Osteoporosis Screening Practice Considerations for Patients with Disabilities

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How to Use This Resource

This resource is intended for both the healthcare provider who orders osteoporosis screening (referred to as the primary care provider) and the imaging center staff responsible for conducting the screening. To help readers quickly find guidance relevant to their role, major sections are labeled for Primary Care Provider, Imaging Center Staff, or both.

The guidance focuses on disability-related barriers, accommodation needs, and strategies to support accessible osteoporosis screening for patients with mobility disabilities, sensory disabilities, and intellectual and developmental disabilities (IDD). While information is organized by disability type, many barriers and accommodations apply across multiple disability groups. Healthcare providers and imaging center staff should use this resource to support identifying and addressing each patient's individual needs rather than relying solely on disability categories.

This resource is not a substitute for disability and trauma-informed care training. Healthcare providers and imaging center staff are strongly encouraged to complete relevant training programs and use this resource as a practical guide for planning and delivering accessible osteoporosis screening. Visit the Screening for All Resource Library to explore training.

This resource was revised in July 2026 based on feedback from healthcare providers and people with lived experience.

A Note on Language

Sensory disabilities: In this resource, sensory disabilities refers to disabilities that affect a person's ability to receive or process sensory input. This includes individuals who are blind, have low vision, are deaf, hard of hearing, or deafblind. Experiences and terminology preferences vary among individuals and communities.

Person-first vs. identity-first: This resource uses both patients with disabilities and disabled patients interchangeably. While person-first language (patients with disabilities) may be more common in clinical contexts, identity-first language (disabled patients) is preferred by many within the disability community. Our use of both reflects respect for diverse preferences and the evolving language norm in both the medical and disability communities. Preferences vary by person, and best practice is to use whatever language the patient uses and/or ask which they would prefer.

Why This Matters

Audience: Primary Care Providers

With approximately 61 million adults in the United States living with a disability, ensuring accessible screening processes is both a legal requirement and a clinical necessity. The Americans with Disabilities Act (ADA) requires healthcare systems to ensure equitable access to healthcare for people with disabilities and provide reasonable accommodations.

USPSTF Guidelines

These practice considerations apply to patients with disabilities who meet standard U.S. Preventive Services Task Force (USPSTF) osteoporosis screening criteria. The 2025 USPSTF recommendation states that asymptomatic women 65 and older, as well as asymptomatic postmenopausal women younger than 65 who are at increased risk for osteoporosis, should be screened.

Guideline Limitations for Patients with Disabilities

The current guidelines explicitly exclude people, including men, with medical conditions or medications associated with bone loss, which describes a large share of patients with disabilities. This means many disabled patients fall outside standard screening criteria for the exact reason they need earlier, individualized assessment: they develop secondary osteoporosis through disability-related mechanisms that age-based, primary-osteoporosis-focused guidelines were never designed to catch.

Clinical eligibility for osteoporosis screening should be determined more broadly for patients with disabilities; research demonstrates that certain disabilities and disability-related factors significantly increase osteoporosis risk regardless of age or menopause status.

Disability-related Osteoporosis Risk Factors

Key Risk Factors

Non-ambulatory status: Patients with cerebral palsy, spina bifida, and spinal cord injuries are at increased risk for low bone mineral density (BMD) and experience osteoporosis at earlier ages than the general population (Fritz et al., 2021; Sheridan, 2009). For patients with cerebral palsy, low BMD can be identified as early as age 2 and worsen progressively through childhood (Henderson et al., 2005; Jasien et al., 2012).
Intellectual and developmental disabilities (IDD): Bone mass density is shown to be decreased in both men and women with IDD, including those who are ambulatory (Jasien et al., 2012). Fracture patterns observed in this population indicate premature development of osteoporosis (Frighi et al., 2022).

Medications That Compound Risk

Individuals with mobility disabilities and IDD often take medications that compound their osteoporosis risk through various mechanisms:

Depot medroxyprogesterone acetate (Depo-Provera): Commonly prescribed for menstrual management or contraception in non-ambulatory women and those with IDD since the 1990s. This medication suppresses estrogen production, leading to decreased bone formation (Watson et al., 2006).

Anti-epileptic drugs (AEDs): Medications including phenytoin, phenobarbital, carbamazepine, and valproic acid, are required by many patients with IDD to control seizure disorders. These medications cause the body to break down vitamin D too quickly. Since vitamin D is essential for bone mineralization, this deficiency may contribute to early-onset osteoporosis (Fritz et al., 2021).

