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Introduction Neuropathic pain is a common symptom, present in 39% of the patients with cancer pain. Treating this type of pain is challenging, as this patient group is often frail and has comorbidities which increase the risk of side events and hence influences their quality of life. Clinical practice guidelines ( CPGs) can be helpful for clinicians, especially when scientific evidence is uncertain or weak. In this study, we focused on the quality of the review of the literature used in treatment recommendations in the selected European CPGs. Methods In a previous study, 9 CPGs from European countries that contained at least one paragraph on treatment for neuropathic pain in cancer were included. Recommendations with their grade (according SIGN 55 classification) and supporting literature (first author, patients' population, year and type of publication) were compared between CPGs. Results In all CPGs, amitriptylin was mentioned as the drug of first choice. Six guidelines proposed also gabapentinoids. Only 30 of the 163 citations (18%) were based on studies in patients with cancer. Seven CPGs did not argue the indirect evidence due to extrapolation of study results from non-cancer to patients with cancer. Conclusion The majority of guideline development groups extrapolated their results from non-cancer publications to formulate recommendations. Consequently, these guidelines fail to address important issues such as altered kinetics and side effect profiles in these patients. We recommend creating specific recommendations by an international expert group for the treatment for neuropathic pain in patients with cancer supported by targeted research in patients with cancer. [ABSTRACT FROM AUTHOR]

Background Neuropathic pain is a prevalent symptom in patients with cancer, which needs a more specific algorithm than nociceptive pain or neuropathic pain from other origin. Clinical practice guidelines ( CPGs) can be helpful in optimizing the diagnosis of neuropathic pain in patients with cancer. Methods In this study, 9 national CPGs in Europe on the diagnosis of neuropathic pain in patients with cancer were included. Recommendations with their grade (according SIGN 55 classification) and supporting literature (first author, patients' population, year, and type of publication) were compared between CPGs. Results Nine CPGs including recommendations on neuropathic pain could be selected and were assessed. In total, they used 149 references of which 72 (48%) were about cancer conditions, 39 (26%) about neuropathic pain, and only 3 about neuropathic pain in patients with cancer (2%). Only 28 (19%) references were shared between 2 or more guidelines. There was only one shared reference specifically related to cancer neuropathic pain. Recommendations and their evidence grading strongly differ between CPGs. Conclusion This work demonstrates an important heterogeneity between European recommendations on diagnosis and assessment of neuropathic pain in patients with cancer. The main weaknesses are the low level of evidence and the absence of specific data focusing on neuropathic pain in patients with cancer. We recommend that physicians dealing with neuropathic pain in patients with cancer should be specially trained, that a specific methodology to develop CPGs should followed, and that specific research should be developed on the diagnosis of neuropathic pain in patients with cancer. [ABSTRACT FROM AUTHOR]

The article presents a follow-up study which investigates whether the practice of continuous palliative sedation has changed after the introduction of a national guideline in Netherlands. It discusses the results of the study including the reported last case of continuous sedation in both the baseline and follow-up studies and the significant increase in patient involvement. It concludes that physicians reported changes in palliative sedation practice comply with the recommendations of the released guidance, in which the use of benzodiazepines for sedation increased.

Fatigue has been mentioned as an important complaint in several groups of disease-free patients after curative treatment for cancer. However, it has never been investigated in a sample of patients who have been treated for a bone or soft tissue tumor in the past. In the current study, these patients participated. Measurement included posted questionnaires at baseline and at follow-up (two years later). Baseline results indicated that fatigue is a severe problem for 28% of the investigated patients. Percentages were equal for patients who were treated for malignant or benign tumors. Fatigue complaints seem to be most severe for patients who finished treatment relatively recently, and for patients who had to undergo more than one operation. In addition, fatigue was associated with several psychological and physical variables. At follow-up, the majority of all patients who were severely fatigued at baseline continued to be severely fatigued. Severe fatigue at follow-up was predicted by oncological complications after initial treatment, less optimism, and more somatization. It can be concluded that fatigue is an important problem for more than a quarter of a sample of patients who have been treated for a malignant or benign bone or soft tissue tumor in the past. [Copyright &y& Elsevier]

Context: A gold standard or validated tool for monitoring the level of discomfort during continuous palliative sedation (CPS) is lacking. Therefore, little is known about the course of discomfort in sedated patients, the efficacy of CPS, and the determinants of discomfort during CPS.Objectives: To identify the course of discomfort in patients receiving CPS.Methods: A prospective observational multicenter study in nine hospices and palliative care units was performed. The Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) was independently assessed for monitoring of patient discomfort during CPS. The DS-DAT scores range from 0 (no observed discomfort) to a maximum of 27 (high level of observed discomfort). Using a mixed model, the mean group score of discomfort between four predefined time frames of CPS was compared, correcting for confounding patient characteristics.Results: A total of 130 patients were sedated, and the DS-DAT was completed in 106 patients at least once. The median duration of the sedation in these 106 patients was 25.5 hours (range 2-161). The mean score of the DS-DAT in the phase before sedation was 12.16 (95% CI 9.83-14.50) and decreased significantly to 8.06 (95% CI 5.53-10.58) in the titration phase of sedation. The mean score of the DS-DAT in the final phase of sedation was 7.42 (95% CI 4.90-9.94).Conclusion: This study shows that CPS is associated with a decrease in the level of discomfort within an acceptable time frame, although in some sedated patients higher levels of discomfort in the last hours of life occurred. Although the DS-DAT seems to be of value for monitoring the level of discomfort during CPS, the results of this study should be interpreted within the constraints of the limitations, and further research on the psychometric properties of this tool is needed before the DS-DAT can be used in clinical practice. [ABSTRACT FROM AUTHOR]

Context: Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning.Objectives: This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life.Methods: A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed.Results: A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P < 0.001), the use of psycholeptics (P = 0.003), and higher Edmonton Symptom Assessment System distress score (P = 0.05). Multivariate logistic regression analysis showed that only the use of opioids at admission (odds ratio 1.90; 95% confidence interval 1.18-3.05) was significantly associated with the administration of CPS.Conclusion: Physicians should be aware that patients who use opioids at admission have an increased risk for the administration of CPS at the end of life. In this group of patients, a comprehensive personalized care plan starting at admission is mandatory to try to prevent the development of refractory symptoms. Further research is recommended, to identify other determinants of the administration of CPS and to investigate which early interventions will be effective to prevent the need for CPS in patients at high risk. [ABSTRACT FROM AUTHOR]

Background: Palliative care is mainly restricted to terminal care. General practitioners (GPs) are not trained to early identify palliative patients with cancer, COPD or heart failure. With the help of the RADboud indicators for PAlliative Care needs (RADPAC), we trained GPs to identify patients' needs and to make a proactive care plan. They were also able to join two role-plays where they discussed the patient's future, and consulted a palliative care consultant to fine-tune the care plan. We evaluated the programme with the GPs and consultants and noted its impact on their daily practice. Methods: Two years after they had participated in the programme, we held semi-structured interviews with the GPs and a focus group interview with the consultants and performed a thematic content analysis. Results: Six consultants and nine GPs participated in the programme. Most GPs and consultants mentioned positive changes in the thinking or acting of GPs regarding early palliative care. A number continued to use the tool to identify patients; most of the others noted they had internalised the indicators. Although half of them still considered discussing end-of-life aspects difficult, particularly in patients with organ failure, the others were more easily able to discuss the future with their palliative patients. Conclusion: Although most GPs and consultants were positive about the training programme and applying it in daily practice, we conclude that in future programmes, more attention needs to paid to timely identification of palliative patients with COPD or CHF and how to discuss the future with them. [ABSTRACT FROM AUTHOR]

