Reliability and validity of ultrasound elastography for evaluating muscle stiffness in neurological populations: A systematic review and meta-analysis

Tiev Miller, Michael Ying, Charlotte Sau Lan Tsang, Meizhen Huang, Marco Y.C. Pang

Research output: Journal article publicationReview articleAcademic researchpeer-review

16 Citations (Scopus)


Objective: Ultrasound elastography is an emerging diagnostic technology used to investigate the biomechanical properties of the musculoskeletal system. The purpose of this study was to systematically review the psychometric properties of ultrasound elastography techniques for evaluating muscle stiffness in people with neurological conditions. Methods: A systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using software, reviewers independently screened citations for inclusion. Peer-reviewed studies that evaluated in vivo muscle stiffness in people with neurological conditions and reported relevant psychometric properties were considered for inclusion. Twenty-one articles were included for final review. Data relevant to measurement technique, site, and neurological condition were extracted. The Consensus-Based Standards for the Selection of Health Measurement Instruments checklist was used to rate the methodological quality of included studies. The level of evidence for specific measurement outcomes was determined using a best-evidence synthesis approach. Results: Reliability varied across populations, ultrasound systems, and assessment conditions (ie, joint/body positions, active/passive muscle conditions, probe orientation), with most studies indicating moderate to good reliability (ICC = 0.5-0.9, n = 13). Meta-analysis results showed a good overall correlation across studies (r = 0.78, 95% confidence interval = 0.64-0.86), with no between-group difference based on population (Q1 = 0.00). Convergent validity was demonstrated by strong correlations between stiffness values and measures of spasticity (n = 5), functional motor recovery or impairment (n = 5), and grayscale or color histogram pixel intensities (n = 3). Discriminant or known-groups validity was also established for multiple studies and indicated either significant between-group differences in stiffness values (n = 12) or within-group differences between more and less affected limbs (n = 6). Responsiveness was observed in all intervention studies reporting posttreatment stiffness changes (n = 6). Conclusions: Overall, ultrasound elastography techniques showed moderate reliability in evaluating in vivo muscle stiffness, good convergent validity with relevant clinical assessments, and good divergent validity in discriminating tissue changes within and between groups. Impact: Ultrasound elastography has clinical utility in assessing muscle stiffness, monitoring its temporal changes, and measuring the response to intervention in people with neurological conditions.

Original languageEnglish
Article numberpzaa188
JournalPhysical Therapy
Issue number1
Publication statusPublished - 4 Jan 2021


  • Cerebral Palsy
  • Measurement: Applied
  • Muscular Dystrophies
  • Neurology
  • Parkinson Disease
  • Stroke
  • Ultrasonography

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation


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