Echolight REMS Discussion Group

06/09/2026

From Dr. Andrew Bush [post 3 of 3]

Accepting change is difficult, but it is often necessary to achieve a desired goal. To implement a bone health assessment program that will accurately and reliably determine fracture risk and that is globally accessible will require making changes to the current densitometry systems and the accepted dogma that underpins the system. To escape the shackles of BMD determination novel methods need to be developed that investigate and assess the structural integrity of bone to determine its strength. Methods already exist that can perform these types of assessments quite accurately, the most promising of which are based on CT-scanning techniques using Finite Element Analysis for fracture modeling [16]. However, the risks of radiation exposure from CT-based methods and its known association with carcinogenesis [17] as well as the limited availability of the necessary equipment and facilities make any CT-based system as unlikely to achieve the goal of global fracture risk screening as is the case with DXA [1].

The use of modern, ultrasound-based, bone assessment technology will provide the method to attain the elusive goal of global fracture risk assessment. Historically, quantitative ultrasound (QUS) and the QUS-determined Stiffness Index (SI) demonstrated the ability of sound waves to characterize bone structure and predict fracture risk [18-20]. However, due to technical limitations of transmission ultrasound, densitometry assessment could only be performed at peripheral sites (i.e., the calcaneus) and not at the WHO established axial Regions of Interest (i.e., the lumbar spine and the hips). Pulsed echographic sonography ushered in the era of bone microarchitecture assessment to determine bone strength at WHO designated axial Regions of Interest [21,22]. This technology is now an accepted method to diagnose osteoporosis [23-25] and determine fracture risk [26,27]. REMS technology, developed by Echolight SPA, Lecce, Italy, is already being used world-wide for the assessment of bone mass and toughness. The REMS-determined Fragility Score has proven to be an accurate, reliable, reproducible, portable, and radiation-free method of determining fracture risk by determining bone strength [28].

Unfortunately, the topic of sonographic densitometry was not mentioned or discussed in the IOF Position Paper [1]. For the past three decades, focus has remained on the radiation-based and imperfect methods of bone assessment, with the irrational hope that these systems could be made more relevant and accurate in predicting fracture risk by applying a patchwork of workarounds. But the time to change focus is upon us. REMS needs to be recognized as the powerful technology it is, so that the usual standards of rigorous academic assessment can be applied to determine its full capabilities. It is wrong to continue to ignore REMS, which has the potential to help solve the current fracture risk prediction conundrum and improve equity of access especially in low and middle-income countries [25]. REMS should be introduced into the current bone health care discussions to contribute to the development and implementation of a standardized global policy and uniform method for determining fracture risk and preventing fragility fractures.
16. Johannesdottir F, Allaire B, Bouxsein ML. Fracture Prediction by Computed Tomography and Finite Element Analysis: Current and Future Perspectives. Curr Osteoporos Rep. 2018 Aug;16(4):411-422. doi:10.1007/s11914-018-0450-z. Erratum in: Curr Osteoporos Rep. 2022 Oct;20(5):364. PMID: 29846870.
17. Smith-Bindman R, Chu PW, Azman Firdaus H, et.al. Projected Lifetime Cancer Risks From Current Computed Tomography Imaging, JAMA Intern Med, 2025;185;(6):710-719. doi:10.1001/jamainternmed.2025.0505
18. Hans D, Baim S. Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk. J Clin Densitom. 2017 Jul-Sep;20(3):322-333. doi:10.1016/j.jocd.2017.06.018. Epub 2017 Jul 21. PMID: 28739081.
19. Diez-Perez A, et al. Prediction of absolute risk of non-spinal fractures using clinical risk factors and heel quantitative ultrasound, Osteoporosis Int (2007) 18: 629-639.
20. McCloskey EV, Kanis JA, Odén A, Harvey NC, Bauer D, González-Macias J, et al. Predictive ability of heel quantitative ultrasound for incident fractures: an individual-level meta-analysis, Osteoporos Int. 2015 Jul;26(7):1979-87. doi:10.1007/s00198-015-3072-7. Epub 2015 Feb 18.
21. Conversano F, Franchini R, Greco A, Soloperto G, Chiriacò F, Casciaro E, et al. A novel ultrasound methodology for estimating spine mineral density. Ultrasound Med Biol. 2015 Jan;41(1):281-300. doi:10.1016/j.ultrasmedbio.2014.08.017. Epub 2014 Nov 15. PMID: 25438845.
22. Casciaro S, Peccarisi M, Pisani P, Franchini R, Greco A, De Marco T, et al. An Advanced Quantitative Echosound Methodology for Femoral Neck Densitometry, Ultrasound Med Biol. 2016 Jun;42(6):1337-56. doi:10.1016/j.ultrasmedbio.2016.01.024. Epub 2016 Mar 28. PMID: 27033331.
23. Di Paola M, Gatti D, Viapiana O, Cianferotti L, Cavalli L, Caffarelli C, et al. Radiofrequency echographic multispectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck. Osteoporos Int. 2019 Feb;30(2):391-402. doi:10.1007/s00198-018-4686-3. Epub 2018 Sep 4. PMID: 30178159.
24. Cortet B, Dennison E, Diez-Perez A, Locquet M, Muratore M, Nogués X, et al. Radiofrequency Echographic Multi Spectrometry (REMS) for the diagnosis of osteoporosis in a European multicenter clinical context. Bone. 2021 Feb; 143:115786. doi:10.1016/j.bone.2020.115786. Epub 2020 Dec 2. PMID: 33278653.
25. Fuggle NR, Reginster J-Y, Al-Daghri N, Bruyere O, Burlet N, Campusano C, et al. Radiofrequency echographic multi spectrometry (REMS) in the diagnosis & management of osteoporosis: state of the art. Aging Clin Exp Res 2024;36:135. doi.org/10.1007/s40520-024-02784-w
26. Adami G, Arioli G, Bianchi G, Brandi ML, Caffarelli C, Cianferotti L, et al. Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study, Bone, 2020 May;134:115297. doi: 10.1016/j.bone.2020.115297. PMID: 32092480.
27. Pisani P, Greco A, Conversano F, Renna MD, Casciaro E, Quarta L, et al. A quantitative ultrasound approach to estimate bone fragility: A first comparison with dual X-ray absorptiometry. Measurement, 2017 April;101:243-49. ISSN 0263-2241, doi: 10.1016/j.measurement.2016.07.033.
28. Pisani P, Conversano F, Muratore M, Adami G, Brandi ML, Caffarelli C, et al. Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years, Aging Clin Exp Res. 2023 Feb 8. doi:10.1007/s40520-023-02358-2. PMID: 3675295.

