Effect of a Nursing Intervention Based on Health Education on Functionality, Depression Symptoms, and Quality of Life in Patients With Ischemic Stroke: A Quasi-Experimental, Longitudinal, and Prospective Clinical Trial
Phase: NA
Conditions: Ischemia Stroke, Post-stroke Depression, Post-stroke, Quality of Life, Health Education
Sponsor: University of Santiago de Compostela

1 
 
 
 
 
Effect of a nursing intervention based on health education 
on functionality, depression symptoms and quality of life in 
patients with ischemic stroke. 
 
 
 
 
 
 
 
 
 
 
• 
Protocol code:  
• 
Version 1.1 of protocol dated 22/10/2025 
 
• 
Promoter: María del Rosario Marín Arnés 
• 
Principal Investigator: María del Rosario Marín Arnés, nurse, neurology and 
neurosurgery unit, Lucus Augusti University Hospital.  
• 
Collaborating researchers: 
◦ 
Eva Gómez Fernández (neurology nurse HULA) 
◦ 
María Irene Núñez Hernández (neurology nurse HULA) 
◦ 
Mercedes Fernández Vázquez (neurology nurse HULA) 
◦ 
María Lourdes Bermello López (nurse at the HULA neurology clinic) 
◦ 
Emilio Rubén Pego Pérez (Professor of Nursing Faculty USC) 
◦ 
Emilio Gutiérrez García (Professor of Psychology USC) 
◦ 
Félix Martínez Eiriz (EIR, PhD student) 
 
 
 

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Index 
 
Summary ........................................................................................................................................................... 3 
Background and justification of the project ........................................................................................................ 3 
Study hypothesis ............................................................................................................................................... 5 
Objectives .......................................................................................................................................................... 5 
Type of study ..................................................................................................................................................... 6 
Material and methods ........................................................................................................................................ 6 
Scope of study ............................................................................................................................................... 6 
Definition of the subjects to be studied ......................................................................................................... 6 
Subject selection and withdrawal .................................................................................................................. 6 
Recruitment and recruitment of participants ................................................................................................. 6 
Assignment/Randomization Procedure ......................................................................................................... 7 
Justification of the sample size...................................................................................................................... 7 
Primary and secondary variables .................................................................................................................. 8 
Instruments .................................................................................................................................................... 8 
Description of the intervention ....................................................................................................................... 8 
Timeline and expected completion date. ....................................................................................................... 9 
Statistical analysis plan ................................................................................................................................ 11 
Ethical-legal aspects ......................................................................................................................................... 11 
Compliance with Good Clinical Practice Standards, Declaration of Helsinki, Oviedo Convention, as well as 
data protection regulations, management of medical records and other applicable regulations depending 
on the type of study. ..................................................................................................................................... 11 
Informed consent models. ........................................................................................................................... 12 
Confidentiality of the information collected in the context of the study........................................................ 12 
Commitment to publish results .................................................................................................................... 12 
Economic report and source of funding ........................................................................................................... 12 
Bibliography ..................................................................................................................................................... 12 
Data collection notebook ................................................................................................................................. 18 
Annexes ........................................................................................................................................................... 18 
Annex I. Description of the instruments ...................................................................................................... 18 
Annex II. Development of interventions. ..................................................................................................... 19 
Annex III. Data collection notebook ............................................................................................................. 23 
 
 
 
 

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Summary  
This study is entitled "Effect of a nursing intervention based on health education on functionality, depression 
symptomatology and quality of life in patients with ischemic stroke". The promoter and principal investigator is 
María del Rosario Marín Arnés. 
This is a quasi-experimental, longitudinal and prospective clinical trial, which will be carried out in patients who 
have suffered an ischemic stroke and who were treated in the neurology unit of the Lucus Augusti University 
Hospital, where this same study will be carried out.  
The main objective of the study is to determine the effect of a nursing intervention based on health education 
on quality of life and symptoms of depression in people who have suffered an ischemic stroke. 
To achieve this objective, variables such as cognitive status, symptoms of depression, autonomy and ability to 
perform in basic activities of daily living, neurological deficit and quality of life will be assessed. 
Regarding the total number of subjects under study, according to the Atlas of Stroke in Galicia published by 
the Spanish Society of Neurology in 2018, the autonomous community of Galicia had a population of 2,701,819 
inhabitants. Applying an incidence rate of 187.4 cases per 100,000 inhabitants, according to the IBERICTUS 
study, 5,064 new cases of stroke are estimated each year in Galicia per 100,000 inhabitants. The province of 
Lugo has 324,842 inhabitants on 1 January 2024, according to the INE, which, applying the same incidence 
rate, estimates 609 new cases of stroke per 100,000 inhabitants per year. Considering the proportion of 
ischemic strokes compared to other types of strokes 80:20, the estimated cases of the same would be 487 
new cases in Lugo. The representative sample size of stroke patients in the province of Lugo would be 70 
patients, 35 patients receiving the intervention and 35 controls. 
 
Términos MESH: Ischemic Stroke; Nursing; Depression; Anxiety; Health Education; Quality of Life 
Background and justification of the project  
Stroke is defined as a syndrome with rapid onset of a focal neurological deficit of vascular origin. Classically, 
strokes are divided into two large groups: ischemic strokes, which will occur 80-85% of the time, and 
hemorrhagic strokes, which account for 15-20% of strokes. Specifically, ischemic stroke is defined as an 
episode of neurological dysfunction caused by focal cerebral infarction delimited by an occluded artery that 
decreases cerebral blood flow. Its etiology classification can be differentiated into five main subtypes: 
atherothrombotic stroke of large artery, cardioembolic stroke, lacunar of small vessel, stroke of rare cause and 
stroke of undetermined origin. In any case, as a consequence there will be an area of ischemia at risk of cell 
death and an infarcted area already necrotic, causing irreversible damage. The functional evolution of the 
patient after a stroke is classically established in three periods. An acute period that goes from the onset of 
symptoms to hospital discharge, a subacute period in which there is a progressive functional improvement, 
which continues in most cases during the first 3-6 months and finally a chronic phase of functional stabilization. 
Epidemiologically speaking, stroke is the second cause of death and third cause of disability worldwide and 
the first in Europe, with its incidence and prevalence being higher in women. While it is true that on the one 
hand there is a decrease in mortality in developed countries, on the other hand, there is an increase in the 
incidence associated with aging and an increase in life expectancy. For this last issue, it is estimated that 
mortality from ischemic stroke will increase in Spain by about 39% between 2015 and 2035. In Spain in 2022, 
cerebrovascular disease accounted for 48% of total admissions due to a neurological cause. It affects 1.5% of 
people, increasing to 3% from the age of 65 and to 10% from the age of 80. In Europe, the sex-adjusted 

