A concussion is a type of traumatic brain injury that can be caused by a blow to the head, face, or neck. Symptoms can range from mild to severe and can include headache, dizziness, confusion, and memory problems.
The Buffalo Concussion Treadmill Test (BCTT) is a standardized test used to assess an individual’s ability to tolerate physical activity after a concussion. It is also used to determine an individual’s post-concussion fitness level and make recommendations for returning to play, work, or school.
Specifically, the BCTT assesses a person’s response to physical exertion following a head injury to establish the health and function of their autonomic nervous system.
Until recently, complete brain rest was considered the cornerstone of proper concussion management. Over the past decade, however, thanks to research pioneered by Drs John Leddy and Barry Willer at the University of Buffalo, this thinking has shifted dramatically. Not only do we now know that brain rest is ineffective, but it’s actually harmful to concussion recovery, and often results in much worse outcomes for patients prescribed this archaic treatment.
The evidence now suggests that performing sub-symptom threshold EXERCISE after 24-48 hours of symptom-limited rest following a concussion actually speeds up concussion recovery and reduces the risk of persistent concussion symptoms (PCS) by almost 50%!
The first step to figuring out a safe level to encourage your patients to exercise at, is to test their physical capacity with the Buffalo Concussion Treadmill Test. With that in mind, it is critical to provide instructions on how to accurately and efficiently perform the BCTT which is why in this blog post, we will discuss what it is, how it is performed, and what the results mean.
WARNING – This test should only be performed by experienced clinicians with advanced training and expertise in concussion management. This post by no means constitutes medical advice and is not intended to be performed without direct medical supervision. If you need to have a treadmill test done, please find a certified concussion clinic in your area by visiting clinics.completeconcussions.com
Equipment Needed
*Within this post we also provide you with a FREE downloadable PDF copy of the BCTT template, as well as treadmill test wall sheets that you can hang in your clinic and use with your patients!
DOWNLOAD FREE BCTT TEST SHEET & WALL CHART
The Buffalo Concussion Treadmill Test is, as stated above, a standardized test used to assess an individual’s ability to tolerate physical activity after a concussion. It is performed in a controlled environment with specialized medical supervision.
The test is based on the theory that individuals who have sustained a concussion may have difficulty with physical exertion due to their brain’s inability to regulate blood flow to the body; which is ultimately a function of the autonomic nervous system.
A recent study that was completed through the use of Complete Concussions’ own large data set found that the BCTT was also prognostic for sub-acute concussion in helping to determine patient recovery time.
The BCTT is a three-step process that is relatively simple to perform. However, accuracy and precision are a must if you want to get the most accurate and specific results. The first step is gathering pre-test information based on the condition of the patient prior to starting the test.
In the first stage of the test we first need to assess whether the patient is well enough to perform the test. It is important for the clinician to be aware of potential contraindications to test performance – which include the following:
Once absolute and relative contraindications have been ruled out, the next question is whether the patient is well enough symptomatically to go through with the test. The criteria utilized for determining failure of the BCTT is an increase (or worsening) of the patients self-reported overall condition by 3 or more points on a scale from zero to ten (0-10) – see image:
The overall condition is rated by the patient and should be taken to meet the following description:
If you were to take all of your symptoms together and give yourself an overall score of how you feel at this moment, based on this picture, how would you rate yourself?
As such, a patient should be deemed not well enough to participate in the treadmill test if their pre-test overall condition is rated as a 7/10 or higher.
If their overall condition is a 6/10 or lower, you may proceed with the test.
Additional data to collect prior to starting the treadmill test includes resting heart rate, resting rate of perceived exertion, and blood pressure. More instructions for this stage can be found on our free BCTT patient test sheet.
Following the Pre-Test Readiness Assessment , the individual is placed on the treadmill, and the test begins at a low intensity and gradually increases over time.
Throughout the test, the individual’s heart rate, perceived exertion levels, and overall condition are closely monitored to ensure that they are not in any danger of overexertion.
