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Checklist Individual Strength
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The '''Checklist Individual Strength (CIS)''' is a 20-item fatigue questionnaire developed by the Dutch research team of Vercoulen et al. in 1994.<ref name=":0">{{Cite journal | last = Vercoulen | first = J.H. | last2 = Swanink | first2 = C.M. | last3 = Fennis | first3 = J.F. | last4 = Galama | first4 = J.M. | last5 = van der Meer | first5 = J.W. | last6 = Bleijenberg | first6 = G. | date = Jul 1994 | title = Dimensional assessment of chronic fatigue syndrome | url =https://www.ncbi.nlm.nih.gov/pubmed/7965927 | journal = Journal of Psychosomatic Research | volume = 38 | issue = 5 | pages = 383–392|issn=0022-3999|pmid=7965927}}</ref> The questionnaire has been translated into multiple languages and is used in various illnesses, including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). An 8-item subscale of CIS that measures subjective fatigue regularly acts as a primary outcome in randomized trials on the effects cognitive behavior therapy in ME/CFS. The use of this subscale in a ME/CFS patient population however has been criticized for displaying ceiling effects. == Background == === Origin === The Checklist Individual Strength (Checklist individuele Spankracht) was developed by the Dutch research team of Vercoulen et al. in 1994 at the universities of Amsterdam and Rotterdam.<ref name=":0" /> CIS was intended to be a questionnaire to test the “behavioural, emotional, social, and cognitive aspects” of ME/CFS and to identify the multiple dimensions of ME/CFS patients’ disability. ===20 questions, 4 subscales: === Initially the questionnaire consisted of 24 items but after testing in 298 patients who suffered from unexplained chronic fatigue for more than a year, 4 items were removed.<ref name=":0" /> The factor analysis indicated 4 components<ref name=":0" /> in the remaining 20 questions. These were easy to interpret and were called: # Subjective fatigue (8 items) # Concentration (5 items) # Motivation (4 items) # Physical activity (3 items) === 1-7 Likert score: === The CIS consists of 20 statements on fatigue-related problems respondents might have experienced in the past 2 weeks.<ref name=":1">https://meetinstrumentenzorg.blob.core.windows.net/test-documents/Instrument160/160_1_N.pdf</ref> A Likert scoring scheme is used. With each statement respondents have to indicate a score from 1 to 7, indicating either “yes, that is true” or “no, that is not true.” Examples of statements are: “I feel tired”, “I have trouble concentrating” or “, I don’t do much during the day” etc.<ref>https://meetinstrumentenzorg.blob.core.windows.net/documents/Instrument160/CIS%20meetinstr.pdf</ref> Almost half of the questions are inverted, meaning the statements indicate fitness instead of fatigue and the scoring system is reversed. “Yes, that is true” would then indicate a score of 1 instead of 7. Examples of such statements are: “. I feel fit, “I feel rested” or “I am full of plans”.<ref name=":2">https://www.me-pedia.org/images/f/f8/Checklist_Individual_Strength_overzicht.pdf</ref> == Reliability == === Internal consistency === CIS has shown good internal consistency, with a Cronbach alpha of 0.90<ref name=":3">{{Cite web | url = https://openaccess.leidenuniv.nl/handle/1887/23044 | title = NormQuest : reference values for ROM instruments and questionnaires | last = Schulte-van Maaren | first = Yvonne Wilhelmina Maria | last2 = LUMC | date = Jan 21, 2014 | website = openaccess.leidenuniv.nl|language=en|access-date=2019-02-17}}</ref> and a Gutman split-half reliability coefficient of 0.92.