06/09/2026

From Dr. Andrew Bush [post 2 of 3]

Bone Strength vs. Bone Mineral Density: Which predicts fragility fractures better?

Andrew Bush

Commentary on the Position Paper resulting from an International Osteoporosis Foundation (IOF) Working Group: [Nicholas C. Harvey, Nasser Al‑Daghri, Charlotte Beaudart, Maria Luisa Brandi, Nansa Burlet, Claudia Campusano, et al, Barriers and solutions for global access to osteoporosis management: a Position Paper from the International Osteoporosis Foundation, Osteoporosis International (2025) 36:1495–1507. https://doi.org/10.1007/s00198-025-07628-5]

The International Osteoporosis Foundation (IOF) has recently issued a Position Paper that deserves recognition and applause for boldly addressing issues that unfortunately, are often avoided when discussing bone health care. One issue addressed is the BMD dilemma. Although Bone Mineral Density (BMD) has been considered the “gold standard” for decades it actually is not a reliable method to determine fracture risk. The stated position of the authors is: “…BMD alone is a poor screening tool…” and “…BMD captures the likelihood of fracture incompletely.” Also, the authors discuss the confusion surrounding the use of the word “osteoporosis.” The “disparity between the conceptual and densitometric definitions of osteoporosis…” results in “confusion between diagnostic and interventional thresholds,” which, in addition to multiple other issues, are “limiting access” to advances in determining and managing fracture risk in multiple countries around the world [1].

Several issues associated with using a BMD-derived T-score-based method for fracture prediction are explained and discussed. Recommendations for improvements of the current BMD/T-score system are suggested in the form of add-on, clinically based risk indicators factored into algorithms for prediction of fracture risk. FRAX, Garvan and other systems are offered as examples of fracture risk calculators based on factors associated with fragility fractures [2]. The authors also recommended moving away from a DXA-based system due to the economic and physical challenges that limit access to DXA-determined BMD for a large portion of the world’s population and discussed how the confusion caused by the lack of uniformity in the use of the diagnosis of “osteoporosis” is an obstacle to establishing a standardized treatment protocol. “High Fracture Risk Syndrome and Absolute Fracture Probability” are the novel terms being proposed to standardize terminology. The authors have announced a “Call to Action” for the WHO and nations globally to address these issues to “ensure that all people at high fracture risk worldwide be identified and receive appropriate assessment and treatment to optimize their bone health.” [1]

However, after this thorough discussion and proposed recommendations for action, a single important question remains unanswered:

Why is densitometric-determined BMD an unreliable measure to determine fracture risk?

