CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

BEST PRACTICE FOR CONCUSSION MANAGEMENT

Clinician’s Topic:
What is best practice for treating patients with oculomotor dysfunction following concussion or mild TBI? Include recommendations
for screen time following concussion, as well as the factors that contribute to or slow recovery (i.e., prognostic factors).

Specific focus: Does the Buffalo Concussion Treadmill Test accurately determine exercise tolerance in patients following concussion
for return to sport, as measured by sensitivity (negative result rules out the diagnosis)?

Clinical Bottom Line:

No, sensitivity of the Buffalo Concussion Treadmill Test (BCTT) does not accurately determine exercise tolerance in patients
following concussion for return to sport since there is no current evidence supporting this. I recommend clinicians perform the BCTT
in conjunction with other neurocognitive scores to determine if a patient has recovered from a sport related concussion to a safe level.
This will ensure that other factors not accounted for in graded treadmill testing are considered in order to decrease adverse events
from returning to play too early.

Refresh Date: March 2019

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated:
Key Findings
 General Summary
o Overall, the breadth of literature in regard to the Buffalo Concussion Treadmill Test (BCTT) is very limited. Therefore, there is
extremely limited evidence for the BCTT as a diagnostic tool for return to play. Slightly more evidence is available regarding the
Balke protocol, which is the basis for the BCTT. The majority of the literature pertained to non-exercise related concussion tests.
 Research Quality
o The quality of the evidence is poor. There are numerous threats to validity including lack of protocol explanation so that it can be
reproduced, blinding the examiners, and referencing a gold standard. Lack of statistical analysis and baseline measurements also limit
the research quality.
 Level of Evidence
o The level of evidence for the literature is poor (levels range from 3-5). Cross-sectional design and retrospective chart reviews were
included. Even though these studies utilize reference standards, they were downgraded due to no statistical analysis, no defined
measurements, no blinding, and mechanism-based reasoning,
 General Limitations
o The articles focus on multiple aspects of concussion recovery in relation to the BCTT and Balke protocol rather than just the accuracy
of the BCTT’s diagnostic ability for safe return to sport. Sample sizes were limited, and participant characteristics varied among the
studies. Furthermore, evidence lacked consistency with the reference standard and index measure.
 Take Home Findings
o No evidence specifically on sensitivity of the BCTT was found. Evidence included the Balke protocol and BCTT, but it is not reliable
to accurately diagnose concussion recovery for return to play. However, it may be useful when used in conjunction with other
concussion tests as it helps to assess exercise tolerance.
 Clinical Relevance
o Use of the BCTT to diagnose readiness for return to play after sport related concussion should not be used alone since there is not
strong enough evidence to support its accuracy. The BCTT should be performed with other neurocognitive tests to determine if a
patient is safe to return to play after a sport related concussion.

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated:
Search Methodology: (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
PubMed Buffalo concussion treadmill test No limits applied 9
1
AND diagnosis
2 PubMed Concussion AND treadmill walking No limits applied 3
PubMed Mild TBI AND buffalo concussion No limits applied 0
3 treadmill test
4 PubMed Mild TBI AND treadmill walking No limits applied 0
5 PubMed Mild TBI AND treadmill No limits applied 5
6 PubMed Concussion AND graded treadmill No limits applied 10
SPORTDiscus Concussion AND buffalo No limits applied 7
7
concussion treadmill test
SPORTDiscus Concussion AND treadmill No limits applied 0
8
walking
9 SPORTDiscus Concussion AND graded treadmill No limits applied 3
CINAHL Plus Buffalo concussion treadmill test No limits applied 1
10
AND diagnosis
CINAHL Plus Balke AND concussion AND No limits applied 0
11
diagnosis

Search Results Summary:

