Fix Your Post Concussion Exercise Intolerance with the Buffalo Concussion Treadmill Test



Exercise intolerance is a common symptom that can occur days, weeks, or months after suffering a concussion. Common symptoms of exercise intolerance include headache, throbbing or stabbing sensation, dizziness, blurred/double vision, off balance, neck pain, and/or the inability to keep exercising. Typically symptoms will worsen with increased exercise time and/or intensity.

Exercise is an important component of the healing process as exercise promotes blood flow, healing, and neuroplasticity for the injured tissues. The "old school" post-concussion recommendation of "cocooning", or avoiding all stimulus and activity, is no longer in practice. The "new school" recommendation involves exercising as early as 3 days following the initial concussion injury. The key to exercise is finding the proper dosing to ensure the optimal healing stimulus for the injured brain. The Buffalo Concussion Treadmill Test (BCTT) is the answer. It is a graduated exercise protocol that provides objective heart rate data that is used to determine aerobic exercise capacity. The heart rate data along with symptom information gathered from the test helps guide a safe, progressive, aerobic exercise program.

Read the research on the BCTT here


To perform the Buffalo Concussion Treadmill Test, a few pieces of equipment are required:

  1. Exercise clothes and shoes

  2. Water & Towel

  3. Treadmill with 12-15 degree incline

  4. Heart Rate monitor (or smart watch)

  5. Rating of Perceived Exertion (RPE) Scale

  6. Symptom Scale

  7. Assistant to record information

  8. Chair

You have the supplies, you're ready to go, but wait… Before initiating the test, a few safety considerations should be reviewed:

  1. Contraindications: risk for cardiopulmonary disease, focal neurological deficits, significant balance deficits that interfere with safely walking on a treadmill.

  2. Precautions: Beta Blocker use, depression, obesity, high blood pressure.

  3. Patient familiarity with walking on a treadmill.

  4. If exercise intolerance exists, this test will provoke symptoms.

  5. Consider environmental distractions such as a busy gym, TV, etc. that may contribute to symptoms during the test.

Now that you've cleared all safety considerations, it's time to do the test. Remember, the test will provoke symptoms if you have exercise intolerance. Increase in symptoms could last minutes, hours, or even into the next day.

  1. Speed remains constant (based on height): 3.2mph < 5’5 or 3.6mph > 5’5

  2. Incline starts at 0 degree and increases 1 degree each minute

  3. Each minute record: Heart Rate, effort level with the Rating of Perceived Exertion (6-20), Symptom Scale (0-10), Subjective Symptoms

  4. Stop the test when: Exhaustion (defined by a rating of 19.5 on the Rating of Perceived Exertion scale); Rapid increase in subjective symptoms (defined by a >3/10 change in less than 1 minute); It is unsafe to continue due to symptoms.


You've done the test, now how can you use the information gathered on the Buffalo Concussion Treadmill Test?

Start an exercise program based on your heart rate threshold which is 80% of the maximum heart rate achieved on BCTT. The goal is to exercise 20 minute each day at, or below this HR threshold. Stop your exercise session if you experience your familiar concussion symptoms.

To progress your exercise program, repeat the BCTT every 2-3 weeks to determine if your heart rate threshold has changed.

If you can’t redo BCTT, increase exercise heart rate threshold by 5 to 10 bpm every 2 weeks as tolerated (i.e. no symptoms with exercise).

Exercise intolerance no longer exists when you can perform your desired exercise program without limitations and without symptoms. This likely coincides with your age predicted maximum HR (220-age) and the maximum HR achieved on the BCTT.

Research suggests that aerobic exercise helps general health as well as brain healing post concussion. Improvements in overall fitness including cardiovascular health, joint and cartilage health, and improves a general sense of well-being occur with regular exercise. During and after exercise there is increased cerebral blood flow which increases oxygen delivery, increases protein production, and promotes neuroplasticity. Autonomic function is improved including improved heart rate and blood pressure control during exercise. Mental health benefits such as improved mood and reduction in depression are also noted with regular exercise.


7 Benefits of Physical Exercise: Mayo Clinic



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