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.[1] 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[edit | edit source]

Origin[edit | edit source]

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.[1] 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:[edit | edit source]

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.[1] The factor analysis indicated 4 components[1] in the remaining 20 questions.  These were easy to interpret and were called:

  1. Subjective fatigue (8 items)
  2. Concentration (5 items)
  3. Motivation (4 items)
  4. Physical activity (3 items)

1-7 Likert score:[edit | edit source]

The CIS consists of 20 statements on fatigue-related problems respondents might have experienced in the past 2 weeks.[2] 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.[3]  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”.[4]

Reliability[edit | edit source]

Internal consistency[edit | edit source]

CIS has shown good internal consistency, with a Cronbach alpha of 0.90[5] and a Gutman split-half reliability coefficient of 0.92.[1][2]

Convergent validity[edit | edit source]

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).[6] 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.[7] In other studies, the concentration subscale of the CIS correlated with the subscale concentration problems of the Sickness Impact Profile (SIP),[8] while the subscale fatigue severity correlated with activity levels measured by an Actometer.[9]

Discriminative validity[edit | edit source]

Discriminative validity of the CIS was tested by Beurskens et al.[6] 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[1] or multiple sclerosis.[10]

Use[edit | edit source]

Multiple languages and diseases[edit | edit source]

The CIS has been translated into different languages, including English, Portuguese,[11] Polish,[12] Japanese[13] and Turkish.[14] The questionnaire has been used in various illnesses including fibromyalgia,[15] rheumatoid arthritis,[16] multiple sclerosis,[17] cancer,[18] asthma,[19] amyotrophic lateral sclerosis,[20] sarcoidosis,[21] and mitochondrial disorders.[22]

Average scores[edit | edit source]

Indicative scores and standard deviations for the CIS and the subjective fatigue subscale are given below.[4][5]

  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.[23]  On the subjective fatigue subscale of CIS, a score of 35 is seen as indicative of severe fatigue.[24]

Criticism[edit | edit source]

Ceiling effects[edit | edit source]

The subjective fatigue (also called fatigue severity) subscale of the CIS has been the most widely used in the field of ME/CFS.[25][26][27][28] 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.[29] 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.”[30]

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.[31] 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.[32] 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%.[29]