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incidence of stroke was 191.9 per 100,000 person-years and the sex-adjusted prevalence was 9.2%. In 2019, 
the total number of disability-adjusted life years related to stroke exceeded 125 million worldwide. 
Economically, ischemic stroke accounts for 3-4% of health expenditure in Western countries and is expected 
to quadruple in the future. 
The main deficits, disabilities and complications observable after a stroke include paralysis, emotional 
imbalance, speech and language disorders, visual disturbances, cognitive deficits, physical and mental fatigue, 
epileptic seizures and pain. The greatest risk factor predicting poor prognosis of ischemic stroke is age, which 
is directly related to epidemiological data. 
Ischemic stroke is the leading cause of acquired disability in adults. Two out of three people affected by a 
stroke associate difficulties in basic tasks such as showering or bathing without help and in household chores. 
A high percentage of these people perceive their state of health as fair (37.3%), or bad or very bad (36.5%) 
and a majority suffer pain or discomfort (62.4%) and difficulties in carrying out their daily activities (59.1%). 
The mental health of those who have suffered a stroke is also severely affected, with women and those over 
65 scoring significantly worse. It is estimated that between 20 and 50% of stroke survivors develop depressive 
symptoms at some point, which can have a direct impact on the patient's physical and cognitive recovery. The 
manifestation of post-stroke depression includes everything from persistent sadness to loss of interest in 
activities that the patient previously enjoyed, changes in appetite or difficulties concentrating or falling asleep. 
In the same way, dysphagia, a common complication after an ischemic stroke, is also related to the appearance 
of depressive symptoms. Other risk factors have been described when it comes to developing symptoms of 
depression in patients who have suffered a stroke, such as low educational level or low economic level. Early 
identification and treatment of depression in post-ischemized patients is crucial for improving their quality of 
life and early rehabilitation. 
Patient function after stroke is associated with the likelihood of hospital readmission. Patients with poor function 
at discharge are more likely to need long-term care and intensive rehabilitation plans. Functionality includes 
the interaction of positive aspects between the 3 main components: body functions and structures; activity and 
participation; and environmental and personal factors. Post-stroke functionality has not yet been 
comprehensively assessed. Some authors postulate a progressive functional improvement beyond 12 months 
when accompanied by rehabilitation treatment and, on the contrary, a progressive functional deterioration in 
the absence of specific rehabilitation therapy. 
The greatest attention to stroke patients has commonly focused on the acute phase, which has managed to 
reduce morbidity and mortality. However, studies focused on the subacute phase are less frequent and few 
are those that focus on long-term evolution. Other authors postulate that differences in functional status at 
three months are associated with significant differences in survival and performance status during a seven-
year follow-up. 
In relation to the subacute phase, the evaluation of the functional status of ABVD is recorded in only 24.6% of 
cases at discharge and for six months after the episode. 
To assess the autonomy of stroke patients, it is necessary to consider how the physical, cognitive, and 
psychological impacts of stroke may lead to a wide range of activity limitations and participation restrictions. 
Patients who have suffered a stroke are often predisposed to a sedentary lifestyle that affects performance in 
activities of daily living, thus increasing the risk of relapse. Resuming activities of daily living is therefore of 
great importance for life satisfaction and is considered as a primary goal for rehabilitation. The first six months 
after stroke are therefore considered critical for rehabilitation. Rehabilitation plays a fundamental role in this 

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process since it directly influences the reduction of disability and handicap by reducing the personal, family 
and social cost, and its usefulness is fully established. 
The functional evolution varies with the initial clinical severity. Maximum functionality is reached on average at 
2 months in patients with initially mild strokes, at 3 months in patients with moderate strokes, at 4 months in 
severe strokes and at 5 months in very severe strokes. In addition, several studies have shown that functional 
outcome after stroke is a potent predictor of long-term mortality, therefore, we need to promote maximum 
functional independence of stroke survivors living at home through supervised and tailored nursing 
interventions and physical activities. Results from previous studies indicate that Barthel's delta, i.e. the change 
in a patient's functional autonomy, is equal to 0 for those interventions performed in routine clinical practice 
other than treatment with rt-PA or thrombectomy after suffering from an ischemic stroke. Therefore, it can be 
deduced that they are not having a clear or optimal effect on functional improvement in those patients who 
have suffered an ischemic stroke. 
Experts recommend a series of services and resources for a good functional recovery of patients who have 
suffered a stroke. Among other issues are training and health education programs. In this way, the nursing 
profession is trained to formulate personalized comprehensive care plans, promote comprehensive recovery, 
and strengthen communication with patients and their families. Nurses should perform interventions in 
accordance with general practice to provide continuity of care for stroke patients throughout the patient's 
recovery journey. Integrated care is desirable and constitutes a reference model for all situations considered. 
Planning for teaching and discharge from hospital can help families of patients who have suffered a stroke to 
make specific long-term arrangements for the expected functional outcome. In addition, post-discharge follow-
up and support interventions should be implemented that are individualized to the caregiver's needs. Early 
rehabilitation intervention and evidence-based nursing interventions showed significant improvements in their 
scores on tests related to cognitive impairment and neurological deficit, as well as improved disability. However, 
there are hardly any standardized, approved and scientifically proven health education programs. The 
application of nursing interventions, through health education, to minimize the levels of depression caused by 
the disease, to two groups, case and control, will allow us to evaluate the influence of health education on the 
symptomatology of depression and improve the quality of life in patients who have suffered an ischemic stroke. 
 
Study hypothesis  
A nursing intervention based on health education will improve quality of life and reduce the symptoms of 
depression in patients who have suffered an ischemic stroke. 
Objectives 
General objective: to determine the effect of a nursing intervention based on health education on quality of 
life and depression symptoms in people who have suffered an ischemic stroke. 
Specific objectives: 
1. To assess and compare the level of depression in patients who have suffered an ischemic stroke. 
2. To assess and compare the degree of autonomy and level of functional dependence of patients who 
have suffered an ischemic stroke. 
3. To assess and compare the cognitive status of patients who have suffered an ischemic stroke. 
4. To assess and compare neurological deficits of patients who have suffered an ischemic stroke. 

