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REVIEWARTICLE
Systematic review of the Multidimensional Fatigue SymptomInventory-Short Form
Kristine A. Donovan & Kevin D. Stein & Morgan Lee &
Corinne R. Leach & Onaedo Ilozumba & Paul B. Jacobsen
Received: 5 May 2014 /Accepted: 5 August 2014# Springer-Verlag Berlin Heidelberg 2014
AbstractPurpose Fatigue is a subjective complaint that is believed tobe multifactorial in its etiology and multidimensional in itsexpression. Fatigue may be experienced by individuals indifferent dimensions as physical, mental, and emotional tired-ness. The purposes of this study were to review and charac-terize the use of the 30-item Multidimensional Fatigue Symp-tom Inventory-Short Form (MFSI-SF) in published studiesand to evaluate the available evidence for its psychometricproperties.Methods A systematic review was conducted to identify pub-lished articles reporting results for the MFSI-SF. Data wereanalyzed to characterize internal consistency reliability ofmulti-item MFSI-SF scales and test-retest reliability. Correla-tion coefficients were summarized to characterize concurrent,convergent, and divergent validity. Standardized effect sizeswere calculated to characterize the discriminative validity ofthe MFSI-SF and its sensitivity to change.Results Seventy articles were identified. Sample sizes report-ed ranged from 10 to 529 and nearly half consisted exclusivelyof females. More than half the samples were composed of
cancer patients; of those, 59 % were breast cancer patients.Mean alpha coefficients forMFSI-SF fatigue subscales rangedfrom 0.84 for physical fatigue to 0.93 for general fatigue. TheMFSI-SF demonstrated moderate test-retest reliability in asmall number of studies. Correlations with other fatigue andvitality measures were moderate to large in size and in theexpected direction. The MFSI-SF fatigue subscales were pos-itively correlated with measures of distress, depressive, andanxious symptoms. Effect sizes for discriminative validityranged frommedium to large, while effect sizes for sensitivityto change ranged from small to large.Conclusions Findings demonstrate the positive psychometricproperties of the MFSI-SF, provide evidence for its usefulnessin medically ill and nonmedically ill individuals, and supportits use in future studies.
Keywords Fatigue . Chronic illness . Cancer .
Multidimensional Fatigue Symptom Inventory
Introduction
Fatigue is generally defined as a sense of persistent tirednessor exhaustion that is often distressing to the individual. It is acommon subjective complaint among persons with chronicillness, including cancer, and among persons who are healthyor acutely ill. Accordingly, the etiology of fatigue is believedto be multifactorial [1]. Fatigue is often described by thosewho experience it in terms of physical, mental, and emotionaltiredness. These sensationsmay be sufficiently consistent as tobe characterized as unidimensional or, conversely, as suffi-ciently distinct in their expression as to be characterized asdifferent dimensions of fatigue [2]. This multidimensionalcharacterization of fatigue is evidenced by the large numberand variety of multidimensional fatigue measures currentlyavailable [3–5].
K. A. Donovan (*) : P. B. JacobsenHealth Outcomes and Behavior Program, Moffitt Cancer Center andResearch Institute, 12902 Magnolia Drive, MRC-SCM, Tampa,FL 33612, USAe-mail: [email protected]
K. D. Stein :C. R. LeachBehavioral Research Center, Intramural Research Department,American Cancer Society, Atlanta, GA, USA
K. D. Stein :C. R. Leach :O. IlozumbaDepartment of Behavioral Sciences and Health Education, EmoryUniversity Rollins School of Public Health, Atlanta, GA, USA
M. LeeDepartment of Psychology, University of South Florida, Tampa, FL,USA
Support Care CancerDOI 10.1007/s00520-014-2389-7
Although the availability of multidimensional fatigue mea-sures heralds the wide acceptance of fatigue as multidimen-sional in nature, it also makes the decision of which measureto use and when to use it a challenge. As we have previouslynoted [6], the choice depends on several considerations [4, 5,7]. These include what dimensions of fatigue one wishes tomeasure, the practical aspects of any one measure’s usability,the measure’s clinical and/or research utility, and whether thescale possesses robust psychometric properties, including thestrength of the evidence for the measure’s reliability andvalidity and the population(s) on which the psychometric dataare based [8].
The Multidimensional Fatigue Symptom Inventory-ShortForm [9] (MFSI-SF), first published in 1998, is a 30-item self-report measure derived from an initial pool of 83 items de-signed to assess five empirically derived dimensions of fa-tigue: general fatigue, physical fatigue, emotional fatigue,mental fatigue, and vigor. A total fatigue score may be calcu-lated by subtracting the vigor subscale score from the sum ofthe four fatigue subscales. The psychometric properties of theMFSI-SF were originally established in women with a diag-nosis of breast cancer and women with no history of cancer.The measure was further validated in a study of males andfemales with a variety of different cancer diagnoses [10].Since its development, theMFSI-SF has been used to describefatigue in a variety of clinical and nonclinical populations andas a patient-reported outcome measure in clinical studies.
A cursory review of the literature demonstrates that theMFSI-SF is a widely used multidimensional measure of fa-tigue. We believe that as the MFSI-SF continues to be usedand the data based on its use accumulate, it is important toexamine how it has been used subsequent to the originalvalidation studies and to characterize the evidence basesupporting its current and future use. Toward that end, theaims of this paper are to review and characterize the use of theMFSI-SF in published studies and to evaluate the availableevidence for its psychometric properties. To accomplish this,we conducted a systematic review of the literature to identifypublished studies that reported results on the MFSI-SF. Thesedata were used to describe the characteristics of studies thathave used the MFSI-SF and were analyzed based on statisticalconsiderations to summarize evidence regarding the reliabili-ty, validity, and sensitivity to change of the MFSI-SF.
Methods
Search and selection strategy
The identification of relevant publications began with anelectronic search of Web of Science to identify journal articlesciting one of two published papers that described the devel-opment and early validation of the MFSI-SF [9, 10]. We also
searched Medline, PsycINFO, and Cumulative Index to Nurs-ing and Allied Health (CINAHL) from 1998, the year theMFSI-SF was first published, through December 2013 usingthe search term Multidimensional Fatigue Symptom Invento-ry. Study abstracts were screened based on two eligibilitycriteria. The first criterion was that each study must have beenpublished in a peer-reviewed English language journal. Thesecond was that each study had to report results based on theadministration of the MFSI-SF. Studies in which fatigue wasassessed without using the MFSI-SF were excluded. Similar-ly, reviews summarizing results of published studies of fatiguewere excluded. Reference lists from studies retrieved alsowere reviewed to ensure that all possible studies that derivedempirical results for the MFSI-SF were captured. Discrepan-cies among reviewers in the selection of studies were resolvedby discussions designed to yield consensus. Bias was reducedby conducting a comprehensive search of published studies inseveral electronic databases and searching reference lists ofpublished reviews.
Review and data extraction
Each member of a pair of authors separately reviewed thestudies that met eligibility criteria and collected relevant in-formation from each of the studies using a standardized formto ensure consistency within as well as between paired au-thors. As with article selection, discrepancies in the informa-tion extracted were resolved through consensus discussion.The information included participants’ demographic and clin-ical characteristics, the purpose and design of the study, andthe MFSI-SF subscales for which results were reported. Inaddition, studies were reviewed to determine if they containedresults bearing on the reliability and validity of the MFSI-SF,and if so, this information also was collected. With respect toreliability, evidence for the internal consistency and test-retestreliability of the instrument was identified. With respect toconstruct validity, evidence of structural, concurrent, conver-gent, divergent, and discriminative validity was extracted. Forpurposes of this review, we considered structural validity to bethe extent to which the original factor structure of the MFSI-SF was reproducible, concurrent validity to be the degree towhich MFSI-SF scales are correlated with other publishedmeasures of fatigue, convergent validity to be the degree towhich MFSI-SF scales correlated with measures of conceptu-ally related constructs, and divergent validity to be the degreeto which MFSI-SF scales either negatively correlated or didnot correlate with measures of constructs believed to be con-ceptually distinct from fatigue. Discriminative validity wasevident if MFSI-SF scores of one group differed as expectedfrom those of a comparison group. Finally, evidence of thesensitivity to change of the MFSI-SF as a result of an inter-vention or disease treatment likely to alter the level of fatiguewas extracted.
Support Care Cancer
Statistical analysis
Descriptive statistics, including means and percentages, werecalculated to characterize the samples identified in the relevantarticles. The psychometric properties were evaluated usinginformation available from the published articles. Cronbach’salpha coefficients and correlation coefficients, when reported,were used to assess the internal consistency reliability andtest-retest reliability of the MFSI-SF subscales, respectively.Correlation coefficients between MFSI-SF subscales and oth-er published measures were examined when available to char-acterize the concurrent, convergent, and divergent validity ofthe MFSI-SF. Summary statistics in the form of mean corre-lation coefficients with two-sided 95 % confidence intervalsfor the mean were calculated in some instances for illustrativepurposes. Consistent with Cohen [11], correlation coefficientsin the order of 0.10 were considered small, those of 0.30moderate, and those of 0.50 large. Finally, Cohen’s d [11], ameasure of effect size, was calculated to characterize thediscriminative validity of the MFSI-SF and a standardizedeffect size [12] using baseline and follow-up scores. Thestandard deviation of baseline scores was calculated to char-acterize the sensitivity of the MFSI-SF to change. An effectsize of 0.20 to 0.30 was considered a small effect, around 0.50a medium effect, and around 0.80 a large effect [11]. Wheneffect sizes were calculated by the authors of the publishedstudies, we did not recalculate these statistics but reproducedthem in our results.
