Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 49, No. 5S, October 15, 2003, pp S175S183
DOI 10.1002/art.11405
2003, American College of Rheumatology
MEASURES OF FATIGUE AND SLEEP
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
FATIGUE QUESTIONNAIRE
General Description
Purpose. To assess the severity of fatigue in
general practice settings.
Content. Seven items related to physical
symptoms of fatigue (e.g., Do you feel weak? Do
you need to rest more?). Four items related to
mental symptoms of fatigue (e.g., Do you have
difculty concentrating? How is your memory?).
Developer/contact information. Chalder T,
Berelowitz G, Pawlikowska T, Watta L, Wessely S,
Wright D, Wallace EP. Trudie Chalder: Academic
Department of Psychological Medicine, Kings
College School of Medicine and Dentistry &
Institute of Psychiatry, 103 Denmark Hill London
SE5 8AZ, UK. E-mail: sphatrc@iop.kcl.ac.uk.
Versions. Has been translated into other
languages but author of questionnaire does not
maintain a list of these translations.
Number of items in scale. 11 items.
Subscales. Total score most often used, but 2
scores, one for physical fatigue (items 17) and one
for mental fatigue (items 8 11) may be used.
Populations. Developmental/target. Adults 18
45 years seen in general practice settings (1).
Geri B. Neuberger, RN, MN, EdD: University of Kansas
School of Nursing, Kansas City.
Address correspondence to Geri B. Neuberger, RN, EdD,
University of Kansas School of Nursing, Mail Stop 4043,
3901 Rainbow Blvd., Kansas City, KS 66160. E-mail:
gneuberg@kumc.edu.
Submitted for publication April 23, 2003; accepted April
24, 2003.
Other uses. Chronic Fatigue Syndrome (2,3),
Gulf War syndrome (4), postinfectious fatigue (5),
general population (6,7).
WHO ICF Components. Participation restriction.
Administration
Method. Paper and pencil questionnaire.
Training. No special training required.
Time to administer/complete. Probably 25
minutes.
Equipment needed. Pencil.
Cost/availability. No cost. Questions published
in original Chalder et al (1) article in Appendix on
page 153. Items 5,12, and 14 were eliminated from
the 14-item fatigue scale printed in the Appendix
leaving 11 items for the nal version. Copy
available at the Arthritis Care & Research Web site
at http://www.interscience.wiley.com/jpages/0004-
3591:1/suppmat/index.html.
Scoring
Responses. Scale. Scoring using a bimodal
response system or a Likert score with weights
assigned to each response choice. Likert or
bimodal rating scales with 4 response options. For
the Likert Scale: better than usual 0, no more
than usual 1, worse than usual 2, much worse
than usual 3. For the bimodal scale: better than
usual 0, no more than usual 0, worse than
usual 1, much worse than usual 1. Sum all
items for a total score.
Score range. Range is 0 11 for bimodal response
format; 0 33 for Likert Scale.
S175
S176
Interpretation of scores. Higher score indicates
more fatigue.
Method of scoring. Sum responses for total
score.
Time to score. Less than 5 minutes.
Training to score. None.
Training to interpret. None.
Norms available. In a community sample of
15,283 women and men, ages 18 45 years, 18.3%
had substantial fatigue (bimodal score 4 or
lasting 6 weeks or longer) (6).
Psychometric Information
Reliability. Internal consistency. Cronbachs
alpha () for the 11-item scale was 0.89. The for
the physical fatigue subscale was 0.85 and for the
mental fatigue subscale was 0.82 (1).
Validity. Construct. Principal component
analysis of a 14-item scale supported a 2-
dimensional solution of 1) physical fatigue and 2)
mental fatigue. Three items were eliminated
leaving 11 items (1).
Discriminant. Relative Operating Characteristic
analysis was used to dene a cut-off score on the
Fatigue Questionnaire to discriminate between
cases and non-cases (1).
Sensitivity/responsiveness to change. Fifteen of
18 children ages 1118 years with Chronic Fatigue
Syndrome improved their fatigue scores after an
intervention of family cognitive behavioral therapy
(2).
Comments and Critique
Measures severity of physical and mental
fatigue. Use has been primarily with persons with
Chronic Fatigue Syndrome. One strength is that in
addition to a total score, separate scores can be
calculated for physical and mental fatigue.
