The analysis of the older participants’ and physiotherapists’ perspectives and reflections on motor–cognitive exercises during the co-creation process resulted in four themes: discovering the motor–cognitive concept through engagement in activity, balancing safety and challenge, navigating the complexity of individualisation, and managing motivation and compliance (Table 4) and below each theme is described with its respective categories and is illustrated by quotes from the workshops’ audio recordings.

Table 4 An overview of categories and themesDiscovering the motor–cognitive concept through engagement in activity

The categories within this theme pertain to participants’ journey of assimilating knowledge and comprehension of this novel concept, a prerequisite for in-depth discussions. At first, participants struggled to understand and integrate the context, so it was important to give enough time and focus to this basic component. Engaging in practical, hands-on activities and testing the prototypes expedited learning, leading to enhanced recognition of the concept of interest and new perceptions of the participants’ own abilities.

To Grasp a new concept can be challenging

The motor–cognitive concept was novel to the older participants, and initially, they encountered challenges in comprehending the concept. Therefore, exploring past experiences and providing examples of motor–cognitive activities in everyday life was initially expressed as difficult by the older participants. After discussing the concept together, the older participants were able to share experiences from their own contexts, which made the concept more concrete. For example, they described various sports that they currently engaged in or had previously practiced, such as alpine skiing, yoga, or ball sports as motor–cognitive activities. Additionally, several older participants described cognitive strategies employed in everyday life activities; for example, memorising grocery shopping lists based on the layout of the grocery store. They concluded that shopping in this manner could be considered a motor–cognitive activity. Through collaborative discussions and sharing experiences, they were able to identify more experiences. For instance, they recognised that walking in a busy area while using headphones, or talking with a friend, or even just navigating uneven terrain in the forest, walking the dog, or hunting might constitute a motor–cognitive challenge. Despite initially struggling to pinpoint concrete examples, the older participants acknowledged that they likely engage in numerous motor–cognitive activities in their daily lives without consciously realising it.

“I hadn’t really thought about it, it was just when I saw this project that I started pondering it, specifically the combination of…that yes, perhaps it enhances memory when one has a bit of movement, or vice versa.” (male older participant, workshop 1).

Dancing with a partner was another activity regarded as a motor–cognitive activity. One group reasoned that if you can dance without conscious thought, your dual-task ability is good. Conversely, in their experience, less skilled dancers often pause their dancing when conversing with their dance partner. The older participants also expressed awareness of the risks associated with engaging in activities that pose a high motor–cognitive challenge. For example, stepping down a sidewalk edge while simultaneously looking out for traffic was perceived as a demanding task. The physiotherapists knew of the concept but had limited or no prior experience of using motor–cognitive exercise in their practice. Some physiotherapists had themselves utilised motor–cognitive exercises, or were aware of colleagues who had done so, such as walking while simultaneously tossing a ball in the air.

Practice leads to enlightenment

When the older participants engaged with prototypes of motor–cognitive exercises, the concept became clearer to them. The experience of performing the prototyped motor–cognitive exercises was both enjoyable and meaningful for the older participants. Although they found the exercises beneficial, some were challenging to perform and led to new perceptions of their own abilities.

“I found it interesting to discover that I couldn’t do things I thought I would be able to.” (male older participant, workshop 2).

Some concerns were expressed by the older participants in relation to performing the motor–cognitive exercises; for example, following exercise instructions through headphones while performing them alone in a public setting could be embarrassing. Furthermore, the older participants experienced that they prioritised the balance task over the cognitive task when faced with more challenging activities. The physiotherapists also enjoyed the motor–cognitive exercises but were concerned they might be too advanced for patients with severely impaired balance. Therefore, they emphasised the importance of targeting the appropriate population for this type of exercise. Also, the physiotherapists believed these exercises could be practical, useful, and easily integrated into patients’ daily activities. Developing and utilising motor–cognitive exercises in practice was described as being of the utmost importance.

“Being able to stand and let go and do something while being disturbed, like if someone calls out or the phone rings, it is very transferable, regardless of function or starting point in terms of capacity.” (physiotherapist, workshop 3).

Balancing safety and challenge

The categories within this theme encompass the challenge of engaging in effective balance exercise unsupervised at home. Safety was paramount for both the older participants and the physiotherapists, albeit from slightly different perspectives.

