Systematic review of the Multidimensional Fatigue · PDF fileSystematic review of the Multidimensional Fatigue Symptom Inventory-Short Form ... The Multidimensional Fatigue Symptom

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 /Published online: 22 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 Cancer (2015) 23:191–212DOI 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.

192 Support Care Cancer (2015) 23:191–212

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 (2015) 23:191–212 193

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


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


(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]


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]


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


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


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


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


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


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]


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


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


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]


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


2monthspastsurgery,


betweenchild

maltreatm

ent

andquality

oflifein

breast

cancersurvivors

132patients

100%

female

51.7(9.5)

Cross-sectional

Total,em

otional,

general,mental,

physical,vigor


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


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


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


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


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


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)


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


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)


Table 3 (continued)


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


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)


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)


(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)


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)


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)


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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