Effects of Fumanet Exercise Program on Risk of Falling, Body and
Cognition Function in Elderly Patients
IKHWAN EUN
Function Improvement Support Team, Dalseong Rehabilitation Center
Daegu, SOUTH KOREA
SEUNGMIN NAM
Department of Sports Rehabilitation & Exercise Management, Yeungnam University Collage,
Daegu, SOUTH KOREA
Abstract: - This study was conducted to investigate the effect of Fumanet exercise program on risk of falling,
body and cognition function in elderly patients. The purpose of this study is to investigate effective intervention
methods for the prevention of falls in the elderly. The subjects of this study were 30 elderly inpatients at a
nursing hospital located in South Korea. The patients were randomly divided into a experimental group and a
control group. The experimental group performed Fumanet exercise program, and the control group performed
conservative exercise program. Each group was trained for 20 minutes five times a week for four weeks. Risk
of falling was measured using Tetrax. Balance function was measured using the TUG. Gait function was
measured using 10MWT. Lower extremity strength was measured using FTSST. cognitive function was
measured using MMSE-K. The results of the Fall index, TUG, 10MWT showed a significant differences after
training in the experimental group (p<.05), but not in the control group (p>.05). In these two tests, significant
differences were observed between the groups (p<.05). The results of the FTSST, MMSE-K showed no
significant differences after training in both the experimental group and control group (p>.05). Fumanet
exercise program resulted in significant improvement in balance and gait function, risk of falling in elderly
patients.
Key-Words: - Fumanet Exercsie Program, Elderly Patients, Risk of Falling, Balance Function, Gait Function,
Lower Extremity Strength, Cognitive Function.
Received: July 9, 2021. Revised: May 21, 2022. Accepted: June 15, 2022. Published: July 19, 2022.
1 Introduction
Fall means falling from the original position to a
lower position or to the floor regardless of one's
intention while performing the activity of daily life
[1]. This fall is a typical geriatric accident, and the
risk of falling is 10 times higher than that of other
age groups [2]. In addition, it has been reported that
a fall requires a lot of rehabilitation costs, and even
a slight fall can cause serious damage, and even
cause life-threatening [3]. The deterioration of body
functions such as lower extremity strength, balance
function, and gait function and cognitive functions
such as consciousness, orientation, memory, and
judgment due to aging increase the risk of fall and
instability in the elderly [4]. In other words, there is
a need for a fall prevention program that can be
applied to the elderly.
Risk factors for fall are closely related to body
function and cognitive function according to the
aging process. The first cognitive function is the
ability to process input information to make
judgments and decisions, and refers to mental
processes and intellectual processes. In the case of
the elderly, it has been reported that cognitive
function decreases as aging progresses, and in
particular, it has been reported that attention is
reduced and they experience difficulties in the
activity of daily life [5]. Also, it was reported that
about 13% of elderly people affected the balance
function and gait function due to moderate or severe
cognitive function impairment, increasing the risk of
fall [5]. That is, the decline in cognitive function
leads to a decline in motor function and increases
the incidence of fall. The second body function
refers to the physical condition that maintains and
enhances the activity of daily life ability. In general,
body function can be evaluated directly or indirectly
through evaluation of balance function, gait
function, and lower extremity strength. The balance
function is the ability to maintain the center of
gravity of the body on the base of suppot, and plays
an important role in preventing fall [7]. In the
elderly, the functions of balance-related organs such
as visual, vestibular, and proprioceptor decrease,
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and as a result, posture sway increases, leading to a
decrease in balance function [8]. It has also been
reported that as the balance function decreases, the
gait function decreases and the risk of fall increases
[9]. In addition, the skeletal muscle of the elderly
showed a marked decrease in muscle strength and a
10-fold higher risk of fall compared to other age
groups [10]. In particular, a decrease in the strength
of the quadriceps femoris shows a 40% decrease
compared to other age groups and increases the risk
of fall [11].
According to a previous study on the exercise
method for fall prevention, a universal exercise
program was reported to be effective in maintaining
physical strength, balance function, gait function,
and increase of range of motion [12]. Also, in many
studies, lower extremity strength training, balance
training, and gait training using an elastic band were
reported to be effective in fall prevention [13] [14].
However, most of the previous studies focused on
body function improvement related to fall, and
studies on the fall prevention exercise program
considering cognitive function impairment were
lacking.