6 
5. Assess and compare the risk of bronchoaspiration, the presence of pressure ulcers, swallowing, blood 
pressure, temperature and glucose level and assess the level of pain. 
6. To correlate the cognitive state and the level of depression symptomatology with implemented 
variables. 
7. To reduce the psychological impact of depression in patients who have suffered an ischemic stroke 
who have received health education. 
8. To compare the level of depression symptoms in patients who have suffered an ischemic stroke who 
received health education with those who did not. 
Type of study 
It is a quasi-experimental, longitudinal and prospective clinical trial. 
Material and methods 
Scope of study 
For the preparation of this study, the target population was patients who have suffered an ischemic stroke for 
the first time and were treated by physicians from the Neurology and Neurosurgery Service of the Lucus 
Augusti University Hospital (HULA). 
 
Definition of the subjects to be studied 
A representative sample size of patients who have suffered an ischemic stroke for the first time and treated by 
physicians from the Neurology and Neurosurgery Service of the HULA will be collected. From this sample, 2 
groups will be extracted: the group to which a health education program will be applied and the control group 
to which this program will not be applied. 
 
Subject selection and withdrawal 
Inclusion criteria: anterior or posterior cerebral occlusion, age ≥ 18 years. 
Exclusion criteria: intracranial hemorrhage, pregnancy, cognitive inability to participate, non-acceptance to 
participate in the study and administer questionnaires. 
 
Recruitment and recruitment of participants 
Priorto the recruitment process,  the required informed consent signed by said participant will be obtained.  
Next,  the variables will be collected. The recruitment of participants will be carried out by the principal 
investigator and collaborating researchers of the study in the neurology and neurosurgery ward: 
- 
Eva Gómez Fernández 
- 
Mercedes Fernández Vázquez 
- 
María Irene Núñez Fernández 
- 
María del Rosario Marín Arnés 
The tasks "Bibliographic Review, Study Design, Documentation Presentation, Database Design" will be carried 
out by the collaborating researcher Félix Martínez Eiriz supervised and in collaboration with the collaborating 
researchers Emilio Rubén Pego Pérez and Emilio Gutiérrez García. 

7 
The recruitment of patients and immediate data will be carried out consecutively on the neurology and 
neurosurgery floor of the HULA by the collaborating researchers Eva Gómez Fernández, Mercedes Fernández 
Vázquez, María Irene Núñez Fernández and the principal investigator María del Rosario Marín Arnés and by 
the collaborating researcher in neurology consultation at the HULA María Lourdes Bermello López. 
The performance of the sessions is conditioned by the time of diagnosis of the stroke. In this way, it is 
necessary to recruit a minimum group of patients to carry out the workshops according to the established 
methodology. Subsequently, these will be carried out by the collaborating researcher Félix Martínez Eiriz. After 
3 and 6 months following the workshops, the same researcher together with the collaborating researcher María 
Lourdes Bermello López will carry out the follow-up and reevaluation in the neurology consultation of the 
HULA. 
Finally, the process of integrating data and statistical analysis together with the final task of writing results, 
discussion and conclusions and their dissemination will be carried out by the collaborating researcher Félix 
Martínez Eiriz. 
First, the initial evaluation of the patients will be carried out for the collection of variables to be studied in the 
neurology and neurosurgery floor of the HULA. Subsequently, recruitment will be carried out after delivering a 
sheet with all the information and the due consent document and they will be scheduled in outpatient clinics 
where the intervention of this study will be applied.  
 
Assignment/Randomization Procedure  
The procedure for assigning the members of each group will be random and the EPIDAT program will be used 
to make this selection. 
 
Justification of the sample size 
According to the Atlas of Stroke in Galicia published by the Spanish Society of Neurology in 2018, the 
autonomous community of Galicia had a population of 2,701,819 inhabitants. Applying an incidence rate of 
187.4 cases per 100,000 inhabitants, according to the IBERICTUS study, 5,064 new cases of stroke are 
estimated each year in Galicia per 100,000 inhabitants. The province of Lugo has 324,842 inhabitants on 1 
January 2024, according to the INE, which, applying the same incidence rate, estimates 609 new cases of 
stroke per 100,000 inhabitants per year. Considering the proportion of ischemic strokes compared to other 
types of strokes 80:20, the estimated cases of the same would be 487 new cases in Lugo. 
In relation to the calculation of the sample size, the following formula is applied. 
 
𝑛𝑛=
൤𝑍𝑍1−𝛼𝛼
2ඥ2𝑝𝑝(1 −𝑝𝑝) + 𝑍𝑍1−𝛽𝛽ඥ𝑝𝑝1(1 −𝑃𝑃1) + 𝑝𝑝2(1 −𝑝𝑝2)൨
2
(𝑝𝑝1 −𝑝𝑝2)2
 
 
 
Where: 
- 
P2 (frequency of exposure between controls) = 0.4 
- 
OR=4 
- 
Assuming a 1:1 ratio of controls per case 
- 
n = participants as the minimum sample size. 

8 
Assuming the calculations, the representative sample size of stroke patients in the province of Lugo would be 
70 patients, 35 patients receiving the intervention and 35 controls. 
 
Primary and secondary variables  
Independent variables: 
• 
Socioepidemiological: sex, age (< 65 years, 65-80 years, >80 years), date of ischemic event. 
• 
Clinical Signs: type of stroke, treatment modality (received rt-PA or mechanical thrombectomy 
according to the candidates' protocol), number of falls, degree of pain, presence of pressure ulcers, 
genesis of new pressure ulcers, episodes of bronchoaspiration, presence of pneumonia, presence of 
dysphagia, vital signs (blood pressure, glycemia, temperature). 
• 
You receive health education after a stroke or do not receive health education after a stroke. 
 
Dependent variables: 
• 
Assessment of cognitive status by scoring the Mini Mental State Examination (MMSE) questionnaire. 
• 
Assessment of depression symptomatology by scoring on the Beck questionnaire (BDI) or also called 
depression self-report inventory. 
• 
Assessment of autonomy and ability to perform in basic activities of daily living by means of a score 
from the Barthel Index. 
• 
Neurological deficit using the NIHSS scale. 
• 
Assessment of quality of life by scoring on the European Quality of Life Scale. 
 
Instruments 
This section lists the instruments that will be used to measure the variables under study. They are described 
in a more extensive manner in Annex I. 
1. Mini mental status examination (MMSE). 
2. Beck Questionnaire (BDI). 
3. Barthel index. 
4. National institute of Health Stroke Scale (NIHSS). 
5. Visual Analog Scale (VAS) 
6. European Quality of Life Scale (EQLS). 
 
