Electromyographic Validation of the DMA Clinical Pilates Method for Classifying Muscle Impairments in Chronic Ankle Instability
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe paper is a clinically important study of motor dysfunction in individuals with chronic ankle instability (CAI) during single-leg stance using surface electromyography (sEMG). The application of the DMA Clinical Pilates™ model to discriminate muscle impairments is new and holds practical implications for rehab. The use of Bayesian statistics is also an asset, giving a probabilistic interpretation to the results.
Critical Revisions
- Introduction
- Since the DMA Clinical Pilates method is being presented, directional trauma and muscle activation pattern relation could be explained more precisely. Adding one sentence connecting the biomechanical cause (e.g., inversion trauma → compensatory dorsiflexion/eversion overactivation of muscles) to the predicted sEMG outcome may prove helpful.
- Methods
- Electrode Placement and Cross-Talk: Authors acknowledge the risk of cross-talk between gluteus Maximus and Medius due to anatomical proximity of location. Consider:
- Adding a sentence on why these muscles were chosen despite the risk.
- Stating whether cross-talk compensation techniques (e.g., cross-correlation analysis) were employed.
- Outlining how this limitation can influence the interpretation of gluteal muscle results.
- Sample Size Justification: Despite the presentation of Bayesian sample size calculation, include a sentence as to whether this was based on a pilot study or previous literature effect sizes.
- Results
- Interpretation of Bayesian Factors: Some BF₁₀ values fall in the "anecdotal" range (i.e., 0.35–0.64). Consider:
- How these were interpreted in the framework of the study hypotheses.
- Arguing whether anecdotal evidence or moderate/strong evidence alone needs to be reported.
- Table Readability: Tables are congested and may be difficult to read. Consider:
- Column headers reduced.
- Use of subheadings or grouping by muscle or condition.
- Moving complex tables to appendix and highlighting key findings in the body.
- Discussion
- Biomechanical Interpretation: The interpretation would be enriched by additional explicit biomechanical detail on why specific muscles (e.g., tibialis anterior, fibularis longus) are overactive:
- Correlate overactivation with compensatory mechanics for dysfunctional proprioception or ligamentous laxity.
- Describe how these findings relate to or contrast with finite element models or gait analyses of CAI.
- Clinical Implications: Explain in detail how the findings are specifically guiding rehabilitation (e.g., what kind of non-weightbearing exercises, progression standards).
- Limitations: Explain in detail how the prior interventions (or lack thereof) impacted the findings. Think about stratifying or controlling for this in future studies.
- Figures
- Figures 1 and 2: Ensure that these figures are clear and well-labeled. If possible, include anatomical landmarks or schematics to increase clarity.
Minor revisions
- Abbreviations: Define every abbreviation upon first use (e.g., DMA, MVIC, BF₁₀).
- Grammar and Clarity: There are small grammatical errors (e.g., "DMA Clinical Pilates™ assesses for directional trauma" → "DMA Clinical Pilates™ uses directional trauma assessment"). Recommend a thorough proofread.
- Consistency: Use consistent naming of muscles (e.g., "fibularis longus" or "peroneus longus" in Table 1).
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript entitled “Directional trauma predicts motor dysfunction during single-leg stand in chronic ankle instability” addresses an important topic in the field of musculoskeletal rehabilitation. The study explores motor dysfunction in patients with chronic ankle instability (CAI) using surface electromyography during a single-leg stance task, with an interesting attempt to validate the DMA Clinical Pilates™ framework. The topic is clinically relevant, the methods are generally well described, and the results provide useful insights into muscle activation differences between CAI, recovered, and healthy individuals.
The introduction offers a comprehensive background and is well referenced, but it could be made more concise by reducing some repetition regarding the role of tibialis anterior and fibularis longus muscles. The methods are detailed, with appropriate ethical approval and registration, and the EMG acquisition and normalization procedures are clearly presented. One concern is that the manuscript tends to be overly descriptive in some methodological sections, which could be streamlined to improve readability.
The results are presented extensively, with numerous tables reporting Bayesian analyses. While the inclusion of Bayes factors is commendable, the number of tables and the volume of statistical detail risk overwhelming the reader. The main findings could be more effectively summarized in the text, while detailed values might be moved to supplementary material. Figures are appropriate, but further clarity in visualization (e.g., highlighting the most relevant muscle activation patterns) would increase impact.
