In 2022, Dr. John Leddy, clinical professor of orthopaedics, received the prestigious Stockton Kimball Award in recognition of his exceptional scientific accomplishments and dedicated service.
During the recent Stockton Kimball Lecture, he presented on the topic of Exercise Testing in Buffalo: from the Heart to the Brain.
Below is an interview between Dr. Leddy and Bianca Gowanny, an HR and Marketing Communications Specialist at UBMD Orthopaedics and Sports Medicine, discussing his lecture at UB and his experience of receiving the Stockton Kimball Award in 2022.
Bianca: You won the award last year, what was that like and what is the typical nomination process for that?
Dr. Leddy: I was stunned to win the award. I didn’t even think about it, to be honest with you. As far as the nomination process, I am not exactly sure because I have never been on that committee. I think you have to demonstrate a consistent body of research over a period of time that makes a considerable contribution to the literature of the field and that promotes the University at Buffalo and reflects well on UB. I guess they looked at our concussion research, which has been going on for about 20 years now.
We’ve been pretty successful and our research has led to international changes in clinical concussion treatment and management. We just completed something called the Amsterdam Consensus Conference on Concussion in Sport, which really sets the worldwide standard for concussion care of athletes, but it has application to non-athletes too in some respects. A lot of work in Buffalo is included in that consensus statement, and there are ten systematic reviews that accompany the consensus statement – one of them was on rest and exercise after a concussion. I was the lead author on that and Dr. Barry Willer of the Department of Psychiatry was one of the co-authors. That topic has the most new and powerful scientific evidence since the last statement was published in 2017.
Back then, the consensus was that controlled aerobic exercise may help athletes recover after a concussion but we didn’t have solid evidence. Since that time, largely through the work in Buffalo, there have been randomized clinical trials published, and systematic reviews of our work and of others, that when you pool all of the data from different institutions, aerobic exercise treatment really does appear to be effective and safe. The most recent guidelines are going to say that sub-symptom threshold aerobic exercise is now considered to be a treatment for concussion. In fact, it is the only treatment for concussion that we know of that works. That has changed the return to sport strategy so that exercise is no longer simply a stage in the recovery process but is rather a form of treatment for athletes to help them recover faster.
The assessment tools we developed, the Buffalo Concussion Treadmill Test and the Buffalo Concussion Bike Test, are highlighted in the outputs from that meeting in terms of ongoing assessment after the initial acute phase.
I think one reason the Stockton Kimball Group was interested in the Buffalo work is that the “Buffalo Protocol”, as it’s known in the concussion world, means systematically assessing exercise tolerance early after a concussion, usually on the Buffalo Concussion Treadmill or Bike Test, and then prescribing individualized controlled sub-symptom threshold aerobic exercise treatment that does two things. One is to help speed recovery and two, , it prevents a substantial portion of patients from having delayed or prolonged recovery, which is defined as symptoms persisting for more than a month. That’s important because it’s that group of children or adolescents that really have trouble with getting back to school, they’re not playing their sport, they’re having trouble with headaches and sleeping, and they report a reduced quality of life… So a big benefit of prescribing aerobic exercise treatment early after a concussion is that we keep many kids who would otherwise have had symptoms for more than a month from a prolonged absence from exercise, schoolwork, and sport participation.
Bianca: What other key points would you like to discuss regarding the topic? That’s huge to have such advanced testing done in Buffalo.
Dr. Leddy: The reason I gave the lecture the title ‘From the Heart to the Brain’ was because Buffalo has a rich history with exercise testing. As I said in my talk, I was in medical school here when Dr. John Naughton was the dean – he was a cardiologist and a sort of exercise guru who worked in the 1960s with some other people and developed cardiac treadmill testing. That’s really what treadmill testing has been traditionally used for – to test the presence and severity of heart disease and to help people who have had heart attacks and heart disease develop exercise programs for their recovery. Before he passed away, he was a patient of mine and we would talk. He said, “In the 60s when I started doing this, people said I was crazy and that I would kill these patients” and they said, “You can’t put patients who have had a heart attack on a treadmill.” He laughed and said, “Well, we proved them wrong.” And he certainly did. It has now become a standard of care everywhere.
