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Fibromyalgia Impact Questionnaire (FIQ)

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General Description

Purpose

To assess the current health (i.e., physical function, symptoms) of patients with fibromyalgia in clinical and research settings1.

Content

The FIQ was developed from information gathered from patient reports, functional status instruments, and clinical observations. This instrument measures physical functioning, work status (missed days of work and job difficulty), depression, anxiety, morning tiredness, pain, stiffness, fatigue, and well-being over the past week.

Disclaimer

This website is a reference and should not be considered as a complete reference of all instruments used in research studies. For permission to use the instruments users should contact the instrument developers listed within the reference. Furthermore, the instruments described under the tabs are not endorsed by the ACR/ARHP.

Developer/contact information

Fibromyalgia Information Foundation (FIF): www.myalgia.com/

The FIQ was created by Burckhardt et al1. Contacting author is Carol S. Burckhardt, PhD, School of Nursing SN-4S, Oregon Health Sciences University, Portland, OR 97201-3098.

The Revised Fibromyalgia Impact Questionnaire (FIQR) was created by Bennett et al2. Contacting author is Robert M. Bennett, Fibromyalgia Research Unit, Oregon Health & Science University, 3455 SW Veterans Rd, Portland, OR 97239.

Versions

The original FIQ reported in 1991 contained 10 items (10 sub-items in the physical scale)1. Modifications were made in 1997, 2002, and 2009, each with different scoring mechanisms. The 1997 modifications were the additions of an item to the physical function scale about stair climbing, hash marks to the visual analog scales, and the words "including housework" to the two work-related items. The scoring was modified in 2002 for FIQs that contained crossed-out questions or other incomplete data3. The final score was to be adjusted to reflect a final maximum score of 100 to maintain homogeneity on a 0 to 100 continuum, both within and between studies. The FIQR published in 2009 has the same 3 domains as the FIQ (i.e. Function, Overall Impact, and Symptoms). It differs from the FIQ in having modified function questions and the inclusion of questions on memory, tenderness, balance, and environmental sensitivity. It has comparable scoring characteristics to the original FIQ, making it possible to compare past FIQ results with future FIQR results. The FIQ has been translated into several languages including Dutch11, French7, German6, Hebrew5, Italian9, Japanese23,Korean13,14, Portuguese10, Spanish8, Swedish4, and Turkish12,24.

Number of items in scale

The version from 19911 consisted of 10 items with 10 sub-items in the physical function scale (total items + sub-items = 19). The modified version from 1997 consists of 20 items with 11 physical function items (total items + sub-items = 30). The 2009 version consists of 21 items across the 3 domains of Function (n = 9), Overall Impact (n = 2), and Symptoms (n = 10).

Subscales

Subscales from the 1991 version1 include physical function (10 sub-items), feel good (1 item), missed work (1 item), do job (1 item), pain (1 item), fatigue (1 item), rested (1 item), stiffness (1 item), anxiety (1 item), and depression (1 item). The modified version contains the same subscales with the changes noted above.

Populations.

The FIQ was developed in and for adult patients with fibromyalgia.

Other uses

A modified version of the FIQ was used in patients with post-Lyme disease syndrome15. This version includes 2 additional items that evaluate problems with memory and concentration and with self-care.

WHO ICF Components

Original FIQ and 1997 and 2002 modifications

d5202 (caring for hair), d4500 (walking short distances),d6300 (preparing a simple meal), d6402 (cleaning living area),d430 (lifting and carrying an object), d4551 (climbing), d6408 (doing housework), d4153 (maintaining a sitting position), d6200 (shopping), d2302 (completing daily routine), b1809 (experience of self and time function), b2800 (generalized pain), b1300 (energy level), b7800 (sensation of muscle stiffness), b1343 (quality of sleep), b152 (emotional function), b1470 (psychomotor function)

Additions to FIQR

b144 (memory function), b2702 (sensitivity to pressure), b2531(vestibular function of balance), b2708 (sensory function related to temperature and other stimuli)

Administration

Method

Self-administered questionnaire. Easy to complete.

Training

None required; self-explanatory.

Time to administer/complete

Approximately 5 minutes.

Equipment needed

Pen and paper. The FIQR was administered online2.

Availability/cost

The FIQ is free for academic and clinical use. The original instrument was published in the Journal of Rheumatology, 19911, and the scoring rubric may be obtained as a .PDF file by contacting Dr. Bennett. The 2002 modified version is available at: http://www.myalgia.com/FIQ/FIQ_D.pdf, and its scoring rubric is available at: http://www.myalgia.com/FIQ/FIQ%20scoring_Da.pdf. The 2009 version was published in Arthritis Research and Therapy2. An on-line license to use the FIQ may be obtained by registering at: http://www.myalgia.com/FIQ/FIQ_academic_agreement.htm.

