The Cutting Movement Assessment Score (CMAS) Qualitative Screening Tool: Application to Mitigate Anterior Cruciate Ligament Injury Risk during Cutting
, Christopher Thomas 2, Alistair McBurnie 3, Thomas Donelon 4, Lee Herrington 2 and Paul A. Jones 2Round 1
Reviewer 1 Report
I’d like the idea of creating a sort of manual to practitioners! This can be very helpful.
However, considering the main aim of this review, I do not see the additional value of Chapters 1-2. The rationale of the CMAS can be introduced in a much shorter way.
Line 25: the CMAS doesn’t examine knee joint loads. You need force plates for this.
Figure 1 doesn’t match exactly with text, new elements have been added.
Line 364: be more specific what does ‘positive experience’ mean ?
Line 381: please find an easier word for ‘parallax’
Line 384: be more specific what does ‘recently had better observations’ mean ?
Line 396/397: why do you mention this ? if you keep it, please be more specific of why this was done and what the result was.
Line 402: be more specific what does ‘had a lot of success’ mean ?
Table 2: please put the Yes and No in a more clear position. Now it looks confusing to me, is the differentiation left/right or top/bottom ?
For item 3, 4 and 5: it’a good to mention these are anatomical rotations and not ‘in space’.
Line 606: higher total score ?
Line 609-611: please provide a reference to these sentence for these cut offs.
Line 623: this sentence doesn’t run well.
Line 629-632: do you really think predicting injury is a feasible and desirable goal considering the multifactorial nature of injury ? what if a player scores bad CMAS score in September/preseason and gets an injury in March ? Is this truly related to each other…. ? Very questionable. This should be more a monitoring purpose.
Line 637: Myer isn’t a training article in a sense that it doesn’t give specific advice on the how to do it. I’d suggest to delete this one. It’s more about risk factors and screening.
Figure 6: Lateral trunk flexion. What is difference between training recommendation 1 and 5 ? And why is ‘external cues’ only advices for lateral trunk flexion? And I assume you mean external focus cue ? Please descriptive appropriately according to correct definitions. This training advice should then also be added to the list of references in line 637.
Author Response
I’d like the idea of creating a sort of manual to practitioners! This can be very helpful.
However, considering the main aim of this review, I do not see the additional value of Chapters 1-2. The rationale of the CMAS can be introduced in a much shorter way.
Response: Thank you for your comment. We agree, and therefore we have significantly reduced these sections. We have removed approximately 1100 words, taking the word count from 6172 to 4907. We now only have a 309 word introduction section which is more concise and leads into the CMAS.
Line 25: the CMAS doesn’t examine knee joint loads. You need force plates for this.
Response: Thank you for your comment. This has been removed.
Figure 1 doesn’t match exactly with text, new elements have been added.
Response: Thank you for your comment. In light of your earlier comment about editing sections 1 and 2, this has been removed.
Line 364: be more specific what does ‘positive experience’ mean ?
Response: Thank you for your comment. We have removed this term and have just stated that we have used the CMAS during 45 degree cuts in unpublished research. Please see line 252.
Line 381: please find an easier word for ‘parallax’
Response: Thank you for your comment. With respect, we do not want to change this word because this is the correct biomechanical term to use in this context. Parallax error is defined as: “The error/displacement caused in in the apparent position of the object due to the viewing angle that is other than the angle that is perpendicular to the object.” As such, we are saying that we need an additional camera to try and obtain video footage where the athletes (who pre-rotate) will now be perpendicular to the camera positioned at 20-45°.
Line 384: be more specific what does ‘recently had better observations’ mean ?
Response: Thank you for your comment. We have amended this in light of suggestions. We have stated the following: “Although published research placed the third camera at 45° [55, 94], we have recently had better observations of CMAS trials with a camera positioned at 20°. This approach has tended to reduce parallax error because the subjects who pre-rotate are more perpendicular to the 20° camera in contrast to 45° camera observations. As such, this has made subsequent screening of relevant criteria easier and is therefore our preferred method going forward.” Please see line 277.
Line 396/397: why do you mention this ? if you keep it, please be more specific of why this was done and what the result was.