Results
- Randomized controlled trial (1)
- Review (2)
- Prospective (4)
- Retrospective (1)
- Cross-sectional (1)
1 - Actors as subjects (mimicking
Author(s): Paige Lyford
Reviewer(s):
Reasons for Inclusion Reasons for Exclusion # of Articles
Included
- Balke protocol for symptom - Aerobic exercise effect on days to 1
exacerbation recovery
- Study design: review
- Exercise treatment program
symptoms of concussion)
- MRI activation
- No reference comparison to
Buffalo Concussion Treadmill Test
Date Created: March 4, 2018
Date Updated:
 - Quasi-experimental (1)
2 - Prospective (2)
3 - No search results
4 - No search results
- Comparative (2)
- Clinical trial (1)
- Review (1)
5 - Quasi-experimental (1)
- Retrospective (1)
- Review (4)
- Systematic Review (1)
- Prospective (2)
6 - Cross-sectional (1)
- Pilot (1)
- Randomized controlled trial (1)
- Retrospective (2)
- Review (1)
- Prospective (3)
7
8 - No search results
Author(s): Paige Lyford
Reviewer(s):
- N/A (no articles included)
- N/A (no search results)
- N/A (no search results)
- N/A (no articles included)
- Balke protocol used as diagnostic
tool
- N/A (no articles included)
- N/A (no search results)
Date Created: March 4, 2018
Date Updated:
- Horses as subjects 0
- Effects of heading soccer balls on
walking stability
- N/A (no search results) 0
- N/A (no search results) 0
- Cardiorespiratory fitness 0
outcomes
- Peak aerobic capacities and
ventilator thresholds
- Moderate TBI
- Severe TBI
- Rats as subjects
- Moderate and severe TBI 1
- Study design: review
- Migraine headache
- Cognitive rest intervention
- Cardiovascular response
- Functional outcomes rather than
diagnosis
- Actors as subjects (mimicking
symptoms of concussion)
- Aerobic exercise effect on days to 0
recovery
- Article included in search #1
above
- Study design: review
- Actors as subjects (mimicking
symptoms of concussion)
- Exercise treatment program
- Etiology of post concussion
symptoms
- N/A (no search results) 0
 - Prospective (1) - N/A (no articles included) - Actors as subjects (mimicking 0
- Review (1) symptoms of concussion)
9
- Case report (1) - Study design: review
- Migraine headache
10 - Review (1) - N/A (no articles included) - Study design: review 0
11 - No search results - N/A (no search results) - N/A (no search results) 0

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated:
Research Participant and Study Characteristics:
Reference Participant Key Clinical Reference Standard Index Measure Level of
Characteristics Evidence
Kozlowski et al - Diagnosed with sport- Subjects gathered from historical Standard Balke protocol Level 3
2013 related or non-sport data and matched to subjects with - Start: 3.3 mph, 0% (cross-
related concussion concussions: incline sectional but
- Average time from injury - Sedentary prior to - Minute 1: grade downgraded
to enrollment: 226 days enrollment but otherwise increased to 2.0% due to no
- Sedentary prior to healthy - Minute 3 (and each blinding)
enrollment (< 30 minutes - No history of head injury minute after): grade
of purposeful physical increased by 1.0%
activity per week for 3 - Termination: unable to
months) maintain speed, onset or
- 17 males; 17 females exacerbation of
- Mean age: 25.9 years symptoms, or reached
maximum test capability
(21 minutes)
Cordingley et al - Diagnosed with acute Immediate Post-Concussion Buffalo Concussion Treadmill Level 5
2016 sport related concussion Assessment and Cognitive Testing Testing:
(SRC) or post-concussion (ImPACT) - Start: 3.2 mph, 0% grade
syndrome (PCS) - First 15 minutes: grade
secondary to SRC Neuropsychological testing: increased 1% per minute
- Age: mean =15.1 years; - Computerized - After 15 minutes: speed
range = 11-19 years neurocognitive tools and/or increased 0.2 mph per
- 43.4% males pencil and paper instruments minute
- 57.6% sustained prior - Interpreted by registered - RPE rating on Borg scale
concussions clinical neuropsychologist every minute
Termination: onset or
exacerbation of symptoms or
maximal exhaustion (RPE: 18-
20 on Borg scale)

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated:
Outcomes:
Reference
Mean (SD)
Cohen d effect
Event/Outcome Experimental Group
Control Group size
Kozlowski et al (Post Concussion Syndrome)
2013 Termination of test due to:
Test duration in
symptom exacerbation OR Test duration in minutes:
minutes: 2.3 (high)
worsening of symptoms present 8.5 (4.4)
17.9 (3.6)
at start of test

Positive Negative
Diagnosis Sensitivity Specificity
Likelihood Ratio Likelihood Ratio
Statistical analysis was not performed. Therefore, these values were not
stated in the article.

Results provided:
ImPACT scores:
Physiologically recovered: able - Within normal limits = 10 subjects deemed physiologically recovered
Cordingley et al
to reach maximal exertion with by treadmill testing
2016
no onset of concussion - Borderline range = 1 subject deemed physiologically recovered by
symptoms treadmill testing
- Less-than-5th-percentile range = 1 subject deemed physiologically
recovered by treadmill testing
Neuropsychological testing
- Within normal limits = 9 subjects deemed physiologically recovered
by treadmill testing
Multi-domain cognitive impairments = 2 subjects

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated:
References:
Kozlowski KF, Graham J, Leddy JJ, Devinney-Boymel L, Willer BS. Exercise intolerance in individuals with postconcussion
syndrome. J Athl Train. 2013;48(5):627-635. doi:10.4085/1062-6050-48.5.02.

Cordingley D, Giardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: Safety, clinical use,
and patient outcomes. J Neurosurg Pediatr. 2016;18:693-702. doi:10.1017/cjn.2017.209.

Author(s): Paige Lyford Date Created: March 4, 2018

Reviewer(s): Date Updated: