Introduction
Stroke, also known as cerebrovascular accident, is a medical emergency characterized by interruption of cerebral blood flow, resulting in permanent or transient involvement of one or more brain regions and affecting one or more blood vessels1,2.
Globally, stroke is the second leading cause of mortality and the first cause of disability; however, in high-income countries it ranks as the third leading cause of death3.
In Mexico, the incidence is 2.4 cases/1,000 inhabitants, with a higher frequency in men than in women and a predominance from 65 years of age onward4.
Stroke is classified as ischemic or hemorrhagic. Ischemic stroke is the most frequent (~80%), caused by occlusion of a cerebral artery due to thrombotic or embolic events, which leads to hypoperfusion, hypoxia, release of inflammatory mediators and free radicals, cellular injury, and apoptosis5,6. Hemorrhagic stroke accounts for ~20% of cases and is mainly due to rupture of a blood vessel, resulting in intracerebral or subarachnoid hemorrhage7.
Risk factors include systemic hypertension (the most important), diabetes mellitus, dyslipidemia, smoking, alcohol use, physical inactivity, obesity, depression, and cardiac disease (history of acute myocardial infarction and atrial fibrillation)8,9.
Clinical presentation depends on the affected artery or arteries and may include hemiparesis, hemiplegia, hypotonia, hyperreflexia, gait disturbances, sensory deficits, and aphasia, among others10,11.
Diagnosis is based on clinical manifestations and neuroimaging – computed tomography or magnetic resonance imaging – which are crucial to determine stroke type and location and to enable optimal, timely treatment12,13.
One of the most important post-stroke issues is disability, which poses a challenge for health systems and families due to the need for prolonged care, rehabilitation, and readaptation14.
Another relevant aspect is loss of quality of life (QoL) due to post-stroke sequelae, which can negatively affect emotional, cognitive, family, and social domains15,16.
In this context, early rehabilitation has become central to comprehensive stroke management. Multiple studies and guidelines have shown that early rehabilitation – initiated within 24-72 h after stroke – plays an important role in functional recovery and QoL (mobility, independence, social participation)17,18.
The objective of the present study was to compare QoL in patients with ischemic stroke who received early rehabilitation.
Material and methods
We conducted a comparative, impact, longitudinal, single-center, homodemic, prospective study at a secondary-level hospital of the Instituto Mexicano del Seguro Social (IMSS) in Puebla, Mexico. Patients ≥ 18 years with ischemic stroke diagnosed by computed tomography were included. Patients with prior stroke and those with other concomitant neurologic diseases were excluded; those who requested withdrawal for any reason or for whom a second evaluation at 30 days could not be performed were removed.
Patients were divided into two groups: group 1 received early rehabilitation (within the first 7 days after stroke) and group 2 did not.
The intervention included physical rehabilitation (mobility and gait, balance, muscle strength), occupational therapy (basic activities of daily living), and speech-language therapy (for aphasia or dysarthria) delivered by physiotherapists, occupational therapists, and communication therapists, either institutionally or privately; sessions lasted 45 min, 3 times/week.
The group without early rehabilitation received standard in-hospital care with active and passive mobilization when possible, as well as patient/caregiver education.
Sociodemographic and clinical data were recorded, including age, sex, risk factors, sequelae, QoL, and rehabilitation.
QoL was assessed at 72 h and 30 days after the event using two instruments. The Stroke-Specific QoL scale (SS-QoL; stroke-specific quality of life scale [ECVI]-38 in Spanish), developed in 2004 and validated in 2008 by Fernández et al., comprises 38 items grouped into 8 domains (cognition, physical state, feelings, emotions, communication, basic activities of daily living, instrumental activities of daily living, and socio-family functioning). Each item uses a Likert-type response (1-5); domain scores range 0-100 (lower scores = better QoL); a total score is obtained by averaging all domain scores. It has a Cronbach’s alpha of 0.79-0.95 and an intra-class correlation coefficient of 0.81-0.9619.
Interpretation20:
- − < 25: no impairment
- − 25 a < 50: mild impairment
- − 50 a < 75: moderate impairment
- − 75-100: severe impairment
The modified Rankin Scale (mRS) evaluates the degree of dependence after stroke or other neurologic conditions, scoring from 0 (asymptomatic) to 6 (death); higher scores indicate greater disability21.
Statistical analysis was performed using Statistical Package for the Social Sciences v.25. Descriptive statistics used measures of central tendency and dispersion. The Kolmogorov-Smirnov test assessed the distribution of quantitative variables. To compare QoL by ECVI-38 and mRS between the early-rehabilitation and no-rehabilitation groups at 72 h and 30 days, the Chi-square (nnnnnnnnn2) test was used. A p < 0.05 was considered statistically significant.
This study was approved by the IMSS Local Health Research Committee No. 2108. All patients provided informed consent. Information was handled with strict confidentiality and for research purposes only.