Background. Although fatigue is the most frequently occurring symptom in patients with cancer, hardly anything is known about fatigue of their informal caregivers and the impact fatigue might have on perceived burden with providing care. We investigated the presence of fatigue in caregivers, its course and the relation of fatigue severity between caregivers and patients. Furthermore, we explored in caregivers whether fatigue severity was correlated to experienced burden. Material and methods. Informal caregivers and patients on cancer treatment in the palliative phase completed questionnaires at baseline and follow-up (6 months later). To measure fatigue severity, both groups completed the Checklist Individual Strength. Additionally, caregivers completed the Caregivers Strain Index to assess experienced burden with providing care. Descriptive analyses, paired t-tests, χ2-tests, Pearson's correlations and regression analysis were performed. Results. At baseline 111 couples (patients and caregivers) participated, at follow-up 75 couples. At both time points 23% of caregivers were severely fatigued. There was no significant correlation between patients and caregivers on fatigue. Higher fatigue in both patients and caregivers was correlated with higher burden in caregivers and over 30% of burden could be explained by fatigue. Conclusion. Almost a quarter of caregivers of patients on active palliative treatment were severely fatigued, which figure remained stable over time. Fatigue in both patients and caregivers was related to caregivers' burden. This observation should be taken into account with the growing demand on caregivers and the increase in cancer treatment options in the palliative setting. [ABSTRACT FROM AUTHOR]

Objective Fatigue is the most frequently occurring and distressing symptom in patients with advanced cancer, caused by multiple factors. Neither a specific histological diagnosis of malignancy nor the type of anticancer treatment seem to be strongly related to fatigue, which support the idea that other factors may play a role. This study investigated to what extent the model of fatigue-perpetuating factors that is known for cancer survivors was applicable for patients with advanced cancer. Methods Patients on active treatment for various incurable cancers were asked to complete the Checklist Individual Strength, subscale fatigue severity and physical activity, the Acceptance scale of the Illness Cognition Questionnaire, the Hospital Anxiety and Depression Scale, the Fatigue Catastrophizing Scale, the Symptom Checklist subscale sleep, and the van Sonderen Social Support List-Discrepancies. Results The questionnaires were filled in by 137 patients. Inappropriate coping, fear of progression, fatigue catastrophizing, discrepancies in social support, depressive mood, self reported physical activity, and sleeping problems were all related to fatigue severity in univariate analyses, of which the latter two were significant in a multivariate linear regression analysis. Conclusion This study tested fatigue-perpetuating factors known to be of relevance in cancer survivors, for their relation with fatigue severity in palliative patients. We demonstrated that these factors were also relevant for patients on palliative treatment. On the basis of our results, we suggest clinicians confronted with palliative patients with serious fatigue to address sleeping problems and promote physical activity. In case of persistent fatigue, personalized cognitive behavioral therapy can be considered. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Little is known about the determining factors related to the administration of continuous palliative sedation. Knowledge of these determinants may assist physicians in identifying patients who are at high risk of developing refractory symptoms, enable physicians to inform patients, and optimize close monitoring. Objective: The aim of this systematic review was to identify determinants of the administration of continuous palliative sedation. Design: A systematic review of PubMed, EMBASE, and CINAHL was performed to identify English, Dutch, and German language papers published from January 1990 through April 2011. Inclusion was based on the following criteria: patient-based research on continuous palliative sedation, studies investigating determinants of palliative sedation and/or comparison between sedated and nonsedated cohorts, and studies using multivariate analyses and of fair to good or good methodological quality. Results: In total, eight papers were reviewed. The following nine factors were found to be associated with the administration of continuous palliative sedation: younger age, male sex, having cancer, feelings of hopelessness, dying in a hospital, living in a Dutch speaking community setting, very nonreligious or extremely nonreligious physicians, physicians working in 'other hospital' specialties, and physicians in favor of assisted death. Conclusions: Given the variation in study designs and the limitations of the included studies, the outcomes should be interpreted carefully. Further research is needed, particularly regarding factors that can be influenced and that may alter the course of a patient's symptoms and the patient's eventual need for palliative sedation. [ABSTRACT FROM AUTHOR]