Fumanet Exercise Program was developed to
improve gait function and fall prevention for the
elderly. Rather than improving muscle strength, it is
an exercise that focuses on the learning process
during the exercise process. It has been reported to
be effective in motor and cognitive functions of the
elderly [15]. The learning process of the program
can prevent fall by improving collaboration of
central nervous system functions including
peripheral tissues and visuals, and improving gait
function and balance function. In addition, the
sensory that perceives the image and memory of the
step, the location of the net, and the location of the
foot, the sensory area of the cerebral cortex and the
motor area, and the interaction with the peripheral
muscles of the whole body improve the balance
function and the gait function [16] . As such, it has
been reported that the Fumanet Exercise Program is
effective for fall prevention by improving body and
cognitive functions of the elderly. However, studies
have been conducted on normal elderly people, and
there are insufficient studies on the elderly with a
high risk of falling. In addition, most studies have
investigated the effects of the Fumanet Exercise
Program on the body function of the elderly, and
studies examining the multifaceted effects are
scarce. Therefore, the purpose of this study is to
investigate the effect of the Fumanet Exercise
Program on the risk of falling, balance function, gait
function, lower extremity strength, and cognitive
function in elderly patients with a high risk of fall.
And, to investigate effective intervention methods
for the prevention of falls in the elderly.
2 Methods
2.1 Subjects
This study was conducted on elderly people aged
65 and over who were admitted at S Nursing
Hospital in Gyeongsangbuk-do in October 2020.
After explaining the purpose and contents of the
study to all study subjects, the experiment was
conducted after obtaining consent to participate. The
experimental procedure was approved by the
Institutional Review Board. The selection criteria of
the subjects were selected as the elderly who can
stand and walk independently or using assistive
devices, the elderly who have no abnormalities in
the visual, auditory and vestibular organs, and
conducted a study on the final 30 subjects.
2.2 Study Protocol
The experimental group Fumanet Exercise Program
was taught by combining the steps in the square in
order using the properties of the net. After that, the
subject moved without stepping on the square of the
net while maintaining a constant speed. The basic
steps were repeated until the subject learned enough
and a natural step appeared. As a tool, a net was used
with a square of 50 cm wide and 50 cm long, with a
total of 3 horizontal and 8 vertical rows. The first step
of the Fumanet Exercise Program was a warming up
step, and 10 times of standing steps and 2 basic steps
were performed. In the second stage, for the purpose
of learning, as part of the dual-task, the steps were
performed 3 times while clapping, singing, and
changing positions. The third step was stretching for
relaxation. The total exercise time was 20 minutes,
and the exercise program was applied every day for 4
weeks. For the control group, general balance
training and gait training were applied. For the
smooth progress of this exercise program, all steps
were assisted and supervised by a physical
therapist(fig 1).
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Fig. 1: Fumanet Exercise Program
2.3 Measurement Tools and Measurement
Methods
2.3.1 Fall Risk Measurement
Tetrax balancer (Israel) was used to measure the
risk of falls. The Tetrax balancer uses a total of four
force plates, one on each heel and toes on both
sides of the lower limb. The subject took off his
shoes and placed his feet on the power plate and
tested in a total of eight positions. First, the posture
facing the front with the eyes open (normal eye
open; NO), then the posture facing the front with
the eyes closed (normal eye close; NC), and the
posture facing the head with the eyes closed head
right (HR), head left (HL), head up (HU), head
down (HD). The test is performed with the foam-
rubber pillow under the feet and the eyes open (PO)
and eyes closed (PC) facing the front. There is a
risk of falling when eyes are closed or standing on
a soft support surface, so the examiner is allowed to
stand around the subject. Through the 8 postures,
the degree of posture sway is measured. A fall risk
score is automatically calculated based on the
degree of postural sway. Fall risk consists of 0-100
points, and the higher the value, the higher the fall
risk [17].
2.3.2 Berg Balance Scale (BBS)
The Berg Balance Scale (BBS) can objectively
assess the fall risk, static balance ability, and
dynamic balance ability of the elderly by measuring
the functional performance of their balance through
sitting, standing, and posture changes [18]. The
scale is composed of 14 items, and if the task
cannot be performed, the total score is 56, a
maximum four points being applied to each item if
it is independently performed. In general, the
higher the score, the better the balance ability.
2.3.3 10-Meter Walk Test (10 MWT)
The 10-meter walk test (10 MWT) is a test method
that evaluates walking ability by measuring the
walking speed of the examinee.19 No special
equipment is required, so you can easily evaluate
your walking ability in a short time. The method
measures the time required to walk 10 m by taking
into account acceleration and deceleration between
the start and the end and measures a total of three
times to obtain the average.
2.3.4 Lower Extremity Strength
Five Times Sit to Stand Test (FTSST) is a test
method that starts from a sitting position on a chair
and measures the time to perform the sitting and
sitting motion five times. FTSST is a measure that
predicts the recurrence of falls and the
independence of daily life performance by
measuring functional aspects of the lower extremity
strength [20]. Subject was instructed to wake up
five times as soon as possible and then sit down.
