Bone densitometry http://courses.washington.edu/bonephys/opbmd.

html

Bone density
Techniques
Bone density losses with aging
T and Z scores
Details about T and Z scores
The WHO definitions
Bone density and risk of fracture
Discordance between spine and hip
How to read a DEXA printout, step-by-step
BMAD
Size, shape and rotation
Standardizing results
Reproducibility
Find the mistakes
Clinical indications for BMD
Ultrasound
Fracture risk calculator

Techniques

DEXA

Several methods are available to measure bone density, but currently the most
widely used technique is DEXA (Dual Energy Xray Absorptiometry). This is the
method used to determine efficacy in the recent large clinical trials, and to
characterize fracture risk in large epidemiological studies. Older methods such as
single photon absorptiometry do not predict hip fractures as well as DEXA. Three
companies manufacture these densitometers: Hologic, Norland, and Lunar.

Ultrasound

Newer techniques such as ultrasound appear to offer a more cost-effective method of

screening bone mass. Ultrasound measurements are usually performed at the
calcaneous and it is not possible to measure sites of osteoporotic fracture such as the
hip or spine. Adding an ultrasound measurement to a DEXA does not improve the
prediction of fractures. Although some have said that ultrasound measures the
"quality" of bone, more careful studies suggest that it mainly measures the bone
mass.

QCT

Quantitative computed tomography of the spine must be done following strict

protocols in laboratories that do these tests frequently; in community settings the
reproducibility is poor. The QCT measurements decrease more rapidly with aging, so
the "T scores" in older individuals will be much lower than DEXA measurements.
Click to see table of T scores using QCT compared to those using DEXA

Other

Several techniques can measure bone density at the hand, radius or ankle. These
include single energy absorptiometry, metacarpal width or density from hand xrays.
Magnetic resonance imaging is a new method of measuring bone density.

Bone Density Loss with Aging

This graph shows how the bone
density of the total hip decreases
with age. The units are
standardized bone density in

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(mg/cm2). The lines show the

average values, and for each age,
race and gender a range of values
occurs in the ordinary population.

The bone density is

important because it
can help to predict the
risk of getting a
fracture. The fracture
risk calculator can be
used to predict fracture risk from
the DEXA results.

Bone density results in teenagers can be found in this web site from Laura Bachrach at
Stanford: teen normals

Here is a new REFERENCE RANGE for CHILDREN by Kalkwarf.

Bone density results have been reported in a variety of ways that have been confusing
to physicians and patients. The next sections will attempt to clarify these issues, such as
T-score, Z-score and the redefinition of "normal".

T and Z scores
T and Z scores are based on the statistical
unit of the standard deviation. Shown
here is the classical bell-shaped curve
with the percent of a population lower
than that value shown next to the curve.

The T-score is the number of standard

deviations below the average for a young
adult at peak bone density. There are
different T-scores depending on which
group of young adults were used as the
reference (for example, Caucasian
women, Hispanic men). The Z-score is the
number of standard deviations below an
average person of the same age. There are also different Z-scores depending on the
group used as a reference (for example, the group could include everybody of the same
age, or it could be limited to people with the same age, race, gender and weight).
Furthermore, a person can have one T-score at the femoral neck, another at the total
hip, and another at the spine.

Click to read more details about the relationships between T-score, Z-score and g/cm2,
including conversion formulas, data tables and some of the misconceptions about the
interpretation of the scores.

The WHO definitions

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The World Health Organization has defined the following

categories based on bone density in white women:

Normal bone: T-score better than -1

Osteopenia: T-score between -1 and -2.5
Osteoporosis: T-score less than -2.5
Established (severe) osteoporosis
includes the presence of a non-traumatic fracture.

The WHO committee did not have enough data to create

definitions for men or other ethnic groups.

One standard deviation is at the 16th percentile, so by

definition 16% of young women have osteopenia! As
Cutoff values for osteopenia using total Hip shown below, by the time women reach age 80, very few
BMD are considered normal.
T-score Hologic Lunar Norland Standard
It is important to realize that the T-score alone does not
-1 .820 .886 .800 833 predict fractures, and osteopenia is not a disease.

-2.5 .637 .706 .615 648

Percentage of US Caucasian women in WHO categories

Age 25 Age 50 Age 65 Age 80

Normal 84% 66% 40% 10%

Osteopenia 15% 33% 40% 35%
Osteoporosis 1% 1% 13% 27%
Established osteoporosis 1% 1% 7% 27%

Here's another way of looking at it. If I took 100 ordinary women at each of three ages
(35, 55 and 75 years) and lined them up according to their bone density, they would
stand like this. The ones in purple would have a fragility fracture within the next ten
years. (Kanis JA)

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Updated 6/18/08

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