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Measures of Fatigue
The Fatigue Questionnaire, Fatigue Severity Scale, Multidimensional
Assessment of Fatigue Scale, and Short Form-36 Vitality (Energy/Fatigue)
Subscale of the Short Form Health Survey
Geri B. Neuberger
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S176 Neuberger
Interpretation of scores. Higher score indicates relaxation therapy for chronic fatigue syndrome: a 5-
more fatigue. year follow-up study. Am J Psychiatry 2001;12:2038
42.
Method of scoring. Sum responses for total 4. Chalder T, Hotopf C, Unwin C, Hull L. Ismail A,
Wessely S. Prevalence of Gulf war veterans who
score.
believe they have Gulf War syndrome: questionnaire
study. BMJ 2001;323:473 6.
Time to score. Less than 5 minutes. 5. Wessely S, Chalder T, Hirsch S, Pawlikowska T,
Wallace P, Wright DJM. Postinfectious fatigue:
Training to score. None. prospective cohort study in primary care. Lancet
1995;345:1333 8.
Training to interpret. None. 6. Pawlikowska T, Chalder T, Hirsch SR, Wallace P,
Wright DJM, Wessely SC. Population based study of
Norms available. In a community sample of fatigue and psychological distress. BMJ 1994;308:763
15,283 women and men, ages 18 45 years, 18.3% 6.
had substantial fatigue (bimodal score 4 or 7. Chalder T, Power MJ, Wessely S. Chronic fatigue in
lasting 6 weeks or longer) (6). the community: a question of attribution. Psychol
Med 1996;26:791 800.
Psychometric Information
Reliability. Internal consistency. Cronbachs FATIGUE SEVERITY SCALE (FSS)
alpha () for the 11-item scale was 0.89. The for
the physical fatigue subscale was 0.85 and for the General Description
mental fatigue subscale was 0.82 (1). Purpose. To measure fatigue severity in a
manner that facilitates research in the experience
Validity. Construct. Principal component of fatigue in a variety of medical and neurologic
analysis of a 14-item scale supported a 2- disorders (1).
dimensional solution of 1) physical fatigue and 2)
mental fatigue. Three items were eliminated Content. Nine statements concerning
leaving 11 items (1). respondents fatigue, e.g., how fatigue affects
motivation, exercise, physical functioning, carrying
Discriminant. Relative Operating Characteristic out duties, interfering with work, family, or social
analysis was used to dene a cut-off score on the life.
Fatigue Questionnaire to discriminate between
cases and non-cases (1). Developer/contact information. Developers were
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg
Sensitivity/responsiveness to change. Fifteen of AD. Contact Lauren B. Krupp, Department of
18 children ages 1118 years with Chronic Fatigue Neurology, School of Medicine, Health Sciences
Syndrome improved their fatigue scores after an Center, State University of New York at Stony
intervention of family cognitive behavioral therapy Brook, Stony Brook, NY 11794-8121. E-mail:
(2). Lauren.krupp@sunysb.edu.
WHO ICF Components. Participation restriction. and 90% of SLE subjects correctly classied versus
normal controls (1).
Administration
Concurrent. Correlation of FSS with visual
Method. Paper and pencil questionnaire. analog scale (n 74) was r 0.68; P 0.001 (1).
Vitality scores, measured by the Rand Index of
Training. No special training required.
Vitality, were inversely correlated with Fatigue
Severity Scores supporting divergent validity (17).
Time to administer/complete. Not stated, but
probably 23 minutes.
Sensitivity/responsiveness to change. Clinical
improvement after treatment was associated with
Equipment needed. Pencil.
reduction in FSS score t(7) 2.16; P 0.01 (1).
Cost, availability. No cost, questionnaire
published in original article (1) in Table 2 on page Comments and Critique
1122. Copy available at the Arthritis Care & Research In rheumatology, this questionnaire has been
Web site at http://www.medal.org/adocs/docs_ch1/ used to measure fatigue in patients with SLE and
doc_ch1.05.html. bromyalgia. Items are related to the consequences
of fatigue. The original construct validity was
Scoring tested with small numbers of subjects (1).
