International Journal of

Environmental Research
and Public Health

Article
A Cross-Sectional Study: Determining Factors of Functional
Independence and Quality of Life of Patients One Month after
Having Suffered a Stroke
Josefa González-Santos, Paula Rodríguez-Fernández, Rocío Pardo-Hernández , Jerónimo J. González-Bernal ,
Jessica Fernández-Solana * and Mirian Santamaría-Peláez

Department of Health Sciences, University of Burgos, 09001 Burgos, Spain

* Correspondence: jfsolana@ubu.es

Abstract: (1) Background: loss of quality of life (QoL) and functional independence are two of the
most common consequences of suffering a stroke. The main objective of this research is to study which
factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so
that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted
which sample consisted of 81 people who had previously suffered a stroke. The study population
was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of
Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after
participants experienced a stroke, and the main study variables were quality of life, measured with the
Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with
the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the
factors associated with a worse QoL and functional capacity one month after having suffered a stroke
Citation: González-Santos, J.;
were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity
Rodríguez-Fernández, P.;
(p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was
Pardo-Hernández, R.;
related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions:
González-Bernal, J.J.;
Fernández-Solana, J.;
the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are
Santamaría-Peláez, M. A determining aspects in functional independence and QoL during the first weeks after a stroke.
Cross-Sectional Study: Determining
Factors of Functional Independence Keywords: stroke; quality of life; functional independence; upper limb functionality; determining
and Quality of Life of Patients One factors
Month after Having Suffered a Stroke.
Int. J. Environ. Res. Public Health 2023,
20, 995. https://doi.org/10.3390/
ijerph20020995 1. Introduction
Academic Editors: Marco Tofani and According to the World Health Organization (WHO), a cerebrovascular accident (CVA)
Giovanni Galeoto or stroke is defined as “a cerebrovascular disease with clinical signs of focal disorders of
brain function, that develops rapidly, with symptoms lasting 24 h or more or leading to
Received: 20 October 2022 death, with no other apparent cause than a vascular origin” [1].
Revised: 29 December 2022
This condition continues to be the second leading cause of death and the third leading
Accepted: 1 January 2023
cause of death and disability combined worldwide. Globally, a cost of more than USD 891
Published: 5 January 2023
billion (approximately, 1.12% of global GDP) is estimated [2]. In Spain, CVA has been the
third highest cause of death since 2020 (with a higher prevalence in the female gender),
with COVID-19 and ischemic heart diseases ahead, according to the latest data from the
Copyright: © 2023 by the authors.
National Institute of Statistics (INE) [3]. According to data from Iberictus, there is an annual
Licensee MDPI, Basel, Switzerland. incidence of 187 per 100,000 inhabitants [4], although according to other studies based on
This article is an open access article INE data the annual stroke incidence is 252 per 100,000 inhabitants. Likewise, in Spain it is
distributed under the terms and considered the first cause of disability in adulthood and the second of dementia, seriously
conditions of the Creative Commons impacting the lives of patients and families and causing a significant health and social
Attribution (CC BY) license (https:// burden [1,5].
creativecommons.org/licenses/by/ Stroke is a multifactorial disorder associated with a series of risk factors which can
4.0/). be classified into modifiable (such as hypertension, dyslipidemia, lack of physical activity,

Int. J. Environ. Res. Public Health 2023, 20, 995. https://doi.org/10.3390/ijerph20020995 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 995 2 of 13