Response: Thank you for your comment. We have removed the sentence: “We have also used white boards to code the respective videos and usually organise athletes in a specific order to facilitate easier data collection.” We have added some more detail to the sentence before. We now state: “From our experience, we have been able to collect CMAS video footage for 6 trials (3 trials per limb) in groups of athletes as large 12 in less than 15 minutes, highlighting the simplicity and application for large mass screening in contract to 3D motion analysis.” Please see line 292.
Line 402: be more specific what does ‘had a lot of success’ mean ?
Response: Thank you for your comment. We have amended this sentence in light of your comment. We now state the following: “and we have found this software to be more than adequate for qualitative screening purposes” Please see line 299.
Table 2: please put the Yes and No in a clearer position. Now it looks confusing to me, is the differentiation left/right or top/bottom ?
Response: Thank you for your comment. We have now added a vertical line to divide the table. We hope this is clearer.
For item 3, 4 and 5: it’a good to mention these are anatomical rotations and not ‘in space’.
Response: Thank you for your comment. Apologies, but we do fully understand this comment. By “space” we are referring to the “space” between the line and the lateral aspect of the knee (as illustrated in the images). This is just useful visual way to help assist in screening. We fully appreciate that these are anatomical rotations.
Line 606: higher total score ?
Response: Thank you for your comment. Yes, a great observation. Apologies for this omission. This has been amended. Please see line 513.
Line 609-611: please provide a reference to these sentence for these cut offs.
Response: Thank you for your comment. Apologies for this omission. This has been amended. Please see line 518.
Line 623: this sentence doesn’t run well.
Response: Thank you for your comment. We have divided this sentence into two. We now state the following: “For example, an athlete with a low CMAS may still display “high-risk” cutting deficits, such as knee valgus, lateral trunk flexion, limited knee flexion, or hip internal rotation. Therefore, in this scenario, the athlete would still warrant specific injury risk mitigation training and conditioning.” Please see line 512.
Line 629-632: do you really think predicting injury is a feasible and desirable goal considering the multifactorial nature of injury ? what if a player scores bad CMAS score in September/preseason and gets an injury in March ? Is this truly related to each other…. ? Very questionable. This should be more a monitoring purpose.
Response: Thank you for your comment. We agree with your points. ACL injuries are multifactorial, and we agree that screening is only representative of the movement quality at that specific time of the year. We agree it is erroneous to assume that the movement quality will be representative of the technique 6-12 months later. That said, prospective research is still being conducted in the literature and It would be interesting to use the CMAS in this capacity. Nevertheless, in light of your comments, we have removed the following sentences: “The ability of the CMAS to predict injury or non-contact ACL injury has yet to be established. Consequently, longitudinal prospective studies are required to ascertain whether the CMAS can predict injury and to establish a cut-off value for identifying potentially “at-risk” athletes.” We now state that: “Nevertheless, practitioners are recommended to use the CMAS as a regular monitoring tool to assist in identifying “high-risk” cutting deficits in their athletes. This can be used to inform and help develop individualised training programmes to modify the specific deficits and mitigate potential ACL injury risk.” Please see line 535
Line 637: Myer isn’t a training article in a sense that it doesn’t give specific advice on the how to do it. I’d suggest to delete this one. It’s more about risk factors and screening.
Response: Thank you for your comment. This has been removed.
Figure 6: Lateral trunk flexion. What is difference between training recommendation 1 and 5 ? And why is ‘external cues’ only advices for lateral trunk flexion? And I assume you mean external focus cue ? Please descriptive appropriately according to correct definitions. This training advice should then also be added to the list of references in line 637.
Response: Thank you for your comment. Apologies for the oversight. You make some great suggestions. We have revised our training recommendations in this figure. We now state: “external focus” and we have included this for multiple training recommendations and CMAS criteria such as PFC braking, knee flexion, lateral foot plant distance etc. We do not want to expand on the training recommendations that much in text. That is why we encourage the readers to view other training recommendation articles. We have now included the reference of Benjaminse et al. (2015) who discusses novel feedback techniques. Additionally, in our previous review (Dos’Santos et al., 2019) we also discuss coaching cues to address movement quality. We are conscious of the word count, especially in light of the comments from reviewer 2.