However, a subsequent factor analysis conducted
Responses. Scale. Scale is a 7-point Likert scale
by Winstead-Fry (16) of data from 131 rural cancer
where 1 Strongly Disagree and 7 Strongly
patients all 9 items loaded on 1 factor supporting
Agree. Sum responses and divide by number of
construct validity.
items for scale score.
9. Packer TL, Martins I, Krefting L, Brouwer B. Post- other exercising). Respondents are asked to reect
polio sequelae: activity and post-polio fatigue. on their experience of fatigue for the past week. A
Orthopedics 1991;14:1223 6. Global Fatigue Index (GFI) is calculated.
10. Drory VE, Goltsman E, Reznik JG, Mosek A, Korczyn
AD. The value of muscle exercise in patients with
Developer/contact information. Basia Belza,
amyotrophic lateral sclerosis. J Neurol Sci 2001;191:
PhD, RN, Department of Biobehavioral Nursing and
1337.
11. Stone P, Hardy J, Huddart R, Hern RA, Richards M. Health Systems, Box 357266, University of
Fatigue in patients with prostate cancer receiving Washington, Seattle, WA 98195-7266. E-mail:
hormone therapy. Eur J Cancer 2000;36:1134 41. basiab@u.washington.edu. Website for MAF users:
12. La Chapelle DL, Finlayson MAJ. An evaluation of http://www.son.washington.edu/research/maf/
fatigue in patients with brain injury and healthy users-guide.asp.
controls. Brain Inj 1998;12:649 59.
13. Shulman LM, Taback RL, Bean J, Weiner Versions. Originally developed in English.
WJ. Comorbidity of the nonmotor symptoms of Numerous language versions are available from the
Parkinsons disease. Mov Disord 2001;16:50710. MAPI Research Institute (Lyon, France) such as
14. Means MK, Lichstein KL, Epperson MT, Johnson CT. Spanish for Mexico, Spanish for the United States,
Relaxation therapy for insomnia: nighttime and day
and Portuguese for Brazil. To gain access to and
time effects. Behav Res Ther 2000;38:66578.
15. Aguillard RN, Riedel BW, Lichstein K, Grieve FG, information about a translated version contact
Johnson CT, Noe SL. Daytime functioning in MAPI at their website at www.mapi-research-
obstructive sleep apnea patients: exercise tolerance, inst.com.
subjective fatigue, and sleepiness. Appl
Psychophysiol Biofeedback 1998;23:20717. Number of items in scale. The MAF consists of
16. Winstead-Fry P. Psychometric assessment of four 16 items. Only 15 items are used to calculate the
fatigue scales with a sample of rural cancer patients. GFI.
J Nurs Meas 1998;6:11122.
17. Krupp LB, Coyle, PK, Doscher C, Miller A, Cross Subscales. Although dimensions are not
AH, Jandorf L, Halper J, Johnson B, Morgante L, intended as subscales for descriptive purposes
Grimson R. Fatigue therapy in multiple sclerosis:
some researchers have reported mean scores for
Results of a double-blind, randomized, parallel trial
severity (items 1,2), distress (item 3), degree of
of amantadine, pemoline, and placebo. Neurology
1995;45:1956-61. interference in activities of daily living (items 4
14), and timing (items 15,16).
Equipment needed. Paper and pencil. 0.88) and stability (n 37), r 0.87 (10).
