Psychometric Properties of the

Modified Fatigue Impact Scale

Rebecca D. Larson, PhD

Psychometric assessments are tests or questionnaires that have been designed to measure constructs of
interest in an individual or a target population. A goal of many of these self-report instruments is to
provide researchers with the ability to gather subjective information in a manner that might allow
for quantitative analysis and interpretation of these results. This requires the instrument of choice to
have adequate psychometric properties of reliability and validity. Much research has been conducted
on creating self-report quality of life questionnaires for individuals with multiple sclerosis (MS). This
article focuses on one in particular, the Modified Fatigue Impact Scale (MFIS). The article starts with
a brief description of the rationale, construction, and scoring of the inventory. Next, the best available
reliability and validity data on the MFIS are presented. The article concludes with a brief discussion
on the interpretation of scores, followed by suggestions for future research. This summative analysis
is intended to examine whether the instrument is adequately measuring the impact of fatigue and
whether the scores allow for meaningful interpretations. Int J MS Care. 2013;15:15–20.

M
ultiple sclerosis (MS) is a chronic, pro-
gressive, and degenerative disease of the
central nervous system characterized by
demyelination1 and axonal deterioration.2 Symptoms
of MS include abnormal gait, deficient balance, muscle
weakness, spasticity, and fatigue, all of which can reduce
physical function and profoundly affect health and qual-
ity of life.1 Fatigue is one of the most common symp-
toms, affecting more than 75% of people with MS.3,4
Fatigue has been defined as “a subjective lack of physi-
cal or mental energy that is perceived by the individual
or caregiver to interfere with activities of daily living.”5
Fatigue can be considered primary or secondary. Pri-
mary fatigue refers to factors directly associated with
the disease process, whereas secondary fatigue relates
to the consequences of primary fatigue and may result
from lack of conditioning, depression, and medication
side effects.6 Despite the known prevalence of fatigue
From the Department of Kinesiology, University of Georgia, Athens,
GA, USA. Dr. Larson is now with the Department of Health and
Exercise Science, University of Oklahoma, Norman, OK, USA. Cor-
respondence: Rebecca D. Larson, PhD, Department of Health and
Exercise Science, University of Oklahoma, Norman, OK 73019;
e-mail: rdlarson@ou.edu.
DOI: 10.7224/1537-2073.2012-019
© 2013 Consortium of Multiple Sclerosis Centers.
in MS and its negative effects on quality of life, the
pathophysiology of MS-related fatigue remains unclear.
Additionally, the difficulty of measuring fatigue due to
its subjective nature and its impact on quality of life has
been troublesome.
According to the Multiple Sclerosis Council for Clin-
ical Practice and Guidelines, a subjective (self-reported)
measure of fatigue should be based on the individual’s
assessment of fatigue and its impact on quality of life,7
which requires the measure to have adequate psycho-
metric properties including reliability and validity.
After performing a review of the literature, the Council
recommended using the Modified Fatigue Impact Scale
(MFIS).7 Although the Council called for further psy-
chometric evaluation, researchers have been repeatedly
using the MFIS in the absence of such a comprehensive
evaluation of the instrument.
The MFIS is a modified version of the 40-item
Fatigue Impact Scale (FIS), which was originally devel-
oped to assess the effects of fatigue on quality of life in
patients with chronic diseases, specifically MS.3 The FIS
has patients rate the extent to which fatigue has affected
their life in the past 4 weeks on a questionnaire consist-
ing of 10 “physical” items, 10 “cognitive” items, and 20
“social” items, with 0 indicating “no problem” and 4
indicating “extreme problem.” The maximum possible