Scoring

Responses

Scale. In the original 1991 version, the physical impairment items use a 4-point Likert scale response set ranging from "always" to "never." The "Feel Good" item response set is the number of days of the past week. The "Work Missed" item response is the number of work days in the past week. The other symptom-based items use 100-mm anchored visual analog scales. In the modified version, the visual analog scales for the symptom based items are scored in numerical increments from 0 to 10. Score range. Final score should range from 0 to 80 (if work-related items are not included). This format is recommended in the scoring rubric by authors.

Interpretation of scores

Higher scores indicate greater impact of fibromyalgia on functioning.

In a pooled analysis of 2228 patients with fibromyalgia from three studies, the estimated minimal clinically important differences in the FIQ total score (95% confidence interval) was 14% (13; 15) and for FIQ stiffness it was 13% (12; 14). In the severity analysis a FIQ total score from 0 to <39 was found to represent a mild effect, >or= 39 to <59 a moderate effect, and >or=59 to 100 a severe effect. Minimal clinically important difference in the fibromyalgia impact questionnaire2. Bennett RM, Bushmakin AG, Cappelleri JC, Zlateva G, Sadosky AB. J Rheumatol. 2009 Jun;36(6):1304-11. Epub 2009 Apr 15.

Method of scoring

For the 1991 version the final scores for each scale should range from 0 (no impairment) to 10 (maximum impairment).

Physical Impairment: (Questions 1 a - j) Sum all items and divide the sum by the number of questions answered; multiply this value by 3.33. Feel Good: (Question 2): Reverse scoring (so that a higher number indicates impairment). Then multiply new score by 1.43.

Work Missed: (Question 3) Multiply raw score by 2. Do Job: (Question 4) Raw score is final score. Pain: (Question 5) Raw score is final score. Fatigue: (Question 6) Raw score is final score. Rested: (Question 7) Raw score is final score. Stiffness: (Question 8) Raw score is final score. Anxiety: (Question 9) Raw score is final score. Depression: (Question 10) Raw score is final score.

Modified 2002 version scoring mechanism: Each scale should range from 0 (no impairment) to 10 (maximum impairment). Physical Impairment: The raw scores for each item range from 0 to 3. Questions 1 - 11 are scored. Sum all items and divide the sum by the number of questions answered; multiply this value by 3.33. Feel Good: (Question 12) Reverse scoring (so that a higher number indicates impairment). Then multiple new score by 1.43. Work Missed: (Question 13) Multiply raw score by 1.43.

For each symptom-based item (Questions 14 - 20) the raw score ranges from 0 to 10. If the patient marks between 2 hash marks the item is given a score that includes 0.5. Do Job: (Question 14) Raw score is final score. Pain: (Question 15) Raw score is final score. Fatigue: (Question 16) Raw score is final score. Rested: (Question 17) Raw score is final score. Stiffness: (Question 18) Raw score is final score. Anxiety: (Question 19) Raw score is final score. Depression: (Question 20) Raw score is final score. In each instance, the final score is the sum of the scores for the Physical Impairment, Feel Good, Pain, Fatigue, Rested, Stiffness, Anxiety, and Depression scales (does not include 2 work items.)

For the 2009 FIQR, the scoring is much simpler than the FIQ2. The main improvements are that the summed score for Function is divided by 3, the summed score for Overall Impact is not changed, and the summed score for Symptoms is divided by 2. Then, the total FIQR is the sum of these 3 modified domain scores. The authors point out that the weighting of the 3 domains in the FIQR differs from the FIQ. For the FIQR, 30% of the total score is assigned to "function" with the FIQR (10% in the FIQ), 50% is credited to "symptoms" (70% in the FIQ), and "overall impact" remains the same as the FIQ at 20%. The total maximal score of the FIQR is 100, which is the same as the FIQ.

Time to score

Brief for the FIQ; varies depending on use of computer to calculate final score. Authors of the FIQR indicate that investigator scoring was completed in 1 minute2.

Training to score

Minimal.

Training to interpret

Minimal.