That question has an unequivocal answer, but that answer will not be found in any of our medical textbooks. We must desert our established medical rubrics to venture over to learn from our structural engineering colleagues. To understand fracture risk, we must understand the basic scientific principles of structural engineering since bone is a structural material [3]. That will require embracing new terminology: elastic and plastic deformation and the yield point, as well as understanding how a stress-strain curve explains mechanical failure. The obvious needs to be stated – engineers do not measure density to determine if a structure such as a bridge, a building, an airplane wing, or a car frame, can withstand applied loads and not catastrophically fail [4]. Therefore, why is does Medicine depend on measuring BMD to attempt to determine the failure point of bone if bone is a structural material?

Density, which is a physical property of bone, was chosen to assess the skeleton over 30 years ago because bone density could be measured with, what was at the time considered to be a reasonable degree of accuracy by x-ray absorptiometry. At the time it provided the only non-invasive method to measure a single physical property of bone that had some relevance in determining skeletal frailty [1] and therefore, fracture risk. However, a bone fracture is an example of material failure which is a mechanical property. Mechanical properties describe how materials behave when subjected to external forces or loads and are determined by the combined interactions of all the physical properties of the material. Density is only one of multiple physical properties that determine the mechanical properties of a structural material, and it alone cannot accurately or reliably determine how a material will behave when a loading force is applied. Measuring density alone to attempt to determine structural failure is inadequate and unreliable [5,6]. Therefore, BMD is not a reliable measurement to determine if a bone will break [7]. The reported statistic that 50% of all fragility fractures happen in individuals who do not have osteoporosis exposes the weakness of using density to determine fracture risk [8,9].

Thirty years later, it is established that bone should be evaluated in a similar manner to how other real-world structures are evaluated. Bone is a structural material and therefore, understanding the basic concepts of mechanical load and structural failure will lead to a better understanding of the mechanism of bone failure – that is how a bone fractures. Bone failure can be determined only if the mechanical properties such as strength, stiffness and toughness of bone are known [8,9]. Determining bone strength is the single most important aspect of diagnostic bone assessment – strong bone is fracture-resistant, weak bone breaks [8-14].

Over the past three decades many attempts have been made to rectify the issues with DXA-determined BMD and improve its ability to determine fracture risk. However, there have been no significant improvements due to the limitations and constraints of x-ray absorptiometry. The development of the Trabecular Bone Score (TBS) has been proposed as a solution to make DXA more relevant [15]. TBS offers a method of assessing bone structure within the lumbar vertebrae to determine bone strength. However, TBS has limits because it is intimately tied to its foundational technology, x-ray absorptiometry, the accuracy of which is known to be adversely affected by radiological artifacts and technical errors.

1. Harvey N C, Al‑Daghri N, Beaudart C, Brandi M-L, Burlet N, Campusano C, et al. Barriers and solutions for global access to osteoporosis management: a Position Paper from the International Osteoporosis Foundation, Osteoporosis International (2025) 36:1495–1507. https://doi.org/10.1007/s00198-025-07628-5
2. Kanis JA, Johansson H, Harvey NC, McCloskey EV. A brief history of FRAX. Arch Osteoporos. 2018 Oct 31;13(1):118. doi:10.1007/s11657-018-0510-0. PMID: 30382424; PMCID: PMC6290984.
3. Zimmermann EA, Ritchie R. Bone as a Structural Material, Advanced Healthcare Materials, 2015; 4;(9):1287-1304, https//doi.org/10.1002/adhm.201500070
4. Murphy W. Structure Stability, International Journal of Solids and Structures. 37 (2000); 55-67.
5. Leslie WD, Majumdar SR, Morin SN, Lix LM. Why does rate of bone density loss not predict fracture risk? J Clin Endocrinol Metab. 2015 Feb;100(2):679-83. doi:10.1210/jc.2014-3777. Epub 2015 Jan 22. PMID: 25611114.
6. Garg MK, Kharb S. Dual energy X-ray absorptiometry: Pitfalls in measurement and interpretation of bone mineral density. Indian J Endocrinol Metab. 2013 Mar;17(2):203-10. doi:10.4103/2230-8210.109659. PMID: 23776890; PMCID: PMC3683192.\
7. Friedman AW. Important determinants of bone strength: beyond bone mineral density, J Clin Rheumatol, 2006, Apr;12(2):70-7, doi:10.1097/01.rhu.0000208612.33819.8c.
8. Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The Assessment of Fracture Risk, J Bone Joint Surg Am. 2010; Mar;92(3):743-753. doi:10.2106/JBJS.I.00919
9. Wainwright SA, Marshall LM, et al. Hip fracture in women without osteoporosis, J Clin Endocrinol Metab, (2005) 90:2787-2793. https://doi.org/10.1210.jc.2005-1568
10. Curry J. Measurement of the Mechanical Properties of Bone: A Recent History. Clin Orthop Relat Res. 2009 March 14:467(8):1948-1954. doi:10.1007/11999-009-0784-z
11. Seeman E. Bone’s material and structural strength, Current Opinion in Orthopedics, Sept 2007;18(5):494-498. doi:10.1097/BCO.0b013e3282a9c162
12. Hart NH, Nimphius S, Rantalainen T, Ireland A, Siafarikas A, Newton RU. Mechanical basis of bone strength: influence of bone material, bone structure and muscle action. J Musculoskelet Neuronal Interact. 2017 Sep 1;17(3):114-139. PMID: 28860414; PMCID: PMC5601257.
13. Boskey A. Using bone quality to assess fracture risk, AAOS Now, American Academy of Orthopedic Surgery, July 1, 2011.
14. Paschalis E, Mendelsohn R, et al. Infrared Assessment of bone quality – a review, Clin Orthop Relat Res (2011) 469: 2170-2178.
15. Silva BC, Leslie WD, Resch H, Lamy O, Lesnyak O, Binkley N, et al. Trabecular bone score: a noninvasive analytical method based upon the DXA image. J Bone Miner Res. 2014 Mar;29(3):518-30. doi:10.1002/jbmr.2176. Erratum in: J Bone Miner Res. 2017 Nov;32(11):2319. PMID: 24443324.

