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Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1); system of care (section 2); clinical management (section 3); characterisation of TBI (section 4); outcome assessment (section 5); prognosis (Section 6); and new directions for acquiring and implementing evidence (section 7). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

The study aimed to illustrate how contact (from match‐event data) and head acceleration event (HAE) (from instrumented mouthguard [iMG]) data can be combined to inform match limits within rugby. Match‐event data from one rugby union and rugby league season, including all competitive matches involving players from the English Premiership and Super League, were used. Playing exposure was summarised as full game equivalents (FGE; total minutes played/80). Expected contact and HAE exposures at arbitrary thresholds were estimated using match‐event and iMG data. Generalised linear models were used to identify differences in contact and HAE exposure per FGE. For 30 FGEs, forwards had greater contact than backs in rugby union (n = 1272 vs. 618) and league (n = 1569 vs. 706). As HAE magnitude increased, the differences between positional groups decreased (e.g., rugby union; n = 34 and 22 HAE >40 g for forwards and backs playing 30 FGEs). Currently, only a relatively small proportion of rugby union (2.5%) and league (7.3%) players exceeded 25 FGEs. Estimating contact and HAEs per FGE allows policymakers to prospectively plan and model estimated overall and position‐specific loads over a season and longer term. Reducing FGE limits by a small amount would currently only affect contact and HAE exposure for a small proportion of players who complete the most minutes. This may be beneficial for this cohort but is not an effective HAE and contact exposure reduction strategy at a population level, which requires individual player management. Given the positional differences, FGE limits should exist to manage appropriate HAE and contact exposure. Highlights: Estimating contact events and head acceleration events (HAEs) per full game equivalents (FGE, i.e., 80 minutes) allows policymakers to prospectively plan and model estimated overall and position‐specific loads over a season and longer term.Through retrospectively analysing FGE exposure, the findings demonstrate that only a small proportion of rugby players would be affected by a feasible reduction in FGE limits, but the difference in contact and HAE exposure for these players could be significant over the duration of a playing career.Per FGE in both rugby codes, forwards have a greater expected contact and head acceleration event exposure than backs, and thus any implemented FGE limits should at least be position group‐specific and ideally incorporate individual player management. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the difference in head acceleration event (HAE) incidence between training and match‐play in women's and men's players competing at the highest level of domestic rugby union globally. Players from Women's (Premiership Women's Rugby, Farah Palmer Cup) and Men's (Premiership Rugby, Currie Cup) rugby union competitions wore instrumented mouthguards during matches and training sessions during the 2022/2023 seasons. Peak linear (PLA) and angular (PAA) acceleration were calculated from each HAE and included within generalized linear mixed‐effects models. The incidence of HAEs was significantly greater in match‐play compared to training for all magnitude thresholds in both forwards and backs, despite players spending approximately 1.75–2.5 times more time in training. For all HAEs (PLA > 5 g and PAA > 400 rad/s2), incidence rate ratios (IRRs) for match versus training ranged from 2.80 (95% CI: 2.38–3.30; men's forwards) to 4.00 (3.31–4.84; women's forwards). At higher magnitude thresholds (PLA > 25 g; PAA > 2000 rad/s2), IRRs ranged from 3.64 (2.02–6.55; PAA > 2000 rad/s2 in men's backs) to 11.70 (6.50–21.08; PAA > 2000 rad/s2 in women's forwards). Similar trends were observed in each competition. Players experienced significantly more HAEs during match‐play than training, particularly at higher magnitude thresholds. Where feasible, HAE mitigation strategies may have more scope for HAE reduction if targeted at match‐play, particularly where higher magnitude HAEs are the primary concern. However, the number of HAEs associated with different training drills requires exploration to understand if HAEs can be reduced in training, alongside optimizing match performance (e.g., enhancing contact technique). [ABSTRACT FROM AUTHOR]

