What NICE decided in July 2026 about DXA, REMS and the other ways of measuring bone — and what it means for you.
International Institute for Musculoskeletal Health Education · August 2026 · Written for people who have had, or are considering, a bone density scan.
NICE — the National Institute for Health and Care Excellence — sets the standards the NHS in England follows. On 29 July 2026 it published new guidance on assessing the risk of breaking a bone, called NG259. It replaces guidance that had stood since 2012.
Alongside it NICE published a 237-page technical review of the scanning technologies. That review asked one very specific question, and it is not the question most people assume. It did not ask how accurately does a scanner measure bone density? It asked how well does a scan tell us, in advance, who is actually going to break a bone? Those are different questions, and the answer to the second one is more sobering than most people expect.
| Type of scan | What NICE found | Where it stands now |
|---|---|---|
| DXA — the standard NHS X-ray bone density scan | Identifies who will go on to break a bone only modestly well. NICE’s own wording for its performance in predicting the common fractures is “poor”; for hip fractures specifically, it is “poor to moderate”. | Still the recommended scan throughout the NHS — but NICE now says a DXA result must never be used on its own to predict fracture risk. |
| REMS — the portable ultrasound bone scan | Only one study anywhere in the world met NICE’s strict quality rules. Its results were also in the “poor” range, and NICE rated the confidence in them as very low. | Not part of the NHS pathway. But NICE has made research into it a top priority — see below. |
| QCT — a specialised CT scan | Two studies. One returned the best results in the whole review for predicting hip fracture. | Not part of the NHS pathway. Research recommended, but not made a priority. |
| TBS — extra analysis added to a DXA image | One study, in men only. Results slightly better than DXA alone. | Not part of the NHS pathway. Research recommended, but not made a priority. |
The most important conclusion in the whole review is about the standard NHS scan, not about any of the newer ones.
NICE pooled results from studies covering tens of thousands of people and found that a DXA bone density measurement, used by itself, is only modestly better than a coin toss at telling apart the people who will break a bone from the people who will not. NICE’s conclusion, in its own words, is that your DXA result should not be used on its own to predict your fracture risk. It should be read alongside your fracture history, a risk calculation such as FRAX or QFracture, and everything else known about you.
This is not a criticism of DXA, and it does not mean your scan was a waste of time. It means bone density is one piece of the picture rather than the whole of it, which is something bone specialists have argued about for thirty years, and NICE has now settled.
NICE looked at three newer or additional technologies — REMS, QCT and TBS — and decided the evidence for all three was too thin to recommend any of them. It asked for more research on all three. But it marked only the REMS research as a key priority.
Its stated reasons are about the practical qualities of the technology, not about how well it performed. REMS is quick, uses no X-rays so needs no radiation shielding, is safe in pregnancy, and the machine can be carried to the patient rather than the patient travelling to the machine, which could bring scanning to communities that will never have a DXA scanner. Of the three technologies, REMS was the only one for which NICE recorded any benefit of this kind.
This is worth being clear about, because it is being reported in both directions and neither is right.
NICE has not approved REMS. It does not appear in any NHS recommendation, and its measured performance in the one qualifying study was the weakest of the three technologies considered.
NICE has not rejected REMS either. It selected REMS, ahead of two better-performing alternatives, as the technology whose unanswered question is most worth answering, and set out exactly what research would answer it.
The honest summary is that NICE has not decided where REMS belongs. It has decided that finding out is a priority.
Each of these is explained in section 6.
NICE guidance is what your GP, your hospital and the person reporting your scan are expected to follow. NG259 covers who should have their fracture risk assessed, how it should be assessed, how spinal fractures should be found, when medication should be considered, and how often people should be reassessed.
It replaces guidance from 2012, so this is the first substantial rethink in fourteen years. A further update covering treatments themselves is expected in 2027.
Underneath the guidance sits the technical work. One of those documents, Evidence Review D, is the one that decided which scanning technology the NHS should use. That is the document this guide is mostly about.
Most people, understandably, assume the test of a bone scanner is whether it measures bone density accurately. NICE asked something harder.
It asked whether the scan could identify, before anything has happened, the people who will go on to break a bone. To answer that, it would only accept studies that scanned people first and then followed them forward in time, for years, to see who actually fractured. Studies that compared one scanner with another, or that scanned people who had already broken a bone, were not eligible. That is a demanding rule, and it is the reason only a handful of studies survived it.
Why this distinction matters. A scan can measure bone density perfectly accurately and still be only modestly useful at predicting whether a person will break a bone. That is because bones break for many reasons at once: how strong the bone is, how it is built internally, whether someone falls and if so how often, how old a person is, what has been broken before, what medicines a person takes, and what other conditions they have.
Bone density is one of those things. It is not the only one, and NICE’s review has now measured how much of the picture it accounts for.
DXA is the scan you will have had, or will be offered, on the NHS. You lie on a couch, a low-dose X-ray arm passes over your lower spine and one or both hips, and it takes a few minutes. It produces the T-score you may already have been given.
