Introduction
This article reports on a qualitative, co-creative study that developed a motor-cognitive exercise programme for community-dwelling older adults (aged 65 and above) in Sweden. Grounded in Participatory and Appreciative Action and Reflection (PAAR), the project aimed to produce knowledge through positive, action-oriented engagement with older people and physiotherapists. The approach emphasised collaboration, ownership, and iterative refinement of ideas to generate a practical intervention that integrates balance and cognitive tasks.
Methods and Design
The study used a PAAR-inspired, co-creative design with six workshops conducted at Umeå University. Data collection encompassed audio recordings, notes, and participant reflections, analysed via qualitative content analysis using MAXQDA. Participants included 17 older adults (≥65 years) and 4 physiotherapists with geriatric rehabilitation experience. Ethical approval was obtained, and the Consolidated Criteria for Reporting Qualitative Research (COREQ) guided reporting to ensure transparency.
Participants and Recruitment
Older adults living in ordinary housing in Umeå were recruited through senior services and local networks. Inclusion criteria required independence in certain daily activities and the ability to participate in group discussions. Preference was given to diversity in age and gender. Four physiotherapists were recruited from regional geriatric services. Some participants and a few therapists withdrew or paused participation for health-related reasons, which shaped the final sample and workshop dynamics.
Workshop Structure and Co-Creation Process
The workshops combined planning, action, reflection, and evaluation, with iterations between sessions. In total, six workshops were held, with the older participants attending five (split into two groups for some sessions) and physiotherapists joining the later sessions. Moderators from a multidisciplinary team guided discussions, while participants provided feedback and test-driven prototypes of motor-cognitive exercises. A six-month interval between workshops 5 and 6 allowed researchers to refine the prototype before testing it with participants in workshop 6.
Data Management and Analysis
Audio data were transcribed verbatim and analyzed using qualitative content analysis. The research team triangulated findings through coding, subcategories, and theme development, culminating in four overarching themes. Credibility was enhanced through member-checking at workshop conclusions and iterative cross-checking among authors with diverse backgrounds in geriatrics, physiotherapy, and occupational therapy.
Findings: Four Core Themes
Thematic analysis yielded four latent-content themes: (1) discovering the motor–cognitive concept through engagement in activity, (2) balancing safety and challenge, (3) navigating the complexity of individualisation, and (4) managing motivation and compliance. Below, each theme is unpacked with supporting categories and illustrative insights from the workshops.
1) Discovering the motor–cognitive concept through engagement in activity
Participants initially struggled to grasp the dual-task idea. Hands-on testing and practical prototypes helped crystallize understanding and revealed everyday examples of motor–cognitive activities, such as dancing, navigating busy environments, or performing routine tasks with cognitive loads (e.g., memorizing store layouts). As one participant noted, movement can enhance memory, and vice versa. Physiotherapists acknowledged the concept’s potential in practice but cautioned about choosing appropriate patient groups for these exercises.
2) Balancing safety and challenge
Safety emerged as a central concern for both groups. Older adults emphasized personalised safety and the need for some instability to elicit balance benefits, while clinicians highlighted the risk of adverse events and the necessity of supervision, especially for high-challenge tasks. The debate extended to home settings, where equipment and environmental safety influenced adoption. The consensus suggested a staged approach: supervised, group-based initiation transitioning to home-based practice, with ongoing risk assessment.
3) Navigating the complexity of individualisation
Participants recognised substantial variability in preferences, capabilities, and progression needs. Some preferred guided, supervised formats, others valued digital or paper-based materials, and opinions on instruction modalities varied widely. The physiotherapists emphasized that progression must balance motor and cognitive demands while preventing memorization of tasks. The team proposed starting with supervised, potentially group-based sessions, then progressively shifting to home routines with tailored follow-up.
4) Managing motivation and compliance
Group exercise was highlighted as meaningful for enjoyment, safety, social support, and accountability. Instructors were viewed as central to motivation, with plans to initiate programmes in group formats before transitioning to independent practice. Regular, individualized follow-ups were deemed critical to maintain motivation, yet resource constraints posed challenges for sustained reinforcement across care settings. The collaboration among healthcare providers was also seen as essential to embedding the programme within routine practice.
Implications for Practice
The co-creative PAAR approach produced a motor-cognitive exercise framework grounded in older adults’ lived experiences and clinicians’ expertise. Key implications include: designing flexible progression that accounts for heterogeneity, prioritising safety with appropriate supervision, leveraging group formats to enhance motivation, and ensuring ongoing follow-ups to sustain engagement. A collaborative, cross-disciplinary model is likely required to scale this intervention in real-world settings.
Conclusion
Through participatory engagement, older adults and physiotherapists co-developed a motor-cognitive exercise programme that integrates balance and cognitive tasks with attention to safety, individualisation, and motivation. The study demonstrates how PAAR-informed co-creation can yield practical, acceptable interventions for fall prevention and cognitive-motor health in aging populations.
