Move&Connect-Youth: A Virtual Group Intervention for Youth Experiencing Persisting Symptoms After Concussion

ABSTRACT

Move&Connect-Youth (M&C-Y) is an interdisciplinary virtual group intervention for youth experiencing persisting symptoms after concussion (PSAC) that includes psychoeducation, active rehabilitation, and goal-setting. Using an intervention mapping framework, this paper describes the iterative development of M&C-Y and findings from initial feasibility testing. Ten youth participated in M&C-Y completing pre-intervention demographic questionnaires and semi-structured exit interviews to understand participants’ experience and gather feedback. M&C-Y was feasible based on apriori criteria and findings from interviews provided insights related to: (1) intervention structure, (2) intervention engagement, and (3) intervention takeaways. M&C-Y is a meaningful, feasible, and engaging intervention for youth with PSAC.

KEYWORDS:

• Concussion
• feasibility study
• interprofessional care
• intervention development
• pediatrics

Introduction

Up to 30% of young people experience prolonged difficulties after a concussion¹ where a heterogeneous group of symptoms continues beyond four weeks after the injury.² (Note: for the purpose of this manuscript, young people/youth includes children and adolescents ≤18 years old). These persisting symptoms after concussion (PSAC) can impact physical (e.g. headache, dizziness, fatigue, sleep), cognitive (e.g. memory, concentration), and emotional/behavioral (e.g. irritability, anxiety, mood)² domains, potentially affecting the young person’s overall quality of life,^3–5 as well as their learning and achievement.⁶ The burden PSAC places on youth and their families underscores the importance of developing evidence-based interventions for this population.

The biopsychosocial model⁷ provides a useful framework for understanding the impact of concussion and for generating individualized and personal interventions.⁸ Concussion starts as a biological event with damage to the brain⁹; however, PSAC are maintained by a confluence of biological, psychological, and social factors.¹⁰ Although youth with PSAC can demonstrate ongoing neurological impairment resulting from the injury (biological element in this model),^11–13 as time passes, psychosocial factors increasingly become more important in exacerbating and prolonging their symptoms.^14–16 Psychological factors such as symptom expectation, coping strategies, and motivational issues have also been shown to predict the severity and duration of symptoms.^17–19 For example, a young person’s emotional reaction and cognitive appraisal of their situation can influence the duration and intensity of their headaches and irritability. Social factors such as a young person’s family or school can affect their recovery. By acting as a source of support, positive interpersonal experiences from peers can help alleviate a young person’s symptoms.²⁰ Inversely, a young person’s social context may act as a stressor and exacerbate symptoms. Social factors such as parental adjustment, parental distress, and family functioning are also associated with prolonged symptoms post-concussion.^14,21 Taken together, evidence for the biopsychosocial model shows the importance of taking a multilevel approach to understanding PSAC, and interdisciplinary care is recommended to support the recovery of this complex population in an integrated manner.²²

Unfortunately, empirical evidence for the comprehensive treatment of PSAC remains limited²³ and no interventions currently exist that address each domain of the biopsychosocial framework, comprehensively weaving together physical, psychological, and social treatments to tackle the multidimensional nature of PSAC. Given the expert opinion that interdisciplinary care is needed to support young people with PSAC,^24,25 we set out to create an intervention to bridge this treatment gap. To support recovery in youth with PSAC and their caregivers, our team developed the Move&Connect program, which has two parallel intervention arms for youth experiencing PSAC (Move&Connect-Youth) and caregivers of young people with PSAC (Move&Connect-Caregiver). Both interventions are delivered virtually, interdisciplinary in nature, and were co-designed by youth with PSAC, their caregivers, clinicians, and researchers. This paper will focus specifically on the development process and initial feasibility findings for the Move&Connect-Youth (M&C-Y) intervention arm. M&C-Y incorporates biological (active rehabilitation), psychological (emotions, behavior, goal-setting), and social (peer support) domains, combined with concussion psychoeducation and rehabilitation strategies. Given the high reported rates of social isolation in youth with PSAC,^20,26 it is important to allow youth the opportunity to connect with others through shared experiences. As such, M&C-Y takes place in a group setting, which has been used successfully in treating other chronic conditions such as asthma, chronic pain, and diabetes.²⁷ Active rehabilitation (AR) is a key component of M&C-Y as physical exercise interventions generally, and AR in particular, have been shown to reduce post-concussion symptoms in youth and improve their mental health and behavior^28–30; AR is now considered a best-practice standard for treatment of youth concussion.^25,31 Additionally, M&C-Y was delivered virtually as virtual interventions have been found to enable youth with a concussion to participate in their concussion management and recovery.^32,33 Virtual interventions can have numerous benefits for youth such as decreasing barriers to participation, increasing convenience and flexibility, and enhancing comfort by participating within the home environment.³⁴

To maintain rigor throughout intervention development and early-stage testing, we followed an intervention mapping (IM) framework.³⁵ IM is a planning framework that provides a detailed protocol for intervention development and evaluation.³⁵ The IM framework includes a six-step planning process from intervention concept, establishing feasibility, examining efficacy, and implementation, including: (1) needs assessment; (2) objective identification; (3) selection of theory and intervention design; (4) intervention production; (5) creation of an implementation plan; and, (6) development of an evaluation plan.³⁵ IM is an iterative process where the steps are not necessarily performed in a linear order; they can be re-visited and refined, as appropriate.³⁶ The IM approach is consistent with established knowledge translation theory^37,38 that also emphasizes needs assessments, co-design, and constant refinement with end-users.³⁹ Considering these tenets at the point of intervention concept and conducting systematic design and development is considered best-practice in intervention development and is thought to improve later intervention uptake and reduce the evidence-to-practice transition period.⁴⁰

To better establish evidence-based practices within rehabilitation healthcare, it is essential that the development of interventions be better described within the literature.⁴¹ As such, the objectives of this paper are to: (1) describe the development of the M&C-Y intervention design and curriculum, and (2) examine iterative results from intervention feasibility testing (IM steps 1–4). To do this, a mixed-method pre-post phased design was chosen to allow for data triangulation and continued intervention refinement.

