BUFFALO treadmill protocol

The Buffalo Treadmill Protocol was designed to assess post-concussion patients. It is a sort of stress test that looks at patients’ heart rate response to a graded exercise regimen, and if there is any correlation of that with the patients’ symptoms.

Back in the day, strict rest used to be the cornerstone of concussion management. Research now shows that rest beyond the first few days is not the ideal approach. Many scientific articles have shown that excessive rest and excessive exercise/activity can hinder recovery; and that exercise of the ‘right’ exertion level improves patients’ symptoms.


Exercise provides many beneficial effects:

1. It improves mood and energy level. Mood issues are very common post-concussion and they tend to hinder rehabilitation.

2. Exercise has been linked with a decrease in cognitive decline.

3. It increases BDNF (brain-derived neurotrophic factor) which has many beneficial effects on the nervous system. It helps support the integrity of existing neurons, and encourages the development of new neurons and synapses. It is active in many parts of the brain and has a positive effect on cognition.

4. It promotes healthy cerebrovascular physiology in the brain.

5. It promotes health functioning of the autonomic nervous system, a system with far-reaching effects on every aspect of your physiology and how you feel/function.


Research is showing that patients should be supported in in getting back into cardiovascular exercise and this test is a currently the standard of care in determining the ideal place to start.

  1. Treadmill with capacity to reach 12 degrees of elevation
  2. Accurate Heart rate monitor
  3. Two different rating scales that the patient and rehab team member use to score exertion and symptoms.
  4. Chair, water and towel for patient recovery after exercise

Dress comfortable (comfortable clothing, running shoes, etc.), ready to exercise. Wear your glasses/contacts if you have them. Come rested and well hydrated. Arrive on time.

The following things are measured every minute:

  1. Treadmill settings
  2. Your heartrate
  3. Your level of perceived exertion
  4. How you feel in general
  5. The symptoms you have
  6. Your posture and biomechanical strategy to exercise
  • Testing will be done on a treadmill or exercise bike.
  • Initially, a resting heart rate will be taken. You will be asked to rate the intensity of exercise on a minute-to-minute basis.
  • The intensity of exercise will increase on a minute-to-minute basis
  • Testing will terminate under when one of the following criteria are met:
    • Most commonly, when the test is finished, i.e., after 20 minutes.
    • The test may be stopped prior to 20 minutes under the following circumstances:
      • Maximum exertion (i.e., 19.5 on the RPE) is reported
      • Symptoms are increased by more than 3 points on the Likert scale when compared to the resting score
      • The addition of several new symptoms,
      • There is a marked increase in the severity of symptoms resulting in difficulty continuing test
      • The health care provider (HCP) notes a rapid progression of complaints (e.g., headache turns into migraine symptoms) between symptom reports, patient appears faint or unsteady, or the HCP determines that continuing the test constitutes significant health risk for the participant
      • Patient reports an inability to continue the test safely
      • The patient wants to stop

It is an exercise protocol used to determine the following in post-concussion patients:

  1. Level of exercise tolerance
  2. Assess for the influence of your physiological changes (or lack thereof) on your symptoms
  3. Ascertain the ideal starting point to train you from a cardiovascular perspective.

After the test, the data is given to the TCC team and then a custom cardiovascular exercise prescription is created for. The information gained from the Buffalo Treadmill Protocol in the context of your other clinical data is used to create this exercise prescription.

We currently perform this test in nearby gyms. The main reason is for flexibility of scheduling. Once you consent to doing this testing, our team will reach out to pick an appropriate time and place for you to do the testing and then send a confirmatory email.

Last update: July 2018