Proton pump inhibitors (PPIs): High-dose (multiple daily doses) and/or long-term (a year or longer) PPI therapy are associated with modest increased risk for osteoporosis-related fractures of the hip, wrist, and spine (Fraser et al., 2013).

Antipsychotics: Prescribed for behavioral management. These medications affect bone health through multiple mechanisms, including prolactin elevation and impacts on bone cell activity (Azimi Manavi et al., 2023; Mercurio et al., 2024; Weerasinghe et al., 2023).

Compounding Factors

Risk factors related to the cumulative effects of multiple medications are further compounded in disability populations by additional factors, including poor nutrition (decreased calcium and vitamin D intake), vitamin D deficiency from limited sun exposure, and feeding difficulties (Fritz et al., 2021; Burke et al, 2019). Disability is also associated with an increased risk of falls (Alenazi et al., 2024).

Coverage and Guideline Gaps

While the Fracture Risk Assessment Tool (FRAX), released in 2008, accounts for some risk factors, such as current smoking, glucocorticoids, alcohol consumption, and “secondary osteoporosis,” it does not explicitly account for ambulatory status or other medications commonly taken by people with disabilities. This creates a critical gap; insurance companies may legally deny coverage for patients under 65 years old who do not meet the postmenopausal qualification, even with clear disability-related factors. These systemic and policy-level barriers contribute to the underdiagnosis and undertreatment of osteoporosis in people with disabilities; thereby increasing their risk of hazardous fractures that severely impact morbidity, mortality, and independence (Fritz et al., 2021; Mercurio et al., 2024; Watson et al., 2006).

Coverage, however, is not limited to age-based screening. Bone density testing is reimbursed through two distinct pathways, and the distinction matters for disabled patients. The first is preventive screening, which follows age-based USPSTF criteria and excludes most patients under 65. The second is diagnostic, or medically necessary, bone mass measurement, which is age-independent. Under Medicare's national coverage rules (42 CFR §410.31, the rule underlying Medicare's NCD 150.3, and mirrored by many private and Medicaid payers, though specifics vary), testing is covered once at least 23 months have passed since the last measurement (roughly every two years, or more often when medically necessary) for a patient who meets any one qualifying indication:

an estrogen-deficient woman at clinical risk for osteoporosis;

vertebral abnormalities on imaging indicative of osteoporosis, low bone mass (osteopenia), or vertebral fracture;
long-term glucocorticoid therapy (≥5 mg/day prednisone-equivalent for more than 3 months);
primary hyperparathyroidism; or
monitoring response to an FDA-approved osteoporosis medication (Bone Mass Measurement: Conditions for Coverage and Frequency Standards, 42 C.F.R. § 410.31, 2006).

Some patients with disabilities may qualify under one of these diagnostic indications even when they fall outside age-based screening criteria. When a patient qualifies, ordering the test as a medically necessary diagnostic study and documenting the qualifying condition and disability-related risk factors is often more effective than requesting it as screening. If coverage is still denied, providers can request prior authorization or a peer-to-peer review with the insurer (see Strategies to Address Coverage Denials, below).

Updating screening guidelines and ensuring appropriate insurance coverage are critical steps toward achieving health equity in bone healthcare for individuals with disabilities (Weinick et al., 2024).

Strategies to Address Coverage Denials

When insurance denies coverage for patients who fall outside USPSTF eligibility or alternative screening options, healthcare providers have several options to discuss with the patient:

Order as diagnostic rather than screening. When a patient meets a diagnostic indication above, order the test as a medically necessary study and document the qualifying condition and disability-related risk factors, rather than submitting it under a screening code.
Predetermination of benefits: Request a written predetermination from the payer before ordering, so coverage is confirmed in advance rather than discovered after the scan. Many plans do not require prior authorization for bone density testing but will issue a predetermination on request.
Alignment with the plan’s medical policy: Obtain the payer’s medical-policy language for bone density testing and ensure the order and documentation match its stated criteria. The facility’s billing staff can confirm requirements before the claim is submitted.
Peer-to-peer review: Healthcare providers can request a peer-to-peer conversation with the insurer to advocate for prior authorization, presenting the patient’s disability-related risk factors and research supporting the increased risk of osteoporosis.
Referral to physical therapy for bone-health management.
Referral to rheumatology for injectable biologics.