References
1. (Original) Chalder T, Berelowitz G, Pawlikowska T,
Watts L, Wessely S, Wright D, et al. Development of a
Fatigue Scale. J Psychosomatic Res 1993;37:14753.
2. Chalder T, Tong J, Deary V. Family cognitive
behaviour therapy for chronic fatigue syndrome: an
uncontrolled study. Arch Dis Child 2002;86:957.
3. Deale A, Husain K, Chalder T, Wessely S. Long-term
outcome of cognitive behavior therapy versus
Neuberger
relaxation therapy for chronic fatigue syndrome: a 5-
year follow-up study. Am J Psychiatry 2001;12:2038
42.
4. Chalder T, Hotopf C, Unwin C, Hull L. Ismail A,
Wessely S. Prevalence of Gulf war veterans who
believe they have Gulf War syndrome: questionnaire
study. BMJ 2001;323:473 6.
5. Wessely S, Chalder T, Hirsch S, Pawlikowska T,
Wallace P, Wright DJM. Postinfectious fatigue:
prospective cohort study in primary care. Lancet
1995;345:1333 8.
6. Pawlikowska T, Chalder T, Hirsch SR, Wallace P,
Wright DJM, Wessely SC. Population based study of
fatigue and psychological distress. BMJ 1994;308:763
6.
7. Chalder T, Power MJ, Wessely S. Chronic fatigue in
the community: a question of attribution. Psychol
Med 1996;26:791 800.
FATIGUE SEVERITY SCALE (FSS)
General Description
Purpose. To measure fatigue severity in a
manner that facilitates research in the experience
of fatigue in a variety of medical and neurologic
disorders (1).
Content. Nine statements concerning
respondents fatigue, e.g., how fatigue affects
motivation, exercise, physical functioning, carrying
out duties, interfering with work, family, or social
life.
Developer/contact information. Developers were
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg
AD. Contact Lauren B. Krupp, Department of
Neurology, School of Medicine, Health Sciences
Center, State University of New York at Stony
Brook, Stony Brook, NY 11794-8121. E-mail:
Lauren.krupp@sunysb.edu.
Versions. An expanded 29-item version (2).
Translated into German.
Number of items in scale. There are 9 items.
Subscales. None.
Populations. Developmental/target. Adults with
multiple sclerosis (MS), systemic lupus
erythematosus (SLE).
Other uses. Systemic lupus erythematosus (35),
bromyalgia (6), Lyme Borreliosis (7), multiple
sclerosis (8), post-polio (9), amyotrophic lateral
sclerosis (10), cancer (11), brain injury (12),
Parkinsons disease (13), insomnia (14), sleep
apnea (15).
Fatigue
WHO ICF Components. Participation restriction.
Administration
Method. Paper and pencil questionnaire.
Training. No special training required.
Time to administer/complete. Not stated, but
probably 23 minutes.
Equipment needed. Pencil.
Cost, availability. No cost, questionnaire
published in original article (1) in Table 2 on page
1122. Copy available at the Arthritis Care & Research
Web site at http://www.medal.org/adocs/docs_ch1/
doc_ch1.05.html.
Scoring
Responses. Scale. Scale is a 7-point Likert scale
where 1 Strongly Disagree and 7 Strongly
Agree. Sum responses and divide by number of
items for scale score.
Score range. Range is 17.
Interpretation of scores. Higher score indicates
more severe fatigue.
Method of scoring. Calculate a mean score by
hand or computer.
Time to score. 12 minutes.
Training to score. No special training.
Training to interpret. None.
Norms available. Mean 2.3 (SD 0.7) in normal
healthy adults (1).
Psychometric Information
Reliability. Cronbachs Alpha: 0.89 for SLE
subjects (n 28), 0.81 for MS subjects (n 25),
0.88 for normal healthy adults (n 20), and 0.88
for total sample of 74 subjects (1).
Test-retest. (2 time points separated by 533
weeks) showed no signicant changes in FSS
scores when no clinical change was expected (r
0.84) (1).
Validity. Construct. Factor analysis identied
one factor when tested in a sample of 131 rural
patients with cancer (16). Discriminant function
analysis: 98% of MS subjects correctly classied
S177
and 90% of SLE subjects correctly classied versus
normal controls (1).
Concurrent. Correlation of FSS with visual
analog scale (n 74) was r 0.68; P 0.001 (1).
Vitality scores, measured by the Rand Index of
Vitality, were inversely correlated with Fatigue
Severity Scores supporting divergent validity (17).