NICE combined the results of studies covering tens of thousands of people. To describe how well a test separates those who will have an event from those who will not, researchers use a figure between 0.5 and 1.0. A score of 0.5 means the test is no better than tossing a coin. A score of 1.0 would mean it is always right. NICE set out in advance how it would read these numbers:
| Score | NICE’s description |
|---|---|
| 0.50 or below | Worse than chance |
| 0.50 to 0.60 | Very poor |
| 0.61 to 0.70 | Poor |
| 0.71 to 0.80 | Moderate |
| 0.81 to 0.90 | Good |
| 0.91 to 1.00 | Excellent |
NICE also decided in advance that a test would only be recommended if it scored 0.70 or above.
For the common fragility fractures — hip, spine, shoulder and wrist taken together — DXA scored between 0.63 and 0.66 depending on which part of the skeleton was measured. On NICE’s own scale, that is poor. None of the measurements reached the 0.70 mark NICE had set as the bar for recommending a test.
For hip fracture on its own, DXA did better: 0.66 to 0.77, which NICE described as poor to moderate.
NICE explained the best of those figures in plain terms. If you picked two people at random, one who was going to break a hip and one who was not, a total hip DXA measurement would correctly give the higher risk to the person who fractures about 77 times out of 100. For the more common fractures, the equivalent figure was about 66 times out of 100.
NICE also found that the results varied enormously between studies, so much so that it concluded there is substantial uncertainty about how well DXA will perform in the next group of people it is used on.
None of this means a person should refuse a DXA scan or ignore the result. NICE continues to recommend DXA throughout the NHS, because it has by far the largest body of evidence behind it and because it genuinely does contribute to the decision about whether treatment is right for you.
What has changed is the weight the result is allowed to carry on its own. The T-score is now formally one of four things a clinician should be weighing up, alongside fracture history, calculated risk score, and individual risk factors.
REMS is an ultrasound-based bone scan. A probe is passed over the hip or lower spine, there is no X-ray exposure at all, and the machine is small enough to be moved between sites. It is available privately in the UK in a number of clinics; it is not available on the NHS.
Only one study met NICE’s rules: a five-year follow-up of 1,516 Italian women aged 30 to 90 who had been referred for a DXA scan, published in 2020. Follow-up was completed in 1,370 of them, over an average of 3.7 years. Among those women there were 192 fractures of the common types and 21 hip fractures.
The scores were: 0.63 for the common fractures at both the hip and the spine measurement sites; 0.60 at the hip site and 0.66 at the spine site for hip fracture specifically. On NICE’s scale that is poor, and NICE rated its confidence in all four numbers as very low, partly because 21 hip fractures is a very small number to draw conclusions from, and partly because of how the study was designed and reported.
Because that study scanned the same women with both machines on the same day, it allows a direct comparison. In those women, for the common fractures, REMS scored slightly higher than DXA (0.63 against 0.58 and 0.60). For hip fracture the two were close, with DXA slightly ahead at one site.
This is being reported as REMS performing as well as DXA. However, it is more complicated than that.
In this particular study, DXA performed worse than in any of the other eleven groups of people NICE looked at, well below its own average. There are understandable reasons: the women were relatively young, with an average age of 60, and the study counted a broader range of fractures than NICE’s standard definition.
So the fair reading is nuanced. In this one group of women, the two scans ranked people’s risk to a similar and fairly modest degree. That does not tell us how REMS would perform in a group where DXA behaves the way it usually does, and there is no second REMS study to check against.
That gap is precisely what NICE has now asked researchers to fill.
It is worth noting what this review did not cover. The only REMS outputs NICE examined were the two bone density readings. The Fragility Score, and any other measure the REMS report may show, were not assessed. A study of the Fragility Score was identified but could not be included, because the people in it had not been selected in the way NICE’s rules required.
So, for a REMS report with a Fragility Score on it, nothing in NG259 either supports or contradicts that number. NICE simply did not look at it.
These two are usually left out of summaries, but they change the story, so they are worth looking at.
QCT is a specialised CT scan that measures bone in three dimensions rather than as a flat image as DXA does. In one study of 250 older men it scored 0.88 to 0.90 for predicting hip fracture, comfortably the best result anywhere in NICE’s review, and rated with more confidence than any DXA or REMS result. It uses a higher radiation dose than DXA and needs a CT scanner, and the study has not been repeated. NICE asked for more research on it but did not make it a priority.
TBS is not a separate scan. It is an extra piece of software analysis applied to the DXA image you have already had, describing the internal texture of the spine bone rather than just its density. In one study, in men, adding TBS improved DXA’s hip fracture score from around 0.73 to 0.78. NICE is particularly interested in whether it helps in people whose bone loss has an underlying cause, such as long-term steroid treatment. Again, research is recommended but not prioritised.
This is the question that has generated most of the commentary, so here is what NICE actually wrote.
Having decided the evidence for REMS, QCT and TBS was insufficient to recommend any of them currently, NICE marked only the REMS question as a key research priority. Its reasons, in its own words, were that REMS is quick and safe, requires no special arrangements and no radiation shielding, is easily portable, and can be used in a variety of settings.
