Concussions result from indirect or direct impacts to the head and usually lead to neurological symptoms [1]. While most individuals who sustain a concussion recover within days of the injury, an estimated 10% to 20% of individuals experience persistent symptoms after the injury requiring intervention [2]. Following a concussion sustained in the workplace, there is an increased likelihood of reporting persistent symptoms [3,4]. This may be attributed to several factors, including access to worker’s compensation, fear of returning to the site of the injury [3], and the demands of work that can exacerbate symptoms. Timely access to care can be challenging for workers in remote and rural communities due to poor access to specialized clinicians [5-8]. The COVID-19 pandemic further presented challenges to accessing in-person care for workplace injuries [9,10].

Virtual care, the remote delivery of health care services that may address some of these challenges, often uses visual and audio communication or videoconferencing technology [11,12]. For patients with a concussion, virtual care could improve access to care [7,13-16] and has been shown to be beneficial from the perspective of clinicians, although not without limitations [17]. A recent study by van Ierssel et al [17] explored the perspectives of 25 clinicians on assessing and managing concussions through virtual care approaches. They reported that clinicians believed that virtual care could be beneficial for monitoring the functional status at follow-up, for screening patients, and for identifying those who may require further in-person assessment. Moreover, participants did not believe care to be jeopardized by virtual follow-up assessments. In general, the literature supports the view that clinicians recognize advantages to using virtual care approaches for concussion assessment and management, but there is a need to further explore the effectiveness of virtual assessment in the context of concussion care.

There is limited information on the barriers and facilitators associated with virtual care from the perspectives of people with a concussion. One study [18] explored virtual care experiences from the perspectives of patients, caregivers, and health care providers in the geriatric medicine setting. Uncertainty about accuracy (ie, the ability to validly identify deficits) was reported as a concern with patients and caregivers, who questioned whether a comprehensive understanding of patient status was captured [18]. However, patient and caregiver participants in this study highlighted the benefits, such as improved access to care and engagement with caregivers in appointments, emphasizing that a hybrid approach to care may be superior to virtual-only approaches [18]. However, with regard to concussion care, experiences may differ from those in the geriatric medicine setting. People with concussion may experience greater fatigue when compared to other populations due to screen exposure [19]. Furthermore, most concussions occur in younger people (<30 years) when compared to the geriatric population [20], who are potentially more comfortable and less intimidated by the technology involved [21]. Both the clinician and patient perspectives are important for a comprehensive understanding of the potential usefulness of the technology [11], and therefore, a detailed exploration of experiences associated with virtual assessments from the perspectives of people living with workplace concussion is needed.

There is a critical need to identify the barriers and facilitators associated with the main domains of the physical examination (ie, neurological examination, vestibular, oculomotor, and cervical spine), when completing a hands-on comprehensive assessment is not possible [22-24]. There is an additional need to evaluate the effort used during an assessment, which is particularly the case in the context of injured workers, as the presence of and access to compensation following a work-related injury could influence performance (if low effort is used) and subsequent findings on an examination [25]. While the evaluation of effort is not a clinical domain, it is considered a component of the examination used to interpret the clinical results and is therefore presented as a separate “domain” throughout this paper.

This study aimed to (1) explore the barriers and facilitators related to engaging in virtual concussion assessments from the perspective of people living with workplace concussions; (2) document the barriers and facilitators associated with completing a virtual concussion examination (ie, neurological examination, vestibular, oculomotor, and cervical spine domains and effort) as identified by concussion expert clinicians with experience in completing virtual assessments; and (3) document concussion expert clinicians’ opinions regarding which clinical measures from the aforementioned domains work best in a virtual practice. This study focused on the assessment of physical domains due to substantial adaptations required to administer these measures virtually and due to individual interpretations of how best to administer these when compared with measurements of emotional or cognitive health.

In this paper, we report on a part of a mixed methods study. The full protocol [26] and initial findings from surveys and a working group to identify targeted clinical measures [27] have been recently published. This paper reports on focus group discussions related to the previously identified clinical measures. This paper follows the guidelines outlined by the Standards for Reporting Qualitative Research (Multimedia Appendix 1).

Research ethics approval was obtained from the Ottawa Health Sciences Network Research Ethics Board (20210575-01H), the University of Ottawa Board of Ethics (H-02-22-7611), and the Bruyère Research Ethics Board (M16-22-006). Verbal consent over the telephone was obtained from all participants before participation in the focus groups. Privacy and confidentiality were maintained by using deidentified data. Participants were provided with a CAD $30 (US $22) gift card for their participation in the focus group.

