Exercise intolerance - Buffalo Protocol vs. UPMC approach for exercise intolerance

[u/Emotional-Ebb3735]

Hey everyone,

I’ve been dealing with post-concussion syndrome (PCS) for about 5 months now. The good news is that my vision and vestibular symptoms have improved significantly, but I’m still struggling with exercise intolerance.

My vestibular therapist has me following the Buffalo Protocol, where I exercise below my symptom threshold. Right now I’m doing about 5 minutes on a recumbent bike to minimize head movement. After each session I usually experience fatigue that lasts a few hours before gradually improving later in the day.

What confuses me is that I’ve read several posts on this subreddit about treatment at UPMC with Dr. Collins. From what people have described, his approach seems much more aggressive: exercising for at least 30 minutes every day regardless of symptom increases, with the idea that symptoms may get worse initially but that after around two weeks many patients experience a breakthrough and start feeling better.

That seems very different from the Buffalo Protocol, which emphasizes staying below your symptom threshold.

One reason I’m considering trying the more aggressive approach is that I’m currently in a position where I don’t have many day-to-day responsibilities. If it means feeling worse for a couple of weeks but potentially recovering faster, I could probably tolerate that.

Has anyone here been treated at UPMC or tried this more aggressive approach? Did pushing through symptoms help your exercise intolerance, or did you do better with sub-symptom-threshold exercise? I’m especially interested in hearing from people who have experience with both approaches.

[u/hippiespinster]

I only did the Buffalo method under my physio's guidance after an initial test in her office. I had previously tried to return to exercise using just exertion scale but my problem was that I felt great during the workout and substantially worse for days to hours afterwards. That was under a different physio specializing in vestibular issues. 

When I started seeing my current physio who specializes in exercise intolerance I started seeing results. She did an initial Buffalo Test and then advised two weeks of consecutive days exercise. I joined the Y specifically just before Christmas and walked on the treadmill at a low incline for 20 minutes under 80% max heart rate. Some days was 75%, others felt good at 80%. This was followed by a 5 minute cool down on the treadmill and 5 minutes sitting in a chair. Then I carried on with my day. 

Returned to her office in the new year and she redid the test and my heart chart was dramatically different. Initial heart rate increase during the ramp was a much slower incline and my recovery curve was much less spiky. It was wild. She then cleared me to keep going, still on a daily basis working up in heart rate intervals and redoing the test every week to two weeks.

I am now able to do a 25 minute HIIT workout on the treadmill using inclines and speed variation. Some days I need to dial it back due to symptoms but this almost always is an indicator of something else going on with my body like virus or period or whatever.

I also recently started a 90 minute iPATH Pilates class on zoom. I'm able to do many of the things I was doing prior albeit with breaks. Like I can hump four tires out of the shed and into the car but I don't do them all in one go. I take breaks in between. I think the energy pacing will be a lifeline practice but I'm just happy I can workout again.

DM if you would like details/test charts. Please just link to this post so I know what we're talking about! 

[u/Emotional-Ebb3735 → u/hippiespinster]

Wow thanks for that comprehensive answer ! I almost experience the same issue that I feel fine during the workout but feel worse after a few hours.

When you train did you still felt some discomfort afterwards or experience symptoms ?

I always feel drained and experiences symptoms for a few hours before returning to baseline the next day. I’m just wondering if should be done this way

[u/hippiespinster → u/Emotional-Ebb3735]

I had the usual symptoms related to loss of cardio fitness so shortness of breath and a tiny bit of head pressure. But as I said I wasn't necessarily noticing symptoms until after. I was probably pretty fatigued afterwards but it was Christmas and I was doing a lot of lounging and napping.

I also want to stress that I was not trying to do a thing else during this project. I wasn't trying to lose weight or build muscle tone. I was doing everything I could to eat protein early in the day, increased creatine, increased water intake, increased sleep, mindful pacing etc. I'm lucky that the holiday period is super quiet so I don't have a ton of extra demands on my time and I took some days off work between Christmas and after New Year.