










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW 
  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 

 
 

Rest and Therapeutic Interventions Following Sport-Related 
Concussion: An Evidence-to-Practice Review 
Alyssa L. Bolno, SCAT, ATC*; Brittni G. Hoover, MS, ATC*; Ryan J. Michels, SCAT, ATC*; Allison B. Smith, 
PhD, ATC†; Zachary K. Winkelmann, PhD, SCAT, ATC* 
*University of South Carolina, Columbia, SC; †University of Louisiana – Lafayette, Lafayette, LA 

  

 
ABSTRACT 
Sport-related concussion (SRC) is among the most common 
injuries seen in both sports and recreation, especially collision 
and full contact sports. However, there has been controversy 
surrounding which recovery protocol would be best used in 
the rehabilitation of a person who has suffered from SRC.  
Symptoms and dysfunctions can vary from patient to patient. 
The average recovery time for adults is 14 days post 
incidence. Although most patients recover over the first few 
days/weeks post-injury, 15% reported recovery time of 30 
or more days. Previous research determined a need for 
cognitive and physical rest of 24-48 hours, or until acute 
symptoms resolve to then begin a six-step progressive return-
to-activity. Evidence from recent research shows that 
prolonged physical and cognitive rest may not be as 
effective as previously determined for concussion and post-
concussion syndrome management. Multiple studies have 
shown that a multimodal active recovery helps patients 
diagnosed with concussion or post-concussion syndrome have 
a timely return-to-activity, as well as increases improvement 
in overall symptoms. Within these studies, researchers have 
determined that patients should avoid exacerbating 
symptoms by staying below their symptom threshold, which 
can be determined through the implementation of the Buffalo 
Concussion Treadmill Test. Although not all research has 
shown an increase in recovery from SRC using active 
rehabilitation, a substantial number of researchers have seen 
a positive effect. Even with the limited amount of research 
and evidence, clinicians should highly consider the use of 
active rehabilitation following a 24 to 48 hour period of rest 
for SRC. Therefore, primary purpose of this article is to 
evaluate the evidence related to determining if rest is 
beneficial following a concussion, and what the optimal 
duration of rest should be. The secondary purpose is to 
evaluate the evidence of active treatment, and rehabilitation 
effectiveness, for athletes who have experienced SRC. 
Key Phrases 
Therapeutic exercise; functional testing  
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Bolno AL, Hoover BG, Michels RJ, Smth AB, 
Winkelmann ZK. Rest and therapeutic interventions 
following sport-related concussion: An evidence-to-
practice review. Clin Pract Athl Train. 2021;4(3): 10-
16. https://doi.org/10.31622/2021/0004.3.3.    
 
Submitted: December 3, 2020 Accepted: May 6, 
2021. 

ORIGINAL REFERENCE 
Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert 
T, McCrea M, Silverberg ND, Feddermann-
Demont N, Iverson GL, Hayden A, Makdissi M. 
Rest and treatment/rehabilitation following 
sport-related concussion: a systematic review. 
Br J Sports Med. 2017;51(12):930-934. 
https://doi.org10.1136/bjsports-2016-
097475.  
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Sport-related concussion (SRC) is among the most 
common injuries seen in sports and recreation, 
especially in collision and full contact sports and 
has been defined as external or biomechanical 
force causing neurological and altered brain 
function impairments along functional disturbances 
leading to clinical signs and symptoms.1,2 Sport-
related concussion has a heterogeneous clinical 
presentation representing multiple subtypes of 
disease. At the time of suspected SRC, a 
multifaceted assessment starts with immediate 
considerations such as cervical spine injury and 
neurological assessment followed by extensive 
concussion assessment including orientation, 
memory, cognition, balance, and vestibular 
oculomotor screening (VOMS) completed by a 
licensed healthcare provider with training and 
education in sport-related concussion 
management.2 Symptoms and neurological 
problems following a concussion can vary from 
patient to patient with typical recovery time for 
adults being reported around 14 days.1,3 
Although most patients recover over the first 10-
14 days following the injury, 15% have reported 
trajectory of 30 days or more.3 As of 2019, 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2021/0004.3.3
https://doi.org10.1136/bjsports-2016-097475
https://doi.org10.1136/bjsports-2016-097475


Rest and Therapeutic Interventions Following Sport-Related Concussion: An Evidence-to-Practice Review 
 