Benjaminse, A.; Gokeler, A.; Dowling, A.V.; Faigenbaum, A.; Ford, K.R.; Hewett, T.E.; Onate, J.A.; Otten, B.; Myer, G.D. Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor learning and reduce injury risk. J Orthop Sport Phys 2015, 45, 170-182.
Dos’Santos, T.; McBurnie, A.; Thomas, C.; Comfort, P.; Jones, P.A. Biomechanical Comparison of Cutting Techniques: A Review and Practical Applications. Strength Cond J 2019, 41, 40-54.
Reviewer 2 Report
Thank you for the opportunity to review the review-article entitled “The Cutting Movement Assessment Score (CMAS) Qualitative Screening Tool: Application to Mitigate Anterior Cruciate Ligament Injury Risk During Cutting”.
A brief summary
Thank you for the opportunity to review the review-article entitled “The Cutting Movement Assessment Score (CMAS) Qualitative Screening Tool: Application to Mitigate Anterior Cruciate Ligament Injury Risk During Cutting”.
This review article discusses the implications, risk factors, and mechanisms of ACL injury, and provides practitioners with a comprehensive and detailed overview regarding the rationale and implementation of the Cutting Movement Assessment Score (CMAS). Additionally, this review provides guidance on CMAS methodological procedures, CMAS operational definitions, and training recommendations to assist in the development of more effective non-contact ACL injury risk mitigation programmes.
This review include several main topics in the field of ACL injury implication, risk factors, mechanism of ACL injury (not stated in the title) and implementation of CMAS. In my opinion, there are too many topics and the manuscript are far too long with almost 200 references. The readers (and reviewers) lose focus and unfortunately I cannot Review this article in detail. It should be enough to discuss CMAS, the other topics are well known and there are several systematic reviews in these topics.
Author Response
Thank you for the opportunity to review the review-article entitled “The Cutting Movement Assessment Score (CMAS) Qualitative Screening Tool: Application to Mitigate Anterior Cruciate Ligament Injury Risk During Cutting”.
This review article discusses the implications, risk factors, and mechanisms of ACL injury, and provides practitioners with a comprehensive and detailed overview regarding the rationale and implementation of the Cutting Movement Assessment Score (CMAS). Additionally, this review provides guidance on CMAS methodological procedures, CMAS operational definitions, and training recommendations to assist in the development of more effective non-contact ACL injury risk mitigation programmes.
This review include several main topics in the field of ACL injury implication, risk factors, mechanism of ACL injury (not stated in the title) and implementation of CMAS. In my opinion, there are too many topics and the manuscript are far too long with almost 200 references. The readers (and reviewers) lose focus and unfortunately I cannot Review this article in detail. It should be enough to discuss CMAS, the other topics are well known and there are several systematic reviews in these topics.
Response: Thank you for your comment. In light of your comments and Reviewer 1’s comments, we have significantly reduced these sections, and removed the implications and mechanism of injury sections. We have removed approximately 1100 words, taking the word count from 6172 to 4907. We now only have a 309 word introduction section and removed two figures. Additionally, we have reduced the references from 190 to 142.
Round 2
Reviewer 1 Report
The authors have done a great job being more to the point and more specific in their statements. Well done. For items 3, 4 and 5, please mention these are anatomical rotations. I think this is of additional value to the reader, as from my experience graders could easily consider this as ration 'in space'.
Author Response
Response: Thank you for your comment: This has been amended. We have added “anatomical rotation” on lines 397, 403, and 420. Additionally, “anatomical rotation” has been added to Table 4 for items 3, 4 and 5. We have also removed the term “space” and changed this to “gap” to avoid confusion for the reader in Table 4. For example, we state the following: “Practitioners may consider visualising or using drawing lines (video software permitting) from the greater trochanter to the lateral malleoli and if a clear gap is present between the lateral aspect of the knee and the line, then a score (+1) is awarded (as illustrated in the images)”.
