{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T16:27:36Z","timestamp":1786120056394,"version":"build-2736575974"},"reference-count":27,"publisher":"Oxford University Press (OUP)","issue":"Supplement_1","funder":[{"DOI":"10.13039\/100016156","name":"U.S. Army Medical Research and Development Command","doi-asserted-by":"publisher","award":["HT9425-24-9-0028"],"award-info":[{"award-number":["HT9425-24-9-0028"]}],"id":[{"id":"10.13039\/100016156","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Department of Veterans Affairs Medical Research"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,8,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>The widely used head injury criterion (HIC) has improved human safety and vehicle design in automotive environments. Because of its application to civilians, tests that led to HIC were conducted without helmets. Studies focusing on military environments are sparse. Behind helmet blunt trauma (BHBT)-specific head injury criteria do not exist to the best knoweldge of the authors. The objective of this study is to present a focused literature review of military studies and a novel paradigm for developing enhanced BHBT medical injury criteria (EMIC) for assessing helmet performance and advancing combat and medical readiness of the Warfighter.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and Methods<\/jats:title>\n                    <jats:p>The widely used PubMed database was accessed to identify articles for a systematic literature review ranging from its inception to August 30, 2025. The review focused on experimental head injury articles with a focus on tests pertinent to the replication of the injury and developing injury criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The review identified literature involving different surrogates: The PubMed database query identified 390,032 and 102,390 articles for the key words \u201cimpact system\u201d and \u201cinjury criteria\u201d. Using the key words \u201cinjury risk curve\u201d and \u201cblunt impact,\u201d the database returned 11,517 and 5,619 articles. \u201cBlunt impact\u201d and \u201cinjury risk curve\u201d identified 31 articles, while \u201cblunt impact\u201d and \u201cinjury criteria\u201d had 313 articles. BHBT-specific articles with biological surrogates were limited and discussed in the body of the paper. A reanalysis of post-mortem human subject surrogate (PMHS) test data was done to develop force and deflection injury risk curves. One paper in the database used a live animal model; however, brain injury and skull fracture outcomes were not presented.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The literature review identified limited studies for BHBT-specific scenarios. Available PMHS test data are inadequate to develop robust region-specific injury criteria for skull fractures. A novel hybrid paradigm combining cadaveric human and animal, and live animal experimentation, and computational modeling is needed to develop human BHBT injury risk curves from which injury criteria can be specified for EMIC for Warfighter protection from skull fractures and brain injuries. The academic consortium from the present study authors is pursuing studies along these lines.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/milmed\/usag270","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T11:46:50Z","timestamp":1779968810000},"page":"714-722","source":"Crossref","is-referenced-by-count":0,"title":["A Hybrid Paradigm to Develop Head Injury Criteria for Behind Helmet Blunt Trauma"],"prefix":"10.1093","volume":"191","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3376-4456","authenticated-orcid":false,"given":"Narayan","family":"Yoganandan","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Medical College of Wisconsin , Milwaukee, WI 53226,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tyler F","family":"Rooks","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical College of Wisconsin , Milwaukee, WI 53226,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wade","family":"Mueller","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical College of Wisconsin , Milwaukee, WI 53226,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Panzer","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Virginia , Charlottesville, VA 4040,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Salzar","sequence":"additional","affiliation":[{"name":"Department of Mechanical and Aerospace Engineering, University of Virginia , Charlottesville, VA 4040,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cameron R","family":"Bass","sequence":"additional","affiliation":[{"name":"Department