The feasibility study was a mixed methods design conducted at Western Michigan University (WMU) Laboratory for Advancements in Rehabilitation Sciences. The participants were recruited from local clinics, hospital emergency departments, senior living facilities, and senior centers. A total of 15 community members were interested in the study. Of the members not enrolled (n=2), 1 expressed severe physical limitations prohibiting travel to the study site, and 1 declined due to the data collection schedule. The investigators established the sample size based on the timeline of funding and successfully enrolled 13 eligible older adults (June 2022- June 2023).

The inclusion criteria included individuals aged >65 years, who had the cognitive means to answer health-related questionnaires and the physical ability to perform testing. The general cognitive and physical abilities were screened via verbal communication over the telephone during the study explanation. In this screening, the primary investigator (PI) explained the study protocol and asked participants if they had concerns about memory testing or exercising on a stationary stepper. The PI (CAB) assessed for verbal inconsistencies in language, memory, and processing throughout all interactions with participants. In addition, the PI (CAB) screened the cardiovascular system, the cervical spine and neck, and mobility status of each participant to determine medical clearance and safety before data collection. The exclusion criteria excluded ages younger than 65 years; screening abnormal for neck screening (ligamentous instability or vertebral artery insufficiency) [13]; or not having the physical ability to perform the aerobic testing [15].

The PI (CAB) collecting data was state-licensed, certified in advanced older adult cognitive screening and cardiopulmonary resuscitation (basic life support), and worked as a board-certified specialist in neurologic physical therapy for 17 years in direct access, providing services to patients with neurologic conditions.

The WMU institutional review board (IRB) reviewed and approved this study under the expedited review with a waiver of written informed consent (application IRB-2022‐205). The participants were assigned study numbers, and all data were collected on hard copy forms. The data were entered into the computer as deidentified data. The raw data were analyzed under the study numbers. The coinvestigators (AD-d-S, MGG, Lizzie Butkis, Ashley Helmer, and Mike Peres) analyzed all deidentified data. All participants verbalized and signed the written IRB-approved consent before enrollment. The study was grant-funded by the WMU Faculty Research and Creative Award (grant 2020). Through this funding, the participants received US $30 gift card incentive to participate in the study.

Research supported that older adults with mTBI could complete participant-reported and health status forms [3,5]. Previous studies included individuals with mTBI experiencing symptom provocation when they were exposed to visual, cognitive, and movement stimulation [16,17]. Investigators (CAB, Ashley Helmer, Mike Peres, and Lizzie Butkis) created an a priori observational table to document the completion of each participant-reported form. There was limited research on a similar tool. The senior coinvestigators (AD-d-S and MGG) peer-reviewed the observation table. After the collaboration, all investigators unanimously agreed to mark the completeness of each of the forms to be marked as “completed without or minimal assistance,” “completed with moderate assistance,” and “unable to complete: [reason].” Participants were categorized as “completed without or with minimal assistance” when they independently marked all form prompts without or with less than 50% cues provided by the investigator (verbal, visual, and physical) to complete missed form prompts. Participants were marked as “completed with moderate assistance” when they needed cues more than 50% and up to 100% of the time in filling out each form. Participants were considered “unable to complete: [reason]” when they were not able to complete the form, even with visual, verbal, or physical cues from the PI, and the reason reported. The “unable to complete” was anticipated to be used for participants who became overstimulated from significant mTBI symptoms due to cognitive or physical processing demands.

The total sample was 13 (n=9 without mTBI, n=4 with mTBI), including participants aged 65‐91 years (n=7 female). The participants reported their race to be White (n=10) or chose not to fill out race (n=3). The participants fully completed the health form without or with minimal assistance (N=13, 100%). Most participants fully completed the PSFS (n=11, 85%) with minimal to no cues. The participants who completed the PSFS with moderate verbal cues (n=2, 15%; n=1 without mTBI, n=1 with mTBI) required verbal cues to define “activities” and redirection due to their extensive details of chosen activities. All the participants completed the PCSS (N=13, 100%) with minimal to no cues. The participants completed the MSQ and BCBT-M to their maximum safe effort. In the MSQ, 1 participant with mTBI tested positive for benign paroxysmal positional vertigo (BPPV) and needed 50% assistance to complete testing. A different participant without mTBI, in completing the MSQ, required 75%‐90% assistance for the standing and turning component due to a previous diagnosis of bilateral lower extremity neuropathy. Most of the participants (n=10, 77%) were not able to fully complete the 10 minutes of the BCBT-M due to contraindicated cardiovascular pulmonary responses or reported joint discomfort. Of importance, no participants experienced significant adverse mTBI signs or symptoms from any of the testing [15].

