The Relationship Between Fhysical Function ing and Mood State

in Fersons with Cancer

by

Wendy W. Crabbe

THESIS

Submitted in partial satisfaction of the requirements for

the degree of

MºSTER OF SCIENCE

in

NURSING

in the

GRADUATE DIVISION

Of the

UNIVERSITY OF CALI FORNIA

San Francisco

copyright (1992)

by

Wendy W. Crabbe

ii

Acknowl edgements

I would like to thank my husband Matt for re-doing my

tables and for his unfail ing love and support , and to my

son, Christopher for my inspiration . I would al sc l i ke to

thank my mother Sharon for her typing skills, love , and

support , and my friends Jeff and Mary for their computer in

my time of need .

Thanks also go to Drs. Fatricia Larson , Christine

Mi ask owsk: i , and Suzanne Dibble for their many hours of

expertise and support. Special thanks go to Dr. Maryl in

Dodd for the use of the data from the NCI funded study

"Self-Care to Decrease Chemotherapy Morbidity".

iii

The Relationship Between Physical Function ing and Mood State

in Fersons with Cancer by Wendy W. Crabbe

Abstract

The in it i at ion of chemotherapy of ten causes a literationsin physical and emotional health ; which places the burden ofmanaging the effects of chemotherapy on the patient at home ,on their own . The purpose of this study was to determinethe relationship between physical function in g and mood stateof cancer patients receiving four consecutive cycles ofchemotherapy. The larger study, where the data weregenerated by Lodd et al . ( 1988) Lised the Stress and Cop ingtheory of Lazarus & Fol k man ( 1984) as back ground to assessthe experience of chemotherapy related treatment morb 1 d 1 tyin persons with cancer. The conceptual framework for thisreport focuses on how physical function ing and mood stateare related to the way individual s eval uate and cope withthe stresses of ill ness and of everyday l l ving . Themajority of the participants (N = 1.27) were caucasian (89%) ,middle-aged (mean age of 52) , female (68.5%) ,married/partnered (61%) , with two years of collegeeducation . The most common cancer diagnosis was breastcancer (42.5%) , foll owed by lung cancer (15%) . Fhysicalfunction ing was measured using the Karnofsky FerformanceScore (KF5) and Fhysical Health Status (FHS) duest icnnaires.Higher scores indicate better physical function ing. Moodstate was measured L1s ing the Frofile of Mood States (FON15) -Higher scores of the FOMS subscales reflected more anger ,depression , f at i gue , and mood disturbance . All threeinstruments were administered as self-report questionnairesbefore chemotherapy was in it i ated (T 1) , and every cycle(T2-T4) for four months. The relationship between KFS , FHS,and FOMS were tested using Fearson 's Correl at i conCoefficients. Sign if i cant correl at 1 ons were found betweenK.FS and Total Mood List Lurbance (TMD) and between FHS and TMDat all four cycles, indicating that a decreased abil it y tofunction physical 1 y was associated with greater mooddisturbance. Fatigue, Vigor, and TMD were highly correl atedwith KFS and FHS at all 4 cycles of chemotherapy. ResultsOf this study emphasize the need for health professional s,especial 1 y nurses to make ongoing assessments of physicalfunction ing and mood state of patients receivingchemotherapy. Further research is needed to determine thespecific factors that contribute to alterations in physicalf Lunction in g and mood state .

iv.

Chapter I :

Chapter II :

Chapter I I I :

Chapter IV:

Ühapter V:

Chapter VI :

Table c + Contents

Introduct i On to the Froblem

Purpose

Assumptions

Lief in it i on cyf Terms

Concept Llal Framework

Literature Review

Fhysical Function ing and Mood State

Functional Status and Performance

Modd State

Methods

Research Iles ign

Sample

Research Setting

Instruments

Frocedures

Data Analysis

Results

Sample Lemographics

St Ludy Furpose 1

Study Furpose 2

Study Furpose 3

L. 1 scussion

Sign if i cance

Limitations

Impl i cat i Ons for Fract ice

2

33

36

37

Table of Contents ( continued )

References

Tables 1

through 7

Figures 1

through 1 Q

Appendix A Demographic Questionnaire

Appendix B Karnofsky Ferformance Score

Appendix C Fhysical Health Status Questionnaire

Appendix II Frofil e Of Mood State

E -,--|--

71

*,*-

.

;

vi

Table

Table

Table

Table

TAble

Table

Table

2

5

List of Tables

Demographic Characteristics of Fatients

Lescriptive and F'sychometric Froperties of

Variables

Fearson Correl at icºn's Between Physical

Function in g and Mood State

Sign i + 1 cant Changes in Mood State Over Time

Sign if i cant [.. if + erences in Fhysical Function ing

and Mood State in Individual s with Breast Cancer

and Individuals with Other Types of Cancer

Significant Differences in Physical Function ing

and Mood State in Individual s Without Metast as is

and Those with Metastasis

Statistics of Individual s Unable to Complete

4 Months of Study

vii

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

2

List of Figures

Lazarus & Folk man 's Stress, Appraisal , and

Coping Theoretical Framework with Study

Variables

Changes in

Over Time

Changes in

Over Time

Changes

Changes

Ühanges

Changes

Changes

Changes

Changes

in

in

in

in

in

in

in

Üver Time

Karnofsky Performance Scores

Fhysical Health Status Scores

Tension Scores Over Time

Depression Scores Over Time

Anger Scores Over Time

Vigor Scores Over Time

Fat i gue Scores Uver T 1 ■ he

Confusion Scores Over Time

Total Mood Listurbance Scores

|

.

-

2

Chapter I : Introduction to the Froblem

Many new antineoplastic drugs have been devel oped in

the last decade. As a result, many types of cancer can be

cured or control led with the administration of chemotherapy.

It is recognized cl i ni call y that the in it i at 1 on of

chemotherapy chal lenges the patient physica i l y and

emotional l y. However, the relationship between physical

function ing and emotional status of persons undergoing

chemotherapy has not been empirical l y described .

The physical health of persons undergoing chemotherapy

for their cancer is chal lenged by repeated episodes of

nausea, vomiting , and weakness, which can lead to major

disruptions in performance and functional capabil it i es at

work or at home (Schag, Heinrich , & Ganz , 1783; Freidenbergs

et al . , 1781-82; and Meyerowitz, Sparks, & Spears, 1777) .

Even though the Karnofsky Ferformance Score (KFS) is

frequently assessed by physicians during the course of

chemotherapy, l itt i e i = written about the specific changes

in physical function ing associated with treatment , and the

impact of these changes on the patient (Schag, Heinrich , &

Ganz , 1783; and Fre idenbergs et al . , 1981-82).

In add it i con 1 ittle is known about the effect

chemotherapy has cyn the emotional status of an individual .

Mood is one indi cat cor of an individual 's emotional status .

Mood changes could affect an individual 's ability to

function or v i sa versa, but the exact nature of this

rel at i onship is unclear . Depending on the patient 's

perception of the severity of the physical and emotional

effects of chemotherapy, patients may exhib it ineffective

coping behaviors, which may interfere with the treatment

plan and support from others (Mages & Mendol sohn , 1777 ;

Holmes, 1789; Love, Leventhal , Easterling , & Nerenz , 1989) .

Purpose

1. The primary purpose of this study was to determine the

rel at ionship between physical function i ng and mood state of

cancer patients receiving four consecutive cycles of

chemotherapy.

2. A second purpose was to determine if a relationship

existed between the demographic variable ( i.e. , age) and

physical function ing and mood state.

3. A third purpose was to determine if there was a

difference in physical f Lunction ing and mood state between

individual s with breast cancer and those with other types of

cancer ; between men and women ; and between individual s with

no evidence of metast as is and those with evidence of

metast as is .

fassumption=

The Lunderlying assumptions used in this study were as

+ C) l l ows :

1 . The experience of receiving chemotherapy is stressful to

the cancer patient , especial l y as reflected by the

individual ‘s perception of their physical + Lunction in G and

mood state during the + our cycles of chemotherapy.

2. A component of physical health includes phys 1 cal

function i ng of an individual .

3. A component of emotional health is mood state .

4. Cognitive appraisal of the person toward his/her cancer

and its treatment can affect the individual ‘s perception of

physical function ing and mood state. Fhysical function ing

and mood are related to the way individual 5 evaluate and

cope with the stresses of ill ness and everyday living

(Lazarus & Folk man, 1984) .

Lief in it i Cºn D+ Terms

1 . Fhysical function i ng - is defined as performance and

functional status, or one 's abil it y to take care of onesel f ,

or perform in the multiple role capacities at work or at

home, as measured by the Karnofsky Performance Score (KFS)

and the Fhysical Health Status Quest i connaire (FHS)

(Karnofsky & Burchenal , 1947; and Stewart, Ware, Brook: , &

Davies-Avery, 1978) . Fhysical function i ng also refers to

the patient 's ability to carry out normal activities such as

driving , walk i ng , bending , c 1 imb in g stairs, bath in g : eat in g .

dress l ng , and to il et . (Schag , Heinrich , & Ganz , 1984; and

Stewart, Ware, Brook: , & Davies–Avery, 1778) .

2 . Mood state - is the psychol og i cal traits and reactions

an individual has to a situation (Gottschal k. , 1784) , as

measured by the Frofile of Mood State (FDMS) (McNair, Lorr,

& Dropp 1 eman, 1971 ) .

3. Cancer - is uncontrol led cell proliferation which , when

left untreated , can be fatal (Holl eb , 1786) .

5

4. Metastasis - patients with documented evidence of

metastatic disease ; and with breast cancer patients,

evidence of one or more positive lymph nodes.

5. Four consecutive cycles of chemotherapy - In it i at i on of

chemotherapy is cycle 1 (Time 1 ) , the second cycle begins

approximately one month or 4 weeks after the first cycle

(Time 2) through the fourth cycle (Time 4) .

Chapter II : Conceptual Framework.

The theoretical framework for this study was guided by

the larger study (Dodd et al . , 1988) which used the stress,

coping , and adaptation theory of Lazarus & Folk man ( 1984) .

Coping is defined as "constantly changing cognitive and

behavioral efforts that are appraised as tax i ng or exceeding

the resources of the person" (Lazarus & Folkman, 1984, p.

141 ) . The importance of the cognitive process of appraisal

is to distinguish a potential l y stressful / harmful situation ,

such as the changes in physical function ing and mood state

as a result of chemotherapy, from potentially beneficial or

irrel evant stimul i . The presumed stressful stimul Lus in this

study is the chemotherapy experience.

Appraisal processes are also influenced by the

characteristics of the individual . The characteristics of

the individual of interest in this study were the perceived

physical function ing and mood state of the person during the

cancer chemotherapy experience . How a person appraises and

copes with the stressful situation of chemotherapy can be

influenced by physical function ing and mood state.

Lazarus & Folk man ( 1984) proposed that a person who

appraises a situation as a chal lenge may have a higher level

of physical function ing and a different physic] og i cal stress

response, than the person who appraises a situation as a

threat . Fhysical function ing has been reported to change

during chemotherapy treatment (Schag, Heinrich , & Ganz ,

1984; Fre idenbergs et al., 1981-82; and Meyerowitz , Sparks,

7

& Spears, 1%.7%) . Cl in i cally it is known that an individual

may devel op chemotherapy-induced nausea, vomiting , and/or

diarrhea that makes them so weak , they may need assistance

to use the commode; or may require them to take time off

from work ; or require them to seek assistance with household

activities and child care.

Chall enge appraisal s are also characterized by positive

emotions such as eagerness, excitement , and better mood. In

contrast , threat appraisal is characterized by negative

emotions such as anxiety, fear , and anger (Lazarus &

Folk man , 1984) . Fatients receiving outpatient chemotherapy

usual l y devel op and manage the side effects from their

chemotherapy at home. The chemotherapy treatment regimen

occurs over cycles, usual l y every four weeks for 4 to 6

months. Cl in i call y and from a study by Lodd et al . . ( 1990 ) ,

it is recognized that the first four cycles of therapy are

crial l enging . The emotional react i cºn to this stress may

el ic it feel ings of anxiety, depression , f at i gue , confusion ,

and mood changes. The patient has to appraise the stressful

situation and determine whether the situation presents as

harmful , a threat , or a chal lenge. The variables and time

points of interest in this study are presented in Figure 1 .

The cut come of this appraisal process impacts on the

patient 's physical function ing and mood state. For example,

if the individual appraises the side effects of chemotherapy

or even the chemotherapy itsel f as harmful , they may decide

not to continue with the chemotherapy treatments. This

B

decision could result in disease progression , which impacts

the patient physical l y and emotional l y. Fhysical ly, the

individual may experience more discomfort and l Cse their

ability to function as they move from an active treatment

state to the terminal stage of the ill ness. Emotional ly,

the person may become anxious , depressed , or confused about

his/her decision and situation , which may impact on his/her

Qual it y of 1 if e.

On the other hand , l if the person appraises chemotherapy

and the resultant side effects as a chal lenge , the person

will seek out as much informat i cri as possible and en l ist the

help of others to help manage the side effects (Lazarus &

Folk man, 1784) . If the individual is vomiting in excess,

s/he may try to manage on his/her own symptoms in it i al ly,

and if not successful may call the physician for more

effective relief . If successful , the individual 's

performance, functional status, and mood will increase to an

acceptable level . The person may then feel less anxious and

depressed because they are taking control of the situation.

In conclusion , the appraisal of a situation as

stressful and cop in g efforts to deal with this stress are

influenced by the interrel at i on ship between the person and

the environment or situation (Lazarus, Dunkel –Schettor,

Del ong is , & Gruen, 1986) . Fhysical function ing and mood

(positive and negative feel ings ) are related to the way

individual s eval uate and cope with the stresses of ill ness

and of everyday living (Lazarus & Folk man , 1984) .

Chapter I I I : Literature Review

This review emphasizes studies that eval uated physical

function ing and mood state of cancer patients using the

Karnofsky Performance Score (KFS) , the Fhysical Health

Status Questionnaire (FHS) , and the Profile of Mood States

(FDMS) . Research on physical function ing and mood state in

cancer patients have examined relationships between disease

status, age , depression , self-care abil it i es , and survival .

