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Chalder fatigue scale
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=== 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" />
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