Visual Problems are Associated with Long-Term Fatigue after Stroke


  • Synne Garder Pedersen Department of Rehabilitation, University Hospital of North Norway
  • Mari Løkholm Department of Rehabilitation, University Hospital of North Norway
  • Oddgeir Friborg Faculty of Health Sciences, Department of Psychology, UiT – The Arctic University of Norway
  • Marianne Berg Halvorsen Department of Pediatric Rehabilitation, University Hospital of North Norway, Tromsø, Norway
  • Marit Kirkevold Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Model and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo
  • Guri Heiberg Department of Rehabilitation, University Hospital of North Norway
  • Audny Anke Department of Rehabilitation, University Hospital of North Norway; Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Model and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo; Faculty of Health Sciences, Department of Clinical Medicine, UiT – The Arctic University of Norway, Tromsø, Norway



Fatigue, health-related quality of life, stroke, visual disorder


Objective: Post-stroke fatigue may be associated with functioning even in patients with mild stroke. In order to guide rehabilitation, the aim of this study was to investigate the independent contribution of 12 function-related domains to severe long-term fatigue.
Design: Observational follow-up study.
Subjects: A total of 144 stroke survivors (mean age 67.3, standard deviation (SD) 10.9 years) were included.
Methods: Fatigue 3–4 years post-stroke was measured with the Fatigue Severity Scale (cut-off ≥5). Independent variables were the multidimensional Stroke-Specific Quality of Life scale with 12 domains, demographics, and baseline stroke characteristics.
Results: Most of the participants had mild and moderate stroke. Thirty-five percent (n = 51) reported severe fatigue 3–4 years after stroke. Those living with a significant other, and working participants reported significantly less fatigue. All domains of the Stroke-specific Quality of Life scale were significantly associated with the Fatigue Severity Scale. Adjusted for age, sex, marital status, and work status, the domains “energy”, “mood”, and, unexpectedly, the domain “vision”, were all variables independently associated with severe long-term fatigue.
Conclusion: Stroke survivors with prominent self-reported visual problems were more likely to experience fatigue. This finding should be verified in further studies. Visual examination and visual rehabilitation may reduce fatigue in selected stroke survivors.

Post-stroke fatigue presumes worse outcomes for rehabilitation and recovery after stroke. More knowledge of how specific long-term consequences relate to fatigue is needed to guide care and rehabilitation. The aim of this study is to investigate whether specific areas of function are related to fatigue 3–4 years after stroke. In total, 144 stroke survivors with predominantly initial mild and moderate stroke severity were included. Self-reported questionnaires with 12 function-related areas from a stroke-specific health-related quality of life measurement were tested in relation to a fatigue scale. This study found severe fatigue in 35% of participants. All functional areas were related to fatigue. When corrected for age, sex, and marital status the domains “energy”, “mood”, and “vision” were of particular importance for severe fatigue. The results of this study indicate that stroke survivors with prominent visual problems may especially be at risk of severe fatigue.


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Elf M, Eriksson G, Johansson S, von Koch L, Ytterberg C. Self-reported fatigue and associated factors six years after stroke. PloS One 2016; 11: 1-9. DOI: 10.1371/journal.pone.0161942 DOI:

Paciaroni M, Acciarresi M. Poststroke fatigue. Stroke 2019; 50: 1927-1933. DOI: 10.1161/STROKEAHA.119.023552 DOI:

Hinkle JL, Becker KJ, Kim JS, Choi-Kwon S, Saban KL, McNair N, et al. Poststroke fatigue: emerging evidence and approaches to management: a scientific statement for healthcare professionals from the American Heart Association. Stroke 2017; 48: 159-170. DOI: 10.1161/STR.0000000000000132 DOI:

Ramirez-Moreno JM, Munoz-Vega P, Alberca SB, Peral-Pacheco D. Health-related quality of life and fatigue after transient ischemic attack and minor stroke. J Stroke Cerebrovasc Dis 2019; 28: 276-284. DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.046 DOI:

Glader EL, Stegmayr B, Asplund K. Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke 2002; 33: 1327-1333. DOI: 10.1161/01.str.0000014248.28711.d6 DOI:

Naess H, Lunde L, Brogger J, Waje-Andreassen U. Fatigue among stroke patients on long-term follow-up. The Bergen Stroke Study. J Neurol Sci 2012; 312: 138-141. DOI: 10.1016/j.jns.2011.08.002 DOI:

Snaphaan L, van der Werf S, de Leeuw FE. Time course and risk factors of post-stroke fatigue: a prospective cohort study. Eur J Neurol 2011; 18: 611-617. DOI: 10.1111/j.1468-1331.2010.03217.x DOI:

van der Werf SP, van den Broek HL, Anten HW, Bleijenberg G. Experience of severe fatigue long after stroke and its relation to depressive symptoms and disease characteristics. Eur J Neurol 2001; 45: 28-33. DOI: 10.1159/000052085 DOI:

van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E. Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health-related quality of life in chronic stroke? Cerebrovasc Dis 2007; 23: 40-45. DOI: 10.1159/000095757 DOI:

Cumming TB, Packer M, Kramer SF, English C. The prevalence of fatigue after stroke: a systematic review and meta-analysis. Int J Stroke 2016; 11: 968-977. DOI: 10.1177/1747493016669861 DOI:

Vitturi BK, Mitre LP, Kim AIH, Gagliardi RJ. Prevalence and predictors of fatigue and neuropsychiatric symptoms in patients with minor ischemic stroke. J Stroke Cerebrovasc Dis 2021; 30: 1-7. DOI: 10.1016/j.jstrokecerebrovasdis.2021.105964 DOI:

Pedersen SG, Anke A, Aadal L, Pallesen H, Moe S, Arntzen C. Experiences of quality of life the first year after stroke in Denmark and Norway. A qualitative analysis. Int J Qual Stud Health Well-being 2019; 14: 1-14. DOI: 10.1080/17482631.2019.1659540 DOI:

Almhdawi KA, Jaber HB, Khalil HW, Kanaan SF, Shyyab AA, Mansour ZM, et al. Post-stroke fatigue level is significantly associated with mental health component of health-related quality of life: a cross-sectional study. Qual Life Res 2021; 30: 1165-1172. DOI: 10.1007/s11136-020-02714-z DOI:

Williams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke 1999; 30: 1362-1369. DOI:10.1161/01.STR.30.7.1362 DOI:

Chen YK, Qu JF, Xiao WM, Li WY, Weng HY, Li W, et al. Poststroke fatigue: risk factors and its effect on functional status and health-related quality of life. Int J Stroke 2015; 10: 506-512. DOI: 10.1111/ijs.12409 DOI:

Wu S, Mead G, Macleod M, Chalder T. Model of understanding fatigue after stroke. Stroke 2015; 46: 893-898. DOI: 10.1161/STROKEAHA.114.006647 DOI:

Wist S, Clivaz J, Sattelmayer M. Muscle strengthening for hemiparesis after stroke: a meta-analysis. Ann Phys Rehabil Med 2016; 59: 114-124. DOI: 10.1016/ DOI:

Bolognini N, Russo C, Edwards DJ. The sensory side of post-stroke motor rehabilitation. Restor Neurol Neurosci 2016; 34: 571-586. DOI: 10.3233/RNN-150606 DOI:

de Haan EH, Nys GM, Van Zandvoort MJ. Cognitive function following stroke and vascular cognitive impairment. Curr Opin Neurol 2006; 19: 559-564. DOI: 10.1097/01.wco.0000247612.21235.d9 DOI:

Sand KM, Midelfart A, Thomassen L, Melms A, Wilhelm H, Hoff JM. Visual impairment in stroke patients - a review. Acta Neurol Scand Suppl 2013; Suppl 127: 52-56. DOI: 10.1111/ane.12050 DOI:

Borthwick S. Communication impairment in patients following stroke. Nurs Stand 2012; 26: 35-41. DOI: 10.7748/ns2012. DOI:

Kim JS. Post-stroke mood and emotional disturbances: pharmacological therapy based on mechanisms. J Stroke 2016; 18: 244-255. DOI: 10.5853/jos.2016.01144 DOI:

Lagogianni C, Thomas S, Lincoln N. Examining the relationship between fatigue and cognition after stroke: a systematic review. Neuropsychol Rehabil 2018; 28: 57-116. DOI: 10.1080/09602011.2015.1127820 DOI:

Berthold-Lindstedt M, Johansson J, Ygge J, Borg K. Vision-related symptoms after acquired brain injury and the association with mental fatigue, anxiety and depression. J Rehabil Med 2019; 51: 499-505. DOI: 10.2340/16501977-2570 DOI:

Pedersen SG, Friborg O, Heiberg GA, Arntzen C, Stabel HH, Thrane G, et al. Stroke-specific quality of life one-year post-stroke in two Scandinavian country-regions with different organisation of rehabilitation services: a prospective study. Disabil Rehabil 2021;43: 3810-3820. DOI: 10.1080/09638288.2020.1753830 DOI:

Lerdal A, Wahl A, Rustoen T, Hanestad BR, Moum T. Fatigue in the general population: a translation and test of the psychometric properties of the Norwegian version of the fatigue severity scale. Scand J Public Health 2005; 33: 123-130. DOI: 10.1080/14034940410028406 DOI:

Ozyemisci-Taskiran O, Batur EB, Yuksel S, Cengiz M, Karatas GK. Validity and reliability of fatigue severity scale in stroke. Topics in Stroke Rehabilitation 2019; 26: 122-127. DOI: 10.1080/10749357.2018.1550957 DOI:

Pedersen SG, Heiberg GA, Nielsen JF, Friborg O, Stabel HH, Anke A, et al. Validity, reliability and Norwegian adaptation of the Stroke-Specific Quality of Life (SS-QOL) scale. SAGE Open Med 2018; 6: 1-10. DOI: 10.1177/2050312117752031 DOI:

Muus I, Williams LS, Ringsberg KC. Validation of the Stroke Specific Quality of Life Scale (SS-QOL): test of reliability and validity of the Danish version (SS-QOL-DK). Clin Rehabil 2007; 21: 620-627. DOI: 10.1177/0269215507075504 DOI:

Duncan F, Lewis SJ, Greig CA, Dennis MS, Sharpe M, MacLullich AM, et al. Exploratory longitudinal cohort study of associations of fatigue after stroke. Stroke 2015; 46: 1052-1058. DOI: 10.1161/STROKEAHA.114.008079 DOI:

Cohen J. Statistical power analysis for the behavioral sciences. 2nd edn. New York: Routledge, 1988.

Kinney AR, Eakman AM, Graham JE. Novel effect size interpretation guidelines and an evaluation of statistical power in rehabilitation research. Arch Phys Med Rehabil 2020; 101: 2219-2226. DOI: 10.1016/j.apmr.2020.02.017 DOI:

Wu S, Barugh A, Macleod M, Mead G. Psychological associations of poststroke fatigue: a systematic review and meta-analysis. Stroke 2014; 45: 1778-1783. DOI: 10.1161/STROKEAHA.113.004584 DOI:

Sand KM, Wilhelmsen G, Naess H, Midelfart A, Thomassen L, Hoff JM. Vision problems in ischaemic stroke patients: effects on life quality and disability. Eur J Neurol 2016; 23: 1-7. DOI: 10.1111/ene.12848 DOI:

Berthold-Lindstedt M, Ygge J, Borg K. Visual dysfunction is underestimated in patients with acquired brain injury. J Rehabil Med 2017; 49: 327-332. DOI: 10.2340/16501977-2218 DOI:

Schow T, Teasdale TW, Quas KJ, Rasmussen MA. Problems with balance and binocular visual dysfunction are associated with post-stroke fatigue. Topics in Stroke Rehabilitation 2017; 24: 41-49. DOI: 10.1080/10749357.2016.1188475 DOI:

Wolter M, Preda S. Visual deficits following stroke: maximizing participation in rehabilitation. Top Stroke Rehabil 2006; 13: 12-21. DOI: 10.1310/3JRY-B168-5N49-XQWA DOI:

Berthold-Lindstedt M, Johansson J, Ygge J, Borg K. How to assess visual function in acquired brain injury - asking is not enough. Brain Behav 2021; 11: 1-8. DOI: 10.1002/brb3.1958 DOI:

Corriveau H, Hebert R, Raiche M, Prince F. Evaluation of postural stability in the elderly with stroke. Arch Phys Med Rehabil 2004; 85: 1095-1101. DOI: 10.1016/j.apmr.2003.09.023 DOI:

Papageorgiou E, Hardiess G, Schaeffel F, Wiethoelter H, Karnath HO, Mallot H, et al. Assessment of vision-related quality of life in patients with homonymous visual field defects. Graefes Arch Clin Exp Ophthalmol 2007; 245: 1749-1758. DOI: 10.1007/s00417-007-0644-z DOI:



How to Cite

Pedersen, S. G., Løkholm, M., Friborg, O. ., Halvorsen, M. B., Kirkevold, M. ., Heiberg, G., & Anke, A. (2023). Visual Problems are Associated with Long-Term Fatigue after Stroke. Journal of Rehabilitation Medicine, 55, jrm00374.



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