Methods

Objective 1: Intervention Design and Curriculum Development (IM Steps 1–3)

Development of the M&C-Y intervention design and curriculum followed steps 1 (needs assessment), 2 (project objectives and outcomes), and 3 (intervention design) of the IM framework. Each step informed the next and iterative refinement was undertaken with the goal of designing the intervention structure and curriculum. In this section, we outline the intervention design process. All design outcomes are described in the Results section below.

Needs Assessment (IM Step 1)

Youth clients of the Persistent Concussion Clinic at Holland Bloorview Kids Rehabilitation Hospital⁴² and their caregivers were first surveyed through a quality improvement exercise to scope relative interest in a group intervention and assess broad development specifications. Survey topics included: intervention structure (length of intervention, length of sessions, timing of intervention), content (session activities and topics of interest), and physical exercises (strengthening, cardiovascular, stretching). Descriptive statistics were employed to examine survey responses.

Intervention Objectives and Outcomes (IM Step 2)

Following completion of the survey and a series of team meetings and iterative document reviews, the M&C-Y development team set and refined the intervention objectives. This interdisciplinary team consisted of an occupational therapist (AH), physiotherapist (KMo), social worker (TB), psychologist (SS), trainees and staff members (HAH, KMa), knowledge translation specialist (CP), and a youth and family member with lived experience (BK, PK).

Intervention Curriculum Design and Development (IM Step 3)

The biopsychosocial model⁷ was identified through a comprehensive literature review to underpin the intervention objectives. The biopsychosocial model is widely considered to be a useful theory for PSAC given the heterogeneous nature of resulting symptoms, as well as the impact of possible preexisting features on symptom exacerbation.⁸ The aforementioned survey results and intervention objectives were then used to develop the M&C-Y intervention structure and content.

The M&C-Y intervention structure, content, and curriculum wireframe were co-designed through a two-step process: (i) iterative design with the development team; and (ii) review of the intervention structure and curriculum wireframe with a small group of youth with PSAC through an in-person practice run of the intervention. For the first process, the M&C-Y development team used the survey results and engaged in a series of design meetings. The occupational therapist (AH) and physiotherapist (KMo) collaboratively integrated recommendations from design meetings and reengaged the M&C-Y development team for final approval.

In order to refine our intervention concept, ensure it met the needs of our end-users (young people with PSAC), and adhered to co-design principles, we engaged a small group of youth with PSAC to complete an in-person practice run of the intervention and provide feedback on intervention structure and content (n = 6, mean age = 14 years, time since last concussion = 4–12 months). This end-user feedback group was approved by the Holland Bloorview Research Ethics Board (#19–866). Qualitative exit interviews were used to explore participant experience from the perspective of both youth and caregivers. Participant feedback on the intervention concept was then incorporated and the intervention structure and content were confirmed for feasibility testing (objective 2).

Objective 2: Intervention Feasibility Testing (IM Step 4)

Design

This project stage aligned with IM step 4 (intervention production and feasibility testing). A single-arm intervention study design was completed to examine intervention feasibility. Two M&C-Y groups were delivered, where primary data collection methods included pre-intervention demographic questionnaires and post-intervention semi-structured exit interviews. Participants attended the intervention weekly for six weeks; each session lasted approximately 60 minutes. The study design of delivering two intervention groups was beneficial as we continued to receive iterative feedback, consistent with user-centered design approaches,³⁹ that was integrated into the curriculum following the completion of the first group.

Participants

Participants were recruited through the Persistent Concussion Clinic at Holland Bloorview Kids Rehabilitation Hospital. Clinic referral criteria are purposefully broad; youth must have sustained a concussion and be experiencing concussion symptoms for >4 weeks post-injury (no upper bound restrictions).⁴² Youth were eligible to participate if they: (1) were between the ages of 12–18 years, (2) completed a physiotherapy assessment in the Persistent Concussion Clinic, (3) were willing to engage in weekly sessions, and (4) had access to a reliable internet connection (Wi-Fi/cellular data). Youth could be excluded if they were unable to read or speak English, unable to provide informed consent, or did not have access to a reliable internet connection; however, no participants met these criteria. Given that this was a feasibility study consisting of a small sample, individuals with physical or developmental disabilities that could limit group participation were excluded. Ethics approval was provided by the Holland Bloorview Research Ethics Board (REB #0319).

Outcome Data

Feasibility Metrics

To demonstrate intervention feasibility, we followed criteria outlined in Orsmond and Cohn.⁴³ The intervention feasibility metrics (recruitment capability, acceptability, evaluation of resources to implement the intervention, and evaluation of participant responses) were examined against apriori criteria (see Table 1) which were established in the literature through studies with a similar design⁴⁴ or population.^45–47 Of note, Orsmond and Cohn⁴³ describe a fifth metric, refinement of data collection procedures, which examines study feasibility. Given the focus of this paper is on examining the feasibility of the M&C-Y intervention itself, this metric was not included.

Table 1. Intervention feasibility metrics and apriori criteria.