<ref name=":0" /><ref name=":1" /> === Convergent validity === Research has shown that the results of the CIS are comparable to those other measure of fatigue, such as fatigue measured on a unidimensional five point Likert scale or the scale exhaustion of the Maslach burnout inventory—general survey (MBI-GS).<ref name=":4">{{Cite journal | last = Beurskens | first = A.J. | last2 = Bültmann | first2 = U. | last3 = Kant | first3 = I. | last4 = Vercoulen | first4 = J.H. | last5 = Bleijenberg | first5 = G. | last6 = Swaen | first6 = G.M. | date = May 2000 | title = Fatigue among working people: validity of a questionnaire measure | url =https://www.ncbi.nlm.nih.gov/pubmed/10769302 | journal = Occupational and Environmental Medicine | volume = 57 | issue = 5 | pages = 353–357|issn=1351-0711|pmc=1739950|pmid=10769302}}</ref> Using a large sample of 351 persons of the working population, De Vries et al. showed that the CIS correlated with other fatigue questionnaires such as the Chalder Fatigue Scale.<ref>{{Cite journal | last = De Vries | first = J | last2 = Michielsen | first2 = H | last3 = Van Heck | first3 = G L | date = Jun 2003 | title = Assessment of fatigue among working people: a comparison of six questionnaires |url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765720/ | journal = Occupational and Environmental Medicine | volume = 60 | issue = Suppl 1 | pages = i10–i15|doi=10.1136/oem.60.suppl_1.i10|issn=1351-0711|pmc=1765720|pmid=12782741}}</ref> In other studies, the concentration subscale of the CIS correlated with the subscale concentration problems of the Sickness Impact Profile (SIP),<ref>{{Cite journal | last = Vercoulen | first = JH | last2 = Swanink | first2 = CM | last3 = Fennis | first3 = JF | last4 = Galama | first4 = JM | last5 = van der Meer | first5 = JW | last6 = Bleijenberg | first6 = G | date = 1996-05-01 | title = Prognosis in chronic fatigue syndrome: a prospective study on the natural course. | url = http://dx.doi.org/10.1136/jnnp.60.5.489 | journal = Journal of Neurology, Neurosurgery & Psychiatry | volume = 60 | issue = 5 | pages = 489–494|doi=10.1136/jnnp.60.5.489|issn=0022-3050}}</ref> while the subscale fatigue severity correlated with activity levels measured by an Actometer.<ref>{{Cite journal | last = Vercoulen | first = J.H.M.M. | last2 = Bazelmans | first2 = E. | last3 = Swanink | first3 = C.M.A. | last4 = Fennis | first4 = J.F.M. | last5 = Galama | first5 = J.M.D. | last6 = Jongen | first6 = P.J.H. | last7 = Hommes | first7 = O. | last8 = Van Der Meer | first8 = J.W.M. | last9 = Bleijenberg | first9 = G. | date = Nov 1997 | title = Physical activity in chronic fatigue syndrome: Assessment and its role in fatigue | url =http://dx.doi.org/10.1016/s0022-3956(97)00039-3 | journal = Journal of Psychiatric Research | volume = 31 | issue = 6 | pages = 661–673|doi=10.1016/s0022-3956(97)00039-3|issn=0022-3956}}</ref> === Discriminative validity === Discriminative validity of the CIS was tested by Beurskens et al.<ref name=":4" /> in five sets of employees with expected differences in fatigue. The CIS was able to differentiate between healthy employees and those with a somatic or mental reason for fatigue. Vercoulen et al. showed that the CIS discriminates between ME/CFS patients from healthy controls and patients with functional bowel syndrome<ref name=":0" /> or multiple sclerosis.