What This Means for Screening

Healthcare providers should consider individualized bone health assessment for patients with certain disabilities beginning in early adulthood, particularly for those with cerebral palsy, intellectual disabilities, mobility disabilities, or multiple risk factors. More research is needed to determine an appropriate starting age for osteoporosis screening in these populations, but healthcare providers should approach each patient's bone health proactively, recognizing that waiting until traditional screening ages may miss critical opportunities for prevention and early intervention.

Barriers and Clinical Considerations, by Disability Type

Audience: Primary Care Providers and Imaging Center Staff

Beyond the coverage and guideline gaps in the previous section, patients with disabilities encounter barriers during the screening process itself. Common barriers include inaccessible bone density scanning equipment, healthcare provider assumptions about patients’ quality of life and screening benefits, and healthcare providers’ inadequate understanding of disability-specific risk factors (Buckley et al., 2024; Smeltzer & Sharts-Hopko, 2005).

This section describes clinical considerations and the barriers people with disabilities may experience with osteoporosis screenings. These barriers are important to address because they can lead to delayed screening, later-stage diagnosis, and poorer health outcomes. Although the guidance is organized by disability type, barriers are not mutually exclusive. Healthcare providers should consider each patient's individual needs and circumstances rather than assuming that a barrier applies only to one disability group.

Mobility Disabilities

Patients with physical or mobility disabilities face multiple structural and procedural barriers to bone density screening. Barriers include:

Standard dual-energy X-ray absorptiometry (DXA) tables are not height-adjustable, making wheelchair-to-table transfers difficult.
Maintaining required positioning for hip/spine scans may be impossible for patients with contractures, spasticity, or involuntary movements.
Standard scans are frequently hard to obtain because skeletal deformity or difficulty holding still during the scan can compromise the measurement, so alternative techniques are often required (Jasien et al., 2012).
Surgical hardware can interfere with standard scanning sites. In patients with cerebral palsy, measuring whole body, spine, hip, or even forearm sites are often not possible due to underlying bone pathology or surgical hardware (Fritz et al., 2021; Sheridan, 2009).

Sensory Disabilities

Patients with sensory disabilities face communication and information-access barriers that can interfere with bone density screening and potentially lead to inadequate care, missed screenings, or traumatic experiences. These barriers are concerning because effective communication is essential for informed consent, proper positioning, and patient safety. Effective communication is a prerequisite for informed consent, not an optional enhancement. These barriers can vary by disability type and can affect care quality in different ways.

For patients who are blind or have low vision, they may have difficulty accessing written materials, spatial orientation to exam environment, and procedure positioning.
For patients who are deaf or hard of hearing, communication barriers can lead to missed or misunderstood explanations and instructions, resulting in errors in care, inadequate informed consent, or discomfort during scanning. The lack of qualified interpreters may lead to overreliance on writing or lipreading, which may be inadequate for some patients, and may be problematic for patients who use American Sign Language (ASL) as a first language.
For patients who are deafblind, the challenges are compounded, as they require specialized tactile or adaptive communication support that healthcare providers may be unfamiliar with. Staff lacking experience with disability-specific communication needs can create additional barriers, leading to frustration, miscommunication, and potentially unsafe care situations.

Intellectual and Developmental Disabilities (IDD)

Patients with IDD face barriers to bone density screening related to healthcare provider assumptions, communication challenges, consent processes, and sensory sensitivities.

Healthcare providers may incorrectly assume that screening is not beneficial or that patients cannot understand the procedure, creating a barrier to accessing care.
Patients may have difficulty understanding medical terminology, screening recommendations, or procedural explanations without adapted communication strategies. Some patients may feel embarrassed to ask questions or disclose that they do not understand. This can lead to anxiety, misunderstanding, inadequate informed consent, or avoiding future screenings.
Patients with IDD, particularly autistic patients, may find the sensory aspects of bone density scanning (positioning, machine sounds, unfamiliar environment) overwhelming without proper preparation.

The Primary Care Visit

Audience: Primary Care Providers

The primary care visit is often the first opportunity to identify barriers to osteoporosis screening and begin accommodation planning. During this visit, providers should assess the patient’s osteoporosis risk, screening eligibility, discuss previous experiences, identify support needs, and coordinate referrals to imaging facilities capable of providing appropriate accommodations.