 

11 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 
 

rehabilitation guidelines are based on expert 
opinion found in a consensus documents based on 
group meetings from concussion experts including 
researchers in clinical medicine, sports medicine, 
neuroscience, neuroimaging, athletic training and 
sports science.2,4 These individuals concluded a 
need for a period of cognitive and physical rest 
of 24-48 hour, or until acute symptoms resolve, 
followed by a progressive six-step return to 
academics and sport, is the best course of action.2 
This period of rest is critical due to the 
pathophysiological changes in the brain during 
the first 48 hours such as: ion influx leading to 
migraines and headaches; a decrease in glucose 
metabolism and metabolite N-acetylaspartate 
(NAA) in frontal white matter leading to increased 
risk of second injury; and finally impaired 
neurotransmission leading to impaired cognition, 
slowed processing, and slowed reaction time.5 
Due to this critical period being recommended, the 
primary purpose of this article was to evaluate the 
evidence related to determining if rest is 
beneficial following a concussion and what the 
optimal duration of rest (after the 48-hour period) 
should be. The secondary purpose of this article 
was to evaluate the evidence of active treatment 
and rehabilitation effectiveness for athletes who 
have experienced SRC.3 

SUMMARY OF LITERATURE 

The initial search terms selected for the search 
strategy were created and modified by the 
original authors of the systematic review. The 
following electronic databases were used for the 
search strategy: MEDLINE, CINAHL, PsycINFO, 
Cochrane Central Register of Controlled Trials, 
SPORTDiscus, EMBASE and Proquest Dissertations 
and Theses Global.3 Inclusion criteria for the 
review included (1) original research, (2) the focus 
of the study had SRC as a source of injury, and (3) 
the study evaluated the effect of rest or 
treatment.2 The Downs and Black (DB) checklist 
was used to evaluate the risk of bias in the articles 
and it was used in cases when the authors did not 

agree on a decision. A total of 28 studies with 
3218 participants were included in the systematic 
review, which included five randomized control 
trials, nine cohort studies, two quasi-experimental 
studies, and 12 case studies.3 

SUMMARY OF OUTCOMES 

There were various interventions and treatment 
options listed within the nineteen studies. Research 
determined strict rest after SRC decreases energy 
and patients had longer symptom period of more 
than 10-14 day average.2  However, there is 
conflicting data that shows the efficiency of rest 
following a concussion that aids the recovery of 
function and symptom resolution, Studies that 
researched treatments for concussion were 
categorized into rehabilitation, exercise, medical 
and other (symptom-free waiting period). 
Rehabilitation treatment was divided into 
multimodal physiotherapy, collaborative care, 
cognitive rehabilitation, and multifaceted physical 
therapy with exercise. Multifaceted rehabilitation 
included treatment regimens such as adaptation, 
balance, musculoskeletal, aerobic, anaerobic, and 
sport specific.3 Other areas within rehabilitation 
that were mentioned were vestibular and manual 
therapy, specifically exercises that focus on 
improving pain and function for patients with 
cervical spine symptoms. Vestibular therapies 
were reported to have a positive effect on 
symptoms and recovery, such as improving neck 
pain, headaches and dizziness. Active recovery 
treatment involved exercise which introduced sub-
symptom submaximal aerobic exercise multiple 
times per week, which did not exacerbate 
symptoms but rather improved symptom scores 
and the time for return to baseline cognitive 
scores.  

Medical treatment was divided into either 
interventional or traditional pharmacological 
measures to help with post-traumatic headaches.3 
Treatment in these categories only showed 
minimal benefits. All these interventions were 



Rest and Therapeutic Interventions Following Sport-Related Concussion: An Evidence-to-Practice Review 
 

 

12 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 
 

compared against rest and a symptom-free 
waiting period to determine which intervention 
helped decrease SRC symptoms and facilitate a 
safe and timely return-to-activity. 