Few studies have directly eval uated the relationship between

the physical and emotional status of cancer patients

receiving chemotherapy. Only one study focused specifical ly

on both the physical function ing and mood state of cancer

patients (Cell a , Drofilamma , & Holl and , et al . , 1787) .

However , all the studies reported on here include some

measure of either physical function ing or emotional status.

Physical Functioning and Mood state

The studies reviewed in this section examined the

relationship between disease, treatment, physical

function ing, adjustment, and psychol og 1 cal distress referred

to as mood in this study. The relationship between extent

of disease, performance status, and psychol og ical distress

was studied in lung cancer patients receiving chemotherapy

for limited (n = 304) versus extensive disease (n = 151 )

(Cell a , Drofiamma, & Holl and , et al., 1987) . Ferformance

status (ECOG scale) was measured using a 5-point scale (C) =

no impairment to 4 = bedridden) . Fsychol og ical distress was

assessed Lising the Frofile of Mood States (FDMS) - Based on

1 (I)

correl at i on and regression anal yses, the data from th l =

study suggest that patients with more extensive d 1 sease and

poorer performance status had increased mood disturbance

(overal l regression , p < .. QQ1 ) .

In addition , age , marital status, gender , and education

were also tested as predictor variables of psychol cq i cal

distress. Only female gender and decreased performance

status had a sign if i cant association with Total Mood

Listurbance (TMD) scores as measured by the FOMS, indicating

that women with a poorer performance status had greater mood

disturbance . Fearson correl at i Ons where done between

Ferformance Status Rat in g (FSR) and the 7 variables Cyf the

FUMS. All correl at ions were sign if i cant , but in the low

range : FSR to tension ( . 17) ; FSR to depression ( . 14) ; FSR

to anger ( .. Q6) ; FSR to vigor (- .34) ; FSR to fatigue (.35) ;

FSR to confusion (.25) ; and FSR to TMD ( .26) (Cell a ,

Ordif i amma , & Holl and , et al . , 1987) . No p values were

reported .

The role of i l l ness and treatment-related Factors as

predictors of psychosocial adjustment was evaluated in 78

breast cancer outpatients ( Tayl or , Lichtman , Wood, Bluming ,

Losik , & Leibowitz , 1985) . I l l ness and treatment-related

factors assessed included physical dysfunction , prognosis,

type of surgery, radiation , and chemotherapy. The FON15 .

Rosenberg Self-Esteem score , Campbe il , Converse, & Rodgers

Index of Wei l-Being , Lock-wall ace Scal e of Marita

Adjustment , and the Global Adjustment to I l l ness Scal e

11

(GAIS) along with open and close ended quest ions were used

to measure psychol og i cal adjustment . [I is abil it y , rated on a

1 to 5 scale for each dimension included assessment of

phantom l imb sensation , pain , and/or arm Luse difficulty.

The results of this study ( Tayl or et al . , 1985) suggest

that poorer prognosis was associated with poorer

psychol og i cal adjustment (r. = .26 , p < .. Q3) . Whether or not

the subject was currently receiving chemotherapy did predict

adjustment (r. = .30 , p & . QQ8) , showing that patients

receiving chemotherapy were having trouble with

psychol og i cal adjustment . However , when the same data was

control led for prognosis, the relationship declined (r. =

. 15, p < . 1 1 ) , suggesting that poorer prognosis rather than

chemotherapy-related disability was the reason for the poor

adjustment . FOMS was used as part of the measure of

psychol og i cal adjustment but results of this study cannot be

compared to cyther studies using the PDMS due to the lack of

reported scores.

Functional Status and Ferformance

The Karnofsky Ferformance Score (KFS) has been the

"gol d standard" + or eval Lating the changes in performance

status associated with chemotherapy since 174% (Schag,

Heinrich , & Ganz , 1984) . The KPS has been widel y used in

making cl in ical decisions about escal at i ng chemotherapy

doses ; as one of the evaluation criteria in cl in ical trial s :

in evaluating the impact of chemotherapy on a patient ‘s

qual it y of l if e : and in guiding the physician in the

12

individual ization of treatment plans. In addition , the KFS

has been a predictor of responses to therapy and survival

(Kennealey, & Mitchel 1 , 1777; Mor, LaLiberte, Morris, &

Wiemann , 1784; Conil 1, Verger, & Sal amero, 17%); and Schag,

Heinrich , & Ganz , 1984) .

To help define performance status further and improve

the validity of KFS ratings, multiple regression analyses

were Lused to compare the KFS and Cancer Inventory of Froblem

Situations (CIFS) in 2%.3 patients (Schag, Heinrich , & Ganz,

1984) . The four components of the KFS are evidence of

disease, daily activity, self-care abil it iss, and work . A

strong relationship was found between the four components of

the KFS and the performance activities of the CIFS using

multiple regression techniques: ability to work , drive a

car, energy level , grooming , and an increase or decrease in

weight (p & . Q.5) (Schag, Heinrich , & Ganz , 1784) . The

behavior components help define the KFS in terms of physical

Health and f Lunction i ng .