Description of the intervention 
The initial evaluation of the patients will be carried out for the collection of the variables to be studied upon 
admission. Subsequently, 2 groups will be established: the group to which a health education program will be 
applied (intervention of this study that will be specified below) and the control group. Finally, a follow-up is 
proposed at 3 and 6 months after the health education intervention to collect data related to the 
chronic/stabilization phase in post-stroke recovery. 
 
Nursing intervention: Health education for post-stroke patients 
Objectives 
- Learn to identify and recognize prodromal symptoms of a new ischemic event. 

9 
- Identify what changes have occurred or may occur in patients after the sequelae of the ischemic event and 
how they may impact their daily lives. 
- Describe the recommended care that patients can incorporate into their daily lives to reduce the impact of 
sequelae and improve their quality of life. 
- Learn to recognize and manage early signs and symptoms of low mood and depressive symptoms. 
Methodology 
The sessions taught are based on meaningful learning, also supported by constructivist, cognitivist and 
behavioural learning. 
The program consists of 3 fundamental pillars: session 1. Early symptoms of stroke and recognition, session 
2. Living with stroke: the day-to-day care, session 3. Mood management. In addition, a workshop (session 4) 
will be designed for intervention in depression based on the development of coping tools through full breathing 
techniques, relaxation techniques, psychotherapy and mindfulness. All sessions will preferably be group. The 
contents of these sessions are detailed in Annex II. 
Taking into account that 35 patients will receive the health education program, it is estimated that 3-4 groups 
of 8-12 people distributed independently in the sessions taught by the same instructor. 
 
Materials 
- Classroom for health education at HULA. 
- Physical and digital support to support the sessions. 
 
Time scheduling 
The sessions will be divided into two different days. 
Day 1 (40 minutes) 
- Session 1: Early symptoms of stroke and recognition of these. 
- Session 2: Living with stroke: the day-to-day care. 
Day 2 (40 minutes) 
- Session 3: Mood management and depression. 
- Session 4: relaxation workshop with guided meditation (mindfulness) 
 
Timeline and expected completion date.  
Once the  Santiago-Lugo  Research Ethics Committee issues this research plan as favorable, the study will 
begin following the following schedule: 
 
Task 
July 
and 
August 
2025 
September 
2025 to 
November 
2025 
November 
2025 to 
May 2026 
June 
to 
August 
2026 
September 
2026 to 
January 
2027 
February 
to 
December 
2027 
January 
2028 to 
September 
2028  
Literature 
review 
 
 
 
 
 
 
 
Study design 
 
 
 
 
 
 
 
Submission of 
documentation 
 
 
 
 
 
 
 

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Database 
design 
 
 
 
 
 
 
 
Patient 
recruitment 
and immediate 
data 
 
 
 
 
 
 
 
Conducting the 
workshops 
 
 
 
 
 
 
 
Follow-up 
3 
months 
 
 
 
 
 
 
 
Follow-up 
6 
months 
 
 
 
 
 
 
 
Data 
integration and 
statistical 
analysis 
 
 
 
 
 
 
 
Results, 
discussion, 
conclusions 
 
 
 
 
 
 
 
Scientific 
dissemination 
 
 
 
 
 
 
 
 
The tasks "BibliographicReview, Study Design, Presentation of Documentation, Database Design" will be 
carriedout by the collaborating researcher Félix Martínez Eiriz. 
The recruitment of patients and immediate data will be carried out consecutively on the neurology and 
neurosurgery floor of the HULA by the collaborating researchers Eva Gómez Fernández, Mercedes Fernández 
Vázquez, María Irene Núñez Fernández and the principal investigator María del Rosario Marín Arnés and by 
the collaborating researcher in consultation of the neurology of the HULA María Lourdes Bermello López. 
The performance of the sessions is conditioned by the time of diagnosis of the stroke. In this way, it is 
necessary to recruit a minimum group of patients to carry out the workshops according to the established 
methodology. Subsequently, these will be carried out by the collaborating researcher Félix Martínez Eiriz. After 
3 and 6 months following the workshops, the same researcher together with the collaborating researcher María 
Lourdes Bermello López will carry out the follow-up and reevaluation in the neurology consultation of the 
HULA. 
Finally, the process of integrating data and statistical analysis together with the final task of writing results, 
discussion and conclusions and their dissemination will be carried out by the collaborating researcher Félix 
Martínez Eiriz. 
The collaborating researchers Emilio Rubén Pego Pérez and Emilio Gutiérrez García  will be in charge  
throughout the research process of the work surrounding  it with respect to the contribution to the conception 
and design of the work, acquisition and analysis of the study data, critical review with important intellectual 
input, responsibility for the accuracy and completeness of the research, supervision, final approval , and project 
management.  
 

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Statistical analysis plan  
A descriptive analysis will be carried out using measures of central tendency, such as mean (M), and 
dispersion, using standard deviation (SD), to examine quantitative variables. In the case of qualitative 
variables, absolute frequencies and percentages will be used. To determine the correlation between groups, 
the Chi-square test (Chi²) will be applied to the qualitative variables. Regarding the quantitative variables, the 
Kolmogorov-Smirnov test will begin to evaluate the normality of the distribution (n=70). If the quantitative 
variables show a non-parametric distribution, the Kruskal-Wallis test will be used to compare more than two 
groups, while the differences between pairs will be analyzed using the Mann-Whitney U test. If they are 
parametric, it will be appropriate to resort to ANOVA, Tuckey and Bonferroti. The association between the 
variables will be evaluated in terms of strength and direction using Spearman's correlation coefficient. 
Distracting factors (age and sex) that usually tend to normal will be tested with ANOVA and Levene. The effect 
of the intervention will be determined using relative risk (RR) Statistical analyses will be performed using PASW 
Statistics software (version 23.0; SPSS Inc., Chicago, Illinois), establishing a bilateral significance level of 
p<0.05. 
 