of Biomedical Engineering, Wayne State University , Detroit, MI 48201,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valeta Carol","family":"Chancey","sequence":"additional","affiliation":[{"name":"Injury Biomechanics and Protection Group, U.S. Army Aeromedical Research Laboratory , Fort Rucker, AL 36362,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederick","family":"Brozoski","sequence":"additional","affiliation":[{"name":"Injury Biomechanics and Protection Group, U.S. Army Aeromedical Research Laboratory , Fort Rucker, AL 36362,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,6]]},"reference":[{"key":"2026080616034125100_usag270-B1","doi-asserted-by":"publisher","first-page":"132","DOI":"10.7205\/milmed-d-09-00238","article-title":"Inpatient hospitalizations of U.S. military personnel medically evacuated from Iraq and Afghanistan with combat-related traumatic brain injury","volume":"176","author":"Heltemes","year":"2011","journal-title":"Mil Med"},{"key":"2026080616034125100_usag270-B2","doi-asserted-by":"publisher","first-page":"347","DOI":"10.1093\/milmed\/usx216","article-title":"Retrospective analysis of injuries in underbody blast events: 2007-2010","volume":"183","author":"Vasquez","year":"2018","journal-title":"Mil Med"},{"key":"2026080616034125100_usag270-B3","first-page":"268","volume-title":"Otolaryngology\/Head and Neck Surgery Combat Casualty Care in Operation Iraqi Freedom and Operation Enduring Freedom","author":"Esquivel","year":"2015"},{"key":"2026080616034125100_usag270-B4","doi-asserted-by":"publisher","first-page":"1064","DOI":"10.1016\/j.injury.2018.03.028","article-title":"The burden of gunshot wounding of UK military personnel in Iraq and Afghanistan from 2003-14","volume":"49","author":"Stevenson","year":"2018","journal-title":"Injury"},{"key":"2026080616034125100_usag270-B5","doi-asserted-by":"publisher","first-page":"S108","DOI":"10.1016\/j.amepre.2009.10.006","article-title":"Traumatic brain injury hospitalizations of U.S. army soldiers deployed to Afghanistan and Iraq","volume":"38","author":"Wojcik","year":"2010","journal-title":"Am J Prev Med"},{"key":"2026080616034125100_usag270-B6","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/j.amepre.2023.01.043","article-title":"Trends in traumatic brain injury among U.S. Service members deployed in Iraq and Afghanistan, 2002-2016","volume":"65","author":"Le","year":"2023","journal-title":"Am J Prev Med"},{"key":"2026080616034125100_usag270-B7","volume-title":"Accidental Injury: Biomechanics and Prevention","author":"Prasad","year":"2015"},{"key":"2026080616034125100_usag270-B8","doi-asserted-by":"publisher","first-page":"243","DOI":"10.4271\/2013-22-0010","article-title":"Development of brain injury criteria (BrIC)","volume":"57","author":"Takhounts","year":"2013","journal-title":"Stapp Car Crash J"},{"key":"2026080616034125100_usag270-B9","doi-asserted-by":"publisher","first-page":"923","DOI":"10.1097\/00005373-200011000-00021","article-title":"Consequences of nonpenetrating projectile impact on a protected head: study of rear effects of protections","volume":"49","author":"Sarron","year":"2000","journal-title":"J Trauma"},{"key":"2026080616034125100_usag270-B10","doi-asserted-by":"publisher","first-page":"236","DOI":"10.1097\/01.ta.0000133575.48065.3f","article-title":"Dynamic effects of a 9 mm missile on cadaveric skull protected by aramid, polyethylene or aluminum plate: an experimental study","volume":"57","author":"Sarron","year":"2004","journal-title":"J Trauma"},{"key":"2026080616034125100_usag270-B11","doi-asserted-by":"publisher","first-page":"1305","DOI":"10.1097\/01.ta.0000064209.21216.4e","article-title":"Ballistic impact to the forehead, zygoma, and mandible: comparison of human and frangible dummy face biomechanics","volume":"56","author":"Viano","year":"2004","journal-title":"J Trauma"},{"key":"2026080616034125100_usag270-B12","doi-asserted-by":"publisher","first-page":"2479","DOI":"10.1016\/j.jbiomech.2009.07.018","article-title":"Tolerance of the skull to blunt ballistic temporo-parietal impact","volume":"42","author":"Raymond","year":"2009","journal-title":"J Biomech"},{"key":"2026080616034125100_usag270-B13","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1111\/1556-4029.12570","article-title":"Injuries of the head from backface deformation of ballistic protective helmets under ballistic impact","volume":"60","author":"Rafaels","year":"2015","journal-title":"J Forensic Sci"},{"key":"2026080616034125100_usag270-B14","doi-asserted-by":"publisher","first-page":"287","DOI":"10.1093\/milmed\/usx210","article-title":"Preliminary investigation of skull fracture patterns using an