alcohol consumption, smoking) and non-modifiable (such as age, sex, race, ethnic group
or genotype before stroke) risk factors [1,6,7]. It is important to add that, after age, hy-
pertension is the most associated factor. Likewise, obesity should be considered because
in addition to being an independent risk factor, it is also a powerful determinant of the
evolution of stroke [1].
As expected, stroke has a great impact on both the physical and mental health of the
affected patients and their quality of life (QoL), which is directly related to the severity
of the episode and the number of comorbidities that the patient suffers. Therefore, the
assessment of physical and mental health is of great importance to determine both the
consequences and the possible treatment of stroke [8].
According to the International Classification of Functioning, Disability and Health
(ICF), stroke can cause impairments in function and alterations of body structures that lead
to functional limitations [9]. Significant impairment in upper limb function can be observed
in more than 80% of stroke survivors [10,11]; which, in turn, is usually associated with the
QoL in all its areas. This acquired deficit can significantly impair Activities of Daily Living
(ADL), so that between 23% and 53% of patients have total or partial dependence [11].
These can determine the level of functional impairment that the patients have in their daily
lives, and are a clinically relevant outcome measure to assess the level of recovery after
stroke [12,13].
Some of the most common physical consequences that can be found in patients
who have suffered a stroke are muscle weakness or paralysis in the affected hemibody,
impaired muscle coordination, an alteration in superficial, exteroceptive and proprioceptive
sensitivity, pain that can limit the joint range of motion (ROM), alterations in the tone of the
musculature and/or an apparent deformity of the entire upper limb [11,14]. On the other
hand, the possibility that a stroke can cause a certain degree of cognitive impairment has
been also confirmed. The prevalence of post-stroke cognitive impairment is high and both
demographic (age, education and occupation) and vascular factors represent risk factors
for cognitive impairment after stroke [15,16], significantly affecting the QoL of patients and
their functional recovery capacity [17,18].
Regarding its prognosis, multiple factors affect the development and functional recov-
ery of the upper limb, such as the great variability in performance between individuals,
cognitive, sensory and motor function, psychological factors, age, gender and the domi-
nant hand [19]. Functional impairment is the most common consequence, in addition to
cognitive impairment [20], which can lead to greater dependence on ADL performance,
job loss and decreased QoL [21]. Therefore, the main objective of this research is to study
which factors are related to functional capacity and QoL a month after suffering a stroke,
so that these can be considered in early interventions.

2. Materials and Methods

2.1. Participants
This cross-sectional study was conducted in Burgos and Córdoba (Spain). The sample
consisted of 81 people who had previously suffered a stroke. As inclusion criteria, it was
required that the participants were older than 18 years and had a diagnosis of residual
hemiparesis due to stroke, where movement of the affected upper limbs was classified
between stages II and IV of the Brunnstrom Scale [22].
The study population was recruited at discharge from the Neurology Service and
Stroke Unit of both hospitals through consecutive sampling.
The sample size was estimated following the procedure for finite populations, using
the formula n = N × (Zα = 1.96) × 2 × p × qδ2 × (N − 1) + (1.96)2 × p × q. The known
population reported by the National Institute of Statistics (INE) [23] was taken into account,
establishing a proportion of strokes in the population and assuming a sampling error of
1%. Based on this, it was concluded that the sample should be made up of 81patients with
strokes under care at the University Hospital of Burgos (HUBU).
Int. J. Environ. Res. Public Health 2023, 20, 995 3 of 13