When Dr. Willer and I started doing this, and I say Dr. Willer and me because it’s Buffalo, it’s not just me, it’s Dr. Willer just as much as it is me. We realized that some of these patients just weren’t getting better by telling them to rest until all of the symptoms go away. People were afraid physical activity after a concussion would cause brain damage and delay recovery. But we reasoned there must be a safe way to get athletes active again so why not take sort of a cardiac approach to the brain and put people on a treadmill, take their exercise intensity up very slowly, and find out where their symptoms go up more than a little bit? The idea was to take the heart rate where their symptoms went up more than mildly and give them an exercise heart rate to follow that is below where they got symptoms. That’s exactly what you do with cardiac rehabilitation. You find out where patients get angina, which is heart pain, and you give them an exercise prescription below that level. We did it for the brain instead of the heart.
Initially, we applied this approach to patients who had symptoms for more than a month because people in the field were very concerned back then that exercising somebody too soon after a concussion could kill them or cause irreversible brain damage. It was very similar to some of the criticism Dr. Naughton got in the 60s for Cardiac Treadmill Testing. We did it initially in people who were farther out from the injury and found it was effective. We then decided to do it earlier on after concussion, within the first week after injury in adolescents, specifically high school kids and showed that we could safely assess how tolerant they were of exercise. Then we used the heart rate data from the treadmill test to give them an exercise prescription. We call it, ‘exercise as medicine for concussion.’ The kids go home and do it with a heart rate monitor so they know the heart rate they are working at., which is the dose of the medicine. Just like any medicine your doctor prescribes, you want to adhere to that dose carefully.
What happens if you underdose a medication? Well, you’re not going to get the intended physiological effect. What happens if you overdose on a medication? You’ll get a side effect. It’s important they stick to the heart rate, the exercise dose. As long as they do that, even if their symptoms go up mildly, it will not delay their recovery – another important result of our work. We showed the world that it was OK to have mild symptom exacerbation during exercise after a concussion, that it didn’t harm the brain, it didn’t delay recovery, it didn’t cause them to have a stroke or a brain bleed. If you adhere to this principle of no more than a mild increase in concussion symptoms during activity, it is quite safe to keep exercising for as long as you want to. We just ask that patients try to adhere to the prescribed intensity, which is the heart rate determined after systematic exercise testing.
We know now that the “Buffalo Protocol” works quite well. It speeds recovery by about 5 days on average. Importantly, it prevents about half the kids who are at risk for delayed recovery from having that delayed recovery – and they’re the ones who are really struggling during school and cannot get back to sports.
Bianca: I guess it’s probably different with every patient, but is there a set time frame that patients undergo the treatment? Is it dependent on the case?
Dr. Leddy: It’s better to do it within the first week but it’s OK to do it later than that. Just like anything else in medicine, if you treat it earlier, you’re going to get a better response. For example, if you have a sore throat that is treatable with antibiotics, it’s much better to get the medication early on as opposed to waiting 10 days. It doesn’t mean the medication would be ineffective, but you will be feeling sick for longer. Same thing with using exercise as medicine for concussion.
It’s better to start controlled exercise during that first week after the concussion if possible but it doesn’t mean it’s not effective even if it has been weeks or months. We use aerobic exercise as part of a treatment program for people who have had symptoms for more than a month; generally, however, they need something else in addition to that. Exercise is one part of a treatment program for those with prolonged symptoms whereas if you use it early on it’s probably the only treatment they will need.
Bianca: When they go home and do the exercise, is there a timeframe it is typically recommended to do it for?
Dr. Leddy: We typically tell patients to do it for 20 minutes a day if they can. But we tell them that they can go as long as they want until their symptoms go up by more than 2 points on a 0 to 10 scale when you compare it to their pre-exercise value.