Excellent internal consistency of the MAF-GFI also
Cost/availability. Permission to use the MAF is was supported in a study of 183 HIV-positive men
obtained by completing the permission form with a Cronbachs alpha 0.96 (8).
accessed from a website: http://www.son.washington.
edu/research/maf/users-guide.asp. There is no charge Validity. Construct. Original factor analysis of
for individual use of the MAF. Colleagues in data from adult RA patients supported a 1-factor
industry who would like to use the MAF may be solution (1). Two factor analyses of the MAF scores
charged a nominal fee. of subjects with cancer (10,17) did not support a
one-factor solution (fatigue). However, Bormann et
Scoring al (8) found that 15 items loaded on one factor
(level of fatigue) in a non-rotated factor analysis.
Responses. Scale. Numerical rating scale (110)
for items 1, and 4 14 (1 not at all, 10 a great Concurrent. Correlated with the POMS fatigue
deal), item 2 (1 mild to 10 severe), item 3
subscale (r 0.84, P 0.01) (1). Meek et al (10)
(1 no distress, 10 a great deal of distress),
also found moderately high correlations of the
Categorical response (1 4) for Timing items 15 and
MAF-GFI with selected POMS subscales (10).
16.
Divergent. Negative correlation with POMS vigor
Score range. For GFI, score range is 150 (1
subscale (r 0.62) (3). Divergent validity was
no fatigue, 50 severe fatigue).
supported by an inverse relationship of the MAF-
GFI with the Short Form-36 vitality scale (r
Interpretation of scores. Higher scores indicate
more severe fatigue, fatigue distress, or interference 0.80; P 0.001) (8).
with activities of daily living.
Sensitivity/responsiveness to change. GFI scores
Method of scoring. To calculate the GFI, convert indicated less fatigue in adult RA patients with
item 15 to a 0 10 scale by multiplying each score anemia of chronic disease after treatment of their
by 2.5 and then sum items 1,2, and 3, average of anemia (7). Global Fatigue Index increased
items 4 14, and newly scored item 15. Item 16 is signicantly from baseline to posttest measures for
not included in the GFI. Do not assign a score to mothers of infants on apnea monitors (16). Meek et
items if respondent indicated they do not do any al (10) found the MAF responsive to changes in
activity for reasons other than fatigue. If fatigue after radiation or chemotherapy. GFI
respondents select no fatigue on 1, assign a zero to increased in HIV-infected men after treatment with
items 216. Mean scores for Severity, Interference Interleukin-2 and returned to baseline at 1-month
in ADLs, and Timing can also be calculated. post-treatment (9).
WHO ICF Components. Activity limitation. norm data are available in the scoring manual that
must be purchased. In one study, normal female
control subjects (n 126) had a vitality
Administration transformed score of 60 (2).
Method. Self-administered questionnaire (14
years or older). Computerized administration or
administration by an interviewer. Psychometric Information
Reliability. For Vitality subscale Cronbachs
Training. None for Vitality subscale. alpha 0.87 (n 3,445) (3).
Time to administer/complete. For subscale less Validity. SF-36 Version 1.0. Construct validity
than one minute. supported by factor analysis (4). Vitality subscale
had a relative validity of 0.67 in discriminating
Equipment needed. Pencil. between patients with minor versus serious
medical conditions, but poor discriminant validity
Cost/availability. No charge to academic in distinguishing patients with serious medical
institutions or persons with academic conditions from psychiatric patients.
appointments. Charge to commercial institutions.
Scoring Manual for SF-36 Version 1 is $108 and Sensitivity/responsiveness to change. SF-36
can be ordered from the SF-36 website. Vitality subscale increased following treatment of
Questionnaires can be printed from the website. anemia of chronic disease in patients with
rheumatoid arthritis (5). SF-36 Vitality subscale
scores improved in osteoarthritis patients after hip
Scoring
replacement surgery (6) and following treatment of
Responses. Scale. Likert 1 6 response format for early rheumatoid arthritis with etanercept or
SF-36 Version 1 where 1 All of the time, 6 methotrexate (7).