Domains	Term	Definition	Information Source	apriori Criteria
Recruitment Capability	Enrollment Rate	Number of participants who enrolled in the intervention out of the number of individuals contacted by the research team	Excel Recruitment Tracking	>10% response rate from approached participants^Citation40,Citation42
Acceptability	Retention Rate	Number of enrolled participants who completed all intervention components	Excel Data Collection Tracking Sheet	>90% retention rate among participants^Citation41,Citation42
	Adherence Rate	Attendance and engagement with the sessions	Excel Attendance Document, Field Notes, Zoom Polls	80% attendance at sessions (five out of six sessions) 80% engagement in session activity^Citation42,Citation43
Evaluation of Resources to Implement the Intervention	Intervention Management	Documentation of technological concerns and adverse events. Review of study and team resources	Field Notes, Adverse Events Form, Initiation of Safety Plan	No significant burdens or concerns^Citation41,Citation42 Appropriate study and team resources
Evaluation of Participant Responses	Participant Experience	Participants’ experience with the intervention	Semi-structured exit interviews	See evaluation of participant responses section for details

Semi-Structured Exit Interview

To better understand participants’ experiences with the intervention and to gather feedback for future M&C-Y iterations, semi-structured exit interviews were conducted after the completion of the intervention. During the interview, participants were asked open-ended questions about their experience with M&C-Y and were encouraged to share feedback about the intervention. The interview guide focused on questions related to the intervention structure, meeting peers with similar experiences, and goal-setting (for the interview guide, see supplementary material). These interviews took place over Zoom for Healthcare, ranged from 11–24 minutes, and were audio recorded and conducted by a member of the study team.

Data Analysis

Demographic information was grouped using descriptive statistics. Frequencies and ratios were used to summarize feasibility metrics and were then compared to apriori criteria.

Interview transcripts were analyzed using a qualitative content analysis approach.⁴⁸ This included multiple readings of the data, coding, and concept mapping.⁴⁹ Codes were then grouped into categories and subcategories based on their patterns and commonalities to capture participants’ experiences with M&C-Y. To enhance trustworthiness and rigor of analysis, two of the authors coded the interviews separately (HA, AL). One of the authors (HA) was not involved in any of the M&C-Y sessions to control for potential bias. Checking of results and peer debriefing with the broader team occurred throughout the analytical process, including codebook creation, coding, and category development.

Results

Objective 1: Intervention Design and Curriculum Development (IM Steps 1–3)

Needs Assessment (IM Step 1)

All youth clients of the Persistent Concussion Clinic and their caregivers who completed the survey (n = 24) expressed interest in participating in a group-based AR intervention and most preferred a 6-week intervention duration with 60-minute sessions. The surveyed youth and caregivers had several preferred psychoeducational topics, including goal-setting, coping strategies, headache management, fatigue and sleep management, advocacy, and social life support. They also indicated a preference for an equal distribution of strengthening, cardio, and dynamic stretching for the AR component.

Intervention Objectives and Outcomes (IM Step 2)

Consistent with the IM framework, the objectives for the M&C-Y intervention, included: (1) to educate youth about concussion; (2) to promote functional and active strategies to support symptom management; and, (3) to provide a space for youth to share their lived experiences with peers and promote connectedness.

Intervention Curriculum Design and Development (IM Step 3)

An integrated knowledge translation approach³⁷ and user-centered design principles³⁹ were leveraged throughout intervention development and early-stage iterative testing to ensure that the intervention was patient and family-centered. To do this, we used the survey responses, best-practice guidelines (Living Guideline for Pediatric Concussion),²⁵ as well as feedback from the end-user group, to create the foundations of structure and content for the M&C-Y intervention (see Table 2). By completing two intervention groups, minor iterative changes were made between the groups such as the addition of a warm-up prior to the start of the exercise circuit.

Table 2. Move&connect-youth intervention overview.

Session	Title	Learning Objectives	Activities	Exercises*
1	Introduction to M&C-Y & the Benefits of Exercise	1. To understand the benefits of exercise for youth with PSAC 2. To identify group norms and expectations for participating in M&C-Y	Introductions Icebreakers Setting group norms Psychoeducation about the benefits of exercise Warm-up Exercise circuits & debrief Goal-setting	Cardio: High knee march/jog Balance: Single leg stance with chair toe tap Coordination: Sock ball tosses Strength: Standing core (oblique crunches)
2	Headache Management	1. To share individual experiences with headache management strategies 2. To identify evidence-based strategies for headache management and prevention	Icebreaker Reflection on previous goals Psychoeducation about headache management Warm-up Exercise circuits & debrief Goal-setting	Cardio: Cross country ski jumps Balance: Single leg standing with under leg clap Coordination: Tissue toss Strength: Reverse/side lunges
3	Fatigue Management	1. To share individual experiences with fatigue management strategies 2. To identify evidence-based strategies for fatigue management	Icebreaker Reflection on previous goals Psychoeducation about fatigue management Warm-up Exercise circuits & debrief Goal-setting	Cardio: Running in place with heels to buttocks Balance: Single leg clock drill Coordination: Two sock toss Strength: Push-ups & triceps dips
4	Stress Management	1. To share individual experiences with stress management strategies 2. To identify evidence-based strategies for stress management	Icebreaker Reflection on previous goals Psychoeducation about stress management Warm-up Exercise circuits & debrief Goal-setting	Cardio: Jumping jacks Balance: Single leg cross-body punches Coordination: Sock/ball keep ups Strength: Body weight squats
5	Self-Advocacy Skills	1. To share individual experiences with self-advocacy 2. To identify evidence-based strategies for self-advocacy	Icebreaker Reflection on previous goals Psychoeducation about self-advocacy skills Warm-up Exercise circuits & debrief Goal-setting	Cardio: Side to side hops Balance: Curtsy lunges with side kick Coordination: Plastic bag juggle Strength: Body weight ski jumps
6	Wrap-up	1. To reflect on key concepts learned during M&C-Y 2. To identify personal accomplishments achieved throughout M&C-Y	Icebreaker Reflection on previous goals Discussion about overall intervention experience and key lessons learned Warm-up Exercise circuits & debrief Goal-setting	“People’s Choice:” Favourite exercise from each category**

