In musculoskeletal studies, results are commonly reported either as shear modulus in kilopascals or as shear-wave speed in metres per second. The review stresses that these units describe related biomechanical properties but cannot be treated as interchangeable when comparing results from different studies or devices. SWE is non-invasive and provides real-time assessment of anatomical structures, allowing researchers to investigate how the mechanical properties of musculoskeletal tissue vary with health, movement, training, injury and treatment.

The researchers registered the review protocol in PROSPERO as CRD42023468863 and followed PRISMA 2020 reporting guidance. They searched PubMed/MEDLINE, Scopus, Web of Science and selected resources accessed through Ovid SP and EBSCOhost, beginning in October and November 2023 and updating the search in May 2026. Two reviewers independently screened titles, abstracts and full texts, extracted study data and assessed risk of bias with tools selected for randomised, non-randomised and diagnostic studies.

Of 1,834 records identified, 99 underwent full-text assessment and 67 met the eligibility criteria. The included publications dated from 2012 to 2026, with most appearing between 2021 and 2023. Skeletal muscle was by far the most frequently examined tissue, while smaller numbers of studies investigated tendons, nerves, the temporomandibular joint disc, annulus fibrosus, adipose tissue, deep fascia and skin.

The most common participant groups were children with cerebral palsy, typically developing children, athletes, children with Duchenne muscular dystrophy and infants with congenital muscular torticollis. Other populations included children with scoliosis, Osgood–Schlatter disease, Fukuyama muscular dystrophy, bruxism, juvenile idiopathic arthritis, intoeing gait, paediatric carpal tunnel syndrome associated with mucopolysaccharidosis, nocturnal enuresis and type 1 diabetes. The range of applications demonstrates broad exploration, but the evidence varies considerably in depth and quality across conditions and anatomical sites.

Twenty-two studies assessed the reliability of SWE, reporting intraclass correlation coefficients that ranged from near zero to approximately 0.99. Reliability therefore extended from poor to excellent and depended on the structure and examination conditions. Sonographer experience was associated with measurement consistency, while probe compression, movements of adjacent organs or the chest, patient positioning, anatomical location and transducer orientation could affect results.

The review notes that increasing probe pressure can increase measured muscle stiffness. To improve repeatability, the authors advise standardising the anatomical site, patient position and acquisition procedure, averaging multiple measurements from the same structure, and maintaining the same system, transducer and protocol during longitudinal comparisons whenever possible. Among children with cerebral palsy, several studies reported higher gastrocnemius or soleus stiffness than in typically developing peers, although findings varied by muscle, resting state and passive stretching.

One investigation found higher lateral gastrocnemius shear modulus across all tested ankle positions, while another detected higher medial gastrocnemius shear-wave velocity but no significant soleus difference. A further study found no group difference at rest but higher medial gastrocnemius stiffness during passive stretching. SWE measurements were also associated with the Modified Ashworth Scale, Modified Tardieu Scale, ankle range of motion and Reimers’ hip migration index.

These findings show potential for complementary quantitative assessment, but the review concludes that evidence remains insufficient to support routine SWE use in managing paediatric neurological disease. Duchenne muscular dystrophy was another major focus of the evidence. Comparisons with healthy controls commonly showed higher muscle stiffness in affected children, with the most consistent differences involving the gastrocnemius, rectus femoris and vastus lateralis.

One study reported significantly higher shear modulus in tibialis anterior, gastrocnemius medialis, vastus lateralis, biceps brachii and triceps brachii in children with Duchenne muscular dystrophy, while another found higher shear-wave velocity in both rectus femoris and medial gastrocnemius muscles. Findings for tibialis anterior were less consistent. The included studies interpreted variations in muscle elasticity as potentially reflecting a mixture of fibrosis and fatty degeneration, but only one study followed children for one year.

A proposal that SWE may detect early elasticity changes more sensitively than magnetic resonance imaging remains unconfirmed. Intervention studies showed that SWE can register some changes over time, although several effects were short-lived. After botulinum toxin injections for spastic cerebral palsy, studies most often reported lower gastrocnemius shear modulus at early follow-up around three weeks or one month; these changes commonly diminished or became non-significant by three months.

