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Buffalo Concussion Treadmill Test

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Buffalo Concussion Treadmill Test

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Buffalo Concussion Treadmill Test was developed to systematically evaluate exercise tolerance in individuals with prolonged concussion symptoms (i.e., more than 3 to 6 weeks).

The test is based on the Balke Cardiac Treadmill Test which requires a gradual increase in workload while walking and has been shown to be safe and reliable in patients with cardiac problems.

Before the Buffalo Concussion Treadmill Test can begin, the patient must be asymptomatic of any concussion symptoms at rest. By determining subthreshold exercise heart rate, the test helps to determine when the individual can start doing exercises to regain or restore physical fitness and the level that the individual can work at while not causing symptoms.

The data from the test allow the examiner to develop an individualized exercise treatment program to restore the physiology to normal enhancing recovery. If symptoms were provoked during vestibular oculomotor testing, then cycling may be chosen as the exercise device to minimize head movement compared with the treadmill.

Regardless of the modality used, patients are instructed to inform the examiner whether there is any worsening of symptoms. If needed, the Buffalo Concussion Physical Examination can be completed before the treadmill test. Exercise testing should be considered only for patients without orthopedic or vestibular problems that increase the risk of falling off the treadmill, bike, or elliptical machine and only if the patient does not suffer from cardiac disease.

See Also: Tests for Proprioception

What is the Buffalo concussion treadmill test used for?

  1. To investigate exercise tolerance in patients with postconcussive symptoms (PCS) lasting more than 3 weeks.
  2. To help establish appropriate levels of exercise to aid in Return to Play for concussed athletes and assist in treatment protocols.
  3. To aid in differentiating between possible diagnoses for concussive symptoms (e.g., cervicogenic injury, PCS) and etiology of the concussion.
  4. To identify physiological variables associated with exacerbation of symptoms, and the patient’s level of recovery.

BCTT Eligibility

Before beginning the Buffalo Concussion Treadmill Test, participants should be evaluated for medical and physical ability to exercise. Considerations may include (but are not limited to): cardiovascular illness, respiratory dysfunction, serious vestibular/balance problems, motor dysfunction, and certain orthopedic injuries.

Do not follow the Buffalo Concussion Treadmill Test if the patient is experiencing such cervical dysfunction that the test could cause considerable pain or harm, is experiencing severe vestibular/balance issues that would impair walking on a treadmill, has a history of unstable cardiac or respiratory disease, or has a lower extremity or spinal orthopedic pathology that compromises safe walking.

The Buffalo Concussion Treadmill Test is not recommended for patients scoring higher than 7/10 for symptom severity.

Buffalo Concussion Treadmill Test- Symptom Severity Scale
Symptom Severity Scale

How to Perform a Buffalo Concussion Treadmill Test?

Equipment Requirements:

  • Treadmill with capacity to reach 15 degrees of elevation. Note: Test can be adapted for treadmills that can reach a minimum of 12 degrees elevation
  • Heart rate monitor (Polar brand recommended)
  • Borg RPE Scale (Rating of Perceived Exertion) and Concussion Symptom Severity Scale
  • Likert scale
  • Test Results form for monitoring heart rate, changes in RPE and symptoms, and relevant
  • observations
  • Chair, water, and towel for participant recovery after exercise.

Attach heart rate monitoring device according to manufacturer’s instructions. Post RPE and Symptom scales within comfortable viewing distance of participant while on treadmill (it is suggested that participant should not have to turn head to view scales).

Buffalo Concussion Treadmill Test Protocol

Starting the Test:

  • Inform participant about test procedures and what to expect during the Buffalo Concussion Treadmill Test.
  • Explain and demonstrate the RPE and Likert scales and obtain resting scores. Remind participant that he/she will be asked to rate exertion and symptom severity at each minute during exercise. The RPE scale is a measure of perceived physical activity, and can be explained to participants as a measure of “how hard you feel like your body is working”. The scale’s numbers (6–20) and descriptors should be pointed out. The Likert symptom scale is a measure of symptom severity (“how good/bad your symptoms are making you feel right now”), and should be distinguished as being distinct from RPE. The scale’s numbers (1–10) and pictures (expressions of physical pain) should be pointed out.
  • Patient should begin by standing on the ends of the treadmill while the treadmill is turned on. The experimenter should set treadmill at a speed of 3.6 mph for patients over 5’5”, and 3.2 mph for those 5’5” and under. Starting incline is 0 degrees. Speed can be adjusted depending on athletic status or overall comfort of treadmill speed — patients should be moving at a brisk walking pace.
  • After one minute at this pace, treadmill incline is increased to 1 degree. Participant is asked to rate RPE and symptom severity. Subjective scores and heart rate (bpm) are recorded. This procedure is repeated each minute, with ratings and heart rate being recorded, and treadmill increasing in incline at a rate of 1 degree/minute. Changes to Likert rating should be specifically clarified/noted (for example, if the rating moves from 2 to 3, it should be clarified if this reflects the addition of a new symptom, increased severity of an existing symptom, etc.). Experimenter should also record general observations as the test progresses.
  • Once treadmill reaches maximum incline (15 degrees or 12 degrees in modified test), speed is increased by 0.4 mph each minute in lieu of increased incline.
  • Once Buffalo Concussion Treadmill Test is terminated, speed is reduced to 2.5 mph and incline reduced safely back to 0 for a 2-minute cooldown (if participant is safe to continue). During this time, Likert ratings should continue to be reported each minute.