*The physiotherapist provided grading and modification for all exercises. Grading example for jumping jacks: (1) arms only; (2) arms with toe taps (no jumping); (3) traditional jumping jacks; (4) traditional jumping jacks at increased speed.

**Each week participants completed a Zoom poll that asked about their favorite exercise. In the final session, participants’ favorite exercise in each category were completed.

The M&C-Y intervention was developed for both in-person and virtual settings. For this study, the intervention took place virtually over Zoom for Healthcare and was co-facilitated by two clinicians (an occupational therapist and a physiotherapist) with a study team member observing the session. Each week, the session included an icebreaker, psychoeducation, exercise circuits, and goal-setting. Prior to each session, participants were emailed a handout on the psychoeducational topic (e.g. headache management; see Table 2 for additional psychoeducational topics). The psychoeducation was led by the occupational therapist and began with an open-ended question related to the weekly topic to provide an opportunity for youth to share their experiences and personal strategies related to the topic. This was then followed by two to three didactic PowerPoint slides and a group discussion.

AR was integrated into the intervention with weekly graded exercise circuits consisting of cardio, balance, coordination, and conditioning/strength exercises (see Table 2 for exercises). Exercises were selected to be easily completed with items readily available in participants’ homes (e.g. chairs, socks, etc.), in order to make the intervention accessible and low-cost. Different exercises were selected each week with the aim of increasing intervention engagement and fostering youths’ self-efficacy in approaching new types of exercise. Exercises were explained by the physiotherapist in a stepwise manner to provide youth with multiple options for participating based on their abilities and comfort level. If youth experienced an increase in self-reported concussion symptoms, they were encouraged to take a break until their symptoms returned to pre-exercise levels. The occupational therapist completed the exercises with participants while the physiotherapist observed and provided cues. Music was played during the exercise component of the session and youth were encouraged to provide song suggestions.

Goal-setting was embedded in the intervention by asking participants to identify a goal they hoped to accomplish over the next week. Participants were encouraged to set a goal related to the psychoeducational topic or exercise. At the beginning of the next session, participants were invited to reflect on and share their goal progress over the previous week.

Objective 2: Intervention Feasibility Testing (IM Step 4)

Demographic Information

Ten youth (five in each group) participated in the complete M&C-Y intervention. All youth were experiencing physical, fatigue, emotional, and cognitive concussion symptoms prior to participating in the intervention. See Table 3 for demographic information.

Table 3. Participant demographic information (n = 10).

Demographic	Participants
Gender, n (%)
Male	1 (10.0)
Female	9 (90.0)
Age, mean (SD)	14.5 (1.58)
Age, n (%)
12	1 (10.0)
13	2 (20.0)
14	2 (20.0)
15	2 (20.0)
16	2 (20.0)
17	1 (10.0)
Preinjury history, n (%)
Headache/migraine	2 (20.0)
Psychological/psychiatric conditions (including anxiety, depression)	2 (20.0)
Developmental conditions (ADHD, LD)	1 (10.0)
None	6 (60.0)
Setting of concussive injury, n (%)
Sport-related	5 (50.0)
Non-sport-related	5 (50.0)
Time since injury (months), mean (SD)	20.60 (17.05)
Previous diagnosed concussion, n (%)
0	8 (80.0)
1+	2 (20.0)
School attendance and accommodations, n (%)
Full time attendance	9 (90.0)
Special education accommodation	1 (10.0)
Gifted program accommodation	2 (20.0)
Individualized education plan (IEP)	4 (40.0)
Organized sport participation in the last 12 months, n (%)	6 (60.0)
Therapies/supports accessed for concussion support/management, n (%)
Yes	9 (90.0)
Physiotherapy	8 (80.0)
Occupational therapy	7 (70.0)
Social work	6 (60.0)
Psychology	4 (40.0)
Massage therapy	4 (40.0)
Osteopathy	3 (30.0)
Naturopathy	2 (20.0)
Chiropractic	4 (40.0)
Vision therapy	3 (30.0)
No	1 (10.0)
Previous group program attendance for concussion management, n (%)	1 (10.0)
Previous virtual program attendance for concussion management, n (%)	2 (20.0)

Recruitment Capability

Fifteen youth were contacted by the research team with 12 (80%) that enrolled in the study, therefore, meeting the feasibility criteria for recruitment. One participant enrolled but never attended any group sessions due to scheduling conflicts.

Acceptability

Acceptability consists of retention and adherence. When considering retention, one participant dropped out after two sessions resulting in an intervention retention rate of 91% and therefore, meeting the feasibility criteria. For the two groups, attendance was 89% across all sessions surpassing the feasibility criteria of 80%. When examining engagement during the sessions, among youth participants that were present, 93% were engaged with the exercises and 95% were engaged with the group discussion. 100% of participants who completed the full intervention were engaged in discussions about group norms and weekly icebreaker activities. All engagement statistics exceed the feasibility criteria of 80% engagement.