One study also found lower tibialis anterior shear modulus after a gastrocnemius injection. Extracorporeal shockwave therapy was associated with decreased soleus shear modulus, with the largest predicted effect around the thirteenth week, while a very small study linked anti-gravity treadmill training with changes in contrast, entropy and shear-wave velocity. Stretching findings were inconsistent: five minutes of static stretching reduced rectus femoris shear modulus in adolescent athletes but two minutes did not, and a high-intensity passive stretching session improved dorsiflexion without consistently changing gastrocnemius stiffness.

Scoliosis, sports medicine and congenital muscular torticollis supplied additional possible applications. Differences in paraspinal muscle elasticity depended on where the transducer was positioned, while intercostal and lateral abdominal muscles often showed no significant group differences. In congenital muscular torticollis, the affected sternocleidomastoid was generally less elastic than the healthy side or control tissue, and the technique could be used from the earliest days of life.

Athlete studies suggested possible uses for identifying tissue asymmetry and monitoring training or injury-related changes, but small samples and the absence of validated thresholds limited interpretation. The review’s central conclusion is that paediatric SWE has demonstrated research potential rather than an established diagnostic or prognostic role. Only two included studies were randomised, and both raised concerns about bias in outcome assessment.

Many intervention studies lacked control groups, most observational studies had concerns, often involving absent blinding, and samples were frequently small. Long-term observational studies were scarce, while inconsistent terminology, equipment, body and limb positioning, probe orientation and compression limited comparison among results. Robust paediatric reference values that account for age, growth, body size and developmental stage are also unavailable for most structures.

SWE may ultimately provide a complementary quantitative assessment, but current evidence supports further standardization and validation rather than its use as a standalone diagnostic method or direct transfer of measurements between devices, centres or patients.

Subject of Research: Systematic review of paediatric musculoskeletal shear-wave elastography for tissue stiffness assessment and monitoring

Article Title: Musculoskeletal shear-wave elastography in the paediatric population: a systematic review

Article References: Domin, M., Pałac, M., & Linek, P. (2026). Musculoskeletal shear-wave elastography in the paediatric population: a systematic review. Pediatric Radiology. https://doi.org/10.1007/s00247-026-06816-7

Image Credits: AI Generated

DOI: 10.1007/s00247-026-06816-7

Keywords: shear-wave elastography, paediatric ultrasound, muscle stiffness, cerebral palsy, Duchenne muscular dystrophy, adolescent idiopathic scoliosis, congenital muscular torticollis, sports medicine, treatment monitoring, measurement reliability, Musculoskeletal, shear-wave

A new explorative qualitative study published in BMC Pediatrics by Salome Keller of the Zurich University of Applied Science and colleagues at the Department of Chiropractic Medicine at University Hospital Balgrist and the University of Zurich has now documented, in parents’ own words, how attitudes toward chiropractic intervention evolve across the course of treatment for infants with suspected arthrogenic torticollis. The research team recruited families whose babies had been referred to chiropractic care with a suspected diagnosis of the condition and conducted semi-structured interviews at two points in time: a baseline round with twelve parents before or at the start of treatment, and a follow-up round with seven parents after they had experienced the therapy firsthand. The design allowed the investigators to compare expectations and fears before treatment with perceptions and judgments afterward, capturing a psychological trajectory that is rarely documented in this clinical population.

Methodologically, the study followed a deductive-inductive qualitative analysis based on Kuckartz’s approach, a structured framework for qualitative content analysis that combines theory-driven categories with themes emerging from the data themselves. All interviews were coded using MAXQDA 24, a widely used software platform for qualitative research, and the reporting was guided by the COREQ checklist, an international standard designed to improve the transparency and completeness of qualitative study reporting. From this analysis, four main themes crystallized: everyday life, perception of the infant’s health status, prior knowledge, and attitude toward chiropractic treatment. These themes formed an interpretive map of the parental experience, showing how the practical demands of caring for an affected infant, the parents’ reading of their child’s condition, whatever they knew beforehand about manual therapy, and their evolving stance toward the treatment all interacted to shape the overall journey.

