This study aimed to identify differences in physical activity level and in the quality of life of stroke survivors in two cities differing in economic aspects of the human development index. The main findings of the present study were that factors such as location and socioeconomic issues cannot be considered, de per si, indicators of quality of life, and that physical activity plays an important role in improving quality of life, regardless of the HDI-I economic indicator or HDI national ranking status of the city of residence.
When evaluating the indicators of HDI in the two cities, significant differences were found with regard to per capita income (245.425 R$ in MC and 557.435 R$ in BH), HDI-I, which represents the gross domestic product (0.691 in MC and 0.828 in BH) and the position of the municipalities in the Brazilian HDI ranking (968th place for MC and 80th place for BH). However, other indicators showed no major differences, such as the education-related HDI-E, which was 0.929 in BH and 0.872 in MC. It is noteworthy that Montes Claros, although economically poorer, has a higher life expectancy at birth (LEB) than does Belo Horizonte (72.242 yrs in MC and 70.520 yrs in BH) . Contrary to our findings that the economic indicators of HDI were not decisive determinants of quality of life in survivors of stroke, another study found that socioeconomic conditions and difficulties in accessing health services tend to expose people to an increased risk of death [20, 21].
One possible explanation for stroke survivorship and quality of life, regardless of economic indicators in HDI, can be attributed to the fact that there is now a universalized health system in Brazil. The Brazilian health care system now offers more standard treatments, more accurate diagnoses, and acts within a time considered optimal, i.e. within three hours after the stroke and with the most appropriate procedure [22–29]. In recent years there has been a downward trend in cerebrovascular problems, which allowed Brazilian indices to be close to those seen in countries like the U.S. and Canada. This is a reflection of improvements in public health policies pursued in recent years .
Diagnosis and treatment carried out in the early stages of stroke tend to decrease the length of stay in hospital, improve patient prospects and decrease chances of permanent sequelae. These findings from our previous study  leads us to believe that economic standing seems not to be a determining factor in quality of life. This explains the absence of significant differences in quality of life in patients affected by stroke in Belo Horizonte and Montes Claros, who were subjected to similar treatment despite the aforementioned economic differences (HDI-R BH = 0.828 and MC = 0.691). On the other hand, delayed treatment may be more difficult and leave sequelae, regardless of location .
Comparing our results with those of other studies, research conducted in Chile with patients who had suffered a stroke more than three years before showed better results than those found in our study in terms of quality of life. In that study, 59 patients (average age of 62 and 51% female) were evaluated. Nearly half (n = 29: 49.1%) of the patients had some limitation. Thirty patients (50.9%) presented with functional independence, despite showing minimal sequelae. The group of stroke survivors (aged 20-36 years) achieved an average of 84 points, and the older group (average age of 75 years) achieved an average quality of life score of 63 points .
It is believed that changes in lifestyle play a major role in the prognosis of patients who suffered stroke [32, 33]. Likewise, a study conducted in Japan showed that physical activity tends to reduce the risk of mortality in patients who had stroke . Physical activity is also believed to be beneficial in cases of ischemic stroke, reducing the area of ischemia in animals [35–37]. Although caution should be taken when extrapolating results from animal studies to humans, it appears that physical activity may lessen the severity of stroke, improving quality of life and the capacity for work and leisure, thereby reducing the chances of new strokes and the functional imitations they can bring [34, 36]. In this sense, physical activities can be considered the best way to improve the psychosocial indicators, quality of life and stress levels in people with physical limitations, bringing about improvements in social and emotional health .
Additionally, physical exercises are a major method of reducing stress and improving social and emotional well-being in people with physical limitations . Specifically in relation to stroke survivors, daily physical activity can improve quality of life as confirmed in a previous study of 40 stroke survivors. We assessed participation in daily physical activity post stroke in relation to quality of life and health. The results suggest that daily physical activity on an outpatient basis is associated with a better quality of life and health in stroke survivors . Similar results were obtained in a study of stroke survivors subjected to water activities . Quality of life was better in the physically active stroke survivors than those who were not active .