Modified Fatigue Impact Scale
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Modified Fatigue Impact Scale

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Purpose

The MFIS is a modified form of the Fatigue Impact Scale (Fisk et al., 1994) based on items derived from interviews with MS patients concerning how fatigue impacts their lives. This instrument provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning.

Acronym MFIS

Cost

Not Free

Diagnosis/Conditions

  • Brain Injury Recovery
  • Multiple Sclerosis

Populations

Multiple Sclerosis
Brain Injury

Key Descriptions

  • The full-length MFIS has 21 items while the abbreviated version has 5 items.
  • The full-length version has the advantage of generating subscales.
  • The MFIS is a 21-item shortened version of the 40-item FIS and has been recommended for use by the Multiple Sclerosis Council for Clinical Practice Guidelines. It assesses the perceived impact of fatigue on the subscales physical, cognitive and psychosocial functioning during the past 4 weeks (Rietberg et al., 2010).
  • The MFIS is one of the components of the MSQLI.
  • Description of scoring: Likert scale. Participants rate on a 5-point Likert scale, with 0 = ‘Never’ to 4 = ‘Almost always’ their agreement with 21 statements.
  • Total score (0‐84) and subscales for physical (0‐36), cognitive (0‐40) and psychosocial functioning (0‐8). The 5-item version is scored (0‐20). Higher numbers indicate greater fatigue.
  • Rasch analysis revealed that the 21-item scale was found to contain a “physical” and a “cognitive” dimension (the original 2 social items were found to be part of the physical dimension).
  • The scoring for Standard 21-item version is either represented as a total score by summing the totals from each subscale or by each individual subscale (see below).
  • Subscale scoring:
    1) Physical subscale: range from 0-36; Add raw scores on items: 4+6+7+10+13+14+17+20+21
    2) Cognitive subscale: range from 0-40; Add raw scores on items: 1+2+3+5+11+12+15+16+18+19
    3) Psychosocial subscale: range from 0-8; Add raw scores on items: 8+9
  • Scoring for 5-item version: Total score is the sum of items 1+9+10+17+19; Range from 0-20

Number of Items

21
Abbreviated: 5

Equipment Required

  • Questionnaire
  • Pen

Time to Administer

2-10 minutes

Approximately 5-10 minutes for the full-length version and 2-3 minutes for the abbreviated version.

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Tammie Johnson, PT, DPT, MS and the TBI EDGE task force of the Neurology Section of the APTA in 9/2012.

ICF Domain

Body Structure
Body Function
Activity
Participation

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

NR

UR

UR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

R

R

R

R

R

StrokEDGE

NR

NR

UR

UR

UR

TBI EDGE

NR

LS

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

R

R

R

NR

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

Yes

Yes

No

StrokEDGE

No

No

Yes

Not reported

TBI EDGE

No

No

No

Not reported

Considerations

  • The MFIS is a shortened modification of the Fatigue Impact Scale, designed as a self-report measure to rate fatigue in Multiple Sclerosis.
  • The MFIS cannot be used to generate a single overall score of fatigue. The conceptual interaction between the two dimensions remains unclear, which poses problems when interpreting change scores in these individual scales. Studies in which a global MFIS score was used as either an outcome measure or selection tool may need to be re-evaluated (Mills et al., 2010).

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Multiple Sclerosis

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Minimally Clinically Important Difference (MCID)

Multiple Sclerosis: (Rietberg, 2010; n= 43; ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) 

  • Smallest Detectable Change (SDC) = 16.2
  • Minimal Detectable Change (MDC) % = 19.3%

Normative Data

Multiple Sclerosis: (Tellez et al, 2005; 231 MS patients and 123 healthy controls, 164 patients with relapsing-remitting, 47 with secondary progressive, 12 with primary progressive) 

  • Median MFIS score= 33.0 (range 0-82) 

 

Test/Retest Reliability

Multiple Sclerosis: (Rietberg, 2010; n= 43; ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) 

  • Excellent test-retest reliability (ICC =0.85)

Interrater/Intrarater Reliability

Multiple Sclerosis: (Amtmann et al, 2012; n=1271 individuals with MS living in the community, 80% female, 36.2% reported being employed 20 or more hours a week; mean age 50.7, mean disease duration 13.2 years, MS severity as minimal (EDSS≤4.0) for 32.4% and intermediate (EDSS 4.5-6.5) for 47.9% and advanced (EDSS≥7.0) for 19.7%) 

  • Excellent reliability: Cronbach’s alpha = 0.94-0.96 for total MFIS

Internal Consistency

Multiple Sclerosis: (Kos et al, 2005)

  • MFIS has been found to show change after intervention. 
  • After a 4‐week rehabilitation program, the MFIS did change, but the FSS did not.

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Multiple Sclerosis: (Rietberg, 2010; n= 43; ambulatory patients with MS; mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5)

  • Excellent: MFIS vs. Fatigue Severity Scale (FSS): r = 0.66; MFIS vs. the Checklist Individual Strength (CIS20R): r = 0.54 

 

Multiple Sclerosis: (Tellez et al, 2005; (231 MS patients and 123 healthy controls, 164 patients with relapsing-remitting, 47 with secondary progressive, 12 with primary progressive)

  • Excellent: between MFIS and FSS (r=0.68, p<0.0001)
  • Adequate to Excellent: between MFIS subscale and FSS
    • MFIS-physical: r=0.75, p<0.0001
    • MFIS-cognitive: r=0.44, p<0.0001
    • MFIS-psychosocial: r= 0.62, p<0.0001 

 

Construct Validity

Multiple Sclerosis: (Mills et al, 2010; n=415)

  • Given the Rasch analysis, Mills et al. suggested that the physical and cognitive subscales should be used separately eliminating questions 4, 14, 17 from the physical and questions 1‐3, 5, and 11. In addition, the authors suggest the total score not be used.