2.2. Instruments
For the statistical analysis, a series of quantitative and qualitative variables related
to social and clinical aspects of interest were used. The main variables were functional
independence and quality of life one month after having suffered a stroke.
To assess the degree of independence in ADLs, the Functional Independence Measure-
Functional Assessment Measure (FIM-FAM) was used [24–26]. This is a scale that assesses
the degree of global disability with a Cronbach’s alpha of 0.968 [27]. It contains 18 items
that can be used either independently or attached to 12 items belonging to the FAM. It
scores on an ordinal scale from 1 (total dependence) to 7 (total independence), with a total
of 210 points indicating greater functional independence [24–26].
Regarding quality of life, the Stroke-Specific Quality of Life Measure (NEWSQOL) was
used [28]. This is the first questionnaire translated into the Spanish language to specifically
measure QoL in patients with a stroke. It includes 38 items grouped into eight domains
(physical state, communication, cognition, emotions, feelings, ADLs, IADLs and socio-
family functions) rated from 1 (no difficulty in performing tasks) to 5 (extreme difficulty in
performing tasks), so that a higher score will be indicative of worse results in the QoL of
the person. The NEWSQOL has excellent values of internal consistency, with Cronbach’s
alpha coefficients between 0.88 and 0.97 [29]. This Spanish version has demonstrated good
validity and reliability [28].
Regarding the independent variables, the Fugl-Meyer Assessment of the Upper Ex-
tremity (FMA-EU) was used to assess functional capacity [30–32]. It is a scale translated
into Spanish and validated in the Spanish population, with good reliability and validity
and a Cronbach’s alpha of 0.973. It consists of 33 items distributed in four domains (motor,
sensory, range of motion and pain), which score from 0 (non-realization) to 2 (complete
realization), with a total score of 66 points and partial scores of 36 points for the proximal
part of the arm and 30 for wrist and hand. Higher total scores on the scale mean increased
upper limb functionality, normal exteroceptive and proprioceptive sensitivity, a correct
range of passive mobility and no pain [30–32].
For the cognitive assessment, the Montreal Cognitive Assessment (MOCA) was
used [31–34]. It evaluates six cognitive domains (memory, visuospatial function, exec-
utive function, attention/concentration/working memory, language and orientation). Its
maximum score is set at 30 points, the maximum score being the non-existence of cognitive
impairment (Cronbach’s alpha of 0.70). It is always necessary to take into account when
using this evaluation the educational level of the person and the cut-off score should be
placed at 26 to assess the existence of cognitive impairment [35,36].
Sociodemographic data, such as age, sex, nationality, level of education, marital status,
number of children, place of residence, type of dwelling, with whom a participant lives,
tobacco use, alcohol consumption or physical activity; general clinical variables, such
as hypertension, dyslipidemia, myocardial infarction, diabetes mellitus (DM) or obesity;
and clinical variables of interest after stroke such as the dominant and affected side and
cognitive ability and functionality of the upper limbs at one month after stroke were
obtained.

2.3. Procedure
This was a multicenter study performed at the University of Burgos (UBU) in collabo-
ration with the HUBU, Hospital San Juan de Dios (Burgos) and the Reina Sofía Hospital in
Córdoba. After signing the collaboration and confidentiality agreement document with the
participating centers, the data collection necessary for this research began. The participating
centers positively valued the research plan in the IR Approval Committee HUBU 2134/2019.
The data obtained were sent to the research team after an anonymization process; from this
moment on, they are always treated anonymously and together.
The data were collected just one month after suffering a stroke. All participants signed
an informed consent form before starting.
Int. J. Environ. Res. Public Health 2023, 20, 995 4 of 13

Once the data was obtained, a matrix was created for evaluation using the statistical
program Software IBM SPSS (Statistical Package for the Social Sciences) in its 25th version.

2.4. Data Analysis

Descriptive analyses of the characteristics of the sample were performed, expressing
the categorical variables in absolute frequencies and percentages and the continuous ones
in means and standard deviations (Sd). The normality of the dataset was contrasted using
the Kolmogorov–Smirnov test. To assess the association between functional independence
and quality of life (the main variables of the study) and the categorical variables of two
groups, the Student’s T test was used for the independent samples. The association between
functional independence and quality of life and the categorical variables of three or more
groups was analyzed using the ANOVA test. Pearson’s correlation was used to assess the
relationship between the study’s primary variables and the different continuous variables.
Statistical analysis was performed with SPSS software version 25 (IBM Inc., Chicago,
IL, USA). For the analysis of statistical significance, a p-value < 0.05 was established.

