After a concussion, youth can experience an array of physical, cognitive, and emotional and behavioral symptoms [1]. Although most youth recover relatively quickly from concussion, up to 30% continue to experience persisting symptoms after concussion (PSaC) for months or even years [2,3]. PSaC can negatively impact youths’ quality of life [4,5] and lead to ongoing mental health challenges [6,7]. Youth with PSaC also experience feelings of isolation and a lack of social support and understanding from peers [8].

An interdisciplinary approach is recommended to support youth with PSaC [9,10], and active rehabilitation (ie, subthreshold aerobic exercise, coordination exercises) [11] and psychoeducation are considered standard best practices in the treatment of PSaC [12]. Active rehabilitation has been shown to reduce symptoms and improve mental health outcomes in youth with PSaC [13-16]. Psychoeducational intervention about recovery expectations and treatment recommendations is important for youth with PSaC and their caregivers [17,18]. In addition to these approaches, emerging research has explored the feasibility and impact of providing concussion care in a virtual model [19-21] and virtual active rehabilitation to youth with PSaC [22-25]. These virtual approaches are safe and tolerable for youth with PSaC and provide comfort and convenience for families [19,21-23,26].

Caregivers play a critical role in managing their child’s PSaC and describe burden [27] and elevated stress regarding their child’s recovery [28]. Caregiver and family functioning may have an important bidirectional association with PSaC after pediatric concussion [29]. Providing caregivers with psychoeducation and therapeutic support can help to navigate challenges after concussion [30]. Caregivers report a need for clear and reliable information about concussion recovery [31], and caregiver education on concussion signs and symptoms has been linked to reduced recurrence rates [32]. Despite this, there is a dearth of interventions tailored to caregivers of youth with PSaC and a clear need to develop support that targets caregivers’ well-being during concussion recovery [33,34].

The Move&Connect program was designed to support youth with PSaC and their caregivers and consists of 2 parallel intervention arms: Move&Connect-Youth (M&C-Y: for youth with PSaC) and Move&Connect-Caregivers (M&C-C: for caregivers of youth with PSaC). M&C-Y and M&C-C are 6-week virtual group interventions with 1-hour sessions that were developed using the intervention mapping framework [35] and codesigned with youth, caregivers, and clinicians. The detailed design and development processes of these interventions are described elsewhere [36,37].

Delivering rehabilitation interventions such as M&C-Y and M&C-C via virtual platforms (eg, Zoom Healthcare) can enhance access to services, support participation, and promote continuity of care [38,39]. The virtual group model in Move&Connect is particularly appropriate for youth with PSaC and their caregivers due to geographic inequities accessing specialized concussion care [40-42], family burden navigating appointments [43,44], and engagement of individuals who may become symptomatic with travel or in-person appointments [42]. The Move&Connect program differs from existing virtual concussion and group rehabilitation programs [25,45-48] due to the parallel youth and caregiver intervention design, theory driven development, and interdisciplinary delivery.

M&C-Y is guided by the biopsychosocial model [49] and includes psychoeducation, active rehabilitation, and goal-setting. Each week, the intervention begins with an ice breaker followed by an education or discussion topic (eg, headache management, managing stress, advocacy). Youth then complete exercises (ie, cardiovascular, balance, coordination, strength) with the goal of improving their confidence and tolerance to different physical demands. All exercises are designed to be completed at home with no equipment required. In-session music during exercise and weekly polls are used to engage participants. At the end of the session, youth set a weekly goal, often related to the psychoeducation topic or exercise, which is reviewed and discussed in a solution-focused manner [50] the following week [36].

M&C-C is guided by the family-directed approach to brain injury (FAB) model [51] and includes psychoeducation and active skill development to promote family communication and problem-solving. Psychoeducation, discussion, and activities are completed as a group and are related to weekly themes: the ripple effect, school advocacy, considering your child’s well-being, family and you, stress and daily challenges, and parenting is hard. Weekly take-home reflection activities are introduced at the end of each session, and caregivers share their insights during the group discussion the following week [37].

Initial testing of M&C-Y [36] (n=10) and M&C-C [37] (n=9) revealed that the interventions were feasible based on the key domain areas (recruitment, acceptability, and evaluation of participant responses) from Orsmond and Cohn [52] and our a priori criteria. Youth indicated that M&C-Y was enjoyable and they were able to form meaningful peer connections [36]. Caregivers indicated that M&C-C was a safe space to share personal experiences and they valued receiving advice from facilitators and their peers [37].