International Journal of MS Care

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Larson
score is 160. The MFIS evolved from the FIS during
the development of a clinical inventory assessing over-
all quality of life in individuals with MS, the Multiple
Sclerosis Quality of Life Inventory (MSQLI). During
the phase 2 field testing of the MSQLI, the 40-item FIS
was abbreviated into the 21-item MFIS by “eliminating
items which appeared both content-redundant and had
high inter-item correlations,”8 but the exact procedures
and data have not been published. The MFIS contains
9 “physical” items, 10 “cognitive” items, and 2 “psycho-
social” items. The maximum possible score is 84, with
higher scores indicating a greater impact on quality of
life (Appendix 1). The original intention was to use the
total score to reflect a global (unidimensional) score.3,9
The authors of the FIS and those involved in the modi-
fication of the FIS into the MFIS have not published
evidence verifying the underlying structure of the instru-
ment or the rationale for the three subscales and the
items selected to create the subscales.
The underlying structure of the MFIS has been
examined through principal components analysis with
varimax rotation using data from 181 MS patients
from four different European countries: Belgium (n =
51), Italy (n = 50), Slovenia (n = 50), and Spain (n =
30).10 All 21 items meet the required item-loading fac-
tor of 0.500. However, the first item, “I feel less alert”
(a cognitive item), had a factor loading of 0.495 but
also loaded with the psychosocial factor at 0.599. The
eighth item, “I am less motivated to participate in social
activities” (a psychosocial item), had a factor loading of
0.528 but also loaded with the physical factor at 0.499.
The ninth item, “I am less motivated to do things away
from home,” from the psychosocial subscale, was actu-
ally assigned to the physical factor. These results are not
in agreement with the original underlying structure of
the subscales, leading Kos and colleagues to recommend
caution when interpreting the psychosocial subscale.10
The lack of agreement in the underlying structure could
confound the interpretations of the MFIS as an outcome
measure.
The total score of the MFIS ranges from 0 to 84. The
ranges of scores for each subscale are as follows: physical,
0 to 36; cognitive, 0 to 40; and psychosocial, 0 to 8. No
data have so far been published regarding population
norms for the MFIS and its subscales. Some studies use
a total score of 38 as a cutoff to discriminate fatigued
from nonfatigued individuals.10,11 The score of 38 was
based on a study that correlated the MFIS with another
International Journal of MS Care
16
fatigue inventory and its defined scores for fatigued and
nonfatigued.12 Verification of these results has been less
than adequate, with researchers simply citing the study
of Flachenecker et al.12 as a rationale for using a cutoff
score of 38 to discriminate fatigued from nonfatigued
individuals with MS. The lack of population norms and
a possibly inappropriate cutoff score raise some questions
about the instrument and the ability to interpret scores.
Reliability
The reliability of the MFIS has been evaluated in a
small number of articles10,13 and in the MSQLI technical
inventory, which includes the MFIS. When consider-
ing reliability, two questions come to mind: 1) Is the
MFIS reliable (internal consistency)? 2) Is the impact of
fatigue experienced by individuals with MS stable and
reproducible with repeated measurements? The MSQLI
technical inventory provides some of the better reliability
(internal consistency) evidence. The phase 2 field testing
of the MSQLI instrument studied a sample of 300 indi-
viduals with MS selected from 4 MS clinics in Canada.
The sampling of subjects was focused on gender and
a commonly used measure of disability, the Expanded
Disability Status Scale (EDSS), keeping it similar to
those of previous epidemiological studies.8 The reported
internal consistency of all the MFIS scores was “excel-
lent,” with the following Cronbach α values: total, 0.81;
cognitive, 0.95; physical, 0.91; and psychosocial, 0.81.8
The technical guide suggests that the MFIS can be used
as a comprehensive (total score) and multidimensional
(separate subscales) assessment of the impact of fatigue.
The internal consistency reported by Kos et al.10 in 2005
showed similar results for the total score and two of the
subscales, physical and cognitive (Cronbach α values
of 0.92, 0.88, and 0.92, respectively). However, the
Cronbach α for the psychosocial subscale was 0.65.10
The lack of agreement with the psychosocial subscale
could be explained by the fact that the studies involved
individuals with different cultural backgrounds, which
could also influence the other subscales. Lack of agree-
ment does not invalidate the subscale but does suggest
further exploration of cultural differences as a confound-
ing variable.
The second question regarding reliability relates
to whether the impact of fatigue experienced by the
individuals varies from test to test. The MFIS has been
used as an outcome measure in several clinical trials,14,15
which assumes that the impact of fatigue persists and is