The participants’ and the investigators’ perspectives were observed within the identified themes of study protocol and environment. For example, the investigators described the theme of the study protocol of time, as the time needed for the participant to communicate, transfer, walk, and write; and the time allowed by the investigator to allow space to complete the tasks (Table 2). Similarly, the investigators defined the theme for the study environment to include categories of assessment, documentation, and safety from each of the participants and the investigator’s perspectives. For example, documentation influenced the participant’s ability to complete participant-reported forms (denoted by P, participant impact) and the investigator’s ability to record data while concurrently monitoring the participant (designated by I, investigator consideration). The codes under only the study protocol theme included “patient contact, explaining the study, scheduling calls, and study site visit” which related to telephone usage; “delivery of patient test day instructions” which revealed a need to communicate through general postal mailing as email was not an option; “explaining the consent slowly allowing space to ask questions,” which increased the timeframe of data collection; and “after testing participant recovery,” which required time, skilled assessment, and directions to guide the participant to safely cool down. The code under only the study environment theme was “equipment use.” Various participant and investigator interactions and perspectives contributed to the overlapping of the categories, codes, and examples in both the study protocol and environment themes (Table 2). The codes that included both themes were physical assistance and testing, data collection, laboratory space, and participant feedback.

The contextual relevance findings were further analyzed due to the unanticipated positive emotions evoked by the participants [28]. In the code “unsolicited participant feedback,” participants stated comments such as, “that was fun,” and “I didn’t know I could do all this.” In the analysis of the participants’ quotes, we conceptualized the participants’ perceptions of their roles and how they identified in society through the framework, the Role Theory of Active Aging (Figure 1) [29]. According to researchers who described the Role Theory of Active Aging, as individuals age, their perceived societal roles change, as does a potential loss of identity and a lack of understanding of their new roles [29,30]. The three main contributing categories that intersect within the Role Theory of Active Aging included (1) value or positive social role recognition, (2) environment or the space that allows for role fulfillment, and (3) behavior or interaction based on role expectation. Respectively, under these categories, this study applied the Role Theory of Active Aging concepts of (1) self-worth or a term for one’s internal sense of being worthy of or good enough for a task, person, or situation; (2) belonging or one’s affinity of inclusion, acceptance, or identity; and (3) participation or the action of taking part in an action or event (Figure 1). The concepts all overlapped, thereby contributing to active aging [29]. We adapted this framework to active aging through older adult participant research involvement.

Previous research has supported standard evaluation and assessment protocols for individuals aged <65 years with mTBI, including medical history interviews, self-reported outcomes, motion provocation screening, and submaximal aerobic testing [11,13,25]. The research supporting mTBI management in older adults has been limited [11]. This study provided early findings that the use of standard evaluation measures was safe in participants aged >65 years. This feasibility study included two aims: (1) to determine the feasibility of older adults’ tolerance to the mTBI practice guidelines with a focus on participant-reported forms and symptom provocation tests, and (2) to describe an emergent thematic analysis contextualized within the ICF model relevant to research protocols and data collection in aging populations.

This study was a feasibility study in evaluating older adults with and without mTBI and therefore had inherent limitations. The sample size was small, the enrollment was a sample of convenience, and the shortened recruitment timeline was based on resource availability. Although we recruited from demographically different areas and worked with senior services across local facilities, the participants were not representative of the US population. We have discussed more rigorous recruitment and enrollment strategies for improved representation in future research.

Another limitation was having 1 investigator collect data. Early in the study, the investigators established that to ensure participant safety, data collection must be performed by a licensed health care provider with experience in the assessment of older adults. The PI (CAB) addressed mitigating bias by member checking documented participant feedback and deidentifying all data before analysis. Future studies would include training specific to older adults with mTBI and extend data collection to multiple sites.

Diffusion in the study design was also a concern, as some of the participants arrived at the testing site in pairs. The PI (CAB) separated the participants during testing to maintain data collection integrity; however, this was verbalized by the participants as challenging. The participants who had more comorbidities relied heavily on their partners for accuracy in reporting timelines. The PI (CAB) encouraged participants to independently answer to their best ability. Future studies may involve acquiring electronic medical records to triangulate the accuracy of health form reporting. Despite this, the participants were able to complete the health forms without or with minimal cues (N=13, 100%), and this simulated individual participant reporting in a clinic appointment.

The evaluation of individuals for baseline assessment and initiation of treatment has been identified as crucial in reducing recovery times following mTBI [13-15]. The evaluation of older adults with mTBI, clinical guideline recommendations, and testing tolerance has been limited in the research [11,13]. This feasibility study was critical for further development of methodology and implementation of future large sample studies using provocation testing in older adults with mTBI. This study contributed to a deeper understanding of key contextual variables, including temporal constraints, safety protocols, communication strategies, and environmental settings, that shape research methodologies for evaluating older adults. The study also highlighted the potential benefits of research participation for older adults, particularly with societal expectations surrounding active aging. Further development and validation of these findings could guide physical therapists in delivering safe, evidence-informed care to the aging population with mTBI. Continued research is essential to establish standardized testing protocols that are tailored to the unique needs and vulnerabilities of older adults with mTBI [13].