Objectives To identify the prevalence and causes of neuropathic pain in Dutch nursing home residents; to establish the prevalence of painful and nonpainful diabetic polyneuropathy in a subsample of individuals with diabetes mellitus and central poststroke pain ( CPSP) in a subsample of individuals who had a stroke; and to study the prescription of antineuropathic drugs. Design A descriptive, retrospective, cross-sectional study conducted by analyzing medical records. Setting Data were collected in 12 Dutch nursing homes. Participants The data were derived from the medical records of 497 residents of chronic long-term stay and rehabilitation nursing home units. Measurements Four groups were defined: actual (at some time in the previous year) neuropathic pain ( ANP), possible neuropathic pain ( PNP), neuropathic pain in the past ( NPP), and no signs of neuropathic pain ( No NP). Results The prevalence of ANP was 10.9% (95% confidence interval ( CI) = 8.4-13.8%) and of PNP was 5.6% (95% CI = 3.9-7.9%). The most common causes were CPSP and phantom limb pain. In the subgroup with diabetes mellitus, 6.3% had nonpainful diabetic polyneuropathy, 0.7% had painful diabetic polyneuropathy, and 0.7% had possible painful diabetic polyneuropathy. In the poststroke subsample, 4.7% were identified as having CPSP, and 5.2% were identified as possibly having CPSP. Within the ANP group, 68.5% of the residents received antineuropathic drugs on the day the medical records were examined; 48.1% used anticonvulsants. Conclusion Dutch nursing home residents frequently experience neuropathic pain; therefore, neuropathic pain should receive more attention in frail elderly adults. [ABSTRACT FROM AUTHOR]

Introduction: In order to facilitate GPs in their work and increase the possibilities for patients to remain at home, it is important to identify the obstacles which hinder the delivery of primary palliative care. From previous research we learned about some of the problems experienced by GPs. In this survey we aimed to identify the prevalence of such problems in providing palliative care and its determinants. Methods: The prevalence of obstacles and its determinants were identified by a questionnaire to 320 GPs in three regions of the Netherlands. Obstacles were grouped as follows: communication, organisation & co-ordination of care, knowledge & expertise, integrated care, time for relatives. The potential determinants were GP characteristics and expertise development activities. Results: The response rate was 62.3%. GPs experienced considerable obstacles in all aspects of palliative care. The most prevalent were: problems with bureaucratic procedures (83.9%), the time necessary to arrange home care technology (61.1%) and the difficulties accompanied with the wish or necessity to obtain extra care (56.3%). In general, more years of GP experience and the participation in (multidisciplinary) case discussions were associated with less perceived obstacles. Discussion: Based on the results of our survey policymakers and practitioners can plan and set priorities in handling the obstacles. There is a high necessity of firstly overcoming the barriers within organisation and coordination of care. Furthermore, our study can help in choosing the (additional) expertise needed in the future and in the realisation of the preferred expertise advancement activities. [ABSTRACT FROM AUTHOR]

The article attempts to determine the adherence to guidelines for palliative sedation with regard to prescription in the Netherlands. It shows that the rate of 43 percent noncompliance to the guidelines was mostly associated to the omission of continued antipsychotic treatment for delirium and the use of morphine as the single therapy for the purpose of deep sedation.