<ref>{{Cite journal | last = Vercoulen | first = J.H. | last2 = Hommes | first2 = O.R. | last3 = Swanink | first3 = C.M. | last4 = Jongen | first4 = P.J. | last5 = Fennis | first5 = J.F. |last6 = Galama | first6 = J.M. | last7 = van der Meer | first7 = J.W. | last8 = Bleijenberg | first8 = G. | author-link8 = Gijs Bleijenberg | date = Jul 1996 | title = The measurement of fatigue in patients with multiple sclerosis. A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects |url =https://www.ncbi.nlm.nih.gov/pubmed/8929171 | journal = Archives of Neurology | volume = 53 | issue = 7 | pages = 642–649|issn=0003-9942|pmid=8929171}}</ref> == Use == === Multiple languages and diseases === The CIS has been translated into different languages, including English, Portuguese,<ref>{{Cite journal | last = Maes | first = Stan | last2 = Leal | first2 = Isabel | last3 = Cordeiro | first3 = Andreia | last4 = Gouveia | first4 = Maria João | last5 = Gucht | first5 = Véronique De | last6 = Marques | first6 = Marta | date = 2013-03-28 | title = Psychometric Properties of the Portuguese Version of the Checklist of Individual Strength (CIS20-P) | url = https://pch.psychopen.eu/article/view/57 | journal = Psychology, Community & Health|language=en | volume = 2 | issue = 1 | pages = 11–18|doi=10.5964/pch.v2i1.57|issn=2182-438X}}</ref> Polish,<ref>{{Cite journal | last = Makowiec-Dabrowska | first = Teresa | last2 = Koszada-Włodarczyk | first2 = Wiesława | date = 2006 | title=[The CIS20R Questionnaire and its suitability for prolonged fatigue studies] | url = https://www.ncbi.nlm.nih.gov/pubmed/17133914 | journal = Medycyna Pracy | volume = 57 | issue = 4 | pages = 335–345|issn=0465-5893|pmid=17133914}}</ref> Japanese<ref>{{Cite journal | last = Aratake | first = Yutaka | last2 = Tanaka | first2 = Katsutoshi | last3 = Wada | first3 = Koji | last4 = Watanabe | first4 = Mayumi | last5 = Katoh | first5 = Noritada | last6 = Sakata | first6 = Yumi | last7 = Aizawa | first7 = Yoshiharu | date = Nov 2007 | title = Development of Japanese version of the checklist individual strength questionnaire in a working population | url =https://www.ncbi.nlm.nih.gov/pubmed/18075205 | journal = Journal of Occupational Health | volume = 49 | issue = 6 | pages = 453–460|issn=1341-9145|pmid=18075205}}</ref> and Turkish.<ref>{{Cite journal | last = Ergin | first = Gülbin | last2 = Yildirim | first2 = Yücel | date = Nov 2012 | title = A validity and reliability study of the Turkish Checklist Individual Strength (CIS) questionnaire in musculoskeletal physical therapy patients |url =https://www.ncbi.nlm.nih.gov/pubmed/22324761 | journal = Physiotherapy Theory and Practice | volume = 28 | issue = 8 | pages = 624–632|doi=10.3109/09593985.2011.654321|issn=1532-5040|pmid=22324761}}</ref> The questionnaire has been used in various illnesses including fibromyalgia,<ref>{{Cite journal | last = Zijlstra | first = T.R. | last2 = Taal | first2 = E. | last3 = van de Laar | first3 = M. A. F.J. | last4 = Rasker | first4 = J.J. | date = 2006-06-06 | title = Validation of a Dutch translation of the fibromyalgia impact questionnaire | url =http://dx.doi.org/10.1093/rheumatology/kel171 | journal = Rheumatology | volume = 46 | issue = 1 | pages = 131–134|doi=10.1093/rheumatology/kel171|issn=1462-0332}}</ref> rheumatoid arthritis,<ref>{{Cite journal | last = van Hoogmoed | first = Dewy | last2 = Fransen | first2 = Jaap | last3 = Bleijenberg | first3 = Gijs | last4 = van Riel | first4 = Piet | date = Jul 2010 | title = Physical and psychosocial correlates of severe fatigue in rheumatoid arthritis |url =https://www.ncbi.nlm.nih.gov/pubmed/20353956 | journal = Rheumatology (Oxford, England) | volume = 49 | issue = 7 | pages = 1294–1302|doi=10.1093/rheumatology/keq043|issn=1462-0332|pmid=20353956}}</ref> multiple sclerosis,<ref>{{Cite journal | last = van der Werf | first = S.P. | last2 = Jongen | first2 = P.J. | last3 = Lycklama à Nijeholt | first3 = G.J. | last4 = Barkhof | first4 = F. | last5 = Hommes | first5 = O.R. | last6 = Bleijenberg | first6 = G. | author-link6 = Gijs Bleijenberg | date = 1998-10-08 | title = Fatigue in multiple sclerosis: interrelations between fatigue complaints, cerebral MRI abnormalities and neurological disability | url = https://www.ncbi.nlm.nih.gov/pubmed/9849800 | journal = Journal of the Neurological Sciences | volume = 160 | issue = 2 | pages = 164–170|issn=0022-510X|pmid=9849800}}</ref> cancer,<ref>{{Cite journal | last = Servaes | first = P. | last2 = van der Werf | first2 = S. | last3 = Prins | first3 = J. | author-link3 = Judith Prins | last4 = Verhagen | first4 = S. | last5 = Bleijenberg | first5 = G. | date = Jan 2001 | title = Fatigue in disease-free cancer patients compared with fatigue in patients with chronic fatigue syndrome | url =https://www.ncbi.nlm.nih.gov/pubmed/11147137 | journal = Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer | volume = 9 | issue = 1 | pages = 11–17|issn=0941-4355|pmid=11147137}}</ref> asthma,<ref>{{Cite journal | last = Van Herck | first = Maarten | last2 = Spruit | first2 = Martijn A. | last3 = Burtin | first3 = Chris | last4 = Djamin | first4 = Remco | last5 = Antons | first5 = Jeanine | last6 = Goërtz | first6 = Yvonne M.J. | last7 = Ebadi | first7 = Zjala | last8 = Janssen | first8 = Daisy J.A. |last9 = Vercoulen | first9 = Jan H. | author-link9 = Jan Vercoulen | date = 2018-11-23 | title = Fatigue is Highly Prevalent in Patients with Asthma and Contributes to the Burden of Disease | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306949/ | journal = Journal of Clinical Medicine | volume = 7 | issue = 12|doi=10.3390/jcm7120471|issn=2077-0383|pmc=|pmid=30477110 | pages = |quote= | authorlink = Maarten Van Herck|via=}}</ref> amyotrophic lateral sclerosis,<ref>{{Cite journal | last = Panitz | first = S. | last2 = Kornhuber | first2 = M. | last3 = Hanisch | first3 = F. | date = Jun 2015 | title = The checklist individual strength (CIS20-R) in patients with amyotrophic lateral sclerosis - a longitudinal study | url = https://www.ncbi.nlm.nih.gov/pubmed/25639482 | journal = Acta Neurologica Scandinavica | volume = 131 | issue = 6 | pages = 372–380|doi=10.1111/ane.12349|issn=1600-0404|pmid=25639482}}</ref> sarcoidosis,<ref>{{Cite journal | last = Korenromp | first = Ingrid H.E. | last2 = Heijnen | first2 = Cobi J. | last3 = Vogels | first3 = Oscar J.M. | last4 = van den Bosch | first4 = Jules M.M. | last5 = Grutters | first5 = Jan C. | date = Aug 2011 | title = Characterization of chronic fatigue in patients with sarcoidosis in clinical remission | url =https://www.ncbi.nlm.nih.gov/pubmed/21330380 | journal = Chest | volume = 140 | issue = 2 | pages = 441–447|doi=10.1378/chest.10-2629|issn=1931-3543|pmid=21330380}}</ref> and mitochondrial disorders.<ref>{{Cite journal | last = Smits | first = Bart | last2 = van den Heuvel | first2 = Lambert | last3 = Knoop | first3 = Hans | last4 = Küsters | first4 = Benno | last5 = Janssen | first5 = Antoon | last6 = Borm | first6 = George | last7 = Bleijenberg | first7 = Gijs | last8 = Rodenburg | first8 = Richard | last9 = van Engelen | first9 = Baziel | date = Sep 2011 | title = Mitochondrial enzymes discriminate between mitochondrial disorders and chronic fatigue syndrome | url =https://www.ncbi.nlm.nih.gov/pubmed/21664495 | journal = Mitochondrion | volume = 11 | issue = 5 | pages = 735–738|doi=10.1016/j.mito.2011.05.005|issn=1872-8278|pmid=21664495}}</ref> === Average scores === Indicative scores and standard deviations for the CIS and the subjective fatigue subscale are given below.