Following establishment of feasibility, it is important to consider intervention fidelity, which is the ongoing assessment, monitoring, and enactment of the reliability and internal validity of a study [53]. Intervention or treatment fidelity (herein referred to as intervention fidelity) is a critical part of intervention research as it increases confidence that changes in the study outcome of interest (dependent variable) are due to the intervention (independent variable) [54]. A rigorous fidelity plan should include study design, training, and quality and consistency of delivery [54,55]. Importantly, recent studies have emphasized moving beyond only assessing intervention delivery to including a greater focus on the understanding of participants’ receipt and enactment (collectively called engagement) of intervention activities [53,56,57]. Understanding intervention engagement is especially important as it is multifaceted and may be influenced by numerous contextual factors [57] (eg, virtual delivery, group setting, multiple intervention components). Engagement has previously been described by King and colleagues [58] as the affective (expecting positive outcomes), cognitive (believing that therapy will be effective), and behavioral (actively participating in therapy tasks) involvement or investment in a therapy session [58]. Using engagement-promoting strategies is recommended to improve adherence to interventions [59-62]. Additionally, family members being actively engaged in their child’s rehabilitation journey is associated with better outcomes [63]. Thus, exploring intervention fidelity and participant engagement are vital steps in delivering an intervention study.

Based on the aforementioned promising feasibility findings, we conducted a pilot study of M&C-Y and M&C-C. Within the context of the broader pilot study, the goal of this paper was to (1) evaluate intervention fidelity and (2) explore facilitators and barriers to youth and caregiver engagement.

This paper describes a multimethod fidelity and engagement evaluation of M&C-Y and M&C-C. Between November 2022 and June 2025, 10 M&C-Y and 9 M&C-C groups were delivered. Group interventions were delivered virtually using Zoom Healthcare. Two trained clinician facilitators delivered each M&C-Y (occupational therapists and/or physiotherapists) and M&C-C (neuropsychologist, neuropsychology trainee, and/or social worker) session. A research staff observer attended all M&C-Y and M&C-C sessions to record observations and support any technological challenges. Youth were allocated to groups by age/grade, when possible (ie, elementary and high school), to account for developmental differences. Caregivers were also allocated to groups for those with elementary or high school–aged children. Participants were provided with weekly reminder emails of upcoming sessions including any supplies and weekly handouts or materials in advance of each session.

To ensure safety and personalization during M&C-Y, modifications to make each exercise more or less challenging were provided, breaks were encouraged, and clinicians monitored participant symptom changes. Consistent with concussion best practice guidelines [12], if youth experienced >2-point change in their symptoms on a symptom severity scale ranging from 0 to 10, they were instructed to stop the activity until their symptoms had returned to their baseline level. Virtual breakout rooms were utilized for 1-on-1 conversations regarding symptom monitoring. Reminders about participant privacy and group confidentiality were provided at the beginning of each session. The study’s principal investigator randomly audited intervention sessions. No adverse events occurred during the study.

Youth and caregiver participants also completed outcome measures before (T₀), immediately following (T₁), and 3 months following (T₂) intervention completion. Clinical outcome results will be described in subsequent publications, as the primary contribution of this paper is the evaluation of intervention fidelity and engagement. Intervention fidelity evaluation involved data collected during intervention delivery and at the T₁ follow-up. Engagement evaluation involved optional youth and caregiver exit interviews completed at T₁. The qualitative components of the study follow guidelines outlined in the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist [64] (see Checklist 1).

Youth were included if they were between the ages of 8 years and 21 years, had a diagnosis of concussion, and had been experiencing PSaC for >4 weeks at intervention onset. Youth were excluded if they had a physical condition that would impact participation (eg, requiring a mobility device), a disorder of social cognition or communication (eg, intellectual disability, autism spectrum disorder), a functional neurological disorder (eg, conversion disorder, somatization), or an acute psychiatric condition that resulted in a recent hospital admission. Given the pilot nature of the study, youth with these conditions were excluded as they may have unique support and safety needs. Caregivers were included if they had a child (aged 8‐21 years) who was diagnosed with a concussion and had been experiencing PSaC for >4 weeks at intervention onset. Youth and caregivers had to be able to read and understand English, be willing to engage in weekly sessions, and have access to a reliable internet connection. Youth and caregivers could enroll as a dyad (ie, both youth and caregiver enroll) or independently (ie, youth could enroll without caregiver; caregiver could enroll without youth). Recruitment predominantly occurred via convenience sampling through concussion services at Holland Bloorview Kids Rehabilitation Hospital (HBKRH) [10], but community participants were also eligible.

