Barriers and Facilitators Associated With Remote Concussion Physical Assessments From the Perspectives of Clinicians and People Living With Workplace Concussions: Focus Group Study

Introduction

Background

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.

Objectives

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.

Methods

Overview

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).

Ethical Considerations

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.

Participants and Recruitment

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.

Data Collection

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.

Data Analysis

Clinician and Patient Participant Identification of Barriers and Facilitators

Two reviewers (KB and MK) used inductive qualitative content analysis [31] in NVivo qualitative data analysis software (version 12; QSR International Inc). Analysis started simultaneously with data collection so that data saturation (the point at which no new themes were identified) could be monitored. The analytic process is presented in Figure 1 [29,32-34].

To ensure that inferences being derived from the data were valid, the coders analyzed the data using the same coding scheme (consisting of codes to be used by the reviewers based on an initial review of the transcripts) [29,32]. They met weekly to peer review data analyses and discuss interpretations until reaching consensus. Frequency counts were generated for each theme by tabulating the number of times each theme was identified in the transcripts, and the percentage of times each theme was reported by the participants was presented.

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The clinician subthemes were further categorized into the predefined categories (domain-specific and general categories). Domain specific was defined as any barrier or facilitator that was discussed in relation to specific measures under the following domains: neurological examination, vestibular, oculomotor, cervical spine, and effort. General was defined as any barrier or facilitator that relates to the virtual assessment not specific to the domains. The patient participant subthemes were all categorized as general barriers and facilitators. NVivo was used to calculate Cohen κ coefficients to determine the agreement between the 2 coders for all the codes.

Clinician Participant Selection of Clinical Measures

Prereading materials were provided, to the clinician participants only, before the focus group. These materials contained descriptions of the clinical measures identified by clinicians in an earlier study [27] to be discussed in the focus groups, YouTube links with video demonstrations of the measures, and a summary of select psychometric properties of each measure. Details of these materials are described elsewhere [27]. From this list, the clinicians selected the ones that they perceived would provide the most information when administered virtually. The 2 reviewers independently documented the frequency of the clinician selection of each clinical measure.

Results

Focus Group Structure

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.

Participants

Patient Participants

Table 1 presents the demographic information of the patient participants. The age range of the patient participants was between 20 and 59 (mean 40.9, SD 13.1) years. Most participants were female (11/15, 73%). All participants were experiencing persistent symptoms after workplace concussion injury at the time of their virtual assessment. Injury dates upon participation in the focus group ranged from 9 months to approximately 4 years after a concussion. All participants reported physical symptoms as most common (15/15, 100%), followed by cognitive (6/15, 40%) and emotional symptoms (2/15, 13%).

Clinician Participants

Table 2 presents the demographic information for the clinician participants. Each focus group consisted of a mix of clinicians. A total of 8 physicians (ie, sports medicine physicians, physiatrists, and a family medicine physician) and 6 other clinicians (ie, athletic therapists and physiotherapists) participated. The clinicians’ virtual assessment experience ranged from ≤10 virtual assessments completed in the last year to over 20 completed virtual assessments completed in the last year. Most clinicians self-reported their competency of completing the in-person and virtual assessment as “strongly competent” and “competent,” respectively.

Themes

Barriers

Overview

Tables 3 and 4 present the barriers for both the patient and clinician participants. Quotes are represented as numbers in the text within each aggregate category. For example, “P12-Q1” refers to quote number 1 from Patient participant 12 or “C2-Q7” refers to quote number 7 from Clinician participant 2. For the clinicians only, categorization of the subthemes (domain specific or general) are presented. Percentage of times each theme was reported by the participants is presented. This was calculated by dividing the frequency of times a specific theme was mentioned by participants by the total number of times all themes were mentioned by participants. For example, location and setup at home was identified as a barrier by patient participants (ie, due to limited space, noise at home, being in a different province, etc) 9.9% (16/162) of the time. Clinical process–related factors were identified as a barrier by clinician participants 10.5% (21/201) of the time. Rankings associated with the barriers reported by the patient and clinician participants are presented in Multimedia Appendix 2.

Patient Participant Barriers

Organizational Level

Patient participants reported some issues with being in a province different from that of the assessing clinician. For example, some professional associations require clinicians to be licensed to practice in the province in which the patient is located for the virtual assessment (the patient may be located in Quebec and the clinician in Ontario). Participants further voiced concerns regarding privacy associated with using a videoconferencing platform such as the fear of people overhearing conversations and concerns regarding the security of the videoconferencing platform (Q1).

Individual Level

Patient participants expressed safety concerns (Q2). Participants believed that certain components of the assessment would feel safer when done in person, specifically the balance tests. They believed this would have an impact on the results; participants felt that they could “perform better” and “push out of their comfort zone” with the in-person assessments when compared to the virtual assessments.