The baseline interviews revealed a striking emotional landscape. Parents initially experienced considerable uncertainty and emotional strain, driven by two distinct sources. The first was simple unfamiliarity: chiropractic care for infants is not part of most parents’ medical vocabulary, and many did not know what the treatment would entail, how safe it was, or what evidence supported it. The second source was more visceral: watching a practitioner apply manual techniques to a tiny, fragile baby provoked anxiety that no amount of rational reassurance could entirely dispel. The researchers found that this ambivalence, a mixture of hope that the therapy would help and fear that it might somehow harm, was a defining feature of the pre-treatment mindset. Parents arrived at the clinic carrying questions they often felt hesitant to ask, and their first encounters with the treatment setting were colored by this underlying tension.

What happened next, according to the follow-up interviews, was a gradual transformation. As parents became familiar with the process, observing what the practitioner actually did, understanding the gentle nature of the techniques used on infants, and seeing how their baby responded during and after sessions, their emotional state shifted measurably. Confidence grew. Trust in the professionals deepened. Acceptance of the treatment, which had been tentative at best before the first session, solidified into genuine endorsement. Crucially, the researchers identified a powerful catalyst for this shift: observable improvement in the infant’s condition. When parents could see their child turning the head more freely, holding it more symmetrically, or feeding and sleeping more comfortably, their abstract anxieties about the therapy gave way to concrete, experience-based conviction that the intervention was working.

The study’s findings on the factors shaping parental attitudes carry practical weight for clinicians. Three elements stood out as decisive. Clear communication emerged as the foundation: parents who received thorough explanations of the diagnosis, the rationale for chiropractic treatment, and what each session would involve reported far less distress and far greater engagement than those left to guess. Observable health benefits formed the second pillar, providing the experiential evidence that no verbal reassurance could replace. Prior experience with therapeutic interventions for their infant constituted the third factor: families who had already navigated physiotherapy or other treatments for their child arrived with a framework for understanding a new therapy, which buffered the initial shock of the unfamiliar. Together, these factors suggest that the trajectory from skepticism to trust is not automatic but is actively constructed through information, demonstration, and results.

The clinical context makes these findings particularly significant. Arthrogenic torticollis, involving the upper cervical joints, is precisely the kind of diagnosis that prompts parents to seek specialized manual assessment, and chiropractic medicine in Switzerland, where the study was conducted, is an integrated, university-trained medical discipline rather than an alternative practice. At University Hospital Balgrist, chiropractic medicine operates within the hospital system, with practitioners trained to medical standards. Nevertheless, the researchers emphasize that the general public often does not distinguish between regulated, hospital-based chiropractic care and less formally grounded versions of the practice, which contributes to the initial wariness parents bring through the clinic door. The gap between the actual, regulated nature of the treatment and parental perceptions of it is exactly where communication interventions can do the most good.

The broader implications extend well beyond this single condition. The study offers a template for understanding how families engage with any unfamiliar treatment for infants, a situation that arises constantly in pediatrics, from osteopathy to novel physiotherapy protocols to emerging conservative orthopedic approaches. The central insight is that parental acceptance is dynamic, not fixed: it can be cultivated through structured communication and validated through visible outcomes. The authors highlight that supporting families through this psychological transition does more than improve satisfaction scores; it reduces stress during the infant’s care, and reduced parental stress is itself a meaningful clinical outcome, given how strongly caregiver anxiety can affect feeding, bonding, and the consistency with which families complete a treatment course.

The researchers are careful about the scope of their conclusions. As an explorative qualitative study with twelve baseline and seven follow-up participants, it cannot quantify how common each attitude pattern is, nor can it speak to the clinical efficacy of chiropractic treatment for arthrogenic torticollis itself, which was not the object of investigation. What it does establish, with methodological transparency, is the shape of the parental experience: an arc that begins in uncertainty and emotional strain, passes through familiarization and observation, and ends, for the families studied, in confidence and acceptance. The deductive-inductive coding framework and adherence to the COREQ checklist strengthen the trustworthiness of the thematic findings, and the two-timepoint design gives the study a longitudinal dimension that most qualitative work in this area lacks.