Ethics approval was obtained from HBKRH (REB #0513). All procedures complied with the ethical principles outlined in the Declaration of Helsinki. Youth and caregivers were informed that their decision to participate in the study would not affect the care that they received at HBKRH. A capacity assessment (ie, a formal assessment of decision-making capacity) [65] was performed for all youth participants, and all participants (youth and caregivers) provided informed written consent.

Youth and caregiver participant progression throughout the study is outlined in Figure 1.

A total of 40 youth enrolled in the study (32 as dyads with parent/caregiver participants; 8 independents): 4 youth withdrew before the intervention began, 2 youth withdrew from the intervention due to scheduling demands, and 6 youth participants attended group sessions but were lost to T₁ follow up.T₁ follow-up procedures were completed by 28 youth. At the time of enrollment, youth participants completed a demographics form (see Table 2 for youth characteristics). All youth who attended T₁ follow-up (n=28) were invited to an optional semistructured interview: 16 youth completed an interview (10 identified as girls, 5 identified as boys, and 1 identified as gender fluid), and 12 youth declined. All 6 M&C-Y sessions were attended by 7 of the 16 youth who were interviewed, and interviews lasted from 4 minutes to 27 minutes (mean 18 minutes). For clarity, this leaves the following sample sizes: demographics, attendance, and engagement ratings: n=34, 27 dyads, 7 independents; exit satisfaction survey data for fidelity of enactment: n=28, 21 dyads, 7 independents; and interviews: n=16, 11 dyads, 5 independents).

A total of 40 caregivers enrolled in the study (32 as dyads with their child as youth participants; 8 independents): 3 caregivers withdrew before the intervention began, 1 caregiver withdrew during the intervention, and 5 caregivers attended group sessions but were lost to T₁ follow-up. T₁ follow-up procedures were completed by 31 caregivers. At the time of enrollment, caregiver participants completed a demographics form (see Table 3 for caregiver characteristics). All caregivers who attended T₁ follow-up (n=31) were invited to an optional semistructured interview: 19 caregivers completed an interview (16 identified as women/mothers, and 3 identified as men/fathers), and 12 caregivers declined. All 6 M&C-C sessions were attended by 14 of the 19 caregivers who were interviewed, and interviews lasted between 13 minutes and 46 minutes (mean 26 minutes). For clarity, this leaves the following sample sizes: demographics, attendance, and engagement ratings: n=36, 27 dyads, 9 independents; exit survey data for fidelity of enactment: n=31, 21 dyads, 10 independents; and interviews: n=19, 11 dyads, 8 independents.

This section describes the results of the intervention fidelity assessment for M&C-Y and M&C-C.

This section describes factors that influenced participant engagement within M&C-Y and M&C-C. Facilitators and barriers to intervention engagement are organized across 3 overarching categories: (1) individual characteristics, (2) intervention-related components, and (3) contextual considerations (Figure 2). Findings for M&C-Y are presented first, followed by those for M&C-C.

Within the context of a broader pilot study, we used a multimethod approach to assess the fidelity of the M&C-Y and M&C-C interventions in terms of intervention development, training, delivery, receipt, and enactment. Second, we explored barriers and facilitators to youth and caregiver engagement with the interventions at the individual, intervention, and contextual levels. A rigorous approach to fidelity monitoring ensured high adherence to our theory-driven intervention protocols, quality of virtual delivery, and participant satisfaction and engagement. Caregivers showed consistent and high levels of satisfaction with M&C-C, whereas youth satisfaction with M&C-Y had some variability, particularly related to exercise difficulty. Both youth and caregivers expressed that clinician facilitators established a supportive, nonjudgmental environment that was central to building feelings of comfort and supported engagement. The group format provided important validation of youth and caregiver experiences and supported accountability to apply strategies outside of the interventions. Barriers to youth engagement included concussion symptoms, baseline fitness, and previous knowledge of education, whereas barriers to caregiver engagement included stress, scheduling demands, and limited access to intervention materials. Results provided important implications for delivering virtual group interventions for youth with PSaC and their caregivers.

