01/05/2026
IIMHE/OsteoscanUK Response to Margaret Martin's Blog
Many of you have seen and commented on this blog this week and were interested in Nick Birch's response to it. Here it is.
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[IMHE response to a blog posted by Ms Margaret Martin regarding REMS and DEXA] 1st May 2026
IIMHE recognises the significant contribution made by Ms Martin’s thoughtful blog post that examines the relationship between DEXA and REMS in the light of recently published peer-reviewed literature. The Institute welcomes the open and honest debate that the blog post has started. The piece is well-written and makes this important subject accessible to the lay reader.
The blog demonstrates a keen focus on bone health that recognises the additional value and benefits of REMS as a new assessment technology while framing REMS within the wider scope of the long-established use of DEXA worldwide. It recognises that the use of REMS and DEXA overlap and both have strengths and weaknesses.
One key consideration currently is fitting the two into the diagnostic sweet spot that best serves patients who are undergoing screening or follow-up.
Ms Martin’s blog calls for legitimate scientific scrutiny including an examination of:
• REMS algorithm transparency
• REMS results reproducibility
• Densitometry operator dependence
• The issue of correlation vs causation in scientific publications
• Understanding how demographic inputs affect densitometry output
The blog references the 2025 Practice Parameters paper, led by IIMHE Director of Education Dr Kim Zambito MD, an important publication that has helped to define appropriate professional standards for REMS use. Ms Martin also recognises that there are clinical circumstances where REMS may be demonstrably more informative than DEXA, particularly where conventional X-ray densitometry is affected by artefact, limited access, radiation exposure concerns, or technical constraints.
However, there are a number of inaccuracies and omissions that require clarification:
1: Osteoscan UK is not, and has never been, a distributor of REMS equipment in the
United Kingdom. It is a bone health screening service provider and educational contributor. Confusing provider networks with commercial distribution risks misleading readers.
2: Considerable emphasis in the blog is placed upon recently published studies by Bobelyak and Chan. These papers pose important questions, as all scientific work should, and they raise flags that need to be recognised and addressed. However, both are based on relatively small datasets (50 in the Bobelyak paper and 209 in the Chan paper).
IIMHE is aware of several studies, including reviews of Echolight reference data and analysis of independent real-world clinical results, that are currently in preparation or in peer review, which look at the very questions being raised but use much larger datasets.
• Echolight is integrating their original reference data to examine the influence of age and weight on REMS and DEXA outputs in 8,000 Italian patients.
• The real-world data from Australia and the UK analyses the results from over 5,500 patients with over 15,000 scans. The latter study, independently analysed by an experienced biostatistical team, appears to demonstrate that REMS can genuinely identify outliers and show clinically meaningful variation within age and BMI groupings. This is precisely the type of variation that smaller studies may fail to capture.
The registration and pivotal studies comparing REMS and DEXA in Europe provided data from almost 10,000 patients. These have been written up as patents and regulatory clinical evaluation reports in 45 countries around the world including the US (FDA), the EU (MDD), the UK (MHRA) and Australia (TGA) and were published between 2018 and 2023.
Drawing sweeping conclusions from two small-cohort studies about a technology with a 10-year R&D history and worldwide regulatory acceptance is therefore problematic, particularly when studying a new methodology designed to detect variation across broad populations.
4: Ms Martin’s blog underplays one of the most significant realities in bone densitometry: the widespread technical variability of DEXA itself. In day-to-day practice, DEXA accuracy can be materially affected by positioning error, vertebral selection inconsistency, degenerative spinal change, scoliosis, abdominal calcification, machine calibration differences, operator technique, and reporting inconsistency.
Additionally, the differences between machines produced by different DEXA device manufacturers using different reference databases to convert BMD into a T-score precludes uniformity of DEXA BMD assessment. These are not minor issues. They are among the commonest reasons for discordant or misleading results.
Any fair comparison must acknowledge that DEXA, while established, is far from infallible.
5: Criticism of the REMS rebuttal letter, published by Osteoporosis International with 38 signatories from around the world, for not addressing the Chan paper is misplaced.
The rebuttal letter was prepared and submitted BEFORE the Chan paper was published by the journal. It is not reasonable to criticise authors for failing to respond to material not yet in the public domain.
6: Criticism that REMS does not "detect fractures" misunderstands the intended purpose of the technology. REMS is an ultrasound-based bone assessment system. It was never designed to function as a fracture imaging technology in the same way that no conventional ultrasound system is used as a primary fracture detection tool.
Equally, a standard DEXA cannot be used for fracture detection as only a single projection is used to evaluate bone mineral density in the spine in the hip. Orthogonal views are required for fractured detection. Only a DEXA with a VFA will definitively add to fracture detection.
Judging REMS negatively for not being an X-ray is neither scientifically fair nor clinically helpful.
More broadly, the adversarial framing of "REMS versus DEXA" serves neither clinicians nor patients well.
IMHE's position is unambiguous: both REMS and DEXA are components of the comprehensive assessment of fracture risk, and a person is not,
and should never be, defined by a single number such as a T-score.
Therefore, it is important that the benefits of older and newer technologies are looked for and utilised in the most appropriate manner to enhance the ability of clinicians to advise patients regarding their bone health in the best possible manner.
Ultimately, this debate is centred on how to prevent fractures and having additional tools to assist the clinician and patient to have a better understanding of both overall bone health and fracture risk can only be positive.
The strongest voices drawn up in battle lines have often come from entrenched DEXA adherents rather than those advocating complementary use of newer technologies.
At IIMHE, our consistent position has been, and remains, that the conversation should be about evidence-informed appropriate use of technology, not tribal allegiance to one platform or another.
IIMHE Board of Founders
www.iimhe.org
1 May 2026
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