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We performed a double\u2010blind, randomized, placebo\u2010controlled trial to: (1) determine head strike (HS) incidence, during US Army Basic Airborne Course's Improved Swing Landing Trainer (ISLT) training, (2) test protective efficacy of ketone monoester (KME) supplementation, and (3) assess blood\u2010based mTBI biomarker signatures. We enrolled 354 active\u2010duty male and female service members randomized 1:1 to placebo (PLA) or KME;\n                    <jats:italic>n<\/jats:italic>\n                    \u2009=\u2009318 completed ISLT and assessments (PLA\u2009=\u2009157, 142\u2009M\/15F; KME\u2009=\u2009161, 144\u2009M\/18F).\n                    <jats:italic>N<\/jats:italic>\n                    \u2009=\u2009112 (35.2%; 35.7% in PLA, 34.8% in KME) experienced HS, defined as whiplash or helmet\u2010to\u2010ground impact. Assessments included the Automated Neuropsychological Assessment Metric (ANAM\u20104), SWAY balance testing, and plasma biomarkers. One ANAM\u20104 measure (Simple Reaction Time\u2010Repeat;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.024) and one SWAY measure (Single Leg Right;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.014) demonstrated significant HS \u00d7 Time \u00d7 Treatment interactions, with performance decrements in HS\u2009+\u2009PLA not observed in HS\u2009+\u2009KME. Several HS \u00d7 Time interactions were observed for ANAM\u20104 and SWAY variables, indicating HS\u2010induced cognitive and balance decline. No relevant blood\u2010based biomarker patterns were associated with HS or KME. Predictive modeling identified variables associated with HS risk with moderate accuracy. In conclusion, ISLT resulted in ~32% head injury incidence and KME supplementation showed limited protection of cognitive and balance without corresponding biomarker changes.\n                  <\/jats:p>","DOI":"10.14814\/phy2.70818","type":"journal-article","created":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T07:39:10Z","timestamp":1773905950000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Assessing head injury risk and neuroprotective effect of ketone monoester supplementation in military airborne training"],"prefix":"10.14814","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9762-9918","authenticated-orcid":false,"given":"Toshiya","family":"Miyatsu","sequence":"first","affiliation":[{"name":"Healthspan, Resilience and Performance Research, Florida Institute for Human and Machine Cognition  Pensacola Florida 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