FINDINGS AND CLINICAL IMPLICATIONS 

The guiding systematic review compared articles 
that were focused on concussion research that 
analyzed the overall effects of rehabilitation, 
medical, and other forms of post-concussion 
treatment on patients.3 Individuals who 
experience concussions can experience 
neurological, vestibular, oculomotor, along with 
physical ailments due to the etiology of the injury. 
Of these treatment types, none were found to 
have better outcomes over the other. As a result 
of these findings, additional research may be 
required on these treatments. However, there is 
data that suggest that post-concussion patients 
can begin to partake in physical and cognitive 
functions after 24 to 48 hours of rest.3 Manual 
therapy, such as cervical lateral glides and 
occipital muscle energy, combined with specific 
exercises involving either balance, adaptation, or 
low level aerobics were found to improve function 
and pain in patients with SRC.2 Clinicians need to 
understand the importance of completing these 
tasks in which the individual stays under the 
symptom exacerbation threshold to avoid 
increasing symptoms,3 which can be done by 
implementing the Buffalo Concussion Treadmill 
Test (BCTT) as demonstrated in Figure 1. By using 
this test, clinicians can determine the exact level of 
aerobic activity and heart rate that exacerbates 
symptoms. The completion of the BCTT can 
correlate to the duration of clinical recovery as 
well as give an estimate on the stage of return-to-
play (RTP) process and to help understand how 
much rehabilitation exercise to prescribe within 
each treatment session for the patient.6  

Regardless of the treatment chosen, it is important 
for both the clinician and patient to keep the 
symptoms underneath the exacerbation during 

post-concussion assessment.3  From the research 
conducted, indications for rehabilitation programs 
involving a controlled symptom threshold limit, 
with submaximal exercise for athletes who have 
persistent symptoms, may be of long-term 
benefit.3 Clinicians should return athletes 
gradually to their non-sport activities, as tolerated 
while making sure the patient does not have any 
return of symptoms 24 hours before progressing 
in the process, and should avoid heavy exertion 
related activities until fully cleared.1,7,8 
Specifically, the 2016 Berlin Consensus Statement, 
recommended a five stage return-to-learn (RTL) 
protocol in which children and adolescents should 
gradually resume academics before returning to 
sport or other physical activity. The consensus 
statement did agree that while gradually 
returning the athlete to school, the patient could 
begin an early introduction into symptoms limited 
activity, such as low cardiovascular exercises 
determined by BCTT, following the 24 to 48 hours 
rest period.1,8 The RTL process is important due to 
the changes in attention, cognitive processing 
speed, short term memory and executive function 
that makes learning difficult following an SRC. 
Clinicians should introduce the RTL prior to RTP as 
integration of learning may exacerbate 
neurological changes which can in return affect the 
overall RTP process.8  

In terms of specific rehabilitation options, 
vestibular rehabilitation was found to show 
positive effects, especially with patients who have 
persistent vestibular findings after SRC.3 
Examples of vestibular rehabilitation used include 
Cawthorne-Cooksey exercises, sensory 
integration balance training, gaze stabilization, 
ocular tracking, vestibular ocular reflex training, 
and dynamic gate. Other technology that can be 
used in vestibular rehabilitation includes 
Dynavision D2, Fit Light System, Geobard, and the 
Interactive Metronome Neurotiming.3  If clinicians 
are looking for confirmation of vestibular 
oculomotor dysfunction following a SRC, clinicians 
should look to use to VOMS, which has  unique 



Rest and Therapeutic Interventions Following Sport-Related Concussion: An Evidence-to-Practice Review 
 

 

13 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 
 

aspects for determining vestibular function not 
assessed by other post-concussion test.3 Before 
performing the VOMS, clinicians either need to be 
trained in administering the exam or refer to a 
healthcare professional who is trained in 
administering the exam for the most accurate 
results.9 There is little to no evidence to support the 
use of pharmacological  management strategies 
such as analgesics, non-steroidal anti-
inflammatory drugs, or acetaminophen for 
treating SRC.3,10 Every individual is different and 
there is no standard timeline for how and when a 
patient can and will recover from a concussion. The 
return-to-activity decision should be decided by 
an interprofessional healthcare team, and all 
factors closely analyzed. 

