia. Above −1.0, you are "normal."

This framework is tidy. It's also incomplete in ways that matter enormously for the patients most at risk.

This is not an isolated anomaly. It is a demonstration of a structural limitation that has been documented in the literature for years.

Think about who our aging patients actually are. They have arthritis. They have osteophytes. Many have had joint replacements. Many have the very degenerative spinal changes that are most common in the population most vulnerable to fracture. In precisely these patients, DEXA can produce a false sense of security — a reassuring number derived from calcified tissue and bony overgrowth rather than healthy, resilient bone.

A "good" DEXA score is not always good news. And a technology that cannot distinguish between a healthy vertebra and one encrusted with arthritic change is, by definition, limited in its diagnostic value.

What DEXA Measures — and What It Doesn't

DEXA measures areal bone mineral density: the mineral content of a scanned region divided by its projected area. It is a two-dimensional measurement of a three-dimensional structure, and it captures only one variable: how much mineral is present.

What it does not measure is bone quality — the microarchitecture, the elasticity, the structural resilience that determine whether a bone will actually hold up under load and impact. You can have relatively dense bone that is still brittle. You can have slightly lower density bone that is robust and flexible. BMD and fracture risk are correlated, but they are not the same thing.

This means a meaningful number of people who fracture a hip or vertebra while doing ordinary things — bending over, stepping off a curb, sitting down too hard — were never told they were at significant risk. Their DEXA looked "just fine."

What REMS Adds to the Picture

REMS technology uses ultrasound — the same safe, radiation-free technology used in prenatal imaging — to assess bone at the lumbar spine and femoral neck. But it does something DEXA cannot: it analyzes the quality of the ultrasound signal passing through bone, not merely a density number derived from X-ray attenuation.

The result includes not just a BMD estimate, but a proprietary Fragility Score — a 0–100 metric that incorporates microstructural features of the bone: its elasticity, its ability to absorb and distribute force, its overall resilience. It asks, in essence, how likely is this bone to break?

In the case of our 75-year-old patient above, the answer was: very likely. A number her DEXA scan simply could not produce.

Additional advantages that matter clinically:

No radiation. REMS delivers zero ionizing radiation. For patients who need frequent monitoring — those on anabolic therapies like Teriparatide or Romosozumab, those undergoing bone-loading exercise programs, those making significant lifestyle interventions — this is not a small thing. Being able to scan every six months to track real response without cumulative X-ray exposure changes what monitoring can look like.

Unaffected by artifact. Because REMS relies on acoustic signal rather than X-ray attenuation, the degenerative changes, osteophytes, and hardware that confound DEXA do not distort the measurement in the same way. The signal is cleaner where DEXA is noisiest.

Fast and portable. A complete REMS scan takes approximately 10–15 minutes and requires no special room shielding. The device can operate in a clinic, a mobile health setting, or a physician's office.

Reproducible. Precision error rates below 0.4% at both the spine and hip mean that serial measurements are meaningful. You can genuinely track change over time.

Apples to Apples: Why I Baseline Every Onero Client

Every client who enters my Onero program receives a REMS scan at intake. We repeat it at six-month intervals. What I'm watching for is not just whether density improves — I'm tracking the fragility score, observing how the bone signal changes in response to targeted loading, and building a longitudinal record that belongs to the patient and follows them wherever they go.

This is how we should be practicing bone health medicine. Not a single DEXA every two years, read in isolation, compared against a population average, and filed away. An ongoing, dynamic picture of an individual skeleton — and a clear record of whether interventions are working.

If You're Reading This as a Patient

If your physician has recommended medication and you're not sure that's your first step — that is a reasonable position to explore, not a reckless one. There are evidence-based, non-pharmacologic interventions for bone health, and understanding your actual baseline before making a treatment decision is entirely legitimate. REMS can help clarify what you're working with and whether a structured exercise program like Onero is an appropriate path forward for you.

If you left your last appointment feeling fragile and frightened by a number — I understand that response, and I want to offer some perspective. A T-score is not a sentence. It is a data point. It does not tell you about the quality of your bone, the trajectory it's on, or what you are capable of doing to change it. Some patients who arrive at my clinic with alarming DEXA scores have better fragility scores on REMS than expected. Others have worse. In either case, knowing is the beginning of doing something about it — and doing something, with the right program, is what actually moves the needle.

A Note to Physicians: This Is a Complement, Not a Challenge

I want to be clear about something, because I know this conversation can feel like an attack on a tool that physicians have relied on — and trusted — for thirty years. That is not my intent.

DEXA is standardized, widely available, extensively studied, and deeply integrated into treatment thresholds and prescribing guidelines. For most straightforward diagnostic scenarios, it works. The FRAX algorithm, treatment initiation criteria, and pharmacologic monitoring protocols are all built around it. I am not suggesting we discard it.

What I am suggesting is this: when DEXA falls short — and in a substantial subset of your patients, it does — REMS is a validated, radiation-free alternative that provides information DEXA cannot. And for patients actively engaged in bone health interventions, serial REMS monitoring offers a level of granularity and safety that changes what follow-up can look like.

The ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis) published a consensus paper on REMS in 2024, affirming its diagnostic performance and utility — particularly for bone quality assessment and radiation-free monitoring. Research continues to grow. Guidelines will follow.

For physicians with patients who have significant degenerative spinal changes, prior joint replacement, or contraindications to frequent radiation exposure — REMS is a referral option worth knowing about now, not two years from now when guidelines catch up.

The Standard Needs to Evolve

Medicine is not static. We updated our understanding of cardiovascular risk when we learned that LDL particle size mattered, not just total cholesterol. We revised screening protocols when the evidence supported different intervals. We adopted MRI where X-ray once sufficed. Every "gold standard" is gold until something better comes along — or until we understand its limitations well enough to need something alongside it.

Bone health is overdue for that conversation. We have a technology that is radiation-free, fast, reproducible, and capable of measuring bone quality rather than just density. We have case reports of DEXA missing osteoporosis in patients who then fractured. We have a population of aging adults who deserve more than a T-score every 24 months and a referral for calcium supplements.

My patients get a baseline. They get serial tracking. They get an actual picture of what their bones are doing in response to the hardest, most evidence-backed work we can ask of them. That is what they came for — and it is what they deserve.

If you have a patient with a history of degenerative joint disease, prior hardware, persistent pain with a clean DEXA, or who is actively working with a bone-loading program and needs meaningful progress monitoring — I would welcome the referral. REMS scanning is available at Better Bones Rx inside the Ecke YMCA in Encinitas. Results are delivered same-day with a full clinical summary.

The gold standard is a starting point. Let's use every tool we have.