Beyond Rest: Using Exertion Testing for a Safer Return to Activity After Concussion

As clinicians, we've all faced the challenge of determining the right time for a patient to return to physical activity after a concussion. For years, the standard advice was to rest until symptoms subsided. However, emerging evidence suggests that a more active approach, guided by objective testing, may lead to better outcomes. A key tool in this approach is the use of graded exertion tests, and the Buffalo Concussion Treadmill Test (BCTT) is one of the most well-researched protocols. A 2022 systematic review published in the *Journal of Concussion* provides a comprehensive overview of the clinical application of the BCTT and its lesser-known counterpart, the Buffalo Concussion Bike Test (BCBT). The review, which analyzed 11 studies, found strong evidence for the safety and construct validity of the BCTT in patients with both acute concussion and post-concussion syndrome (PCS). This means we can be confident that the test is not only safe to perform but also accurately measures what it's intended to: exercise intolerance. The BCTT protocol is a graded treadmill test that helps us identify the heart rate threshold at which a patient's concussion symptoms begin to appear or worsen. The test starts at a slow walking speed with no incline. Every minute, the incline is increased, and the patient's symptoms, heart rate, and rate of perceived exertion (RPE) are monitored. The test is stopped when the patient experiences a significant increase in symptoms, and the heart rate at that point is noted as the symptom-exacerbation threshold. This information is incredibly valuable for a few reasons. First, it provides an objective measure of a patient's exercise tolerance, which can be more reliable than relying solely on subjective symptom reporting. Second, it allows us to prescribe a sub-symptom threshold exercise program. This involves having the patient exercise at a heart rate below their symptom-exacerbation threshold for a specific duration and frequency. This approach has been shown to be effective in treating PCS and can help patients gradually return to physical activity without exacerbating their symptoms. The systematic review also found moderate evidence for the prognostic value of the BCTT. This means that the results of the test can give us an idea of how long it might take for a patient to recover. For example, a lower heart rate threshold on the initial test may be associated with a longer recovery time. While the BCTT is a valuable tool, it's not without its limitations. The test requires a treadmill and a trained clinician to administer it, which may not be feasible in all clinical settings. Additionally, the systematic review found very limited research on the BCBT. The bike test is a promising alternative, especially for patients who may have vestibular or cervicogenic symptoms that are aggravated by the movement of a treadmill. However, more research is needed to establish its validity and reliability. In conclusion, the evidence strongly supports the use of the BCTT as a safe and effective tool for managing patients with concussion. By using this test to objectively measure exercise intolerance and guide our treatment recommendations, we can help our patients return to physical activity more safely and effectively. As research in this area continues to evolve, we may see even more refined protocols and the emergence of new tools like the BCBT.