Ethical-legal aspects 
Compliance with Good Clinical Practice Standards, Declaration of Helsinki, Oviedo 
Convention, as well as data protection regulations, management of medical records and 
other applicable regulations depending on the type of study. 
The review and approval of the research plan by the Santiago-Lugo Research Ethics Committee is requested, 
following local and international regulations in the field of medical research and the standards established by 
the Declaration of Helsinki. The development of this thesis will be carried out respecting the Declaration of 
Helsinki of the World Medical Association of 1964 and ratifications of the following assemblies on ethical 
principles for medical research on human beings, and the Convention on Human Rights and Biomedicine, 
signed in Oviedo on April 4, 1997 and successive actions. The researchers participating in this study undertake 
that all clinical data collected from the study subjects will be separated from the personally identifiable data, 
so that the anonymity of the patients is ensured; respecting the Law on the Protection of Personal Data and 
Guarantee of Digital Rights (Organic Law 3/2018, of 5 December), Law 41/2002, of 14 November (basic 
regulation of patient autonomy and rights and obligations in terms of clinical information and documentation), 
as well as Law 3/2001, of 28 May (regulating informed consent and clinical documentation),  as well as Law 
3/2005, of 7 March, amending Law 3/2001 and Decree 29/2009 of 5 February, which regulates access to 
electronic medical records. The patient's data will be collected by the investigator in the study-specific data 
collection notebook (CRD). Each CRD will be encrypted, protecting the patient's identity. Only the research 
team and the health authorities, who have a duty to maintain confidentiality, will have access to all the data 
collected for the study. The data controller will be the HULA. Information may only be transmitted to third parties 
that cannot be identified. Once the study is completed and the thesis is finished, the data collected will be 
destroyed or kept anonymous for use in future research according to what each participant chooses in the 
signing of the consent. An Information Sheet will be provided to the participants and informed consent. 
Information regarding the identity of patients will be and is considered confidential for all purposes. In order to 
properly maintain confidentiality with respect to patient information, an appropriate coding and identification 
dissociation will be carried out in the database, so that only the researcher may associate such data with an 

12 
identified or identifiable person. The database that will generate the study will not contain any identification of 
the patient. Once the study is complete, the database will be deleted. With regard to the data of the study, the 
provisions of the Organic Law on "Protection of Personal Data" in force will be followed. 
 
Informed consent models. 
The informed consent forms have been drafted, to be delivered individually to the participants. 
 
Confidentiality of the information collected in the context of the study.  
In order to properly maintain confidentiality with respect to patient information, an appropriate coding and 
identification dissociation will be carried out in the database, so that only the researcher may associate such 
data with an identified or identifiable person. Once the study is completed, the data will be deleted or kept 
pseudonymized as selected by the patient in the Consent. 
 
Commitment to publish results 
The researcher undertakes to disseminate the results of his or her research, whether positive or negative.  
 
Economic report and source of funding 
Not applicable. 
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Alvarez-Sabín J, Quintana M, Masjuan J, et al. Economic impact of patients admitted to stroke units in Spain. 
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18 
Data collection notebook  
The data collection notebook is detailed in Annex III. 
Annexes 
Annex I. Description of the instruments 
Mini Mental State Examination (MMSE): created in 1975 by Marshal Folstein and later in 1979 adapted to 
the Spanish version by Lobo: the Mini-Cognitive Exam (MEC). This test is used to assess cognitive impairment, 
allowing the detection of cognitive problems such as dementia. It covers several areas: temporal and spatial 
orientation, fixation or immediate memory, calculation and concentration, delayed memory, language (naming, 
repetition, comprehension, reading and writing) and finally graphic constructive praxis. The maximum score is 
30 points, which is interpreted as the absence of cognitive impairment. The cut-off point for suspecting 
cognitive impairment is a value <23 points. Its application lasts approximately 5 minutes. Its categories are: 
30-27 points no cognitive impairment, 26 and 25 points doubtful cognitive status, 24-10 points mild-moderate 
cognitive impairment, 9-6 points moderate-severe cognitive impairment, 6 points: severe cognitive impairment. 
 
Beck Depression Inventory (BDI): The BDI allows the severity of depressive symptoms to be measured. It 
was originally published in 1996 by Beck et al. and later adapted to Spain. It consists of 21 items that cover 
questions about the depressive symptoms experienced in the last few weeks. Each question is assigned a 
score of 0-3, with 0 being less severe and 3 being greater. The maximum score that can be obtained is 0. 
According to the score obtained, we find four groups from least to most severe, from 14 points is when it is 
considered that there is a clinically significant depression. The application of this scale takes approximately 10 
minutes. Categorization: Minimum range: 0-13; Mild depression: 14-19; Moderate depression: 20-28; Severe 
depression: 29-63 points. 
 
Barthel Index: The Barthel Index or Maryland Disability Index was created in 1965 by Mahoney and Barthel. 
It is one of the most widely used instruments to determine functional capacity. It is a scale that assesses 
patients' independence in basic activities of daily living (ABVD). Its application takes between 2-5 minutes as 
a self-report and up to 20 minutes if it is carried out by direct observation. It assesses 10 ABVD, seven of which 
are activities related to personal care (eating, washing, dressing, grooming, bowel movements, urination, toilet 
use) and the other three have to do with mobility (ambulation, transferring, and going up/down stairs). Each 
activity is scored according to the degree of independence, with values ranging from 0 (total dependence) to 
15 (total independence). The maximum score is 100, which would indicate that it is totally independent, while 
the minimum score is 0 and would indicate that the patient has total dependence. Its interpretation is as follows: 
100 points independence, ≤ 60 mild dependence, 40-55 moderate dependence, 20-35 severe dependence 
and 5-20 total dependence. 
 
Visual Analogue Scale (VAS): on the Visual Analogue Scale EVA, the intensity of pain is represented on a 
10 cm line. At one end is the phrase "no pain" and at the opposite end "the worst pain imaginable". The distance 
in centimeters from the point of "no pain" to the one marked by the patient represents the intensity of the pain. 
It may or may not have marks every centimetre, although for some authors the presence of these marks 
decreases their accuracy. The way in which the patient is presented, whether horizontal or vertical, does not 
affect the outcome. It is the most widely used scale, even in critically ill patients. For some authors it has 

19 
advantages over others. The patient needs to have good motor and visual coordination, so it has limitations in 
the elderly patient and in the sedated patient. A value below 4 in VAS means mild or mild-moderate pain, a 
value between 4 and 6 implies the presence of moderate-severe pain, and a value greater than 6 implies the 
presence of very severe pain. 
 
NIHSS Scale: This scale is a tool used to assess the severity of a stroke and its neurological effects. It was 
developed in 1989. It is used both for the initial assessment of the patient and for follow-up. It is widely used 
in clinical practice and in research related to cerebrovascular diseases. It is made up of 11 items which assess: 
the level of consciousness, sensory-motor impairment, language and vision, giving scores to each one 
according to the degree of impairment. Therefore, the scores will vary between 0 (normal function) and 4 
(deterioration). The individual scores for each item are added together to calculate a patient's total NIHSS 
score. The maximum possible score is 42, with the minimum score being 0. Based on the categorization of the 
scale, a score of 0 points is considered asymptomatic, a minimum deficit a score of 1; mild deficit a score 
between 2-5, moderate deficit a score between 6-15, significant deficit values between 16-20 points and severe 
deficit > 20 points. 
 