Results
Search results and characteristics of selected studies
A total of 431 abstracts were screened, and the completetexts of 178 studies were retrieved and reviewed (seeFig. 1). Ultimately, we identified 70 articles publishedbetween 1998 and 2013 that reported results on the admin-istration of the MFSI-SF; this includes the 1998 study [9] ofthe psychometric properties of the instrument (see Table 1).Forty-four studies involved cancer patients; of these, 26studies were exclusively of women with a diagnosis ofbreast cancer, and 15 were of a mix of cancer types, includ-ing three studies [13–15] that included women with gyne-cologic cancer. Among studies of cancer patients, 11 stud-ies included noncancer controls. Various points in the can-cer treatment trajectory were represented; results are report-ed for patients who completed the MFSI-SF before begin-ning treatment, while undergoing treatment, after havingcompleted treatment, and well into posttreatment survivor-ship. While the MFSI-SF seems to have been used predom-inantly to assess fatigue in cancer patients, especially breast
cancer patients, results also have been reported for a varietyof health conditions, including, but not limited to, fibromy-algia [16], osteoarthritis [17], stroke [18], and hypertension[19, 20], and in kidney transplant candidates [21]. We alsoidentified six studies [22–27] that used the MFSI-SF exclu-sively to assess fatigue in individuals with no reportedhealth conditions.
The MFSI-SF was administered across a range of studydesigns. Thirty-five studies employed a cross-sectional designand 25 employed a longitudinal design. The MFSI-SF wasalso administered in ten randomized controlled trials.
Thirty-one studies reported results on all five subscales ofthe MFSI-SF. Twenty studies reported results limited to totalfatigue (sum of four fatigue subscales minus vigor subscale)while 17 studies reported on four or fewer subscales consistentwith the purpose of the particular study; in those studies, themajority reported on the physical subscale of the MFSI-SF.Two studies, the original validation study of the MFSI-SF thatled to the final 30-item version and a study [28] to estimate theprevalence of severe fatigue according to draft InternationalStatistical Classification of Disease and Related HealthProblems-10 criteria for cancer-related fatigue, used the orig-inal 83-item version.
Four studies reported results based on translations of theMFSI-SF into Chinese [29], German [30, 31], and Italian [23].Two studies reported results based onmodified approaches forscoring the MFSI-SF: One was the study [29] examining thepsychometric properties of the Chinese version of the MFSI-SF in a patient sample of mixed cancer types that combinedthe physical and general subscales to create a new physicalsubscale. The other study [32] adapted the vigor subscale toassess “energy” in a study of “healthy and recreationallyactive individuals.”
431 potentially relevant abstracts and cross
references identified via Web of Science, Medline,
PsycINFO, CINAHL, and manual search of
reference lists
188 duplicate abstracts
243 abstracts screened
178 studies obtained for
further assessment of
eligibility
65 abstracts excluded (e.g., fatigue not
assessed with MFSI-SF, reviews of
fatigue measures, reviews of cancer-
related fatigue
108 full-text articles excluded (e.g.,
fatigue not assessed with MFSI-SF,
MFSI-SF data not reported sufficient for
review
70 studies included in
present review
Fig. 1 Study identification
Support Care Cancer
Tab
le1
Characteristicsof
studiesreportingresults
ontheadministrationof
theMultid
imensionalFatigue
Symptom
Inventory-Sh
ortF
orm
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
Steinetal.[9]
Breastcancer
About
tostarttreatment
andposttreatm
ent
Develop
andvalidatea
multidim
ensional
measureof
fatigue
forusewith
cancer
patients
275patients;70
noncancer
controls
100%
female
Activetreatm
ent5
3.6
(12.2)
(28-83),
posttreatm
ent5
4.1
(13.7)
(32–86),
noncancer53.4
(11.5)
(34–77)
Longitudinal
Emotional,general,
mental,physical,
vigor
Broeckeletal.[40]
Breastcancer
Atleast5yearspostdiagnosis
orrecurrence
Examinecharacteristics
andcorrelates
ofsexual
functioning
inlong-term
breastcancersurvivors
treatedwith
chem
otherapy
comparedto
noncancer
controls
58patients;61
noncancer
controls
100%
female
Patients56.2(8.8),
noncancercontrols
54.6(8.9)
Cross-sectional
Total
Mantovani
etal.[59]
Mix
ofcancertypes
Histologically
confirmed
advanced
stagetumor;
signsof
cancer-related
anorexia/cachexia
syndromepresent
Testtheefficacy
andsafety
ofan
integrated
treatment
(pharm
aconutritional,
antioxidant,and
drug)
inadvanced
cancerpatients
with
CACS/OS
25patients
52%
female
58.2(9.0)
Longitudinal
Total,vigor
Steinetal.[10]
Mix
ofcancertypes
About
tostartchemotherapy
Evaluatethefactorial
andconstructv
alidity
oftheMFS
I-SF
304patients
80%
female
54.9(11.5)
(28–88)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
deLeeuw
,Studtsand
Carlson
[41]
Temporomandibular
disorders
Diagnosed
with
temporomandibular
disorder;atleast
3monthsof
pain;
reported
painin
pastmonth
Investigatethepresence
and
magnitude
ofself-reported
fatigue
andfatigue-related
symptom
sanddeterm
ine
whetherfatigue
canbe
distinguishedas
aunique
clinicalsymptom
ina
sampleof
patients
diagnosedwith
chronic
temporomandibularjoint
ormasticatorymusclepain
55patients;55
healthy
controls
Patients:96
%female;
healthycontrols:
96%
female
Patients32.3(12.5),
healthycontrols
32.6(12.7)
Cross-sectional
Emotional,general,
mental,physical,
vigor
HelgesonandTo
mich
[68]
Breastcancer
4.5-6.8yearspost-diagnosis
Evaluatethelong-term
impact
ofbreastcanceron
QOL
bycomparing
disease-free
survivors,survivorsw/
arecurrence,and
healthy
controls
267diseasefree
patients,
37patientswith
arecurrence,187
noncancercontrols
100%
female
Disease
free
patients
54.4,patientswith
arecurrence
51.2,
controls53.2
Longitudinal
General,m
ental,
physical
Lim
etal.[24]
None(nonclinicalsample)
NA
Examinetheassociations
amongobesity,depressive
symptom
s,cytokine
levels,
andmultidim
ensional
fatigue
symptom
sam
ong
asym
ptom
aticandhealthy
individuals
70individuals
51%
female
36(7.8)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Liu
etal.[63]
Breastcancer
New
lydiagnosed;
scheduled
toreceiveatleast4
3weekcycles
ofadjuvant
orneo-adjuvant
anthracycline-based
chem
otherapy
Investigatetheassociation
betweenfatigue
and
light
exposuream
ong
patientswith
breast
cancer
63patients
100%
female
52.0(10.5)
Longitudinal
Total,em
otional,
general,mental,
physical,V
igor
Millsetal.[65]
Breastcancer
29patients
100%
female
49.5(11)
Longitudinal
Total
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
StageI-IIIA
andreferred
for
adjuvant
orneoadjuvant
anthracycline-based
chem
otherapy
Determinewhether
chem
otherapy-induced
changesin
theinflam
matory
markersSICAM-1,V
EGF,
andIL-6
areassociated
with
fatigue,depressed
mood,
andpoorerquality
oflife.
Ancoli-Israeletal.[51]
Breastcancer
Scheduledto
beginneoadjuvant
chem
otherapy
oradjuvant
chem
otherapy
Examinesleep,fatigue,and
circadianrhythm
sin
breast
cancerpatientsbeforestart
ofchem
otherapy
85patients
100%
female
51.2(10.0)
(34–79)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Banthiaetal.,2006[39]
Breastcancer
Post-treatment,between1month
and3yearspreviously
Investigatecorrespondence
betweendaily
andweekly
ratings
offatigue
over
1month
period
byfatigued
breastcancersurvivors
(defined
as5+
scoreon
MFS
Igeneral)
25patients
100%
female
53.7(12.6)
(32–83)
Longitudinal
Emotional,general,
mental,physical,
Vigor
Bardw
elletal.[19]
Hypertension
NA
DetermineifSE
Spartially
explains
ethnicdisparities
infatigue
40African
Americans,
64Caucasian
Americans
47%
female
Range=25-52
Cross-sectional
General
Gramignano
etal.[23]
None(nonclinicalsample)
Activetreatm
ent
Testefficacy
andsafety
ofL-carnitinesupplementation
inpatientswho
hadadvanced
canceranddevelopedfatigue,
high
bloodlevelsof
reactive
oxygen
speciesor
both
12patients
83%
female
60(9)(42–73)
Longitudinal
Total,em
otional,
general,mental,
physical,vigor
Mantovani
etal.[61]
Mix
ofcancertypes
Histologically
confirmed
advanced
stagetumor;
signsof
cancer-related
anorexia/cachexia
syndromepresent
Testtheefficacy
andsafety
ofan
integrated
treatment
(pharm
aconutritional,
antioxidant,and
drug)in
advanced
cancerpatients
with
CACS
39patients
41%
female
58.9(9.1)
Longitudinal
Total
Prue
etal.[13]
Gynecologiccancers
Various
pointsbutw
ithin
meanof
3months
ofstartingtreatm