Evaluation of Resources to Implement the Intervention

Participating in the M&C-Y intervention did not result in any adverse events, initiation of safety plans, or major technological issues or concerns. When considering study and team resources, the team had access to required resources including REDCap^50,51 and Zoom for Healthcare. No unexpected resources were required, or costs incurred.

Evaluation of Participant Responses

This metric was evaluated through semi-structured exit interviews. Overall, participants described their experience with M&C-Y as positive and enjoyable, and three main categories were developed and are described below: (1) intervention structure, (2) intervention engagement, and (3) intervention takeaways. The first category, intervention structure, describes the intervention design, content, and delivery. The second category, intervention engagement, illustrates how youth formed group connections, learned from facilitators and shared experiences, participated in AR, and practiced goal-setting skills. The third category, intervention takeaways, summarized the lessons learned and outcomes that resulted from M&C-Y participation. The section below describes the categories, subcategories, specific M&C-Y elements, and supporting quotes using research-team derived pseudonyms for participants.

(1) Intervention Structure

M&C-Y design and content. M&C-Y is composed of six weekly sessions of one hour duration, where each session begins with a psychoeducation topic and discussion followed by AR exercises and embedded goal-setting. Hazel described the session layout and balance of activities as “the perfect in-between.” In addition, the educational topics and exercises were different each week; and that was highlighted as a key feature that kept the sessions engaging as Evelyn noted: “I feel like [the group] is interesting because something is going to be different each week.”

Participants also liked the visual slides that accompanied the psychoeducation component, including the minimal text, colorful layouts, and visual figures. The content and design of the presentation slides promoted interactions among the group (see Table 4). Youth appreciated the diversity of the weekly topics designed to help support their recovery. They described the content as comprehensive, informative, and well-rounded. Georgia illustrated: “They were all really hitting the mark on which areas that were most affected by concussion, and I learned a lot from each of them.” To add, the AR exercises were described to be stimulating and enjoyable. While most participants noted the exercises to be tolerable, they also stressed that the exercises were challenging in a good way and encouraged them to improve their fitness levels (see Table 4). It was noted that including an assortment of AR exercises each week was desirable and made the sessions interesting. For example, Mae commented: “It was one of the best parts because [the exercises] were different each week, so you got to like try new things.” Since participants had different fitness levels coming into M&C-Y, it was important that facilitators were able to tailor and adapt the AR exercises based on their abilities. Personalizing the exercises facilitated motivation among group members and helped them reengage with moving their body.

Table 4. Subcategories, M&C-Y elements, and supporting quotes related to intervention structure.

Subcategories	Specific M&C-Y elements	Supporting quotes
M&C-Y design and content	Slides	Hazel: “The slides kind of helped me be engaged because it was more like a visual which I definitely was more engaged in as well as like the talking and stuff. So I learned from the visual and the person speaking.”
	Exercises	Julia: “As far as concussion wise goes, there were exercises that you could make modifications if you needed to […] I had another injury on the side so that sort of made it that I wasn’t able to do everything.” Jordan: “I feel like the [exercises] that were a little bit more challenges were the jumping ones, like the jumping jacks, or the squats.”
Enhanced convenience through virtual delivery	Benefits	Georgia: “I think I felt better because I was able to be in my own space and [was] just more comfortable and everybody was just doing their own thing and no like judgment or anything.” Julia: “I liked that I was able to do it in my own space. I know like my desk area, […] it’s the same every single time. I’m not in a new place or whatever, so I think that also helps that you’re a little bit more comfortable and willing to share because you’re in your safe space.”
Challenges of a virtual setting	Comfort	Kristen: “I mean having your camera on when you work out is always like a bit of a weird thing to get used to, but I think once you got over like the original fear of it and knew that you were with other kids it wasn’t as bad.”
	Building connections	Julia: “It’s different when you’re online because you only see […] that one part of them. […] So I think it would have been neat to meet them in person as well. I know with COVID, that’s hard to do, but I think that that would have been an easier way to connect with them as well.”

Enhanced convenience through virtual delivery. The virtual delivery of M&C-Y was described as an accessible method for intervention participation. Many youth were living far from the hospital, so, they appreciated conducting the study from the comfort of their own homes and saving on commute time. This also provided them with participation flexibility.

In addition, the experience of completing AR exercises online was described as positive and convenient. All necessary materials for exercising were readily available household items leading to feasible exercise sessions. Many described feeling comfortable exercising in their own space in comparison to new and unfamiliar environments (see Table 4).

Challenges of a virtual setting. Despite the convenience and accessibility of the program, participants discussed some challenges when exercising in a virtual setting, including limited physical space at home and feelings of awkwardness. While many of the participants enjoyed the online format of M&C-Y, some noted that in-person interventions offer a unique opportunity for forming friendships. Further, some shared that in-person interactions would have facilitated easier connections among members of the group (see Table 4).

(2) Intervention Engagement

Forming group connections. Many of the participants described relating to one another when discussing their personal stories as a group. They reported bonding with other group members due to their shared lived experiences and intrinsic understanding of each other. As Melissa described: “we are all in this together.” M&C-Y sessions quickly became a safe and non-judgmental environment where participants felt understood and welcomed (see Table 5). Many participants also shared that they had not met others with PSAC prior to M&C-Y participation, which contributed to their feelings of isolation with Jordan noting: “I found like [the intervention] helped me notice that I wasn’t like the only one that has a concussion.” Other participants highlighted the importance of connecting with other youth with PSAC in validating their own experiences with concussion. For example:

Tara: “I thought it was really good. I thought it was so cool that like, I wasn’t going through the experience alone because normally, like, when you’re sitting in a doctor’s appointment, they’re always telling you like oh, like you’re fine and it’s normal and other people do it too. But like, you don’t really get to see those people and talk to them.”

