The Tele-AR intervention targets adolescents (aged 13-17 years) who continue to experience symptoms at least 2 weeks after concussion. All mechanisms of injury are considered, including sport, falls, and motor vehicle accidents.

In recent decades, health care usage for pediatric concussion has increased substantially in Canada [1] and the United States [54]. In Ontario, this increase has been most pronounced among adolescents [1], for whom the average annual incidence of physician-diagnosed concussion was approximately 1500 per 100,000 from 2008 to 2016 [55]. Adolescents are also known to be at high risk for prolonged recovery [56]. According to a Canadian multicenter prospective study, a substantial subset of adolescents, approximately 30%, continue to experience symptoms beyond 1 month after concussion [3], which may lead to mood disturbances [5], reduced quality of life [4], and impaired activity performance [7]. Results from the same multicenter study also indicate that symptom improvement occurs primarily within the first 2 weeks of injury and levels off 2 to 4 weeks after injury [57]. Exercise-based active rehabilitation programs initiated in the subacute phase of recovery (1-2 weeks after injury) are feasible and may reduce the risk of persistent symptoms [19,20,24,26]. The Tele-AR intervention therefore targets adolescents continuing to experience symptoms beyond 2 weeks after concussion who are at risk for developing secondary consequences related to mood, activity performance, and quality of life.

Primary health outcomes for the Tele-AR intervention include postconcussion symptoms and perceived occupational performance, a measure of performance in daily activities.

The most recent (2016) international consensus statement on sports-related concussion defines recovery as the resolution of concussion symptoms and return to normal activities, including school, work, and sport [2]. Self-reported concussion symptoms remain the most common measure of recovery from concussion [58] and are measured in adolescents using an age-appropriate symptom scale such as the Postconcussion Symptom Inventory [59]. However, there is growing recognition that symptom reports do not always accurately reflect recovery [13]. Concussion-like symptoms (eg, fatigue, headache, and dizziness) are common in individuals without a history of concussion, and symptom reporting is influenced by a variety of noninjury factors such as personality, comorbid mood disorders, and familial factors [12]. Activity limitations are common among adolescents with concussion [7-9]; therefore, a measure of performance in daily activities (ie, occupational performance) is beneficial for evaluating recovery. The Canadian Occupational Performance Measure has been identified as a useful tool for measuring functional recovery among youth participating in active rehabilitation [7]. Concurrent measurement of symptoms and occupational performance can provide a more complete assessment of recovery than symptom reduction alone.

Current evidence indicates that persistent symptoms and activity limitations after concussion are best understood through a biopsychosocial perspective [38,39,60]. A key tenet of the biopsychosocial model is that the interaction among biological, psychological, and social factors determines health outcomes and that these factors must therefore not be addressed in isolation [61].

Biological or physiological factors after concussion include autonomic nervous system and cerebral autoregulatory dysfunction [35], impaired balance and coordination [62], visual and vestibular dysfunction [63], sleep disturbances, and fatigue [64]. Exercise intolerance, which reflects autonomic and cerebrovascular dysfunction, is a prognosticator of recovery [65], as are visual and vestibular dysfunction [63].

There is growing recognition that psychological mechanisms related to cognitive, behavioral, and emotional reactions to concussion influence outcomes [39]. Negative illness perceptions, including beliefs about injury timelines, consequences, and level of control, are associated with poor outcomes [60,66]. Various cognitive biases may precipitate negative illness perceptions, including causal misattribution (ie, misattribution of common benign symptoms to concussion), catastrophizing (ie, misinterpretation of symptoms as dangerous), good-old-days bias (ie, tendency to overestimate preinjury health or function), and the nocebo effect (ie, concussion outcomes shaped by the expectations of illness or dysfunction after the injury) [39]. Negative illness perceptions often lead to maladaptive coping behaviors such as fear avoidance (ie, fear of provoking symptoms leads to avoidance of activities), endurance (ie, pushing through symptoms), or all-or-nothing behavior (ie, alternating between periods of extremely low and extremely high levels of activity) [60,67]. Emotional responses such as stress, anxiety, and depression can result from, or reinforce, negative perceptions and behaviors and have been shown to influence outcomes [68]. In youth, self-efficacy is also reduced after concussion [69], and lower levels of self-efficacy predict greater symptom burden [70]. Cognitive, behavioral, and emotional factors interact to form vicious cycles that maintain the experience of symptoms and functional limitation.