Patient Assessment

Assumptions about patients with disabilities can create significant barriers to osteoporosis screening leading to inadequate care, missed screening opportunities, and health disparities. Examples include assuming a patient cannot undergo bone density testing, has poor quality of life that does not warrant screening, cannot understand the procedure, or lacks decision-making capacity. Instead:

Consider that standard risk assessment tools may not capture disability-specific risk factors, requiring supplemental clinical judgment about earlier screening needs.
Assess each patient individually and avoid making broad assumptions based on disability type.
Assume screening is possible until proven otherwise through careful assessment while considering patient safety and comfort.
Inquire about previous bone density testing (DXA scan) experiences and any concerns or accommodations needed, recognizing that some patients may have had negative healthcare experiences that affect their willingness to undergo testing.
Ask about disability-specific risk factors in a routine, nonjudgmental manner as part of comprehensive bone health assessment, including medication use, mobility limitations, and fall history. For example: “I ask all my patients about medications, mobility, and falls because they can affect bone health. Can you tell me about any long-term medications you take? How does your mobility work day to day? Have you had any falls or fractures?”
Evaluate medications that may affect bone health, particularly antiseizure medications, depot medroxyprogesterone acetate (Depo-Provera), long-term corticosteroids, and antipsychotic medications.
Respect the patient's autonomy in medical decision making and evaluate capacity for informed consent based on the individual's demonstrated understanding, not disability status.

A Note on Guardianship and Conservatorship

Some disabled patients may have a legal guardian or conservator; however, disability status alone does not determine a person's ability to make healthcare decisions. Guardianship and conservatorship arrangements vary considerably in scope and may apply to some decisions but not others.

Healthcare providers should:

Review the patient’s medical record before the appointment to understand any guardianship or conservatorship arrangements.
Determine whether the arrangement affects healthcare decision-making and whether there are limitations relevant to the screening visit.
Speak directly to the patient and involve them in discussions to the greatest extent possible.
Consult with your clinic’s legal, compliance, or risk management team if there is uncertainty about consent requirements or decision-making authority.

To learn more about your state’s specific laws, connect with your state’s Protection & Advocacy organization.

Accommodations PCPs Can Offer, by Disability Type

This section describes accommodations and strategies primary care providers can use during a preventive care visit. Although the guidance is organized by disability type, many accommodations may benefit patients across disability groups. Providers should use the full range of options to address each patient's individual needs, preferences, and circumstances rather than limiting support to a single disability category.

To learn more about accommodations imaging centers may be able to offer, see The Imaging Center Visit section.

Mobility Disabilities

If the patient may find standard bone density scans challenging and needs accommodations:

Include pertinent information on the order. Include any transfer needs and standing/positioning limitations. This allows the imaging center to prepare equipment and staff time in advance.
Proactively identify local imaging centers that specialize in osteoporosis screening, have experience working with people with disabilities, and have accessible equipment. Consider accessible parking, entrances, restrooms, and changing rooms with adequate space. For additional details on identifying accessible imaging centers, refer to the Screening for All Implementation Plan.

If the patient has contractures, spasticity, or cannot maintain standard positioning for hip/spine DXA for another reason: Consider ordering a peripheral DXA at wrist or heel.

If DXA scanning is not possible despite accommodations: Consider QUS of the heel or other peripheral sites.

Sensory Disabilities

Many patients with sensory disabilities, including disabilities related to vision and hearing, use auxiliary aids and services. Auxiliary aids and services are communication tools or assistance that enable effective communication. Examples include sign language interpreters (in person or via Video Remote Interpretation), Communication Access Real-Time (CART) caption services, Braille materials, large-print materials, audio materials, and more.

Best Practices:

Ask your patient what communication method they prefer. If your clinic is unable to provide that method, work with your patient to choose an alternative that results in effective communication.
Always speak directly to the patient instead of their support person or interpreter. Do not rely on family members or caregivers as interpreters except in emergencies.
Do not begin any explanation or procedure until the auxiliary aid is present and functioning.
If possible, schedule longer appointment slots (at least an extra 10–15 minutes) when interpreters or communication supports are needed so there is adequate time for communication exchange and processing.
If an auxiliary aid or service was used, document it and if it worked well for future reference.

If the patient is deaf or hard of hearing: Ask how the patient receives and expresses communication. Some patients understand spoken language but express themselves using sign language, so an interpreter may still be needed for the patient’s response.