For example, if you had a concussion and you came into our clinic and we said, “Ok, we want you to go home and exercise at a heart rate of 130 beats per minute,” we would give you a 0 to 10 scale that says “How do I feel now right before I’m going on the treadmill?” You would say “Oh, I’m at about a 4. I don’t feel well but I’m not that horrible”. Then you get on the bike and after 10 minutes at 130 beats per minute heart rate, if your symptoms only increase by 1 or 2 points compared with that initial value of 4, you can keep going. Whenever you find that the value has increased beyond 2 points, we ask you to stop. Now, that can be at 10 minutes if you just started this program, but that’s OK. At least you got 10 minutes of exercise in. We just don’t want you to keep going beyond that mild symptom exacerbation point. If, however, you were still only at a 2-point change, you could go the full 20 minutes, or you could go 30 minutes or however long until you were tired or your symptoms went up. We have evidence now that the more of this type of exercise is done within the first week to 10 days after a concussion, the faster you recover.
Bianca: That’s great! So how long was that in testing prior to coming to that conclusion? How long was that study for?
Dr. Leddy: We did 2 studies, 2 randomized controlled trials and each of them took 2 years. The first one was published in 2019 in JAMA Pediatrics. The second was published in 2021.
Bianca: How many participants throughout the two years? Was it just a couple you were focusing on?
Dr. Leddy: We did around 220 combined in the two studies. Half of the subjects were randomly assigned to the aerobic exercise treatment plan. The other half were assigned to a stretching program, which is a good placebo-like condition for athletes because it gives them something they’re used to doing but it doesn’t raise their heart rate.
In the second study, we gave them heart rate monitors to go home with so we knew what most of them were doing. We published a study just last year that even those who had more severe concussions, that is they had more symptoms early on, actually did the program better and recovered faster than ones with fewer symptoms and a less severe concussion. One of the criticisms of our work before this was that ‘Oh you’re just treating the ones with only a few symptoms, they’re going to get better anyway, they feel good enough to exercise, you’re not really helping the ones with severe concussions, etc.’ In fact, the opposite is true.
Bianca: Awesome, are there any other key talking points from the lecture or the award at all that you want to be included?
Dr. Leddy: My talk was really more about the history of how the program developed and the research we engaged in. It was based upon me having really good mentors. Dr. Pendergast in physiology. Dr. Epstein in behavioral medicine and particularly Dr. Barry Willer who, if it wasn’t for him, we wouldn’t even have this program. He was interested in concussion research back in the late 90s and he came over to where I was in sports medicine. I’m not a neurologist, I’m a sports medicine doctor. I said, “Yeah, you know I treat these concussed athletes all the time. A lot of them aren’t getting better, let’s try to figure this out.” That was really the beginning of it.
It was by taking a sports medicine physiology lens to a brain injury that changed everything because the recommendation from neurologists, researchers, and neuropsychologists was “You better not disturb the brain after a concussion, you’re going to harm them and delay their recovery.” So it’s not surprising that back then doctors were telling patients, “Don’t do anything until your symptoms go away.” For athletes, though, that doesn’t make any sense at all. Imagine an athlete sprains his knee and you tell him not to do anything until the pain and the swelling go away. Well, that’s malpractice now. We know that the way to treat sprained knees and ankles is by early active and controlled rehabilitation exercise- even back in the 90s we were doing that.
Sports medicine is about early specific diagnosis and early targeted rehabilitation. The goal is to return athletes, of whatever level and age, back to the sport as safely and as soon as possible. We took that approach to the brain with a concussion and showed that it worked. It’s just an example of taking a different lens that has not been applied before to a problem. That gives you a new way to look at it and suggests a new way to evaluate and treat it. I was lucky to have very good mentors here at UB and still do.
I think there is a lot of value in finding a mentor you like working with. It’s really important to consider other points of view, to evaluate a problem or issue using the lens of other disciplines. We have benefited enormously from input from physical therapists, athletic trainers, medical students, residents, neuroscientists, orthopaedic surgeons, etc. There are lots of different influences that led to the development of the Buffalo concussion program. If you go to a concussion clinic in New Zealand, Australia, Europe, Japan, or South America, they know what the Buffalo protocol is and it’s more than likely that they use the Buffalo Concussion Treadmill and Bike tests.
Bianca: That is quite the accomplishment to be well known around the world.
Dr. Leddy: Thank you, – it’s gratifying. It took a while to get there. Like anything else, it’s not easy but we just kept plugging away.
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