None of the time.
reliability across diverse patient groups. Med Care outcomes in osteoarthritis patients undergoing total
1994;32:40 66. hip and knee replacement surgery. Osteoarthritis
4. McHorney CA, Ware JE, Raczek AE. The MOS 36-item Cartilage 2001:9:137 46.
short-form health survey (SF-36): II. Psychometric and 7. Kosinski M, Kujawski SC, Martin R, Wanke LA,
clinical tests of validity in measuring physical and Buatti MC, Ware JE, et al. Health-related quality of
mental health constructs. Med Care 1993;31:247 63. life in early rheumatoid arthritis: Impact of disease
5. Kaltwasser JP, Kessler U, Gottschalk R, Stucki G, and treatment response. Am J Manag Care
Moller, B. Effect of recombinant human 2002;8:231 40.
erythropoietin and intravenous iron on anemia and 8. Ghandhi SK, Salmon JW, Zhao SZ, Lambert BL, Gore
disease activity in rheumatoid arthritis. J Rheumatol PR, Conrad K. Psychometric evaluation of the 12-item
2001;28:2430 6. short-form health survey (SF-12) in osteoarthritis and
6. Bachmeier CJ, March LM, Cross MJ, Lapsley HM, rheumatoid arthritis clinical trials. Clin Ther 2001;23:
Tribe KL, Courtena BG, et al. A comparison of 1080 1.
Fatigue
Psychometric properties
Response Method of Time for Validated
Measure/scale Content Measure outputs No. of items format administration administration populations Reliability Validity Responsiveness
Fatigue Measure of fatigue Total score or separate 7 items measure Likert scale Self-administered 5 minutes Adults with chronic Excellent Good Good but more data
Questionnaire severity subscale scores for physical (03): fatigue syndrome, internal needed on
physical and mental symptoms of 0 better Gulf War syndrome, consistency responsiveness
fatigue. fatigue than usual postinfectious
Higher score equals 4 items measure 1 no more fatigue, general
more severe fatigue mental than usual population.
symptoms of 2 worse
fatigue than usual
3 much
worse than
usual
Bimodal
responses
the same
but scoring
is (0,0,1,1).
Fatigue Severity Negative statements Mean score: 9 items Likert Scale Self-administered 5 minutes Adults with SLE, Excellent Excellent Good but more data
Scale about how fatigue Higher score more 1 Strongly bromyalgia, Lyme internal needed on
affects functioning severe fatigue. Disagree Borreliosis, chronic consistency responsiveness
related to 7 Strongly fatigue syndrome, and stability.
motivation, exercise, Agree post-polio, ALS,
physical functioning, multiple sclerosis
carrying out duties, cancer, brain injury,
interference with Parkinsons disease,
work, family, or insomnia, Guillaine-
social life Barre Syndrome,
sleep apnea, brain
injury.
Multi-dimensional Measures four Global Fatigue Index Severity, 2 items; Numerical Self-administered 5 minutes RA, HIV-positive Excellent Excellent Good
Assessment of dimensions of (GFI) (150). Item 16 Distress, 1 rating scale adults, multiple internal convergent
Fatigue fatigue: severity, is omitted in item; of 110 for sclerosis, coronary consistency and divergent
distress, timing, calculating GFI. Interference with items 114 heart disease, Fair - good validity
interference in ADLs, 11 Categorical women, oncology stability
ADLs. items; response mixed cancer
Timing, 2 items. for items diagnosis, rural
15 and 16. oncology.
SF-36-Version 1 Total score is 4 items 6-point Likert Self-administered 1 minute for Adults with OA, hip Excellent Good Good
Vitality (Energy/ transformed to a 0 16 scale or interview. 4-item subscale replacement, RA, internal
Fatigue) 100 scale so score Sjogrens Syndrome. consistency.
Subscale can be compared to SF-36 widely used in
norms. numerous ill or well
populations.
* SLE systemic lupus erythematosus; ALS amylotrophic lateral sclerosis; RA rheumatoid arthritis; HIV human immunodeciency virus; ADLs activities of daily living; SF Short Form; OA
osteoarthritis.
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