Sensitivity/responsiveness to change. Clinical
improvement after treatment was associated with
reduction in FSS score t(7) 2.16; P 0.01 (1).
Comments and Critique
In rheumatology, this questionnaire has been
used to measure fatigue in patients with SLE and
bromyalgia. Items are related to the consequences
of fatigue. The original construct validity was
tested with small numbers of subjects (1).
However, a subsequent factor analysis conducted
by Winstead-Fry (16) of data from 131 rural cancer
patients all 9 items loaded on 1 factor supporting
construct validity.
References
1. (Original) Krupp LB, LaRocca NG, Muir-Nash J,
Steinberg AD. The Fatigue Severity Scale:
application to patients with multiple sclerosis and
systemic lupus erythematosis. Arch Neurol 1989;46:
11213.
2. Schwartz JE, Jandorf L, Krupp, LB. The measurement
of fatigue: a new instrument. J Psychosom Res 1993;
37:753 62.
3. Austin JS, Maisiak RS, Macrina DM, Heck LW.
Health outcome improvements in patients with
systemic lupus erythematosus using two telephone
counseling interventions. Arthritis Care Res 1996;9:
3919.
4. Krupp LB, LaRocca NG, Muir J, Steinberg AD. A
study of fatigue in systemic lupus erythematosus.
J Rheumatol 1990;17:1450 2.
5. Ramsey-Goldman R, Schilling EM, Dunlop D,
Langman C, Greenland P, Thomas RJ, et al. A pilot
study on the effects of exercise in patients with
systemic lupus erythematosis. Arthritis Care Res
2000;13:2629.
6. Alexander RW, Bradley LA, Alarcon GS, Trianna-
Alexander M, Aaron LA, Alberts KR, et al. Sexual
and physical abuse in women with bromyagia:
association with outpatient health care utilization
and pain medication usage. Arthritis Care Res 1998;
11:10215.
7. Ravdin LD, Hilton E, Primeau M, Clements C, Barr
WB. Memory functioning in lyme borreliosis. J Clin
Psychol 1996;57;282 6.
8. Giovannoni G, Thompson AJ, Miller DH, Thompson
EJ. Fatigue is not associated with raised
inammatory markers in multiple sclerosis.
Neurology 2001;57:676 81.
S178
9. Packer TL, Martins I, Krefting L, Brouwer B. Post-
polio sequelae: activity and post-polio fatigue.
Orthopedics 1991;14:1223 6.
10. Drory VE, Goltsman E, Reznik JG, Mosek A, Korczyn
AD. The value of muscle exercise in patients with
amyotrophic lateral sclerosis. J Neurol Sci 2001;191:
1337.
11. Stone P, Hardy J, Huddart R, Hern RA, Richards M.
Fatigue in patients with prostate cancer receiving
hormone therapy. Eur J Cancer 2000;36:1134 41.
12. La Chapelle DL, Finlayson MAJ. An evaluation of
fatigue in patients with brain injury and healthy
controls. Brain Inj 1998;12:649 59.
13. Shulman LM, Taback RL, Bean J, Weiner
WJ. Comorbidity of the nonmotor symptoms of
Parkinsons disease. Mov Disord 2001;16:50710.
14. Means MK, Lichstein KL, Epperson MT, Johnson CT.
Relaxation therapy for insomnia: nighttime and day
time effects. Behav Res Ther 2000;38:66578.
15. Aguillard RN, Riedel BW, Lichstein K, Grieve FG,
Johnson CT, Noe SL. Daytime functioning in
obstructive sleep apnea patients: exercise tolerance,
subjective fatigue, and sleepiness. Appl
Psychophysiol Biofeedback 1998;23:20717.
16. Winstead-Fry P. Psychometric assessment of four
fatigue scales with a sample of rural cancer patients.
J Nurs Meas 1998;6:11122.
17. Krupp LB, Coyle, PK, Doscher C, Miller A, Cross
AH, Jandorf L, Halper J, Johnson B, Morgante L,
Grimson R. Fatigue therapy in multiple sclerosis:
Results of a double-blind, randomized, parallel trial
of amantadine, pemoline, and placebo. Neurology
1995;45:1956-61.
Additional Reference
Taylor RR, Jason LA, Torres A. Fatigue rating scales: an
empirical comparison. Psycol Med 2000;30:849-56.