See also[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Vercoulen, J.H.; Swanink, C.M.; Fennis, J.F.; Galama, J.M.; van der Meer, J.W.; Bleijenberg, G. (July 1994). "Dimensional assessment of chronic fatigue syndrome". Journal of Psychosomatic Research. 38 (5): 383–392. ISSN 0022-3999. PMID 7965927.
  2. ↑ 2.0 2.1 https://meetinstrumentenzorg.blob.core.windows.net/test-documents/Instrument160/160_1_N.pdf
  3. ↑ https://meetinstrumentenzorg.blob.core.windows.net/documents/Instrument160/CIS%20meetinstr.pdf
  4. ↑ 4.0 4.1 https://www.me-pedia.org/images/f/f8/Checklist_Individual_Strength_overzicht.pdf
  5. ↑ 5.0 5.1 Schulte-van Maaren, Yvonne Wilhelmina Maria; LUMC (January 21, 2014). "NormQuest : reference values for ROM instruments and questionnaires". openaccess.leidenuniv.nl. Retrieved February 17, 2019.
  6. ↑ 6.0 6.1 Beurskens, A.J.; Bültmann, U.; Kant, I.; Vercoulen, J.H.; Bleijenberg, G.; Swaen, G.M. (May 2000). "Fatigue among working people: validity of a questionnaire measure". Occupational and Environmental Medicine. 57 (5): 353–357. ISSN 1351-0711. PMC 1739950. PMID 10769302.
  7. ↑ De Vries, J; Michielsen, H; Van Heck, G L (June 2003). "Assessment of fatigue among working people: a comparison of six questionnaires". Occupational and Environmental Medicine. 60 (Suppl 1): i10–i15. doi:10.1136/oem.60.suppl_1.i10. ISSN 1351-0711. PMC 1765720. PMID 12782741.
  8. ↑ Vercoulen, JH; Swanink, CM; Fennis, JF; Galama, JM; van der Meer, JW; Bleijenberg, G (May 1, 1996). "Prognosis in chronic fatigue syndrome: a prospective study on the natural course". Journal of Neurology, Neurosurgery & Psychiatry. 60 (5): 489–494. doi:10.1136/jnnp.60.5.489. ISSN 0022-3050.
  9. ↑ Vercoulen, J.H.M.M.; Bazelmans, E.; Swanink, C.M.A.; Fennis, J.F.M.; Galama, J.M.D.; Jongen, P.J.H.; Hommes, O.; Van Der Meer, J.W.M.; Bleijenberg, G. (November 1997). "Physical activity in chronic fatigue syndrome: Assessment and its role in fatigue". Journal of Psychiatric Research. 31 (6): 661–673. doi:10.1016/s0022-3956(97)00039-3. ISSN 0022-3956.
  10. ↑ Vercoulen, J.H.; Hommes, O.R.; Swanink, C.M.; Jongen, P.J.; Fennis, J.F.; Galama, J.M.; van der Meer, J.W.; Bleijenberg, G. (July 1996). "The measurement of fatigue in patients with multiple sclerosis. A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects". Archives of Neurology. 53 (7): 642–649. ISSN 0003-9942. PMID 8929171.
  11. ↑ Maes, Stan; Leal, Isabel; Cordeiro, Andreia; Gouveia, Maria João; Gucht, Véronique De; Marques, Marta (March 28, 2013). "Psychometric Properties of the Portuguese Version of the Checklist of Individual Strength (CIS20-P)". Psychology, Community & Health. 2 (1): 11–18. doi:10.5964/pch.v2i1.57. ISSN 2182-438X.
  12. ↑ Makowiec-Dabrowska, Teresa; Koszada-Włodarczyk, Wiesława (2006). "[The CIS20R Questionnaire and its suitability for prolonged fatigue studies]". Medycyna Pracy. 57 (4): 335–345. ISSN 0465-5893. PMID 17133914.
  13. ↑ Aratake, Yutaka; Tanaka, Katsutoshi; Wada, Koji; Watanabe, Mayumi; Katoh, Noritada; Sakata, Yumi; Aizawa, Yoshiharu (November 2007). "Development of Japanese version of the checklist individual strength questionnaire in a working population". Journal of Occupational Health. 49 (6): 453–460. ISSN 1341-9145. PMID 18075205.
  14. ↑ Ergin, Gülbin; Yildirim, Yücel (November 2012). "A validity and reliability study of the Turkish Checklist Individual Strength (CIS) questionnaire in musculoskeletal physical therapy patients". Physiotherapy Theory and Practice. 28 (8): 624–632. doi:10.3109/09593985.2011.654321. ISSN 1532-5040. PMID 22324761.
  15. ↑ Zijlstra, T.R.; Taal, E.; van de Laar, M. A. F.J.; Rasker, J.J. (June 6, 2006). "Validation of a Dutch translation of the fibromyalgia impact questionnaire". Rheumatology. 46 (1): 131–134. doi:10.1093/rheumatology/kel171. ISSN 1462-0332.
  16. ↑ van Hoogmoed, Dewy; Fransen, Jaap; Bleijenberg, Gijs; van Riel, Piet (July 2010). "Physical and psychosocial correlates of severe fatigue in rheumatoid arthritis". Rheumatology (Oxford, England). 49 (7): 1294–1302. doi:10.1093/rheumatology/keq043. ISSN 1462-0332. PMID 20353956.
  17. ↑ van der Werf, S.P.; Jongen, P.J.; Lycklama à Nijeholt, G.J.; Barkhof, F.; Hommes, O.R.; Bleijenberg, G. (October 8, 1998). "Fatigue in multiple sclerosis: interrelations between fatigue complaints, cerebral MRI abnormalities and neurological disability". Journal of the Neurological Sciences. 160 (2): 164–170. ISSN 0022-510X. PMID 9849800.
  18. ↑ Servaes, P.; van der Werf, S.; Prins, J.; Verhagen, S.; Bleijenberg, G. (January 2001). "Fatigue in disease-free cancer patients compared with fatigue in patients with chronic fatigue syndrome". Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer. 9 (1): 11–17. ISSN 0941-4355. PMID 11147137.
  19. ↑ Van Herck, Maarten; Spruit, Martijn A.; Burtin, Chris; Djamin, Remco; Antons, Jeanine; Goërtz, Yvonne M.J.; Ebadi, Zjala; Janssen, Daisy J.A.; Vercoulen, Jan H. (November 23, 2018). "Fatigue is Highly Prevalent in Patients with Asthma and Contributes to the Burden of Disease". Journal of Clinical Medicine. 7 (12). doi:10.3390/jcm7120471. ISSN 2077-0383. PMID 30477110.
  20. ↑ Panitz, S.; Kornhuber, M.; Hanisch, F. (June 2015). "The checklist individual strength (CIS20-R) in patients with amyotrophic lateral sclerosis - a longitudinal study". Acta Neurologica Scandinavica. 131 (6): 372–380. doi:10.1111/ane.12349. ISSN 1600-0404. PMID 25639482.
  21. ↑ Korenromp, Ingrid H.E.; Heijnen, Cobi J.; Vogels, Oscar J.M.; van den Bosch, Jules M.M.; Grutters, Jan C. (August 2011). "Characterization of chronic fatigue in patients with sarcoidosis in clinical remission". Chest. 140 (2): 441–447. doi:10.1378/chest.10-2629. ISSN 1931-3543. PMID 21330380.
  22. ↑ Smits, Bart; van den Heuvel, Lambert; Knoop, Hans; Küsters, Benno; Janssen, Antoon; Borm, George; Bleijenberg, Gijs; Rodenburg, Richard; van Engelen, Baziel (September 2011). "Mitochondrial enzymes discriminate between mitochondrial disorders and chronic fatigue syndrome". Mitochondrion. 11 (5): 735–738. doi:10.1016/j.mito.2011.05.005. ISSN 1872-8278. PMID 21664495.
  23. ↑ Bültmann, U.; de Vries, M.; Beurskens, A.J.; Bleijenberg, G.; Vercoulen, J.H.; Kant, I. (October 2000). "Measurement of prolonged fatigue in the working population: determination of a cutoff point for the checklist individual strength". Journal of Occupational Health Psychology. 5 (4): 411–416. ISSN 1076-8998. PMID 11051524.
  24. ↑ "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". oatext.com. Retrieved February 17, 2019.
  25. ↑ Prins, Judith B; Bleijenberg, Gijs; Bazelmans, Ellen; Elving, Lammy D; de Boo, Theo M; Severens, Johan L; van der Wilt, Gert Jan; Spinhoven, Philip; van der Meer, Jos WM (March 2001). "Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial". The Lancet. 357 (9259): 841–847. doi:10.1016/s0140-6736(00)04198-2. ISSN 0140-6736.
  26. ↑ Wiborg, Jan F.; van Bussel, Jose; van Dijk, Agaat; Bleijenberg, Gijs; Knoop, Hans (2015). "Randomised Controlled Trial of Cognitive Behaviour Therapy Delivered in Groups of Patients with Chronic Fatigue Syndrome". Psychotherapy and Psychosomatics. 84 (6): 368–376. doi:10.1159/000438867. ISSN 0033-3190.
  27. ↑ Knoop, Hans; van der Meer, Jos W.M.; Bleijenberg, Gijs (October 2008). "Guided self-instructions for people with chronic fatigue syndrome: randomised controlled trial". British Journal of Psychiatry. 193 (04): 340–341. doi:10.1192/bjp.bp.108.051292. ISSN 0007-1250.
  28. ↑ Janse, A.; Worm-Smeitink, M.; Bleijenberg, G.; Donders, R.; Knoop, H. (February 2018). "Efficacy of web-based cognitive–behavioural therapy for chronic fatigue syndrome: randomised controlled trial". The British Journal of Psychiatry. 212 (02): 112–118. doi:10.1192/bjp.2017.22. ISSN 0007-1250.
  29. ↑ 29.0 29.1 Stouten, Bart (May 13, 2005). "Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution". BMC health services research. 5: 37. doi:10.1186/1472-6963-5-37. ISSN 1472-6963. PMC 1175848. PMID 15892882.
  30. ↑ 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
  31. ↑ "My feedback on content of CDEs (Fatigue) - Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) CDE Public Review". Science for ME. Retrieved February 17, 2019.
  32. ↑ sasusa (March 21, 2016). "PACE: The research that sparked a patient rebellion and challenged medicine". Sense About Science USA. Retrieved February 17, 2019.