2.3.5 Korean Version, Mini-Mental State
Examination (MMSE-K)
The Korean version of the Mini-Mental State
Examination (MMSE-K) is the most widely used
dementia screening tool in Korea and has the
advantage of being able to easily assess the
intellectual condition and cognitive function of the
subject in a short time. The Korean version of the
MMSE-K consists of 12 questions, including five
points of orientation relating to time, five points of
orientation relating to place, three points pertaining
to memory registration, three points to memory
recall ability, five points to attention and
computation, and nine points to understanding,
judgment, and language. It consists of 30 points
[21].
2.4 Statistical Analyses
The Shapiro-Wilk test was performed to check for
the normal distribution of each measurement item,
and the results for all items satisfied normality. The
data were presented as mean ± standard deviation
(Mean ± SD), and the general characteristics of the
subjects were presented as descriptive statistics. A
paired t-test was performed to compare pre and
post training performance within the experimetal
and control groups. An independent t-test was
performed for between group comparisons. The
data collected for this study was statistically
processed using SPSS 23.0 for Windows (IBM,
New York, USA) and the statistical significance
level P value of <0.05.
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3 Results
A homogeneity test showed no statistical difference
between the groups (p>.05) (Table 1). The results
of the Fall index, TUG, 10MWT showed a
significant differences after training in the
experimental group (p<.05), but not in the control
group (p>.05). In these two tests, significant
differences were observed between the groups
(p<.05). The results of the FTSST, MMSE-K
showed no significant differences after training in
both the experimental group and control group
(p>.05), with no significant difference between the
groups (p>.05)(Table 2).
Table 1. General characteristics of subjects
Group
EG
(N=15)
CG
(N=15)
p
Gender (M/F)
4/11
5/10
.690
Age (year)
78±7.69
80.93±6.61
.741
Height (㎝)
155.33±11.43
154.8±9.71
.993
Weight (㎏)
51.73±13.34
48.46±10.72
.944
Mean±SD: Mean±Standard Deviation
EG: Fumanet exercise program group; CG: Conservative exercise program group
*p<.05
Table 2. Comparison of fall index, balance and gait function, lower extremity strength for each group
EG
(Mean±SD)
CG
(Mean±SD)
p
Fall index
pre
93.53±5.19
90±7.34
.140
post
81.13±5.38
88.4±7.37
.005
p
.000*
.260
TUG
pre
14.38±2.37
15.14±1.63
.316
post
12.47±1.93
14.07±1.84
.028
p
.000*
.057
10MWT
pre
14.07±2.08
14.82±2.76
.411
post
12.14±1.42
13.81±2.12
.017
p
.000*
.108
FTSST
pre
21.57±3.39
21.73±3.93
.907
post
21.73±3.93
20.44±3.45
.347
p
.922
.253
MMSE-K
pre
20.4±1.54
20±2.29
.581
post
21.13±2.23
20.13±2.47
.255
p
.202
.610
Mean±SD: Mean±Standard Deviation
EG: Fumanet exercise program group; CG: Conservative exercise program group
TUG: Time Up & Go; 10MWT: 10-Meter Walk Test; FTSST: Five Sit to Stand Test; MMSE-K:
Korean version Mini-Mental State Examination
*p<.05
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4 Discussion
This study was conducted to investigate the effect
of the Fumanet Exercise Program on the risk of
falling, balance function, gait function, lower
extremity strength, and cognitive function in
elderly patients with a high risk of fall. As the risk
of fall increases with aging, this study was
presented as one of the fall prevention exercise
programs for the elderly. Previous studies simply
focus on body function evaluation, so there are
insufficient studies on cognitive function and
objective risk of falling. In addition, in the previous
study, an exercise program was simply
implemented to improve body function. However,
this study also focused on improving cognitive
function by conducting the Fumanet Exercise
Program.
As a result of this study, there was an improvement
in balance function and gain function in the
experimental group. There was a significant
difference between groups. It is thought that the
experimental group did not step on the net and the
repetitive activity of gaiting according to the steps
improved the balance function of the weight shift
and improved the gait function. According to
previous studies, the Fumanet Exercise Program
enables interaction with the sensory area of the
cerebral cortex, the motor area, and the peripheral
muscles of the whole body [22]. Also, according to
previous studies, the Fumanet Exercise Program
was consistent with the research results that
improved the gait function of the elderly [23]. That
is, the Fumanet Exercise Program remembers the
steps, perceives the edge of the net and one's own
foot location, and the repetitive process of walking
improves gait function by promoting the interaction
of the motor and sensory of the central nervous
system and the muscles and joints of the peripheral
nervous system. It is presumed that it was done
Also, according to a previous study, it was reported
that multi-directional step-up Training with
rhythmic auditory Stimulation had a significant
effect on improving the gait and balance function
of stroke patients. These results were consistent
with the effect of Fumanet training providing visual
feedback, and it is thought that the provision of
sensory feedback was effective in enhancing
balance and gait function[24].