ent
Exploreincidenceandmagnitude
offatigue
anddeterm
ine
acceptability
ofMFS
I-SF
with
gynecologiccancerpatients
30patients
100%
female
60.9(13.5)
(31-84)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Siegeletal.[69]
Chronicfatigue
syndrome
(CFS
)Diagnosisof
CFS
Com
pareclinicalpresentation
ofCFS
patientswith
and
withoutclinically
reduced
naturalk
illercellactivity
(NKCA)
22lowNKCApatients,
19norm
alNKCA
patients
100%
female
Low
NKCA45.3(9.6)
(36–55),norm
alNKCA43.5(8.9)
(35–52)
Cross-sectional
Mental
Thomas
etal.[26]
None(nonclinicalsample)
NA
Examinehowdiscrimination
andethnicidentifyrelate
tosleeparchitectureand
fatigue
37African
Americans,
56Caucasian
Americans
African
Americans:
49%
female;
Caucasian
Americans:
39%
female
African
Americans38.1
(1.4)(37–40),Caucasian
Americans35.6(1.0)
(35–37)
Cross-sectional
Emotional,general,
mental,physical,
vigor
Young
andWhite[28]
Breastcancer
Com
pleted
curative
treatmentatleast
6monthspreviously
Estim
ateprevalence
ofseverefatigue
according
todraftICD-10criteriafor
cancer-related
fatigue;
identifyprevalence
and
moderatorsof
clinicalsyndrome
69patients
100%
female
59(26–81)
Cross-sectional
Global,affective,
behavioral,
cognitive,
somatic,vigor
51patients
88%
female
Cross-sectional
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
Balasubramaniam
etal.[70]
Temporomandibular
disordersin
fibrom
yalgia
orfailedback
syndrome
Atleast6monthspost-diagnosis
offibrom
yalgiaor
failedback
syndrome
Determineprevalence
oftemporomandibular
disordersandevaluate
psychosocialdomains
inpatientswith
fibrom
yalgia
comparedwith
patients
with
failedback
syndrome
Fibrom
yalgiapatients52.2
(7.8),failedback
syndromepatients
50.0(9.1)
Emotional,general,
mental,physical,
vigor
Feuerstein
etal.[71]
Brain
tumor
Com
pleted
primarytreatm
ent
Investigateroleof
both
non-modifiableand
modifiablefactorsin
braintumor
survivors
andtheirassociation
toworklim
itations
95patients;131noncancer
controls
Patients:59
%female;
noncancercontrols:
79%
female
braintumor=20–29:
13.7
%,
30–39:
22.1
%,40–49:
34.7
%,50–59:2
5.3%,
60–70:
4.2%;n
oncancer
controls=20–29:
21.4
%,
30–39:
35.8
%,40–49:
37.9
%,50–59:4
.2%,
60–70:
3.2%
(range=20–70)
Cross-sectional
Physical
Meadetal.[18]
Stroke
Post-stroke
Identifywhich
currently
available
fatigue
scaleismostv
alid,
feasible,and
reliablein
stroke
patients
T1=55
patients;T2=51
patients
44%
female
Median=73
Longitudinal
General
Clayton,D
udleyand
Musters[43]
Breastcancer
2or
moreyearspost-treatment
Investigatehowfatigue
and
communicationarerelatedto
survivor
uncertaintyandmood
state,andsurvivor
perception
ofpatient-centered
communicationforwom
enwith
varyingfatigue
levels
60patients
100%
female
61.67(11.30)(31–87)
Cross-sectional
Total
Collado-H
idalgo
etal.[72]
Breastcancer
1to
5yearspost-diagnosis;
completed
prim
ary
treatment
Examinesingle-nucleotide
polymorphismsin
prom
oters
ofcytokine
genesas
genetic
risk
factorsforcytokine-related
fatigue
infatiguedandnon-
fatiguedbreastcancersurvivors
33fatiguedpatients;
14non-fatigued
patients
100%
female
Fatiguedpatients54.1
(8.3),nonfatigued
patients61.1(8.5)
Cross-sectional
General
Hansenetal.[73]
Breastcancer
Com
pleted
prim
arytreatm
ent
Determinewhetherphysical
fatigue,depression,anxiety,
andcognitive
limitations
are
differentially
associated
with
worklim
itations
inbreast
cancersurvivorsversus
non-cancercontrols
100patients;103noncancer
controls
100%
female
Patients49.5(8.5),noncancer
controls39.8(10.8)
Cross-sectional
Physical
Mantovani
etal.[60]
Mix
ofcancertypes
Histologically
confirmed
advanced
stagetumor;
signsof
cancer-related
anorexia/cachexia
syndromepresent
PhaseIIIrandom
ized
trailto
establishthemosteffective
andsafesttreatm
entto
improvekeyprim
ary
endpointsof
CACS:
increase
ofLBM,decreaseof
REE,
andim
provem
ento
ffatigue.
Secondaryendpointsalso
evaluated.
125patients
41%
female
61.9(12.1)
Longitudinal
Total
Strigo
etal.[74]
Major
depressive
disorder
Unm
edicated
fordepression
Examinehypothesisthatyoung
adultswith
MDDwould
show
increasedaffectivebias
topainfuland
nonpainful
experimentalp
ainstim
uli
15patients,15
healthy
controls
80%
female
Patients24.1(5.6)
(19-30),healthy
controls23.9
(5.2)(19-29)
Longitudinal
Total
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
Banthiaetal.[50]
Breastcancer
Post-treatment
Examineage,cancerstage,
sleepquality
anddepressed
moodas
predictorsof
5dimensionsof
fatigue
infatiguedbreastcancer
survivors(defined
as5+
scoreon
MFS
Igeneral)
70patients
100%
female
52.5(12.2)
(32–83)
Cross-sectional
Emotional,general,
mental,physical,
vigor
Calvioetal.[34]
Malignant
braintumor
0-27
(mean=4)
years
post-diagnosis
Investigateperceivedcognitive
functionin
employed
malignantbraintumor
survivorsrelativeto
healthy
groupof
workers
113patients;123noncancer
controls
Patients:65
%female;
noncancercontrols:
73%
female
NR
Cross-sectional
Physical
Günaydinetal.[45]
Ankylosingspondylitis
Disease
duration:
mean(10.3),
range(1-35)
Evaluatethefrequencyand
multidim
ensionalnatureof
fatigue
andidentifyassociations
with
demographic,disease-
specific,and
othervariables
(e.g.depression,sleep
disturbancein
ASpatients
62patients
16%
female
39.6(10.3)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Krummenacheretal.
[30]
Venousthromboem
bolism
(VTE)
Atleast3monthsafter
anobjectivelydiagnosed
venous
thromboem
bolic
event;scheduledfor
outpatient
thrombophilia
work-up
Investigatetheassociations
ofsubjectivesleepquality,
fatigue,and
vitalexhaustion
with
plateletcountinVTE
patients
205patients
45%
female
47.2(14.8)
(18–80)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Liu
etal.[48]
Breastcancer
New
lydiagnosed;
scheduled
toreceiveatleast4
3weekcycles
ofadjuvant
orneo-adjuvant
anthracycline-
basedchem
otherapy
Exploreassociations
between
sleepdisturbance/fatigue/
depression
symptom
cluster
categories
beforetreatm
ent
andlongitudinalp
rofilesof
thesymptom
sduring
chem
otherapy
76patients
100%
female
51.1(9.1)
Longitudinal
Total
Lukas
etal.[31]
Deepvein
thrombosis
(DVT)andpulm
onary
embolism
(PE)
Outpatient
with
objectively
diagnosedvenous
thrombotic
event(DVT
and/or
PE)
Investigaterelationships
betweenQOL,psychological
distress
(anxiety
and
depression),andfatigue
inoutpatientswith
aprevious
DVTand/or
PE
205patients
45%
female
47.4(14.9)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Roepkeetal.[36]
Alzheim
er’ scaregivers
andelderlynon-caregiver
NA
Examinewhetherpersonal
mastery
moderates
relationship
betweencaregiverstatus
andfatigue
73caregivers;4
1non-caregivers
Caregivers:74
%female;
non-caregivers:
78%
female
Caregivers72.2(9.6)
(63–82),noncaregivers
68.4(6.7)(62–75)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Schm
idtetal.[75]
Masticatorymusclepain
Diagnosisof
pain
foratleast
2months
Com
pareem
otionalreactivity
andphysiologicalresponse
inmasticatorymuscle
pain
patientsvs.pain-free
controls
22patients;23
healthy
controls
100%
female
Patients41.0(12.6)
(28–54)Controls:
Matched±5
Cross-sectional
Emotional,general,
mental,physical,
vigor
Calvioetal.[76]
Breastcancer
1-10
(mean=3)
yearspostprim
ary
treatment
Investigaterelationship
betweenperceived
cognitive
functionat
workandmoregeneric
performance-based
neuropsychological
measuresof
thesefunctions
122patients;113
noncancercontrols
100%
female
Patients44.9(9.5),
noncancercontrols
39.2(11.9)
Cross-sectional
Physical
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
andworkoutput
inoccupationally
activebreast
cancersurvivorsrelative
tonon-cancercontrolg
roup
Lee
etal.[77]
Sleepapnea
Not
specified
Examinetherelationship
betweenthePsychomotor
VigilanceTask
(PVT)and
subjectivefatigue
40sleepapneicpatients;
8norm
alpatients
19%
female
49.2(9.4)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Mantovani
etal.[57]
Mix
ofcancertypes
Histologically
confirmed
advanced
stagetumor;
signsof
cancer-related
anorexia/cachexia
syndromepresent
ProspectivephaseII
clinicaltrialtotestthe
safety
andeffectiveness
ofan
interventionwith
theCOX-2
inhibitorcelecoxib
onkeyvariablesof
cachexia
(including
fatigue)in
patients
with
advanced
cancerof
differentd
isease
sites
24patients
46%
female
60.6(9.7)
Longitudinal
Total
Mantovani
etal.[58]
Mix
ofcancertypes
Histologically
confirmed
advanced
stagetumor;
signsof
cancer-related
anorexia/cachexia
syndromepresent
PhaseIIIrandom
ized
trailto
establishthemosteffective
andsafesttreatm
entto
improvekeyprim
ary
endpointsof
CACS:
increase
ofLBM,decrease
ofREE,and
improvem
ent
offatigue.S
econdary
endpointsalso
evaluated.