For parents facing a torticollis diagnosis, the study’s message is quietly reassuring: the fear and ambivalence they may feel before their infant’s first chiropractic session are common, documented, and, according to the families interviewed, likely to fade as understanding and visible progress replace the unknown. For clinicians, the message is more actionable. Every explanation offered before a session, every question answered patiently, and every improvement pointed out explicitly is not merely courtesy but an active ingredient in the therapy’s acceptance. In a field where the youngest patients cannot voice their own experience and their caregivers hold the decision-making power entirely, the psychology of the parent may be as important to a treatment’s success as the technique applied to the infant’s neck. This Swiss study makes that psychology visible, and in doing so, offers both families and practitioners a clearer map of the emotional terrain they must cross together.

Subject of Research: Parental attitudes toward chiropractic treatment of infants with arthrogenic torticollis

Article Title: Parental attitude towards chiropractic intervention before and after treatment in infants with an arthrogenic torticollis: an explorative qualitative study

Article References: Keller, S., Paravicini, I., Wirth, B., Schweinhardt, P., & Langenfeld, A. (2026). Parental attitude towards chiropractic intervention before and after treatment in infants with an arthrogenic torticollis: an explorative qualitative study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07760-z

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07760-z

Keywords: arthrogenic torticollis, chiropractic care, parental attitude, infants, manual therapy, parental stress, healthcare communication, pediatrics, qualitative research, congenital muscular torticollis, cervical spine, physiotherapy

The original study, published on 18 August 2026, set out to answer a deceptively simple question: when a trained examiner palpates and assesses the upper cervical spine of an infant, does that clinical judgment correspond to what is visible on radiological digital images of the same region? The upper cervical spine, comprising the atlas and axis vertebrae at the top of the spinal column, is a technically demanding area to evaluate in babies. Infants cannot report symptoms, the anatomy is small and largely cartilaginous, and positional asymmetries of the head and neck, often presenting as torticollis, can arise from many different underlying causes. Establishing whether hands-on assessment tracks with imaging findings is therefore a methodologically meaningful question, and one with direct implications for how clinicians decide when imaging is warranted.

In their letter, Tahir and colleagues acknowledged the methodological quality of the Swiss work and expressed general agreement with the authors’ interpretation of the findings. Their critique, however, focused on two distinct issues. The first concerned the use of radiological digital pictures of the upper cervical spine in infants presenting with torticollis. The second concerned the use of spinal mobilization as a treatment approach for the same condition. Crucially, the letter framed both objections in the context of congenital muscular torticollis, a specific diagnosis in which shortening or fibrosis of the sternocleidomastoid muscle causes the head to tilt and rotate. That framing, the Swiss authors argue, is where the critique loses its footing.

In their reply, published on 9 September 2026, Jan Peter, Miklos Csato, Inga Paravicini, Martina Wehrli, Petra Schweinhardt and Anke Langenfeld point out a fundamental mismatch between the critique and their study population. The infants enrolled in the cross-sectional study had been referred for chiropractic assessment and treatment only after undergoing evaluation for congenital muscular torticollis by the referring pediatrician or chiropractor. None of the infants had actually received a diagnosis of congenital muscular torticollis. In other words, the study examined a group of babies whose head and neck posture problems remained unexplained after the most common muscular cause had been ruled out, a population that is clinically distinct from the one the letter’s cited guidelines address.

This distinction matters because torticollis is not a single disease but a descriptive sign. Congenital muscular torticollis is the most frequent cause in infancy, but positional plagiocephaly, ocular imbalance, skeletal anomalies, and neurological conditions can all produce a similar tilted head posture. Guidelines recommending one management pathway or another are typically written for a specific diagnosis, and the Swiss authors note that the guidelines cited in the critical letter refer specifically to congenital muscular torticollis, not to other forms of torticollis. Applying those recommendations to a cohort deliberately composed of infants without that diagnosis, they contend, misreads what the study was designed to show.