the same within an individual and across repeated mea-
sures. A few studies have been conducted to investigate
the test-retest reproducibility of the MFIS.10,13 In 2003,
Kos et al.13 conducted a study in which participants (n
= 51) completed the MFIS on two separate occasions
at the same time of day. The subscales, along with the
total score, were considered stable over the 3 days using
a Wilcoxon rank sum test to assess differences from day
to day. Similar results were observed in a subsequent
study in 200510 in a much larger sample (n = 181). Once
again, the MFIS was administered on two occasions 3
days apart, with no significant difference found in scores
(intraclass correlation coefficient [ICC] of the subscales
ranged from 0.84 to 0.91 and of the total was 0.91).
However, a limitation of this study is the lack of expla-
nation in the methodology regarding administration of
the MFIS and whether confounding variables such as
sleep or caffeine intake were accounted for. These data
suggest that the MFIS has adequate test-retest reliability;
however, because of the possibility of confounding vari-
ables affecting test results, this reliability should be veri-
fied by conducting a study in which these variables are
controlled. Another confounding aspect that could affect
reproducibility is the notion that fatigue may or may not
be stable in a person with MS.
Validity
An instrument can be reliable but not valid; this is
akin to the important distinction between precision
and accuracy. Validity refers to how well the instru-
ment is measuring the construct of interest. In assessing
whether an instrument is valid, one should consider the
nomological network under which the instrument was
constructed. The nomological network under which the
MFIS was constructed has not been directly established
or clarified. Therefore, we must first identify what fac-
tors should correlate highly with the MFIS, as well as
those factors that should be unrelated or weakly correlat-
ed. If the construct is assessing what it purports to assess,
it should correlate highly with other measures of similar
constructs (convergent validity), and it should weakly
correlate with constructs that are theoretically unrelated
(discriminant validity). One way to assess these aspects
of validity is to simultaneously administer the MFIS
with other related and unrelated psychometric instru-
ments and assess the strength of their correlations.
Because the MFIS assesses the impact of fatigue,
it should converge with other subjective measures of
International Journal of MS Care
17
Psychometric Properties of the MFIS
fatigue. The MFIS does have moderate to strong correla-
tions with the Fatigue Severity Scale (FSS), a measure of
fatigue in general use,11,12 which is not surprising given
that the FIS was derived from the FSS. Tellez et al.11
reported correlations between the FSS scores and the
total MFIS score, with a correlation coefficient of 0.68.
The subscales also correlated with the FSS, with correla-
tion coefficients of 0.75 for the physical subscale, 0.44
for the cognitive subscale, and 0.62 for the psychosocial
subscale.11 Kos et al.13 reported a correlation of 0.66
between the FSS and the total MFIS score. With both
instruments assessing fatigue, a much higher correlation
might be expected; however, it should be considered that
the MFIS assesses primarily the impact of fatigue, while
the FSS also assesses severity and frequency. When the
FSS is correlated with the separate subscales from the
MFIS, the physical subscale shows a stronger correlation
than the other subscales. This is not surprising given that
the impact of fatigue questions on the FSS focus more
on the physical aspects of daily living. Results from the
phase 2 trial assessing the validity of the MSQLI indi-
cated significant correlations of the 36-item Short Form
Health Status Survey (SF-36) vitality scale (r = −0.59),
the Sickness Impact Profile (SIP) Sleep and Rest Scale
(r = 0.47), and the SIP Alertness Scale (r = 0.65) with
the MFIS.8 Both the SF-36 and the SIP are widely used
instruments. The correlation with the vitality scale helps
establish validity, because it is logical that fatigue could
be accompanied by decreased vitality. The correlations
with the Sleep and Rest Scale and the Alertness Scale
might suggest problems with the MFIS in that it cannot
distinguish between sleepiness and alertness with respect
to impact of fatigue.
Depression could be a symptom of fatigue, and
fatigue could be a symptom of depression, leading to a
long-standing debate about the causal direction between
these variables. Tellez et al.11 found a clear relationship
between depression and fatigue in individuals with MS,
with a significant correlation (r = 0.70) between the
MFIS total score and depression measured with the Beck
Depression Inventory (BDI). Depression and fatigue
are often associated with disease-specific variables such
as disability and disease duration. When EDSS scores
were controlled, the correlation between depression and
fatigue remained positive.11 When these variables were
analyzed using multiple linear regression, EDSS score,
depression, and disease duration were all independent
predictors of all the MFIS subscale and total scores.11
Larson
However, Greim et al.16 reported that depressed MS
patients subjectively felt significantly more tired than
nondepressed MS patients (mean [SD] = 49.8 [13.1]
vs. mean [SD] = 32.6 [16.8]; P < .003), supporting the
notion that a depressed mood can affect the subjective
estimation of fatigue.
The validity of a subjective instrument can be
strengthened when it is paired with an objective mea-
sure, provided that the measures are appropriate sur-
rogates. The study conducted by Greim et al.16 assessed
objective and subjective measures of mental and physical
fatigue in individuals with and without MS. Participants
completed subjective measures of fatigue, specifically
the MFIS, before and after a 30-minute vigilance test
(an objective test of mental fatigue) and a hand-dyna-
mometer test (an objective test to assess physical fatigue).
Depression was controlled during the study because of
its possible influence on subjective and objective mea-
sures of fatigue. A significant correlation between the
subjective feelings (MFIS) and the objective measures
was observed in the individuals with MS. The indi-
viduals with higher levels of subjective fatigue performed
worse on the objective measures. However, the depres-
sion scale (BDI) was significantly correlated with the
measures of fatigue, confirming previous data indicating
an interaction between fatigue and depression that can
confound study results and subsequent interpretations.
Considerable research has been conducted to find
ways to reduce the impact of fatigue in individuals with
MS. Various pharmacologic agents are used to this end,
and data from these studies can provide validity evi-
dence for the MFIS. Modafinil (Provigil), a commonly
prescribed medication used to reduce the symptoms of
fatigue with the aim of reducing the impact of fatigue
on quality of life, was tested during a 9-week single-
blind study involving a sample of 72 individuals with
MS.14 All participants received the medication, but
the treatment sequence was blinded. The medication
regimen included a placebo run-in period (weeks 1–2),
200 mg/day of modafinil (weeks 3–4), 400 mg/day of
modafinil (weeks 5–6), and a placebo washout period
(weeks 7–9). The MFIS was one of the main outcome
variables for this study. The MFIS total score, along
with scores for the three subscales, were significantly
reduced when individuals were administered 200 mg/
day of modafinil.14 The actual mean score went from
44.7 to 37.7 (7-point reduction). However, when par-
ticipants were administered the higher dosage (400 mg/
International Journal of MS Care
18
day), the mean MFIS score (42.1) did not differ from
that of the placebo run-in period. The mean MFIS score
following the placebo washout period was roughly equal
to that after the placebo run-in period (43.0 and 44.7,
respectively).14 This does provide some evidence that the
MFIS can detect a change in scores; however, the lack of
a true control group and the failure to control for other
variables such as sleep and depression may confound the
outcomes. These results suggest that the MFIS is sensi-
tive to change but that the interpretation of these results
is limited to just that: a reduction in MFIS scores.
Little to no research has been published outlining
what a change in MFIS scores (increasing or decreasing)
reflects objectively. Currently the interpretation is lim-
ited to change directions—that is, a reduction in scores,
no significant change in scores, or an increase in scores.
The term clinically meaningful or clinically relevant has
been used in a number of studies in an attempt to give
meaning to the results and allow for some kind of inter-
pretation of the scores.15,17 However, these studies do
not provide sufficient evidence for their selection of what
is deemed clinically meaningful. A study by Kos et al.17
considered a change in score of 10 or more to be clini-
cally relevant, based on other studies that found a differ-
ence in MFIS scores of 7 to 20.1. Another article used
a cut-point of 45 or more for the total MFIS score as a
study entry criterion, without providing a clear rationale
for the selection of that score.15 The lack of objective
anchors for the MFIS total and subscale scores limits the
interpretations of this instrument’s results.
A more recent article found flaws in the underlying
structure of the MFIS and used the Rasch measurement
model to determine that the use of the total score is
invalid.18 The Rasch model represents the interactions
between subjects and the test items to produce linear
measurements: “The model states that the probability of
a person giving a certain answer to an item is a logistic
function of the difference between the person’s ‘ability’
and the item’s ‘difficulty.’”18 In the case of the MFIS,
a person with high levels of fatigue would affirm items
expressing high levels of fatigue, while a person with low
levels of fatigue would have difficulty affirming these
items. According to Wright and Linacre,19 it is the only
way in which ordinal observations of clinical phenomena
can be converted into linear measurements. The 21-item
MFIS did not fit the Rasch model, which does not
support the use of the total score as a global index but
rather indicates that it is multidimensional.18 Mills and