332patients
45%
female
Mean(SD):Arm
1=61.5
(9.7)Arm
2=60.6(13.5)
Arm
3=62.8(11.5)
Arm
4=62.4(11.9)
Arm
5=62.4(9.4)
Longitudinal
Total
Prue
etal.[15]
Gynecologiccancers
New
lydiagnosed
with
notreatm
ent
except
surgery
Examinecourse
andcorrelates
offatigue
ingynecologic
cancerpatients
65patients;60
noncancer
controls
100%
female
Patients57.4(13.9)
(23–86),noncancer
controls55.4(13.6)
(24–86)
Longitudinal
Total,em
otional,
general,mental,
physical
Riefetal.[25]
None(nonclinicalsample)
NA
Testhypothesisthatnocturnal
secretionof
inflam
mation
markersandcatecholam
ines
would
beassociated
with
moodandstress
variables
130individuals
43%
female
34.9(9.6)(24.5–44.5)
Longitudinal
Total
Shochatetal.[27]
Asymptom
aticBRCA
1/2carriers
Atg
eneticrisk
(asymptom
atic
BRCA1⁄2mutation
carriersandnon-carriers)
Investigateassociationbetween
BRCA1/2status
andsleep
quality
inasym
ptom
atic
wom
en
17BRCA1/2carriers,
20non-carriers,
36controls
100%
female
BRCA1/2carriers:5
1.4
(9.1)(42-61),
non-carriers54.5(9.4)
(45–64),controls49.9
(6.8)(43–57)
Cross-sectional
Total
Taylor
etal.[49]
Breastcancer
Com
pleted
initial
treatmentfor
breastcancer
Examinerelationshipam
ong
cardiorespiratoryfitness,
physicalactivity,and
psychosocialvariablesin
overweighto
robesebreast
cancersurvivors
260patients
100%
female
55(9.4)(28–81)
Cross-sectional
Total
Bevansetal.[46]
Allogeneichematopoietic
stellcelltransplant
patientsandcaregivers
Pre-HSCT,
post-H
SCT,
and6weeks
post-
discharge
Explorepsychometricproperties
ofDistressTherm
ometerby
exam
iningrelationshipwith
BriefSy
mptom
Inventory-18
andMFS
Iin
allogeneicHSC
Tpatientsandcaregivers
65patients;91
caregivers
Patients:37
%female;
caregivers:75%
female
Patients47.4(14.3),
caregivers52.3(13.5)
Longitudinal
Total,em
otional,
general,mental,
physical,vigor
Donnelly
etal.[14]
Gynecologiccancer
Post-surgery
andin
active
treatmento
rpost-treatment
Determinefeasibility
and
efficacy
ofphysicalactivity
33patients
100%
female
53(10.3)
Total
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
andwithin
3yearsof
diagnosis
behavioralchange
intervention
inmanagingcancer-related
fatigue
Randomized
controlled
trial
Fagundes
etal.[47]
Breastcancer
Com
pleted
treatm
entw
ithin
thelast2years;atleast
2monthspastsurgery,
radiotherapy
orchem
otherapy
(whicheveroccurred
last)
Evaluaterelationships
between
fatigue
andboth
sympathetic
andparasympatheticnervous
system
activity
inbreastcancer
survivors/exam
inerelationships
betweenfatigue
andautonomic
activity
atrest,aswellasin
response
tostandardized
laboratory
stressor
109patients
100%
female
51.7(9.4)
Longitudinal
Total,em
otional,
general,mental,
physical,vigor
Haw
keretal.[17]
Osteoarthritis
(OA)
Difficulties
with
movem
ent
inthelast3months;
swelling,pain,orstiffness
lastingatleast6
wks
Examinetherelationships
betweenOApain,
disability,fatigue,
anddepressedmood
529peoplecompleted
allthree
assessments
78%
female
75.4(56.7–95.8)
Longitudinal
Total
Pien
etal.[29]
Mix
ofcancertypes
Underwenttreatmentb
utdid
notreceive
intravenous
chem
otherapy
Examinepsychometric
propertiesof
Chinese
versionof
MFS
I-SF
107patients;46
noncancer
controls
65%
female
Patients:53.56±11.02;
range=
26–83
Cross-sectional
Total,physical(a
combinationof
physicaland
general),
emotional,
vigor,mental
Rodrigueetal.[21]
Kidneytransplant
candidates
andrecipients
Beforeandafterkidney
transplantation
Examinefatigue
andsleep
quality
beforeandafter
kidney
transplantation
100pre-tx
patients;
100post-txpatients
Pre-txpatients:38
%female;post-tx
patients:46
%female
Pre-tx
patients52.112.2,
(40–64),post-txpatients
53.1(11.3)
(42–64)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Tomfohr
etal.[44]
Obstructivesleepapnea
Havenotreceived
treatmentfor
OSA
Examineeffectsof
continuous
positiveairw
aypressure
(CPA
P)on
fatigue
inpatients
with
obstructivesleepapnea
59patients
86%
male,14
%female
Placebo:
48.30(9.04),
range=
39–57;
Treatment:
48.14(9.69),
range=
38–58
Randomized
controlled
trial
Total
Ancoli-Israeletal.[53]
Breastcancer
Priorto
starto
fchem
otherapy
tolastweekof
cycle4
Testwhetherincreasedmorning
bright
light,com
paredto
dim
light,resultsin
less
fatigues
during
chem
otherapy
39patients
100%
female
54(9.1)(32–70)
Randomized
controlled
trial
Total,em
otional,
general,mental,
physical,vigor
Bow
eretal.[54]
Breastcancer
Atleast6monthspost-
treatmentw
ithpersistent
cancer-related
fatigue
Determinefeasibility
and
efficacy
oflyengaryoga
interventionforbreastcancer
survivorswith
persistent
cancer-related
fatigue
31patients
100%
female
Intervention:
54.4(5.7);
controlg
roup
=53.3
(4.9);range=
40–65)
Randomized
controlled
trial
Vigor
Breckenridgeetal.[78]
Breastcancer
1yearor
morepost-primary
treatment
Examinerelationshipof
adjuvant
endocrinetherapyandperceived
andperformance-based
cognitive
functionin
occupationally
active
breastcancersurvivors
survivorson
adjuvant
endocrinetherapy=77;
survivorsnotonadjuvant
endocrinetherapy
100%
female
SERM/AImn=44.9(9.99)
NoSE
RM/AI=
44.8
(8.88)
Cross-sectional
Physical
Cordero
etal.[22]
None(nonclinicalsample)
NA
Examinefatigue
accordingto
acculturationstatus
andto
evaluatethefactor
structure
oftheMFS
I-SF
inaHispanic
community
sample
158Hispanics;1
76Anglos
Hispanics:6
9%
female;
Anglos:62
%female
Hispanics
41.2(16.1);
Anglos58.7(16.9)
Cross-sectional
Emotional,general,
mental,physical,
vigor
Fagundes
etal.[79]
Breastcancer
Com
pleted
treatm
entw
ithin
thelast2years;atleast
2monthspastsurgery,
Examinetherelationships
betweenchild
maltreatm
ent
andquality
oflifein
breast
cancersurvivors
132patients
100%
female
51.7(9.5)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
radiotherapy
orchem
otherapy
(whicheveroccurred
last)
Liu
etal.[64]
Breastcancer
New
lydiagnosed;
scheduled
toreceiveatleast4
3week
cycles
ofadjuvant
orneo-
adjuvant
anthracycline-based
chem
otherapy
Examinetherelationships
betweenfatigue,objective
andsubjectivemeasures
ofsleep,andinflam
matory
markers
53patients
100%
female
50.3(9.9)
Longitudinal
Total
Liu
etal.[52]
Breastcancer
New
lydiagnosed;
scheduled
toreceiveatleast4
3week
cycles
ofadjuvant
orneo-
adjuvant
anthracycline-based
chem
otherapy
Explorelongitudinalrelationship
betweenfatigue
andboth
subjectivelyandobjectively
measuredsleep
97patients
100%
female
50.7(9.8)
Longitudinal
Total,em
otional,
general,mental,
physical,vigor
Redwineetal.[35]
Chronicheartfailure
NA
MeasurewhetheraTaichi
interventioneffectively
reducessomaticand/or
cognitive
symptom
sof
depression
inpatients
with
heartfailure(copied
directly
from
abstract)
24patients
13%
female
67(11.9)
(43–83)
Randomized
controlled
trial
Total,physical
Ritterband
etal.[55]
Mix
ofcancertypes
Atleast1month
since
completionof
active
treatment
Evaluateeffectsof
internet
interventiondesigned
toim
provesleepof
cancer
survivorswith
insomnia
28patients
86%
female
56.7(11.7)
(45–68.5)
Randomized
controlled
trial
Total,em
otional,
general,mental,
physical,vigor
Sadjaetal.[20]
Hypertension
Not
taking
bloodpressure
medication
Examinepredictorsof
exercise
adherenceto
12-w
eekexercise
intervention
51individuals
53%
female
Total:46.64(9.38);
wom
en:4
9.07
±8.63
range=
40–58;
men:4
3.92
±9.61
range=
34–54
Randomized
controlled
trial
Physical
Schm
idtetal.[16]
Fibrom
yalgia
Pain
durationof
atleast
sixmonths;current
painlevelo
fatleast
30on
a0–100visual
analog
scale
Evaluateeffectsof
focused
breathingtechnique
designed
toenhance
self-regulationin
patients
with
fibrom
yalgia
20patients
100%
female
40.8(13.7)
(27–55)
Longitudinal
Emotional,general,
mental,physical,
vigor
Aynehchietal.[80]
Headandneck
cancer
Atleast3months
post-treatment
ValidateModifiedBrief
Fatigue
Inventory
52patients,57
noncancer
controls
55%
female
59.2(12.8)
(26–86)
Cross-sectional
Total
Bartonetal.[62]
Mix
ofcancertypes
Within
2yearsof
diagnosis,in
active
treatmento
rcompleted
treatment;experiencing
cancer-related
fatigue
Evaluateefficacy
andtoxicity
ofAmerican
ginsengfor
cancer-related
fatigue
341patients
78%
female
Intervention:
55.3
(12.7),controls:
55.9(11.8)
Randomized
controlled
trial
Total,general,
emotional,mental,
physical,vigor
Bennettetal.[81]
Breastcancer
Com
pleted
treatm
entw
ithin
thelast3years;atleast
2monthspostsurgery,
radiotherapy
orchem
otherapy
(whicheveroccurred
last)
Investigatecortisol
andIL-6
responsesto
acutelaboratory
stressor
inform
erandnever
smokers
89patients(64never
smokers,25
form
ersm
okers)
100%
female
Neversm
okers:51.2
(10.2),former
smokers:52.0(7.5)
Cross-sectional
Total
Cormieetal.[38]
Prostatecancer
NR
Determinethesafety
and
efficacy
ofresistance
exercise
byprostate
cancersurvivorswith
bone
metastatic
disease
20patients
100%
male
Patients:73.1(7.5);
controls:7
1.2(6.9);
range(57–83)
Randomized
controlled
trial
Total,general,
emotional,mental,
physical,vigor
Ganzetal.[82]
Breastcancer
Com
pleted
prim
arytreatm
ent
within
past3months
Examinerelationshipbetween
subjectivecognitive
complaints
andneuropsychological
189patients
100%
female
51.8
Longitudinal
Mental,physical
Support Care Cancer
Tab
le1
(contin
ued)
Authors
Disease
Positionin
disease/
treatmenttrajectory
Studypurpose
Samplesize
Sex
Age
(mean
andSD
)(range)
Design
Scales
reported
inanalyses
function,chem
otherapy
exposure,and
menstrualstatus