impactor representative of helmet Back-Face deformation","volume":"183","author":"Weisenbach","year":"2018","journal-title":"Mil Med"},{"key":"2026080616034125100_usag270-B15","doi-asserted-by":"publisher","first-page":"655","DOI":"10.7150\/ijms.5004","article-title":"Intracranial pressure response to non-penetrating ballistic impact: an experimental study using a pig physical head model and live pigs","volume":"9","author":"Liu","year":"2012","journal-title":"Int J Med Sci"},{"key":"2026080616034125100_usag270-B16","doi-asserted-by":"publisher","first-page":"505","DOI":"10.1007\/s00414-014-1073-2","article-title":"Development of a skull\/brain model for military wound ballistics studies","volume":"129","author":"Carr","year":"2015","journal-title":"Int J Legal Med"},{"key":"2026080616034125100_usag270-B17","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1002\/ca.21106","article-title":"Use of postmortem human subjects to describe injury responses and tolerances","volume":"24","author":"Yoganandan","year":"2011","journal-title":"Clin Anat"},{"key":"2026080616034125100_usag270-B18","volume-title":"Bass Develop\u00adment of a Portable Oculomotor Assessment Platform and Analysis Suite for Assessing mTBI","author":"Shah","year":"2015"},{"key":"2026080616034125100_usag270-B19","first-page":"1251","article-title":"The sheep as a large animal model for the investigation and treatment of human disorders","volume":"11","author":"Banstola","year":"2022","journal-title":"Biology (Basel)"},{"key":"2026080616034125100_usag270-B20","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1080\/01902148.2020.1797246","article-title":"Severe, transient pulmonary ventilation-perfusion mismatch in the lung after porcine high velocity projectile behind armor blunt trauma","volume":"46","author":"Rocksen","year":"2020","journal-title":"Exp Lung Res"},{"key":"2026080616034125100_usag270-B21","doi-asserted-by":"publisher","first-page":"e2462","DOI":"10.1093\/milmed\/usae297","article-title":"Analysis of injury metrics from experimental cardiac injuries from behind armor blunt trauma using live swine tests: a pilot study","volume":"189","author":"Yoganandan","year":"2024","journal-title":"Mil Med"},{"key":"2026080616034125100_usag270-B22","doi-asserted-by":"publisher","first-page":"659","DOI":"10.1093\/milmed\/usae214","article-title":"Behind armor blunt trauma: liver injuries using a live animal model","volume":"189","author":"Yoganandan","year":"2024","journal-title":"Mil Med"},{"key":"2026080616034125100_usag270-B23","first-page":"418","volume-title":"Military Injury Biomechanics: The Cause and Prevention of Impact Injuries","author":"Franklyn","year":"2017"},{"key":"2026080616034125100_usag270-B24","doi-asserted-by":"publisher","first-page":"e001194","DOI":"10.1136\/tsaco-2023-001194","article-title":"Matched-pair hybrid test paradigm for behind armor blunt trauma using an experimental animal model","volume":"9","author":"Yoganandan","year":"2024","journal-title":"Trauma Surg Acute Care Open"},{"key":"2026080616034125100_usag270-B25","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1016\/j.expneurol.2014.07.002","article-title":"Scaling in neurotrauma: how do we apply animal experiments to people?","volume":"261","author":"Panzer","year":"2014","journal-title":"Exp Neurol"},{"key":"2026080616034125100_usag270-B26","doi-asserted-by":"publisher","first-page":"410","DOI":"10.1089\/neu.2019.6576","article-title":"Investigation of cross-species scaling methods for traumatic brain injury using finite element analysis","volume":"37","author":"Wu","year":"2020","journal-title":"J Neurotrauma"},{"key":"2026080616034125100_usag270-B27","doi-asserted-by":"publisher","first-page":"071003","DOI":"10.1115\/1.4053209","article-title":"Integrating human and nonhuman primate data to estimate human tolerances for traumatic brain injury","volume":"144","author":"Wu","year":"2022","journal-title":"J Biomech Eng"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/191\/Supplement_1\/714\/70491483\/usag270.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/191\/Supplement_1\/714\/70491483\/usag270.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,6]],"date-time":"2026-08-06T20:03:47Z","timestamp":1786046627000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/191\/Supplement_1\/714\/8752249"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":27,"journal-issue":{"issue":"Supplement_1","published-online":{"date-parts":[[2026,8,6]]},"published-print":{"date-parts":[[2026,8,1]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag270","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,7]]},"published":{"date-parts":[[2026,7]]}}}