Objectives: Describe head acceleration events (HAEs) experienced by professional male rugby union players during tackle, ball‐carry, and ruck events using instrumented mouthguards (iMGs). Design: Prospective observational cohort. Methods: Players competing in the 2023 Currie Cup (141 players) and Super Rugby (66 players) seasons wore iMGs. The iMG‐recorded peak linear acceleration (PLA) and peak angular acceleration (PAA) were used as in vivo HAE approximations and linked to contact‐event data captured using video analysis. Using the maximum PLA and PAA per contact event (HAEmax), ordinal mixed‐effects regression models estimated the probabilities of HAEmax magnitude ranges occurring, while accounting for the multilevel data structure. Results: As HAEmax magnitude increased the probability of occurrence decreased. The probability of a HAEmax ≥15g was 0.461 (0.435–0.488) (approximately 1 in every 2) and ≥45g was 0.031 (0.025–0.037) (1 in every 32) during ball carries. The probability of a HAEmax >15g was 0.381 (0.360–0.404) (1 in every 3) and >45g 0.019 (0.015–0.023) (1 in every 53) during tackles. The probability of higher magnitude HAEmax occurring was greatest during ball carries, followed by tackles, defensive rucks and attacking rucks, with some ruck types having similar profiles to tackles and ball carries. No clear differences between positions were observed. Conclusion: Higher magnitude HAEmax were relatively infrequent in professional men's rugby union players. Contact events appear different, but no differences were found between positions. The occurrence of HAEmax was associated with roles players performed within contact events, not their actual playing position. Defending rucks may warrant greater consideration in injury prevention research. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to examine head acceleration event (HAE) propensity and incidence during elite-level men's and women's rugby union matches. Methods: Instrumented mouthguards (iMGs) were fitted in 92 male and 72 female players from nine elite-level clubs and three international teams. Data were collected during 406 player matches (239 male, 167 female) using iMGs and video analysis. Incidence was calculated as the number of HAEs per player hour and propensity as the proportion of contact events resulting in an HAE at a range of linear and angular thresholds. Results: HAE incidence above 10 g was 22.7 and 13.2 per hour in men's forwards and backs and 11.8 and 7.2 per hour in women's forwards and backs, respectively. Propensity varied by contact event, with 35.6% and 35.4% of men's tackles and carries and 23.1% and 19.6% of women's tackles and carries producing HAEs above 1.0 krad/s2. Tackles produced significantly more HAEs than carries, and incidence was greater in forwards compared with backs for both sexes and in men compared with women. Women's forwards were 1.6 times more likely to experience a medium-magnitude HAE from a carry than women's backs. Propensity was similar from tackles and carries, and between positional groups, while significantly higher in men than women. The initial collision stage of the tackle had a higher propensity than other stages. Conclusion: This study quantifies HAE exposures in elite rugby union players using iMGs. Most contact events in rugby union resulted in lower-magnitude HAEs, while higher-magnitude HAEs were comparatively rare. An HAE above 40 g occurred once every 60–100 min in men and 200–300 min in women. Future research on mechanisms for HAEs may inform strategies aimed at reducing HAEs. [ABSTRACT FROM AUTHOR]

The article presents the discussion on correction notice "Instrumented Mouthguards in Elite‑Level Men's and Women's Rugby Union: The Incidence and Propensity of Head Acceleration Events in Matches."

Context: Chronic athletic groin pain (AGP) is common in field sports and has been associated with abnormal movement control and loading of the hip and pelvis during play. A single-leg squat (SLS) is commonly used by clinicians to assess movement control, but whether it can provide insight into control during more dynamic sporting movements in AGP patients is unclear. Objective: To determine the relationships between biomechanical measures in an SLS and the same measures in a single-leg drop landing, single-leg hurdle hop, and a cutting maneuver in AGP patients. Design: Cross-sectional study. Setting: Biomechanics laboratory. Patients: 40 recreational field-sports players diagnosed with AGP. Intervention: A biomechanical analysis of each individual's SLS, drop landing, hurdle hop, and cut was undertaken. Main Outcome Measures: Hip, knee, and pelvis angular displacement and hip and knee peak moments. Pearson product-moment correlations were used to examine relationships between SLS measures and equivalent measures in the other movements. Results: There were no significant correlations between any hip or pelvis measure in the SLS with the same measures in the drop landing, hurdle hop, or cut (r = .03-.43, P > .05). Knee frontal- and transverse-plane angular displacement were related in the SLS and drop landing only, while knee moments were related in the SLS, drop-landing, and hurdle hop (r = .50-.67, P < .05). Conclusion: For AGP patients, an SLS did not provide meaningful insight into hip and pelvis control or loading during sporting movements that are associated with injury development. The usefulness of an SLS test in the assessment of movement control and loading in AGP patients is thus limited. The SLS provided moderate insight into knee control while landing and therefore may be of use in the examination of knee-injury risk. [ABSTRACT FROM AUTHOR]