Content Validity

Multiple Sclerosis: (Amtmann et al., 2012; n=1271 individuals with MS living in the community, 80% female, 36.2% reported being employed 20 or more hours a week. Mean age 507, mean disease duration 13.2 years, MS severity as minimal (EDSS≤4.0) for 32.4% and intermediate (EDSS 4.5-6.5) for 47.9% and advanced (EDSS≥7.0) for 19.7%)

  • Validity: Spearman Rank Correlation Fatigue Severity Scale to MFIS:
    • Excellent for MFIS total and subscales of physical and psychosocial (0.69-0.77) 
    • Adequate for MFIS cognitive subscale
  • IRT analyses indicate that the FSS is less precise in measuring both low and high levels of fatigue, compared with the MFIS. 
  • For those interested in measuring both physical and cognitive aspects of fatigue, and whose sample is expected to have higher levels of fatigue, the MFIS is a better choice even though it is longer.

Floor/Ceiling Effects

Multiple Sclerosis: (Amtmann et al., 2012; n=1271 individuals with MS living in the community, 80% female, 36.2% reported being employed 20 or more hours a week; mean age 50.7, mean disease duration 13.2 years, MS severity as minimal (EDSS≤4.0) for 32.4% and intermediate (EDSS 4.5-6.5) for 47.9% and advanced (EDSS≥7.0) for 19.7%) 

  • Floor effects: (number of respondents with the lowest possible score)
    • MFIS total= 1.1% 
    • MFIS-phy=1.6%
    • MFIS-cog=2.7%
    • MFIS-psychosocial=7.4% 
  • Ceiling effect: (number of respondents with the highest possible score)
    • MFIS total= 0.7%
    • MFIS-phy=1.6%
    • MFIS-cog=0.9%
    • MFIS-psychosocial=9.0%

Brain Injury

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Normative Data

Traumatic Brain Injury: (Sendroy-Terrill et al., 2010, n=243, 73% men, less than 5% of participants unconsciousness of < 1 day, 41 % showed LOC 1 day to 1 week, 31 % LOC from 1 week to 1 month, 24% had LOCs from 1 month to 1 year. Recived treatment in a comprehensive inpatient rehabilitation hospital. Cohorts based on years postinjury (1 to >30 years)) 

  • Mean for total MFIS= 23.7±21.1

  • Mean for MFIS - Physical= 10.2±9.6

  • Mean for MFIS - Cognitive=11.4±10.4

  • Mean for MFIS - Psychosocial= 2.0±2.0

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Traumatic Brain Injury: (Sendroy-Terrill et al., 2010, n=243, 73% men, less than 5% of participants unconsciousness of < 1 day, 41 % showed LOC 1 day to 1 week, 31 % LOC from 1 week to 1 month, 24% had LOCs from 1 month to 1 year. Recived treatment in a comprehensive inpatient rehabilitation hospital. Cohorts based on years postinjury (1 to >30 years))

  • MFIS-physical: with each additional decade of age at time of injury, there was a 2 point increase on the MFIS-physical score (P=.02)
  • MFIS-psychosocial: with each additional decade of age at time of injury, there was a 0.5 point increase (P=.01)

Bibliography

Amtmann, D., Bamer, A. M., et al. (2012). "Comparison of the psychometric properties of two fatigue scales in multiple sclerosis." Rehabil Psychol 57(2): 159-166. Find it on PubMed

Belmont, A., Agar, N., et al. (2006). "Fatigue and traumatic brain injury." Ann Readapt Med Phys 49(6): 283-288, 370-284. Find it on PubMed

Fisk, J. D., Ritvo, P. G., et al. (1994). "Measuring the functional impact of fatigue: initial validation of the fatigue impact scale." Clin Infect Dis 18 Suppl 1: S79-83. Find it on PubMed

Kos, D., Kerckhofs, E., et al. (2005). "Evaluation of the Modified Fatigue Impact Scale in four different European countries." Mult Scler 11(1): 76-80. Find it on PubMed

Mills, R. J., Young, C. A., et al. (2010). "Rasch analysis of the Modified Fatigue Impact Scale (MFIS) in multiple sclerosis." J Neurol Neurosurg Psychiatry 81(9): 1049-1051. Find it on PubMed

Ponsford, J. L., Ziino, C., et al. (2012). "Fatigue and sleep disturbance following traumatic brain injury--their nature, causes, and potential treatments." J Head Trauma Rehabil 27(3): 224-233. Find it on PubMed

Rietberg, M. B., Van Wegen, E. E., et al. (2010). "Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires." Disabil Rehabil 32(22): 1870-1876. Find it on PubMed

Sendroy-Terrill, M., Whiteneck, G. G., et al. (2010). "Aging with traumatic brain injury: cross-sectional follow-up of people receiving inpatient rehabilitation over more than 3 decades." Arch Phys Med Rehabil 91(3): 489-497. Find it on PubMed

Tellez, N., Rio, J., et al. (2005). "Does the Modified Fatigue Impact Scale offer a more comprehensive assessment of fatigue in MS?" Mult Scler 11(2): 198-202. Find it on PubMed

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