3. Results
Data were obtained from a total of 81 patients a month after suffering a stroke, whose
mean age was 68.42 ± 12.43 years old. The distribution by sex was homogeneous, with
54.3% men (n = 44) and 45.7% women (n = 37).
Most of the participants were right-handed (n = 78, 96.3%), but 51.9% (n = 42) suffered
the injury in the right hemisphere, so their affected side was the left one; and the remaining
48.1% (n = 39) suffered the injury in the left hemisphere, so their affected side was the right
one.
Regarding sociodemographic variables, more than half of the sample had completed
basic studies (n = 45, 55.6%) and 23.5% (n = 19) had no studies. 55.6% (n = 46) of the
participants were married or were part of a couple at the time of the stroke, while 24.7%
(n = 20) were single and the remaining 18.5% (n = 15) were separated, divorced or widowed.
Half of the respondents (n = 41, 50.6%) had children.
Regarding the participants’ place of residence, 81.5% of the subjects resided in Burgos
(53 in the city and 13 in towns in the province) and the remaining 18.5% in Córdoba (12 in
the city and 3 in towns in the province). The majority lived accompanied (n = 75, 92.6%)
and 67.9% (n = 55) of the total lived in a flat, 22.2% (n = 18) in a house, 2.5% (n = 2) in
a nursing home and 7.4% (n=6) in another type of dwelling such as in a community of
religious men or women.
Regarding the clinical characteristics of the study, Table 1 shows the average score
obtained in the different quantitative variables. The most frequent comorbidities were
arterial hypertension (n = 34, 42%), dyslipidemia (n = 16, 19.75%), diabetes mellitus (n = 16,
19.75%) and obesity (n = 16, 19.75%). Only 23.5% (n = 19) of the participants practiced
physical exercise before the stroke, and 22.2% (n = 18) and 12.3% (n = 10) were habitual
consumers of tobacco and alcohol, respectively.

Table 1. Descriptive data of the evaluation instruments related to the clinical variables of study.

Quantitative Variables Mean ± Sd

FIM-FAM 159.06 ± 44.57
NEWSQOL 94.49 ± 32.93
MOCA 20.22 ± 7.37
FMA-EU Mobility 44.12 ± 20.58
FMA-EU Sensitivity 6.60 ± 3.46
FMA-EU Range/Pain 42.96 ± 7.75
Total FMA-EU 96.69 ± 26.84
Sd: Standard Deviation; FIM-FAM: Functional Independence Measure-Functional Assessment Measure;
NEWSQOL: Stroke-Specific Quality of Life Measure; MOCA: Montreal Cognitive Assessment; FMA-EU: Fugl-
Meyer Assessment of the Upper Extremity.
Int. J. Environ. Res. Public Health 2023, 20, 995 5 of 13

3.1. Functional Independence

Table 2 summarizes the differences between the independent study variables of two
groups in functional independence. No statistically significant differences were found in
functional independence depending on the sociodemographic and clinical variables of
the two groups (sex, children, with whom they live, practice of physical activity, tobacco
and/or alcohol consumption, hypertension, dyslipidemia, atrial fibrillation, myocardial
infarction, diabetes mellitus, obesity, dominant side and affected side).

Table 2. Differences between independent study variables of two groups in functional independence
using student’s t test for independent samples.

FIM-FAM
Categorical Variables from Two Groups
Mean Sd t p Value (Bilateral)
Female 162.70 41.50
Gender –0.672 0.504
Male 156.00 47.26
No 161.03 48.10
Children 0.389 0.698
Yes 157.15 41.35
Alone 180.33 30.82
Whom subject lives with 1.219 0.227
Accompanied 157.36 45.21
Left 170.67 37.43
Dominant side 0.457 0.649
Right 158.62 44.67
Left 157.38 49.35
Affected side –0.350 0.727
Right 160.87 39.34
No 148.76 53.41
Physical activity –1.882 0.065
Yes 169.11 30.47
No 159.64 50.53
Tobacco use 0.370 0.713
Yes 154.72 40.25
No 156.44 48.47
Alcohol consumption -0.603 0.548
Yes 166.10 34.44
No 145.54 55.28
HTA –1.482 0.144
Yes 163.44 39.66
No 155.38 51.80
Dyslipidemia –0.161 0.872
Yes 157.45 36.74
No 158.12 47.12
Myocardial infarction 0.715 0.477
Yes 134.00 38.18
No 156.20 45.94
DM –0.180 0.858
Yes 158.63 51.24
No 155.43 45.21
Obesity –0.862 0.392
Yes 166.81 50.34
Sd: Standard Deviation; FIM-FAM: Functional Independence Measure-Functional Assessment Measure; HTA:
arterial hypertension; DM: Diabetes Mellitus.