Table 5. Subcategories, M&C-Y elements, and supporting quotes related to intervention engagement.

Subcategories	Specific M&C-Y elements	Supporting quotes
Forming group connections	Group bonding	Evelyn: “I never really had a group that I could relate to everyone in the group with […] the headaches, with the concussion, with the dizziness. That was good to know that there [were] other people going through what I’m going through, especially from like, around my age.” Kristen: “Hearing how other people manage their symptoms was kind of, it was interesting- it was just nice to hear other people that kind of understood and had […] advice I would actually listen to because I knew these people would understand.”
	Rapport-building activities	Tara: “We did an icebreaker, which I really liked, that was like kind of fun to see and hear about other than concussions.” Georgia: “I just like that […] it wasn’t related to concussions or anything it was just like a fun little uh like we get to know people and share something about yourself.”
Learning from facilitators & shared group experiences	Psychoeducation	Tara: “I was kind of scared it sounded like a lot of work and I didn’t like the fact that I was going to have to do it every week. But after like the first couple sessions, I had a lot of fun with it.” Georgia: “It educated me […] on like different strategies that I hadn’t thought of before that would um, like help me manage and cope with different um fields or like areas that had been affected since my concussion.”
	Group norms	Kristen: “I thought everybody was really cooperative they would talk, and I like that we had like rules to keep our cameras on because that was something-like it makes it a lot easier to share when we can see peoples faces so I really liked that rule.”
Promoting movement through active rehabilitation	Group exercise	Mae: “I think if you did it by yourself you wouldn’t like really like get much I would try, but when you’re [exercising] with other people like you’re more like motivated, so it was like better because people are into exercise.” Ella: “And like I said, it was in a good environment where like if I wasn’t able to do like the triceps dips, for example, not being able to actually do them, like, they weren’t mean about it. They weren’t telling me just to do it. Like they were encouraging, you know.” Julia: “We got to put in song suggestions for the different music that was played, and I did really enjoy that [the occupational therapist facilitator] was [exercising] with us as well. Yeah, I think that was done well.”
	Exercise engagement	Tara: “The workout out part allowed me to experience like different workouts and what I would want to incorporate into my own daily routine.” Mae: “Well, I think for example […] like the-the [sock ball] keep ups. I like did them more outside of the program.”
Practicing goal-setting skills	Motivation	Melissa: “Well, we would just like at the end of [the session] normally be like okay so our goal this week and then like a few times during the week it would come up and I would be like ‘hey I’m gonna do this goal’ and I – and I would so.” Ella: “Um, I think it was just because like you have a set goal and if you like don’t accomplish it like that’s okay, but like at least you know like what you’re kind of going toward.”

Furthermore, the group activities were described as fun and engaging. A few participants expressed appreciation that the sessions did not feel like school because of the group-based personal and interactive discussions. Importantly, participants appreciated that the topic of discussions were not always concussion centered. Specifically, the facilitators encouraged conversations related to school and friendships leading to improved feelings of connectedness among members of the group (see Table 5).

Learning from facilitators and shared group experiences. All participants emphasized that the educational component of M&C-Y was beneficial to their learning. The ability to share information and receive advice from the facilitators and their peers was described as one of the best features of M&C-Y. Hearing each other’s perspective on recovery and learning tips and strategies promoted a feeling of cohesion among the group (see Table 5). The facilitators were frequently described as attentive, knowledgeable, and upbeat. Having access to facilitator-led education combined with anecdotal experiences was a unique outlet that encouraged participants to discuss and learn in an open manner. In addition, establishing rules in the group like keeping cameras on, and respecting privacy and confidentiality encouraged a safe learning environment. In fact, many youth shared that they wished the learning and discussions continued for longer and suggested dedicating more time to group discussions (see Table 5).

Promoting movement through active rehabilitation. Participants noted that working out in a group fostered motivation to give the AR exercises their best effort (see Table 5). For example:

Jordan: “I feel like, if I were to just exercise alone I probably just would’ve quit or I wouldn’t have done the 25 minutes that we did on Move&Connect so I feel like it really kept me going.”

In addition, they shared that the AR exercises allowed them to integrate meaningful physical activity back into their lives again. A few youth noted that they were able to apply the exercise routines outside of M&C-Y, which helped them build healthy exercise habits. For example:

Georgia: “I think the exercise sessions were good because I find like I haven’t been too active lately, so [the intervention] gave me a chance like once a week to do some exercise for half an hour.”

The AR exercises allowed participants to move their body, encouraging them to enhance their fitness and build on exercise routines. They also noted feeling good and energized after AR exercises. As Ella noted, “Yeah, I felt good afterward, knowing I actually worked out because I don’t usually do that.” For many participants, M&C-Y allowed them to experience different kinds of workouts, expanding their exercise knowledge.

Another feature that contributed to a motivating virtual environment while completing AR exercises was the addition of energizing music and the facilitators’ themselves exercising with the group. Participants highlighted the importance of receiving encouragement and praise from the facilitators while participating in the AR exercises (see Table 5).

Participants also appreciated facilitators incorporating their opinions and feedback on the AR exercises and music suggestions. For example, facilitators asked the group to vote on their favorite exercises each week, and then curated an exercise list for the last session based on the highly rated exercises. Georgia noted: “[the facilitators] showed that they value our opinions.”