The preval ence of clepressive states as well as the

rel at i Onship between medical and demographic variables and

depressive states were studied in 62 hosp it il ized cancer

patients (Bukberg , Fenman , & Hol l and , 1784) . The modified

LISM-III Depression Scale, Hamilton Rating for Depression ,

and KFS were Lused to measure depression . The majority of

depressed patients (18/26 or 70%) had a performance score of

60 or less, while the majority of patients without

depression (27/365 Cr 75% ) had a KFS C+ 6 () or greater. When

13

compared with other medical and demographic data , the extent

of physical disability (KFS scores) was the con l y variable

significantly related to depression (p & . QQ1 ) . The factor

most clearly associated with depression in cancer patients

in this study was a decreased KFS score (Buk berg , Fenman , &

Holl and , 1984) .

The relationship between psychol og i cal factors and

length of survival was studied in 35 women with metast at i c

breast cancer (Derogat is , Abel of f , & Mel i saratos, 1979) .

Patients were class i + i ed as short-term or long-term

survivors. Short-term survivors were those that died less

than one year from basel ine measurement and l ong-term

survivors lived for one year or longer. Instruments Lused

were the Global Adjustment to Ill ness Scale (GAIS) ; Fatient

Attitude , Information, and Expectancy Form (FAIE) which

measures accuracy of the patient 's appreciation of his/her

illness and treatment ; KFS ; Affect Balance Scale (ABS) which

measures patient 's mood in terms of positive and negative

mood dimensions ; SCLA-9QR measuring psychol og ical distress ;

and an open-ended interview concerning psychosocial

adjustment. The mean KFS scores for short-term survivors (n.

13) was 77, while the mean KFS for long-term survivors (n.

22) was 95. These differences while not statistical ly

sign if i cant , do demonstrate that long-term survivors had

better physical function ing. Fatients classified as

long-term survivors had more mood disturbance (as measured

by Affect Balance Scale, (p & . Ö5) . Short-term survivors had

14

more positive mood scores, but these d 1 fferences were not

statistical l y sign if i cant . The study find ings do not

suggest a relationship between physical function in G and mood

state. A limitation of this study was that short-term

survivors received significantly more chemotherapy (p &

. Q.5) , which may have influenced their survival and therefore

their performance status.

The efficacy of providing proactive information on

self-care was evaluated in 60 outpatients receiving

chemotherapy (Dodd , 1788) - Fatients were randomized to

receive standard patient teaching compared to the provision

Of specific side effect management (SEM) information . The

mean KFS scores in the control group pre and post

chemotherapy were 77.8 and 81 .3, respectively (p = . 14) .

KFS scores increased significantly from the pre to post

intervention interview for the experimental group (81.4 and

87.7, p = . QQ5) , who received the SEM information . The

results of this study indicate that proactive information

may positively affect performance status by enabling the

individual to manage the side effects of chemotherapy.

Previous studies (Bukberg, Fenman, & Holl and , 1984;

Derogat is , Abel of f, & Mel i saratos, 1979; and Lodd, 1988)

that have eval uated performance status using the KFS

demonstrated that cancer patients were in relatively good

physical health , with most mean KFS scores over 80 ,

indicating that the patient could participate in normal

activities with effort and that there were some signs and

symptoms of the disease (Karnofsky & Burchenal , 174%) .

The Fhysical Health Status Questionnaire (FHS) , was

selected to measure acute and chronic l imitations in

performance in four basic function ing categories: self-care

activities, mobil it y , physical activities, and role

activities. The FHS has only been used in studies of the

general population. Therefore, there are no studies to

critique in the cancer population Lising this instrument .

However , cancer patients do have both acute and chronic

l imitations, and it is important to ascerta in these

dimensions. The results of this study will provide

in format i on about the Lusef Ll ness of the FHS instrument in

patients with cancer .

Mood State

A multitude of studies have used the FON15 as a measure

of mood state , emotional distress and psychosocial status in

patients with cancer (Weisman & Worden , 1976-77; McCork le &

Benol i el , 1983; Cassil eth , Lusk , Brown , & Cross, 1986) .

