Concussion BCTT Test Form

Buffalo Concussion Treadmill / Bike Test
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Blood Pressure:*
Heart Rate:*
Calculate Maximum Heart Rate:*
220 - _____ (Age) x _____ % = ______ BPM
Test #:*
Purpose:
- Investigate exercise tolerance in patients with concussion.
- Identify the Heart Rate (HR) at which concussion-specific symptom exacerbation occurs (Heart Rate Threshold [HRT]) in concussed patients and assist in treatment protocols.
- Aid in differentiating between possible diagnoses for concussive symptoms (Physiologic, Vestibulo-Ocular, Cervicogenic, Psychological) and etiology of the concussion.
- Identify physiological variables associated with exacerbation of symptoms and the patient’s level of recovery.

Treadmill / Bike*

	Min	Speed	Incline	HR	RPE	Sx Scale	Symptom Reports	Observations
Rest
0
1
2
3
4
5
6
7
8
9
10
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14
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20
Post

Post Test Evaluation*

	Pass/Fail/BPM
Passed:
Failed:
Maximum HR at Failure BPM:
Sub-Symptom Threshold BPM:

DIAGNOSES (ICD-10)
Concussion W/O LOC (Subsequent Visit) S06.0X0D*

YesNo
Concussion W/ LOC < 30 Min (Subsequent Visit) S06.0X1D*

YesNo
Concussion W/ LOC Unspecified Duration (Subsequent Visit) S06.0X9D*

YesNo
Persistent Concussive Symptoms (PCS)AKA Post Concussion Syndrome F07.81*

YesNo
Convergence Insufficiency H51.11*

YesNo
Dizziness R42*

YesNo
BPPV H81.10*

YesNo
Any additional diagnoses?
PLAN / RECOMMENDATIONS
BESS Testing*

FailedPassed
Sub-Symptom Exercise: When the patient fails the BCTT, this represents Physiologic Concussion. The patient is instructed to begin sub-symptom threshold exercise with target HR of 80% of the BCTT symptom threshold HR (90% for athletes).

Sub-Symptom Threshold = Enter BPM BPM

Patient instructed to continue with sub-symptom threshold exercise for 20-30 minutes daily. Patient was instructed that if the exercise induces symptoms, they are to stop the exercise that day. Continue exercise the following day at HR 10% lower.
Schedule Vestibulo-Ocular PCS Exam*

YesNo
Schedule Cervicogenic PCS Exam*

YesNo
Neurocognitive Testing*

YesNo
Neurologic Co-Management*

YesNo
Psychological Complicating Factors Present*

YesNo
Time: Today, I spent enter minutes minutes were spent reviewing the patient’s current status, outcome measures, performing BCTT, discussing my recommendations, documenting my findings and completing the chart note. The patient indicated an understanding of our discussion and we will implement the above treatment plan.

99203 (New Patient; 30-44 Min) 99211 (Est Patient; Brief OV) 99212 (Est Patient; 10-19 Min) 99213 (Est Patient; 20-29 Min) 99214 (Est Patient; 30-39 Min) 99215 (Est Patient; 40-54 Min) 97750 (Physical Performance Test / BCTT) 97112 (Neuromuscular Re-education)
Doctors Notes:
Doctor Signature*

Clear
Date*

MonthDayYear
Date
C 2022 First Care Concussion Clinic, LLC
Should be Empty:

Buffalo Concussion Treadmill / Bike Test

DIAGNOSES (ICD-10)

PLAN / RECOMMENDATIONS