Practicing goal-setting skills. Participants engaged in goal-setting activities at the end of every M&C-Y session. Most shared that setting goals at the end of each session encouraged them to begin their week on a positive note (see Table 5). Furthermore, youth described goal setting as benefiting them in several ways. The most common advantage included increased feelings of accountability and motivation to perform their goals. For example, Tara noted, “I did meet my goals almost every week.” Being a part of a group where all members were working toward goals helped youth remain accountable and task oriented while the support from facilitators and other group members eliminated negative feelings associated with not being able to achieve a weekly goal (see Table 5).

(3) Intervention Takeaways

Access to PSAC-related psychoeducation. All participants commented on the value of having access to psychoeducation about concussion management. Many youth noted being able to apply these strategies to their daily lives. For example, Hazel described how they implemented a strategy discussed during the sessions into their daily routine: “Just one of their examples was having more snacks instead of meals during the day kind of helps with fatigue and I find that worked for me. So, I’m doing that more.” M&C-Y topics were also described to be relevant to participants’ daily lives. Many commented on learning new tips supporting their recovery that they were not aware of (see Table 6).

Table 6. Subcategories, M&C-Y elements, and supporting quotes related to intervention takeaways.

Subcategories	Specific M&C-Y elements	Supporting quotes
Access to PSAC-related psychoeducation	Strategies to support recovery	Melissa: “I’ve had like uh, quite a few concussions so my headaches are really bad and that definitely helped, like even I think one of the tips was to um like put a heat pad on and I’d never done that before and now that’s my go to thing to do.” Georgia: “I think that the day we talked about time management like that day, um all the tips like really helped me um, really helped me start my schoolwork earlier and like plan my day.”
Feelings of confidence	Exercise self-efficacy	Ella: “I felt good [after exercising], knowing I worked out because I don’t usually do that.”

Feelings of confidence. Youth reported feeling accomplished following the AR exercises. For many, it increased their confidence to re-integrate exercise back into their daily routine. They also recognized additional benefits to engaging in physical activity such as an increased energy and fitness levels. For instance:

Tara: “I felt that like at the first session when we were doing the exercises, it was kind of hard to keep up, but at the end, it was a lot easier and now, like I’m working out like on my own time.”

With goal-setting activities done during sessions, it instilled self-confidence among participants. For example, Kristen described: “It was also just kind of nice, myself to see what I could improve on and then come back and actually have some good news which I liked a lot.” In general, the M&C-Y group was described as enjoyable, with many participants noting that their experience was positive and that they looked forward to the sessions every week (see Table 6).

Suggestions for Improvement

Participants provided several minor suggestions to improve group delivery, including additions of specific exercises (e.g. stretching, different exercise adaptations), and dedicating more time for group discussions and conversation. See Table 7 for further details.

Table 7. Suggestions for improvement.

Suggestion	Supporting Quotes
Addition of stretching exercises	Julia: “I would maybe say to- I know that it’s only an hour so it’s sort of hard but to maybe include like some stretching into it because I know that that’s a huge part in your recovery, especially when it’s like mine.”
Additional time to discuss group experiences	Kristen: “Uh, I mean I think I would have liked to connect with the individuals a bit more, I liked all the topics, but maybe even to have like a session where like we learn more about each other’s experiences and I know we did do one of those, but I just wanted to know more about them by the end then I got to it- it felt like very little time, but yeah other than that I liked everything.”
Addition of different levels of exercises	Melissa: “like say you brought in three different variants of an exercise, like medium, easy, and hard, then you could choose which one you wanted to try for or you could start easy and go harder and like if you can’t go any harder than you just stay at the easy.”

Discussion

In this study, we used an IM framework and an integrated knowledge translation approach to describe the development of M&C-Y, a group-based interdisciplinary intervention for youth experiencing PSAC. Secondly, using apriori criteria, and rigorous data triangulation methods, we assessed the feasibility of delivering M&C-Y within a virtual setting, as well as the experiences of the youth participants.

As outlined above, we used a multistep approach to ensure our intervention design decisions were purposeful, family-centered, interdisciplinary, and grounded in youth, family, and clinician experiences. Needs assessments led to the development of a curriculum wireframe and an end-user feedback group trialed the intervention, providing iterative suggestions which were further incorporated into the final intervention design and curriculum. The intervention is group-based to promote socialization, connectedness, and address reported feelings of isolation. Active skill building is layered on top of this supportive foundation including the provision of weekly evidence-based psychoeducation, multidomain exercise circuits, and embedded goal-setting activities. The end product was the version of M&C-Y co-facilitated by a physiotherapist and occupational therapist as part of the feasibility testing described within this paper (objective 2).

For this feasibility study (objective 2), data triangulation methods clearly demonstrated that administering M&C-Y is feasible within a virtual setting. All intervention feasibility metrics collected exceeded our pre-established criteria demonstrating high enrollment, retention, and adherence rates, and appropriate resources to implement the intervention. Overall, participants described their experiences with M&C-Y as positive and enjoyable. This included the design and content of the intervention that participants felt were enhanced by the convenience offered by the virtual delivery. As expected, given the purposeful construction of the group elements of this intervention, participants described the importance of many different facets of improved connectedness with peers with similar lived experiences, including forming group connections and learning from peer participants and the group facilitators. The important role that peers with similar concussion experiences can have in providing social support and enhancing recovery has been emphasized in the literature.²⁰ Increased confidence to engage in activity following completion of the intervention was noted and participants felt that the intervention promoted body movement through fun, engaging, and achievable low-intensity exercises. Skill building surrounding goal setting was highlighted as participants had weekly opportunities to practice this skill throughout the intervention. Enhanced knowledge about concussion management and prolonged symptoms was also reported by youth. Finally, participants were keen to provide suggestions of ongoing enhancements for the M&C-Y intervention with thoughtful but minor, recommendations for program additions (stretching, group discussion topics, leveled exercise options) that can be integrated into future iterations of M&C-Y.