If the patient is using a sign language interpreter:

Do not begin the visit until the sign language interpreter is present.
Always speak directly to the patient. Maintain eye contact with the patient, not the interpreter. Refrain from verbal communication until the interpreter is present and in the line of sight of the patient.
Repeat and spell unfamiliar or medical terms.
VRI should only be used if it can be viewable to the patient for the duration of the visit. If this is not possible, then an in-person interpreter should be used instead. Additionally, VRI may not always work well depending on technology, connectivity, and patient preference.

If the patient’s family member or paid caregiver who shares decision-making uses sign language or is English limited: Provide interpretation. This could include sign language or a spoken language other than English.

If the patient is blind or has low vision:

Provide detailed verbal descriptions of the procedure, equipment, room layout, and positioning requirements before and during the visit.
Use appropriate touch (with permission) to guide positioning and provide tactile orientation to equipment and room features.
Describe sensations the patient may experience and provide warning before touching or repositioning to help them prepare for what they will feel.
Provide materials and written instructions in alternative formats upon request and in a timely manner. This may include large-print materials, screen-reader-compatible digital formats, or Braille materials.

If the patient is deafblind:

There are specialized deafblind interpreters who can provide tactile sign language interpretation. Always check what the patient’s preferred communication method is.
Use agreed-upon tactile signals for breathing cues, positioning guidance, and procedural updates.
Work collaboratively with the patient’s preferred communication method, interpreter, and support person, while ensuring the patient remains the primary decision maker.

Intellectual and Developmental Disabilities (IDD)

Communication Best Practices:

Plain language explanations: Use simple, plain language and use short sentences. Avoid medical jargon and acronyms. Practice and rehearse plain language scripts.
Visual supports and social stories: Photos, diagrams, and videos showing the room, equipment, and step-by-step process can reduce anxiety and support understanding. An example visual story (DEXA Bone Scan Rehearsal Guide) and the Screening for All Screening for Osteoporosis: A Guide for Patients are included in the Resources section of this resource.
Check for understanding: Use teach-back techniques to ensure understanding of where the test occurs, how long it takes, what to expect, and the purpose.
Supported decision making: Collaborate with caregivers while ensuring the patient's preferences and autonomy are respected. Use communication aids or support people as needed but obtain consent from the patient directly whenever possible.
Extended appointment times: Schedule longer appointment slots (at least an extra 10–15 minutes), if possible.

If the patient’s caregiver is reluctant about screening: Provide education about osteoporosis risk in people with IDD, discuss the importance of screening, address caregiver concerns, and emphasize patient autonomy in decision making if appropriate.

Alternative Screening Options

Central DXA (hip/spine) remains the gold standard for osteoporosis screening. However, there are some viable alternatives that may work better for people with certain disabilities.

Peripheral DXA Scanning

Peripheral DXA scanning may be appropriate for patients who cannot undergo central DXA scanning due to positioning limitations, contractures, or inability to lie flat (Fritz et al., 2021). Peripheral sites include wrist, heel, and forearm. While peripheral DXA can predict central fracture risk, it should be interpreted with understanding that results may not directly correlate with central site bone density. Consider offering peripheral DXA when central scanning is not feasible despite accommodations.

Quantitative Ultrasound

Quantitative ultrasound (QUS) of the heel or other peripheral sites provides an alternative assessment method that requires minimal positioning, uses no radiation, and can be performed with portable equipment. Portable heel ultrasound devices show promising correlation with standard bone density measurements. In disability populations, heel QUS has been shown to be feasible and well tolerated. In one study of people with intellectual disabilities, measurements successfully obtained in more than 94% of participants, caused little or no distress in 90%, and required less than 10 minutes to complete (Mergler et al., 2010). QUS has been used in larger disability-focused studies, including a national sample of 575 older adults with intellectual disabilities. In that study, 74% of participants met criteria for osteopenia or osteoporosis based on heel QUS findings, and the authors concluded that QUS may be useful when interpreted alongside clinical risk factors (Burke et al., 2019). QUS has similarly served as a useful portable measure of rapid bone loss after spinal cord injury, where axial DXA is limited by practical constraints (Warden et al., 2002). While QUS is not considered equivalent to DXA scanning, this technology may be useful for patients who cannot access DXA equipment or as a monitoring tool between DXA scans.

