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Chalder fatigue scale
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== Criticism == === Ceiling effects === The use of the Chalder Fatigue Scale in ME/CFS has been criticized because ME/CFS patients often record the maximum score on most of the 11 questions.<ref name=":13" /> As a result, 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. As explained by [[Rebecca Goldin]]: <blockquote>“Let us suppose for a moment that 100 people are experiencing extreme fatigue. They each answer “much worse than usual” on the Questionnaire (a 3) to all 11 questions, resulting in a score of 33. Over the course of a year, there are random fluctuations in their health—half get worse, and half get better. Now they take the questionnaire again. Those who get worse still answer “3” to all questions (final score: 33). Those who improve now answer a “2” to all questions, stating that they are just “worse than usual” but not “much worse” (final score: 22). The new average is now 27.5, a significant improvement over the original score of 33.”<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=2019-02-16}}</ref></blockquote>In other words, if patients record the maximum score and half of them improve while the other half deteriorates during follow-up then only the improvement will become visible on the questionnaire.<ref name=":14" /> [[Bart Stouten]]<ref name=":12" /> calculated lower bounds for the number of items with the maximum score on the CFQ for several behavioral intervention studies. High ceiling effects were noted in multiple trials. In the randomized trials of Deale et al. and Powell et al. the intervention group recorded the maximum bimodal score on more than 90% of the questions on the CFQ. A study on 25 patients with ME, found that 50% of the patients recorded the maximum score using the bimodal method. The problem is less pronounced using the [[Likert score]], though 15% of ME patients still indicated the maximum score of 33. In the FINE and PACE trial, 29.1% and 14.5% of the participants respectively scored the maximum score at baseline.”<ref name=":14" /> === Problems with the Likert score === Due to ceiling effects, the [[Likert score|Likert scoring]] has become the more popular version of the CFQ. The [[PACE trial]], for example, changed their primary outcome of fatigue from bimodal scoring as chosen by the protocol, to Likert scoring.<ref name=":15" /> Separate problems have been noted with this scoring method. The introduction to this version of the CFQ, asks respondents to compare themselves to how they felt when they were last well.<ref name=":16" /> A response of ‘no more than usual’ (score 1) would thus indicate full recovery. Persons without fatigue problems would score 11/33, indicating that they had fatigue ‘no more than usual’.<ref name=":14" /> Indeed, the use of the CFQ in healthy community samples yielded scores of 12-14.<ref>{{Cite journal | last = Pawlikowska | first = T. | last2 = Chalder | first2 = T. | last3 = Hirsch | first3 = S.R. | last4 = Wallace | first4 = P. | last5 = Wright | first5 =D.J. | last6 = Wessely | first6 = S.C. | date = 1994-03-19 | title = Population based study of fatigue and psychological distress |url =https://www.ncbi.nlm.nih.gov/pubmed/7908238 | journal = BMJ (Clinical research ed.) | volume = 308 | issue = 6931 | pages = 763–766|issn=0959-8138|pmc=2539651|pmid=7908238}}</ref><ref name=":1" /><ref name=":3" /> The Likert score of the CFQ also offers the option “less than usual” (score 0). It’s not clear what such an answer means. It seems to indicate an abnormal absence of fatigue complaints. Evidence that this option confuses respondents, comes from a trial on cognitive behavioral therapy in patients with multiple sclerosis. Post-treatment MS patients recorded a score of less than 10, indicating they had less fatigue than healthy persons. Even the control which received relaxation therapy had lower fatigue scores than healthy persons.<ref name=":17" /> This may indicate that they misinterpreted the "less than usual” (score 0) option, or that their "healthy" level involved some level of tiredness that disappeared with treatment, or simply that they felt abnormally alert. Results like these can question the reliability of the Likert scoring system of the CFQ. '''<big>Clinical useful difference and similar terms</big>''' In the PACE Trial, a post-hoc analysis defined a clinical useful difference as a change of 2 or more. a This was questioned by Giakoumakis. b This contrasted with a statement in an earlier paper c: “Because the Chalder fatigue scale is relatively new, there is no published definition of equivalence. The researchers in this trial include several of those involved in developing and testing the instrument. Our consensus view was that a difference of less than four, using a Likert scale, is not important.” The researchers in the trial included Trudie Chalder (one of the principal investigators in the PACE Trial) and Simon Wessely. d ''a. White PD, Goldsmith KA, Johnson AL et al. on behalf of the PACE trial management group Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011; 377: 823-836'' ''b. Giakoumakis J. The PACE trial in chronic fatigue syndrome. Lancet. 2011, 377:1831'' ''c. Ridsdale L, Godfrey E, Seed P: Chronic Fatigue in general practice: authors reply. Br J Gen Pract 2001, 51:317–318.'' ''d. Ridsdale L, Godfrey E, Chalder T, Seed P, King M, Wallace P, Wessely S; Fatigue Trialists' Group. Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial. Br J Gen Pract. 2001 51:19-24.''
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