CLINICAL BOTTOM LINE 

Evidence from recent reviews suggest that 
prolonged physical and cognitive rest may not be 
as effective as previously thought for concussion 
and post-concussion syndrome management.11 
Multiple studies have shown that a multimodal 
active recovery, including progressive levels of 
exercise difficulty that increase throughout RTP, 
helps athletes diagnosed with concussion or post-
concussion syndrome efficiently return-to-activity 
and helps with their overall symptoms and 
recovery time.12-14 One research study concluded 
that prolonged rest could impede athlete 
recovery and lead to mood and/or anxiety 
disorders.14 Grabowski et al. (2017) was able to 
further suggest supervised physical rehabilitation, 
involving sub-symptom cardiovascular exercise, 
vestibular/oculomotor therapy, and cervical spine 
rehabilitation, improved symptoms scores in 
exercise tolerance and on graded exercise testing 
and balance.12 Other studies, such as Chrisman et 
al. (2017) who used the Balke treadmill test, which 
is similar to the BCTT, demonstrated symptoms 
decreased exponentially following a progressive 
aerobic exercise program regardless of 
symptoms duration at presentation and none of 
the subjects had worsening of symptoms 

throughout the program.13 Implementation of low-
level activity including sub-symptom 
cardiovascular exercise including biking, walking, 
and jogging, are a few ways to avoid excessive 
rest following concussion.11 Overall, it is becoming 
clear that prolonged and sustained rest from all 
activity following a concussion is not beneficial 
and could potentially be harmful to the recovery 
process. 

Previously, patients were instructed on complete 
rest from both physical and mental activity until all 
symptoms were no longer present. The recent 
research indicates a change in treatment for SRC 
to a more active approach after 24-to-48-hour 
rest, may aid in recovery. Although there is some 
conflicting evidence on active rehabilitation 
providing a benefit towards SRC recovery, it 
should still be considered due to its potential use 
in clinical practice. Clinicians should still follow the 
protocol of 24 to 48 hours of rest post SRC before 
they begin incorporating active rehabilitation. 
Vestibular rehabilitation such as: Cawthorne-
Cooksey exercises, sensory integration balance 
training, and vestibulo-ocular reflex, or cervical 
manual therapy, have shown the most positive 
effects in regards to overall symptom recovery 
and faster RTP of all the different concussion 
related interventions.3 The use of exercise 
tolerance in the active rehabilitation protocol can 
be useful for the differential diagnosis of patients 
with potential post-concussion syndrome and can 
also act as a physiological sign of readiness to 
RTA.11  

If active rehabilitation is the chosen path of SRC 
treatment, the clinician should always be aware 
and ensure the patient's symptoms are staying 
under the original reported symptom scores after 
the initially recorded SRC. Symptom scores should 
be taken daily while going through the 
rehabilitation process to ensure the symptoms are 
resolving and not over the scores from the initially 
recorded SRC.6 Despite the inconclusive findings 
on the effectiveness for active rehabilitation in the  



EVIDENCE-TO-PRACTICE REVIEW 
  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 

 
 

Table 1: Key Information, Helpful Tips, and Take-Home Messages of Management of Sport-Related 
Concussion (SRC) 
Key Information 

● SRC is among the most common injuries seen in sports and recreation, especially in collision and full contact sports.1 
● Typically, recovery time for adults has been reported as 14 days.1 
● Symptoms decrease exponentially following a progressive aerobic exercise program, regardless of symptoms duration 

at presentation, and all of the subjects were without symptom exacerbation throughout the program.9 
Helpful Tips 

● At the time of suspected SRC, a multifaceted assessment starts with ruling out considerations such as cervical spine injury 
and neurological assessment followed by extensive concussion assessment including orientation, memory, cognition, 
balance, and vestibular ocular motor screening. All should be completed by a credentialed medical professional who 
has specialized training in SRC diagnosis and management. 

● An efficient way of ensuring the patient’s symptoms stay below the limit of symptoms worsening would be to implement 
the Buffalo Concussion Treadmill Test. By using this test, you can find the exact level of aerobic activity and heart rate 
that exacerbates symptoms, which may also correlate to the duration of clinical recovery.3 

Take-Home Messages for Clinician   
● Follow the guidance of the medical staff, in collaboration with utilizing evidence-based practice. 
● Clinicians should return athletes gradually to their non-sport activities, as tolerated, and should avoid heavy exertion 

related activities until fully cleared. Activities allowed should be based on patient symptoms but can include light 
cardiovascular or vestibular exercises.  

