Buffalo Concussion Treadmill Test (BCTT): Protocol, Scoring and What the Result Means
Dr. Rob Letizia PT, DPTShare
Medically reviewed by Dr. Rob Letizia, PT, DPT · Doctor of Physical Therapy, 25+ years treating spine & orthopedic conditions · Last reviewed 2026-08-03
Written by Dr. Rob Letizia, PT, DPT - post-concussion specialist serving athletes across Wayne NJ and North Jersey.
If your athlete had a concussion weeks ago but still cannot run, bike, or do any aerobic exercise without symptoms flaring, you are looking at a classic sign of exertional intolerance — a disturbance in how the autonomic nervous system responds to exercise, and one of the most common reasons a concussion recovery stalls.
The Buffalo Concussion Treadmill Test is the single most valuable diagnostic and treatment-planning tool available for this problem. It is also one of the most underused — most physical therapy clinics do not offer it, and most athletes never hear it mentioned.
It goes by several names, and they all mean the same test: the Buffalo Concussion Treadmill Test, the BCTT, the Buffalo treadmill test, the Buffalo concussion test, the Buffalo protocol, or simply the Buffalo test. Its stationary-cycle sibling is the Buffalo bike test, covered further down. Here is what it is, how it runs minute by minute, what comes off the scoring sheet, and how the result turns into an exercise prescription instead of guesswork.
What is the Buffalo Concussion Treadmill Test?
The BCTT is a graded exercise test developed at the University at Buffalo Concussion Management Clinic and validated across dozens of peer-reviewed studies. The protocol is straightforward: the athlete walks or runs on a treadmill with incrementally increasing grade every minute, while the clinician monitors heart rate, blood pressure, and concussion symptoms in real time.
The test continues until either:
- The athlete develops significant symptoms — dizziness, headache, nausea, visual disturbance, brain fog
- Or the athlete reaches age-predicted maximum heart rate and completes the test symptom-free
The heart rate at which symptoms appear is the symptom threshold heart rate (STHR), and it is the number everything after the test is built on.
Credit where it belongs: the protocol is Buffalo's published work, not ours. What a clinic adds is running it properly, reading the result correctly, and turning it into a plan.
What does the Buffalo treadmill test actually identify?
It answers three questions that shape the entire rehabilitation plan:
- Does the athlete have exertional intolerance? If yes, symptoms appear at sub-maximal heart rates. If no, the athlete reaches maximum heart rate symptom-free and can progress through return-to-play more confidently.
- Where is the symptom threshold? This sets the exact training heart-rate zone for sub-symptom-threshold aerobic exercise.
- Has the autonomic nervous system recovered? An abnormal heart-rate response to exertion — slow to rise, or erratic — is an objective measure rather than a description of how someone says they feel.
That third point is why the test matters so much in a stalled recovery. Symptom reports are subjective and they drift; a heart rate number does not.
Athlete Plateaued in Their Concussion Recovery?
The Buffalo Concussion Treadmill Test is available at Spectrum Therapeutics of NJ as part of our post-concussion evaluation. Most athletes see significant progress within 2-4 weeks of adding sub-symptom-threshold aerobic training.
Call (973) 689-7123 See the Concussion ProgramWhy does sub-symptom-threshold training speed up recovery?
Before the BCTT was developed, the standard concussion advice was rest until you feel better, then gradually return to exercise. That turned out to be actively unhelpful beyond the first day or two:
- Extended rest causes cardiovascular deconditioning, which makes any exercise feel harder and provoke more symptoms — a loop that feeds itself
- The autonomic nervous system needs a graded aerobic stimulus to recalibrate after a concussion
- Exercise below the symptom threshold has a therapeutic effect rather than merely a fitness-maintaining one
Athletes given sub-symptom-threshold aerobic training recover faster than those prescribed rest. That finding is why the test exists at all.
What is on the Buffalo Concussion Treadmill Test scoring sheet?
People look for the form itself, usually as a PDF. The form belongs to the Buffalo group and is theirs to distribute, but there is no mystery in what it records, and knowing that is more useful than owning a blank copy. At each minute mark the sheet captures four things:
- Heart rate — the column that produces the STHR, and the one the whole plan hangs on.
- Rate of perceived exertion — how hard the athlete says it feels, usually on a standard 6–20 scale. A perceived-exertion score that climbs far faster than the heart rate is itself informative.
- Symptom score — taken from a validated concussion symptom inventory at baseline and re-checked as the test runs. What matters is the change from that athlete's own baseline, not the raw total.
- The stopping reason — symptom onset, age-predicted maximum heart rate reached, or a pre-set endpoint. Which one ended the test changes the interpretation completely.
A blank sheet is not what makes the test work. The judgement is in deciding what counts as a significant symptom change in front of you, and in stopping at the right moment rather than pushing for a cleaner number.
