Visual symptoms after ABI: mental fatigue, anxiety and depression
Table III. Logistic regression predicting likelihood of anxiety
(HADS-A ≥ 8) based on sex, age group, diagnosis group, visual
interview score, mental fatigue (MFS ≥ 15) and depression (HADS-D
≥8). Sex is for females compared with males, diagnosis group is
compared with stroke
Variable Wald Df Odds ratio Significance
Sex, female
Age group
Diagnosis, stroke
Diagnosis, TBI
Diagnosis SAH/Inf./Tum.
Diagnosis, other
VI score
HADS-D
MFS
Constant 0.021
0.598
4.907
4.117
0.034
0.036
1.487
16.201
3.781
1.626 1
1
3
1
1
1
1
1
1
1 1.076
0.762 0.885
0.439
0.179
0.042
0.853
0.849
0.223
0.000
0.052
0.202
0.233
0.884
1.209
1.105
9.749
3.071
0.302
TBI: traumatic brain injury; SAH: subarachnoid haemorrhage. HADS-A:
Hospital Anxiety and Depression Scale anxiety; HADS-D: Hospital Anxiety
and Depression Scale depression; VI: Visual Interview; MFS: Mental Fatigue
Scale; Inf./Tum.: Infection/Tumour.
exceeding cut-off (≥ 8), was associated with an in-
creased likelihood of exhibiting anxiety (Table III).
Depression
The logistic regression model was statistically signifi-
cant (χ 2 64.394, df = 8, p = 0.000). The model explained
56.4% of the variance (Nagelkerke R 2 ) and correctly
classified 82.1% of the cases. MFS and HADS-A ex-
ceeding cut-off (≥ 8) was associated with an increased
likelihood of exhibiting depression (Table IV).
DISCUSSION
The aim of this study was to determine whether there is
an association between increased levels of self-repor-
ted visual deficits in patients with ABI and increased
levels of self-reported mental fatigue, depression and
anxiety. The study was observational and performed
at a neurorehabilitation centre. The patients had mixed
diagnoses dominated by stroke. As a rule, studies are
Table IV. Logistic regression predicting likelihood of depression
(HADS-D ≥ 8) based on sex, age group, diagnosis group, Visual
Interview score, mental fatigue, and anxiety. Sex is for females
compared with males, diagnosis group is compared with stroke
Variable Wald Df
Sex, female
Age group
Diagnosis, stroke
Diagnosis, TBI
Diagnosis SAH/Inf./Tum.
Diagnosis, other
VI score
HADS-A
MFS
Constant 0.248
0.216
1.551
0.647
0.291
0.024
0.861
15.936
12.285
10.440 1
1
3
1
1
1
1
1
1
1
Odds ratio Significance
0.749
1.201
1.830
0.665
1.196
1.081
9.702
10.971
0.016
0.618
0.642
0.671
0.421
0.589
0.878
0.354
0.000
0.000
0.001
TBI: traumatic brain injury; SAH: subarachnoid haemorrhage. HADS-A:
Hospital Anxiety and Depression Scale anxiety; HADS-D: Hospital Anxiety
and Depression Scale depression; VI: Visual Interview; MFS: Mental Fatigue
Scale; Inf./Tum.: Infection/Tumour.
503
directed towards a single diagnosis, mostly stroke or
TBI. Our starting point was that vision processing is so
widely spread in the brain that it should be susceptible
to injury in most of the diagnoses of ABI that present
at a neurorehabilitation centre.
The prevalence of mental fatigue, (52%), anxiety,
(42%) and depression, (34%) were in line with other
studies (1, 3, 5, 6), and in conformity with other studies
(8, 9), we found an association between mental fatigue
and depression and between depression and anxiety.
Visual deficits
Eight out of 10 of the patients experienced visual-
related symptoms. The most frequent symptoms were
reading difficulties, blurred vision, light sensitivity,
increased need for light and an increased tendency to
bump into objects or persons. These symptoms may
be related to reduction in visual acuity, visual field
defects, reduced contrast vision, ocular health issues
and ocular motor problems, including eye alignment
and accommodation. Thus, a more thorough examina-
tion is necessary to determine the background to the
symptoms. This also highlights the need to have a care
plan that incorporates an optometrist/ophthalmolo-
gist/orthoptist for further assessment to avoid basic
visual function issues being overlooked. Rowe et al.
(29) point out that integration of a vision specialist in
the neurorehabilitation team is a key factor to obtain
successful rehabilitation. This is also highlighted in
patients with combat injuries, as described in an article
by Brahm et al. (30), and in the conceptual model of
vision rehabilitation formed by American Congress of
Rehabilitation Medicine (ACRM) (31).
Visual deficits and fatigue
Mental fatigue after ABI is a multifactorial symptom
with no general definition. Staub et al. (32) define
mental fatigue as: “a feeling of early exhaustion de-
veloping during mental activity, with weariness, lack
of energy, and aversion to effort”. Mental fatigue is
a subjective experience and difficult to define in re-
search, although it is a huge problem for patients with
ABI. A statistically significant association between
increased levels of self-reported visual deficits and
self-reported moderate-to-severe mental fatigue was,
however, found in this study. There are few earlier
studies available with which to compare the present
findings, but the result is in line with the follow-up
study by Sand et al. (33) and the study by Schow
et al. (34). In these studies, an association between
fatigue and visual dysfunctions was described. It is
also known that ocular motor deficits and the efforts
associated with attempts to overcome these, may lead
J Rehabil Med 51, 2019