Results
A total of 90 patients with ischemic stroke were recruited: 50 (55.5%) men and 40 (44.4%) women, aged 29-96 years (mean 68 years; standard deviation ± 13).
Regarding risk factors, 62 (68.8%) had at least one. Systemic hypertension was most prevalent (57.7%), followed by type 2 diabetes (33%) and heart disease (10%) (Table 1).
Table 1. Risk factors
| Comorbidity | (n = 90) | % |
|---|---|---|
| Systemic arterial hypertension | 52 | 57.7 |
| Type 2 diabetes | 29 | 32.2 |
| Heart disease | 9 | 10.0 |
As for post-stroke sequelae, the most frequent was hemiplegia in 67 (74.4%), followed by hemiparesis in 37 (41.1%); aphasia and hearing deficits were least frequent, each in 1 (1.1%). The remainder is shown in table 2.
Table 2. Post-stroke sequelae
| Sequela | (n = 90) | % |
|---|---|---|
| Hemiplegia | 67 | 74.4 |
| Hemiparesis | 37 | 41.1 |
| Aphasia | 1 | 1.1 |
| Dysarthria | 15 | 16.6 |
| Dysphagia | 12 | 13.3 |
| Visual impairment | 0 | 0 |
| Hearing impairment | 1 | 1.1 |
Functional status by mRS showed that at 72 h, severe disability predominated in 50 (55.6%), while only 1 (1.1%) had mild disability. At 30 days, 41 (45.6%) still had severe disability, and 8 (8.9%) had mild or very mild disability. Details are shown in table 3.
Table 3. Modified rankin scale and ECVI-38
| Modified rankin scale | 72 h (n = 90) (%) | 30 days (n = 90) (%) | |||
|---|---|---|---|---|---|
| Asymptomatic | 0 (0.0) | 0 (0.0) | |||
| Very mild | 0 (0.0) | 8 (8.9) | |||
| Mild | 1 (1.1) | 8 (8.9) | |||
| Moderate | 14 (15.6) | 17 (18.9) | |||
| Moderately severe | 25 (27.8) | 16 (17.8) | |||
| Severe | 50 (55.6) | 41 (45.6) | |||
| Death | 0 (0.0) | 0 (0.0) | |||
| ECVI-38 | |||||
| No impairment | 0 (0.0) | 0 (0.0) | |||
| Mild | 13 (14.4) | 23 (25.6) | |||
| Moderate | 30 (33.3) | 26 (28.9) | |||
| Severe | 47 (52.2) | 41 (45.6) | |||
|
ECVI-38: stroke-specific quality of life scale. |
|||||
QoL by ECVI-38 showed that at 72 h, most patients (47, 52.2%) had severe impairment, and only 13 (14.4%) had mild impairment. At 30 days, severe impairment persisted in 41 (45.6%), and mild impairment increased to 23 (25.6%). Results are detailed in table 3.
A total of 37 (41.1%) patients received early rehabilitation; of these, 18 (48.6%) received institutional rehabilitation, and the remainder private. Additional results are detailed in table 4.
Table 4. Early rehabilitation
| Category | n | % |
|---|---|---|
| Early rehabilitation (n = 90) | ||
| Early rehabilitation | 37 | 41.1 |
| No rehabilitation | 53 | 58.9 |
| Type of early rehabilitation (n = 37) | ||
| Institutional | 18 | 48.6 |
| Private | 19 | 51.3 |
Based on mRS, comparing patients with and without early rehabilitation: at 72 h, a higher proportion without early rehabilitation had severe disability (77.4%) compared with those with early rehabilitation (24.3%). Conversely, the early-rehabilitation group showed predominance of moderately severe (45.9%) and moderate (27.0%) disability. This difference was significant (p = 0.000), indicating a substantial impact of early rehabilitation on disability.
At 30 days, differences were accentuated: the no- rehabilitation group predominantly had severe disability (73.6%), whereas the rehabilitation group more frequently had moderate (37.8%), mild (21.6%), and very mild (18.9%) disability. The difference remained statistically significant (p = 0.000), suggesting a positive impact of early rehabilitation on functional recovery. Additional results are in table 5.