cognition Thought processes, including attention, reasoning, and memory.

somatic An adjective relating to the physical body or physical symptoms. It is often contrasted with the adjective "psychological", which refers to the human mind or mental symptoms. In biology, "somatic cells" refer to all the cells of the body, except those which form an egg or sperm.

mitochondria Important parts of the biological cell, with each mitochondrion encased within a mitochondrial membrane. Mitochondria are best known for their role in energy production, earning them the nickname "the powerhouse of the cell". Mitochondria also participate in the detection of threats and the response to these threats. One of the responses to threats orchestrated by mitochondria is apoptosis, a cell suicide program used by cells when the threat can not be eliminated.

somatic symptom disorder A psychiatric term to describe an alleged condition whereby a person's thoughts somehow cause physical symptoms. The actual existence of such a condition is highly controversial, due to a lack of scientific evidence. It is related to other psychiatric terms, such as "psychosomatic", "neurasthenia", and "hysteria". Older terms include "somatization", "somatoform disorder", and "conversion disorder". Such terms refer to a scientifically-unsupported theory that claims that a wide range of physical symptoms can be created by the human mind, a theory which has been criticized as "mind over matter" parapsychology, a pseudoscience.

mitochondria Important parts of the biological cell, with each mitochondrion encased within a mitochondrial membrane. Mitochondria are best known for their role in energy production, earning them the nickname "the powerhouse of the cell". Mitochondria also participate in the detection of threats and the response to these threats. One of the responses to threats orchestrated by mitochondria is apoptosis, a cell suicide program used by cells when the threat can not be eliminated.

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