colleagues18 further explored this concept and were able
to achieve fit to the Rasch model through the removal
of the following items: 4 (“I am clumsy and uncoordi-
nated”; physical subscale), 14 (“I am physically uncom-
fortable”; physical subscale), and 17 (“I am less able to
complete tasks that require physical effort; physical sub-
scale). The authors then identified two subscales of the
MFIS: physical and cognitive. The psychosocial subscale
was eliminated because the items were found to be part
of the physical subscale, consistent with the findings of
Kos et al.10 The authors argue that studies in which the
global MFIS score was used as an outcome measure or a
selection tool might be invalid or subject to misinterpre-
tations. Despite the problems regarding the underlying
structure, it appears that the physical and cognitive sub-
scales can be useful as outcome measures.
Conclusion characteristics of people with multiple sclerosis. Arch Phys Med Reha-
Clearly, the MFIS as an outcome measure has some
problems resulting in limitations in interpreting the
scores. The lack of agreement between the underly-
ing structure and its subscales raises complex issues,
especially if the MFIS total score is invalid. The MFIS
total score has been commonly reported as an outcome
measure, but given the results reported by Mills et al.,18
the interpretations of studies using the MFIS total scores
may need to be reevaluated. Additionally, the potential
effects of confounding variables—specifically, depres-
sion—on MFIS scores may lead to misinterpretation
of the results of uncontrolled studies. There may be no
good way to separate these constructs in some samples
such as people with MS. Probably the biggest problem
with MFIS score interpretation is the lack of objective
anchors. As the measurement stands, the interpretations
PracticePoints
• The Modified Fatigue Impact Scale (MFIS) is a
widely used self-report measure of fatigue in
people with MS, but its reliability and validity
have not been adequately addressed.
• The MFIS has various problems that result in limi-
tations in interpreting the scores.
• In particular, the scale’s lack of agreement
between the underlying structure and its sub-
scales raises complex issues and should be con-
sidered before use of this instrument in clinical
research and practice.
International Journal of MS Care
19
Psychometric Properties of the MFIS
are limited to whether a score changed significantly and
the direction of that change. No studies have yet been
published that objectively show what a change in the
MFIS represents. In other words, if an MS patient’s
physical subscale score on the MFIS improves by 5
points, does that mean that the person can walk farther
and faster? Further research on the MFIS is needed to
address some of the problems described here and to
identify what a change in MFIS score represents on an
objective measure of quality of life in the physical and
cognitive domains. o
Financial Disclosures: The author has no conflicts of interest to
disclose.
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Larson

