HOME > PRACTICE MANAGEMENT > CLINICAL SUPPORT > CLINICIAN RESEARCHERS > OUTCOMES INSTRUMENTATION > Multidimensional Assessment of Fatigue (MAF)

Multidimensional Assessment of Fatigue (MAF)

General DescriptionBack to Top

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.

Purpose
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.

Content
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.

The website for MAF users is http://www.son.washington.edu/research/maf/users-guide.asp

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.

Populations

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 erythematosis (SLE)18, 19; and fibromyalgia7, 20.

WHO ICF ComponentsBack to Top

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).

AdministrationBack to Top

Method
This is a self-administered questionnaire

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. 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.

Scoring

Responses
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.

Score Range
Scores range from 1 (no fatigue) to 50 (severe fatigue).

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 InformationBack to Top

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

Reliability
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 time 1 to 0.47 for controls at time 3.

Validity
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

ReferencesBack to Top

  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, Coulthard-Morris L, Zeng Q. Psychosocial correlates of fatigue in multiple sclerosis. Arch Phys Med Rehab, 1996. 77(2): 165-170.
  14. Belza B, et al. Correlates of physical activity in chronic obstructive pulmonary disease. Nurs Res, 2001. 50(4): 195.
  15. Sullivan MD, et al. Five-year prospective study of the effects of anxiety and depression in patients with coronary artery disease. Am J Cardiol, 2000. 86(10): 1135-1138, A6, A9.
  16. Wambach KA. Maternal fatigue in breastfeeding primiparae during the first nine weeks postpartum. J Human Lactation, 1998. 14(3): 219-229.
  17. Williams PD, et al. Fatigue in mothers of infants discharged to the home on apnea monitors. Appl Nurs Res, 1999. 12(2): 69-77.
  18. Da Costa D, et al. Dimensions of fatigue in systemic lupus erythematosus: relationship to disease status and behavioral and psychosocial factors. J Rheumatol, 2006. 33(7): 1282-1288.
  19. Goligher EC, et al. Minimal clinically important difference for 7 measures of fatigue in patients with systemic lupus erythematosus. J Rheumatol, 2008. 35(4): 635-642.
  20. Hughes LC. Sociocultural, physiologic, and psychologic variables that influence pain in the fibromyalgia patient. 2002, Doctoral dissertation, Un Nebraska Med Cent:176.
  21. Aaronson LS, et al. Defining and measuring fatigue. Image, 1999. 31(1): 45-50.
  22. Belza BL. Correlates of fatigue in older adults with rheumatoid arthritis. Nurs Res, 1993. 42(2): 93-99.
  23. Hewlett S, Hehir M, Kirwan JR. Measuring fatigue in rheumatoid arthritis: a systematic review of scales in use. Arthritis Rheum, 2007. 57(3):429-439.
  24. Neuberger GB. Measures of fatigue. Arthritis Care Res, 2003. 49: S175-S183.
    25. .
  25. Wolfe F. Fatigue assessments in rheumatoid arthritis: Comparative performance of visual analog scales and longer fatigue questionnaires in 7760 patients. J Rheumatol, 2004. 31(10):1896-1902.
  26. Goligher E, et al. Minimal clinically important difference for 7 measures of fatigue in patients with systemic lupus erythematosus. J Rheumatol, 2008. 35(4):635-642.
  27. Whitehead L. The measurement of fatigue in chronic illness: a systematic review of unidimensional and multidimensional fatigue measures. J Pain Sym Manag, 2009. 37(1): 107-128.
  28. Wolfe F. Fatigue assessments in rheumatoid arthritis: comparative performance of visual analog scales and longer fatigue questionnaires in 7760 patients. The Journal of rheumatology, 2004. 31(10): p. 1896-902

Credits
ARHP Research Committee has reviewed and updated portions of this document in September 2012. For questions or comments, contact ARHP@rheumatology.org .

Previous | Index | Next