To effectively challenge balance is inherently unsafe

Participants discussed the challenge of performing balance exercises as they generally involve a degree of risk. The older participants believed some element of instability was needed for balance exercises to be effective.

“Of course, it should be wobbly to get any effect.” (female older participant, workshop 4).

The older participants experienced challenging balance exercise as enjoyable, while recognising that many older people have a fear of falling. The physiotherapists shared a similar perspective, emphasising that the exercises must be sufficiently challenging and even somewhat unsafe to qualify as a balance exercise. Furthermore, they stressed the importance of finding exercises that genuinely challenge balance.

Safety is a crucial aspect

Safety was a frequent topic of discussion among both the older participants and the physiotherapists, albeit from different perspectives. The older participants found what feels safe to be highly individual. They also noted that the importance of security and safety varies among individuals. For example, some disregard safety instructions for exercise machines at the gym, while others believe that clear instructions on how to perform exercises are vital:

If you’re going to exercise and stand on one leg, it’s important to have a stable wall or bench—or something you really trust—preferably on both sides. And you need to know how to start: like making sure you’re properly grounded on the base of your big toe, little toe, and heel so you’re steady before you begin. (Female older participant, workshop 4)

The older participants expressed personal responsibility for their safety when exercising at home and discussed strategies; for example, seeking guidance from healthcare professionals to assess safe exercise environments at home or exercising with the assistance of relatives. The importance of safety during physical activity and exercise was emphasised, with older participants providing several examples and these included the use of studded shoes for outdoor exercise during winter to prevent slips on icy roads:

No, because I’ve become really, really careful about always wearing studded shoes when it’s snowy. I just don’t go out without them. I mean, I can walk to the bus and back, but I can’t imagine walking home without my studded shoes. (Male older participant, workshop 4)

When exercising at home, they highlighted the importance of maintaining a safe physical environment. The use of a rollator was suggested as a potential safety measure to provide support during exercise. However, some older participants had not considered safety when exercising:

Male older participant 1: I have not thought about that…Hehe….

Male older participant 2: I also haven´t thought about safety. Looking at the gym where I spend quite a lot of time there isn´t anything special there, it´s some equipment and stuff that are around you… (male older participants, workshop 4).

Among the physiotherapists, safety was described as a significant and weighty responsibility. They found that safety often took precedence over effective balance exercises in patients’ homes due to their concern and professional responsibility for their—often frail—patients. The physiotherapists defined their responsibility as based on their professional license, and their understanding and experience of the potential consequences of a fall for their patients. They expressed uncertainty about creating a safe yet challenging motor–cognitive exercise programme for patients to perform independently at home, believing it will be difficult to implement in practice. In their work, they were cautious when prescribing home-based high-challenge balance exercises, preferring safer alternatives such as supported balance exercises. However, they acknowledged that they did not believe such alternatives were ‘real balance exercises’:

“No, you’re very cautious. And is also about ensuring a safe environment for both the patient and the caregiver. So, we almost always provide support to prevent any mishaps. Unfortunately, that’s how it is.” (physiotherapist, workshop 3).

Additionally, the physiotherapists reasoned that effective balance exercise likely require some form of supervision to ensure safety. They believed that performing exercises in a facility or clinic, where patients can be supervised, is safer. In addition, a group setting, with a supervisor to observe, instruct, and adjust as needed, could provide an added layer of safety; albeit providing less supervision than one-on-one sessions.

Navigating the complexity of individualisation

Within this theme, the categories describe the challenge of identifying suitable strategies to promote progression among this highly heterogenous population. This challenge is further compounded by the interplay of the different components within the exercises.

It is important to recognise variability within the older population

Peoples’ perception of enjoyable physical activities was discussed among the older participants, and they experienced that this perception could change with age. They described this as one reason as to why individual tailored exercise is important. Life-altering events can also influence exercise preferences and needs:

“I thought that I was the kind of person who wanted to exercise alone, but, as I said, I think I might need the group now to really get started.” (male older participant, workshop 2).