The social influences of concussion are poorly understood. Adolescents with concussion report limitations in school function and social activities [7-9]. Qualitative studies show that concussion has adverse effects on the interpersonal relationships of youth and that the influence of relationships on recovery can be positive or negative [8,71]. In the study by Kita et al [72], female adolescents with concussion identified their friends, parents, clinicians, and peers with personal histories of concussion as key providers of social support that mitigates various challenges in their recovery. Among collegiate athletes, greater satisfaction with social support has been associated with lower postconcussion anxiety [73].

Access to appropriate clinical care may influence how these biological, psychological, and social factors are experienced by the individual and, in turn, their effects on recovery. A systematic review found several studies showing that earlier initiation of clinical care after concussion leads to quicker recovery [74]. Timely access to care allows for early initiation of supervised subsymptom threshold aerobic exercise [33,34]. Conversely, those without guidance may continue to rest until achieving spontaneous symptom resolution, which increases their risk for physical deconditioning and mood disturbances [11,12] or for engaging in levels of activity that may be harmful for recovery. Early education and reassurance from a health care provider can reduce unfavorable psychological responses to injury [75], whereas poor access to care may itself contribute to negative injury perceptions. Communication with a health care provider can also build the capacity of youth to seek social support by providing information about appropriate school accommodations, helping youth to communicate the nature of their injury and encouraging youth to engage those around them to support their recovery [72].

There are currently significant challenges to accessing timely appropriate care for concussion in Canada [49]. Studies have identified knowledge gaps regarding concussion management among primary care providers [76,77]. Access to specialized concussion care is also limited in Canada, especially among individuals in remote communities who may experience significant geographic or socioeconomic barriers and youth who are reliant on caregiver accompaniment. Studies from the United States reveal barriers to accessing pediatric concussion care among families in rural communities, including higher health care expenses [78] and indirect costs related to transportation and lost productivity [79]. Delayed access to care is problematic because it increases the risk of premature return to activity and potential reinjury or development of persistent symptoms and functional limitation.

A critical review of the literature describing active rehabilitation approaches to concussion was performed in the fall of 2019. Key articles were located through search in Google Scholar and PubMed using keywords that included active rehabilitation, exercise, physical activity, concussion, mild traumatic brain injury, youth, and adolescents. Additional pertinent literature was identified through forward and backward searching of reference lists as well as literature previously known to the authors. Intervention characteristics among the studies included in the review are detailed in Multimedia Appendix 1 [7,16-21,24-30,32,80] and briefly summarized in the following paragraphs.

Findings from the review indicated that active rehabilitation interventions typically last 6 weeks and involve a variety of components, including aerobic exercise [7,16,19,20,24-30,32,80-84], sport coordination drills [25-30,32,80,82,83], balance training [32], visualization or relaxation [25-30,80-83], and education and support [25-30,80-83]. The 6-week timeline was established by Gagnon et al [29], who found that a mean intervention duration of 4.4 (SD 2.6) weeks was required to achieve symptom resolution. All the studies identified implemented individual interventions. Active rehabilitation has typically been evaluated through changes in postconcussion symptoms [16-18,24-30,32,82,84]. Improved mood [29,30,80], quality of life [17,30], and occupational performance [7] have also been reported.

Although key components are not fully understood, a study of multimodal active rehabilitation found that youth identified the education, aerobic exercise, and sport coordination drills as most helpful [81]. A combination of education regarding energy management and engagement in supervised physical activity is therefore essential to the approach [81]. Future iterations of active rehabilitation should consider a focus on self-management through education and supervised physical activity involving aerobic and coordination exercise.

Published active rehabilitation interventions typically involve a home exercise program performed several (3-7) days per week and weekly appointments with a clinician. Appointments have occasionally been conducted by telephone [17,31,32], which was reportedly appreciated by participants because the telephone appointments reduced travel requirements [17]. The identified studies required participants to attend in-person appointments for pre- and postintervention assessments, indicating an opportunity to explore interventions designed to be delivered entirely remotely and requiring no in-person appointments.

Systematic reviews of telerehabilitation [45-47] and remote self-management programs [85,86] were consulted to identify best practice recommendations regarding the remote service delivery model for the Tele-AR intervention. Consistent communication with a health care provider was identified as key to promoting retention and positive outcomes among remotely delivered self-management interventions [85]. Ongoing individualized education, lifestyle intervention, adherence support, and clinical review with feedback were also identified as important components [86].

The aforementioned literature provided the foundations for the design of the Tele-AR intervention. On the basis of this literature, it was determined that the intervention should be a 6-week program comprising aerobic exercise, coordination drills, and comprehensive individually tailored education and support to train self-management skills. Telehealth literature indicated that weekly appointments should involve a review of symptoms and activity performance with provider feedback, continued education regarding symptom management strategies, and support to promote motivation and adherence to the home program [85,86].