Table 3 summarizes the differences between the independent study variables of three
or more groups in functional independence. No statistically significant differences were
found in functional independence depending on the level of education, marital status and
place of residence, but they were found to depend on the type of dwelling. The average
score of participants living in a flat was 166.73 ± 37.80, those living in a house reported an
average score of 161.89.36 ± 36.22, those living in a nursing home a score of 118.50 ± 13.43
and those living in other types of dwelling such as religious communities scored an average
of 93.83 ± 73.65. An ANOVA test revealed significant differences between those who lived
in another type of dwelling with respect to those who lived in a flat or house (p < 0.05),
the former being the most dependent. The post hoc test indicates significant differences
Int. J. Environ. Res. Public Health 2023, 20, 995 6 of 13

between those who live on the flatand others (p < 0.001) and also between those who live at
home and others (p = 0.002).

Table 3. Differences between independent study variables of three or more groups in functional
independence using ANOVA.

FIM-FAM
Categorical Variables from Three or More Groups
Mean Sd F p Value
No studies 143.58 52.66
Basic 162.49 43.28
Level of studies 1.100 0.354
Upper 171.22 33.85
University 162.88 39.51
Bachelor 142.90 56.61
Married/coupled 167.67 36.73
Marital status 1.858 0.144
Widower 144.13 55.65
Separated/divorced 165.71 28.65
Burgos city 161.00 48.18
Burgos province 155.15 41.68
Place of residence 0.314 0.815
Cordoba city 160.33 33.88
Cordoba province 136.67 37.65
Flat 166.73 37.80
House 161.89 36.22
Type of address 6.520 0.001
Residence 118.50 13.44
Other 93.83 73.65
Sd: Standard Deviation; FIM-FAM: Functional Independence Measure-Functional Assessment Measure. p < 0.05.

Table 4 summarizes the relationship between the different quantitative study variables
and functional independence. A significant relationship was found between functional
independence and all study variables. Functional independence was negatively correlated
with age (p = 0.048) and positively correlated with the functional capacity of the affected
upper limb (p < 0.001); with the subscales of mobility (p < 0.001), sensitivity (p < 0.001) and
range/pain (p < 0.001); and cognitive ability (p < 0.001).

Table 4. Relationship between the different quantitative study variables and functional independence.

FIM-FAM
Quantitative Variables
r p Value
Age –0.225 0.048
Total FMA-EU 0.677 <0.001
FMA-EU Mobility 0.663 <0.001
FMA-EU Sensitivity 0.408 <0.001
FMA-EU Range/Pain 0.407 <0.001
MOCA 0.576 <0.001
FIM-FAM: Functional Independence Measure-Functional Assessment Measure; FMA-EU: Fugl-Meyer Assessment
of the Upper Extremity.; MOCA: Montreal Cognitive Assessment.

3.2. Quality of Life

Table 5 summarizes the differences between the independent study variables of two
groups in quality of life. No statistically significant differences were found in the quality
of life depending on the sociodemographic and clinical variables of these two groups
(sex, children, with whom they live, practice of physical activity, tobacco and/or alcohol
consumption, hypertension, dyslipidemia, atrial fibrillation, myocardial infarction, diabetes
mellitus, obesity, dominant side and affected side).
Int. J. Environ. Res. Public Health 2023, 20, 995 7 of 13

Table 5. Differences between independent study variables of two groups in quality of life using
student’s t for independent samples.

NEWSQOL
Categorical Variables from Two Groups
M Sd t p Value (Bilateral)
Female 95.62 34.39
Gender –0.281 0.779
Male 93.55 32.02
No 89.28 32.57
Children –1.418 0.160
Yes 99.59 32.87
Alone 79.50 30.24
Whom subjects live with –1.162 0.249
Accompanied 95.69 33.03
Left 96.33 27.75
Dominant side 0.098 0.922
Right 94.42 33.26
Left 94.14 33.35
Affected side –0.099 0.921
Right 94.87 32.90
No 97.52 36.72
Aphysical activity 0.283 0.778
Yes 94.79 30.66
No 89.89 34.37
Tobacco use –1.887 0.064
Yes 107.78 33.71
No 95.00 34.13
Alcohol consumption –0.236 0.814
Yes 97.80 38.01
No 102.39 35.36
HTA 1.022 0.311
Yes 93.29 93.29
No 94.62 34.22
Dyslipidemia –0.864 0.391
Yes 102.70 36.05
No 95.05 34.74
Myocardial infarction –0.903 0.370
Yes 117.50 27.58
No 98.33 36.23
DM 0.842 0.403
Yes 90.00 28.20
No 99.94 33.49
Obesity 2.134 0.036
Yes 79.69 32.83
Sd: Standard Deviation; NEWSQOL: Stroke-Specific Quality of Life Measure; HTA: arterial hypertension; DM:
Diabetes Mellitus.

Table 6 summarizes the differences between the independent study variables of three
or more groups in quality of life. No statistically significant differences were found in
quality of life depending on the level of education, marital status and place of residence, but
were found to depend on the type of dwelling. The average score of participants living in a
flat was 88.85 ± 30.96, those living in a house reported an average score of 98.00 ± 32.79,
those living in a nursing home a score of 126.50 ± 0.70 and those living in other types of
dwelling such as in religious communities scored an average of 125.00 ± 37.67. An ANOVA
test revealed significant differences between those who lived in another type of dwelling
with respect to those who lived in a flat (p < 0.05), with the former reporting a worse quality
of life. The post hoc test indicates significant differences between those who live on the
flatand others (p < 0.051).
Table 7 summarizes the relationship between the different quantitative study variables
and quality of life. A significant negative relationship was found between quality of life
and all quantitative study variables except age. That is, the results showed a higher quality
of life in patients with better functionality (p < 0.001), mobility (p < 0.001), sensitivity
(p < 0.001), range/pain (p < 0.001) of the affected upper limb and better cognitive abilities
(p < 0.001).
Int. J. Environ. Res. Public Health 2023, 20, 995 8 of 13

Table 6. Differences between independent study variables of three or more groups in quality of life
using ANOVA.

Categorical Variables from Three NEWSQOL

or More Groups Mean Sd F p Value
No studies 105.00 37.85
Level of Basic 92.36 31.48
0.914 0.438
studies Upper 86.78 26.59
University 90.25 35.26
Bachelor 104.75 30.68
Married/coupled 87.02 31.87
Marital status 1.893 0.138
Widower 103.43 38.43
Separated/divorced 104.43 33.81
Burgos city 91.00 33.05
Place of Burgos province 102.31 36.32
1.015 0.391
residence Cordoba city 95.25 25.65
Cordoba province 119.33 42.19
Flat 88.85 30.96
Type of House 98.00 32.79
3.195 0.028
address Residence 126.50 0.71
Other 125.00 37.67
Sd: Standard Deviation; NEWSQOL: Stroke-Specific Quality of Life Measure; p < 0.05.

Table 7. Relationship between the different quantitative study variables and quality of life.

NEWSQOL
Quantitative Variables
r p Value
Age 0.160 0.162
Total FMA-EU –0.700 <0.001
FMA-EU Mobility –0.658 <0.001
FMA-EU Sensitivity –0.490 <0.001
FMA-EU Range/Pain –0.462 <0.001
MOCHA –0.498 <0.001
NEWSQOL: Stroke-Specific Quality of Life Measure; MOCA: Montreal Cognitive Assessment; FMA-EU: Fugl-
Meyer Assessment of the Upper Extremity.

4. Discussion
The main objective of this research was to study which factors are related to functional
capacity and QoL a month after having suffered a stroke, so that they can be considered in
early interventions.
The high incidence and the burden of stroke disease indicate the importance of urgent
control of risk factors for the prevention of stroke [37]. However, other very important
points for the prediction of the prognosis in the recovery of patients are the determinants of
functional capacity and QoL. Major risk factors include physical inactivity, hypertension,
smoking, dyslipidemia and obesity [37–39], which may clarify the results found in our
study: 42% of the sample had hypertension, 76.5% of them did not perform physical
exercise and 12.3% were habitual tobacco users.
With regard to obesity, which affected 19% of the patients in our sample, the studies
have focused more specifically on the inverse relationship between BMI and mortality
after suffering a stroke. However, in the case of stroke survivors, the association between
BMI and functional recovery was unclear [40]. Some studies showed that a BMI above
35 kg/m2 was a protective factor of patient independence [41], although, in contrast to our
results, Razinia et al. [42] found no relationship between BMI and functional recovery after
discharge. Likewise, risk factors are also associated in some way with different QoL scores
of patients. However, dyslipidemia does not seem to have a significant effect, perhaps
because of its high prevalence in our country [43].
Int. J. Environ. Res. Public Health 2023, 20, 995 9 of 13

Our results suggest the existence of statistically significant differences between the
independence of the patient, measured with the FIM scale, and the type of dwelling in
which the patient usually resides. In this case, it can be observed how patients who live in
an apartment, compared to other types of dwelling, are more independent in their daily
lives. In turn, statistically significant differences have also been observed when comparing
the type of habitual dwelling with patients’ QoL (ECVI-38), showing that patients with the
best quality of life reside in a flat.
With respect to the level of independence or functional capacity of patients, statis-
tically significant differences have also been found in relation to the functionality of the
upper limbs, in all subscales of the FMA-UE evaluation instrument (mobility, sensitivity,
amplitude and pain); and cognitive ability, assessed by MOCA. Previous studies report that
the degree of motor impairment at baseline may influence the incidence of post-stroke med-
ical complications, which may imply worse functional outcomes months after stroke [44].
Likewise, it is also suggested that other complications, such as the presence of depression,
cognitive impairment, aphasia or unilateral negligence, were also factors that affected the
recovery of motor function [19]. In other investigations, it can be confirmed that a greater
functional impairment and the presence of pre-stroke dependency may also be associated
with a worse short- and long-term subsequent functional prognosis [45].
There are mechanisms such as changes in metabolism and cerebral blood flow that may
explain the relationship between the level of motor and cognitive activity and the degree
of functional independence after a stroke. Studies on the pathophysiology of the brain
and the evolution of functional deficits hypothesize that alteration at the level of cerebral
blood flow can be used as an inducer of brain reorganization, although the mechanisms
underlying neurological recovery are unclear. It may be possible that a better functional
state before the stroke could lead to an increase in blood flow and a decrease in damage
once it has happened; which, in turn, causes improvements in the general functional status
of the patient due to the optimization of brain cells and the reorganization of neuronal
activity [46,47].
In reference to the level of independence, a significant negative correlation is also
shown with the age variable, where an increase in age determines a worse general functional
capacity and a lower level of independence. Poggesi et al. [48] found in their results that
age may also be an influential factor in the patient’s functional outcomes after a stroke,
although it appeared to be associated with sex, so that men’s functional recovery decreased
with increasing age while older women continued to improve regardless of the initial
deficit. Previous studies also found that age, gender and type of stroke predict long-term
functional outcome after discharge [21,38]. Another study also corroborates our results,
indicating that age influences performance and, therefore, may be a prognostic factor for
motor function after a stroke [19].
On the other hand, in the analysis of the QoL of the patients in our study, significant
results are also obtained in relation to the functionality of the upper limbs in all the subscales
of the FMA-EU and the score in MOCA, that is, in the level of cognitive capacity. Better
scores in both evaluations are positively related to better scores in the perception of QoL
in post-stroke patients. It should be noted that there is no widely accepted consensus on
the factors that affect or determine the QoL of stroke patients, but it can be said that stroke
significantly compromises the QoL of these patients [43]. Despite this, the results of another
study corroborate the data obtained in our research, showing that the QoL of patients can
depend significantly on several factors such as the patient’s level of functionality or the
MOCA score [49] and that these, according to our results, can be established as risk factors
or determinants for QoL and the level of functional dependence in stroke patients [50].
Previous studies indicate that QoL is worse 3 months after the occurrence of a stroke
and that the patient’s pre-stroke level is not reached [43,51]. In the same way, there is
evidence in other studies of a significant reduction in QoL during the first month after
a stroke episode, although it has been seen that certain improvements are subsequently
achieved after the third month [52]. As a result, it can be confirmed that this condition has
Int. J. Environ. Res. Public Health 2023, 20, 995 10 of 13

a significant and prolonged disabling effect on QoL, despite improvements in treatment in

the acute phase [43].
Various investigations performed in surviving patients associate cognitive impairment
with a greater affectation of their QoL. This association is found in more than half of
patients, without showing significant variation over time towards the recovery of cognitive
status, but rather showing that it worsens [53]. More than half of these patients present an
alteration in their QoL between moderate and severe; however, the QOL has not shown a
significant relationship with variables such as sex, not having a partner, level of education,
economic situation, location of the injury or having comorbidities. However, greater
neurological involvement, the presence of cognitive impairment and increased age were
influential factors in QoL [53]. According to this study, no significant differences in QoL
scores are found in terms of sex [43], although others do affirm the existence of worse QoL
scores in women up to 12 months later [54,55].
Therefore, the functional status presented by the patient is usually directly linked
to the neurological involvement derived from the injury, and is linked in turn to the
involvement of QoL [53]. Consequently, it can be seen how the functional and cognitive
state of the patient gives rise to a better perception of QoL and level of independence, and
the importance of the control of risk factors can be highlighted to improve QoL globally [43].
As for limitations of our study, we find, on the one hand, that the collection of the
sample was performed by means of a non-probabilistic sampling; and, on the other hand,
the number of subjects in some of the variables studied was small and, therefore, significant
differences may not have been obtained. The need to continue researching in this line is
observed, since few studies have been conducted on this topic, and specifically in such early
stages of stroke. Taking into account the predictor variables of a better functional capacity
and QoL can be a turning point in the lives of patients and, therefore, it would be important
to collect more information by expanding the study samples. As for strengths, we should
highlight the great variety of variables that have been collected in our sample of patients
a month after suffering a stroke, which has allowed us to establish more appropriate
intervention objectives in the early stages of stroke recovery for greater independence and
QoL. Some sociodemographic variables can be a confounding factor for clinical variables.

5. Conclusions
The factors related to a worse QoL and functional capacity a month after having
suffered a stroke were living in a different dwelling than the usual flat or house, cognitive
impairment and having a worse functional capacity in the affected upper limb, and more
specifically a worse sensitivity and mobility, a lower range and greater pain in the affected
upper extremity. Increased age was associated with worse functional capacity one month
after a stroke, but not with QoL.
That is, the type of home, age, cognitive ability and functional capacity of the affected
upper limb are important aspects in functional independence and QoL during the first
weeks after having suffered a stroke.
And, therefore, it is important to highlight these data at the clinical level, since it
can allow professionals dedicated to rehabilitation to initially evaluate these variables
more accurately in order to establish the most appropriate individualized treatment plan
adapted to the characteristics that a patient presents, always keeping in mind the impact
the approach to these variables can have on the autonomy of a patient’s daily life and QoL.

Author Contributions: Conceptualization, J.G.-S., J.J.G.-B., P.R.-F. and J.F.-S.; methodology, J.F.-S.
and M.S.-P.; software, P.R.-F. and M.S.-P.; validation, R.P.-H., J.G.-S. and J.J.G.-B.; formal analysis,
M.S.-P. and R.P.-H.; investigation, J.F.-S., J.G.-S. and M.S.-P.; resources, J.F.-S., R.P.-H., P.R.-F. and
J.G.-S.; data curation, P.R.-F. and J.J.G.-B.; writing—original draft preparation, P.R.-F., R.P.-H. and
J.F.-S.; writing—review and editing, P.R.-F., J.G.-S. and J.F.-S.; visualization, J.J.G.-B., J.G.-S. and
M.S.-P.; supervision, J.F.-S., R.P.-H. and J.J.G.-B.; project administration, J.J.G.-B., J.G.-S. and M.S.-P.
All authors have read and agreed to the published version of the manuscript.
Int. J. Environ. Res. Public Health 2023, 20, 995 11 of 13

Funding: This research received no external funding.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of the University of Burgos (UBU 032/2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Conflicts of Interest: The authors declare no conflict of interest.

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