Exertional Testing Buffalo Protocol

Introduction

This protocol outlines the management of individuals who have failed the Buffalo Concussion Treadmill Test (BCTT) and require a graduated exertional rehabilitation program. This program is designed to improve exertional tolerance and facilitate a safe return to sport or activity. It is crucial that each patient is assessed individually and progressed based on their symptom response.

Clinical Presentation

Patients presenting for exertional rehabilitation following a failed BCTT typically report symptoms such as:

• Headache
• Dizziness
• Nausea
• Fatigue
• Visual disturbances
• Cognitive difficulties (e.g., difficulty concentrating, memory problems)

These symptoms are often exacerbated with physical exertion and subside with rest. A thorough initial evaluation, including a symptom checklist, neurological exam, and vestibular assessment, is essential to rule out other contributing factors.

Rehabilitation Phases

Phase 1: Symptom-Limited Activity

Goal: To establish a baseline of activity that does not provoke symptoms.

• Focus on low-level aerobic activity, such as walking at a comfortable pace.
• Duration: Start with 15-20 minutes, 1-2 times per day.
• Progression: Increase duration by 5-10 minutes as tolerated, maintaining a symptom-free threshold.
• Activity modifications: Avoid activities that exacerbate symptoms (e.g., screen time, loud noises).

Phase 2: Low-Level Aerobic Exercise

Goal: To gradually increase aerobic capacity without provoking symptoms.

• Introduce activities like:
• Stationary cycling (low resistance)
• Elliptical training (low intensity)
• Swimming (light effort)
• Monitor symptom response closely during and after exercise.
• Progression: Increase intensity and duration gradually (e.g., increase resistance on the bike, increase speed on the elliptical).

Phase 3: Sport-Specific Exercise (or Activity-Specific)

Goal: To introduce sport-specific movements and activities in a controlled environment.

• Example for a soccer player: Light jogging, passing drills, agility drills (e.g., cone weaves).
• Example for a construction worker: Simulated lifting (light weight), walking on uneven surfaces, performing overhead tasks.
• Monitor for symptom exacerbation. Reduce intensity or duration if symptoms increase.

Phase 4: Non-Contact Training

Goal: To gradually increase the intensity and complexity of training activities in a non-contact environment.

• Increase the duration and intensity of sport-specific drills.
• Introduce more complex movement patterns.
• Include interval training to improve exertion tolerance.
• Emphasize proper technique and biomechanics.

Phase 5: Full Contact Practice (If Applicable)

Goal: To gradually reintroduce the athlete to full contact activities.

• Start with limited contact drills and gradually increase the level of contact.
• Monitor for any recurrence of concussion symptoms.
• Ensure that the athlete is comfortable and confident before progressing to full participation.

Exercise Examples

1. Neck Isometrics: Flexion, extension, lateral flexion, rotation.
2. Balance Training: Single-leg stance, tandem stance, foam pad exercises.
3. Vestibular Exercises: Gaze stabilization (VOR), smooth pursuit, saccades.
4. Cardio: Walking, jogging, cycling, elliptical, swimming.
5. Light Resistance Training: Bodyweight exercises, resistance bands.
6. Plyometrics: Jumping jacks, box jumps (low height), cone hops.
7. Agility Drills: Cone weaves, shuttle runs, ladder drills.
8. Sport-Specific Drills: Passing, shooting, dribbling (depending on sport).
9. Functional Lifting: Squats, deadlifts (light weight), overhead press (light weight).
10. Core Strengthening: Planks, bridges, abdominal crunches.

Evidence-Based Return to Function Criteria

Progression to the next phase depends on meeting specific criteria, including:

• Absence of concussion symptoms at rest and with exertion during the current phase.
• Successful completion of exertional testing without symptom exacerbation.
• Normal neurological exam.
• Good balance and coordination.
• Adequate cognitive function.

Return to sport/activity is only considered when the individual can successfully complete all phases of the rehabilitation program without symptom recurrence and has been cleared by a physician.

Important Considerations

• This protocol is a guideline and should be individualized based on the patient's specific needs and presentation.
• Close monitoring of symptoms is crucial throughout the rehabilitation process.
• Consultation with a physician or other qualified healthcare professional is recommended.