Several studies (Musc i & Dodd , 1990; Derogat is , Abel of f , &

Mel i saratos, 1979; Rogert ine, Van Kammen , & Fox , 1779;

Weisman & Worden , 1976–77: Morris, Greer, & White, 1977; and

Felton & Rever, son , 1984) also used the FDM15 to predict

cop i ng , self-care behaviors, and as one of a series of

measures to predict survival . Although all of these studies

used the FUMS, the terms Lused varied from emotional health

to d 1 stress to mood disturbance , making interpretation and

general ization of the study find ings difficult . Another

16

limitation, in analyzing studies using the FON15, is that

some researchers Lused the short form of the instrument

(Cell a , Jacobson , & Drav , et al . , 1987; and McCork le &

Benol iel , 1986) . Scores from the long form of the FDMS are

higher than those of the short form and cannot be compared .

Weisman & Worden ( 1776-77) studied the existential

pl ight of cancer in 120 patients with in the first 100 days

of diagnosis. Level s of emotional distress were eval Lated

at 4 to 6 week interval s by an Index of Vulnerabil i ty (VUL )

interview and a self-report scale (FOMS) . However, no VUL

or PDMS scores per se were reported from the study, but the

authors based their interpretations of emotional distress on

the FUM5 and VUL results - Fatients who were classi fied as

having high level s of emotional distress talked more about

health concerns and l isted more symptoms in the first 1 QQ

days after diagnosis. The patients with more advanced

disease (e. g . , 1 ung cancer) were indicated as having higher

TML and VUL scores. The study find ings suggest a positive

relationship between physical symptoms and emotional

di stress .

The level = of symptom d 1 stress, current concerns, and

mood disturbance were compared in 56 l Lung cancer patients

and 65 Myocardial Infarcticn (MI) patients one and two

months after d 1 agnosis (McCork le & Benol iel , 1783) .

Instruments used were the McCork le & Young Symptom Distress

Scal e (SDS) , the Weisman & Worden Inventory of Current

Concerns (ICC) , and the FDMS. The mean TMD score, one month

17

after diagnosis for lung cancer patients, was 32.3 and for

MI patients 17.8. Two months after diagnos 1 = the mean TML.

scores for cancer and MI patients was 22.2 and 14. 1 ,

respectively. The difference in TMD scores between the two

groups was significant (p = .05) with lung cancer patients

exhibiting more mood disturbance than MI patients at both

time periods. Cancer patients also had lower vigor and

higher fatigue scores than MI patients. The decrease in TMD

in both populations, from Time 1 to Time 2, might be

explained by the fact that patients felt relieved that the

symptoms associated with treatment were not as bad as they

had expected (McCork le & Benol i el , 1783) .

F'sychosocial status of 374 cancer patients and 378 next

of k in was measured Lusing the FON15 in a study addressing

normative data of the FOMS (Cassil eth , Lusk , Brown , & Cross,

1986) . The mean TML scores for cancer patients were 20.1

and family members 14.5, respectively . Ferformance status

was a 1 so measured by the ECOG scal e . Fall i at i ve care as

Opposed to active or foll ow-up care was assoc lated with

higher TML scores . A similar association was demonstrated

in an earl ier study with chronic ill nesses including cancer

(Cassil eth et a l . , 1784) . TNTLI scores from other studies

that used the FOMS (McCork le & Benol i el , 1983 : Spiegel ,

B1 ocm , & Gottheil , 1783; Worden, 1977; and McNair, Lorr, &

Dropp 1 eman , 1771 ) were compared to the 1986 study find ings

(Cassil eth et a . , 1986) . The mean TML scores of cancer

patients from previous studies (McCork; le & Benoi i e ] , 1783:

18

Spiegel , Bloom, & Gottheil , 1983; and Worden , 1777) ranged

from 1 1 - 8 to 25.6 , whereas psychotherapy patient E and

college students had mean TMD scores of 77.5 and 43.3 ,

respectively. Cassil eth et al . ( 1786) suggested that

psychiatric outpatients and college students were not

normative samples of the general put, l ic and a more suitable

control group would be large samples of patients with cancer

or normative samples of the general public .

Cop in g strategies and self-care behaviors were studied

in 1 QQ cancer famil ies receiving chemotherapy cºver six

months (Lodd, 1990) . The PDMS and KFS were measured at T 1

(i.e. , in it i at ion of chemotherapy) , T4 ( i.e. , 2 to 3 months

after chemotherapy was in it i ated ) , and T5 ( i .e. , 6 months

after chemotherapy began ) in patients with and without prior

chemotherapy. Although KFS and FOMS scores were considered

to be two of the causal antecedents and predictors of

self-care behaviors and coping strategies, neither the KFS

nor the FOMS scores were statistical l y significant in

predict i ng sell F-care behaviors .

Fatients with a history of chemotherapy reported the

highest TMD at T4 (2 to 3 months after in it i at i cºn cº-f

chemotherapy) . By T5, TMI scores had decreased to a point

l ower than that at the in it i at i on cyf chemotherapy,

indicating that patients without a history of chemotherapy

had the n i gnest TNTLI scores at T 1 with TMI scores decreasing

over time. Results from this study (Dodd , 17% (3) suggest

that TML scores are different between patients who have

1 9

received prior chemotherapy and patients just beginning

chemotherapy. Based on the find ings of the study, Dodd

suggested a profile of patients and family members at risk

+ or problems cop in g : Ol der patients, patients with no

previous history of chemotherapy, and those without

recurrent disease (Dodd, 17%) .