Patient participants were recruited through the Ontario Workers Network clinic at the Ottawa Hospital. Eligible patient participants were adults (aged >18 years) who had attended at least one initial or follow-up virtual assessment following a workplace concussion injury through a videoconferencing platform. Purposive sampling was used to identify these eligible patient participants [28]. The sampling strategy was designed to ensure adequate distribution of specific characteristics such as patient age and sex. Eligible participants were approached by telephone and were provided with a description of the aims of the study before consenting. We attempted to recruit at least 5 participants per group [29,30]; however, some participants did not attend the scheduled group or had to cancel, so the groups ranged from 2 to 5 participants. We attempted to include a diverse group of participants in terms of age, date since injury, and sex.

Eligible clinician participants were Canadian-practicing clinicians (ie, neurologists, physiatrists, family medicine physicians, sports medicine physicians, physiotherapists, athletic therapists, and kinesiologists) with expertise in treating concussions (not specifically workplace concussion) and with experience in completing virtual concussion assessments. Eligible clinician participants were recruited through targeted emails and outreach to rehabilitation clinics across Canada. Purposive sampling was used [26] to ensure the distribution of certain characteristics, such as clinician profession. Similar to the patient participant groups, we attempted to recruit 5 to 7 clinicians per group; however, due to scheduling challenges, the groups ranged from 4 to 5 participants. We attempted to include a diverse group of clinicians in terms of clinical profession.

In a previous paper [24], we surveyed clinicians concerning their use of clinical measures in their in-person practice. The clinicians rank-ordered the measures based on relevant measures to their in-person practice within the following domains: neurological examination, vestibular, oculomotor, cervical spine, and effort assessment. We then documented the perceived feasibility of administering these measures virtually, based on expert clinician opinion [27]. The measures identified in this work were further discussed in this focus group study.

Focus groups were completed over a videoconferencing platform (Microsoft Teams) from August 2022 to January 2023. Consenting participants attended one focus group (either a clinician group or a patient group). Semistructured guides (refer to the study by Barnes et al [26]) were used to direct the discussion for both clinician and patient focus groups. The guides were reviewed and revised by the study team before the commencement of the focus groups to confirm the appropriate wording of the questions and ensure the questions captured the aspects that the team was aiming to explore. The patient interview guide consisted of 9 questions regarding practical and technical barriers and facilitators to undergoing a virtual assessment and sought feedback and recommendations for virtual assessments. The clinician interview guide included 12 questions related to (1) practical and technical barriers and facilitators to virtual assessments and (2) domain-specific questions related to the neurological examination, vestibular, oculomotor, and cervical spine domains and effort assessment, as well as those prompting the participants to discuss and select the outcome measures [24,25] within each clinical domain that they felt would work best in a virtual practice.

Focus groups were moderated by KB, a female registered kinesiologist. KB held a master’s degree in human kinetics and was a PhD candidate in rehabilitation sciences at the time of the study. KB worked as a kinesiologist for 2 years both in a complex care clinic where Workplace Safety and Insurance Board concussion-injured workers were assessed and treated as well as in home-based kinesiology services. A notetaker (MK) was present to prevent loss of data, record nonverbal expressions and key discussion points to add further context to the recording, and aid with technical issues. The focus groups were audio-video recorded and transcribed verbatim by KB.

All participants completed a demographic form following the completion of the focus group. Questions related to age, sex, work status, virtual assessments completed after the concussion, and symptoms were completed for patient participants. Questions related to age, sex, clinical profession, clinical experience, volume of practice of patients with a concussion, virtual assessments completed in the last year, and self-perceived competency associated with completing the in-person and virtual assessment were completed for clinician participants.

Overall, 7 focus groups (4 with people living with workplace concussions and 3 with clinicians) were completed. Saturation was reached after 3 groups for both the patient and clinician groups; however, as we experienced challenges recruiting male participants, we conducted one additional male-only focus group. This allowed us to have 2 mixed-sex focus groups, a female-only focus group, and a male-only focus group. Focus groups were made up of 2 to 5 participants. A total of 15 people with workplace concussions and 14 clinicians participated in the focus groups. The focus group discussion lasted between 30 and 90 minutes each as some groups contained only 2 participants and some groups contained up to 5. Cohen κ was calculated as 0.80 across all groups (considered substantial agreement) for all codes for both the clinician and patient participant focus groups.