MULTIDIMENSIONAL ASSESSMENT OF
FATIGUE (MAF) SCALE
General Description
Purpose. The MAF was originally developed to
measure self-reported fatigue in adults with
rheumatoid arthritis (RA) (1) but subsequently has
been used to measure fatigue in adults with other
chronic conditions. The MAF is a revision of the
Piper Fatigue Scale that was developed and tested
with oncology patients (2).
Content. The MAF is a self-administered
questionnaire to measure 4 dimensions of self-
reported fatigue: degree and severity, amount of
distress it causes, its timing (how often it occurs
and if it changed over the past week), and the
degree to which fatigue interferes with activities of
daily living (e.g., household chores, cooking,
bathing, dressing, working, socializing, sexual
activity, leisure/recreational, shopping, walking,
Neuberger
other exercising). Respondents are asked to reect
on their experience of fatigue for the past week. A
Global Fatigue Index (GFI) is calculated.
Developer/contact information. Basia Belza,
PhD, RN, Department of Biobehavioral Nursing and
Health Systems, Box 357266, University of
Washington, Seattle, WA 98195-7266. E-mail:
basiab@u.washington.edu. Website for MAF users:
http://www.son.washington.edu/research/maf/
users-guide.asp.
Versions. Originally developed in English.
Numerous language versions are available from the
MAPI Research Institute (Lyon, France) such as
Spanish for Mexico, Spanish for the United States,
and Portuguese for Brazil. To gain access to and
information about a translated version contact
MAPI at their website at www.mapi-research-
inst.com.
Number of items in scale. The MAF consists of
16 items. Only 15 items are used to calculate the
GFI.
Subscales. Although dimensions are not
intended as subscales for descriptive purposes
some researchers have reported mean scores for
severity (items 1,2), distress (item 3), degree of
interference in activities of daily living (items 4
14), and timing (items 15,16).
Populations. Developmental/target. Adults with
rheumatoid arthritis.
Other uses. Healthy adults (control) compared
with adults with RA (3), adults with RA (4,5);
recent onset synovitis (6); RA/anemia (7); adults
with a chronic disease (human immunodeciency
virus [HIV]positive adults [8], HIV-positive adults
receiving interleukin-2 treatment [9]); oncology
mixed cancer (10); breast cancer chemotherapy
(11); chronic obstructive pulmonary disease (12);
Multiple sclerosis (13); coronary heart disease (14);
breast-feeding women (15), postpartum women
(16); rural oncology (17).
WHO ICF Components. Activity limitation,
participation restriction.
Administration
Method. Self-administered questionnaire.
Training. No special training.
Time to administer/complete. Author states less
than 5 minutes.
Fatigue
Equipment needed. Paper and pencil.
Cost/availability. Permission to use the MAF is
obtained by completing the permission form
accessed from a website: http://www.son.washington.
edu/research/maf/users-guide.asp. There is no charge
for individual use of the MAF. Colleagues in
industry who would like to use the MAF may be
charged a nominal fee.
Scoring
Responses. Scale. Numerical rating scale (110)
for items 1, and 4 14 (1 not at all, 10 a great
deal), item 2 (1 mild to 10 severe), item 3
(1 no distress, 10 a great deal of distress),
Categorical response (1 4) for Timing items 15 and
16.
Score range. For GFI, score range is 150 (1
no fatigue, 50 severe fatigue).
Interpretation of scores. Higher scores indicate
more severe fatigue, fatigue distress, or interference
with activities of daily living.
Method of scoring. To calculate the GFI, convert
item 15 to a 0 10 scale by multiplying each score
by 2.5 and then sum items 1,2, and 3, average of
items 4 14, and newly scored item 15. Item 16 is
not included in the GFI. Do not assign a score to
items if respondent indicated they do not do any
activity for reasons other than fatigue. If
respondents select no fatigue on 1, assign a zero to
items 216. Mean scores for Severity, Interference
in ADLs, and Timing can also be calculated.
Time to score. 5 minutes.
Training to score. No special training needed.
Training to interpret. No special training
needed.
Norms available. Mean GFI in RA patients (n
51) was 29.2, 28.1, and 26.1 at 3 time periods 6 8
weeks apart. Age- and sex-matched healthy
controls (n 46) had a mean GFI of 17, 16.5, and
15.8 at the 3 time periods (3).
