successful walking is affected by the integration of complex 
 cognition and neuromuscular , sensory , and skeletal factors , which can degenerate with 
 disease and aging2 .
elderly walking is characterized by reduced 
 velocity and increased basal plane . in particular , elderly persons have difficulty changing 
 directions3 , resulting in a high fall 
 risk .
statistical reports have shown that one in three persons over the age of 65 experience a 
 fall annually4 .
elderly persons who have 
 fallen can worry about falling again and develop a phobia of falling , which leads to 
 anxiety .
the falling phobia results in reduced mobility , which limits a person s activities 
 and further increases the risk of falling , thus creating a vicious cycle5 .
increased balance , improved cardiovascular function , and good flexibility achieved through 
 regular exercise are effective management strategies in reducing the risk of falling in 
 elderly individuals6 , 7 . to improve their physical condition ,
elderly individuals have 
 participated in various interventions , such as resistance exercises using elastic bands8 , muscle strength exercises using 
 equipment9 , and tai chi exercises10 . however , because they had to perform 
 monotonous motions repeatedly , they lost interest easily , which resulted in low 
 participation .
it has also been reported that the limitations of locations , tools , and 
 equipment required for exercising are some of the drawbacks of this approach11 .
thus , it is necessary to provide an interesting , efficient complex exercise program that 
 can be performed anywhere , and that maintains a high level of motivation in the 
 participants . as such , the aim of this study was to conduct a complex exercise program for 
 the elderly , and determine the effects of the program on walking ability during direction 
 change and on falls efficacy .
the study also aimed to determine the applicability of this 
 program to other complex exercise programs , and assess the improvements in the mobility of 
 the elderly based on the effects of the program .
in total , 40 subjects who attended the welfare center in gwangju city were selected for 
 this study and assigned randomly to two groups : the complex exercise group ( n = 20 ) , which 
 participated in a complex exercise program , and the general exercise group ( n = 20 ) , which 
 did not participate in the complex exercise program .
this study was approved by the 
 hospital , and all participants provided their written informed consent .
the complex exercise 
 group consisted of twelve men and eight women ( average age , 68.813.48  years ; average 
 height , 158.005.19  cm ; average weight , 58.9411.36  kg ) , and the general exercise group 
 consisted of seven men and 13 women ( average age , 71.505.54  years ; average height , 
 160.077.14  cm ; average weight , 62.6412.12  kg ) .
the selection criteria were as follows : a minimum of 24 points on the korean mini - mental 
 state examination ( k - mmse ) , no medication due to mental illness , no orthopedic disease in 
 the lower limbs , the ability to walk 10 meters or more independently , and the ability to 
 understand the study objective and provide voluntary consent . the complex exercise program consisted of resistance and aerobic exercises .
a bridge exercise , arm and leg 
 stretching in the prone position , the cat pose , and full - body stretching were performed to 
 strengthen the trunk and increase flexibility .
aerobic exercise was achieved by setting the 
 intensity level at 6070% of the participants heart rate reserve , and walking training was 
 conducted according to the participants individual capabilities .
full - body stretching and 
 walking in place were performed for 5 minutes each as warm - up and cool - down exercises , 
 respectively .
the main exercises were performed for 30 minutes , including two 5-minutes rest 
 periods , for a total of 50 minutes .
the four square step test ( fsst ) is a tool that evaluates complex walking ability .
subjects 
 step over four bars placed on the ground orthogonally in the shape of a plus sign  +  ; the 
 height and length of which were 2.5  cm and 90  cm , respectively12 .
one of the quadrants formed by the plus sign , and continues walking over the bars , one by 
 one , in a clockwise direction , until he / she arrives back in the starting quadrant .
then , the 
 exercise is repeated in the counterclockwise direction . during the test ,
if the subject 
 touches a bar , loses his / her balance , or fails to put both feet in the same quadrant , the 
 exercise is re - started .
the figure - of-8 walk test ( f8wt ) measures walking skills in elderly persons with mobility 
 impairments .
it was developed to assess curved walking abilities in daily living , which 
 can not be measured by straight - line walking tests13 .
the subject walks a  figure 8  pattern around cones , and the time 
 and number of steps needed to complete the exercise are recorded . in this study ,
the 
 inter - rater reliability time was 0.90 and the step count was 0.92 , while intra - rater 
 reliability time was 0.84 and the step count was 0.8214 .
the falls efficacy scale ( fes ) is a self - administered questionnaire designed to determine 
 the degree of self - confidence regarding falling ; it represents fears experienced while 
 conducting ten activities required for daily living15 .
the measurement data obtained with these tests were analyzed using spss version 17.0 for 
 windows .
a paired t - test was conducted to determine within - group differences in the results 
 before and after the experiment , and an independent t - test was conducted to determine 
 between - group differences in the results before and after the experiment .
the results before and after the intervention are presented in table 1table 1.the within - group and between - group comparisons of the outcome measurescomplex exercise group ( n=20)general exercise group ( n=20)pre - testpost - testpre - testpost - testfsst ( sec)25.8 ( 8.4)21.6 ( 5.9)27.0 ( 7.3)23.9 ( 6.5)f8wt ( sec)15.9 ( 5.7)11.8 ( 3.9)16.3 ( 5.9)13.9 ( 4.6)f8wt ( steps)22.4 ( 6.8)19.1 ( 5.8)21.9 ( 6.3)20.6 ( 6.0)fes81.4 ( 8.5)94.7 ( 6.2)82.7 ( 8.6)89.7 ( 5.3 ) means ( sd ) .
significant difference within group ( p<0.05 ) ; 
 significant difference within groups ( p<0.05 ) ; 
 significant difference between groups ( p<0.05 ) .
fsst : four square step 
 test ; f8wt : figure - of-8 walking test ; fes : falls efficacy scale .
changes in the fsst values showed a significant decrease in both the complex 
 exercise program and general exercise groups ( p<0.05 ) .
significant difference within group ( p<0.05 ) ; 
 significant difference within groups ( p<0.05 ) ; 
 significant difference between groups ( p<0.05 ) .
fsst : four square step 
 test ; f8wt : figure - of-8 walking test ; fes : falls efficacy scale changes in the f8wt time showed a significant decrease in both groups ( p<0.05 ) ; however , 
 no significant difference was found between the groups .
changes in the f8wt step count 
 showed a significant decrease in both groups as well ( p<0.05 ) .
the complex exercise group 
 showed a more significant improvement than the general exercise group did .
changes in the fes values showed a significant improvement in both the complex exercise 
 group and in the general exercise group .
in this study , a complex exercise program was prescribed to a group of elderly individuals , 
 resulting in improved walking ability during direction change and in falls efficacy .
the fsst is a test that measures the ability to change direction while lifting a foot . 

