Concussions or mild traumatic brain injuries affect thousands of Canadians every year [1]. Workplace injuries account for a notable portion of nonsport concussions [2]. Terry et al [3] reported that approximately 25% of adult concussions occur at work. Workplace injuries resulting in concussions pose a significant challenge for employers and insurers while disrupting the lives of the workers due to greater recovery times compared to non–work-related concussions [4]. In general, roughly 10%-20% of individuals who sustain a concussion experience symptoms lasting beyond the one- to two-week typical recovery time frame [5,6]. In the workplace context specifically, prolonged symptoms lead to reduction in productivity at work or even disability, which in turn has an economic impact on people, companies, and government agencies [3]. Although it is apparent that there is a need for further support and research in the workplace concussion rehabilitation field, a focus on the evaluation of concussion will be an important starting point to individualizing care.

Assessing symptoms and function after concussion presents clinicians with challenges due to the complex and diverse symptom presentation and a lack of sensitive and reliable clinical assessment measures [7]. Symptoms may be physical (such as dizziness, balance issues, headaches, neck pain, and vision difficulties), emotional (such as irritability and disinhibition) or cognitive (such as memory and concentration difficulties) [7-11]. All the domains of concussion symptoms must be considered [8]. Currently, however, a gold standard test to evaluate all concussion symptoms does not exist. Commonly, a battery of tests and symptom self-reports are relied upon [7,12,13]. For example, the Balance Error Scoring System and the Sensory Organization Test are used to assess balance deficits following a concussion injury [14]. The King-Devick test and the Vestibular Ocular Motor Screen may be used to evaluate oculomotor deficits [14,15]. Furthermore, the psychometric properties of the tools involved are often underdeveloped, and clinical utility varies. There is an additional challenge with all assessments of injured workers because of access to compensation that may interfere with the validity of effort provided during the assessment [3]. Measures that allow the examiner to ensure that a valid effort was made to complete the assessment should be considered.

With the shift in clinical service delivery to virtual health care driven by the COVID-19 pandemic, the need for valid and reliable approaches to virtual concussion assessments has become more pressing. In addition, people living in remote areas or for whom travel is difficult due to comorbidities continue to have a great need for assessment that can be carried out at distance [16,17]. Such assessment would also be helpful for people whose symptoms are aggravated by travel and environmental factors such as noise and light [18].

Clinicians are currently completing virtual concussion assessments using a variety of clinical assessment measures; however, as with in-person assessments, there is no standardized approach to assessing adult concussions virtually. Resources have been developed to support completion of the virtual concussion examination, including a training manual for the examination and a living guideline that outlines considerations for the pediatric examination [19,20]. Comparison of the measures identified in these resources when administered in an in-person and virtual context has not yet occurred.

The psychometric properties of many of the assessment measures being used have not been established for use in person or virtually. Accelerated adoption of information and communication technology has been occurring globally to enhance service delivery during the COVID-19 pandemic; however, it is unclear whether the outcomes of assessments completed virtually are consistent with assessments performed in person [21,22]. It is, therefore, important to understand if the measures used to assess concussions in person could provide equivalent results when used virtually [23].

Overall, there are multiple clinical assessment measures being used by clinicians to assess the physical domains impacted by a concussion injury. There is no standardized tool kit of measures available with established psychometric properties that are relevant and feasible in a virtual context, nor are there guidelines outlining specific measures to use in the adult population [12-14].

The objective of this mixed methods study is to produce a tool kit of measures that can be used in virtual assessments of concussion’s physical symptoms.

Ethics approval was obtained by the Ottawa Health Sciences Network Research Ethics Board (20210575-01H) in September 2021 followed by the Bruyère Research Institute Research Ethics Board (M16-22-006) and the University of Ottawa Board of Ethics (H-02-22-7611) in February 2022.

We presented a protocol for a mixed methods study to identify the most appropriate clinical measures to include in a virtual assessment. We hypothesize that the measures identified in the surveys will vary based on clinical profession. We anticipate reliability properties of the identified measures to range from moderate to strong (intraclass correlation coefficients=0.41 to above 0.81). It is anticipated that the working group and focus group discussions will lead to an understanding of some of the real and perceived barriers and facilitators related to participating in or completing a virtual concussion assessment. We expect patient-perceived challenges to relate to the technical issues with technology and clinician-perceived challenges to relate to the challenges associated with engaging in hands-on approaches in virtual care.