The second point of contention, spinal mobilization in infants, touches on one of the most sensitive debates in pediatric musculoskeletal care. An international evidence-based position statement for physiotherapists, published in 2024 by Gross, Olson, Pool and colleagues in the Journal of Manual and Manipulative Therapy, advises against any form of spinal mobilization or manipulation in infants, irrespective of diagnosis. The Swiss authors state that they are very much aware of this position statement and do not dispute its content. Instead, they draw attention to its evidentiary basis: the statement, they note, rests on the limited availability of high-quality evidence, meaning that no firm conclusion can currently be reached about the effectiveness or safety of manual treatments in this age group.

The authors are equally emphatic that their own study cannot fill that gap. The objective of the cross-sectional study, they stress, was not to evaluate treatment effectiveness or to compare therapeutic approaches. Accordingly, they write, the findings should not be interpreted as evidence supporting or rejecting the appropriateness or effectiveness of any particular intervention. This is a point of scientific logic as much as of clinical policy: a study that measures agreement between two diagnostic assessments, in this case examiner judgment and radiological imaging, says nothing about whether treating the identified findings changes outcomes for the child. Conflating diagnostic correlation studies with treatment trials is a common source of misinterpretation in the literature, and the reply serves as a pointed reminder of the difference.

At the same time, the exchange highlights a genuine and unresolved tension in the field. If high-quality evidence on manual therapy in infants is scarce, then both the clinicians who use these techniques and the bodies that advise against them are operating in an evidentiary vacuum. The Swiss authors close their reply by fully agreeing that high-quality evidence on both the effectiveness and the safety of manual treatments in infants, including spinal mobilization and manipulation, is urgently needed. That concession is notable: rather than dismissing the critique, they accept its most important implication while defending the narrower claims of their own research. The letter, they conclude, was critical yet constructive, and they welcome it as such.

For readers outside the specialty, the dispute is a case study in how carefully study populations must be defined before research findings can be generalized. A cohort of infants referred for chiropractic assessment after congenital muscular torticollis was excluded is not a cohort of infants with congenital muscular torticollis, and conclusions drawn from one cannot be transplanted to the other. Similarly, a measurement that is reliable, meaning that repeated assessments produce consistent results, does not automatically constitute a reliable diagnosis, a point captured in the very title of the critical letter. Reliability speaks to consistency; diagnostic validity speaks to whether the measurement identifies a true underlying condition. The two concepts are related but distinct, and much of the friction in this exchange flows from the gap between them.

The reply, authored by clinicians and researchers from the Department of Chiropractic Medicine and the Department of Radiology at Balgrist University Hospital and the University of Zurich, was received on 24 August 2026, revised on 28 August, accepted on 2 September, and published as an open-access Matters Arising contribution. Corresponding author Anke Langenfeld and Petra Schweinhardt drafted the response, with the remaining authors critically reviewing and approving it. The authors declare no competing interests. Whether the exchange will stimulate the large, rigorous trials that both sides agree are lacking remains to be seen, but the episode demonstrates how the peer-reviewed correspondence column continues to function as a venue for sharpening the questions that matter, particularly in a field where the patients are too young to speak for themselves and the stakes of getting the evidence right could not be higher.

Subject of Research: Diagnostic correlation between examiner judgment and radiographic imaging of the upper cervical spine in infants with torticollis

Article Title: Reply to: “A reliable measurement is not the same as a reliable diagnosis” by Nawaz Tahir et al.

Article References: Peter, J., Csato, M., Paravicini, I., Wehrli, M., Schweinhardt, P., & Langenfeld, A. (2026). Reply to: “A reliable measurement is not the same as a reliable diagnosis” by Nawaz Tahir et al.. Pediatric Radiology. https://doi.org/10.1007/s00247-026-06783-z

Image Credits: AI Generated

DOI: 10.1007/s00247-026-06783-z

Keywords: pediatric radiology, torticollis, congenital muscular torticollis, upper cervical spine, chiropractic medicine, spinal mobilization, radiography, diagnostic reliability, infants, manual therapy, position statement, Balgrist University Hospital