GassandGlaros[83]
Headache
6month
orlongerhistory
ofrecurrenth
eadaches
Examineassociationbetween
headachesandautonomic
nervoussystem
activity
21patients;19
healthy
controls
Patients:90
%female;
healthycontrols:
89%
female
Patients:32.9(11.7);
healthycontrols:
30.4(11.2)
Cross-sectional
Total,em
otional,
general,mental,
physical,vigor
Januseketal.[66]
Breastcancer
Postbreastsurgery
Determinewhetherchildhood
adversity
increasesvulnerability
formoreintenseandsustained
behavioralsymptom
s,poorer
quality
oflife,andgreater
immunedysregulation
40patients
100%
female
55.6(9.4)
Longitudinal
Total
Moskowitz
etal.[84]
Breastcancer
Com
pleted
prim
arytreatm
ent
Examinewhethersymptom
clustersappearin
employed
breastcancersurvivorsand
whetherclustersarerelated
tojobstress
andaerobicactivity
94patients;100noncancer
controls
100%
female
Patients:49.5(8.5);
controls:3
9.9(10.8)
Cross-sectional
Physical
Sobel-Fo
xetal.[42]
Mix
ofcancertypes
Com
pleted
treatm
entat
least3
monthsprior;
self-reportedexperience
ofatleast3
episodes
ofdebilitatingfatigue
inpastmonth
Examinerelationshipbetween
unidim
ensionaland
multidim
ensionalassessments
offatigue
incancersurvivors
52patients
64%
female
57.8(13.3)
(28–84)
Longitudinal
Emotional,general,
mental,physical,
vigor
Thorndike
etal.[56]
Insomnia
Diagnosed
with
insomnia;
reported
sleepcomplaints
lastingatleast6
months;
currently
experiencing
sleepdifficultiesand
fatigue-related
daytim
eim
pairment
Investigatewhether
Internet-delivered
cognitive
behavioral
therapyforinsomnia
also
reducescomorbid
psychologicaland
fatigue
symptom
s
44patients
Interventionpatients:
82%
female;control
patients:73
%female
Total:44.9(11.0);
interventionpatients:
44.7(10.6);control
patients:45.1(11.7)
Randomized
controlled
trial
Total
Support Care Cancer
Sample sizes in the identified publications ranged from a lowof 10 in a double-blind crossover study [33] to determine thecontribution of hyperammonemia to minimal hepatic encepha-lopathy development in males and a high of 529 in a longitudi-nal study [17] examining the relationships between osteoarthritispain, disability, fatigue, and depressed mood. Thirty-three of thesamples included in the 70 studies were 100% female; only onestudy [33] included a sample that was 100 % male. Sixty-fivestudies reported mean age of the sample; 34 of these studies alsoreported age range in addition to mean age while two studies[19, 34] reported only range. The mean/median age of partici-pants ranged from 20 to 75 years. There were few studies ofolder cancer patients; only six reported a mean/median agegreater than 65 years of age [17, 18, 35–38].
Reliability of the MFSI-SF
Internal consistency reliability Table 2 presents data related tothe reliability of the MFSI-SF. Sixteen studies reported on the
internal consistency reliability of the multi-item fatigue sub-scales. Eight of these studies [9, 10, 22, 36, 39–42] reported onall five of the subscales: physical mean alpha=0.84 (95 %confidence interval (CI)=0.81–0.86), general mean alpha=0.93 (95 % CI=0.91–0.95), mental mean alpha=0.87 (95 %CI=0.85–0. 90), emotional mean alpha=0.90 (95 % CI=0.87–0.94), vigor mean alpha=0.86 (95 % CI=0.82–0.89).Two studies [36, 40] reported only a range of alpha coeffi-cients for the subscales as a group; the lowest reported coef-ficient was 0.74 and the highest was 0.94. Six studies [17, 21,29, 36, 43, 44] included a Cronbach’s alpha coefficient for thetotal fatigue score. The mean alpha coefficient for total fatiguewas 0.87 (95 % CI=0.83–0.91) and ranged from 0.74 to 0.95.One study [27] combined the MFSI-SF with the Brief Symp-tom Inventory and reported only that Cronbach’s alpha coef-ficients for the combined scales ranged from 0.85 to 0.96.
Test-retest reliability Three studies [9, 18, 29] published dataon the test-retest reliability of the MFSI-SF. The first was the
Table 2 Reliability of the Multidimensional Fatigue Symptom Inventory-Short Form
Authors Internal consistency reliability Test-retest reliability
Stein et al. [9] General (0.96), emotional (0.93), physical(0.85), mental (0.90), vigor 0.88
3 to 4 weeks: general (0.51), physical(0.54), emotional (0.57), mental (0.64),vigor (0.55); 6 to 8 weeks: general (0.60),physical (0.61), emotional (0.66),mental (0.70), vigor (0.64)
Broeckel et al. [40] Subscale alpha range=0.81 to 0.94 (patients), =0.74to 0.91 (noncancer controls)
Stein et al. [85] General (0.96), emotional (0.92), physical (0.87),mental (0.91), and vigor (0.90)
de Leeuw, Studts and Carlson [41] General (0.96), emotional (0.89), physical (0.89),mental (0.90), vigor (0.88)
Helgeson and Tomich [68] Patients: general (0.94), mental (0.91), physical (0.75);controls: general (0.94), mental (0.84), physical (0.81)
Banthia et al. [39] General (0.95), emotional (0.82), physical (0.81),mental (0.84), vigor (0.79)
Mead et al. [18] General: T1 (0.91), T2 (0.93) mean of 3.9 days: general (0.76)
Clayton, Dudley and Musters [43] Total (0.95)
Roepke et al. [36] total alpha=0.86, subscales alpha range=0.87 to 0.94
Hawker et al. [17] Total: T1 (0.74), T2 (0.85), T3 (0.89)
Pien et al. [29] Physical (0.84), mental (0.84), mental (0.84),vigour (0.83), total (0.90) [mental is reportedtwice and emotional is not reported]
2 weeks: total (0.48), physical (0.51),emotional (0.40), mental (0.66),vigour (0.46)
Rodrigue et al. [21] Total (0.89)
Tomfohr et al. [44] Total (0.84)
Cordero et al. [22] Less-acculturated Hispanics: general (0.85), physical(0.83), mental (0.85), emotional (0.93), vigor (0.82);highly-acculturated Hispanics: general (0.89), physical(0.85), mental (0.84), emotional (0.92), vigor (0.86);Anglos: general (0.94), physical (0.81), mental (0.85),emotional (0.91), vigor (0.89)
Sadja et al. [20] Physical (0.85)
Sobel-Fox et al. [42] General (0.94), physical (0.88), mental (0.92),emotional (0.93), vigor (0.90)
Support Care Cancer
original study [9] detailing the development and psycho-metric evaluation of the instrument. In that study, the scalesproduced moderate correlations between assessments at 3-to 4-week intervals (mean=0.56 (95 % CI=0.50–0.62)) and6- to 8-week intervals (mean=0.64 (95 % CI=0.59–0.69))in a group of breast cancer patients about to start activetreatment or in the posttreatment period and in a noncancercontrol group. The test-retest correlation, for example, wasr=0.55 for vigor between the first and second administra-tion of the MFSI-SF and 0.64 between the first and thirdadministration. Test-retest correlations for mental fatiguewere 0.64 in the first interval and 0.70 in the second.Similarly, Pien et al. [29] reported a test-retest intraclasscorrelation coefficient of 0.46 for vigor and 0.66 for mentalfatigue over a 2-week period while Mead et al. [18] reporteda test-retest correlation coefficient of 0.76 for general fa-tigue over a mean of 4 days.
Validity of the MFSI-SF
Structural validity Three studies [10, 22, 29] evaluated thefactor structure of the MFSI-SF; these results reflect whetherthe interrelationships of the dimensions measured by theMFSI-SF correlate with the construct of interest and subscalescores. Stein et al. [10] confirmed the five-factor model of theMFSI-SF in a heterogeneous sample of cancer patients. In astudy [29] examining the psychometric properties of the Chi-nese version of the MFSI-SF in a patient sample of mixedcancer types, factor analysis confirmed four subscales: phys-ical, emotional, mental, and vigor. The physical and generalsubscales were combined to create a new physical subscale;high factor loadings and intercorrelations between subscalessupported the four-factor model of the Chinese MFSI-SF. Inthe third study, Cordero et al. [22] evaluated the factor struc-ture of the MFSI-SF in a Hispanic community sample. Thevigor, mental, and emotional subscales were largely main-tained; the general and physical subscales were not, and thestudy concluded that the general fatigue subscale was “prob-lematic” for Hispanics.
Concurrent validity Evidence bearing on the concurrent va-lidity of the MFSI-SF was reported in seven studies identified.As shown in Table 3, MFSI-SF fatigue subscales have beenshown to be positively correlated with the Profile of MoodStates (POMS) fatigue subscale [10, 18, 19, 25], the FatigueSymptom Inventory (FSI) [10, 21], and the fatigue item of theBathy Ankylosing Spondylitis Disease Activity Index [45].The correlation coefficients between the POMS fatigue sub-scale and the MFSI-SF fatigue subscales range from a low ofr=0.62 with emotional fatigue to a high of 0.88 with generalfatigue; both of these coefficients are from the initial psycho-metric study by Stein et al. [9]. Correlations between the FSIand the MFSI-SF fatigue subscales range from a low of
r=0.36 between the FSI average fatigue item and emotionalfatigue to a high of r=0.82 between the FSI average fatigueitem and general fatigue; these coefficients are from thefollow-up validation study of the MFSI-SF by Stein et al.[10]. Similarly, MFSI-SF vigor has been shown to be posi-tively correlated with the Medical Outcomes Study 36-ItemShort Form (MOS SF-36) vitality scale [9, 10]. The meancorrelation between MFSI-SF vigor and the SF-36 vitalityscale is 0.67 (95 % CI=0.53–0.82).