Pychometric Information
Reliability. Numerical rating scale. Cronbachs
alpha for GFI 0.93 (n 77), stability correlation
ranged from a high of 0.73 for controls at Time 1 to
a low of 0.47 for controls at Time 3 (3). Testing of
the MAF-GFI with 210 cancer patients conrmed
excellent internal consistency (Cronbachs alpha
S179
0.88) and stability (n 37), r 0.87 (10).
Excellent internal consistency of the MAF-GFI also
was supported in a study of 183 HIV-positive men
with a Cronbachs alpha 0.96 (8).
Validity. Construct. Original factor analysis of
data from adult RA patients supported a 1-factor
solution (1). Two factor analyses of the MAF scores
of subjects with cancer (10,17) did not support a
one-factor solution (fatigue). However, Bormann et
al (8) found that 15 items loaded on one factor
(level of fatigue) in a non-rotated factor analysis.
Concurrent. Correlated with the POMS fatigue
subscale (r 0.84, P 0.01) (1). Meek et al (10)
also found moderately high correlations of the
MAF-GFI with selected POMS subscales (10).
Divergent. Negative correlation with POMS vigor
subscale (r 0.62) (3). Divergent validity was
supported by an inverse relationship of the MAF-
GFI with the Short Form-36 vitality scale (r
0.80; P 0.001) (8).
Sensitivity/responsiveness to change. GFI scores
indicated less fatigue in adult RA patients with
anemia of chronic disease after treatment of their
anemia (7). Global Fatigue Index increased
signicantly from baseline to posttest measures for
mothers of infants on apnea monitors (16). Meek et
al (10) found the MAF responsive to changes in
fatigue after radiation or chemotherapy. GFI
increased in HIV-infected men after treatment with
Interleukin-2 and returned to baseline at 1-month
post-treatment (9).
Comments and Critique
The original version of the MAF used a visual
analog scale response format. The response format
was changed to a numerical rating scale and tested
in 50 adults with RA and 26 age- and sex-matched
controls. The mean fatigue level in adults with RA
was higher compared to healthy controls. The
change in response format did not change the
excellent internal consistency of the MAF (3). In
clinic settings where a brief assessment of amount
of fatigue is preferred, the 2-item MAF-severity or
a 1-item visual analog scale, Rhoten Fatigue Scale
(18), can be used. However, these latter two scales
measure only the amount of fatigue and the 1-item
Rhoten Scale cannot be assessed for internal
consistency. The strength of the MAF is that it
measures 4 dimensions of fatigue thus providing
data for a fuller description of fatigue in the
population of interest.
S180
References
1. (Original) Tack (Belza) B. Dimensions and correlates
of fatigue in older adults with rheumatoid arthritis
[dissertation]. San Francisco: University of
California, San Francisco, School of Nursing; 1991.
2. Piper B, Lindsey A, Dodd M, Ferketich S, Paul S,
Weller S. The development of an instrument to
measure the subjective dimension of fatigue. In Funk
S, Tornquist E, Champagne M, Wiese R, editors. Key
aspects of comfort: management of pain, fatigue, and
nausea. New York: Springer; 1989. p. 199 207.
3. Belza B. Comparison of self-reported fatigue in
rheumatoid arthritis and controls. J Rheumatol 1995;
22:639 43.
4. Neuberger G, Press AN, Lindsley HB, Hinton R,
Cagle PE, Carlson K, et al. Effects of exercise on
fatigue, aerobic tness, and disease activity measures
in persons with rheumatoid arthritis. Res Nurs
Health 1997;20:195204.
5. Belza B, Henke C, Yelin EH, Epstein WV, Gilliss CL.
Correlates of fatigue in older adults with rheumatoid
arthritis. Nurs Res 1993;42:939.
6. Gerber L, El-Gabalawy H, Arayssi T, Furst G,
Yarboro C, Schumacher HR. Polyarticular arthritis,
independent of rheumatoid factor, is associated with
poor functional outcome in recent onset
inammatory synovitis. J Back Musculoskeletal
Rehabil 2000;14:1059.
7. Kaltwasser JP, Kessler U, Gottschalk R, Stucki G,
Moller B. Effect of recombinant human
erythropoietin and intravenous iron on anemia and
disease activity in rheumatoid arthritis. J Rheumatol
2001;28:2430 6.
8. Bormann J, Shively M, Smith T, Gifford A.
Measurement of fatigue in HIV-positive adults:
reliability and validity of the Global Fatigue Index. J
Assoc Nurses AIDS Care 2001;12:75 83.