A note on device availability: Healthcare providers should be aware that QUS access has narrowed in recent years. The devices most used by Special Olympics for portable heel QUS — the Hologic Sahara and GE Achilles — have both been discontinued by their manufacturers. Additionally, the USPSTF's 2025 update to its osteoporosis screening recommendation narrowed its evidence review to central DXA only, dropping QUS (and peripheral DXA) from formal consideration, a change from its 2018 recommendation. This means QUS is likely to become an even less familiar option to providers going forward, even though it remains one of the few low-barrier, no-radiation, portable alternatives for patients who cannot access central DXA. We encourage imaging centers and primary care practices serving patients with disabilities to consider purchasing a portable QUS unit to enable routine in-office screening for patients at risk, particularly in situations where DXA poses significant access barriers.

Future Considerations for DXA

Lateral distal femur DXA scanning is a promising alternative site for individuals with cerebral palsy and other conditions where standard hip and spine positioning is not feasible (Henderson et al., 2015). Research to date, though limited and dated, suggests this technique is well tolerated by many children with cerebral palsy and can provide clinically relevant bone density information using a position that is often more accessible than standard positioning (Henderson et al., 2015).

Despite this promise, lateral distal femur DXA remains significantly underutilized in practice. Many imaging centers and technologists are not trained in the scan technique itself, nor in how to interpret the resulting BMD measurements, which use different reference data and positioning protocols than standard hip/spine DXA. As a result, providers may find it difficult to locate a facility able to perform or correctly read this scan, even where it might otherwise resolve a positioning barrier.

This is an area we believe is worth further investment: healthcare providers and imaging centers interested in offering this option are encouraged to review the available literature and consider reaching out to the original research team or their affiliated institution for guidance on training and implementation. See the Resources section for more information.

Accommodation Planning for Osteoporosis Screening

Accommodation planning begins with an explanation of the screening. Some patients may find it difficult to identify accommodations without an understanding of what to expect. Explain the purpose of the screening and what they can expect in plain, simple language, using visual supports if needed. Use the Screening for All Screening for Osteoporosis: A Guide for Patients to help explain the procedure and plan for accommodations.

After explaining the bone density scan, ask questions like:

“What supports would make your bone density scan/DXA scan accessible?”
“Do you need assistance transferring to the equipment? Will you need a mechanical lift?”
“Have you had a bone density scan/DXA scan or X-ray before? What accommodations worked well?”
“If you had a negative experience, what went wrong? What would make it better?”
“Is there anything that might make positioning or movement difficult?”
“Do you experience mental health concerns, like anxiety or sensory issues, which might affect your ability to have a bone density scan/DXA scan?”

Coordinating with the Imaging Center

Effective communication between the primary care provider and imaging center is essential to ensure that accommodations are available when the patient arrives. Whenever possible, accommodation needs should be communicated directly to the imaging center rather than requiring the patient to repeatedly explain their disability, accessibility needs, or previous experiences. Early coordination increases the likelihood that the appropriate equipment, staffing, communication supports, and appointment length can be arranged before scheduling.

When placing the order, include:

Accommodation needs identified during the visit, such as transfer assistance, positioning limitations, preferred communication methods, sensory sensitivities, or support person involvement.
Previous screening experiences, including accommodations that were successful and challenges that created barriers.
Guardianship or conservatorship status and any relevant considerations.
Known logistical barriers that may affect scheduling (e.g., transportation limitations).
The patient’s preferred method of contact and communication (e.g., patient directly, caregiver, TTY/relay, text, email, patient portal).

Whenever possible, document this information directly in the referral order or accompanying clinical documentation. Sharing accommodation needs in advance allows imaging center staff to confirm equipment availability, arrange auxiliary aids and services, schedule additional staff support, and allocate sufficient appointment time before the visit occurs.

The Imaging Center Visit

Audience: Imaging Center Staff

Imaging centers play a critical role in ensuring that a bone density scan is accessible. Accessibility involves more than equipment alone; successful screening often depends on advance planning, effective communication, trained staff, and individualized accommodations. The following considerations can help imaging centers prepare for and conduct accessible appointments.

Accommodation Planning at Scheduling

During scheduling and intake, office staff should proactively inquire about accommodation needs and document them clearly for the clinical team. Staff should be prepared to discuss different accommodation options available and schedule additional time when accommodations are needed. Based on guidance from the Disability Equity Collaborative, consider including the following questions in your scheduling process:

General accommodation needs: “Due to a disability, do you need any additional assistance or accommodations during your visit?”