Objective: Fatigue remains one of the most common and distressing symptoms during treatment for advanced cancer. The TIRED trial demonstrated cognitive behavior therapy's (CBT) significant and clinically relevant effects to reduce fatigue among patients with advanced cancer, while graded exercise therapy (GET) did not prove beneficial. The present study aims to determine the mechanisms by which CBT and GET affect fatigue. Method: The TIRED trial randomized 134 patients with advanced cancer to CBT (n = 46), GET (n = 42), or usual care (n = 46). At 14 weeks, 126 evaluable patients provided fatigue data and of those 117 received ≥1 CBT or GET session or usual care. We tested a prespecified multiple mediation model with four potential mediators (physical activity, exercise capacity, self-efficacy, and fatigue catastrophizing) assessed at baseline and at 14 weeks. Post-hoc analyses also included perceived physical activity and emotional functioning as potential mediators. Results: A total of 82 of 117 patients completed all required measures. CBT reduced fatigue indirectly through its effect on self-efficacy, ab = −3.292; 97.5% bootstrap CI [−6.518 to −0.598]. CBT participants experienced an increase in fatigue self-efficacy, with greater self-efficacy associated with decreased fatigue severity. There was no evidence that changes in physical activity, exercise capacity, perceived physical activity, fatigue catastrophizing, or emotional functioning mediated CBT's or GET's effects on fatigue. Conclusions: The effect of CBT was attributable to changes in cognition, that is, increased self-efficacy led to reduced fatigue severity. No significant mediators for GET were found. The findings inform further refinement of interventions for fatigue in this seriously ill population. What is the public health significance of this article?: Fatigue is one of the most common and burdensome side effects for patients with advanced cancer and for patients with other serious illnesses. The effect of psychosocial treatment for fatigue among patients with advanced cancer can be attributed to changes in beliefs. Specifically, when helping patients with advanced cancer reduce their fatigue, it is important to increase the belief in one's capabilities to carry out behaviors rather than improve actual physical condition. [ABSTRACT FROM AUTHOR]

Objective: Fatigue is investigated in 57 severely fatigued disease-free breast cancer patients and in 57 gender- and age-matched patients with chronic fatigue syndrome (CFS) using multidimensional and multimethod assessment. A comparison between these groups of patients is important to determine whether a cognitive behavioural intervention to reduce fatigue in CFS patients would be appropriate as well for severely fatigued disease-free breast cancer patients.Methods: Measurement included computerised questionnaires and a standardised neuropsychological test. Furthermore, patients filled out a daily Self-Observation List (SOL) and wore an actometer during a period of 12 days.Results: In comparison to severely fatigued disease-free breast cancer patients, CFS patients score more problematic with regard to the level of fatigue, functional impairment, physical activity, pain and self-efficacy. However, a subgroup of severely fatigued disease-free breast cancer patients reports the same amount of problems as CFS patients with regard to psychological well-being, sleep and concentration. Finally, CFS patients and severely fatigued breast cancer patients score equal on measures of social support.Conclusion: There seem to be some similarities but also many differences between severely fatigued breast cancer survivors and females with CFS. Therefore, cognitive behaviour therapy (CBT) to reduce fatigue after treatment for cancer should also differ in certain aspects from cognitive behaviour therapy as it has been developed for patients with CFS. [ABSTRACT FROM AUTHOR]

The article focuses on the fatigue which is a prevalent and inconvenient symptom for patients with advanced cancer. Topics discussed include need for interventional studies like randomized controlled trials for the management of fatigue in advanced cancer patients, professional gatekeeping as a barrier in identification of advanced cancer patients and need for patient participation in order to get information about studies for fatigue and quality of life.

Background: Pain is a common symptom in patients with multiple myeloma (MM). Many patients are dependent on analgesics and in particular opioids, but there is limited information on the impact of these drugs and their side effects on health-related quality of life (HRQoL). Method: In a cross-sectional study, semi-structured interviews were performed in 21 patients attending the hospital with symptomatic MM on pain medications. HRQoL was measured using items 29 and 30 of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30. Results: Patients were able to recall a median of two (range 0-4) analgesics. They spontaneously identified a median of two (range 1-5) side effects attributable to their analgesic medications. Patients' assessment of HRQoL based on the EORTC QLQ-C30 questions 29/30 was mean 48.3 (95 % CI; 38.7-57.9) out of 100. Patients' assessment of their HRQoL in the hypothetical situation, in which they would not experience any side effects from analgesics, was significantly higher: 62.6 (53.5-71.7) ( t test, p = 0.001). Conclusion: This study provides, for the first time, evidence that side effects of analgesics are common in symptomatic MM and may result in a statistically and clinically significant reduction of self-reported HRQoL. [ABSTRACT FROM AUTHOR]