9. Grady C, Anderson R, Chase GA. Fatigue in HIV-
infected men receiving investigational interleukin-2.
Nurs Res 1998;47:22734.
10. Meek PM, Nail LM, Barsevick A, Schwartz AL,
Stephen S, Whitmer K, et al. Psychometric testing of
fatigue instruments for use with cancer patients.
Nurs Res 2000;49:181190.
11. Roscoe JA, Morrow GR, Hickok JT, Bushunow P,
Matteson S, Rakita D, et al. Temporal
interrelationships among fatigue, circadian rhythm
and depression in breast cancer patients undergoing
chemotherapy treatment. Support Care Cancer 2002;
10:329 36.
12. Belza B, Steele BG, Hunziker J, Lakshminaryan S,
Holt L, Buchner DM. Correlates of physical activity
in chronic obstructive pulmonary disease. Nurs Res
2001;50:195202.
13. Schwartz CE, Coulthard-Morris L, Zeng Q.
Psychosocial correlates of fatigue in multiple
sclerosis. Arch Phys Med Rehabil 1996;77:16570.
14. Sullivan MD, LaCroix AZ, Spertus JA, Hecht J. Five-
year prospective study of the effects of anxiety and
depression in patients with coronary artery disease.
Am J Cardiol 2000;86:113538.
Neuberger
15. Wambach KA. Maternal fatigue in breastfeeding
primiparae during the rst nine weeks postpartum. J
Hum Lactation 1998;14:219 29.
16. Williams PD, Press A, Williams AR, Piamjariyakul
U, Keeter LM, Schultz J, et al. Fatigue in mothers of
infants discharged to the home on apnea monitors.
App Nurs Res 1999;12:69 77.
17. Winstead-Fry P. Psychometric assessment of four
fatigue scales with a sample of rural cancer patients.
J Nurs Meas 1998;6:11122.
18. Rhoten D. Fatigue and the postsurgical patient. In:
Norris CM, editor. Concept clarication in nursing.
Rockville (MD): Aspen; 1982; p. 277300.
SHORT FORM-36 (SF-36) VITALITY
SUBSCALE OF THE SHORT FORM
HEALTH SURVEY
General Description
Purpose. To assess vitality (energy level and
fatigue). Subscale of a general health survey
designed for use in clinical practice and research,
health policy evaluation and general population
surveys (1).
Content. Vitality Subscale score is determined
by responses to 4 items: Did you feel full of life?
Did you have a lot of energy? Did you feel worn
out? Did you feel tired?
Developer/contact information. Developers: John
E. Ware, Jr, PhD and Cathy Donald Sherbourne,
PhD. Contact information: John E. Ward, Jr, PhD,
Health Institute NEMC-Box 345, 750 Washington
Street, Boston, MA 02111. Website is
http://www.sf-36.com/.
Versions. SF-36 Version 1.0, SF-36 Version 2.0,
SF-12 and SF-8. The SF-8 and SF-12 have only 1
item to assess energy/fatigue. There is a SF-36
Version 2.0 with new scoring book that was
released in Fall, 2002.
Number of items in subscale. There are 4 items.
Subscales. 4 items in Energy/Fatigue Subscale
on SF-36.
Populations. Developmental/target. 14 years of
age and older.
Other uses. The SF-36 has been widely used in
numerous ill or healthy populations to assess
health status. In rheumatology, it has been used
mainly in adults with osteoarthritis (OA) or hip
replacement for OA. Also has been used in studies
of adults with RA or Sjogrens syndrome (See
selected examples on reference list).
Fatigue
WHO ICF Components. Activity limitation.
Administration
Method. Self-administered questionnaire (14
years or older). Computerized administration or
administration by an interviewer.
Training. None for Vitality subscale.
Time to administer/complete. For subscale less
than one minute.
Equipment needed. Pencil.
Cost/availability. No charge to academic
institutions or persons with academic
appointments. Charge to commercial institutions.
Scoring Manual for SF-36 Version 1 is $108 and
can be ordered from the SF-36 website.
Questionnaires can be printed from the website.
Scoring
Responses. Scale. Likert 1 6 response format for
SF-36 Version 1 where 1 All of the time, 6
None of the time.
Score range. Range is 4 24 for subscale,
transformed score 0 100.
Interpretation of scores. Higher score indicates
higher vitality (greater energy, lower fatigue), lower
score indicates lower vitality (less energy, greater
fatigue).