Appendix 1. Modified Fatigue Impact Scale

Patient’s Code: ________________________  Date: ______/______/______

month day year
Test#: 1 2 3 4
MODIFIED FATIGUE IMPACT SCALE (MFIS)
INSTRUCTIONS
Following is a list of statements that describe how fatigue may affect a person. Fatigue is a feeling of physical tiredness and
lack of energy that many people experience from time to time. In medical conditions like MS, feelings of fatigue can occur
more often and have a greater impact than usual. Please read each statement carefully, and then circle the one number
that best indicates how often fatigue has affected you in this way during the past 4 weeks. (If you need help in marking
your responses, tell the interviewer the number of the best response.) Please answer every question. The interviewer
can explain any words or phrases that you do not understand.
Because
of my fatigue during the past 4 weeks…

Some- Almost
Never Rarely times Often Always
  1. I have been less alert. 0 1 2 3 4
  2. I have had difficulty paying attention for long periods of 0 1 2 3 4
time.
  3. I have been unable to think clearly. 0 1 2 3 4
  4. I have been clumsy and uncoordinated. 0 1 2 3 4
  5. I have been forgetful. 0 1 2 3 4
  6. I have had to pace myself in my physical activities. 0 1 2 3 4
  7. I have been less motivated to do anything that requires 0 1 2 3 4
physical effort.
  8. I have been less motivated to participate in social activities. 0 1 2 3 4
  9. I have been less motivated to do things away from home. 0 1 2 3 4
10. I have had trouble maintaining physical effort for long 0 1 2 3 4
periods.
11. I have had difficulty making decisions. 0 1 2 3 4
12. I have been less motivated to do anything that requires 0 1 2 3 4
thinking.
13. My muscles have felt weak. 0 1 2 3 4
14. I have been physically uncomfortable. 0 1 2 3 4
15. I have had trouble finishing tasks that require thinking. 0 1 2 3 4
16. I have had difficulty organizing my thoughts when doing 0 1 2 3 4
things at home or at work.
17. I have been less able to complete tasks that require physi- 0 1 2 3 4
cal effort.
18. My thinking has been slowed down. 0 1 2 3 4
19. I have had trouble concentrating. 0 1 2 3 4
20. I have limited my physical activities. 0 1 2 3 4
21. I have needed to rest more often or for longer periods. 0 1 2 3 4

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