Convergent validity Evidence bearing on the convergentvalidity of the MFSI-SF was reported in 26 studies (seeTable 3). Correlations were reported with the Distress Ther-mometer [46], a brief screening measure of psychologicaldistress, and measures of depression and anxiety, includingthe Center for Epidemiologic Studies-Depression Scale(CES-D) [9, 17, 24, 28, 47–50], the Beck DepressionInventory-II [29], the Symptom Checklist 90-Revised-Depresssion and Anxiety Scales [15, 41], the HospitalAnxiety and Depression Scale [31], and State Trait AnxietyInventory (STAI) [9]. Among the eight studies [9, 17, 24,47–51] reporting associations with the CES-D, correlationcoefficients ranged from 0.37 to 0.85; the mean correlationof total fatigue with the CES-D was r=0.77 (95 % CI=0.70–0.85). In the one study [9] reporting associations withthe STAI, correlation coefficients range from 0.51 to 0.80.Several studies reported correlations between MFSI-SFfatigue subscales and measures of sleep quality as measuredby the Pittsburgh Sleep Quality Index (PSQI) [21, 27, 36,48, 50, 52, 53]. Among the seven studies reporting associ-ations with the PSQI, correlation coefficients range from0.15 to 0.51. The mean correlation of MFSI-SF total fatiguewith PSQI total was 0.45 (95 % CI=0.41–0.49).
Divergent validity Evidence bearing on the divergent validityof the MFSI-SF was reported in 16 studies (see Table 3). Mostnotably, negative correlations were reported between theMFSI-SF fatigue subscales and the MOS SF-36 scales [9,18, 29, 31] and between the MFSI-SF vigor subscale and theSymptom Checklist-90-Revised [41].
Discriminative validity In Table 4, we present discriminativevalidity data for the MFSI-SF from 30 studies. To brieflysummarize the instrument’s ability to discriminate betweengroups, we focus herein on the 15 studies comparing a patientgroup with a specific medical condition to a nonpatient controlgroup on the MFSI-SF. The mean effect size across the 15studies on each of the subscales is as follows: physical meand=0.73 (95 % CI=0.48–0.98), general mean d=0.78 (95 %CI=0.35–1.20), mental mean d=0.54 (95 % CI=0.19–0.89),emotional mean d=.53 (95 % CI=0.35–0.70), vigor meand=.76 (95 % CI=0.42–0.1.09). Consistent with Cohen’s cat-egorization of effect sizes [11], the magnitude of these effects
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Table 3 Validity of the Multidimensional Fatigue Symptom Inventory-Short Form
Authors Concurrent validity Convergent validity Divergent validity
Stein et al. [9] SF-36-Vitality with vigor (0.64);POMS-F with general (0.88),physical (0.68), emotional(0.62), mental (0.64)
STAI with general (0.58), physical (0.51),emotional (0.80), mental (0.54); CES-Dwith general (0.68), physical (0.61),emotional (0.78), mental (0.64)
SF-36-Vitality with general (-0.78),physical (-0.58), emotional (-0.51),mental (-0.46), vigor (0.64);POMS-F: with vigor (-,59); STAIwith vigor (-0.66); CES-D withvigor (-0.65); MC-20 with general(-0.21), physical (-0.14), emotional(-0.26), mental (-0.22), vigor (-0.13)
Broeckel et al. [40] Patients: worse sexual functioningwith total (0.31)
Stein et al. [10] FSI average with general (0.82),emotional (0.36), physical (0.58),mental (0.50), total (0.74); SF-36vitality with vigor (0.74)
SF-36 physical component scorewith vigor (0.48)
FSI average with vigor (-0.60);SF-36 physical component scorewith general (-0.55), emotional(-0.21), physical (-0.56), mental(-0.34), total (-0.55); SF-36 vitalitywith general (-0.82), emotional(-0.43), physical (-0.53), mental(-0.48), total (-0.78)
de Leeuw, Studtsand Carlson [41]
SCL90-r somatization with general (0.49),physical (0.67), emotional (0.50),mental (0.39); SCL90-r depressionwith general (0.60), physical (0.49),emotional (0.66), mental (0.50), general(0.39); SCL90-R anxiety with physical(0.42), emotional (0.61), mental (0.35);MPI pain with general (0.23), physical(0.42), emotional (0.27), mental (0.10);MPI general activity level with vigor(0.17); PSQI total with general (0.50),physical (0.37), emotional (0.43),mental (0.26)
SCL90-r somatization with vigor(-0.45); SCL90-r depression withvigor (-0.45); SCL90-r anxietywith vigor (-0.37); MPI pain withvigor (-0.31); MPI general activitylevel with general (-0.08), withphysical (-0.13), emotional (-0.05),mental (-0.05); PSQI total withvigor (-0.41)
Lim et al. [63] CES-D with general (0.48), physical (0.35),emotional (0.70), mental (-0.51)
CES-D with vigor (-0.39)
Ancoli-Israelet al. [51]
PSQI total with total (0.46); PSQIsubscales of subjective sleep quality,sleep disturbance, use of sleep medand daytime dysfunction with MFSIsubscales (range=0.22 to 0.71); FOSQsubscales with MFSI total and subscale(range=0.22 to 0.80); FACT-B subscaleswith MFSI subscales (range=0.29to 0.65); CES-D with total fatigue (0.76)
Banthia et al. [39] unstandardized regression coefficient:week 1: daily (visual analogue scale)fatigue with weekly (general) (0.26),(physical) (0.21), (mental) (0.17),(emotional) (0.05); week 2: daily(visual analogue scale) fatigue withweekly (general) (0.26), (physical)(0.25), (mental) (0.25), (emotional)(0.01); week 3: daily (visual analoguescale) fatigue with weekly (general)(0.27), (physical) (0.22), (mental)(0.23), (emotional) (-0.01); week 4:daily (visual analogue scale) fatiguewith weekly (general) (0.25), (physical)(0.15), (mental) (0.18), (emotional)(0.05)
unstandardized regression coefficient:week 1: daily (visual analoguescale) fatigue with weekly (vigor)(-0.27); week 2: daily (visualanalogue scale) fatigue with weekly(vigor) (-0.25); week 3: daily(visual analogue scale) fatigue withweekly (vigor) (-0.24); week 4:daily (visual analogue scale) fatiguewith weekly (vigor) (-0.22)
Bardwell et al. [19] POM-SF fatigue with general:AA (0.91), CA (0.84)
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Table 3 (continued)
Authors Concurrent validity Convergent validity Divergent validity
Young and White [28] TSK-F beliefs about activity with global(0.39), with HADS depression (SR)(0.78); HADS anxiety with global(0.70); HADS total with global (SR)(0.77), total (0.56); EPQ-R-Sneuroticism (0.58)
SPAQ total with global (SR) (-0.17),SPAQ leisure with global (SR)(-0.11), SPAQ work with global(SR) (-0.12)
Mead et al. [18] POMS fatigue with general (0.75),FAS with general (0.71)
SF-36 vitality with general (-0.47)
Clayton, Dudleyand Musters [43]
Patients: Whole Person MPCC 2 withtotal (0.10), POMS-SF with total(0.80), Uncertainty in Illness Scale totalwith total (0.60), PPCS with total (0.23)
Patients: MPCC total with total (0.00),disease illness MPCC 1 with total(-0.17), common ground MPCC 3with total (-0.09)
Hansen et al. [73] WLQ with physical (0.71)
Strigo et al. [74] Average AB (based on test of temperaturesensitivity) with total (0.62)
Banthia et al. [50] CES-D with general (0.38), physical(0.42), mental (0.37), emotional (0.81);PSQI global with mental (0.15),emotional (0.24), general (0.44),physical (0.42)
CES-D with vigor (-0.47);PSQI global with vigor (-0.31)
Günaydin et al.[45]
BASDAI fatigue item with general(0.71), physical (0.74), emotional(0.56), mental (0.45) fatigue,vigor (-0.32)
Krummenacheret al. [30]
JSQ total with total (0.46), MVEQ-SF with(0.75)
Liu et al. [48] PSQI with total (0.46), CES-D with total(0.71)
Lukas et al. [31] HADS total with total (0.74) Total with SF-12 physical (-0.58),SF-12 mental (-0.37)
Roepke et al. [36] PSQI with global (0.50) PMS with (-0.60)
Lee et al. [77] PVT Count of Lapses with total (0.14),general (0.07), physical (0.32),emotional (0.13), mental (-0.04),vigor (0.14); average response timewith total (0.15)
Prue et al. [15] RSCL psychological distress with total(0.66)
Rief et al. [25] POMS-F with total (0.75) NR
Shochat et al. [27] Carriers: PSQI total with total (0.42);non-carriers: PSQI total with total(0.32); controls: PSQI total withtotal (0.43); entire sample: PSQItotal with total (0.41)
Taylor et al. [49] CES-D with total (0.64) RS-ES with total (-0.52), 7-dayphysical activity recall hours/weekwith total (-0.02), 7-day physicalactivity recall met-hours/week withtotal (-0.04)
Bevans et al. [46] Patients (all time points): DT with total(0.56), emotional (0.48), general (0.35),mental (0.30), physical (0.47);caregivers (all time points): DTwith total (0.51), emotional (0.62),general (0.34), physical (0.23)
Patients (all time points): DTwithvigor (-0.48); caregivers (all timepoints): DTwith vigor (-0.45)
Fagundes et al. [47] CES-D with total (0.80)
Hawker et al. [17] CES-D with total: T1 (0.77), T2 (0.82),T3 (0.85)
Pien et al. [29] BDI-II with total (0.68), physical (0.60),emotional (0.71), mental 0.51; SF-36
BDI-II with vigor (-0.27); SF-36mental component with total
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ranged from medium to large with patients consistentlyreporting worse scores on the MFSI-SF than nonpatientcontrols.