The older participants emphasised the importance of the layout and design of the programme as one example of variation in preferences. Moreover, they emphasised the need to consider different preferences when designing instructions, progression, and follow-up procedures. Preferences varied, with some favouring supervised sessions, while others found email communication sufficient or needed no follow-up. While some found audio and video instructions helpful during exercise, others considered them overly complex. Interestingly, the consensus among older participants was that paper-based programmes felt out-dated, ineffective, and difficult to read during exercise. They emphasised that such programmes will not be used by older people. However, the physiotherapists experienced variability in using paper-based programmes or digital solutions among their patients, and they emphasised the importance of acknowledging different needs among older people. Because of the variability in the population of older people, progression of the exercise programme was expressed as challenging to manage:

“Yes…It is really a tough one to solve, I mean difficult to organise somehow because people are different…” (physiotherapist, workshop 3).

Individual preferences can influence task difficulty, with some people, for example, finding tasks like reciting numbers more challenging than reciting letters. Recognising this variability, the physiotherapists proposed beginning with supervised exercise, possibly in a group, and transitioning to unsupervised home-based exercises with follow up.

Multiple components complicate progression

The concept of progression emerged as important for both older participants and physiotherapists. The exercises involve performing both cognitive and motor tasks simultaneously, which poses challenges for designing and implementing progression strategies addressing these components individually and/or in combination. Therefore, the older participants emphasised the importance of precise instructions to be able to correctly perform the exercises. They expressed the importance of and a commitment to performing the exercises accurately and were aware of the complexity introduced by the dual-task nature of the motor–cognitive exercise. The older participants also expressed their probable need for guidance to ensure correct performance and progression of the exercises:

“But then, when you’ve counted backward to a hundred, as you said, eventually you didn’t need to think; it just came. So, then you must come up with something new. That’s what I was trying to do.” (female older participant, workshop 5).

To manage these different potential tasks and their progression in a motor–cognitive exercise programme, the older participants highlighted the need for an individually tailored programme as well as individually tailored follow-ups. The older participants expressed that they thought it would be difficult to independently select exercises and manage progression, further highlighting the need for clear information and instructions and support from an instructor to manage progression.

Physiotherapists expressed the fundamental importance of progression, highlighting that without it the potential effects of motor–cognitive exercise will likely be limited. They acknowledged the complexity of managing progression and expressed uncertainty about the best approach, questioning whether to prioritise motor or cognitive tasks and how to prevent memorisation of cognitive tasks. Given the dual-task nature of motor–cognitive exercises, which vary in difficulty, physiotherapists discussed strategies for facilitating progression in clinical practice. They believed patients would require support to manage progression. Despite the tasks’ complexity, physiotherapists agreed that incorporating cognitive tasks into balance exercises is beneficial but requires practical implementation guidance. They stressed that correct execution and clear instructions on progression are essential to prevent falls.

“I also think about patients with hip fractures who have quite, quite good balance but have trouble challenging themselves enough due to pain when weightbearing. But if one can do something with more static exercises with cognitive elements it may be a great tool to add. If you know how to do it, which I don´t do today. Other than just by talking or not talking…” (physiotherapist, workshop 3).

Managing motivation and compliance

Within this theme, the categories highlight that exercising together, as well as individualised follow-ups, can increase meaning, enjoyment, and motivation. Initially, establishing exercise routines may necessitate additional support.

To exercise together for enjoyment and social

The older participants described group exercise as being meaningful and enjoyable in several ways. They appreciated the camaraderie of exercising together, the regularity it brought to their exercise routine, the competitiveness that leads to increased intensity, and the overall enjoyment of the activity. As one older woman described her experienced of group exercise in workshop 2:

“Yes, it makes you feel great. I mean, I wasn´t there last week, I’ve been sick, and now I went on Monday, and what a difference it makes! You feel so sprightly when you´ve been, it eventually becomes a must to go there.” (female older participant, workshop 2).

Group exercise led by an instructor was preferred among the older participants. They believed that the instructor could enhance their motivation to exert themselves during the exercise. Furthermore, the older participants felt that group exercise led by an instructor was safer. The social aspect of group exercise was also highlighted as important; not only for fostering social interaction but also for promoting a sense of security. One older male participant discussed this in workshop 5:

“But this social aspect, it´s really the big piece, and the content can almost be secondary. That you meet, socialise, and get some feedback and such things.” (male older participant, workshop 5).