The M&C-Y intervention is aligned with pediatric concussion best practice guidelines that recommend interdisciplinary care for the treatment of PSAC.^24,25 Extending this interdisciplinary concept by incorporating family-centered care was also found to be valued by youth with PSAC and their caregivers, and together they enhance rapport and contribute to more positive relationships.⁵² Additionally, these best practice guidelines also recommend AR as a key component of this care for youth post-concussion.^24,25 M&C-Y builds on past interventions for youth with PSAC^29,45,53,54 by delivering the intervention virtually, in a group format, and combining AR with psychoeducation, skill development, and goal-setting.

Importantly, M&C-Y participants tolerated the virtual delivery of the intervention and the accompanying screen time while also forming connections with other youth with a shared experience. This is consistent with a recent study that found that screen time was not associated with greater concussion symptoms 30 days after an injury compared to those with an orthopedic injury.⁵⁵ There has been an increase in virtual interventions with the delivery of a group-based intervention for individuals with a traumatic brain injury,⁵⁶ and others individually tailored for youth with a concussion.^32,33 In one of the studies that delivered a concussion intervention individually to youth participants over a videoconferencing platform, youth expressed that participating in a virtual intervention was convenient, reduced barriers, and enhanced their ability to participate in their concussion management and recovery.³³ This is aligned with our findings where participants described the virtual delivery of M&C-Y to be convenient, flexible, and lead to increased comfort while exercising. Additionally, a study exploring the delivery of virtual care for youth with concussion found that the therapeutic alliance and care satisfaction were similar between in-person and virtual session delivery.⁵⁷

Limitations and Future Directions

This study has some limitations worth noting. Firstly, participants were recruited from a hospital-based clinic in a large metropolitan area where participants may represent a privileged group of individuals with increased access to concussion services. In order to capture this, more comprehensive youth demographic information related to socioeconomic status and race/ethnicity will be addressed in future iterations and trials of the M&C-Y intervention. The virtual nature of M&C-Y may make it a more accessible intervention for youth in rural communities, and broader recruitment to target these populations should be considered for future studies. Secondly, all but one participant in this study identified as girls/women, therefore our findings may not be representative of the experiences of boys/men with PSAC. This highlights the need to explore the perspectives of boys/men who participate in M&C-Y and understand what encourages them to engage in the intervention (e.g. holding boys/men only groups). Thirdly, although this study used rigorous metrics and methods to establish the feasibility of the M&C-Y intervention, there are currently no widely established/accepted metrics to determine feasibility within the field of concussion. This study focused on demonstrating intervention feasibility within a virtual setting, given the additional complexities of administration via videoconference. Based on the strong study results, and early in-person involvement of youth during the design phase, this intervention could easily be administered in an in-person setting as well. Examining the potential for hybrid (both in-person and virtual components) delivery of the M&C-Y intervention warrants investigation. Future research should build on the results of this feasibility study by completing a larger pilot study of the M&C-Y intervention. The impact of participating in M&C-Y on outcomes such as concussion symptoms, occupational performance, and socioemotional/family functioning warrants further investigation. Finally, caregivers are another key group involved in the delivery of interdisciplinary care for youth with PSAC²⁵ and caregivers of youth with PSAC can experience stress⁵⁸ and family burden.²¹ To address caregivers’ experiences, a parallel intervention arm, Move&Connect-Caregivers, was simultaneously developed by our team.⁵⁹ Investigation of the interplay between these two parallel interventions on family functioning will also be an important direction to explore as nuances of family dynamics following concussion are poorly understood.

Conclusion

M&C-Y is an interdisciplinary group intervention for youth experiencing PSAC that is aligned with best practice recommendations for pediatric concussion and includes psychoeducation, AR, and goal-setting. Findings demonstrate that M&C-Y is an enjoyable, feasible, and engaging intervention for youth experiencing PSAC where youth were able to form meaningful connections with others. The hope is that participating in the M&C-Y intervention will promote concussion recovery as well as enhanced connectedness and well-being among youth experiencing PSAC.

Acknowledgments

Thank you to the clients and families that participated in this study and made this research possible. We would like to acknowledge the efforts of the members of the NOvEL Lab Team (Bloorview Research Institute), specifically Brenda Knapp, Candice Tay, Danielle Duplessis, Orla Curran, Hayley Hawkins, Christine Provvidenza, and Willow Barton. We would also like to acknowledge the clinical team on the Brain Injury Rehab Team (BIRT) at Holland Bloorview Kids Rehabilitation Hospital, specifically: Nicholas Joachimides, Cyndy Bryson, Dr. Janine Hay, Meghan Toswell, Dr. Peter Rumney, Dr. Alysha Ladha, Dr. Ryan Hung, Alexandra Danks, Debra Moroz, Christa MacDonald, Charlotte Coy, and Theja Gunasekera.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17518423.2024.2331455

Additional information

Funding

This work was supported by the Centre for Leadership at Holland Bloorview Kids Rehabilitation Hospital and the Canadian Institutes of Health Research (CIHR) [#463185].