Method of scoring. Two positive energy items:
Did you feel full of pep? and Did you have lots
of energy? must be reverse-scored. Sum values for
a total raw score. Transform each raw scale score
to a 0 100 scale using the following formula:
Transformed Scale (Actual raw score - lowest
possible raw score) (Possible raw score range)
100. It is recommended that respondents must
answer 50% of the items in the scale for the score
to be calculated.
Time to score. 12 minutes.
Training to score. Inform scorer about recoding
of 2 positive energy items.
Training to interpret. No.
Norms available. SF-12 version-2, SF-36
version-2 and SF-8 surveys have up-to-date general
US population norms for both the standard (4-
week recall) and acute (1-week recall) forms.The
S181
norm data are available in the scoring manual that
must be purchased. In one study, normal female
control subjects (n 126) had a vitality
transformed score of 60 (2).
Psychometric Information
Reliability. For Vitality subscale Cronbachs
alpha 0.87 (n 3,445) (3).
Validity. SF-36 Version 1.0. Construct validity
supported by factor analysis (4). Vitality subscale
had a relative validity of 0.67 in discriminating
between patients with minor versus serious
medical conditions, but poor discriminant validity
in distinguishing patients with serious medical
conditions from psychiatric patients.
Sensitivity/responsiveness to change. SF-36
Vitality subscale increased following treatment of
anemia of chronic disease in patients with
rheumatoid arthritis (5). SF-36 Vitality subscale
scores improved in osteoarthritis patients after hip
replacement surgery (6) and following treatment of
early rheumatoid arthritis with etanercept or
methotrexate (7).
Comments and Critique
In 2002, a literature search identied 148
references in which the Vitality Subscale, as part
of the SF-36, was measured in studies of patients
with arthritis. Most of these studies were with
patients with osteoarthritis. Fewer studies were
found with patients with rheumatoid arthritis,
ankylosing spondylitis, or psoriatic arthritis.
According to the SF-36 website, the SF-36 version
1, SF-12 version 1 and SF-8 have been translated
into more than 40 different languages. The 1
vitality item on the SF-8 and SF-12 needs further
testing in patients with rheumatic disorders to
establish its responsiveness for that population (8).
The SF-36 Vitality (energy/fatigue) subscale is
short (4 items) and has strong psychometric data
supporting its reliability and validity.
References
1. (Original) Ware JE, Sherbourne, CD. The MOS 36-item
short-form health survey (SF-36): I. conceptual
framework and item selection. Med Care 1992;30:47383.
2. Tensing EK, Solovieva SA, Tervahartiala T,
Nordstrom DC, Laine M, et al. Fatigue and health
prole in sicca syndrome of Sjogrens and non-
Sjogrens syndrome origin. Clin Exp Rheumatol 2001:
19:313 6.
3. McHorney CA, Ware JE, Lu JFR, Sherbourne CD. The
MOS 36-item short-form health survey (SF-36): III.
Tests of data quality, scaling assumptions, and
S182
reliability across diverse patient groups. Med Care
1994;32:40 66.
4. McHorney CA, Ware JE, Raczek AE. The MOS 36-item
short-form health survey (SF-36): II. Psychometric and
clinical tests of validity in measuring physical and
mental health constructs. Med Care 1993;31:247 63.
5. Kaltwasser JP, Kessler U, Gottschalk R, Stucki G,
Moller, B. Effect of recombinant human
erythropoietin and intravenous iron on anemia and
disease activity in rheumatoid arthritis. J Rheumatol
2001;28:2430 6.
6. Bachmeier CJ, March LM, Cross MJ, Lapsley HM,
Tribe KL, Courtena BG, et al. A comparison of
Neuberger
outcomes in osteoarthritis patients undergoing total
hip and knee replacement surgery. Osteoarthritis
Cartilage 2001:9:137 46.
7. Kosinski M, Kujawski SC, Martin R, Wanke LA,
Buatti MC, Ware JE, et al. Health-related quality of
life in early rheumatoid arthritis: Impact of disease
and treatment response. Am J Manag Care
2002;8:231 40.
8. Ghandhi SK, Salmon JW, Zhao SZ, Lambert BL, Gore
PR, Conrad K. Psychometric evaluation of the 12-item
short-form health survey (SF-12) in osteoarthritis and
rheumatoid arthritis clinical trials. Clin Ther 2001;23:
1080 1.
 Fatigue

Summary Table of Fatigue Measures*

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.
S183