Patient participants felt that virtual assessments could activate physical and emotional symptoms. The use of screens was commonly reported to trigger physical concussion symptoms (headaches, dizziness, vision issues, etc; Q3). Feelings of isolation and depression could be increased during virtual assessment: “you do feel very isolated” and “you are all alone and it gets very depressing.”

Patient participants also reported challenges communicating issues related to their condition and challenges building rapport with their clinicians through videoconferencing platforms (Q4).

Technology Level

A barrier identified included the perspective that less accurate information is obtained with the virtual assessment and the perspective that the virtual assessment is incomplete. The participants perceived that clinicians were unable to see subtle issues associated with their condition, such as “eye twitches” or “tremors.” Participants perceived the in-person examination to feel more in-depth and hands-on, whereas the virtual assessment felt unfinished (Q5). Furthermore, participants expressed a lack of physical contact with the virtual assessment, which seemed to be particularly noticeable for the cervical spine examination.

Participants reported issues with the internet connection and with the videoconferencing platforms used for the virtual assessment. Different clinicians using different platforms, videoconferencing platforms that are difficult to use, and the format of the required documents, such as needing to complete web-based questionnaires, were identified as challenges to completing the virtual assessment (Q6).

Clinician Participant Barriers

Organization Level

Lack of time (due to the additional time required to set the patient up correctly on the screen in a virtual appointment) and lengthy clinical measures were identified as domain-specific barriers (Q7). Challenges due to the lack of administrative support to aid with the virtual assessment process was identified as a barrier, which also relates to the processes in the clinical setting.

Individual Level

Safety concerns were expressed with all balance measures and components of the neurological examination (eg, pronator drift due to a need for the patient to close their eyes during the test and functional squat) by clinician participants (Q8).

Environmental and patient setup was identified as a domain-specific barrier. Specifically, clinicians reported challenges with the patients’ environment, such as lacking space, and challenges getting patients in appropriate positions to complete clinical measures (Q9).

Clinicians reported that computer screens can trigger physical concussion symptoms, which makes it challenging to complete a comprehensive assessment virtually, representing a general barrier. Clinicians expressed that patients have minimal tolerance to screens, which leads to a need to take frequent breaks (Q10).

Clinicians identified challenges with communicating with patients through screens, including challenges with explaining how to complete a measure virtually and challenges associated with building rapport and forming connections with patients, reflecting a general barrier (Q11).

A lack of patient comfort with the virtual assessment and clinician stress or frustration associated with completing the virtual assessment due to technical challenges were identified as barriers. The importance of patient comfort was particularly relevant to the discussion regarding the evaluation of effort (observing if the patient is performing at optimal capacity) in a virtual assessment. Clinicians reported that due to the lack of comfort and confounding factors (ie, fatigue, symptom aggravation associated with the screen, and unclear picture), it would be very challenging to draw conclusions regarding the effort used in a virtual assessment (Q12).

Technology Level

A domain-specific barrier identified by clinician participants included an inability to complete the physical examination in its entirety. For example, clinicians reported an inability to complete a full cranial nerve examination (a part of the neurological examination) virtually and an inability to touch a patient’s neck when completing cervical spine palpation. Clinicians also questioned accuracy for certain measures (such as the modified Balance Error Scoring System and oculomotor tests) when administered virtually (Q13). Furthermore, clinicians expressed challenges associated with identifying subtle deficits experienced by patients and an inability to assess comorbid conditions. Most of these were limitations identified due to the quality of current technology (clarity of the image on the screen).

Clinicians identified an inability to get an understanding of the full picture, such as missing body language cues due to only being able to see a patient’s upper body. Camera limitations were discussed (Q14).

Camera, device, and internet issues were identified as general barriers to completion of the virtual assessment. Unstable internet, the use of different devices (particularly mobile phones), and positioning of the camera were all barriers identified that could influence the quality of the virtual assessment (Q15).

Facilitators

Tables 5 and 6 present the facilitators for both the patient and clinician participants. Rankings associated with the facilitators reported by the patient and clinician participants are presented in Multimedia Appendix 3. A figure presentation of the overarching themes, subthemes, and codes is presented in Multimedia Appendix 4 (patient participants) and Multimedia Appendix 5 (clinician participants). Definitions of the subthemes associated with Tables 3 and 4 are presented in Multimedia Appendices 6 and 7, respectively.

Tables 7 and 8 present the clinician- and patient participant–identified benefits associated with the virtual concussion assessment. While not necessarily facilitators to the use of virtual assessments, the participants identified some benefits to this approach. The information is presented in the same format as has been for the barriers and facilitators, as described earlier.

Patient-Participant Facilitators and Benefits

Organizational Level

A facilitator identified by the participants included having another health care professional in person with them (if in clinic), such as an occupational therapist, while the physician completed the virtual examination. Participants expressed that having easy access to technical support, when needed, would be helpful in troubleshooting technical difficulties and easing feelings of anxiety (Q16).