Tele-AR could be an accessible intervention to reduce the burden of pediatric concussion, especially among those identified as high risk for prolonged recovery [3]. It complements ongoing telemedicine initiatives to improve access to pediatric concussion care in rural and remote Canadian communities [48,49].

Recommendations for the use of telemedicine in concussion management specify the need for initial in-person medical assessment to confirm the diagnosis of concussion as well as regular medical follow-up [49,87]. Tele-AR is therefore designed to serve as an adjunct intervention for youth who have previously undergone in-person medical assessment and continue to receive medical follow-up, including appropriate referral for targeted treatments such as cervical or vestibular therapy. Although there is evidence that earlier initiation of supervised exercise (after 24-48 hours of initial rest) leads to quicker recovery [88], many without access to care continue to rest until symptom resolution, which may contribute to delayed recovery [12]. Remote delivery of active rehabilitation could increase access to care that enables earlier resumption of supervised physical activity and contributes to quicker recovery.

We drew on self-determination theory (SDT) to expand the theoretical foundation for active rehabilitation to address motivation, a key determinant of engagement and outcomes in rehabilitation [41,89]. Motivation is a key facilitator of participation after childhood traumatic brain injury [90] but is often reduced among individuals with a brain injury [42]. Existing theoretical underpinnings of active rehabilitation recognize the importance of motivation [28] but do not address how to promote motivation.

SDT has been identified as a useful framework for conceptualizing motivation in pediatric rehabilitation [41]. SDT is a theory of human motivation that describes the influence of social and cultural factors on an individual’s sense of volition (self-determination), performance, and well-being [91]. According to SDT, three psychological needs foster intrinsic motivation: competence (feeling mastery and success), autonomy (feeling of being able to choose one’s own actions), and relatedness (feeling positive relationships with others) [91]. Systematic reviews demonstrate that health interventions designed using SDT can increase satisfaction of psychological needs, leading to improvements in physical and mental health outcomes [91,92]. Previous articles have highlighted the utility of SDT to identify factors that influence motivation during brain injury rehabilitation [42]. In adults, mild traumatic brain injury reduces fulfillment of psychological needs, suggesting that rehabilitation should address these variables [93].

The Tele-AR intervention is designed to support the 3 psychological needs outlined in SDT to promote motivation and engagement in the program and regular daily activities. Each element is briefly described in the following sections. Table 1 provides examples of how the psychological needs are addressed in the Tele-AR intervention, using the SDT taxonomy from Teixeira et al [94].

The Tele-AR intervention aims to promote a sense of competence by helping adolescents set optimal challenges and increase self-efficacy. This involves gradually increasing experiences of success through participation in school, exercise, and other meaningful activities. An action plan is developed with each participant to identify how they will implement strategies to support recovery (eg, energy management and relaxation). Second, participants are taught to self-monitor exertion during activities to prevent significant symptom exacerbation. They are encouraged to monitor the time during which they engage in activities such as schoolwork and screen use to facilitate gradual progression. Third, the clinician provides feedback and encouragement during appointments using a strengths-based approach, whereby participants are prompted to discuss what has gone well and which strategies they used to support success. An opportunity is provided for participants to identify barriers they are encountering and explore potential solutions with the clinician. Finally, strategies are discussed for dealing with stressful situations that could undermine competence, such as relaxation techniques (eg, deep breathing, muscle relaxation, and visualization) and seeking help.

Autonomy is supported by providing meaningful rationales for active rehabilitation, integrating participant perspectives in program development, and providing choice. The rationale for the active rehabilitation approach is explained to participants at the beginning of the intervention. Education is provided using nonjudgmental language integrating participant perspectives and emphasizing freedom of choice (ie, which strategies to use and how to use them). Participants are engaged in coconstructing the home program based on their needs and interests, including choice about specific exercises. The Tele-AR intervention is designed to empower youth to take responsibility for their recovery through self-management and coping skills. In a previous study, parents reported that active rehabilitation helped their children become more accountable for their recovery by teaching them to self-monitor their condition [81]. Remote service delivery may further enhance the accountability of youth by eliminating the need for parental accompaniment to appointments.

Relatedness (ie, feeling positive relationships with others) is fostered by the clinician through active listening, expressing empathy, and encouraging perspectives and questions from the participant. Studies from a variety of rehabilitation disciplines, including physiotherapy [95], occupational therapy [96], and psychology [97], demonstrate that therapeutic alliance can be developed effectively through videoconferencing. Weekly appointments foster a strong therapeutic relationship, which has been shown to influence adherence to home exercise programs [98]. In addition, the clinician encourages social support seeking from parents, teachers, coaches, and friends using strategies identified by Kita et al [72]. For example, because of the invisible nature of concussion, some adolescents report being called “fakers” by peers [9]. Participants may therefore be taught metaphors to help communicate their invisible injury, such as comparing energy levels to a cellphone battery [72]. Participants are also encouraged to involve friends in the exercise program where possible, such as having a friend join their walk or including a teammate in sport-specific coordination drills.

