Introduction
This article reports on a qualitative study that used a co-creative approach to develop a motor-cognitive exercise programme for community-dwelling older adults. Grounded in Participatory and Appreciative Action and Reflection (PAAR), the study aimed to generate knowledge and practical insights by emphasising constructive potential and collaboration between older participants and physiotherapists. Data were analysed with qualitative content analysis, and reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure transparency.
Study design and participants
Older participants aged 65 years and older, living in ordinary housing in Umeå, Sweden, were recruited through senior services and community networks. Inclusion criteria emphasised independent transfers from seated positions, ability to travel to the university campus for workshops, and effective communication in group settings. A mix of men and women (mean age around 74) participated, with several expressing a history of falls. Four physiotherapists with geriatric rehabilitation experience also participated as co-creators. In total, 17 older adults and 4 physiotherapists contributed across six workshops.
Co-creation process and workshops
Workshops were designed as a creative, hands-on method to collect reliable data and test exercise prototypes. The process followed iterative planning, action, reflection, and evaluation, with ownership and control principles to enhance group creativity. Sessions were moderated by a team of researchers and physiotherapists, with member-checking employed to improve face validity.
Six workshops took place on the Umeå University campus, spread over several weeks and, for logistical reasons, included two groups in some sessions. Between workshops, participants engaged in take-home reflections, and the prototypes of motor-cognitive exercises were refined by the moderators. The six-month interval before the final workshop allowed for substantial development and testing of exercise prototypes in a group setting.
What the motor-cognitive programme entailed
The prototypes integrated balance tasks with cognitive challenges, including dual-task activities such as verbal fluency and serial subtraction performed while balancing or gait tasks. The design targeted key executive functions— inhibition, shifting, and updating—while maintaining a clear emphasis on safety, progression, and real-life applicability. Prototypes evolved from simple movements to more complex dual tasks as understanding and confidence grew among participants and clinicians.
Data collection and analysis
Data consisted of audio recordings, workshop notes, and participant reflections. A qualitative content analysis in MAXQDA identified nine initial subcategories, which were further consolidated into four overarching themes. The analytic team iteratively refined codes and themes, engaging in triangulation by drawing on diverse professional backgrounds and prior experiences. Exemplar quotes illustrate how themes emerged from participants’ lived experiences.
Themes and insights
The analysis yielded four major themes that describe the co-creation process and its implications for practice:
1) Discovering the motor–cognitive concept through engagement in activity
Participants initially struggled to grasp the motor–cognitive idea. Hands-on testing and practical examples helped concrete understanding. Through discussion, participants connected the concept to everyday activities, such as navigating busy environments or routines like shopping, and even dancing partners, highlighting how dual-task demands appear in daily life.
2) Balancing safety and challenge
Safety dominated both groups’ concerns. Older adults valued challenging yet realistic tasks, while physiotherapists stressed the need for safe environments, sometimes favouring supervised settings. The group consensus pointed to a balance between infeasibility and risk, with clear strategies to adapt tasks to home settings without compromising safety.
3) Navigating the complexity of individualisation
Given wide variability in preferences, abilities, and resources, progression proved difficult. Participants advocated for tailored programming with flexible delivery modes—supervised sessions to start, followed by home-based routines. Physiotherapists emphasized progression tools and guidance to avoid under- or over-challenging the dual-task exercises.
4) Managing motivation and compliance
Social aspects of group activities enhanced enjoyment and safety, while regular follow-ups supported adherence. The study highlighted that motivation could be fostered through meaningful goals, routine integration, and structured support from health professionals and peers. A phased transition from group to home exercise was seen as a practical, economical approach for sustained engagement.
Trustworthiness and ethics
Trustworthiness was addressed through credibility, dependability, and transferability measures, including diverse participant experiences and transparent reporting. The study adhered to the Declaration of Helsinki with ethical approval granted by the Swedish ethical review authority. Written informed consent was obtained from all participants.
Implications for practice
The co-created motor–cognitive programme demonstrates how PAAR-informed collaboration can yield practical, user-centered interventions. Key implications include the need for individualized progression, a blended delivery model (group initialization with home-based continuation), and robust follow-up to sustain motivation. The approach also emphasizes safety as an integral design criterion, rather than a barrier to innovation, and foregrounds the social dimensions of exercise as a powerful driver of adherence.
Conclusion
By engaging older adults and physiotherapists in a structured co-creation process, this study produced a motor–cognitive exercise prototype grounded in lived experience and clinical insight. The four identified themes offer a blueprint for future development, evaluation, and implementation of similar programmes in geriatric rehabilitation settings.