What is the Buffalo Concussion Bike Test, and when is it used instead?
Same idea, different machine. The bike version applies graded workload on a stationary cycle rather than grade on a treadmill, and it exists because a treadmill is not always the right tool.
The bike is generally the better choice when balance is affected — which after a concussion it often is — when a lower-limb injury happened at the same time, when the athlete is unsteady enough that a moving belt is a genuine hazard, or when the sport itself is a cycling sport. The treadmill is generally preferred when running is the return-to-play target, because walking and running load the vestibular system in a way that pedalling does not, and that loading is part of what is being tested.
The output is the same either way: a heart rate at which symptoms begin, and a training zone underneath it.
How Dr. Rob runs the BCTT
At Spectrum Therapeutics of NJ, the test is part of a comprehensive four-domain post-concussion evaluation.
Pre-test
Baseline symptom scoring using a validated concussion symptom inventory. Resting heart rate and blood pressure.
Warm-up
Two minutes of walking at an easy pace with no incline.
Incremental increase
Each minute the grade steps up by one percent. Speed usually stays constant, though for an older or deconditioned patient the protocol is adjusted.
Continuous monitoring
Heart rate, perceived exertion and concussion symptoms checked at every minute mark.
Stopping criteria
Symptom onset, age-predicted maximum heart rate, or a pre-determined endpoint. The test is not run to exhaustion.
Post-test analysis
The symptom threshold heart rate becomes the key variable, and the training zone sits just underneath it.
The BCTT Protocol, Minute by Minute
This is the same sequence described above, laid out as it actually runs in the clinic.
| Stage | What happens | Speed and grade | What is being watched |
|---|---|---|---|
| Pre-test | Baseline symptom score on a validated concussion symptom inventory, plus resting heart rate and blood pressure | At rest | The starting number every later reading is compared against |
|
Warm-up 2 minutes |
Walking, to settle heart rate before the graded portion begins | 3.2 mph at 0% grade | Heart rate response, and whether symptoms appear at rest-level effort |
|
Graded increase every minute |
Workload steps up one increment at a time until a stopping criterion is met | Grade increases 1% per minute; speed usually held constant, and adjusted for older or deconditioned patients | Heart rate, rate of perceived exertion, and concussion symptoms checked at every minute mark |
| Stopping criteria | The test ends at the first of these — it is not run to exhaustion | — | ⚠️ Symptom onset, age-predicted maximum heart rate, or a pre-determined endpoint |
| Post-test | The heart rate at which symptoms appeared becomes the number the whole plan is built on | — | STHR (symptom threshold heart rate), and a prescribed training zone of 80-90% of STHR |
The output that matters is not pass or fail. It is a heart rate number — the point at which symptoms begin — and that number is what makes an exercise prescription possible instead of guesswork.
How is the result turned into a training plan?
With the symptom threshold identified, the prescription is a structured aerobic programme rather than a list of exercises.
Weeks 1–2
Fifteen to twenty minutes of steady aerobic exercise — walking or a stationary bike — in the prescribed zone below the threshold, five days a week. Keep the heart rate under the ceiling. Log symptoms daily.
Weeks 3–4
Increase duration to twenty-five or thirty minutes. Begin lifting the heart-rate ceiling in small steps if symptoms stay controlled.
Week 5 onward
Repeat the test to quantify progress. If the threshold has risen, or disappeared entirely because the athlete now reaches maximum heart rate symptom-free, progress into the return-to-play stages.
The Rising-Threshold Check
This is the part I want parents and coaches to take away, because it is where most stalled recoveries go wrong.
Progress is a heart rate number going up, not an athlete saying they feel better. Feeling better is real and it matters, but it moves around with sleep, school stress and how the week went, and it is the least reliable thing to make a return-to-play decision on. The threshold heart rate is not sentimental. Between one test and the next it has either risen or it has not, and that answers a question no conversation can.
Three things follow from reading it that way:
- A threshold that is climbing means the plan is working, even in a week that felt rough. Do not tear up a programme because of a bad few days.
- A threshold that has not moved in three or four weeks means the plan is wrong, not that the athlete needs to push harder. The usual culprits are training above the ceiling without realising, sleep, or a neck or vestibular problem sitting underneath the exertion problem and never addressed.
- A threshold that has disappeared is the finish line for this part — maximum heart rate reached, symptom-free — and the conversation moves to return-to-play stages under whoever is clearing the athlete.
Most athletes see the threshold rise over four to eight weeks. Some do not, and that is information rather than failure.
Who should not do the Buffalo treadmill test?
It is a provocative test by design, so it is not for everyone and not at every moment.
- Not in the first day or two after the injury. The acute window is for relative rest, and the test has nothing useful to say yet.
