Multidimensional Assessment of Fatigue (MAF)

Choice of Instrument

There are many instruments that assess fatigue that have been used in research. Whereas there is no gold standard fatigue instrument for rheumatologic conditions, the developers of this instrument description chose the Multidimensional Assessment of Fatigue (MAF) because of its relatively low patient burden and its potential clinical utility.


The original purpose of the MAF was to evaluate self-reported fatigue in patients with rheumatoid arthritis (RA)1. It has since been used in other populations including people with human immunodeficiency virus (HIV), multiple sclerosis (MS), ankylosing spondylitis2, and various cancers.


The MAF is a 16 item scale that measures fatigue according to four dimensions: degree and severity, distress that it causes, timing of fatigue (over the past week, when it occurred and any changes), and its impact on various activities of daily living (household chores, cooking, bathing, dressing, working, socializing, sexual activity, leisure and recreation, shopping, walking, and exercising).

Developer / Contact Information

The MAF was originally developed by Belza in 19913 and is a modification of the Piper Fatigue Scale4. Contact information for Basia Belza PhD, RN, and developer. Department of Biobehavioral Nursing and Health Systems, Box 357266, University of Washington, Seattle, WA 98195-7266. For more information, see MAF>

Number of items in scale: There are 16 items. The items are used to calculate scores for each of the four dimensions listed above and 15 of the 16 items are used to calculate the global fatigue index (GFI).

Subscales: The four dimensions were not intended for use as subscales; however, some studies include the mean scores for each of the dimensions.


The MAF was developed for use with adults who have RA.

Other Uses

The GFI has been calculated in other samples, such as: healthy adults1; obese adults5; people with RA with recent onset synovitis6 or with anemia7; adults with HIV8,9; cancer10,11,12; multiple sclerosis13; chronic obstructive pulmonary disorder14; coronary artery disease15; breast-feeding women16; post-partum women17; systematic lupus erythematosus (SLE)18,19; and fibromyalgia7,20.

World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Components: Body functions: B130-Energy and Drive Functions: b1300 (Energy level), b1301 (Motivation), b1308 (Energy and drive level, unspecified). B134 - Sleep Functions: b1340 (Amount of sleep), b1341 (Onset of sleep), b1342 (Maintenance of sleep), b1343 (Quality of sleep), b1344 (Functions of the sleep cycle), b1348 (Other sleep functions, specified), b1349 (Other sleep functions, unspecified). B455 - Exercise tolerance functions. B4552-Fatigability.

Activities and Participation

d210 (Undertaking a single task), d220 (Undertaking multiple tasks), d230 (Carrying out daily routine), d430-d449 (Carrying, moving and handling objects), d450-d469 (Walking and moving), d470-d489 (Moving around using transportation), d510-d599 (Self-care tasks-washing, toileting, dressing, etc.), d840-d859 (Work and employment), d910 (Community life), d920 (Recreation and leisure), d930 (Religion and spirituality), d950 (Political life and citizenship), d998 (Community, social and civic life, other specified), d999 (Community, social and civic life, unspecified).


Training: No special training is needed.

Time to administer/complete: The author states it takes 5 minutes or less to complete.

Equipment needed: Paper and pencil

Availability/cost: Permission to use the MAF is obtained by contacting the author, Basia Belza (contact information listed above). There is no charge for individual use of the MAF. Colleagues in industry who would like to use the MAF may be charged a nominal fee. The MAF is copyrighted by Basia Belza.



Numerical rating scale (1 - 10) for items 1, and 4 - 14 ( 1 = not at all, 10 = a great deal), item 2 (1 = mild to 10 = severe), item 3 ( 1 = no distress, 10 = a great deal of distress). Categorical responses (1 - 4) for Timing items 15 and 16.

Method of scoring: To calculate the Global Fatigue Index (GFI), convert item 15 to a 0 - 10 scale by multiplying each score by 2.5 and then sum items 1, 2, and 3, and average 4 - 14, and newly scored item 15. Do not assign a score to items 4 - 14 if the respondent gave a response of "do not do any activity for reasons other than fatigue." If a respondent selects “no fatigue” on item 1, assign a zero to items 2 - 16. Item 16 is not included in the GFI.

Interpretation of scores: A higher score indicates more severe fatigue, fatigue distress, or impact on activities of daily living.

Time to score: 5 minutes

Training to score: No special training is needed

Training to interpret: No special training is needed

Norms available: Mean GFI in RA patients (n = 51) was 29.2, 28.1, and 26.1 at 3 time periods 6 - 8 weeks apart. Age and sex-matched controls ( n = 46) had a mean GFI of 17, 16.5, and 15.8 at the 3 time periods1.