[To be wrapped up in post 3 of 3]

Our ability to optimally manage bone health across the lifecourse, and so minimise the risk of fractures, has advanced substantially in recent decades. Whilst fractures and osteoporosis in older age were historically viewed simply as inherent in normal ageing, they are now recognised as manifestatio...

06/08/2026

From Dr. Andrew Bush [post 1 of 3]

Why I don’t care that you have osteoporosis –
- but I do care if your bones are structurally strong or weak!

Why the statement “I have osteoporosis” should not be the reason that someone uses to justify why they sustained a fragility fracture.

I decided to write this reply as a separate post after thinking over a recent statement someone had made. This person felt that a diagnosis of “osteoporosis” was enough of an explanation why they happened to sustain spine compression fractures. However, there are several reasons why the term “osteoporosis” statement should not be used as the reason for sustaining fragility fractures.

It is the strength of a bone that determines if it breaks and it is the bones structure that determines the bone’s strength – a bone with a weak structure will break and a bone with a strong structure will be fracture resistant. Therefore, if someone sustains a fragility fracture (low-energy fracture) it is necessary to know why the bones in that individual were weak enough to break with low-energy trauma – what caused change in structure that weakened the bone. Weak bone can be the result of many different reasons, ranging from having weak muscles (sarcopenia), to lack of appropriate nutrition a problem with absorbing nutrients, to multiple metabolic conditions, chronic stressful conditions or the use of certain drugs that can cause the breakdown of bone. Usually the problem can be found through a thorough medical history and examination and the use of labs and other diagnostic testing and it is paramount that the appropriate medical evaluation is performed following a fragility fracture to determined what underlying condition weakened the bone.

Sometimes, low-energy fractures can also happen not necessarily from a systemic metabolic reason but from localized bone issues. Examples are: localized arthritis, prior injuries that altered the bone’s anatomy or other structural abnormalities such as scoliosis, cysts, and/or tumors or conditions that weaken muscle such as a stroke, nerve injury, degenerative nerve conditions or diseases like Polio. These conditions can cause bone deterioration (i.e., premature aging of bone) due to abnormal forces being applied to the bone that compromise the structure of the bone with time. Degenerative type processes can locally break down bone making it weaker and more susceptible to fracture. Although a fracture under these circumstances would be a pathological fracture, it would not be considered a fragility fracture.