European Quality of Life Scale (EQ-5D-5L): is a generic questionnaire on health-related quality of life, 
developed by the EuroQol Group. It assesses five dimensions: mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression, each with five levels of severity (no problems, mild problems, 
moderate problems, severe problems, and extreme problems or unable to) that describe 3,125 possible health 
conditions. If in a particular dimension, there are no problems this is represented as level 1, while extreme 
problems are represented as level 5. Hence, each state of health on the EQ-5D-5L can be described using a 
five-digit number, where 11111 indicates perfect health and 55555 indicates the worst possible state of health. 
It also features a visual analog scale (EQ-VAS) where the patient rates their overall health on a vertical scale 
from 0 (worst imagined health) to 100 (best health imaginable). 
 
Annex II. Development of interventions. 
Early symptoms of stroke and recognition of these (10 minutes). 
A stroke is a neurological disease that occurs when blood flow to the brain is interrupted. This prevents blood 
from flowing, which means parts of the brain are damaged and may stop working. A Transient Ischemic Attack 
is a type of stroke that is also caused by the interruption of blood flow, but temporarily, with symptoms usually 
lasting a few minutes and the person recovering completely in less than 24 hours. 
Some of the most common symptoms of stroke are described below: 
- 
Sudden loss of movement or weakness of the arm, leg, or face, especially when it occurs on one side 
of the body. 
- 
Sudden vision problems. 
- 
Sudden headache, with no apparent cause. 
- 
Slurred speech: Drooping lip, babbling, inability to find the right words, or not being able to understand 
what other people are saying. 
- 
Sudden problems walking or loss of balance or coordination. 
- 
Sudden sensation of corking or tingling in the face, arm and/or leg on one side of the body. 
 
Living with stroke: the day-to-day care (30 minutes). 

20 
Stroke can leave behind sequelae that affect different spheres of personal performance. Therefore, the 
essential objective is for the affected person to achieve the maximum autonomy to develop. In general, it is 
interesting to let them do everything they can on their own and if they can't, involve them in some way in the 
tasks and daily life. Most recovery is experienced in the first three months after the stroke. Recovery continues 
more slowly until at least six months, and some people continue to recover slightly into a year. In addition, the 
pharmacological treatment prescribed in each case must be followed. To prevent another stroke it is very 
important to continue with all these measures for the rest of life. 
The most common difficulties and uses when dealing with them are described below. 
 
Slowing down to process information: 
- 
It is "normal" that everything goes slower. 
- 
There is a change of new rhythms and they are not on a whim, so everyone should be aware of the 
change. 
- 
Simplify the information you want to convey in a simple and concise way. 
- 
Decrease the amount of information to be transmitted at any given time. 
- 
When doing an activity or action, it is useful to establish or think about an outline of how it is going to 
be carried out. 
- 
Avoid distractions and noise. 
- 
Maintain a more or less constant level of activation, that is, do not do tasks until exhaustion or rest for 
long periods. 
Concentration difficulties: 
- 
Take many breaks of a few minutes during an activity. 
- 
Choose certain times to carry out more difficult activities. 
- 
Vary the activities to maintain interest in them. 
Cognitive impairment: 
- 
Have pre-established routines and time dynamics. 
- 
Have routines with personal utensils, that is, always leave the same belongings in the same place. 
- 
External aid: diaries, blackboards, reminder notes, alarms, reminders. 
- 
Personalized daily, weekly or monthly calendars with schedules of activities, appointments... 
- 
Reduce the amount of information that needs to be remembered. 
- 
Put into practice what has been learned as soon as possible. 
- 
Modify the environment to facilitate recall: write down information, choose a fixed place to, put labels... 
A language disorder may also occur. An inability to understand and/or utter any type of adequate language or 
a speech alteration may occur: 
- 
Simplify the conversation. 
- 
Avoid noise. 
- 
Speak slowly and vocalize. 
- 
Position yourself where you can maintain eye contact. 
- 
Turn your face toward the person. 
- 
Look the person in the eye. 
- 
Do not shout. 
- 
Repeat what you have said if the person does not understand you. 

21 
- 
Use short sentences. 
 
Behaviour: 
- 
Understand that the brain injury may have changed the way you react. 
- 
Reinforce positive behaviors. 
- 
Correct an inappropriate response with tact. 
- 
Do not react to strange and incorrect behavior. 
Domestic sphere: daily activities such as dressing, hygiene, elimination or eating will be affected to a greater 
or lesser extent. 
Dress: 
- 
Start by undressing, because it is easier. 
- 
Dress seated. 
- 
Wear loose, loose clothing 
- 
Do not wear clothes that are difficult to close. 
- 
Leave enough time to get dressed. 
- 
Break the task down into smaller steps and help only where you need to. 
- 
Always undress the strong side first and always dress the weak side first. 
- 
Whenever possible do without buttons and/or zippers, wear T-shirts, sweaters, sweatshirts... 
- 
Wear comfortable clothes, loose garments and elastic at the waist. 
- 
Replace lace-up shoes with Velcro shoes. 
- 
Wear shoehorns. 
Personal hygiene 
- 
Place grab bars next to the toilet and inside the shower. 
- 
Replace the bathtub with a shower. 
- 
Have a shower seat handy. 
- 
Use soap dispensers instead of bottles. 
- 
Use sponge with handle. 
- 
Put everything you need for the shower within easy reach. 
- 
Use electric shaving machines. 
- 
Use electric toothbrushes. 
- 
Use or manufacture a larger and/or longer handle for the toothbrush. 
Feeding: 
- 
Sit up for all meals. 
- 
Stand very straight. 
- 
Keep your head slightly forward. 
- 
Look at food. 
- 
Take small bites and sips. 
- 
Avoid foods with different textures, preferably with homogeneous consistencies. 
- 
Avoid carbonated drinks. 
- 
Stay upright for at least 20-30 minutes after eating to digest food. 
- 
Place food between the teeth, on the stronger side of the person's mouth 
- 
Give him thick liquids and foods with a homogeneous texture. 

22 
- 
The weak arm should rest on the table. 
- 
Use deep plates. 
- 
Use barriers around the plates. 
- 
Make the handle of the cutlery larger if the person has trouble holding it. 
Hydration: 
- 
When using a straw, always place it on the strong side of your mouth against your cheek. 
- 
If the person cannot drink from a glass or use a straw, use a syringe. 
 