Psychometric Information

Psychometric properties of the original MAF using VAS format analog scales were tested with 133 patients with RA3


Original internal consistency in a study of 133 patients with RA yielded a Cronbach's alpha of 0.933. However, the high internal consistency has been questioned by some who claim the GFI sum score may give greater weight to subscales with more items21. The stability of the Interference scale is supported with test-retest within 24 hours in a sample of 37 patients with cancer (r= 0.74)10. Stability was determined by correlations at 3 time points22. Stability correlations ranged from 0.73 for controls at time1 to 0.47 for controls at time3.


Face and content validity-MAF is an RA-specific revision of the Piper Fatigue Scale with reported face and content validity23. Construct validity-The original factor analysis (done with a sample of 20 patients with RA) supported one-factor instead of the 4 anticipated24. However, another factor analysis (with 7760 patients with RA) showed 3 factors with factors 1 and 2 identified with fatigue with activities and the 3rd factor indicating fatigue severity and distress25 Convergent validity-The MAF is correlated with the Profile of Mood States (POMS) fatigue subscale (r=.78, p<.001) and a fatigue VAS (r = .80, p < .05.)25. Divergent validity-The MAF is negatively correlated with POMS vigor subscale (r=-.60, p<.00).

Minimally Clinical Important Difference (MCID): Using original scaling, the MCID (95%CI) is 5.0 (2.8, 7.2)26.

Responsiveness/Sensitivity to Change

The MAF is sensitive to detecting disease changes in RA patients in a longitudinal study compared with clinical variables and patients treated for RA-related anemia7. The MAF is also sensitive at detecting fatigue changes in patients with cancer-related fatigue10 and in patients with HIV receiving IL-29. In one systematic review, the author reported that MAF was one of only 4 fatigue measures that could detect change over time27. However, even though the MAF was responsive to changes, the reported effect size was quite small, 0.14, in one study10.

Comments and Critique

The strength of the MAF is that it measures 4 dimensions of fatigue thus providing data for a fuller description of fatigue in the population of interest. It has low respondent burden (taking 5 minutes or less to complete), and has fair to good psychometric properties. Compared to similar fatigue measures, MAF was found to have the lowest completion rate (<80%)10,28 and it was suggested that the instructions were too complicated and could lead to underestimated fatigue levels. It may be important to review the instructions with respondents to ensure their understanding before completing the MAF.

The MAF is also reviewed by Hewlett S, Dures E and Almeida C (2011). Measures of Fatigue. Arthritis Care Res, 2011, 49: S263—S286


  1. Belza BL. Comparison of self-reported fatigue in rheumatoid arthritis and controls. J Rheumatol, 1995. 22(4): 639-643.
  2. Turan Y, et al. Assessment of fatigue in patients with ankylosing spondylitis. Rheumatol Int, 2007. 27(9): 847-852.
  3. Tack B. Dimensions and correlates of fatigue in older adults with rheumatoid arthritis. Unpublished doctoral dissertation. School of Nursing, 1991, University of California, San Francisco.
  4. Piper BF, et al. The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncology Nurs For, 1998. 25(4): 677-684.
  5. Gaillard TR, et al. Importance of aerobic fitness in cardiovascular risks in sedentary overweight and obese African-American women. Nurs Res, 2007. 56(6):407-415.
  6. Gerber L, et al. Polyarticular arthritis, independent of rheumatoid factor is associated with poor functional outcome in recent onset inflammatory synovitis. J Back Muscul Rehab, 2000. 14(3): 105-109.
  7. Kaltwasser JP, et al. Effect of recombinant human erythropoietin and intravenous iron on anemia and disease activity in rheumatoid arthritis. J Rheumatol, 2001. 28(11): 2430-2436.
  8. Bormann J, et al. Measurement of fatigue in HIV-positive adults: reliability and validity of the Global Fatigue Index. J Assoc Nurse AIDS Care, 2001. 12(3): 75-83.
  9. Grady C, Anderson R, Chase, GA. Fatigue in HIV-infected men receiving investigational interleukin-2. Nurs Res, 1998. 47(4): 227-34.
  10. Meek PM, et al. Psychometric testing of fatigue instruments for use with cancer patients. Nurs Res, 2000. 49(4): 181-190.
  11. Roscoe J, et al. Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment. Support Care Cancer, 2002. 10(4):329-336.
  12. Winstead-Fry P. Psychometric assessment of four fatigue scales with a sample of rural cancer patients. J Nurs Measure, 1998. 6(2): 111-122.
  13. Schwartz CE%2