Having a choice of device used in the virtual assessment, being prepared in advance of the assessment, and using the features that videoconferencing offers (such as the record function) were facilitators identified by the patient participants that all relate to the process and format in which the assessment is delivered. Specifically, participants reported that having the ability to choose the device and screen size used for the virtual assessment would encourage use of the virtual assessment. Participants felt that having at least one in-person assessment, reflecting a hybrid approach, was helpful to enhance their feelings of comfort with the virtual assessment. Advanced preparation was another key facilitator identified. Participants felt that being contacted before the assessment and being provided with information regarding what to expect would be helpful (Q17).

Having easy access to care was a benefit of virtual assessment use. Participants valued having access to care particularly when they were unable to attend in-person assessments due to various reasons (COVID-19 pandemic restrictions, comorbidities, unable to drive, etc; Q18).

Individual Level

Implementing symptom management strategies throughout the virtual assessment was identified as a facilitator. When clinicians offered screen breaks or recommended symptom management strategies to use during the assessment, such as using blue light glasses, the virtual assessments were more manageable for participants (Q19).

Having equipment such as a chair or another person (a partner or family member) at home were facilitators related to both the individual- and organization-level aggregate domains identified by patient participants. Participants reported feeling safe completing their assessments at home with these safety measures in place (Q20).

Technology Level

A sense of ease, comfort, and control with virtual assessments was expressed as a benefit. Specifically, feeling that care was not jeopardized when assessed virtually and a sense of virtual assessments being more convenient, comfortable, and requiring less energy were facilitators identified (Q21). Furthermore, the participants felt that they could be more independent with the virtual approach (eg, not rely on others to drive to be able to attend an assessment) and could control their environments better at home when compared to a hospital or clinic setting.

Clinician-Participant Facilitators and Benefits

Organization Level

Adequate preparation and integration of the virtual assessment with the in-person assessment (hybrid approach to care where the virtual option is available, if needed) were identified domain-specific facilitators. Clinicians expressed that sending information in advance of the assessment and informing patients of what to expect improved ease of completing a virtual assessment (Q22). In addition, having a backup in case the primary connection for the virtual assessment failed would help with the flow of the virtual assessment. These facilitators relate to the format in which the assessment and material needed for the assessment are delivered.

Using resources to support administration of certain measures virtually, such as mobile apps that can measure cervical spine angles or eye movements or systems that could analyze vestibular deficits, were identified as domain-specific facilitators by clinicians (Q23). For example, there are apps (such as HeadCheck) that clinicians reported using in their virtual practice that provide objective information on eye movements.

A domain-specific facilitator identified by the clinician participants included having access to clinical support in person. Clinicians reported that this would be particularly helpful due to safety concerns and due to challenges seeing subtleties over camera (Q24).

Clinicians reported the benefit of improved access to care that virtual care provides. Clinicians perceived that virtual assessment approaches could eliminate the need for patients to drive to assessment centers (or rely on a family member to drive) and perceived that this could facilitate easier and quicker access to care for the patient (Q25).

Individual Level

Similar to patient participants, clinicians expressed that holding onto a physical support (eg, chair, wall, and another person) facilitated the administration of certain measures virtually and was expressed as useful for most domains of the physical examination. Furthermore, access to emotional and technical support (a family member or partner) at home could help with the virtual assessment process. This also allows clinicians to gain the family member perspective, which could aid in getting collateral information and obtaining a more comprehensive understanding of clinical status (Q26).

Having an appropriate space to complete the virtual assessment at home and appropriately setting up the patient on the screen were identified as domain-specific facilitators. Clinician participants identified strategies, such as placing the computer on a shoebox and asking the patient to stand in a corner to complete certain measures virtually such as balance tests, would facilitate completion of the physical examination (Q27).

Technology Level

Clinicians reported a sense of ease, comfort, and convenience with virtual assessments. Particularly, they expressed that the virtual assessment allows patients to be in the comfort of their homes and eliminates some of the obstacles that need to be overcome to get to assessment centers (time, driving, and costs), which relates to a general benefit (Q28).

Clinician participants reported that using most of the measures to identify gross deficits (rather than specific deficits) or that using some of the measures for subjective information rather than objective information was a facilitator to its use in a virtual context (Q29). For example, when using the modified Balance Error Scoring System, clinicians reported that counting errors is a challenge over camera, so the measure is administered to identify gross balance deficits rather than identify subtle issues. Similarly, when administering the Vestibular/Ocular Motor Screening (VOMS) tool, clinicians rely on subjective reports of symptom changes and do not use this measure to identify specific ocular or vestibular issues.

Clinician Selection of Measures That Would Work Best in Virtual Assessments

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.

Discussion

Principal Findings

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.

Limitations

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.

Conclusions

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.