Length of survival was linked to cop in g and mood state

in several studies ( Derogat is , Abel of f , & Mel i saratos, 1979;

Rogentine, Van Kammen, & Fox , 1977; Weisman & Worden ,

1976–77; Morris, Greer, & White, 1777; and Felton &

Revenson, 1984) . Mood state was measured by a variety of

instruments including the FON15 . Two of the studies

( Derogat is et al . , 177% , and Rogentine et al . , 1777)

reported that 1 ong-term survivors had more symptoms,

increased levels of anxiety, poorer attitudes toward

physicians, and more negative affect, but better coping

abil it y than short-term survivors. These f indings are in

contrast with other work (Weisman & Worden, 1776-77; Morris

et al . , 1977; and Felton & Revenson, 1984) that demonstrated

that short-term survivors had increased level = of anxiety

and depression ; a more negative affect ; and more trouble

cop in g than 1 ong-term survivors. The reason for the

di ++ erences between these studies may be due to trie lack of

homogeneity of research instruments measuring cop in g and

mood state .

Most of these studies have examined perf crimance status

and mood as independent constructs in cancer patients. Few

2C)

studies (Cell a , Urof i amma , & Hol l and , et al . , 1987; and

Tayl or et al . , 1985) have examined the relationship between

physical function ing and mood state in this population , and

no study has eval Liated the relationship between these two

variables over time. What is clear from the l iterature is

that mood disturbance is cºften elevated at the time of

in 1 tial diagnosis, indicating high level sof distress at

this time. Most studies f indings (Weisman & Worden ,

1776-77; Cell a , Urof lamma , & Holl and et al . , 1787; Tayl or et

al . , 1985; and Cassil eth et al., 1986) suggest that cancer

progression also causes people to experience greater mood

disturbance. What is unclear is what happens during the

course of active treatment between physical functioning and

mood state , and how do demographic variables such as age ,

gender , type of cancer , and presence of metastasis influence

physical + Lunction in g and mood state.

Chapter IV: Methods

Research Lesign

A descriptive anal ys is was performed Of C at a collected

from Oncol ogy patients in a long itudinal (four-month)

experimental study entitled "Self-Care Intervent i on to

Decrease Chemotherapy Morbidity" which tested the ability of

a specific nursing intervention to enhance self-care

practices and decrease morbidity of cancer patients

initiating chemotherapy (Dodd et al . , 1988) . The aspect of

the study reported on here focused on physical function ing

and mood state . Signed informed consent was obtained from

each participant that participated in the study as approved

by the Human Subjects Committee at the University of

Cal if ornia, San Francisco .

Sampl =

The sample consisted of 127 adult cancer patients who

were 1) 18 years of age or older ; 2) could speak and read

English ; 3) a Karnofsky performance score × 60 : 4) could

give informed consent at entry into the study : 5) had an

anticipated survival time of greater than four months

according to their primary physician ; and 6) agreed to

participate in the study. Exclusion criteria included :

receiving other cancer therapies like radiation therapy, as

well as patients with diagnoses of leukemia or AIDS.

Fatients were receiving their initial chemotherapy

treatments with at 1 east one of 5 chemotherapy agents or

their anal ogs ( i . e. , doxorub ic in , c is-platinum ,

~ *-y*-*-

cyclophosphamide, 5-fluorauracil , or methotrexate) given

al one or with other agents. Fart icipants were receiving

chemotherapy as outpatients and had no previous history of

chemotherapy treatment for their mal ignancy.

Research Setting

Fatients were referred by nurses and physicians from 18

cl in ical sites including community hospital s as well as

major medical centers from the San Francisco Bay area to Los

Angel es. Research settings included Drivate of f ices and

large out-patient c 1 in ics. The variety of settings were

sel ected to increase the external val idity of the study * =

+ i nd i ngs.

Instruments

The instruments used in this study were : the

Demographic Questionnaire, the Karnofsky Ferformance Score

(KFS) , the Fhysical Health Status Questionnaire (FHS) , and

the short form of the Fro-fi ) e Of Modd States (FDMS) .

The Demograph ic Questionnaire is a 12-item

Guest i onnaire Lised to obtain demographic informat i on about

age , gender , ethnic i ty, educational level , financial status,

mar 1 tal status, and type of cancer. (See Appendix A )

Content va idity of the quest i onnaire was established by a

panel of experts in on cology nursing .