Table 5. Modified rankin scale in relation to early rehabilitation
| Modified rankin scale | Early rehabilitation (n = 37) | No rehabilitation (n = 53) | Chi square (p) | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| 72 h | |||||
| Asymptomatic | 0 | 0.0 | 0 | 0.0 | 0.000 |
| Very mild | 0 | 0.0 | 0 | 0.0 | |
| Mild | 1 | 2.7 | 0 | 0.0 | |
| Moderare | 10 | 27.0 | 4 | 7.5 | |
| Moderately severe | 17 | 45.9 | 8 | 15.1 | |
| Severe | 9 | 24.3 | 41 | 77.4 | |
| Death | 0 | 0.0 | 0 | 0.0 | |
| 30 days | |||||
| Asymptomatic | 0 | 0.0 | 0 | 0.0 | 0.000 |
| Very mild | 7 | 18.9 | 1 | 1.9 | |
| Mild | 8 | 21.6 | 0 | 0.0 | |
| Moderate | 14 | 37.8 | 3 | 5.7 | |
| Moderately severe | 6 | 16.2 | 10 | 18.9 | |
| Severe | 2 | 5.4 | 39 | 73.6 | |
| Death | 0 | 0.0 | 0 | 0.0 | |
| ECVI-38 | |||||
| 72 h | |||||
| No impairment | 0 | 0.0 | 0 | 0.0 | 0.000 |
| Mild impairment | 11 | 29.7 | 2 | 3.8 | |
| Moderate impairment | 18 | 48.6 | 12 | 22.6 | |
| Severe impairment | 8 | 21.6 | 39 | 73.6 | |
| 30 days | |||||
| No impairment | 0 | 0.0 | 0 | 0.0 | 0.000 |
| Mild impairment | 21 | 56.8 | 2 | 3.8 | |
| Moderate impairment | 14 | 37.8 | 12 | 22.6 | |
| Severe impairment | 2 | 5.4 | 39 | 73.6 | |
|
ECVI-38: stroke-specific quality of life scale. |
|||||
ECVI-38 QoL results in relation to early rehabilitation: at 72 h, patients without early rehabilitation predominantly exhibited severe impairment (73.6%) compared with the rehabilitated group (21.6%), while the latter showed higher proportions of moderate (48.6%) and mild (29.7%) impairment. The difference was statistically significant (p = 0.000). At 30 days, results continued to favor the early-rehabilitation group, with mainly mild (56.8%) and moderate (37.8%) impairment, whereas the no-rehabilitation group predominantly showed severe impairment (73.6%). This difference was also statistically significant (p = 0.000), suggesting that early rehabilitation improves QoL (Table 5).
Discussion
Stroke remains a leading cause of disability and mortality worldwide, with rising prevalence across age groups; thus, management strategies have increasingly emphasized early rehabilitation, which has shown a key role in functional outcomes, control of sequelae, and QoL22.
In this study of 90 ischemic stroke patients, male predominance (55.5%) aligns with Herrera et al. (2023), who also reported male predominance (66.7%)23.
Ischemic stroke is associated with risk factors such as systemic hypertension, type 2 diabetes, and tobacco/alcohol use24. Our findings were largely consistent with hypertension and type 2 diabetes present in both.
Regarding mRS, at 72 h and 30 days, severe disability predominated (55.6% and 45.6%, respectively), differing from a 2023 national study in Veracruz25 that included 172 patients and reported 49% with mild disability.
For QoL, our study showed a high proportion with severe impairment at both 72 h (52.2%) and 30 days (45.6%), contrasting with international literature26 reporting predominance of moderate impairment (36.3%) and with national data25 showing 48.2% without impairment and 37.2% with mild impairment. These discrepancies may reflect demographic characteristics, sociocultural factors, and methodological differences.
Post-stroke sequelae significantly impact QoL; therefore, rehabilitation has become essential. International literature indicates that early rehabilitation (24-72 h post-stroke) benefits these patients27.
In our cohort, 41.1% received early rehabilitation and, at 30 days, showed lower disability on mRS (p = 0.000) and less impairment on ECVI-38 (p = 0.000) versus those without early rehabilitation – differences that are statistically significant and indicate improved functional status. These results are consistent with national studies23 showing QoL improvement through the short form-12 (p = 0.02) and improved functional capacity by mRS (p < 0.01).
These findings align with international evidence noting that the immediate post-stroke period exhibits heightened neuroplasticity and better responsiveness; early rehabilitation has therefore yielded improved outcomes across functional domains (reintegration into daily activities) and QoL, as well as reduced psychological impact (post-stroke depression)28.
Main limitations include a relatively small sample size, lack of standardization in rehabilitation type and duration, and limited follow-up. Future studies addressing these gaps will allow more generalizable results.
Conclusion
Early rehabilitation after ischemic stroke yields significant improvements in functional status and QoL at 30 days. Timely implementation of rehabilitation is an effective strategy within comprehensive patient management.
Funding
The authors declare that they have not received funding.
Conflicts of interest
The authors declare no conflicts of interest.
Ethical considerations
Protection of humans and animals. The authors declare that no experiments involving humans or animals were conducted for this research.
Confidentiality, informed consent, and ethical approval. The authors have followed their institution’s confidentiality protocols, obtained informed consent from patients, and received approval from the Ethics Committee. The SAGER guidelines were followed according to the nature of the study.
Declaration on the use of artificial intelligence. The authors declare that no generative artificial intelligence was used in the writing of this manuscript.
