Rethinking Concussion Recovery: The Buffalo Protocol and Early Aerobic Exercise

Historically, concussion management placed a premium on prolonged rest to support neural recovery. The relatively “passive” approach which has largely been the status quo could be due to a number of factors ranging from the pressures of professional coaches, sponsors or even family for sport stars to entertain. This passive approach is being re-thinked and more active early engagements could be the future when it comes to concussion rehabilitation. A growing body of research now advocates for early, controlled sub-threshold aerobic exercise as a more effective strategy for managing concussion symptoms and could contribute to preventing persistent post-concussive symptoms (PPCS) (Leddy et al., 2018).

The Buffalo Protocol: A Paradigm Shift

In order to achieve these “fast-forward” results when it comes to concussion it is worth taking note of the Buffalo Protocol. Developed by researchers at the University at Buffalo, the Buffalo Protocol is designed to identify and prescribe sub-symptom threshold aerobic exercise through the Buffalo Concussion Treadmill Test (BCTT). It allows the rehabilitation team to establish the heart rate at which concussion symptoms worsen. This sub-maximum heart rate is then taken as the cut-off value for individualised exercise prescriptions. Staying just below this threshold allows the injured athlete to continue to train, preventing aerobic deconditioning, while staying symptom free. (Leddy et al., 2017). The end result is a safe, structured activity that supports autonomic regulation and cerebral blood flow recovery while achieving a degree of conditioning.

Evidence for Early Aerobic Intervention

Recent randomised controlled trials and cohort studies have consistently demonstrated that initiating controlled aerobic activity within 2–10 days of injury can:

• Speed up symptom resolution: Adolescents treated with sub-threshold aerobic exercise recovered faster than those advised to rest (Leddy et al., 2019a).
• Reduce incidence of PPCS: Patients engaging in early physical activity were less likely to experience symptoms lasting beyond 4 weeks (Leddy et al., 2019b).
• Support physiological recovery: Aerobic exercise has been shown to positively influence autonomic nervous system regulation, often impaired after concussion (Leddy et al., 2017).

Clinical Application

Once the symptom threshold heart rate is identified using the BCTT, the athlete can in engage in aerobic sessions (e.g., brisk walking, stationary cycling) at 80–90% of the threshold for 20–30 minutes. This is a fluid situation with the threshold heart rate constantly being monitored and adjusted and as tolerance improves, exercise intensity can be gradually increased. The Buffalo protocol offers a structured approach backed up by evidence to be both a safe and effective rehabilitation framework (Leddy et al., 2019a; Leddy et al., 2019b).

Clinical Reflections

The Buffalo Protocol exemplifies a shift toward active, evidence-based rehabilitation concussion management. Gone are the days of sidelining patients indefinitely or playing a guessing game as to the intensities at which returning athletes should be progressing. The beauty about the BCTT approach is that it is practical easy to implement, evidence based and caters for both rehabilitation as well as the conditioning elements of return to play. It now presents clinicians with a meaningful opportunity to reduce recovery time,improve patient confidence and engagement throughout the rehabilitation process.

Closing Reflection

Topics such as the Buffalo Protocol and other novel approaches to active concussion management form part of the broader conversations within our Sports and Exercise Medicine postgraduate degree. Our structured academic forums and critical appraisal of emerging literature, offers students the opportunity to engage with evidence-based practices and translate them into practical, real-world applications. This approach deepens clinical understanding and equips students with the tools to enhance patient outcomes across a range of rehabilitative contexts.

Article by Jacques van Blerk, Learna | Diploma MSc - Sports and Exercise Medicine Tutor

References
Leddy, J.J., Haider, M.N., Ellis, M.J. and Willer, B.S., 2018. Exercise is medicine for concussion. Current Sports Medicine Reports, 17(8), pp.262–270. Available at: https://pubmed.ncbi.nlm.nih.gov/30095546/ [Accessed 7 May 2025].
Leddy, J.J., Baker, J.G., Haider, M.N., Hinds, A. and Willer, B.S., 2017. A physiological approach to prolonged recovery from sport-related concussion. Journal of Athletic Training, 52(3), pp.299–308. Available at: https://pubmed.ncbi.nlm.nih.gov/28387557/ [Accessed 7 May 2025].
Leddy, J.J., Haider, M.N., Ellis, M.J., Mannix, R., Darling, S.R., Freitas, M.S., Suffoletto, H.N., Leiter, J., Cordingley, D.M. and Willer, B.S., 2019a. Early subthreshold aerobic exercise for sport-related concussion: A randomized clinical trial. JAMA Pediatrics, 173(4), pp.319–325. Available at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2723523 [Accessed 7 May 2025].
Leddy, J.J., Haider, M.N., Hinds, A.L., Darling, S. and Willer, B.S., 2019b. A preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males. Clinical Journal of Sport Medicine, 29(5), pp.353–360. Available at: https://pubmed.ncbi.nlm.nih.gov/30239422/ [Accessed 7 May 2025].

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