Sensitivity to change of the MFSI-SF Data reflecting sensitiv-ity of the MFSI-SF to change are presented in Table 5. Forpurposes of this study, we limited our evaluation of sensitivityto change to longitudinal studies involving the effects of anintervention or disease treatment that is likely to alter the levelof fatigue or vigor relative to a pretreatment baseline. Ninestudies [14, 16, 35, 38, 44, 53–56] reported results in thecontext of nonpharmacological interventions designed toameliorate symptoms that included fatigue. These
nonpharmacological interventions involved a randomizedcontrolled trial of light therapy for fatigue in breast cancerpatients in active treatment [53], an Internet intervention forsleep in cancer survivors with insomnia [55, 56], continuouspositive airway pressure on fatigue in individuals with ob-structive sleep apnea [44], yoga for fatigue in breast cancersurvivors [54], physical activity in gynecologic cancer survi-vors [14], diaphragmatic breathing for self-regulation in fibro-myalgia patients [16], Tai Chi in heart transplant patients [35],and resistance exercise in prostate cancer survivors [38]. Themean effect sizes for postintervention versus preinterventionfatigue calculated across more than one study were the fol-lowing: general=2.56 (95 % CI=−1.00–6.11), physical=1.78
Table 3 (continued)
Authors Concurrent validity Convergent validity Divergent validity
mental component with vigor (0.41);SF-36 physical component withvigor (0.17)
(-0.60), physical (-0.50), emotional(-0.60), mental (-0.34); SF-36physical component with total(-0.53), physical (-0.57), emotional(-0.38), mental (-0.41)
Rodrigue et al. [21] Pre-transplant FSI severity scorewith total (0.72); post-transplantFSI severity score with total (0.69)
Pre-transplant PSQI global withtotal (0.49); post-transplantPSQI global with total (0.48)
Liu et al. [52] Baseline: PSQI total with total (0.40),general (0.31), emotional (0.32),physical (0.30), mental (0.34);C4W3: PSQI total with total (0.51),with general (0.43), with emotional(0.40), physical (0.43), mental (0.51)
Baseline: PSQI total with vigor(-0.32); C4W3: PSQI totalwith vigor (-0.36)
Aynehchi et al. [80] MBFI with total (0.81) NR
Ganz et al. [82] PAOFI memory with mental (0.61),physical (0.03); PAOFI HLC withmental (0.47), physical (0.13)
Sobel-Fox et al. [42] Average VAS fatigue rating at W1:general (0.58), emotional (0.52),mental (0.54), physical (0.46);average VAS fatigue rating at W2:general (0.66), emotional (0.54),mental (0.51), physical (0.44);average VAS fatigue rating at W3:general (0.58), emotional (0.51),mental (0.52), physical (0.35);average VAS fatigue rating at W4:general (0.60), emotional (0.62),mental (0.50), physical (0.42); meandaily VAS fatigue ratings at W1:general (0.60), emotional (0.53),mental (0.54), physical (0.49);mean daily VAS fatigue ratings atW2: general (0.66), emotional(0.56), mental (0.53), physical(0.45); mean daily VAS fatigueratings at W3: general (0.57),emotional (0.51), mental (0.51),physical (0.33); mean daily VASfatigue ratings at W4: general(0.62), emotional (0.60), mental(0.50), physical (0.41)
Average VAS fatigue rating at W1:vigor (-0.48); average VAS fatiguerating at W2: vigor (-0.34); averageVAS fatigue rating at W3: vigor(-0.55); average VAS fatigue ratingat W4: vigor (-0.64); mean dailyVAS fatigue ratings at W1: vigor(-0.37); mean daily VAS fatigueratings at W2: vigor (-0.32); meandaily VAS fatigue ratings at W3:vigor (-0.51); mean daily VASfatigue ratings at W4: vigor (-0.64)
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(95%CI=−0.71–4.27), mental=1.29 (95%CI=−0.44–3.02),emotional=0.15 (95 % CI=−1.01–1.30), vigor=−0.75 (95 %CI=−2.50–1.01), and total=0.31 (95 % CI=−0.24–0.87). Themagnitude of these effects ranged from small to large with theintervention group reporting reduced fatigue and increasedvigor from preintervention to postintervention. The remainderof the studies [20, 23, 57–62] presented in Table 5 refers topharmacologic interventions designed to reduce symptoms,including fatigue.
As shown in Table 5, we also identified seven studies[15, 46, 52, 63–66] that assessed fatigue related to diseasetreatment. All seven studies included cancer patients under-going various forms of cancer treatment, including chemo-therapy; four of these studies [52, 63–65] provided datasufficient for us to calculate mean effect size for MFSI-SFtotal fatigue=0.19 (95 % CI=−0.05–0.34). The effect sizefor the five subscales was calculated using data from asingle study [63]: general=0.39, physical=0.26, mental=22, emotional=0.08, vigor=−0.27. The magnitude of theseeffects ranged from small to medium with patients general-ly reporting worsening fatigue and decreasing vigor overthe course of treatment.
Table 4 Discriminative validity of the Multidimensional Fatigue Symp-tom Inventory-Short Form
Authors Discriminative validity
Stein et al. [9] Breast cancer patients versus noncancer controls:general (0.37), physical (0.28), emotional (0.30),mental (0.14), vigor (-0.33);
Broeckel et al.[40]
Breast cancer patients versus noncancer controls:total fatigue (0.73)
de Leeuw, Studtsand Carlson[41]
Temporomandibular disorder patients versuscontrols: general (0.57), physical (0.91),emotional (0.55), mental (0.32), vigor (0.73)
Prue et al. [13] Surgery patients versus no surgery patients: total(1.32), general (0.77), physical (0.99), mental(0.69), emotional (1.33), vigor (0.54); patientsreceiving treatment versus patients awaitingtreatment: total (0.91), general (0.04), physical(0.14), mental (1.15), emotional (1.41), vigor(0.79)
Siegel et al. [69] Low NKCAversus patients normal NKCA patients:mental (1.27)
Thomas et al. [26] African Americans versus Caucasians:general (2.56), physical (3.64), mental(1.72), emotional (1.39), vigor (0.18)
Balasubramaniamet al. [70]
Fibromyalgia patients versus failed backsyndrome patients: general (1.44), emotional(0.92), physical (1.46), mental (1.42), vigor (0.41)
Feuerstein et al.[71]
brain tumor patients versus non-cancer controls:physical (0.51)
Collado-Hidalgoet al. [72]
Fatigued versus non-fatigued: general (1.86)
Hansen et al. [73] Breast cancer patients versus noncancer controls:physical (0.84)
Strigo et al. [74] Major depressive disorder patients versus controls:total (4.35)
Calvio et al. [34] Malignant brain tumor patients versus noncancercontrols: physical (0.54)
Günaydin et al.[45]
Fatigued patients versus non-fatigued patients:general (1.39), physical (1.84), emotional(1.2), mental (0.92), vigor (-0.65)
Roepke et al. [36] Alzheimer’s caregivers versus non-caregivers: total(1.11)
Schmidt et al. [75] Masticatory muscle pain patients versus controls:emotional (0.54), general (1.22), physical (1.74),mental (1.01), vigor (-1.02)
Calvio et al. [76] Breast cancer patients versus noncancer controls:physical (0.88)
Lee et al. [77] Patients with sleep apnea versus patients withoutsleep apnea: total (0.72), general (0.69), physical(0.27), emotional (0.42), mental (0.72), vigor(-0.54)
Prue et al. [15] Gynecologic cancer patients versus noncancercontrols: total baseline (0.08), month 1 (0.11),month 2 (0.11), month 3 (0.10), month 4 (0.08),month 5 (0.06), month 6 (0.07), month 7 (0.09),month 8 (0.07), month 9 (0.04), month 10 (0.03),month 11 (0.05)
Shochat et al. [27] BRCA1/2 carriers versus controls: total(0.22); BRCA1/2 non-carriers versuscontrols: total (0.16)
Table 4 (continued)
Authors Discriminative validity
Bevans et al. [46] Patients versus caregivers: total at baseline (0.21),discharge (0.35), 6 weeks post discharge (0.44)
Fagundes et al.[47]
Fatigued versus non-fatigued: total (1.64)
Pien et al. [29] Cancer patients versus noncancer controls: total(0.71), physical (0.55), emotional (0.56), mental(0.30), vigor (1.22)
Rodrigue et al.[21]
Pre-kidney transplant versus post-kidney transplant:general (0.39), physical (0.63), emotional (0.30),mental (0.42), vigor (-0.41), total (0.56)
Breckenridgeet al. [78]
SERM/A1 versus no SERM/A1: physical (0.04)
Cordero et al. [22] Anglos versus less-acculturated Hispanics: physical(0.40), mental (0.41), emotional (0.46), general(0.33), vigor (-0.29); Anglos versus highly-acculturated Hispanics: physical (0.20), mental(0.08), emotional (0.02), general (0.25), vigor(-0.12)
Fagundes et al.[79]
Breast cancer patients versus noncancer controls:physical (0.51)
Ritterband et al.[55]
Intervention participants versus controls: total (1.16),general (0.91), physical (0.47), emotional (0.77),mental (0.66), vigor (1.63)
Bennett et al. [81] never smokers versus former smokers: total (0.08)
Gass and Glaros[83]
Headache patients versus controls: general (1.03),emotional (0.80), physical (0.87), mental (0.73),vigor (-0.70), total (1.02)
Moskowitz et al.[84]
Patients versus noncancer controls: physical (0.82)
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Table 5 Sensitivity of the Multidimensional Fatigue Symptom Inventory-Short Form
Authors Sensitivity to change/treatment Sensitivity to change/intervention
Mantovani et al. [59] baseline to 1 month: total (-0.79), to 2 months (-0.86), to 4 months(-0.61); from baseline to 1 month: vigor (0.81), to 2 months (0.81),to 4 months (1.31)
Liu et al. [63] C1W-1 to C1W1: total (0.81), general (0.67),physical (0.35), mental (0.37), emotional(0.04), vigor (-0.40); from C4W-1 to C4W1:total (0.13), general (0.11), physical (0.17),mental (0.07), emotional (0.12), vigor (-0.14)
Mills et al. [65] C1W1 to C4W1: total (0.87)
Gramignano et al. [23] baseline to 2 weeks after supplementation: total (-0.61), to 4 weeksafter supplementation (-0.96)
Mantovani et al. [61] baseline to 1 month: total (-0.26), to 2 months (-0.38), to 4 months(-0.38)
Mantovani et al. [60] baseline to post-treatment: total (Arm 1) (-0.32), (Arm 2) (0.54),(Arm 3) (-0.53), (Arm 4) (-0.25), (Arm 5) (-0.49)
Mantovani et al. [57] baseline to post-treatment: total (-0.23)
Mantovani et al. [58] baseline to post-treatment: total (Arm 1) 0.07, (Arm 2) 0.54, (Arm 3)-0.01, (Arm 4) 0.19, (Arm 5) -0.41
