In this Part II of our Bone Health and Echolight interview with Dr. Kimberly Zambito, we explore the clinical use of R.E.M.S. technology (Radiofrequency Echographic Multi Spectrometry) technology and Echolight, an emerging technology for the diagnosis and monitoring of osteoporosis.
3:40: What is the Echolight? How do you describe Echolight to patients?
Answer: Echolight is an ultrasound technology which is used to evaluate bone density and bone quality. It essentially uses unfiltered ultrasound signals, analyzes the signals, and provides information on bone mineral density and bone quality represented as the REMS Fragility Score.
4:30: Is it the same as a DXA scan?
Answer: Echolight REMS gives information such as bone mineral density which is similar to information from a DXA scan. In addition to bone mineral density, it gives information on bone quality. There is a software package which can be added to DXA. This is called trabecular bone score, TBS, which evaluates pixels and provides information on quality of bone. This software is not standard on DXA. The Echolight evaluates both bone mineral density and bone quality.
5:53: Is it better than a DXA scan?
Answer: There are some advantages to the Echolight REMS evaluation. These include evaluation of both bone mineral density and bone quality. DXA does not evaluate both, unless there is a TBS software package. Even then, TBS evaluates the lumbar spine only, not the femoral neck. Researchers with Echolight have shown in various European studies that there is a high correlation between bone mineral density between REMS and DXA, provided quality scans are done. Researchers have also shown that REMS is 5 times more sensitive to BMD changes than DXA. DXA reports can have errors related to positioning,body habitus, arthritis, scoliosis, etc. I typically do not indicate one test is better than the other. I recommend that patients who are closely following their bone health, compare DXA to DXA and REMS to REMS in monitoring their bone health.
10:25: How long does an Echolight REMS evaluation take?
Answer: A REMS evaluation is scheduled for 30 minutes. This allows us time to gather information from the patient such as name, date of birth, race, gender, age at menopause, height, and weight (BMI). Once that information is input into the system, the scan begins. Patients are positioned supine on an examination table. We typically begin with the lumbar spine scan which takes about 2 minutes. Once that scan has been completed, the artificial intelligence analyzes the data which is an unfiltered ultrasound signal. A few minutes later, an analysis is generated. I review the captured images for quality. Next, the proximal femur is scanned. The scan for the proximal femur takes about a minute. As the same process of data analysis and review to ensure quality is performed. I will very briefly review findings with patients, but for a full evaluation and comparison to DXA, requires a separate appointment.
12:15: Why do I have to have a separate appointment for the Echolight and the review/consultation?
Answer: As a physician, I have a medico-legal obligation to review any study I order with a patient. In order to provide a quality review, I put a whole picture together. This includes going through health history, an examination, reviewing labs to look for secondary causes of osteoporosis, and reviewing DXA and Echolight results. If there are differences between DXA and Echolight REMS evaluation, we will discuss potential reasons for differences at the consultation appointment. If a patient wants only the Echolight REMS evaluation, they need to have a prescription from a physician who will take medico-legal responsibility for reviewing the results with the patient and assume treatment for the patient as needed.
13:31: What do I do to prepare for the Echolight scan?
Answer: Patients are asked to come 10-15 minutes prior to their scheduled appointment. The time slots for my scanning days are tight, so when one patient comes late, it changes the start time for everyone after them. Patients are asked to wear loose fitting clothing. Please wear underwear. Avoid eating or drinking 2-3 hours prior to the appointment. Make sure to avoid it prior to the appointment.
14:41: Is it uncomfortable?
Answer: It is not uncomfortable; however, if a patient has an abdominal hernia or sensitivity in the abdominal region, an Echolight scan may not be a good way for them to evaluate their bone health. If a patient has a BMI greater than 35, or carries their weight in the abdomen, it may be a bit uncomfortable due to the pressure needed to get a good ultrasound signal.
15:39: Do I need to bring my DXA?
Answer: If the patient has a DXA report available, then I briefly review the DXA report, and plan to image the same laterality as the DXA- right femur or left femur, sometimes both.
16:14: Do you scan the wrist?
Answer: At this time period, Echolight REMS is not able to scan the wrist. Hopefully, in the future, the Echolight team can develop the technology to evaluate the wrist.
16:41: What if I have a total hip joint?
Answer: If the patient has a total hip arthroplasty or any hardware in the hip, I avoid scanning that hip. This would also be done with a DXA. If the patient has hardware in the lumbar spine or has had a kyphoplasty or vertebroplasty, it is important to tell anyone who is imaging you, whether DXA or Echolight REMS, that you have had this type of procedure done. Also, if you have a history of a lumbar spine fracture.
17:10: What if I have a spine fracture?
Answer: Both DXA and Echolight REMS evaluate the lumbar spine levels of L1- L4. Regardless of the technology you use, it is important to share that information with the person doing your imaging, or your physician, as the particular level can be excluded.
17:44: How do you use the information?
Answer: I do not focus on one single piece of information- whether DXA, REMS, x-rays, or labs. I look at the big picture and pick away at the details. Any of these technologies can have errors, afterall, humans operate all of these technologies. I review the Echolight REMS report in conjunction with the patient’s health history, an examination, imaging studies, and lab work. I assess posture, muscle tone, as well as dynamic and static balance. Posture and balance are so important to address and relate to fall prevention and fracture prevention. A patient is more than just their DXA result or Echolight REMS result. If a DXA report is available for comparison, then I will compare the two, provided the DXA is a good quality DXA and the Echolight REMS scan is a good quality scan.
The REMS Fragility score is a representation of the microarchitecture of the bone. A low number represents good quality bone; a high number represents bone that is degraded. Sometimes, patients will have low bone density and a low REMS Fragility Score, meaning good quality bone. Sometimes I have patients with good bone density, but poor bone quality. The Echolight software creates a 5-year fracture risk based on the BMD and the REMS Fragility Score. Again, I do not base my treatment on one single study. I put the entire picture together with the patient and we formulate a plan. For some patients, it means considering medication. For others, it means addressing lifestyle factors.
28:04: Take home message to patients?
Answer: Remember that you have more than just your DXA scan or your Echolight scan. Do not fret over one single test. There is an entire YOU. So much can affect bone health. It is important to not beat yourself up over one single thing. Work with your doctor to develop a comprehensive plan. Be honest with yourself and your doctor about what you are willing to do to improve your bone health. But most of all, be kind to yourself.
Show notes and resources mentioned: https://bonecoach.com/osteoporosis-testing-echolight-rems/dr-kimberly-zambito
**Part 1 Youtube Video: BONE DENSITY Not Enough? New Osteoporosis Tech To Understand Bone Strength w/ BoneCoach™ + Echolight Medical: Watch on Youtube Now
Where to find Dr. Zambito: https://www.mbortho.com/
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