Between 19% and 39% of patients with cancer pain suffer from neuropathic pain. Its diagnosis and treatment is still challenging. Yet, national clinical practice guidelines ( CPGs) have been developed in several European countries to assist practitioners in managing these patients safely and legally. The aim of this study was to assess the quality of the development and reporting of these CPGs. Methods In collaboration with the European Federation of IASP Chapters, a European inventory of CPGs was conducted. Inclusion criteria were at least one paragraph dedicated to the treatment of neuropathic pain in cancer. Using the Appraisal of Guidelines, Research and Evaluation II instrument, 2 appraisers independently assessed the quality of the development process of the included CPGs in 6 quality domains. Besides, CPGs developed by governmental organization were compared with those developed by professional societies using t-tests. Results Mean scores of the domains 'scope and purpose' (80%) and 'clarity of presentation' (61%) were satisfactory, 'stakeholder involvement' (58%), 'rigor of development' (57%), and 'editorial independence' (53%) were acceptable, and 'applicability' was insufficient (39%). Governmental guidelines had higher quality scores than professional society guidelines for domain 'stakeholder involvement' and 'editorial independence' ( P < 0.01). Conclusions The quality of the development process of the 9 included CPGs varied widely. CPGs should be developed within a structured guideline program, including methodological support. As developing a CPG is expensive and time-consuming, we recommend more international cooperation to increase quality and lower the development costs. [ABSTRACT FROM AUTHOR]

Objective: The Pictorial Representation of Self and Illness Measure (PRISM) measures in a simple, graphic way the burden of suffering due to illness. The question addressed in this study is whether the PRISM is a valid instrument to measure suffering in cancer survivors experiencing severe fatigue. Method: Quantitative and qualitative data of a previous randomized controlled trial demonstrating the efficacy of cognitive behavior therapy (CBT) especially designed for postcancer fatigue was used to assess convergent validity and sensitivity to change in a sample of 83 cancer survivors. Measures: The PRISM, yielding self-illness separation (SIS-fatigue = suffering due to fatigue; SIS-cancer = suffering due to cancer), fatigue severity (Checklist Individual Strength; CIS-fatigue), functional impairment, psychological well-being, quality of life, and coping with the experience of cancer (Impact of Event Scale; IES). Results: Moderate significant correlations were found with the PRISM and the above mentioned measures. On the basis of SIS scores, the sample was divided into two separate groups: cancer survivors who suffered more because of fatigue and cancer survivors who suffered more because they had cancer in the past. The two groups had different scores on CIS-fatigue and IES, in line with that aspect that caused them the most suffering. The qualitative data confirmed this finding. Participants in the CBT condition demonstrated a significant difference between SIS-fatigue at baseline versus 6 months later compared with those in the waiting list condition. No change of SIS-cancer was found. Conclusion: The PRISM seems to be a valuable tool in fatigue research and clinical practice. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. DESIGN: A structured retrospective questionnaire. SETTING: Nationwide nursing home physician study in the Netherlands. PARTICIPANTS: One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. MEASUREMENTS: Characteristics of CPS and requests for euthanasia were measured. RESULTS: Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0–240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0–480 mg/24 h). CONCLUSION: In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended. [ABSTRACT FROM AUTHOR]

Background: the primary objective was to develop an adjective checklist, the Fatigue Quality List (FQL), aimed at assessing different perceptions of fatigue. Methods: 961 participants filled out the FQL (28 adjectives). A component and confirmatory factor analyses were performed and psychometric properties were evaluated. Differences on factor scores between different patients' groups were investigated and pre- and post treatment scores were compared in demonstrating change of perceptions after treatment of fatigue. Results: Four independent factors were found with adequate psychometric properties. Different perceptions were found between the patients' groups. Patients who were recovered after treatment for fatigue showed similar scores on the factors as healthy controls. Conclusion: The FQL appears to be a promising tool in measuring different perceptions of fatigue, which can be especially interesting for clinical practice. [ABSTRACT FROM AUTHOR]