Prue et al. [15] baseline to month 1: total (0.60), to month 2(0.54), to month 3 (0.47), to month 4 (0.31),to month 5 (0.21), to month 6 (0.03), tomonth 7 (0.05), to month 8 (0.00), to month9 (-0.10), to month 10 (-0.27), to month 11 (-0.05)
Bevans et al. [46] prior to transplant to discharge: total: patients(-0.04), caregivers (-0.15)
Donnelly et al. [14] intervention patients pre-intervention to 12 weeks post-intervention:total (0.13), to 6 months post-intervention (0.20)
Tomfohr et al. [44] pretreatment to 3 weeks post treatment: total (placebo CPAP) (-0.10),(Therapeutic CPAP) (-0.53); pre-treatment to 3 weeks posttreatment: (patients with excessive sleepiness and fatigue), total(placebo CPAP) (-0.22), (therapeutic CPAP) (-1.07 )
Ancoli-Israel et al. [53] baseline to treatment cycle 1: (bright white light) general (1.80),physical (3.01), mental (0.88), emotional (-0.76), vigor (-2.10),(dim red light) general (4.52), physical (3.44), mental (1.26),emotional (0.48), vigor (-2.48), to treatment cycle 4 (bright whitelight) general (2.46), physical (2.46), mental (1.33), emotional(-1.37), vigor (-1.11), (dim red light) general (8.28), physical (5.36),mental (5.2), emotional (2.59), vigor (-2.97)
Bower et al. [54] baseline to 3-month follow-up; vigor (yoga versus healtheducation) (1.20)
Liu et al. [64] baseline to C1W2: total (0.21), to C1W3(0.20), to C4W2 (0.58), to C4W3 (0.45)
Liu et al. [52] C1W1 to C1W2: total (-0.33), to C1W3(-0.33), to C4W1 (0.34), to C4W2 (0.27),to C4W3 (0.04)
Redwine et al. [35] pre-intervention versus post-intervention (t'ai chi'): total (0.87)
Ritterband et al. [55] intervention patients pre-post: total (0.80), general (0.70), physical(0.27), emotional (0.40), mental (0.47), vigor (1.20), control patientspre-post: total (-0.36), general (-0.21), physical (-0.20), emotional(-0.37), mental (-0.19), vigor (-0.43)
Sadja et al. [20] pre-medication versus post-medication: physical (sample) -0.21,(men) -0.23, (women) -0.19
Schmidt et al. [16] assessment 1 to assessment 2: total (1.18), general (-0.96), emotional(-0.36), physical (-0.62), mental (-0.84), vigor (0.66)
Barton et al. [62] Baseline to 4 weeks (Ginseng): general (0.62), physical (0.08), mental(0.11), emotional (0.03), vigor (0.10), total (0.33);Baseline to 8 weeks: (Ginseng): general (0.87), physical (0.16),mental (0.15), emotional (0.16), vigor (0.26), total (0.54)
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Discussion
We identified 70 articles published between 1998 and 2013that reported results on the MFSI-SF. The instrument has thusfar been used predominantly with cancer patients, but resultsalso have been reported for patients with other health condi-tions (e.g., osteoarthritis and fibromyalgia) as well as forindividuals with no reported health conditions. In general,the studies reflect a broad range of sample sizes of men andwomen across a wide age range. They also reflect a variety ofstudy designs, including randomized controlled trials.
Reliability of the MFSI-SF has been assessed primarily interms of internal consistency and test-retest reliability. MeanCronbach’s alpha coefficients for MFSI-SF measures rangedfrom 0.83 to 0.93, indicating good internal consistency. Test-retest reliability of the MFSI-SF was reported in only threestudies, but results suggest moderately strong reliability overtime.
Validity of theMFSI-SF has been assessed primarily in termsof its concurrent, convergent, divergent, and discriminative va-lidity. There is good evidence for the concurrent validity of thefatigue and vigor subscales of the MFSI-SF. Studies generallyreported moderate to high correlations between these MFSI-SFsubscales and other measures commonly used with medically illpatients such as the POMS fatigue subscale and the FSI. It isnoteworthy that, to date, no studies have examined the concur-rent validity between the MFSI-SF and item banks such as thePROMIS fatigue item bank. There is good evidence for theconvergent validity of the MFSI-SF. Studies generally reportedmoderate to high correlations of the MFSI-SF with measures ofdistress and depressive and anxious symptomatology and withmeasures of sleep quality and work limitations, among others.Divergent validity of the MFSI-SF has been demonstrated bymoderate to high negative correlations between the MFSI-SFand variousMOSSF-36 scales. Discriminative validity has beendemonstrated in several studies comparing medically ill patientsand nonpatient controls. In general, medically ill patients, in-cluding those with cancer, reported scores indicative of greaterfatigue and less vigor than controls. Effect sizes reported orcalculated based on available data ranged frommedium to large.
With regard to structural validity of the MFSI-SF, existingevidence is too limited to draw conclusions. The fact that theoriginal five-factor structure that gave rise to the five empiri-cally derivedMFSI subscales has been replicated with a cancersample [10] is encouraging. Two other studies [29, 22] did notyield similar results. It should be noted, however, that in onestudy a Chinese language version of the MFSI-SF was admin-istered to cancer patients [29] and in the other study, theEnglish language version of the MFSI-SF was administeredto a Hispanic community sample [22]. Given these differencesin methodology, it is unclear whether the lack of a consistentfactor structure is attributable to cultural differences, linguisticdifferences, or patient versus community status differences.Evaluating the consistency of the factor structure for the En-glish language version in cancer patients should be considereda priority since, as our review indicates, this reflects the mostcommon use of theMFSI-SF. That said, there is also a need forstudies that evaluate all major aspects of validity for translatedversions of theMFSI-SF used with cancer patients. Regardlessof the quality of the translation procedures, the psychometricequivalence of a translated version of a test to the original testcannot be assumed and must be evaluated [67]. The issue ofvariation across cultures for the English language version isalso important and should be addressed initially in studies inwhich the MFSI-SF is administered to specific racial andethnic subgroups of cancer patients.
The sensitivity of the MFSI-SF to change has been dem-onstrated in intervention studies in which fatigue was a pri-mary or secondary outcome and in longitudinal disease treat-ment studies. Across intervention studies, effect sizes rangedfrom small to large, an indication that the interventions gen-erally were effective in reducing fatigue and increasing vigoras measured by theMFSI-SF. Across treatment studies, resultsindicated that fatigue as measured by the MFSI-SF increasedover the course of treatments expected to produce fatigue,such as chemotherapy and radiotherapy; effect sizes in thesestudies were positive and ranged from small to medium.
Taken together, these results strongly support the use of theMFSI-SF as an outcome measure in studies evaluating treat-ments likely to produce fatigue as well as studies testing
Table 5 (continued)
Authors Sensitivity to change/treatment Sensitivity to change/intervention
Cormie et al. [38] Pre-intervention to post-intervention (Exercise): general (0.34),emotional (-0.03), physical (-0.23), mental (0.75), vigor (0.09),total (0.21)
Janusek et al. [66] Total fatigue at least 2 weeks after surgery (T1)to T2 (-0.05), to T3 (-0.10), to T4 (-0.10), toT5 (0.17); T1 to T5 (-0.14)
Thorndike et al. [56] Pre-intervention to post-intervention: total (intervention group)(0.97); pre-intervention to post-intervention: total (interventionBDI-II subgroup) (2.16)
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interventions to prevent or relieve fatigue. It should be noted,however, that the minimal clinically important difference(MCID) for the MFSI-SF scores has yet to be reported.Determining this value would aid investigators in evaluatingthe clinical meaningfulness of any observed treatment- orintervention-related differences in MFSI-SF scores.
A key issue to consider in evaluating a multidimensionalmeasure such as the MFSI-SF is the relationships among thevarious subscales. Surprisingly, we were able to identify onlyone study that reported the correlations among the scales [50].In this study of breast cancer survivors, vigor was correlatednegatively with general, physical, mental, and emotional fa-tigue (range=−0.25 to −0.52), while correlations were allpositive (range=0.16 to 0.67) among the four fatigue sub-scales. Although this pattern would be expected, the low togenerally moderate range of correlations suggests the scalesmay be tapping different aspects of the fatigue experience. Ofrelevance is a recent review of 56 studies examining thebehavior of physical and mental fatigue in cancer patients thatincluded four studies in which the MFSI-SF was administered[2]. Findings suggested that physical and mental fatigue oftenbehave similarly; for example, they both tend to be higher incancer patients than those in healthy controls. In contrast,there is evidence to suggest that physical fatigue is moresevere than mental fatigue in patients with advanced disease.This issue clearly merits additional study and should extendbeyond the physical and mental dimensions of fatigue.
Conclusions
In conclusion, the purposes of this paper were to systemati-cally review and evaluate the psychometric properties of theMFSI-SF based on its use in published research studies and tocharacterize the evidence base supporting its current andfuture use. Our extensive and exhaustive review of the useof the MFSI-SF in published research studies since its incep-tion to the present day not only supports a characterization ofthe MFSI-SF as psychometrically sound but also providesfurther empirical evidence of its usefulness and strongly sup-ports its use in future studies.
Conflict of interest The authors have no conflicts of interest todisclose.
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