● Specifically, the Berlin Consensus Statement (2016) recommended a 5 stage return-to-learn protocol in which children 
and adolescents should gradually be returned to academics before RTP.4  

● The return-to-play decision should be managed as a collaborative effort amongst healthcare providers such as athletic 
trainers, team physician and SRC specialist and all factors such as neurological function, symptom checklist, and 
performance on concussion assessment should be closely analyzed. 

management of a SRC, athletic trainers should 
consider the use of the BCTT due to its ability to 
objectively measure aerobic exercise capacity.6 
The BCTT can be used safely on either a treadmill 
or a stationary bike. While the paradigm of rest 
and symptom recovery has been well adopted in 
sports medicine for concussion management, the 
guiding systematic review identified positive 
effects in most of the studies (16/19) for post-
concussion treatment.3 We recommend that 
athletic trainers and other sports medicine 
professionals managing SRC to evolve their 
practice away from complete rest and move 
towards an integration of active rehabilitation. 
Overall, we suggest that clinicians use active 
rehabilitation following a 24 to 48 hour period of 
rest for SRC. The management of a SRC is also 
complex and multifaceted meaning an integrated 
approach is necessary from multiple providers. As 
athletic trainers begin to reconsider the 
management process through a collaborative and 

interprofessional lens, we suggest using Table 1 
take home and key messages to guide your 
discussions. Following the discussions, we suggest 
the sports medicine team integrate a quality 
improvement process whereby small changes, 
including policy and implementation of active 
rehabilitation strategies, are undertaken 
segmentally to learn more about the necessary 
skills and resources for the changes to their care 
plan. 

REFERENCES 

1. McCrory P, Meeuwisse W, Dvořák J, et al. 
Consensus statement on concussion in sport-the 
5(th) international conference on concussion in 
sport held in Berlin, October 2016. Br J Sports 
Med. 2017;51(11):838-847. 
https://doi.org/10.1136/bjsports-2017-
097699.  

2. Schneider KJ. Concussion part II: 
Rehabilitation - The need for a multifaceted 

https://doi.org/10.1136/bjsports-2017-097699
https://doi.org/10.1136/bjsports-2017-097699


Rest and Therapeutic Interventions Following Sport-Related Concussion: An Evidence-to-Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 
 

approach. Musculoskelet Sci Pract. 
2019;42:151-161. 
https://doi.org/10.1016/j.msksp.2019.01.0
06.  

3. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. 
Rest and treatment/rehabilitation following 
sport-related concussion: a systematic review. 
Br J Sports Med. 2017;51(12):930-934. 
https://doi.org/10.1136/bjsports-2016-
097475.  

4. McCrory P, Meeuwisse WH, Aubry M, et al. 
Consensus statement on concussion in sport: the 
4th International Conference on Concussion in 
Sport held in Zurich, November 2012. J Am 
Coll Surg. 2013;216(5):e55-71. 
https://dx.doi.org/10.4085%2F1062-
6050-48.4.05.  

5. Giza CC, Hovda DA. The new neurometabolic 
cascade of concussion. Neurosurgery. 
2014;75 Suppl 4(0 4):S24-33. 
https://doi.org/10.1227/neu.0000000000
000505.  

6. Haider MN, Leddy JJ, Wilber CG, et al. The 
Predictive Capacity of the Buffalo Concussion 
Treadmill Test After Sport-Related Concussion 
in Adolescents. Front Neurol. 2019;10:395. 
https://doi.org/10.3389/fneur.2019.00395
.  

7. Harmon KG, Drezner JA, Gammons M, et al. 
American Medical Society for Sports 
Medicine position statement: concussion in 
sport. Br J Sports Med. 2013;47(1):15-26. 
https://doi.org/10.1136/bjsports-2012-
091941.  

8. Harmon KG, Clugston JR, Dec K, et al. 
American Medical Society for Sports 
Medicine position statement on concussion in 
sport. Br J Sports Med. 2019;53(4):213-225. 
https://doi.org/10.1136/bjsports-2018-
100338.  

9. Yorke AM, Smith L, Babcock M, Alsalaheen B. 
Validity and Reliability of the 
Vestibular/Ocular Motor Screening and 
Associations With Common Concussion 
Screening Tools. Sports Health. 

2017;9(2):174-180. 
https://doi.org/10.1177/1941738116678
411.  

10. Larsen EL, Ashina H, Iljazi A, et al. Acute and 
preventive pharmacological treatment of 
post-traumatic headache: a systematic 
review. J Headache Pain. 2019;20(1):98. 
https://doi.org/10.1186/s10194-019-
1051-7.  

11. Leddy JJ, Wilber CG, Willer BS. Active 
recovery from concussion. Curr Opin Neurol. 
2018;31(6):681-686. 
https://doi.org/10.1097/wco.0000000000
000611.  

