Return to Play: A Question of Balance.

I t is reassuring to witness the academic interest, clinical activity, and passion of neurological surgeons for sports medicine issues such as return to play after concussion. The concussion issue in sports had been a perfect storm of activity in the media and with our families. Neurological surgeons have been and remain on the front lines of traumatic brain injury (TBI) prevention and treatment. The spectrum of TBI, from mild to severe, still requires a commitment from many of our practices and on-call hospital/community duties. However, concussion, which is on the milder end of the spectrum in TBI, recently received a more significant share of our neurological surgery bandwidth. Nevertheless, the concussion field is not simply owned by one specialty; it is a public health issue for many healthcare providers and a public health challenge for the entire world. The World Health Organization predicts that by 2020 TBI will be one of the leading causes of death and morbidity of all ages. It is currently one of the leading causes of mortality and disability of adolescents worldwide. In the United States, TBI accounts for approximately 30% of all traumatic deaths. The “perfect storm” is a reference to the combination of somber medical reports we have witnessed over the past decade. It is an amalgamation of events including a larger-thanexpected segment of our wounded soldiers returning from Iraq and Afghanistan with TBI and posttraumatic stress disorder, elite athletes suffering concussions with prolonged absences, and youth student athletes suffering tragic and preventable TBIs that have attracted enormous press coverage. Although sports concussions make up only a small fraction of the TBI events in the United States, their high profile has become a lightning rod for action in terms of prevention and management. The epidemiology shows that the majority of TBIs in the United States occur from falls, motor vehicle accidents, assaults, and being struck by an object. In fact, in children, . 50% of TBIs are caused by falls. The Centers for Disease Control and Prevention (CDC) statistics from 5 years ago estimated that 248418 children (#19 years of age) were treated in the emergency departments of US hospitals for concussion from sports-related injuries. That is a 57% rise in injuries reported over the preceding decade. It is now estimated that as a result of improved education and reporting, 1.6 to 3.8 million children perhaps suffer a concussion at a sports-related activity. The number is uncertain because many families do not seek or require medical attention and evaluation in an emergency department after the suspected injury. In my practice, one of the most common concerns of a parent after a child sustains a concussion is the safety of specific sports-related activity. It is easy to show parents the plethora of peer-reviewed literature that demonstrates that the benefits of exercise and organized sports activities are vast. However, that sentiment provides little comfort after a concussion is confirmed. Parents are often incredulous when I show epidemiology statistics that the risk of TBI for their children is much greater outside an organized sports activity. If statistics were purely the driving force of this vigorous focus on safety, then issues related to riding a bicycle, riding in a car, and running on the playground should receive attention equal to that focused on organized sports-related activity. Fortunately, this sports-related focus has had a salutary effect on our youth. It has helped make our beloved organized and intramural sports safer for our student athletes. It is estimated that over 26 million US students (,17 years of age) play some form of a sport in an organized or intermittent fashion. An espnW Aspen Institute Project Play Survey conducted in September 2014 of 1511 households showed that the overriding parental concerns of sports for their children were safety (87.9%), quality or behavior of coaches (81.5%), cost (70.3%), the time commitment required (67.9%), and the emphasis on winning over having fun (66.1%). The number 1 concern of parents is the risk of concussion over joint, bone, or other bodily injuries. Although . 80% of parents would let their children play sports, parents had concerns about concussion in 2 sports in particular. The survey showed that parents would consider restricting their child’s participation in football Richard G. Ellenbogen, MD