Terminating the Test

Buffalo Concussion Treadmill Test continues until:

  • Maximum exertion (RPE score of 19.5) is reported or
  • Test is terminated by experimenter due to a symptom exacerbation that causes significant increase in pain or symptom severity (an increase of more than 3 points on the Likert scale from resting score, addition of several new symptoms, or marked increase in severity of symptoms resulting in difficulty continuing test) or
  • Experimenter notes a rapid progression of complaints (e.g., headache to searing focal pain) between symptom reports, patient appears faint or unsteady, or determines that continuing the test constitutes significant health risk for the participant, or
  • Patient reports an inability to continue the test safely.

Test Outcomes

The Buffalo Concussion Treadmill Test can be used in conjunction with balanced error scoring, cervical proprioceptive screening, manual assessment and soft tissue palpation to determine the presence/absence of postconcussion syndrome or cervical/thoracic injuries. Patients who have symptoms, but do not have a physiologic threshold (can exercise to max) should be evaluated for dysfunction of the cervical spine, vestibular system, or temporomandibular region.

Treatment/Return to Play:

  • On completion of the Buffalo Concussion Treadmill Test, concussion patients may be given an exercise prescription based on 80% of the maximum heart rate reached without symptom exacerbation. Patients are instructed to exercise at this level for 20 minutes daily without exceeding the time, or heart rate constraints. Patients may increase heart rate by swimming, walking, or stationary cycling — the athlete should not attempt resistance training. If any postconcussion symptoms return along the progression, the athlete must return to the previous asymptomatic stage/maximum heart rate.
  • If the patient can exercise to voluntary exhaustion on the Buffalo Concussion Treadmill Test without eliciting symptoms, you may begin the process of returning him/her to play by following the five-step return to play program of the Zurich Consensus Statement.
  • Other prescriptions and recommendations will be based on the patient’s particular complaints. A patient may be recommended for cervical physical therapy, vestibular physical therapy, infusion therapy, or treatment for temporomandibular joint disorders.

Buffalo Concussion Treadmill Test Protocol Contraindications


  • Acute myocardial infarction (within 2 days)
  • High-risk unstable angina
  • Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
  • Symptomatic severe aortic stenosis
  • Uncontrolled symptomatic heart failure
  • Acute pulmonary embolus or pulmonary infarction
  • Acute myocarditis or pericarditis
  • Acute aortic dissection


  • Left main coronary stenosis
  • Moderate stenotic valvular heart disease
  • Electrolyte abnormalities
  • Severe arterial hypertension
  • Tachyarrhythmia or bradyarrhythmia
  • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
  • Mental or physical impairment leading to inability to exercise adequately
  • High-degree atrioventricular block

Safety Considerations

  • On testing, participants must be dressed for exercise (i.e., comfortable clothing, running shoes), wearing any vision or hearing aids (e.g., glasses), and should be hydrated and well rested.
  • It is suggested that two persons assist in conducting the Buffalo Concussion Treadmill Test, in order to assure safety of the participant, with one individual positioned behind the participant (at back of the treadmill) at all times while test is in progress. It is also recommended that one or more persons with CPR training are present during testing.
  • It is important to engage in casual conversation with the patient during the exercise test to assess his/her confidence level as well as any changes in cognitive and communicative functioning. As exercise intensifies, note if patient seems to have difficulty communicating, looks suddenly pale or withdrawn, or otherwise appears to be masking serious discomfort.
  • Be aware of postural and structural changes (i.e., slouching, rounding the back, leaning head) – noting the patient’s thoracic and cervical posture can offer clues on the etiology of the injury.

Stopping Criteria for the Buffalo Concussion Treadmill Test

  1. Exacerbation of symptoms
  2. Feeling faint or light-headed
  3. Borg scale rating of 6 or more
  4. Nausea
  5. Symptom severity scale >1

References & More

  1. Orthopedic Physical Assessment by David J. Magee, 7th Edition.
  2. Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R. 2016 Mar;8(3 Suppl):S91-S100. doi: 10.1016/j.pmrj.2015.10.017. PMID: 26972272. Pubmed
  3. Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013 Nov-Dec;12(6):370-6. doi: 10.1249/JSR.0000000000000008. PMID: 24225521. Pubmed
  4. Kozlowski KF, Graham J, Leddy JJ, Devinney-Boymel L, Willer BS. Exercise intolerance in individuals with postconcussion syndrome. J Athl Train. 2013 Sep-Oct;48(5):627-35. doi: 10.4085/1062-6050-48.5.02. Epub 2013 Aug 16. PMID: 23952041; PMCID: PMC3784364. Pubmed
  5. Leddy JJ, Baker JG, Kozlowski K, et al. Ability of a graded exercise test for assessing recovery from concussion. Clin J Sports Med. 2011;21(2): 89–94.. Pubmed
  6. Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sports Med. 2010;20(1):21–27. Pubmed
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