this result indicates 
 that the complex exercise group improved their direction change ability by improving their 
 balance through regular exercise incorporating various movements .
this finding is consistent 
 with the results of another study , in which patients with chronic stroke participating in 
 functional exercises incorporating various positions showed improved fsst scores , along with 
 a speed moment more reduced than that of the general exercise group .
our results also 
 support the study results of song et al.16 , who reported walking ability improvements through muscular 
 strengthening and flexibility exercises .
the f8wt ( time and step count ) was conducted to determine the between - group differences in 
 the walking abilities of the elderly participants before and after the experiment , and the 
 results showed a significant difference in the f8wt step count , but not in the f8wt time . 

the f8wt ( time and step count ) , which was conducted to determine the curve walking abilities 
 of the elderly , showed a significant difference in the f8wt step count , which indicated that 
 the complex exercise group took fewer steps and had a longer stride when passing over two 
 barriers in the curved lane than the general exercise group .
this result was due to improvements in the balance of the complex exercise group when 
 navigating a curved line , thereby requiring fewer steps .
it has been reported that superior 
 balance requires fewer steps and lengthens the stride required to maintain balance when 
 walking around a curved line17 . in 
 experiments that compared straight walking and curved walking abilities , the differences 
 between the two types of walking were greater in a group of patients with parkinson s 
 disease than in healthy subjects .
in particular , the patients with parkinson s disease 
 exhibited a smaller step width and stride length18 .
the lack of significant difference between the two groups in the time taken to complete the 
 f8wt indicates that there was no significant difference in the time required to navigate a 
 curved path .
the f8wt specifies a gap between barriers of 1.5 meters and a width of 1.2 
 meters .
when the elderly subjects passed over the barriers , they chose a long stride to pass 
 over the barrier safely ; thus , there was no significant difference between the two 
 groups .
will and motivation are important to changes in falls efficacy . both groups experienced a 
 positive psychological effect with respect to falling due to the regular exercises .
balance improved and fear of falling decreased due to the effects 
 of the exercise program , thus improving falls efficacy .
it has been reported that increased 
 muscle strength improves balance , which increases safety in performing daily living 
 activities20 . in addition , increased 
 lower extremity muscle strength has been found to correlate significantly with increased 
 walking speed and falls efficacy21 . in this study , a complex exercise program improved walking ability during direction change 
 and falls efficacy in elderly individuals . in future research , the difference between the 
 effects of various exercises and the complex exercise will be investigated .
in addition , 
 further studies comparing the effects of this complex exercise program on elderly patients 
 suffering from a variety of diseases will be needed in the future .
 [ purpose ] this study was to assessed the efficacy of a complex exercise program for the 
 elderly , with respect to the effects on walking ability during direction change and on 
 falls efficacy . [ subjects ] in total , 40 subjects were selected for this study and assigned 
 randomly to either a complex exercise ( n = 20 ) or a general exercise ( n = 20 ) group . 
 
 [ methods ] the complex exercise consisted of resistance and aerobic exercises . 
 the exercise 
 program was conducted three times a week for eight weeks . 
 we assessed outcome measures of 
 the four square step test , the figure - of-8 walk test , and the falls efficacy scale . 
 
 [ results ] after the intervention , the four step square test , figure - of-8 walk test , and 
 falls efficacy scale values increased significantly in both the complex exercise program 
 and general exercise groups . 
 the complex exercise group showed a more significant 
 improvement than the general exercise group in the figure - of-8 walk test step and falls 
 efficacy scale scores . 
 [ conclusion ] complex exercise improved walking ability during 
 direction change and falls efficacy in elderly individuals . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION