The mortality of stroke has decreased with technological developments in its treatment, although the incidence of stroke has increased [1]. Nevertheless, about half of stroke survivors have imperfect recovery and half of these need assistance with activities of daily living (ADLs) [2]. The recovery of motor function and restoration of ADLs are important outcomes in stroke patients [3]. After the acute medical management, there is a large cost burden involved in managing the rehabilitation, long-term nursing, and employment of such patients. The World Health Organization (WHO)–Global Burden of Disease reports that neurological diseases have a greater cost burden than gastrointestinal and respiratory diseases and malignant tumors combined [4]. In addition to the physical and economic burdens, emotional and social difficulties might worsen the quality of life (QOL) in patients with stroke.

To increase the overall QOL and social participation, multiple domains must be assessed. Stroke patients should return to their ordinary lives through rapid functional restoration, while upgrading their health-related quality of life (HRQoL, hereafter HQ). The WHO defines QOL as ‘an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns’ [5]. Stroke decreases HQ by causing various disorders, including exercise, language, cognition, and psychological impairment. Therefore, these patients require combined medical and HQ assessments. Most patients have a decrease in their HQ after a stroke. Depression and old age are related to the low HQ [67]. Other factors related to HQ include inadequate functional restoration in their daily lives, insufficient social and emotional support, isolation from community members, and sex [4]. In developed countries, the deterioration in patients' daily lives due to cardiovascular diseases exceeds that due to stroke, while in Korea stroke has a significantly greater effect than cardiovascular diseases [68]. However, few studies have examined HQ among stroke patients in Korea.

Therefore, we assessed the demographics, physical and cognitive functions, and psychological status of patients with chronic cerebral infarction as well as the correlation between each item and HQ.

The study enrolled 35 patients (16 females), but 3 were excluded due to insufficient answers. The average patient age (mean ± standard deviation) was 54.4 ± 10.8 (range, 28–75) years. Table 1 summarizes their demographic and clinical characteristics. The average MMSE, a measure of cognitive ability, was 25.9 ± 2.92 (range, 20–30), and the average KMBI, a measure of physical disability, was 3.3 ± 0.8 (range, 1–5). The average BDI-II, a measure of depression, was 14.8 ± 11.8 (range, 0–42).

The WB was significantly negative correlated with BMI and social relationships (Table 2). There was no significant correlation between cognitive function and HQ. The SF-36 scores for the physical function and bodily pain scales were negatively correlated with the mRS and positively correlated with the KMBI (Table 3). The SF-36 physical composite score was also negatively related to the mRS and positively related to the KMBI (Table 4). There was no significant correlation between the WB domain and physical disability. The BDI-II and general health scale of SF-36 were negatively correlated (Table 5). Environmental context and depressive mood were negatively correlated in the WB (Table 6).

Most of the results of the comparisons between HQ and the sociodemographic characteristics of the stroke patients were negative, although mild positive correlations were found with the social relationship scale of the WB and the patient's BMI, personal relationships, and social support. This suggests that stroke patients with a higher BMI have difficulty forming social relationships. We found negative correlations between the daily activities, climbing, and walking and the bodily pain scale of the SF-36. Greater physical disability means more difficulty in the daily lives of stroke patients and the patients are more exposed or sensitive to pain. Conversely, physical disability was not closely related to mental health, including social function or emotion in HQ. Comparing depressive mood and HQ of the stroke patients, a weak negative correlation was found between the social relationship and physical health scales of the WB, including general health, ADLs, mobility, and pain and discomfort of the SF-36, which scores subjective health and depressive mood.

Previous research showed that post-stroke depression decreased the functional status or activities of patients with stroke [1516]. Combined with our results, physical activity may affect the emotional status of stroke patients and vice versa. Another report showed that a higher pre- and post-stroke QOL is associated with better social determinants of health in lower and middle-income countries [17]. Contrasting a previous study, we found that social determinants did not have a major role in HQ in chronic stroke patients; this may result from different incomes in different nations or different stages of the disease (acute versus chronic) [17]. One prospective cohort study showed that the self-perceived HQ deteriorated significantly at 12 months in terms of social interactions and living environment [18]. Depression had a negative association with all four domains of HQ, whereas decreasing disability in the basic ADLs (reflected by an increasing Barthel Index score) had a positive association with the physical and psychological HQ [18]. Another study found that the severity of anxiety symptoms in stroke is independent of sex and depressive symptoms and is associated with a poor stroke-related HQ [19]. We found that depressive mood affected HQ and social relationship scale, and caused more difficulties with the ADLs. Overall, emotion such as depression or anxiety may significantly affect the stroke-related HQ [20]. This means that a severe depressive mood increases the probability that patients consider their health status bad, which causes more difficulty with their ADLs, relationships with others, or performing their own roles in society. We did not find a correlation between cognitive function and HQ. This has several possible explanations. Those with disability after stroke usually may not have tried to find jobs, which were already blocked by social barriers. In addition, the inclusion criterion MMSE ≥ 20 could have masked the social barriers caused by low cognition. Finally, cognition may truly not be correlated with HQ.

Our study had 2 major limitations. First, the small sample size may limit the interpretation of our findings. Because this study was a small investigation, several methods were used to overcome biases. For example, only patients with cerebral infarction due to supratentorial lesions and mRS > 1 were included. Second, this was a cross-sectional study, which can identify only correlations and not causative or confounding factors. Further longitudinal, large-scale studies are needed to answer the remaining questions.

In conclusion, an understanding of the relationships among HQ, disability, and post-stroke depression is required to plan the appropriate rehabilitation of stroke patients. We investigated the relationships between specific items of the generic HQ, sociodemographic characteristics, physical disability, cognitive function, and depression. When planning rehabilitation treatment for stroke patients, physiatrists should consider that improving the physical disability and treating any depression may improve HQ.