Introduction to the Co-Creation Approach
This qualitative study explores how a motor–cognitive exercise programme can be co-created with older adults and physiotherapists using a Participatory and Appreciative Action and Reflection (PAAR) framework. PAAR emphasizes positive knowledge production by focusing on strengths, creativity, and collaborative reflection, rather than problems alone. The study follows a structured, iterative design where planning, action, reflection, and evaluation cycle through six interactive workshops.
Participants and Recruitment
Participants included community-dwelling adults aged 65 and older from Umeå, Sweden, and four experienced physiotherapists in geriatric rehabilitation. Inclusion criteria ensured participants could safely partake in group discussions and attend university workshops. Recruitment aimed for two workshop groups of about 10–12 older adults, balanced by age and gender, with physiotherapists engaged throughout the process. Data collection included telephone background interviews and pre-workshop questionnaires to capture independence, activity levels, and health perceptions.
The Workshops: A Co-Creation Laboratory
Across six workshops held on the Umeå University campus, a team of researchers moderated discussions, tested prototypes, and refined the programme. The design integrated ownership and control to foster creativity, while member-checking at the end of each session helped enhance face validity. Between sessions, participants were given reflections and take-home tasks to deepen engagement and inform subsequent iterations.
Prototype Development and Practical Focus
Prototypes blended balance tasks with cognitive demands, such as verbal fluency and serial subtraction performed in tandem with movement (e.g., stepping, turning, walking with a narrow base of support). The exercises targeted executive functions—inhibition, shifting, and updating—with the aim of translating cognitive engagement into safer, more effective balance under real-life conditions.
Data Management and Thematic Analysis
Audio recordings and field notes from the workshops were analyzed using qualitative content analysis in MAXQDA. The researchers transcribed recordings verbatim, coded meaning units, and iteratively grouped codes into subcategories, categories, and four overarching themes. Credibility was strengthened through triangulation, regular discussion among authors with diverse clinical backgrounds, and ongoing reflection on the data.
Key Findings: Four Thematic Lenses
The analysis yielded four themes that illuminate how older adults and physiotherapists experience motor–cognitive exercises and how these insights can shape practice.
1) Discovering the motor–cognitive concept through engagement
Participants emphasized the learning curve associated with integrating movement and cognition. Hands-on testing of prototypes clarified understanding and revealed everyday contexts where motor–cognitive activities occur, such as dancing, shopping strategies, or navigating busy environments. Practice led to greater confidence, though some participants noted embarrassment or fear when performing tasks in public settings.
2) Balancing safety and challenge
Safety emerged as a central consideration. Participants believed some instability is necessary for challenging balance, but both groups stressed the need for safe environments, clear instructions, and appropriate supervision when at home. Physiotherapists highlighted professional responsibility to prevent falls, sometimes favoring safer, supervised formats, yet acknowledged that supervised-to-home progression is essential for long-term adoption.
3) Navigating the complexity of individualisation
The heterogeneity of older adults means progression must be tailored. Preferences varied in delivery mode (supervised groups vs. home-based), information format (audio/video vs. paper), and follow-up intensity. Group-based initiation followed by guided transitions to independent practice was seen as a practical pathway to accommodate diverse needs.
4) Managing motivation and compliance
Motivation flourished in social, instructor-led group settings and through meaningful, goal-oriented activities. Regular, individualized follow-ups were deemed vital to sustain engagement but were challenged by resource constraints. A collaborative care model across healthcare providers was proposed to streamline routines and support adherence.
Implications for Practice and Future Work
The study underscores that a motor–cognitive programme for older adults benefits from co-creation, balancing safety with meaningful challenge, and providing adaptable progression alongside robust support. PAAR-inspired stakeholder involvement helped ensure the programme reflected real-world needs, preferences, and constraints. Implementers should consider staged group-to-home progression, personalized follow-ups, and cross-provider collaboration to enhance adoption and sustainability.
Ethics and Trustworthiness
Ethical approval was granted by the Swedish ethical review authority, and all participants provided informed consent. The study emphasizes credibility, dependability, transferability, and rich, contextual descriptions through participant quotes and transparent reporting of methods and reflexivity.
Conclusion
Co-creating motor–cognitive interventions with older adults and physiotherapists offers a promising route to safer, more engaging balance-training that integrates cognitive elements. The PAAR-inspired methodology supports a positive, participatory process that can inform scalable, person-centered rehabilitation programs.