Elimination: 
- 
Do not drink anything at least an hour before bedtime. 
- 
Protect the mattress with an underpad or similar. 
- 
Go to the bathroom regularly and at scheduled times. 
- 
The color of your urine should be only slightly darker than water, so it can help to know if you need to 
increase or decrease your water intake. 
- 
Avoid constipation. 
 
People who have suffered a stroke are more likely to fall, so muscle-strengthening and balance exercises are 
important. It is also important to identify and modify as much as possible those aspects of the home that may 
pose a greater risk of falls, such as removing carpets, putting plastic chairs in the bathtub or shower, as well 
as handholds, and wearing shoes with non-slip soles. 
 
Visual disturbances: looking towards the affected side, since with a little training the loss of vision of half of a 
visual field is compensated by turning the head to look to that same side. 
 
Sensitivity disorder (tingling, unpleasant sensations, or lack of sensitivity to touch): Being especially careful 
about forming wounds or burns without the person noticing. 
 
Mood management and depression (15 minutes). 
It is common for mood alterations, anxiety, emotional lability, apathy, irritability or lack of awareness of the 
sequelae of the stroke to occur, as well as emotional "ups and downs", which must be understood and 
managed. Post-stroke depression can manifest itself through a variety of symptoms, including persistent 
sadness, loss of interest in previously enjoyed activities, changes in appetite and sleep, or even difficulty 
concentrating. As can be seen, there are depressive symptoms that can be related to other functional spheres 
and therefore can be easily confused with other types of symptoms. 
In the face of these difficulties, it is advisable to: 
- 
Identify and manage early symptoms of depression. 
- 
Understand that mood swings are usually not directed against anything or anyone. 
- 
Identify and avoid situations that systematically cause an altered state. Help identify in which situations 
you "shoot". 
- 
Leave their own space for the affected person, as they can be overwhelmed with so much protection. 
- 
The patient should not be treated as a sick person. 
- 
It's normal for stroke survivors to cry more easily. 

23 
- 
Minimize frustration when facing a task, intervening as little as possible to ensure the achievement of 
the objective. 
- 
Look for activities that are rewarding, occupy their time, promote their independence and self-
sufficiency as much as possible, sometimes simply with that you can avoid other unwanted behaviors. 
- 
Perform structured exercise programs to relieve symptoms of depression. 
 
It is considered valuable to provide documentary support to the sessions as a summary and future information. 
 
Complete breathing, relaxation, guided meditation and mindfulness workshop (25 minutes) 
The workshop will be guided by the primary structure of mindfulness: 
1. Home - Posture Relaxation 
2. Mindfulness - inhale and exhale. 
3. Open observation – observing emotions while promoting a curious, non-judgmental attitude 
4. Closing - brief reflection. 
 
 
 
Annex III. Data collection notebook 
 
Participant ID  
Sex 
Idade 
Windy 
weather 
Date 
of 
ischemic 
event  
Event 
Type 
BDI to the 
inductor  
BDI 
after 
rt-PA 
BDI 
to 
high 
MMSE 
to 
the 
inductor 
MMSE 
tras 
rt-PA 
MMSE 
to the 
high 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Participant ID  
Barthel 
NIHSS 
Temperature 
TA 
Glycemia 
Swallowing 
assessment  
Breathing 
UPP 
Pain 
(EVA 
Scale) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MMSE 
 
Orientation 
What year are we in? 
What season are we in? 
What date are we on? 
What day are we on? 
What month are we in? 
1 
1 
1 
1 
1 

24 
Where are we? 
Province? 
Province? 
Nation? 
City? 
¿Hospital? 
Plant? 
1 
1 
1 
1 
1 
1 
1 
Fixation 
Name three objects at one-second intervals. 
Then ask the patient all three. 
Score one point for each correct answer. 
Repeat the objects until the patient learns all three. 
3 
Attention and calculation 
Series of seven. Score one point for each correct answer. Stop after five answers. Alternatives: Spell 
"world" backwards. 
5 
Memory 
Recall of the three previously learned objects 
Point to a pencil and clock. Have the patient name them when you point to 2 
Have the patient repeat, "No yes, no no, no ifs and buts." 
Have the patient follow three types of command: "Take the paper in your right hand, fold it in half, put 
it on the floor." 
Have the patient read and obey the following: "Close your eyes" (written in large print) 
Have the patient write a sentence of their own choice (the sentence must have a subject and an object 
to make sense, ignore spelling mistakes when punctuating) 
Enlarge the drawing below up to 1-5 centimeters per side and have the patient copy it (note a point if 
all sides and angles hold and if the intersecting sides form a quadrangle) 
3 
2 
1 
3 
1 
1 
1 
 
 
Total score 
30 
 
 
BDI 
 
Pessimism 
 
I'm not discouraged about my future 
I feel more discouraged about my future than I used to be 
I don't expect things to work out for me 
I feel like there's no hope for my future and it can only get worse 
0 
1 
2 
3 
Sadness 
I don't feel sad 
I feel sad a lot of the time 
0 
1 

25 
I feel sad all the time 
I feel so sad or so unhappy that I can't stand it 
2 
3 
Failure 
 
I don't feel like a failure. 
I've failed more than I should have 
When I look back, I see a lot of failures 
I feel that as a person I am a total failure 
0 
1 
2 
3 
Loss of pleasure 
 
I get as much pleasure as ever from the things I enjoy 
I don't enjoy things as much as I used to 
I get very little pleasure from things I used to enjoy 
I can't get any pleasure from the things I used to enjoy 
0 
1 
2 
3 
Feelings of guilt 
 
I don't feel particularly guilty 
I feel guilty about several things I have done or should have done 
I feel pretty guilty most of the time. 
I feel guilty all the time 
0 
1 
2 
3 
Feelings of punishment 
 
I don't feel like I'm being punished 
I feel like maybe I can be punished 
I hope to be punished. 
I feel like I'm being punished 
0 
1 
2 
3 
Dissatisfaction with oneself 
 
I feel about myself the same as I always do 
I've lost confidence in myself 
I'm disappointed in myself 
I don't like myself 
0 
1 
2 
3 
Self-criticism 
 
I don't criticize or blame myself more than usual 
I'm more critical of myself than I used to be 
I criticize myself for all my mistakes 
I blame myself for everything bad that happens 
0 
1 
2 
3 
Suicidal Thoughts or Desires 
 