<ref name=":2" /><ref name=":3" /> {| class="wikitable" | |CIS-20 total score |CIS-8 subjective fatigue |- |Healthy persons |41.5 (19.8) |17.3 (10.1) |- |Chronic fatigue syndrome |113.1 (14.6) |51.7 (4.6) |- |Multiple Sclerosis |85.1 (21.9) |40.2 (11.8) |- |Functional bowel disorder |71.1 (18.1) |34.1 (8.5) |} In a study on work absence due to fatigue, a cut-off score of 76 on the CIS indicates a risk for subsequent sick leave or work disability.<ref>{{Cite journal | last = Bültmann | first = U. | last2 = de Vries | first2 = M. | last3 = Beurskens | first3 = A.J. | last4 = Bleijenberg | first4 = G. | last5 = Vercoulen | first5 = J.H. | last6 = Kant | first6 = I. | date = Oct 2000 | title = Measurement of prolonged fatigue in the working population: determination of a cutoff point for the checklist individual strength | url = https://www.ncbi.nlm.nih.gov/pubmed/11051524 | journal = Journal of Occupational Health Psychology | volume = 5 | issue = 4 | pages = 411–416|issn=1076-8998|pmid=11051524}}</ref> On the subjective fatigue subscale of CIS, a score of 35 is seen as indicative of severe fatigue.<ref>{{Cite web | url = https://www.oatext.com/an-analysis-of-dutch-hallmark-studies-confirms-the-outcome-of-the-pace-trial-cognitive-behaviour-therapy-with-a-graded-activity-protocol-is-not-effective-for-chronic-fatigue-syndrome-and-myalgic-encephalomyelitis.php | title = An analysis of Dutch hallmark studies confirms the outcome of the PACE trial: cognitive behaviour therapy with a graded activity protocol is not effective for chronic fatigue syndrome and Myalgic Encephalomyelitis. | website = oatext.com|language=en|access-date=2019-02-17}}</ref> == Criticism == === Ceiling effects === The subjective fatigue (also called fatigue severity) subscale of the CIS has been the most widely used in the field of ME/CFS.<ref>{{Cite journal | last = Prins | first = Judith B | last2 = Bleijenberg | first2 = Gijs | last3 = Bazelmans | first3 = Ellen | last4 = Elving | first4 = Lammy D | last5 = de Boo | first5 = Theo M | last6 = Severens | first6 = Johan L | last7 = van der Wilt | first7 = Gert Jan | last8 = Spinhoven | first8 = Philip | last9 = van der Meer | first9 = Jos WM | date = Mar 2001 | title = Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial | url = http://dx.doi.org/10.1016/s0140-6736(00)04198-2 | journal = The Lancet | volume = 357 | issue = 9259 | pages = 841–847|doi=10.1016/s0140-6736(00)04198-2|issn=0140-6736}}</ref><ref>{{Cite journal | last = Wiborg | first = Jan F. | last2 = van Bussel | first2 = Jose | last3 = van Dijk | first3 = Agaat | last4 = Bleijenberg | first4 = Gijs | last5 = Knoop | first5 = Hans | date = 2015 | title=Randomised Controlled Trial of Cognitive Behaviour Therapy Delivered in Groups of Patients with Chronic Fatigue Syndrome | url =https://www.karger.com/Article/FullText/438867 | journal = Psychotherapy and Psychosomatics|language=en | volume = 84 | issue = 6 | pages = 368–376|doi=10.1159/000438867|issn=0033-3190}}</ref><ref>{{Cite journal | last = Knoop | first = Hans | last2 = van der Meer | first2 = Jos W.M. | last3 = Bleijenberg | first3 = Gijs | date = Oct 2008 | title = Guided self-instructions for people with chronic fatigue syndrome: randomised controlled trial | url = http://dx.doi.org/10.1192/bjp.bp.108.051292 | journal = British