12. Grabowski P, Wilson J, Walker A, Enz D, 
Wang S. Multimodal impairment-based 
physical therapy for the treatment of patients 
with post-concussion syndrome: A 
retrospective analysis on safety and 
feasibility. Phys Ther Sport. 2017;23:22-30. 
https://doi.org/10.1016/j.ptsp.2016.06.00
1.  

13. Chrisman SPD, Whitlock KB, Somers E, et al. 
Pilot study of the Sub-Symptom Threshold 
Exercise Program (SSTEP) for persistent 
concussion symptoms in youth. 
NeuroRehabilitation. 2017;40(4):493-499. 
https://doi.org/10.3233/nre-161436.  

14. Mahooti N. Sports-Related Concussion: Acute 
Management and Chronic Postconcussive 
Issues. Child Adolesc Psychiatr Clin N Am. 
2018;27(1):93-108. 
https://doi.org/10.1016/j.chc.2017.08.005.  

 

 

 

 

 

 

https://doi.org/10.1016/j.msksp.2019.01.006
https://doi.org/10.1016/j.msksp.2019.01.006
https://doi.org/10.1136/bjsports-2016-097475
https://doi.org/10.1136/bjsports-2016-097475
https://dx.doi.org/10.4085%2F1062-6050-48.4.05
https://dx.doi.org/10.4085%2F1062-6050-48.4.05
https://doi.org/10.1227/neu.0000000000000505
https://doi.org/10.1227/neu.0000000000000505
https://doi.org/10.3389/fneur.2019.00395
https://doi.org/10.3389/fneur.2019.00395
https://doi.org/10.1136/bjsports-2012-091941
https://doi.org/10.1136/bjsports-2012-091941
https://doi.org/10.1136/bjsports-2018-100338
https://doi.org/10.1136/bjsports-2018-100338
https://doi.org/10.1177/1941738116678411
https://doi.org/10.1177/1941738116678411
https://doi.org/10.1186/s10194-019-1051-7
https://doi.org/10.1186/s10194-019-1051-7
https://doi.org/10.1097/wco.0000000000000611
https://doi.org/10.1097/wco.0000000000000611
https://doi.org/10.1016/j.ptsp.2016.06.001
https://doi.org/10.1016/j.ptsp.2016.06.001
https://doi.org/10.3233/nre-161436
https://doi.org/10.1016/j.chc.2017.08.005


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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 3 – November 2021 

 
 

 

Prior to Testing Start:  

1) Inform the patient about test procedures and what to expect during the test 
2) Explain and demonstrate the Borg Rating of Perceived Exertion (RPE) scale and obtain resting scores (see graphic representation below) 
3) Remind patient that they will be asked to rate exertion and symptom severity at each minute during exercise 
 

6-7 Very, very light 
8-9 Very light 

10-11 Fairly light 
12-13 Somewhat hard 
14-16 Hard 
17-18 Very hard 

19 Very, very hard 
20 Max exertion 

 

 

 Patient stands on 
end of treadmill

Height (in) of 
patient is taken
>5.5” = 3.6 mph
<5.5” = 3.2 mph

Incline = 0°

After each minute, 
increase  incline 
by 1°

Rate RPE and 
symptom severity 
or heart rate
*1-point is given for 
any worsening 
syptom, 1-point is 
given for any new 
symptom

Treadmill incline 
increases at 
1°/minute

Athletic trainer 
should note the 
Likert scale 
reason/symptom 
that sparked 
increase

Maximum incline 
= 15° or 12° at 
modified test

Speed increases 
by 0.4 mph each 
minute with  no 
incline change

Terminate the test 
when RPE is 
reported at 19.5 
or once patient 
reports inability 
to continue due to  
symptoms

*Max time on 
treadmill: 20 
minutes

Once test has 
been terminated, 
reduce speed to 
2.5 mph and 
incline reduced 
back to 0° for a 
2 minute 
cooldown

Patient should rest 
until symptoms 
return to pre-
BCTT value

Modified iteration of Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann-Demont N, Iverson GL, Hayden A, Makdissi M. Rest and treatment/rehabilitation 
following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934. doi: 10.1136/bjsports-2016-097475.   

Figure 1: Buffalo Concussion Treadmill Test Protocol  

 


	ABSTRACT