Norms available

There are no clear norms available. Means and standard deviations for each of the items are presented in Burckhardt et al1. In the study by Pankoff et al16, 28 patients with fibromyalgia (3 male, 25 female), mean age 51.3 years, were recruited from the community; the mean total FIQ score was 49.7 (SD 11.4). Goldenberg et al17 studied 332 patients with fibromyalgia recruited from a tertiary care center. These subjects were actively seeking employment (mean age 44.3 years, range 22 - 70) and reported mean total FIQ scores of 54.8 (SD 19.6). Martinez et al18 in a study of 44 women with fibromyalgia with mean age 43 years and a mean duration of illness of 5.3 years, reported total mean total FIQ score of 47.28 (SD 13.9). Fitzcharles and Esdaile19 reported mean FIQ scores of 57 (SD = 20.5) in a cross-sectional study of 82 patients with fibromyalgia (mean age = 48 years, SD =10) recruited from a tertiary center and a community site.

Psychometric Information

Reliability

Internal consistency. Not reported in original study. In the study by Hedlin et al (3), a Cronbach's alpha of 0.83 was reported. Test-retest/stability. Test-retest correlations using (Pearson's r) ranged from 0.56 (pain) to 0.95 for physical function scale in the original version of the FIQ.

Validity

Content/domain/face. Items for the original FIQ were derived from information gathered from patient reports, functional status instruments and clinical observations. On initial testing, a criterion of ≥ 25% impairment on the Arthritis Impact Measurement Scale (AIMS) was used to assess content validity of each item. None of the 4 activity of daily living scale items met the criteria. Opening a jar (dexterity), doing own housework, 2 mobility items and 4 of 5 physical functioning qualified. Thirty-eight percent of the patients did not work so the 2 work items did not apply.

Construct validity

Principal components analysis identified 5 factors. The first 10 sub-items of the FIQ loaded on physical function (loadings ranged from 0.50 to 0.95). Factor 2 consisted of work difficulty, feeling good, pain fatigue, rest and stiffness. The rest of the items were separate factors.

Concurrent validity

Correlations with the subscales of the AIMS were as follows: the FIQ physical function correlated 0.65 with the AIMS lower extremity physical function scale. The FIQ pain, depression and anxiety scales correlated strongly with the respective AIMS scales (r = 0.69, 0.73, 0.76). The FIQ items were significantly correlated with AIMS items (range 0.28 - 0.83). Correlations between the FIQ subscales and the number of tender points ranged from 0.14 (morning tiredness) to 0.74 for work missed.

The FIQR was compared with the original FIQ, which had been validated in many prior studies2. The total score of the FIQR in fibromyalgia patients was 56.58 ±20 (range: 15-97) statistically different (p=0.03) for the total score for the FIQ was 60.56 ±18.0 (range: 10-96). However, the strong correlation of 0.88 (p<0. 001) between the FIQR and FIQ suggested"… that patients' relative standing on the two scales are very similar"2.

Responsiveness

Dunkl et al20 assessed the responsiveness of the modified FIQ in a sample of 99 patients (8 male, 91 female) with fibromyalgia recruited from a university-based outpatient clinic, mean age 46.9 years (SD 7.9). The degree of correlation between change in FIQ scores and change in patient's global rating of symptoms was moderate (Spearman r = 0.51).

Comments and Critique

The FIQ was developed originally from a fibromyalgia clinic population that was mostly female, and it is possible that the instrument may have a gender bias, especially with items considered to be more likely to be performed by women. Dr. Bennett has pointed out that "…in Western societies in the 21st century,it is not uncommon for men to make meals, use a dishwasher, make beds and do laundry…" so the FIQ may be reasonable to administer in males3. No systematic comparison of the FIQ between men and women has been done. Buskilia et al21 reported that the physical functioning subscale of the FIQ did not differ between men and women.

Difficulties with aggregating data on the psychometric characteristics of this instrument reflect the variable use of scoring mechanisms and versions of the instrument in the research literature. Wolfe et al22 suggest there is no ideal functional assessment tool for use in this population. Specifically, Wolfe et al state that the FIQ "systematically underestimated impairment by its handling of activities not usually performed," and express concerns about the non-linearity of the scales. They recommend use of a modified version of the Health assessment Questionnaire for patients with fibromyalgia. Further examination is needed of the FIQ in clinical trials with specific mention by researchers as to the version used (modified versus original) and scoring rubric implemented.

The FIQ appears to be a relatively useful measure of disease impact in patients with fibromyalgia. Overall, the FIQ has demonstrated good responsiveness to change in clinical studies and a good correlation with similar questionnaires, including the HAQ, AIMS and SF-36.