The frequency of selection of each clinical measure is presented in Table 9. Within their respective domains, clinicians identified the finger to nose test, balance testing, the VOMS tool, saccades, and cervical spine range of motion as the measures that would work best and give the most relevant information in their virtual practice out of the list of measures provided.

This study used focus groups to identify barriers and facilitators associated with virtual concussion assessments. To our knowledge, this work is the first to explore the barriers and facilitators associated with virtual concussion assessments from the perspectives of people living with workplace concussions. The findings of this study indicate that a hybrid approach (first assessment completed in person and follow-ups completed virtually) to concussion assessment is preferred by both people living with workplace concussions and clinicians. It appears that the virtual approach to concussion assessment is of value, highlighting a need to further explore and consolidate information on the effectiveness of the clinical measures used in concussion assessments when administered virtually. People living with workplace concussions seem to prefer having the initial assessment with the care team in person, followed by virtual assessments as needed. Virtual assessments were perceived as most appropriate for follow-ups and for a global screen of deficits rather than for identifying specific deficits.

In this study, overlapping themes were identified for both clinician and patient participants. Interestingly, both clinicians and patients commented on difficulties associated with completing the required documents (questionnaires) virtually. Both expressed a need to verbally complete the required documents with the patients over the phone or have support in place so that they have help to complete them before the virtual assessment. This is in line with Beaton et al [43], who documented that the preferred method of information delivery for people living with a concussion is in auditory format.

Both clinicians and people living with workplace concussions highlighted that inaccurate values may be obtained with the virtual assessment, which was the most common barrier identified (identified by patient and clinician participants approximately 35% and 26% of the time, respectively). Objectivity in assessments conducted using virtual care is a challenge, particularly with the lack of clarity when observing certain movements through videoconferencing, which in turn influences clinicians’ abilities to adequately assess patients [24]. Virtual care has been used for the management of concussions; however, an identified limitation is the challenge associated with the remote physical examination [24]. Subtle abnormalities such as those observed during objective oculomotor assessments could be difficult to capture through videoconferencing [7]. Furthermore, a neurological examination in its entirety is not currently feasible through videoconferencing [44,45]. Particularly, a complete evaluation of the cranial nerves (fundoscopy) cannot be completed along with motor and sensory function, cervical spine palpation, strength testing, muscle reflexes, and neuro-otology maneuvers such as those for vertigo [7,15,36,46]. Both clinicians and patients expressed challenges associated with using technology, including the virtual approach to assessment that can be symptom-triggering, safety concerns with the virtual assessment in relation to potential for falling, challenges with the setup at home, and barriers associated with communicating and establishing a clinician-patient rapport through a screen.

This study identified technical, individual, and organizational-level barriers that are in line with some of the literature on virtual care in people living with neurological conditions. Ownsworth et al [47] reported limitations associated with videoconferencing specifically, which include issues with technology and incompatibility for the patient (inability to use technology). Technical issues such as poor video or audio quality due to either the varying quality of devices used or Wi-Fi signal strength and difficulty placing the camera are identified barriers specific to videoconferencing [11]. Logistical challenges when a caregiver is not present at home to aid with the virtual session contributes to the nonfeasibility of virtual care approaches [13]. Concerns of lack of security and concerns regarding privacy in terms of family members overhearing sessions are described barriers [11], which was a concern expressed by patient participants in this study. Consistent with the findings of this study, the literature documented that the lack of resources including the lack of access to the administrative or skilled personnel support needed and lack of time, as virtual assessments are perceived to take more time to appropriately set up the patient, influence the feasibility and use of videoconferencing approaches [48]. A limitation associated with virtual assessments identified by the participants in this study includes lack of physical presence [47]. Lack of physical presence has been documented to be associated with challenges in terms of building rapport when not face to face as well as an inability to gain a full understanding of the patient’s status [47]. The patient-clinician relationship may be jeopardized if technologies are used due to the difficulties associated with building trust through screens and the challenges of clear communication [15,44,46].