I have no thought of killing myself 
I've had thoughts of killing myself, but I wouldn't 
I'd like to kill myself 
I would kill myself if I had the chance to do it. 
0 
1 
2 
3 
Crying 
 
I don't cry any more than I used to 
I cry more than I used to. 
I cry for any little thing 
I feel like crying, but I can't 
0 
1 
2 
3 

26 
Agitation 
 
I'm no more restless or tense than usual 
I feel more restless or tense than usual 
I'm so restless or agitated that it's hard for me to sit still 
I'm so restless or agitated that I have to always be on the move or doing something 
0 
1 
2 
3 
Loss of Interest 
 
I haven't lost interest in other activities or people 
I'm less interested in other people or things than before 
I've lost almost all interest in other people or things 
It's hard for me to care about anything 
0 
1 
2 
3 
Indecision 
 
I make my own decisions as well as ever 
I find it more difficult than usual to make decisions 
I find it much more difficult than before to make decisions 
I'm having trouble making any decisions 
0 
1 
2 
3 
Devaluation 
 
I don't feel like I'm not valuable 
I don't consider myself as valuable and useful as I used to consider myself 
I feel less valuable when I compare myself to others 
I feel like I'm worthless 
0 
1 
2 
3 
Loss of energy 
 
I have as much energy as ever 
I have less energy than I used to have 
I don't have enough energy to do too much 
I don't have enough energy to do anything. 
0 
1 
2 
3 
Changes in sleep habits 
 
I have not experienced any change in my sleep habits 
I sleep a little more than usual 
I sleep a little less than usual 
I sleep much more than usual 
I sleep much less than usual 
I sleep most of the day 
I wake up 1-2 hours earlier and can't go back to sleep 
0 
 
1 
 
2 
 
3 
Irritability 
 
I'm not as irritable as usual 
I'm more irritable than usual 
I'm much more irritable than usual 
I'm irritable all the time. 
0 
1 
2 
3 
Changes in appetite 
 

27 
I have not experienced any change in my appetite 
My appetite is a little less than usual 
My appetite is a little bigger than usual 
My appetite is much lower than before 
My appetite is much higher than usual 
I have no appetite at all. 
I want to eat all day. 
0 
 
1 
 
2 
 
3 
Difficulty Concentrating 
 
I can concentrate as well as ever 
I can't concentrate as well as usual 
It's hard for me to keep my mind on something for long 
I find that I can't focus on anything 
0 
1 
2 
3 
Tiredness or Fatigue 
 
I'm no more tired or fatigued than usual 
I get tired or tired more easily than usual 
I'm too fatigued or tired to do many of the things I used to do 
I'm too fatigued or tired to do most of the things I used to do 
0 
1 
2 
3 
Loss of interest in sex 
 
I haven't noticed any recent changes in my interest in sex 
I'm less interested in sex than I used to be 
I'm much less interested in sex 
I've completely lost interest in sex 
0 
1 
2 
3 
 
 
BARTHEL'S INDEX 
 
Grooming 
1. Dependent 
2. Independent for washing face, hands and teeth, 
combing and shaving 
0 
5 
Bathing or Showering 
1. Dependent 
2. Independent for bathing or showering 
05 
Eat 
1. Dependent 
2. You need help cutting, spreading butter, using 
seasonings, etc. 
3. Standalone (able to use any instrument) 
0510 
Stool control 
1. Incontinent (or need to be given an enema) 
2. Exceptional accident (one/week) 
3. Continent 
0510 
Urine control 
1. Incontinent, or probed unable to change the purse 
2. Exceptional accident (maximum one/24 hours) 
3. Continent, for at least 7 days 
0510 

28 
Scroll 
1. Motionless 
2. Independent in wheelchair at 50 m 
3. Walk with a little help from a person (physical or 
verbal) 
4. Independent at least 50 m, with any type of crutch, 
except walker 
051015 
Going up and down stairs 
1. dependent 
2. Needs physical or verbal help, can carry any type of 
crutch 
3. Independent to get on and off 
0510 
Moving between the chair and 
the bed 
1. Dependent, not sitting still 
2. Needs important help (1 trained person or 2 people), 
may be sitting 
3. Needs some help (a little physical help or verbal help) 
4. Independent 
051015 
Using the toilet 
1. Dependent 
2. You need some help, but you can do something on 
your own 
3. Independent (coming in and out, cleaning and 
dressing) 
0510 
Dressing and undressing 
1. Dependent 
2. You need help, but you can do about half, without help 
3. Freestanding, including buttons, zippers, laces, etc. 
0510 
 
 
NIHSS 
 
Level of consciousness  
Alert  
Not alert (minimal verbal 
stimuli)  
Non-alert (repeated stimuli)  
Reflex responses  
0  
1  
2  
3  
1.b. Questions  
Both correct answers  
A correct answer  
No correct answer  
0  
1  
2  
What month are we in?  
How old is he?  
1.b. Motor commands  
Both correct answers  
A correct order  
No Correct Order  
0  
1  
2  
Eye Closure  

29 
Open and close your hand s  
Conjugate look  
Normal  
Partial paralysis of the gaze  
Forced Gaze Deviation  
0  
1  
2  
Field of view  
Normal  
Partial Hemianopia  
Complete hemianopia  
Blindness  
0  
1  
2  
3  
Paresia facial  
Normal mobility  
Minor paresis  
Partial paresis  
Complete paralysis of the 
hemiface  
0  
1  
2  
3  
Left 
Upper 
Limb/Right 
Upper Limb  
No limb drop  
Drop 
in 
less 
than 
10 
seconds  
Stress against gravity  
Movement in the horizontal 
plane  
No movement  
0/0  
1/1  
2/2  
3/3  
4/4  
Left 
Lower 
Limb/Right 
Lower Limb  
No limb drop  
Drop in less than 5 seconds  
Stress against gravity  
Movement in the horizontal 
plane  
No movement  
0/0  
1/1  
2/2  
3/3  
4/4  
Limb ataxia  
Absent  
Present in 1 limb  
On 2 or more limbs  
0  
1  
2  
Sensory Scan  
Normal  
Slight/moderate loss  
Severe/Total Loss  
0  
1  
2  
Language  
Normal  
Mild/moderate aphasia  
Severe aphasia  
Global aphasia  
0  
1  
2  
3  
Dysarthria  
Normal  
Light to moderate  
Grave  
0  
1  
2  
Extinction and Inattention  Normal  
Partial extinction  
Complete extinction  
0  
1  
2  
Total (Maximum 42)  

30 
 
 
EUROPEAN QUALITY OF LIFE SCALE