Our approach to fidelity assessment aligned with the framework from Bellg and colleagues [55] and best practices for evaluating intervention fidelity [53,54] by using multiple methods to allow for triangulation and reducing the chance of biases associated with any one approach [73]. Triangulation recognizes that each individual will have a unique perspective on a shared phenomenon [57]. We used clinician facilitator checklists and research staff observer logs and field notes and provided multiple mediums for youth and caregivers to provide their feedback. There is heterogeneity in what constitutes “good” attendance of an intervention [74]; however, it is promising that the majority of participants in this study attended at least 5 of 6 sessions. As recommended by Toomey and colleagues [75], our approach extended beyond intervention delivery to include an evaluation of fidelity receipt and enactment. Opportunities to assess fidelity receipt and enactment were also built directly into the interventions to reduce administrative burden [57]. A rigorous approach to fidelity assessment is especially important in complex interventions like M&C-Y and M&C-C that likely have multiple potential active components, and this fidelity evaluation can enhance replicability and help ensure that future outcomes can more confidently be attributed to the interventions [53,57,75].

Virtual videoconferencing technology (eg, Zoom Healthcare) enables access and scalability of pediatric rehabilitation interventions [76,77], and families report that virtual care offers benefits such as convenience, flexibility, and comfort in the home environment [78]. Similar to findings reported by Shore and colleagues [26], where youth with PSaC and parents appreciated the convenience and comfort of engaging in individual virtual rehabilitation from home, participants in this study described the virtual setting as a facilitator of attendance and felt comfortable completing the interventions from home. Although participants appreciated the benefits provided by the virtual setting and almost all participants felt supported by the other members of the group, some felt that they did not connect with other members of the group. The discontinuous nature of cyberspace or the “loss of shared space” in virtual therapy has been identified as a threat to group engagement and relational processes in virtual groups [79,80]. To increase connection and engagement, some participants requested an in-person component or more time for unstructured or open-ended conversations between participants. The virtual nature of M&C-Y and M&C-C may lack the informal opportunities for connection that happen in the waiting room or parking lot before and after the weekly sessions. Indeed, there seems to be a trade-off between convenience and connection in the virtual group setting for youth with PSaC and caregivers.

The findings from this study have important implications for providing virtual group-based education and active rehabilitation to youth with PSaC. Active rehabilitation and education are recommended in the treatment of PSaC [12], and virtual active rehabilitation interventions are emerging as feasible approach to care [22,23]. The educational and exercise components of M&C-Y were delivered as intended in the majority of sessions, which is especially important as intervention personalization and deviations have been poorly reported in previous exercise interventions for concussion [81]. Although most youth agreed the education was beneficial and relevant to their personal experiences, some youth described that the education was repetitive, with information that they had already received from other health care providers or strategies that they had to previously learn on their own. Importantly, youth in this study had many risk factors for prolonged recovery [2,82] and were an average of almost 1 year postinjury (mean 327 days). As such, perspectives of these youth and their caregivers, as well as their responses to the interventions, could be different than youth injured more recently. Consistent with current clinical care guidelines [12], this suggests that education should be provided earlier in the recovery process.

The M&C-Y program aligns with a recent call-to-action to develop concussion interventions that do not require expensive gym-based equipment (eg, stationary bike) and to implement home exercise programs via virtual care that only require accessible and affordable materials [83]. Interestingly, both high and low levels of baseline fitness were identified as a barrier to engagement in the exercise portion of M&C-Y. The intervention uses a predetermined set of exercises, and clinician facilitators provided modifications for each exercise to make it easier or more challenging, which was viewed as a facilitator to engagement for participants. Even with these modifications, some youth felt that the exercise component was not the right level of difficulty. This is consistent with previously identified challenges with personalizing exercise in the virtual group setting, including decreased direct observation [84] and not being able to use your hands to correct exercise techniques [85]. Future delivery of M&C-Y could mitigate this by providing an individual assessment before the program begins or further individualize the exercises by providing additional opportunities for youth to provide feedback on the exercises throughout the intervention. This aligns with the principles of client and family-centered care, which emphasizes the importance of working with youth with PSaC to align aspects of the intervention to their needs [44].