If YES, continue with the following questions:
“Are you deaf or do you have serious difficulty hearing?”
“Are you blind or do you have difficulty seeing, even when wearing glasses?”
“Do you have serious difficulty walking or climbing stairs?”
“Do you have difficulty remembering or concentrating?”
“Do you have difficulty dressing or bathing?”
“Using your usual language, do you have difficulty communicating (for example, understanding or being understood)?”

These questions can be coded within electronic health records (EHRs) for consistency and data analysis. Please refer to Documenting Disability Status in Electronic Health Records by the Disability Equity Collaborative for more detailed guidance.

You may also consider asking specific questions about bone density scan accommodation such as:

“What supports would make your bone density scan/DXA scan accessible?”
“Do you need assistance transferring to the equipment? Will you need a mechanical lift?”
“Have you had a bone density scan/DXA scan or X-ray before? What accommodations worked well?”
“If you had a negative experience, what went wrong? What would make it better?”
“Is there anything that might make positioning or movement difficult?”
“Do you experience mental health concerns, like anxiety or sensory issues, which might affect your ability to have a bone density scan/DXA scan?”

It may be necessary to schedule longer appointment slots when accommodations are needed. Consider scheduling longer appointment slots. Allow an extra 10–15 minutes for assistance with undressing or dressing, and consider doubling the appointment time when transfer or positioning assistance is needed.

Pre-visit Planning

In preparation for the patient’s visit, imaging centers should do the following:

Review the imaging order and available medical record documentation to understand the patient’s disability-related needs and required accommodations before the visit.
Know what accommodations are possible and available in their setting.
Contact your patient before the appointment to discuss needed accommodations to safely and effectively complete the screening.
Coordinate extra staff, if needed.
Ensure accommodations are available in advance. This may include accessible equipment, transfer equipment, positioning supports, extra staff, auxiliary aids and services, etc.

Implementing Accommodations During the Visit

During the visit, imaging center staff should:

Summarize what they learned from the patient’s chart and confirm that they understand their needs.
Discuss any accommodations they have said worked well in the past and confirm how they can assist them.
Pay attention to verbal and nonverbal signs that the patient may be confused, uncomfortable, overwhelmed, or in need of additional support. Hesitation, limited responses, changes in body language, difficulty following instructions, or signs of distress may indicate that explanations should be clarified or that additional accommodations are needed.

Accommodations Imaging Centers Can Offer, by Disability Type

This section describes accommodations and strategies imaging centers can use during osteoporosis screenings. Although the guidance is organized by disability type, many accommodations may benefit patients across disability groups. Imaging center staff should use the full range of options to address each patient's individual needs, preferences, and circumstances rather than limiting support to a single disability category.

Mobility Disabilities

If the patient cannot get on the DXA table independently: Use a transfer support such as a ceiling-mounted hydraulic lift, portable mechanical lift (Hoyer lift), or slide board. Provide extra staff trained to assist with safe patient transfer using slide boards, mechanical lifts (Hoyer lifts), or other transfer aids as needed.

If the patient has difficulty maintaining positions:

Provide pillows, foam wedges, rolled towels, or extra staff assistance to help patients maintain position during scanning.
Allow breaks between scans if needed and provide clear instructions about scan duration.
Extended appointment times: Schedule additional time to accommodate transfer needs and positioning.

If the patient needs accommodations: Consider doubling the appointment time when transfer or positioning assistance is needed.

Sensory Disabilities

Best Practices:

Ask the patient what communication method they prefer. If your clinic is unable to provide that method, work with the patient to choose an alternative that results in effective communication.
Always speak directly to the patient instead of their support person or interpreter. Do not rely on family members or caregivers as interpreters except in emergencies.
Do not begin any explanation or procedure until the auxiliary aid is present and functioning.
If possible, schedule longer appointment slots (at least an extra 10–15 minutes) when interpreters or communication supports are needed so there is adequate time for communication exchange and processing.
If an auxiliary aid or service was used, document it and if it worked well for future reference.