The older participants shared their experiences of attending group exercises where they cared for each other and engaged in activities outside the exercise, such as enjoying a cup of coffee together. They experienced the social aspect as important and comforting. The physiotherapists echoed the sentiments of the older participants, recounting their experience of facilitating group exercises with their patients, and they noticed that the patients found value in group exercise. In workshop 3, the physiotherapists also suggested that initiating the exercise programme with a high frequency of instructor-led group exercise could potentially simplify the transition for patients to continue the exercise independently at home:

“I’m also thinking that it would be really beneficial to have been in a group for a bit and know, having stood in the square, then it’s easier, and having trained a few times, to do it, transfer it, to when I’m at home exercising by myself. Something like that, pedagogically.” (physiotherapists, workshop 3).

Furthermore, the physiotherapists reasoned that the combination of supervised exercise and the transition to unsupervised home-based exercise could be effective from an economical point of view and manageable in clinical work.

To maintain motivation through meaningful exercise and structure

In terms of maintaining motivation for continued exercise, the older participants proposed several strategies, and they deliberated on whether motivation could be learned or developed in the absence of initial intrinsic motivation. In addition, the importance of discipline was highlighted:

“There are many solutions, but it always requires self-discipline, that you do it and that you don’t trick yourself.” (male older participant, workshop 2).

Discipline and motivation were identified as potential attributes that individuals could possibly acquire through strategic learning, although the older participants acknowledged this could be challenging. Life events, they noted, can impact one’s motivation to exercise. For instance, an older participant who had been exercising their entire life experienced a decline in motivation following a traumatic life event, taking several years to resume their exercise regimen. Therefore, the importance of individualised programmes and follow-ups was emphasised, as individuals require varying types of motivational support at different times.

The older participants’ preferences regarding exercise setting and prescription also influenced their motivation. While some preferred to exercise at home, others found that changing the setting enhanced their motivation. They also expressed the importance of appropriately challenging exercises. If the exercise is too demanding, some of the older participants experienced a loss of motivation. Furthermore, some of the older participants appeared to derive motivation from the performance of the exercise itself, but other older participants believed that a greater meaning or purpose behind exercising could serve as a motivating factor. For example, one male older participant noted that engaging in exercise could help them gain the confidence needed to resume other activities that had been previously discontinued:

“…well-being depends on so many things, it’s not just about having balance, but also when you dare to get up and dance with her.” (male older participant, workshop 4).

To sustain patients’ motivation, to continue exercising and allow progress, the physiotherapists also emphasised the importance of regular, individualised follow-ups. Furthermore, the physiotherapists expressed concern that without follow-ups, there was a risk of diminished patient motivation:

“But someone who checks how it´s going at least, even if you’re exercising by yourself. Someone checks up on whether it’s working well for you now, and someone who checks. You know yourself when you´re going to exercise on your own, it easily falls through the cracks.” (physiotherapists, workshop 5).

The physiotherapists highlighted the challenges of implementing consistent follow-ups in a clinical setting. They expressed frustration over obstacles such as limited resources, which hinder more intensive and sustained rehabilitation, and coordination issues among different healthcare providers. They emphasised that these follow-ups are crucial for patients’ motivation.

To establish routines requires extra support

The older participants believed that incorporating exercise into daily routines was essential for consistency. However, they struggled to independently establish a routine due to the overwhelming number of available exercise programmes in general, the variety of exercises, and uncertainty about the optimal time for practice. Some older participants expressed difficulty in maintaining discipline to exercise alone at home, while this was preferred by others. One female described her morning routine getting ready for a morning exercise show on the television:

“I also believe in scheduling. What´s motivating, and actually motivates me to get up in the morning, is that I want to make sure that I have time to have breakfast, get dressed, and be ready for 10 o’clock. Every morning, and I am.” (female older participant, workshop 4).

Additionally, older participants suggested that support from family, friends, or health professionals could aid in establishing exercise routines. The physiotherapists deliberated on their professional role in supporting patients to establish a routine. They emphasised the importance of collaboration between different healthcare providers. A collaborative approach could streamline the implementation of a novel exercise programme and simplify the development of supportive strategies for patients.