There are limited educational interventions designed specifically for caregivers of youth with PSaC [34]. Unlike youth in this study who described receiving education about managing their concussion from multiple health care providers, M&C-C was the first time that the caregivers received education designed specifically for them. Caregivers were overwhelmingly satisfied with M&C-C, and virtually all caregivers agreed that the facilitators were supportive, meeting other caregivers with similar experiences was important, and the discussions were helpful and relevant to their personal experiences. These findings reinforce the importance of developing and evaluating caregiver-centered interventions and support [34]. Caregivers of youth with PSaC report experiencing high levels of stress [28] and being overwhelmed managing multiple health care appointments to support their child [44]. Similarly, caregivers in this study also identified high levels of stress and busy conflicting schedules as barriers to attendance and engagement in M&C-C. This was apparent, as the most common modification to the M&C-C intervention protocol was omitting the take-home reflection review due to caregivers not completing the reflection between sessions. Strategies like customizing mid-week reminders about reflections were suggested to support caregivers to more fully engage in the intervention.

This study has limitations worth noting. First, as is the case with most intervention studies, results from the T₁ satisfaction surveys and interviews only include the individuals that attended the T₁ data collection session and may represent the perspectives of participants who were most engaged with the interventions. To ensure a balanced approach to intervention receipt and enactment, data from individuals who were lost to T₁ follow-up were included in the demographics, attendance, field notes, and engagement ratings. This is important, as individuals with concussion who do not attend follow-up are vastly underrepresented in the literature [86]. As participation in the interviews was optional, the qualitative findings may also be subject to self-selection and positivity bias and may not fully represent the experiences of all intervention participants. There is also potential of nonindependence of observations from members of the same family. In addition, fidelity receipt and enactment were assessed primarily through indirect observer field notes, engagement ratings, and self-report. The participant engagement rating was developed by the research team, as we were unable to identify a validated, observer-rated measure of in-session engagement that reflected the components of the interventions and was feasible for the virtual group context. Although the scale provided useful exploratory insights, its reliability and validity have not been established and therefore may not capture the intended construct of engagement. The scale may also be subject to observer bias, as sessions were not recorded and observed by a single rater. To mitigate this, our engagement evaluation was multifaceted, and triangulation occurred with surveys and interviews. Additionally, recruitment for this study primarily took place in a hospital-based clinic in a large urban center where individuals may have had increased access to concussion care in general. Although the virtual format of M&C-Y and M&C-C makes the interventions more accessible to individuals living in rural areas, future efforts should be made to provide access to the interventions and evaluate it in this group. In addition, most participants in this study identified as White and were from high socioeconomic status households. There is a dearth of information about the association between socioeconomic status and concussion; however, recent Canadian studies have identified that individuals from households with lower socioeconomic status are less likely to access care for concussion [41,87,88]. Understanding how individuals from diverse backgrounds engage with the Move&Connect program should be a priority for future research. Strategies to engage these underrepresented groups could include providing alternative scheduling, offering translation services, and a focus on community-based recruitment. Last, most participants in this study identified as girls/women. This is consistent with findings from initial feasibility testing of M&C-Y [36] and M&C-C [37] and may indicate a preference by girls/women toward group-based interventions. Future efforts should be made to understand the experiences of boys/men with the interventions and explore barriers they may experience when enrolling in this type of intervention.

This paper aimed to evaluate the intervention fidelity of M&C-Y and M&C-C and explore facilitators and barriers to youth and caregiver engagement with the virtual group interventions. The theory-driven fidelity evaluation, including intervention development, training, delivery, receipt, and enactment, demonstrated that the pilot study of M&C-Y and M&C-C was administered with high delivery adherence. Caregivers reported high levels of satisfaction and engagement, whereas youth satisfaction and engagement had some variability, particularly related to the exercise component. Engagement with the interventions was shaped by individual, intervention, and contextual factors. Important considerations for facilitating virtual group interventions for youth with PSaC and their caregivers are presented. Future research should examine the impact of M&C-Y and M&C-C on outcomes such as concussion symptoms, goal attainment, self-efficacy, mental health, and family functioning.