If the patient is using a sign language interpreter:

Do not begin the visit until the sign language interpreter is present.
Always speak directly to the patient. Maintain eye contact with the patient, not the interpreter. Refrain from verbal communication until the interpreter is present and in the line of sight of the patient.
Repeat and spell unfamiliar or medical terms.
VRI should only be used if the patient can view the screen throughout the visit. VRI may not always be effective depending on technology, connectivity, room configuration, and patient preference. If the VRI screen cannot remain visible to the patient for the duration of the visit, an in-person interpreter should be used instead. When scheduling, consider whether the room layout and clinical workflow can accommodate an in-person interpreter.

If the patient is blind or has low vision:

Provide detailed verbal descriptions of the procedure, equipment, room layout, and positioning requirements before and during the visit.
Use appropriate touch (with permission) to guide positioning and provide tactile orientation to equipment and room features.
Describe sensations the patient may experience and provide warning before touching or repositioning to help them prepare for what they will feel.
Provide materials and written instructions in alternative formats upon request and in a timely manner. This may include large-print materials, screen-reader-compatible digital formats, or Braille materials.

If the patient is deafblind:

There are specialized deafblind interpreters who can provide tactile sign language interpretation. Always check what the patient’s preferred communication method is.
Use agreed-upon tactile signals for breathing cues, positioning guidance, and procedural updates.
Work collaboratively with the patient’s preferred communication method, interpreter, and support person, while ensuring the patient remains the primary decision maker.

If the patient cannot hear standard breathing cues: Implement alternative signaling system (visual cues, tactile signals, or dimming lights) established before procedure begins.

Intellectual and Developmental Disabilities (IDD)

Communication Best Practices:

Plain language explanations: Use simple and plain language and use short sentences. Avoid medical jargon and acronyms. Practice and rehearse plain language scripts.
Visual supports and social stories: Photos, diagrams, and videos showing the room, equipment, and step-by-step process can reduce anxiety and support understanding. An example visual story (DEXA Bone Scan Rehearsal Guide) and the Screening for All Screening for Osteoporosis: A Guide for Patients are included in the Resources section of this resource.
Short verbal descriptions: Use short verbal descriptions to describe the procedure step-by-step as it happens.
Check for understanding: Use teach-back techniques to ensure understanding of where the test occurs, how long it takes, what to expect, and the purpose.
Supported decision making: Collaborate with caregivers while ensuring the patient's preferences and autonomy are respected. Use communication aids or support people as needed but obtain consent from the patient directly whenever possible.
Extended appointment times: Schedule longer appointment slots (at least an extra 10–15 minutes), if possible.

If the patient has sensory sensitivities (lighting, noise, etc.):

Ask patients about environmental modifications that would support their sensory needs. Such modifications include dimmed lighting, calming music, reduced noise, allowing comfort items, sensory items, or fidget toys, and minimizing other sensory stimuli.
Describe sensations patients may experience and provide warning before touching or repositioning to help patients prepare for what they will feel.

If the patient appears anxious about the procedure:

Offer preparatory visit or practice sessions to familiarize patients with the environment, equipment, and staff, which can increase the success of the screening and likelihood of completing future screenings. This may be difficult for some clinics to implement due to scheduling constraints, but it can contribute to a successful screening and positive experience in the long run and can be valuable for some patients. An alternative is using a social story to help patients prepare.
Allow a trusted caregiver, advocate, or chaperone to remain present during the exam if the patient requests.

Follow-up and Continuity Considerations

Audience: Primary Care Providers and Imaging Center Staff

Accessibility does not end when the scan is completed. Documentation of successful accommodations, accessible communication of results, and coordination between providers can improve future screening experiences and support ongoing bone health management.

Results Communication

Provide results in accessible formats appropriate to the patient's communication needs. Take note of the patient’s preferred communication methods (e.g., phone call, email/patient portal message, text message, etc.) Use plain language summaries for patients with intellectual disabilities, ensure interpreter services for deaf patients, and provide large print or screen-reader-compatible formats for patients with vision disabilities. Explain what results mean for the patient's bone health and any recommended follow-up actions.

Documentation of Accommodations

Clearly document all accommodations used and their effectiveness in the patient's medical record. Include specific details about positioning aids, communication methods, and environmental modifications that worked well to facilitate future appointments.

Setting Expectations for Future Screenings

For patients with disability-specific risk factors, establish individualized screening intervals that may be more frequent than standard recommendations. Ensure that accommodation information is transferred when referring to specialists or other facilities.

Coordination with Specialists

If referring patients for specialized bone health evaluation or treatment, clearly communicate accommodation needs and successful strategies to the receiving provider's office to ensure continuity of accessible care.

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