Dual energy X-ray absorptiometry positioning protocols in assessing body composition: A systematic review of the literature



      To systematically identify and assess methods and protocols used to reduce technical and biological errors in published studies that have investigated reliability of dual energy X-ray absorptiometry (DXA) for assessing body composition.


      Systematic review.


      Systematic searches of five databases were used to identify studies of DXA reliability. Two independent reviewers used a modified critical appraisal tool to assess their methodological quality. Data was extracted and synthesised using a level of evidence approach. Further analysis was then undertaken of methods used to decrease DXA errors (technical and biological) and so enhance DXA reliability.


      Twelve studies met eligibility criteria. Four of the articles were deemed high quality. Quality articles considered biological and technical errors when preparing participants for DXA scanning. The Nana positioning protocol was assessed to have a strong level of evidence. The studies providing this evidence indicated very high test–retest reliability (ICC 0.90–1.00 or less than 1% change in mean) of the Nana positioning protocol. The National Health and Nutrition Examination Survey (NHANES) positioning protocol was deemed to have a moderate level of evidence due to lack of high quality studies. However, the available studies found the NHANES positioning protocol had very high test–retest reliability. Evidence is limited and reported reliability has varied in papers where no specific positioning protocol was used or reported.


      Due to the strong level of evidence of excellent test–retest reliability that supports use of the Nana positioning protocol, it is recommended as the first choice for clinicians when using DXA to assess body composition.