References

  1. Burckhardt CS, Clark SR, Bennett RM. The Fibromyalgia Impact Questionnaire: development and validation. J Rheumatol 1991;18:728-33.
  2. The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. Arthritis Res Ther. 2009; 11(4):R120. Epub 2009 Aug 10. Erratum in: Arthritis Res Ther. 2009; 11(5):415.
  3. Bennett R. The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Clin Exp Rheumatol 2005;23:S154-62.
  4. Hedin PJ, Hamne M, Burckhardt CS, Engstrom-Laurent A. The Fibromyalgia Impact Questionnaire, a Swedish translation of a new tool for evaluation of the fibromyalgia patient. Scand J Rheumatol 1995;24:69-75.
  5. Buskila D, Neumann L. Assessing functional disability and health status of women with fibromyalgia: validation of a Hebrew versions of the Fibromyalgia Impact Questionnaire. J Rheumatol 1996;23:903-6.
  6. Offenbaecher M, Waltz M, Schoeps P. Validation of a German Version of the Fibromyalgia Impact Questionnaire (FIQ-G). J Rheumatol 2000;27.
  7. Perrot S, Dumont D, Guillemin F, Pouchot J, Coste J. Quality of life in women with fibromyalgia syndrome: validation of the QIF, the French version of the Fibromyalgia Impact Questionnaire. J Rheumatol 2003;30:1054-9.
  8. Rivera J, Gonzalez T. The Fibromyalgia Impact Questionnaire: a validated Spanish version to assess the health status in women with fibromyalgia. Clin Exp Rheumatol 2004;22:554-60.
  9. Sarzi-Puttini P, Atzeni F, Fiorini T, et al. Validation of an Italian version of the Fibromyalgia Impact Questionnaire (FIQ-I). Clin Exp Rheumatol 2003;21:459-64.
  10. Rosado ML, Pereira JP, daFonseca JP, Branco JC. . Acta Reumatol Port 2006;31:157-65.
  11. Zljlstra TR, Taal E, vandeLaar MA, Rasker JJ. Validation of a Dutch translation of the fibromyalgia impact questionnaire. Rheumatology (Oxford) 2007;46:131-4.
  12. Sarmer S, Ergin S, Yavuzer G. The validity and reliability of the Turkish version of the Fibromyalgia Impact Questionnaire. Rheumatol Int 2000;20:9-12.
  13. Kim Y-A, Lee S-S, Park K. Validation of a Korean version of the fibromyalgia impact questionnaire. J Korean Med Sci 2002;17:220-4.
  14. Bae SC, Lee JH. Cross-cultural adaptation and validation of the Korean fibromyalgia impact questionnaire in women patients with fibromyalgia for clinical research. Qual Life Res 2004;13:857-61.
  15. Fallon J, Bujak DI, Guardino S, Weinstein A. The Fibromyalgia Impact Questionnaire: a useful tool in evaluating patients with post-Lyme disease syndrome. Arthritis Care Res 1999;1.
  16. Pankoff B, Overend T, Lucy D, White K. Validity and responsiveness of the 6 Minute Walk Test for people with fibromyalgia. J Rheumatol 2000;27:2666-70.
  17. Goldenberg DL, Mossey CJ, Schmid C. A model to assess severity and impact of fibromyalgia. J Rheumatol 1995;22:2313-8.
  18. Martinez JE, Ferraz MB, Sato EI, Atra E. Fibromyalgia versus rheumatoid arthritis: a longitudinal comparison of the quality of life. J Rheumatol 1995;22:270-4.
  19. Fitzcharles M, Esdaile J. Nonphysician practitioner treatments and fibromyalgia syndrome. J Rheumatol 1997;24:937-40.
  20. Dunkl PR, Taylor AG, McConnell GG, Alfano AP, Conaway MR. Responsiveness of fibromyalgia clinical trial outcome measures. J Rheumatol 2000;27:2683-91.
  21. Buskila D, Neumann L, Alhoashle A, Bu-Shakra M. Fibromyalgia syndrome in men. Semin Arthritis Rheum 200;30:47-51.
  22. Wolfe F, Hawley DJ, Goldenberg DL, Russell IJ, Buskila D, Neumann L. The assessment of functional impairment in fibromyalgia (FM): Rasch analyses of 5 functional scales and the development of the FM Health Assessment Questionnaire. J Rheumatol 2000;27:1989-99.
  23. Development of the Japanese version of the Fibromyalgia Impact Questionnaire (JFIQ): psychometric assessments of reliability and validityL. Osada K, Oka H, Isomura T, Nakamura I, Tominaga K, Takahashi S, Kojima A, Nishioka K. Int J Rheum Dis. 2011 Feb;14(1):74-80. doi: 10.1111/j.1756-185X.2010.01585.x.
  24. The validity and reliability of the Turkish version of the RevisedFibromyalgia Impact Questionnaire.
    Ediz L, Hiz O, Toprak M, Tekeoglu I, Ercan S.
    Clin Rheumatol. 2011 Mar; 30(3):339-46. Epub 2010 Aug 12.