As a result of this study, the risk of falling was
decreased in the experimental group. There was a
significant difference between groups. This result is
thought to be due to the improvement of balance
function and gait function in the experimental
group. According to a previous study, it was
reported that there was a statistically significant
correlation between the static and dynamic balance
function, the gait function and the risk of falling as
a result of analysis of the correlation between the
body function and the risk of falling [25]. In
addition, it was reported that when the balance
function decreases with the increase of age, the
incidence of fall increases. [26] According to a
previous study, it was reported that the elderly who
experienced a fall had a narrower step length, a
slower gait velocity, and a difference in the gait
pattern than the elderly who did not experience a
fall [27]. Gait is the most basic movement for
locomotion of the human body and is an essential
element in activities daily of life. In the elderly, it is
difficult to control the central nervous system and
maintain body balance, and as the balance function
decreases, the gait function decreases, which is
thought to increase the risk of fall.
As a result of this study, there was no significant
improvement in lower extremity strength in both
the experimental group and the control group.
According to a previous study, it was reported that
the strength through resistance exercise of lower
extremity should be included in the fall prevention
exercise program [28]. In addition, since simple
resistance exercise can easily lose interest, it is
necessary to construct a fall prevention exercise
program that complexly deals with factors such as
balance, gait, and cognitive function [28].
According to a previous study, it was inconsistent
with the research result that there was a significant
effect on lower extremity strength by giving
resistance as a weight band to gait when
performing the Fumanet Exercise Program [16]. In
other words, in this study, it is considered that there
was no effect on improving lower extremity
strength because the Fumanet Exercise Program
was conducted in a situation where no weight was
given. In future studies, it is necessary to plan an
exercise program that focuses on improving lower
extremity strength.
As a result of this study, there was no significant
improvement in cognitive function in both the
experimental group and the control group.
According to previous studies, the Fumanet
Exercise Program did not agree with the research
results showing improvement in memory among
the subdomains of cognitive function [16]. The
Fumanet Exercise Program is a program that
combines cognitive training and exercise, and it is
said that the interaction between the body and the
environment restores the cognitive function by
maximally developing the function to plan and
execute the sequence of exercises [29]. However, in
this study, it is considered that this is the result of
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insufficient cognitive stimulation during the
Fumanet Exercise Program. In addition, according
to previous studies, the average MMSE-K score of
the fall risk group was 17.28 and the MMSE-K
score of the non-fall risk was 22.13. did not match
[30]. As such, it is thought that cognitive function
is highly correlated with fall when it reaches the
level of severe cognitive impairment, and in this
study, the MMSE-K score averaged 20.2 points,
which is a mild cognitive impairment level,
suggesting that it is difficult for the Fumanet
Exercise Program to improve cognitive function.
The limitations of this study are: First, the short
experimental period requires continuous
observation of effectiveness. Second, spatial
control is required so that the subject can focus on
the program. Third, in order to generalize the
results of this study, it is necessary to apply a fall
prevention exercise program comparable to the
control group.
5 Conclusion
The Fumanet Exercise Program of this study is a
complex task activity composed of the body
activity of walking according to the net space and
the cognitive activity of thinking and remembering
the order of stepping left and right according to the
difficulty at the same time. Summarizing the results
of this study, the Fumanet Exercise Program had a
significant effect in reducing the risk of falling and
enhancing balance and gait function in elderly
patients. Therefore, the Fumanet Exercise Program
can be usefully used as a fall prevent exercise
program for elderly patients.
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Contribution of Individual Authors to the
Creation of a Scientific Article (Ghostwriting
Policy)
-IkHwan Eun has organized and executed the
experiments.
-SeungMin Nam was responsible for the Statistics.
Creative Commons Attribution License 4.0
(Attribution 4.0 International, CC BY 4.0)
This article is published under the terms of the
Creative Commons Attribution License 4.0
https://creativecommons.org/licenses/by/4.0/deed.e
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DOI: 10.37394/23203.2022.17.38
Ikhwan Eun, Seungmin Nam
E-ISSN: 2224-2856
346
Volume 17, 2022