If at any point throughout the test, the individual experiences symptoms such as headache, dizziness, nausea, or confusion, that brings their overall condition score above the 3 point cutoff from their pretest score, the test is immediately stopped.
The warm-up is to get the patient feeling comfortable on the treadmill while moving slowly. During this phase, the treadmill speed is set to 2.5 miles per hour (mph) at 0% incline for 2 minutes.
After the 2 minute warm-up it’s time to start the test. At this point, the speed of the treadmill is increased to 3.3 mph and the incline stays at 0%. Note: this pace should be a brisk walk for most people. If you are performing this test on smaller children, a pace of 3.0 mph may be warranted.
After the first minute of the test, the incline of the treadmill is raised by 1%. Each minute, this process is repeated and the incline is raised by 1% until the 15th minute; at which point the treadmill incline is maxed out. A speed of 3.3 mph is maintained throughout the first 15 minutes.
Fail
Pass
If the patient still has not reached their max HR or 18-20 on the Borg Scale and has not had a worsening of their condition by 3 or more points by the 15 minute mark, then the test continues based on increasing speed of the treadmill.
At each minute beyond 15, the tester increases the treadmill speed by 0.4mph and maintains the incline at 15%. I have personally run hundreds (probably thousands) of these tests and I very rarely get a patient who can handle more than 3 of these speed increases before maxing out.
If the patient passes the test (i.e., maxes out HR or exertion level before increasing symptoms), this is an indication that they are NOT exercise intolerant and are safe to begin their return to physical activity. If they are an athlete, they can return to non-contact practices. If they are not an athlete they can resume regular exercise provided there is low risk of subsequent injury.
It is important to note the BCTT is not a clearance test for return to full activity; there are additional tests and steps that need to be completed first. The final decision to return to full athletic competition should be made by a medical professional based on completion of additional milestones and the athlete’s overall health and well-being.
If the patient fails the BCTT (i.e., has a worsening of condition by 3 or more points), this is an indication that they have dysregulation of their autonomic nervous system which is impacting cerebral blood flow. The treatment for this is EXERCISE! But it must be done in the right way…
Subsymptom threshold exercise has been shown to be safe and effective in both acute and chronic concussions. Recent evidence suggests that this should be started within 5 days of concussion injury – regardless of whether the person is symptomatic or not.
“Symptom Threshold” means the heart rate at which the patient’s symptoms hit a 3 or more point increase from their pretest score.
When prescribing an exercise protocol, you want to make sure the patient is exercising at least 5 times per week for 20-30 minutes at a rate of 80-90% of their symptom threshold.
Example Exercise Prescription Calculation:
The Buffalo Concussion Treadmill Test is a valuable tool in assessing an individual’s autonomic nervous system function following a concussion. By following the three-step process of pre-test readiness assessment and warm-up followed by increasing the treadmill speed while monitoring for any increase in concussion-related signs or symptoms, medical professionals can determine if an individual is ready to safely return to physical activity. The BCTT also serves the added bonus of assisting with exercise prescription in the event a patient is unsuccessful in their BCTT attempt. And since exercise now serves as the most important treatment for autonomic nervous system balance and concussion recovery – this test is extremely valuable to the clinical picture.
It’s important to remember that every individual’s recovery from a concussion is unique and may require different testing procedures or recovery timelines. If you suspect that you or someone you know has suffered a concussion, it’s crucial to seek medical attention and follow the guidance of a healthcare professional.
If you are a patient in need of a treadmill test, please locate your nearest certified concussion clinic here.
If you want to learn how to better assess, diagnose, manage, and treat concussion injuries, please check out our many available certification courses for healthcare professionals.
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Free resource:
Buffalo Concussion Treadmill Test Template + Wall Sheet
Download a free PDF copy of the BCTT template, as well as treadmill test wall sheets that you can hang in your clinic and use with your patients!
Free resource:
Buffalo Concussion Treadmill Test Template + Wall Sheet
Download a free PDF copy of the BCTT template, as well as treadmill test wall sheets that you can hang in your clinic and use with your patients!