Journal of Psychiatry | volume = 193 | issue = 04 | pages = 340–341|doi=10.1192/bjp.bp.108.051292|issn=0007-1250}}</ref><ref>{{Cite journal | last = Janse | first = A. | last2 = Worm-Smeitink | first2 = M. | last3 = Bleijenberg | first3 = G. | last4 = Donders | first4 = R. | last5 = Knoop | first5 = H. | date = Feb 2018 | title = Efficacy of web-based cognitive–behavioural therapy for chronic fatigue syndrome: randomised controlled trial | url = https://www.cambridge.org/core/product/identifier/S0007125017000228/type/journal_article | journal = The British Journal of Psychiatry|language=en | volume = 212 | issue = 02 | pages = 112–118|doi=10.1192/bjp.2017.22|issn=0007-1250}}</ref> Because this subscale asks general questions about fatigue such as “I “feel tired” or “I feel weak”, ME/CFS often score close to the maximum score.<ref name=":5">{{Cite journal | last = Stouten | first = Bart | date = 2005-05-13 | title = Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution | url =https://www.ncbi.nlm.nih.gov/pubmed/15892882 | journal = BMC health services research | volume = 5 | pages = 37|doi=10.1186/1472-6963-5-37|issn=1472-6963|pmc=1175848|pmid=15892882}}</ref> The fatigue severity subscale asks 8 questions which gives a score from 8 to 56. While healthy persons score on average 17.3 and patients with other chronic conditions usually score below 40, ME/CFS patients easily reach a score above 50. For example, in a study of homebound ME/CFS patients (which included some of the authors of the CIS), it was noted that “The CIS-fatigue score involves an overall rating and in CFS samples easily reaches the extreme end of its scale.”<ref>Van der Werf S, Prins J, Klein-Rouweler E, Alberts M, van der Meer J, Bleijenberg G: Homebound chronic fatigue syndrome patients. Determinants and consequences of experienced fatigue in chronic fatigue syndrome and neurological conditions. PhD thesis 2000:31-41</ref> As a result ME/CFS patients can no longer indicate a worsening of their fatigue, a phenomenon that is called the ceiling effect. This can influence the findings of randomized trials. For example: If ME/CFS patients record the maximum score on the CIS and half of them improves while the other half deteriorates with the same amount during follow-up, then only the improvement will become visible on the questionnaire.<ref>{{Cite web | url = https://www.s4me.info/threads/my-feedback-on-content-of-cdes-fatigue-myalgic-encephalomyelitis-chronic-fatigue-syndrome-me-cfs-cde-public-review.2017/ | title = My feedback on content of CDEs (Fatigue) - Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) CDE Public Review | website = Science for ME|language=en-US|access-date=2019-02-17}}</ref> If such a result were used as a primary outcome in randomized trial, it might overestimate improvements in fatigue and underestimate deterioration or harms by the intervention.<ref>{{Cite web | url = http://senseaboutscienceusa.org/pace-research-sparked-patient-rebellion-challenged-medicine/ | title = PACE: The research that sparked a patient rebellion and challenged medicine | last = sasusa | date = 2016-03-21 | website = Sense About Science USA|language=en-US|access-date=2019-02-17}}</ref> Bart Stouten calculated the lower bounds for the number of items with the maximum score on the CIS fatigue severity subscale. In some studies this was as high as 46%.<ref name=":5" /> ==See also== *[[Questionnaires and tools to assess ME/CFS symptoms or severity]] == References == {{reflist}} [[Category:Symptom scales]]
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