From a facilitation standpoint, both the clinicians and people living with workplace concussions in this study highlighted the convenience and improved access that virtual assessments provide. Both groups emphasized the need to have appropriate supports and preparation in place; however, only the patient participants identified this as the most common facilitator (identified approximately 27% of the time). The patient participants in this study identified the importance of having easy access to technical support. This is in line with Hale-Gallardo et al [13] who reported that virtual care coordinators and technical clinicians are viewed as resources that could facilitate the adoption of technology-based care in clinical practice. Having assistants help set up the system is a necessary facilitator to videoconferencing [16]. Family support is additionally viewed as a facilitator due to the help they provided with the technical and clinical aspects of videoconferencing [11]. The increased likelihood of family members being present during videoconferencing is an advantage, which could aid with gathering information [49]. This is also helpful to aid with remembering recommendations and next steps of care. Clinician participants identified the format of the assessment and materials (adequate preparation and offering virtual assessments as a complement to in-person assessments) as the most common facilitator (identified approximately 19% of the time). Development of clear instructions and advanced planning to prepare for issues are all necessary facilitators to videoconferencing [16]. The importance of having an initial in-person touchpoint and preference for the hybrid approach was highlighted in the literature. This approach enhances the comfort of the patient with the clinician [11]. Clinician and patient understanding of the benefits of virtual approaches to care, which includes cost savings, autonomy for the user, and reduced travel and wait times act as facilitators for the use of technology-based approaches to assessment [11,16,46].

Several unique findings of this study are specific to a virtual assessment after a concussion. Specifically, the challenges with completing the virtual assessment due to screen intolerance and resulting symptom aggravation were a notable barrier to engaging in a virtual assessment. Depending on the time point in recovery, exposure to screens could be a very challenging barrier to overcome to complete a safe and effective assessment virtually. One strategy to address this issue, which was identified as a facilitator by participants, was implementing symptom management strategies (screen breaks and blue light glasses) so that the virtual assessment could be more tolerable. In addition, due to subtle deficits that are commonly experienced by people living with workplace concussions, virtual care approaches may not be currently adequate to capture these subtleties, and therefore, in-person care may be needed to identify issues that go beyond gross deficits. Furthermore, there are potential contradictions with the focus group data. For example, balance and the VOMS tool were selected as the vestibular measures that would work best in a virtual practice by clinicians. However, several issues were identified with these measures such as the challenges with visualizing subtle deficits associated with eye movements and balance when assessing virtually. Even with these challenges, the clinicians still believed that out of the measures identified in the surveys and discussed in the focus groups, these measures would be most appropriate for virtual assessments.

This work expands on some of the previous work on the clinician perspectives of virtual concussion care to outline barriers and facilitators to completing components of the physical examination [17]. Finally, this work reports on clinician-identified measures that will work best in a virtual context and identifies the barriers and facilitators associated with using these measures virtually so that the most appropriate measure for virtual administration can be selected. This work supports the identification of clinical measures to include in a virtual version of a concussion assessment, which will be further explored in a future planned evaluation study with the aim of documenting the psychometric properties of the measures. These measures will be included in a virtual assessment toolkit, which will be tested in a future study.

There are some important limitations to acknowledge in this work. The context of this work is within workplace injury, and all the patient participants who participated in the focus groups were experiencing persistent symptoms after injury at the time of their virtual assessment. Their experiences may be unique to those experiencing injuries occurring in the workplace, and therefore, the results may not be generalizable to people with concussions from other causes. Furthermore, only 27% of the patient participants were male, which indicates that the results of this study may be more reflective of female experiences. However, Merritt et al [50] reported that the prevalence of concussions is higher in female individuals, so the distribution of male individuals and female individuals in this study may be a close reflection of concussion occurrence in the working population. In addition, while attempts were made to include clinicians from various clinical fields (while focusing on professions that typically complete the physical examination), certain professions were not represented in the focus groups, such as neurology and occupational therapy. Finally, the selection of measures as most appropriate to use in a virtual assessment may be biased based on clinician experiences and practices. Clinician level of comfort with each clinical measure may have influenced their decisions.

It is important to note that patients and clinicians identified limitations and challenges associated with virtual care. A hybrid approach to concussion assessment seems to be the most accepted model to assessment from the perspectives of both clinicians and people living with workplace concussions. This study demonstrates the acceptance and perceived value of virtual approaches in concussion assessment and therefore provides a rationale for further exploration of the psychometric properties of the virtual concussion assessment. There is an identified need to establish reliability and validity properties of the virtual concussion examination.