The Tele-AR intervention is a 6-week home program facilitated through weekly videoconferencing appointments with a rehabilitation clinician (kinesiologist, occupational therapist, or physical therapist). It consists of (1) aerobic exercise, (2) sport coordination drills, and (3) comprehensive concussion education and support. The following sections provide a detailed description of the intervention.

Figure 2 presents an overview of the timeline for the Tele-AR intervention. It begins with assessment and program introduction spread over 2 appointments, each lasting for 1 hour. The first appointment is dedicated to completing the informed consent procedures for the research study and preintervention assessments (see the Assessment section). The second appointment consists of a participative concussion education session and collaborative coconstruction of the home program, integrating the participant’s individual needs and interests within the three components (aerobics, coordination drills, and education and support).

During weeks 1 to 6, participants are asked to perform the home exercise program 3 days per week and meet with the research clinician once per week. The purpose of weekly appointments is to provide continued education and support, modify the exercise program as appropriate, and strengthen motivation for engaging in the home program and other daily activities. The week 3 appointment includes symptom reassessment to evaluate interim changes. Significant deterioration at this point could indicate a need for in-person reassessment or referral to other providers [87]. Postintervention assessment occurs in week 6.

Preintervention assessment is conducted through a clinical interview with youth and their parents during the first appointment and is used to inform home program prescription. Assessment is repeated in week 6 to evaluate postintervention changes.

Assessment is intentionally targeted to ensure clinical application. It includes clinical history of injury details and factors known to affect recovery (eg, concussion history, medical and mental health history, and social history [3,58]), self-reported symptom rating (Postconcussion Symptom Inventory [59]), and self-perceived occupational performance, a measure of performance in daily activities (Canadian Occupational Performance Measure [104]). These measures reflect current understanding of concussion recovery and call for patient-reported outcome measures in concussion rehabilitation that focus on function and well-being [13,105].

Appointments in the Tele-AR intervention are conducted through real-time videoconferencing using a secure platform that meets health privacy standards and allows for collaboration features such as screen sharing. The clinician uses a standard laptop or desktop computer, and participants may engage in the videoconferencing appointments using a computer, tablet, or smartphone.

Videoconferencing is believed to facilitate therapeutic rapport and is the most common method of communication in telerehabilitation for children [46]. Mental health support for youth is acceptable and effective when delivered through videoconferencing [113], and a study in adolescents with concussion found similar ratings of therapeutic alliance and satisfaction between face-to-face and video telehealth visits [114]. Although some individuals with concussion experience screen sensitivity, current evidence does not indicate that strict avoidance of screens improves recovery [115], supporting instead an individualized approach to screen use within tolerable limits. Other screen-based interventions for concussion have been tolerated well, with no screen sensitivity issues reported [116,117]. Subsequent feasibility testing of this intervention will assess participant perceptions and experiences engaging in video-based appointments.

Special attention must be paid to ensure safety in telehealth interventions. Safety considerations for the Tele-AR intervention are summarized in Textbox 2.

Education regarding activity-related symptom exacerbation and the appropriate response is provided during program prescription. Evidence suggests that activity-related symptom exacerbations are transient and not detrimental to recovery [118]. Exercise-related symptom exacerbation generally resolves within 1 hour of rest [17,25,26]. Participants are instructed to terminate exercise upon significant symptom exacerbation, which is operationalized according to the definition from Leddy et al [119] as an increase of ≥3 points on a 10-point visual analog scale (VAS) [119]. Participants are familiarized with the Wong-Baker FACES pain rating VAS for symptoms [119]. The VAS is used by participants to rate their current overall symptom experience before exercise and monitor for any increase during the activity. Participants are instructed to contact the research team if any of the following occurs: (1) exercise-induced symptom exacerbation that does not subside within 24 hours of rest, (2) exercise-induced symptom exacerbation experienced during consecutive exercise sessions, and (3) the participant has concerns about exercise. In these scenarios, the research team provides appropriate support, discusses potential exercise program modification, and considers referral to the primary care provider or other providers. The stopping rule described by Dobney et al [26] is used, whereby the exercise program is suspended if symptom exacerbation occurs during 3 consecutive sessions despite exercise modification.