A toolbox of concussion physical assessments has been proposed by Matuszak et al [14], which includes measures to assess domains that are frequently impacted by a concussion injury; however, many of the physical assessment measures used in the concussion population have limited psychometric data. The proposed toolbox includes evaluation of vital signs, mental status, neurological examination (ie, cranial nerves, manual muscle testing, and reflexes), head and cervicothoracic evaluation, balance or coordination assessment, and vestibulo-ocular evaluation [14]. This toolbox is proposed for the in-person examination. However, many of the virtual resources and guidelines include similar evaluations [19,20].

Although telehealth has existed for a long time, the COVID-19 global pandemic has increased both its need and its use in delivering health care services [34]. The COVID-19 pandemic has accelerated the need for telemedicine-supported remote assessments and has pushed both clinicians and researchers to determine what aspects of medical care could be feasible in a telehealth context [34,35]. A scoping review by O’Neil et al [36] noted that videoconferencing could be a valid means to remotely assess patients with moderate to severe traumatic brain injury. In addition, according to Fjeldstad-Pardo et al [37], no adverse events have been identified during participation in telerehabilitation, indicating that it is a safe approach to deliver services. Specifically, telerehabilitation has been reported to be feasible and effective for the intervention and management of neurological patients [38]. There has been a significant increase in the use of virtual assessments, with a rapid transition due to the pandemic. This transition limited the ability to implement virtual care using a planned and organized approach. The transition was a reaction to the pandemic rather than a planned response [39]. Due to this reactionary response, clinicians have been forced to complete remote assessments with limited information on the accuracy and reliability of the measures used in these assessments.

It is, therefore, important to understand which assessments clinicians are completing both in person and virtually in the context of the concussion examination. A study by Tobler-Amman et al [40] found that correlation values were low when measures assessing similar constructs in people living with stroke were administered in person and virtually. Although clinicians thought the measures were assessing the same construct, the low correlation values indicate that administering the measures in the two different contexts may not provide the same information. Similarly, a study by Wang et al [41] on people living with Parkinson disease found that participants elicited a weaker reach when an assessment was completed virtually compared to in person. In the context of the concussion examination, understanding which assessments are being conducted and how the assessments are being conducted both in person and virtually is necessary to determine the equivalence of the assessments when administered in both contexts. Psychometric properties should be established in both in-person and virtual contexts of use to ensure accurate and reliable implementation in both contexts [23]. If the outcome measures used in person have poor documented psychometric properties or no documented psychometric properties, there may be additional challenges to validity and reliability when using the measure in a virtual context. It is important to gain an understanding of the properties of the clinical measures and their ability to produce equivalent results to the in-person assessment to inform decision-making in terms of their use in practice and their potential use in the virtual context [42].

With the increase in need for the uptake of telehealth in rural and remote areas, and now globally due to the COVID-19 pandemic, standardization of a feasible virtual concussion assessment is needed. The identification of the clinical measures that are most relevant and contribute the most reliable information in an adult concussion examination and the identification of the barriers and facilitators associated with using these specific measures in a telehealth context is an important first step to lead to this standardization. The results of this study and the future planned prospective evaluation study will be published and disseminated to targeted end users and networks.

An important strength of the Delphi method is that it is a useful approach when lack of clarity exists, which is likely the case in the concussion assessment field [43]. It is apparent that although the Delphi approach has many strengths, it also has some limitations. Generally, the Delphi approach lacks agreed-upon standards or consensus [43].

Focus groups have been reported to be beneficial when participants are in different geographical locations [30], which will occur in this project due to the need to gain input from various clinicians and from people living with concussions to inform the follow-up studies. Some important limitations of focus groups include the following: the group setting nature of the focus groups may discourage participants from sharing their input; similarly, one single participant may dominate the focus group discussion (ie, overpower other participants) [30].

This mixed methods study will identify the assessment measures that are currently being used in person to evaluate people living with concussions. This study will further identify the barriers and facilitators as well as the challenges and benefits associated with using the identified measures, virtually. Psychometric properties documented in the literature of the in-person measures that will be discussed in the focus groups will be described. Results from this study will inform the selection of measures to include in a virtual assessment tool kit, which will be tested in follow-up studies. It is apparent that there are multiple gaps in the clinical assessment of concussion. There appears to be a need to further explore and expand on the understanding of the measures used to assess individuals experiencing prolonged symptoms in person; however, there is currently a need to explore the use of these measures in a virtual context. The limitations of the COVID-19 pandemic have highlighted the need for a rapid change in service delivery to virtual means, and although limited information exists regarding concussion assessment in a virtual context, remote assessments are currently being conducted in clinical practice, and therefore, need to be better understood.