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.
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