Most patients with stroke achieve good functional outcomes after rehabilitation , but some patients remain unsatisfied with the lowered quality of life they experience due to residual disabilities after stroke. QoL is a subjective measurement of patient well-being that should be considered in the assessment of stroke survivors. Our study revealed that the mean QoL score of patients with stroke declined over 1-year after discharge, which was in line with the findings of study of Kusambiza-Kiingi and colleagues. They evaluated QoL among 108 stroke survivors at the community health centres with services of physiotherapists. They found poor QoL among patients with stroke, and positive correlation between community reintegration and QoL (r = 0.51, p < 0.0001) . In contrast, Shyu et al. performed longitudinal study of stroke survivors and evaluated QoL at 1, 3, 6 and 12 months .Even though the QoL of patients with stroke improved from first to twelve months after discharge, the QoL scores were considerably less than the normal populations, especially in social and physical functions.
The reasons why QoL of stroke in our study declined over the 1-year after discharge may be explained by 2 reasons, including: 1) More patients with stroke in the TSRR had developed depression by the 1-year after discharge than those that had depression at discharge (21.0% vs. 14.7%) ; and, 2) More than three-fourths (76.8%) of patients with stroke in the TSRR had developed at least one complication within 12 months after discharge from rehabilitation wards and nearly 60% of patients with complications at discharge still had the same complications one year later . The strategies to prevent depression and other complications should be concerned in order to gain QoL score at 1-year period.
Concerning factors related to improve QoL in patients with stroke, the present study found many factors including higher scores of mBI at follow-up period, having no anxiety and no depression, having leisure activity, and no need for caregiver. As reported by Heikinheimo and Chimbay, factors related to QoL were age, gender and functional recovery . Mutai et al. also found age, functions and depression related to QoL . Laurent et al. revealed that life satisfaction and QoL of stroke were significantly impaired in all life domains . In addition, QoL was strongly correlated with functional independence, persistence of hemiplegia, and depressed mood . Functional recovery was another factor reported by many studies [9, 20, 21] which was in line with our study. Even though mBI was one of positive factors, its effect was not large (b=0.63). This might be due to change score of mBI at 1-year and at discharge was 2.39 ± 3.92 . However, the mBI score at 1-year follow-up period was more than discharge period (mean mBI at 1-year and at discharge were 16.04 ± 4.30 and 13.66 ± 4.34 respectively).
Moreover, some reported that greater anxiety and depression were the important factors related to QoL [22-23]. Both anxiety and depression could obstruct rehabilitation process and outcomes, and could be predictors of QoL of patients with stroke. In addition, QoL can be improved in the long-term period if physicians can detect and treat anxiety and depression adequately . Related to anxiety, Tang and colleague measured anxiety using HADS and its effect on patients with stroke, and found that anxiety was associated with HRQoL (r=-0.154) . These studies were in line with our study. However, Morris et al. reported that anxiety appears to be more important than depression in predicting QoL at 6 months after stroke .
There were many studies reported about depression affecting QoL of patients with stroke [9, 21, 26-28]. For example, QoL in stroke with depression was more severe impaired than non-depressed stroke . Depression after stroke has a negative impact on outcomes including self-care functions and QoL after stroke [5, 26]. Not only depression, but also pain and fatigue could determine QoL of stroke . As depression is common consequences after stroke, medical personnel should keep in mind for early detection of these conditions by using simple screening tools such as HADS or Patient Health Questionnaire-9 (PHQ-9), etc.
Concerning leisure activity, patients love to do these activities for relaxation and healing their minds. Our study found that having leisure activity was one of the positive factors to increase QoL score. Authors have experience in using creative art therapy, which was composed of art and music therapy, for enhancement rehabilitation program among 118 inpatient stroke, and found that creative art therapy twice a week for four weeks (8 sessions), combined with conventional physical therapy (20 sessions), can significantly decrease depression, improve physical functions and increase quality of life compared with physical therapy alone .
Another factor related to QoL of stroke survivors was no need of caregiver. There is a study performed in Mongolia reported that being single was one of the factor associated to low QoL . This may indirectly imply that they had no caregiver. Our study also reported that discharge to their home was related to good QoL of patients with stroke. This may be because our people get used to living with extended family more than staying in nursing home as people in Western countries.
There were some limitations including 1) This study did not have a large enough sample, so some variables could not be detected statistical significance. 2) All centres were tertiary care centres, therefore, our study population may not be representative of general stroke patient population. 3) There were many tools for assessment the QoL including the Stroke Impact Scale, the Stroke Specific Quality of Life scale, the Burden of Stroke Scale and WHOQOL-BREF which are specific health-related QoL instruments developed in the last decade , therefore direct comparison could not be performed. 4) Only 60% of subjects from the TSRR project could be followed-up for a full 12 months after discharge. This high loss to follow-up rate was influenced by some factors that may include difficulty in contacting the patient, transportation-related problems, inconvenience of or disinterest in being followed-up at the evaluating hospital, and a failure to remember to attend. It should be noted that nearly 40% of our patients resided in a rural area, which would have made travel to the evaluating centre more difficult and inconvenient. Future studies should include this outcome into the study design and consider physician visits to patients who fail to follow-up in order to strengthen the integrity of these findings.