The discussion reflects a genuine effort to interpret the findings in light of the DMA Clinical Pilates™ theory. However, it is somewhat lengthy and occasionally repetitive. The authors should aim to distill their main messages more clearly, focusing on the clinical implications of tibialis anterior and fibularis longus dysfunction while avoiding redundancy. The conclusions, in particular, should be more cautious. Given the relatively small sample size and cross-sectional design, the findings should be presented as preliminary evidence rather than definitive recommendations against weightbearing exercises in early rehabilitation. The limitations section identifies some important issues, but the potential impact of participant sex distribution, recruitment bias, and electrode crosstalk should also be discussed more explicitly.
In summary, this study is relevant and adds useful data to the literature on chronic ankle instability and motor control. However, the manuscript would be stronger if the text were more concise, the results more clearly synthesized, and the conclusions more cautiously framed. With these revisions, the paper could make a valuable contribution to the field and would be suitable for publication in Biomed.
Comments on the Quality of English LanguageThe English language is generally understandable, but the manuscript would benefit from professional editing to improve fluency, grammar, and consistency of terminology.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for Authors- Title
Evaluation: The title is fairly precise and descriptive. It does have the key concepts: "Directional trauma," "motor dysfunction," "single-leg stand," and "chronic ankle instability." But the phrase "Directional trauma predicts." is somewhat ambiguous. This study is about how to define or identify dysfunction via a directional trauma model, not how to use trauma to predict subsequent dysfunction longitudinally. The title also does not indicate that the research is a validation of the DMA Clinical Pilates method, a main aim.
Suggested Title: "Electromyographic Validation of the DMA Clinical Pilates Method for Classifying Muscle Impairments in Chronic Ankle Instability."
2. Introduction
• Some citations are old (e.g., Kobayashi & Gamada, 2014; Feger et al., 2015). Either replace or add recent studies within the last 5 years to show the novelty and present-day applicability of the study.
•The theoretical extension of the DMA method (initially created for back pain) to the ankle can be better justified with an added sentence on the theoretical application of the "directional bias" idea to peripheral joints.
3. Materials and Methods
• Clinical Pilates Method (Section 2.4): This section is unclear. Figure 1 is referred to but not supplied in the provided text, and hence it is impossible to evaluate. The description is conceptual. One may move this section into the introduction within the theoretical framework, as it is not an experimental "method.".
• Data Management (Section 2.8): The rationale for using unique combinations of trials for reliability (e.g., 1&2 for one and 2&3 for another) is unclear. Employing a standardized procedure (e.g., always using the two most reliable trials) would add rigor. The choice of an ICC cutoff of ≥ 0.5 ("moderate") is adequate but conservative; a larger cutoff (e.g., ≥ 0.75) is commonly applied for reliability.
• Statistical Analysis: Discursively justify why Bayesian analysis should be used in preference to frequentist null-hypothesis testing (e.g., its ability to provide quantitative measures of evidence for both the alternative and null hypotheses). - Results and Discussion
• The results are fully described in the text and appendix tables. BF₁₀ use with interpreted evidence levels (moderate, strong) is comprehensible. But the main text is numbers-heavy; Use summary statements. Example: "On the stable surface, the CAI group exhibited larger activation in the longissimus dorsi, vastus lateralis, and tibialis anterior in dominant-leg stance (all BF₁₀ > 3), with the most significant difference evident in the tibialis anterior in non-dominant stance (BF₁₀ = 36.36) (Table A1)."
5. Discussion:
The discussion is not particularly profound or critical of the broader literature.
1. Start with an unequivocal statement of the main finding.
2. Comparison with Literature:
The debate must clearly state the discrepancy raised in the introduction: why this experiment found augmented tibialis anterior activity but Terada et al. (2022) failed to do so. Give reasons (e.g., differences in participant variables, task settings, EMG normalization protocols). This is a critical step in scientific discussion.
Proximal Compensation: The findings in gluteus medius and vastus lateralis would have to be accounted for in the theory of "proximal compensation" in CAI. Suggest citation: [e.g., "Our finding of altered gluteus medius activity supports the hip-stabilization strategies hypothesis in CAI, as theorized by McCann et al. (2021)"].
3. Clinical Implications: The suggestion that weight-bearing exercise can be harmful in the initial stages is interesting and must be qualified. It can only be best offered as a hypothesis for future research rather than as a definitive suggestion.
4. Limitations: The listed limitations are accurate and well-documented. The comment on gender imbalance is particularly applicable.
6. General Comments
The authors include "Bo on Chong Kwok ⁴⁴". The superscript is likely an error and should be "⁴".
Avoid such colloquial language as "it is possible that" and use more forceful academic language whenever possible.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 3
Reviewer 1 Report
Comments and Suggestions for AuthorsHaving satisfactorily addressed the reviewers' comments, the paper is approved for publication
