Turning behavior links cognitive and motor function to safe mobility post-stroke: a cross-sectional mediation analysis

Introduction Turning behavior is the fundamental component of safe mobility. Despite rehabilitation, nearly three-fourths of falls after stroke occur during turning maneuvers. Consequently, individuals with stroke experience persistent mobility limitations, highlighting turning as a clinically important yet comparatively under-assessed determinant of safe mobility. Because turning engages both cognitive and motor systems, it may serve as a key link between these functions and safe mobility. The current study examined whether turning is linked to safe mobility and mediates the associations between cognitive function, motor function, and safe mobility after stroke. Methods One hundred and five stroke survivors participated in this study. Turning behavior was characterized by turn duration, turn angle, and peak turning velocity measured during dual-task walking. Safe mobility was assessed using Timed Up-and-Go (TUG) duration, Berg Balance Scale (BBS), gait speed, and gait variability score. We used confirmatory factor analysis (CFA) to compute latent scores for safe mobility. Cognitive function was assessed using an extensive neuropsychological battery. Motor function was evaluated using dorsiflexion and plantarflexion strength and motor accuracy on a goal-directed ankle task. We computed the composite score for turning behavior, cognitive, and motor functions. We conducted linear regression to examine the association between turning behavior and safe mobility, and mediation analyses to test whether turning behavior mediates the relationships of cognitive and motor function with safe mobility. Result Poorer turning behavior was associated with compromised safe mobility ( R 2 = 0.66). Mediation analysis revealed that turning mediated the relationship between cognitive function and safe mobility (indirect effect; b = 0.29, SE = 0.11, CI: 0.08 to 0.54). Similarly, turning mediated the relationship between motor function and safe mobility (indirect effect; b = 0.40, SE = 0.10, CI: 0.22 to 0.63). Conclusion Turning behavior is a significant predictor of safe mobility post-stroke. Moreover, turning is a key pathway through which cognitive and motor impairments influence safe mobility after stroke. These findings suggest that incorporating turning-specific training may be an important consideration in gait rehabilitation post-stroke.