The term “osteoporosis” is confusing because it is used in 2 conceptually different ways. The WHO has defined osteoporosis to be a T-score value of ≤ -2.5 SD. Unfortunately, it is also used to describe “weak” bone. However, there are many individuals who have the diagnosis of “osteoporosis” because their T-score is ≤ -2.5 SD but who do not have weak bone and do not fracture when they fall. The current bone health literature documents that approximately 50% of all fragility fractures happen in people who do not have the diagnosis of osteoporosis – they are diagnosed with either “normal density” or “osteopenia.” The International Osteoporosis Foundation has recently published an article addressing the issues that using DXA determined BMD values is not a reliable way of determining fracture risk and that the current use of the term “osteoporosis” needs to be reconsidered: [Nicholas C. Harvey, Nasser Al‑Daghri, Charlotte Beaudart, Maria Luisa Brandi, Nansa Burlet, Claudia Campusano, et al, Barriers and solutions for global access to osteoporosis management: a Position Paper from the International Osteoporosis Foundation, Osteoporosis International (2025) 36:1495–1507. https://doi.org/10.1007/s00198-025-07628-5 ]

[To be continued in post 2]

01/05/2026

Announcing our live webinar with Susan Brady of Nurtured Bones and Dr. Andy Bush on January 7, 2026. Register at the link below.

Join Susan Brady and Dr. Andy Bush on January 7, 2026. Learn the benefits of REMS and the steps you can take now to build stronger, healthier bones.

12/30/2025

Dr. Bush will be back in Northern California — Mill Valley in January! See the info below from OsteoScan USA.

We’re hosting REMS Bone Health Clinics with Dr. Andrew Bush
📅 January 23rd, 24th & 25th - Friday, Saturday & Sunday
This advanced, radiation-free bone scan reveals your bone density, bone quality, and Fragility Score.

As your results appear instantly on screen, Dr. Bush provides a mini consultation on the spot, helping you understand your bone health and what steps to take next.

👉 Schedule now at www.OsteoScanUSA.com
📞 Questions? Call or text (415) 858-8713

Preventive. Proactive. Personal.

Get comprehensive REMS scans using Echolight Technology for bone health. Schedule your consultation today!

10/22/2025

Due to flooding, the Charleston event was rescheduled to Friday, October 24th, and Saturday, October 25th. See the registration link for additional details and to sign up at

Find out more about your actual bone quality through a Echolight REMS bone health scan. Echolight REMS evaluations use ultrasound to determine bone mineral density (BMD) and bone quality via a Fragility score. Dr. Andrew Bush MD is an orthopedic surgeon who specializes in bone health.

10/08/2025

Dr. Bush is in Charleston, SC, for another Echolight REMS event.
Friday, October 10, and Saturday, October 11th. There are still appointments available.

Find out more about your actual bone quality through a Echolight REMS bone health scan. Echolight REMS evaluations use ultrasound to determine bone mineral density (BMD) and bone quality via a Fragility score. Dr. Andrew Bush MD is an orthopedic surgeon who specializes in bone health.

08/07/2025

✨ Exciting News! ✨
Dr. Andrew Bush is coming back to Northern California!

We’re thrilled to announce that OsteoScan USA, in collaboration with Dr. Andrew Bush, will be offering REMS bone health scans again on:

📅 September 5, 6, and 7
📍 Mill Valley, CA

These appointments have been incredibly popular, and every single person has walked away feeling more informed, empowered, and motivated about their bone health. 💪

✅ No radiation
✅ Quick, non-invasive scan
✅ Real-time interpretation by Dr. Bush himself

🎯 This is a great opportunity to take charge of your bone health—whether for prevention, monitoring, or peace of mind.

Spots fill up fast, so don’t wait!
👉 Visit www.osteoscanusa.com and click the Schedule button.

💬 Please share this with friends or family who might benefit. The more interest we show, the more often we can keep Dr. Bush returning to Northern California!

Let’s stay proactive together. 💙

Get comprehensive REMS scans using Echolight Technology for bone health. Schedule your consultation today!

07/31/2025

Final Weekend of Echolight/REMS Bone Health Scans with Dr. Bush – Until September!
There are still appointments available for Echolight/REMS bone health scans with Dr. Andrew Bush this Friday, Saturday and Sunday, August 1-3, in Mill Valley, California.
During your scan, Dr. Bush provides a real-time mini-consult, reviewing your results as they appear on the screen.
This is your last opportunity to get scanned before September!
Participants from last weekend shared how eye-opening and empowering the experience was. With so much confusion around DEXA scans and bone health, this advanced REMS scan provides accurate, actionable insights to help you make confident, informed decisions.
✅ No radiation
✅ Assesses both bone quality and density
✅ Performed by one of the country’s foremost experts in Echolight/REMS scanning and bone health
📍 Location:
55 La Goma Street, 2nd Floor, Mill Valley, CA 94941
📞 Call or Text
415-858-8713
Scheduling is available on the website:
🌐 Website:
www.osteoscanusa.com
📧 Email:
[email protected]
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Get comprehensive REMS scans using Echolight Technology for bone health. Schedule your consultation today!