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        • Nana A.
        • Slater G.J.
        • Hopkins W.G.
        • et al.
        Effects of daily activities on dual-energy X-ray absorptiometry measurements of body composition in active people.
        Med Sci Sports Exerc. 2012; 44: 180-189
        • Johnell O.
        • Kanis J.A.
        An estimate of the worldwide prevalence and disability associated with osteoporotic fractures.
        Osteoporos Int. 2006; 17: 1726-1733
        • Watts J.
        • Abimanyi-Ochom J.
        • Sanders K.M.
        Osteoporosis Costing All Australians. A New Burden of Disease Analysis—2012 to 2022, Sydney2013
        • Lewiecki E.M.
        Clinical applications of bone density testing for osteoporosis.
        Minerva Med. 2005; 96: 317-330
        • Blake G.M.
        • Fogelman I.
        The role of DXA bone density scans in the diagnosis and treatment of osteoporosis.
        Postgrad Med J. 2007; 83: 509-517
        • Rothney M.P.
        • Brychta R.J.
        • Schaefer E.V.
        • et al.
        Body composition measured by dual-energy X-ray absorptiometry half-body scans in obese adults.
        Obesity. 2009; 17: 1281-1286
        • Lee S.Y.
        • Gallagher D.
        Assessment methods in human body composition.
        Curr Opin Clin Nutr Metab Care. 2008; 11: 566-572
        • Georgeson E.C.
        • Weeks B.K.
        • McLellan C.P.
        • et al.
        Body composition change over a professional rugby league season and relationship to rates and types of injury.
        Med Sci Sports Exerc. 2011; 43: 108
        • Hangartner T.N.
        • Warner S.
        • Braillon P.
        • et al.
        The Official Positions of the International Society for Clinical Densitometry: acquisition of dual-energy X-ray absorptiometry body composition and considerations regarding analysis and repeatability of measures.
        J Clin Densitom. 2013; 16: 520-536
        • Nana A.
        • Slater G.J.
        • Hopkins W.G.
        • et al.
        Effects of exercise sessions on DXA measurements of body composition in active people.
        Med Sci Sports Exerc. 2013; 45: 178-185
        • Kiebzak G.M.
        • Leamy L.J.
        • Pierson L.M.
        • et al.
        Measurement precision of body composition variables using the lunar DPX-L densitometer.
        J Clin Densitom. 2000; 3: 35-41
        • National Health and Nutrition Examination Survey (NHANES)
        Body Composition Procedures Manual.
        • Kerr A.
        • Slater G.J.
        • Byrne N.
        • et al.
        Reliability of 2 different positioning protocols for dual-energy X-ray absorptiometry measurement of body composition in healthy adults.
        J Clin Densitom. 2016; 19: 282-289
        • Australian and New Zealand Bone & Mineral Society (ANZBMS)
        Clinical Bone Densitometry Training Course.
        ANZBMS, Sydney2014
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-e34
        • Brink Y.
        • Louw Q.A.
        Clinical instruments: reliability and validity critical appraisal.
        J Eval Clin Pract. 2012; 18: 1126-1132
        • van-der-Wurff P.
        • Hagmeijer R.H.
        • Meyne W.
        Clinical tests of the sacroiliac joint. A systematic methodological review. Part 1: reliability.
        Man Ther. 2000; 5: 30-36
        • May S.
        • Chance-Larsen K.
        • Littlewood C.
        • et al.
        Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review.
        Physiotherapy. 2010; 96: 179-190
        • May S.
        • Littlewood C.
        • Bishop A.
        Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review.
        Aust J Physiother. 2006; 52: 91-102
        • Adhia D.B.
        • Bussey M.D.
        • Ribeiro D.C.
        • et al.
        Validity and reliability of palpation-digitization for non-invasive kinematic measurement — a systematic review.
        Man Ther. 2013; 18: 26-34
        • Barrett E.
        • McCreesh K.
        • Lewis J.
        Reliability and validity of non-radiographic methods of thoracic kyphosis measurement: a systematic review.
        Man Ther. 2014; 19: 10-17
        • Ionan A.C.
        • Polley M.-Y.C.
        • McShane L.M.
        • et al.
        Comparison of confidence interval methods for an intra-class correlation coefficient (ICC).
        BMC Med Res Methodol. 2014; 14: 121
        • Hopkins W.G.
        Measures of reliability in sports medicine and science.
        Sports Med. 2000; 30: 1-15
        • Hopkins W.G.
        • Marshall S.W.
        • Batterham A.M.
        • et al.
        Progressive statistics for studies in sports medicine and exercise science.
        Med Sci Sports Exerc. 2009; 41: 3-13
        • Rankin G.
        • Stokes M.
        Reliability of assessment tools in rehabiliation: an illustration of appropriate statistical analyses.
        Clin Rehabil. 1998; : 187-199
        • Munro B.
        • Visintainer M.
        Statistical Methods for Health Care Research.
        5th ed. Lippincott, Philadelphia2005
        • van Tulder M.
        • Furlan A.
        • Bombardier C.
        • et al.
        Updated method guidelines for systematic reviews in the cochrane collaboration back review group.
        Spine. 2003; 28: 1290
        • Smith-Ryan A.E.
        • Mock M.G.
        • Ryan E.D.
        • et al.
        Validity and reliability of a 4-compartment body composition model using dual energy X-ray absorptiometry-derived body volume.
        Clin Nutr. 2017; 36: 825-830
        • Wilson J.P.
        • Fan B.
        • Shepherd J.A.
        Total and regional body volumes derived from dual-energy X-ray absorptiometry output.
        J Clin Densitom. 2013; 16: 368-373
        • Covey M.K.
        • Smith D.L.
        • Berry J.K.
        • et al.
        Importance of cross-calibration when replacing DXA scanners: QDR4500W and Discovery Wi.
        J Nurs Meas. 2008; 16: 155-170
        • Covey M.K.
        • Berry J.K.
        • Hacker E.D.
        Regional body composition: cross-calibration of DXA scanners QDR4500W and Discovery Wi.
        Obesity. 2010; 18: 632-637
        • Lohman M.
        • Tallroth K.
        • Kettunen J.A.
        • et al.
        Reproducibility of dual-energy X-ray absorptiometry total and regional body composition measurements using different scanning positions and definitions of regions.
        Metabolism. 2009; 58: 1663-1668
        • Bilsborough J.C.
        • Greenway K.
        • Opar D.
        • et al.
        The accuracy and precision of DXA for assessing body composition in team sport athletes.
        J Sports Sci. 2014; 32: 1821-1828
        • Colyer S.L.
        • Roberts S.P.
        • Robinson J.B.
        • et al.
        Detecting meaningful body composition changes in athletes using dual-energy X-ray absorptiometry.
        Physiol Meas. 2016; 37: 596-609
        • Hurst P.R.
        • Walsh D.C.I.
        • Conlon C.A.
        • et al.
        Validity and reliability of bioelectrical impedance analysis to estimate body fat percentage against air displacement plethysmography and dual-energy X-ray absorptiometry.
        Nutr Diet. 2016; 73: 197-204
        • Moon J.R.
        • Stout J.R.
        • Smith-Ryan A.E.
        • et al.
        Tracking fat-free mass changes in elderly men and women using single-frequency bioimpedance and dual-energy X-ray absorptiometry: a four-compartment model comparison.
        Eur J Clin Nutr. 2013; 67: S40-S46