- Not without medical clearance if there is a known cardiac condition, uncontrolled blood pressure, or a medication that blunts the heart-rate response — a beta blocker makes the central number meaningless and the test has to be interpreted differently or not run.
- Not while red-flag symptoms are present. Worsening or severe headache, repeated vomiting, seizure, weakness or numbness in an arm or leg, slurred speech, unusual drowsiness or confusion, or a headache that wakes someone from sleep are reasons to seek emergency care rather than to book an exercise test.
- Not as a stand-alone. A normal test result does not rule out a cervical, vestibular or oculomotor driver, and those are common after a head injury. If exertion is fine and symptoms persist, the answer is somewhere else.
How is this different from ImPACT testing?
They measure different things and are often confused. ImPACT is a computerised neurocognitive test — memory, reaction time, processing speed. The BCTT is a physiological test of how the body responds to exercise. Neither replaces the other, and an athlete can pass one and fail the other. We wrote a full comparison here: ImPACT test vs the Buffalo Concussion Treadmill Test.
Why do most clinics not offer the Buffalo protocol?
Running it requires training in concussion management, familiarity with the research protocol, and comfort provoking symptoms deliberately in a controlled setting and stopping at the right moment. Most general outpatient clinics do not see enough concussion patients to build that, and in New Jersey the test is concentrated in hospital sports-medicine programmes.
Spectrum Therapeutics offers it in a one-on-one setting with Dr. Rob Letizia, DPT, for athletes across Wayne and Northern New Jersey.
Started with an AI assistant? Bring the plan in.
"Buffalo concussion treadmill test protocol" is a question people put to ChatGPT, Gemini, Claude or Copilot before they ask anyone in a clinic, and the general description that comes back is usually accurate: a graded treadmill test, stopped at symptom onset, producing a threshold heart rate. What an assistant cannot do is run it. It cannot see whether the heart rate is rising normally, decide what counts as a significant symptom change in front of a particular athlete, or notice that the exertion problem is sitting on top of an untreated neck.
Bring what you were told, and the numbers if you have them. We will tell you what they mean and what the next four weeks should look like.
Have your rehab plan checked →
Common questions
What is the BCTT protocol?
A graded treadmill test: baseline symptom score, heart rate and blood pressure; a two-minute walking warm-up; then the grade increases by one percent each minute while heart rate, perceived exertion and symptoms are checked at every minute mark. It stops at symptom onset, at age-predicted maximum heart rate, or at a pre-set endpoint — never at exhaustion. The heart rate at symptom onset is the symptom threshold heart rate, and the training zone sits just below it.
How long does the Buffalo concussion test take?
The treadmill portion itself is short — most tests end within the first ten to twenty minutes, because the point is to find the threshold rather than to run someone to exhaustion. The appointment around it is longer, since baseline scoring, monitoring, recovery and interpreting the result are what make the number usable.
Is the Buffalo concussion bike test the same thing?
It is the same principle on a stationary bike instead of a treadmill, and it produces the same output: a threshold heart rate and a training zone. The bike is preferred when balance is affected, when there is a lower-limb injury, or when cycling is the sport. The treadmill is preferred when running is the return-to-play target, because walking and running load the vestibular system in a way pedalling does not.
Where can I get the Buffalo Concussion Treadmill Test scoring sheet?
The form is published by the University at Buffalo group and is theirs to distribute. What it records is no secret: heart rate, rate of perceived exertion, a symptom score against that athlete's own baseline, and the reason the test was stopped, all captured at each minute mark. A blank form is not what makes the test work — the judgement about when to stop is.
What is a normal result on the Buffalo treadmill test?
Reaching age-predicted maximum heart rate without a significant symptom change is the result that indicates exercise tolerance has recovered. Symptoms appearing at a sub-maximal heart rate indicates exertional intolerance, and that heart rate becomes the number the treatment plan is built around. A normal test does not by itself mean the concussion is resolved — cervical, vestibular and oculomotor problems can persist with normal exercise tolerance.
How often should the test be repeated?
Commonly every few weeks while an athlete is in a sub-symptom-threshold programme, because the threshold rising is the objective marker that the plan is working. A threshold that has not moved after three or four weeks is a reason to change the plan rather than to push harder.
Can adults have the Buffalo treadmill test, or is it only for athletes?
Exertional intolerance after a concussion is not limited to athletes, and neither is the test. The same threshold heart rate and the same graded return apply to an adult trying to get back to work, to the gym, or simply to walking the dog without a headache afterwards.
The bottom line
If an athlete is stuck in a concussion recovery, cannot exercise without symptoms flaring, and has been told to keep resting, the Buffalo Concussion Treadmill Test is usually the piece that has been missing. It converts a subjective stall into a number, and a number can be trained against.
Learn more about the full post-concussion syndrome treatment programme at Spectrum Therapeutics, or call (973) 689-7123 to schedule.
