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M. Berthold Lindstedt et al.
visual scanning, making them more demanding (16). An
inability to exert visual accommodation for longer peri-
ods or to shift accommodation consumes more energy
and increases the effort required as supported by expe-
rimental studies (17, 18). In these studies the subjects
were still able to read normally; however, with greater
strain, manifesting as increased visual symptoms.
The visual system is highly integrated in the proces-
ses of cognition and emotion and it is possible that in-
terference with the visual system may lead to increased
levels of depression and anxiety (19, 20). Goodrich et
al. described differences in visual symptoms in patients
with traumatic brain injury (TBI) or both TBI and
post-traumatic stress disorder (PTSD).The groups were
rather similar regarding visual symptoms, although the
TBI-PTSD patients reported more light sensitivity and
more reading problems (21). Another treatment relating
the vision and emotion is Eye Movement Desensitiza-
tion and Reprocessing (EMDR), which is a method
used for PTSD, in which horizontal eye movements
are used as a tool for the treatment (22).
With this background, the aim of this study was to
explore whether visual-related symptoms in ABI are
associated with self-perceived mental fatigue, anxiety
or depression and, if there is an association, whether
this supports further investigations and the develop-
ment of potential interventions.
MATERIALS AND METHODS
Participants
A total of 165 consecutive patients, admitted to the outpatient
neuro-rehabilitation clinic at Danderyd University Hospital,
Stockholm, Sweden, during the period September 2011 to June
2013, were recruited to the study. The clinic offers a team-based
neurorehabilitation, both assessments and day-care rehabilita-
tion, for moderate-to-severe brain-injured patients, including
visual assessment with the Vision Interview (VI). Seventeen
patients were excluded due to severe aphasia (n = 5), incom-
plete admission (n = 7) or another diagnosis showing similar
symptoms as after brain injury, but not caused by brain injury
(n = 5). Of the 148 remaining patients, 123 had answered all 3
questionnaires and were included in the analysis. A total of 145
answered the Visual Interview (VI), 123 answered the Mental
Fatigue Scale (MFS), and 132 answered the Hospital Anxiety
and Depression Scale (HADS). The severity of the brain injury
was measured with the Glasgow Outcome Scale Extended
(GOSE) a well-documented and valid scale (23). The severity
of injury ranged between grade 4 and grade 7 (GOSE 4: 4.1%,
GOSE 5: 49.6%, GOSE 6: 42.3%, GOSE 7: 4.1%).
The brain injuries included diagnoses such as stroke, traumatic
brain injury (TBI), subarachnoid haemorrhage (SAH), infection,
tumour and other diagnoses. The concept, Other diagnoses,
included sinus thromboses, dissection of the vertebral artery,
NMDA-receptor encephalitis, severe epilepsy, surgery of a
foramen of Monroe cyst, cognitive dysfunction after cytostatic
treatment, deterioration after previous stroke, and 2 patients
with anoxic brain injury (Table I). SAH, infection, and tumour
(mainly meningioma) were treated as a single group due to a
small number of patients with each diagnosis, but also due to
their similarities in clinical characteristics.
The patients were divided into 3 age groups, considering the
different demands in life; age 18–34 years (start up your own
life, starting a family), age 35–54 years (active working period,
active family time with great responsibilities and different
demands), and age 55–65 years (children move away, work is
established, higher risk of other diseases). Demographic data
are shown in Table I.
This article is the third report from a cross-sectional study of
patients with ABI admitted for neuro-rehabilitation (13, 24).
Assessment methods
Visual-related symptoms were assessed with the Vision Inter-
view (VI), which is an adapted and translated version of “Die
Anamnese Zerebral betingter Sehestörungen”(25), intended to
pick up visual disturbances after ABI and described in detail
previously (13). The VI has 18 questions, 16 of which cover the
most common visual symptoms and their influence on visual-
based activities. The remaining 2 questions are more general;
one concerns whether the patient has experienced visual changes
and the other whether a previous visual examination has been
performed after injury/illness. The interview was conducted
by the physician during admission and the answers are dicho-
tomous; yes/no. The outcome of the VI was calculated to a
score, between 0 and 17. The question concerning whether an
examination had been performed was not included in the score.
The responses to the other questions, 1–17, were assigned a
value of 0 if answered No (symptom not experienced) and 1 if
answered Yes (symptom experienced).
During the assessment, standard validated self-assessment
instruments were used routinely. The MFS and HADS (26–28)
evaluate the patients’ perceived levels of fatigue, depression and
anxiety. MFS is used mainly in patients after stroke and TBI.
MFS includes 15 questions, one of which is analysed separately
(26). The other 14 questions are graded between 0 and 3, and
the maximum sum of the test is 42. The sum is valuated as no
problems (0–10), mild mental fatigue (10.5–14.5), moderate
mental fatigue (15–20), and severe mental fatigue (20.5–42)
(25). In this study a cut-off value of 15 points was applied,
corresponding to moderate–severe fatigue.
Table I. Patient demographics
Diagnosis Total
n Age, years
Male/Female
n
Mean (SD) Range Mean (SD) Range
Stroke
TBI
SAH, Infection, Tumour
Other
Total 57
33
24
9
123 40/17
19/14
5/19
3/6
67/56 21–65
19–65
19–65
20–62
19–65 6.1 (5.3)
10.3 (4.7)
7.1 (4.5)
7.9 (6.4)
7.6 (8.9) 1–30
1–62
3–18
2–18
1–62
51.5
39.0
47.4
41.7
46.6
(10.3)
(13.6)
(11.7)
(15.7)
(13.0
TBI: traumatic brain injury; SAH: subarachnoid haemorrhage; SD: standard deviation.
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Time range post-injury, months