In its formal research paperwork, NICE went further on one point. Each research recommendation has a section on fairness of access. For QCT and TBS, NICE recorded “none”. For REMS it recorded that the technology involves no ionising radiation, which is safer for patients and particularly for people who are pregnant, and that being portable it may expand access in the community. This fits in well with the aims of the current NHS 10-year plan.
REMS was chosen not because it performed best — indeed it performed the weakest of the three, and the best-performing technology in the review, QCT, was not prioritised at all. It was chosen because of what it might make possible: scanning without X-rays, scanning during pregnancy, and scanning in places where a DXA scanner will never be installed.
Those are good reasons to want an answer. They are not, by themselves, an answer.
NICE has effectively written the study it wants. It should scan people at risk of fracture before anyone knows what will happen to them, follow them forward, confirm every fracture with imaging, and report how well the scan predicted hip fractures and the common fragility fractures. It should be finished in time for the next update of the guideline (which might be another 14 years).
If you are asked to take part in research of this kind, that is why.
| What | What NG259 now says |
|---|---|
| Who should be assessed | Everyone aged 50 and over, and women who have been through the menopause, who have already had a fragility fracture or who take regular steroid tablets. Assessment should also be considered for men over 75, women over 65, and younger people with risk factors such as two or more falls in a year, a parent, brother, sister or child who broke a hip, a low body weight, smoking, or drinking more than 14 units a week. |
| Who gets a DXA scan | Offered straight away after a hip or spine fragility fracture, a single major fracture in the last two years, or two or more fragility fractures. Otherwise, considered if your calculated ten-year risk of a major fracture, using FRAX or QFracture, is 10% or more. This single threshold replaces the age-varying thresholds many services currently use. |
| A check for spinal fractures | A vertebral fracture assessment (VFA), a quick extra image taken during the same DXA appointment, should now be considered for men aged 70 and over and women aged 60 and over, and for younger people with symptoms such as unexplained back pain, height loss of more than 4 cm, or a rounded upper back. This is a real change: spinal fractures are the commonest osteoporotic fracture and often cause no symptoms at all. |
| When treatment is considered | At a T-score of −2.5 or lower; or at −1.5 or lower if you have also had a fragility fracture, take steroids, or have another cause of faster bone loss; or after a hip or spine fragility fracture regardless of the score. |
| Treating without a scan | If a scan is not possible, not tolerated, or would not change the decision, treatment can be discussed and started anyway. Nobody should go untreated simply because a scan was unavailable. |
| Repeat scans | Not offered normally within two years of the last one, because two years is too short for a meaningful change in bone density to show using DXA. Otherwise, reassessment at two to three years if you were close to the treatment threshold, or at five years if not. |
If you pay for repeat private bone scans more often than every two years, it is reasonable to ask what change the clinic expects to be able to detect in that interval, and how they know the scan can detect a change that small reliably. That is a fair question about any technology, including DXA. The key metric is the “Least Significant Change” value. This tells you what the minimum change in bone density between scans needs to be to show an actual difference. For the major manufacturers of DXA these are the usually quoted numbers:
| Manufacturer | Total hip LSC | Femoral neck LSC | AP spine LSC |
|---|---|---|---|
| Hologic | 2.2–3.3% | 4.2% | 3.0% |
| GE Lunar | 2.2–3.3% | 5.5% | 3.4% |
| Norland | 2.2–3.3% | 6.4% | 4.4% |
For REMS the manufacturer quotes 0.88% for the hip and 1.05% for the spine. Real-world figures are somewhat higher, and OsteoScan UK has calculated its LSC values as 1.9% for the femoral neck and 1.6% for the spine.
Nothing in NG259 changes the fact that fracture risk is not fixed. NICE’s own conclusion, that bone density is one input among several, is in a very real sense encouraging, because several of the other inputs are things that can be worked on.
NICE has not approved REMS, and it has not rejected it. What it did was to measure how well the standard NHS scan predicts fractures, find that on its own it does so only modestly, and say so plainly. Bone density is now formally one input among several rather than the only answer.
It then found the evidence for all three newer approaches insufficient to recommend, but chose the REMS question as the one most worth answering, on grounds of radiation safety, portability and equality of access rather than measured accuracy.
The practical message is unchanged by any of this: a bone density result is worth having, and is worth interpreting alongside everything else known about you — but by itself it is not a verdict.
Prepared by the International Institute for Musculoskeletal Health Education. This guide explains published national guidance. It is not medical advice, it cannot take account of your individual circumstances, and it should not be used to change any treatment. Please discuss anything in it with your own consultant, GP or specialist nurse. Sources: NICE guideline NG259, Osteoporosis: risk assessment, published 29 July 2026; and NICE Evidence Review D, Accuracy of bone assessment methods, July 2026. Both are freely available at www.nice.org.uk/guidance/ng259. · IIMHE, August 2026
2nd February 2026 @ 20:00 GMT
Nutrition and musculoskeletal health
Given by: Dr Kimberley Zambito, Orthopaedic Consultant
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Throughout 2026 and beyond, IIMHE (the International Institute of Musculoskeletal Health Education), in partnership with OsteoscanUK, will host a series of engaging educational webinars, open to anyone interested in bone and musculoskeletal health.