Physical Functioning

The Karnofsky Performance Score (KFS) (See Appendix B)

measured the patient * = abil it y to accompl ish normal

activities of daily living , or their need for he ip and

nursing care (Karnofsky & Burchenal , 1947) . The KFS

consists of a series of 8 items. Farticipants were asked to

"describe your abil it i es at the present time". KFS scores

were on a 30 to 1 QQ scale collected at T 1 , T2, T3, and T4 .

A score of 1 QQ signifying adequate health status, with no

complaints and no evidence of disease and a score of 30

indicating disabil it y , with hosp it il ization needed . In

previous research studies primarily physicians, nurses , and

caregivers have completed the scale. However , for the

purpose of this study, the patients rated themselves.

Performance status was rated by two physicians and the

patients themselves (N = 100) using the KFS and Eastern

Cooperative Group (ECOG) to evaluate reliabil ity and

validity of the instruments (Con ill , Verger, & Sal amero ,

1990 ) . Correl at i on 5 were sign if i cant between the two

physicians scores (r. = .75 for KFS, .. 76 for ECOG, p < .. QQ1 )

and between physicians and patients ratings ( - 65 for KF'5,

and .5% for ECUG., p. 3. .. QQ1 ) . To test for construct validity,

the KFS has also been compared to single-item physical

qual it y of l if e scal es, such as the Katz ADL scale. The

results of this comparison found the KFS to be unbiased and

complete , with a correl at ion coefficient of .35 (Mor ,

LaLiberte, Morris, & Wiemann , 1984) . Interrater reliab 11 it y

between two physicians was . 97 in 47 interviewers. Schag,

Heinrich , & Ganz (1784) studied 273 cancer patients to test

the validity of the KFS. They reported the KFS had very

good interrater reliability among physicians (r. = .8%) .

24

The Physical Health Status Quest ionnaire (FHS) (See

Appendix C ) or "Functional Limitations Battery" was

devel oped by the Rand Corporation (Stewart, Ware , Brock , &

Davies-Avery, 1778) . Functional status is defined as both

acute and chronic functional limitations in the persuance of

normal activities of daily living .

Data was collected using the self-administered

questionnaire at T 1 , T2, T3, and T4. The FHS duestionnaire

is a 13-item scale with instructions to "circle the answer

that best describes your current abil it i es at this time".

Each question had two parts: are they able to do an

activity, and if not , how 1 ong have they been unable to do

the activity, (1) "less than one week " , (2) "one to three

weeks", or (3) "more than three weeks." The range of scores

is 13 to 27. The lower the score the more disabled the

person 1 s.

Dayton established four categories of functional

l imitations from a review of the l iterature , thereby

establish ing content val idity. The four categories are :

( 1 mobil it y , (2) physical , (3) role, and (4) self-care.

Coefficients of reproducibility were all above .90 and

internal consistency reliability was .8% ; thereby making the

rel i abil it y of the FHS scale acceptable. Test-retest

rel i abil it y was .46 or greater and gamma coefficients were

above .90 + or a l l categories. The Rand Corporation also

provided evidence of convergent and discriminant validity of

the categories of physical function ing (Stewart, Ware,

ry E.

Brook , & Davies–Avery, 1978) . In the present study,

internal consistency ranged from .83 to .85 for the four

cycles (see Table 1 ) .

The Prof ill e of Mood States (FUMS) (See Appendix II) was

devel oped by McNair, Lorr, & Dropp 1 eman ( 1971) and used

original l y with psychiatric outpatients and college

students. Administration time for the original FOMS

containing 65-items (McNair, Lorr, & Dropp 1 eman , 1771 ) , was

considered too long for ill patients ( i.e. , 15–20 minutes) .

Therefore a shorter version of the PDMS was devel oped by

Shacham ( 1983) contal ning a 37-item questionnaire with a

5-point Likert scale which halved the time to complete the

scale. The questionnaire measures six mood states

incl Lud in g : (1) tension-anxiety , (2) depression-deject iOn ,

(3) anger-hostil it y , (4) vigor-activity, (5)

fatigue-inert i a , and (6) confusion-bewilderment .

The five-point scale ranges from Q "no feel ing" to 4

"extreme feel ings". The instructions tell the patient to

"circle the number that best describes how you have been

feel ing during the past week including today." The

rational e for using a crie-week rating time was to devel OD a

range 1 ong enough to characterize the patient 's usual moods

and continuous mood responses to what is currently happen ing

in the patient ' s life, while still being short enough to

eval uate the immediate effects of treatment (McNair, Lorr, &

Droppleman, 1971) . A TML score can also be obtained by

add l ng the scores of all six factors, negatively weighing

26

vigor. The TMD score is a summary measure of distress, with

higher scores indicating more mood disturbance .

In her study of 83 cancer patients, Shacham (1783)

reported that internal consistency scores ranged from .803

to .907, and were used as standards for reducing the factors

+rom 65 to 37. The correl at i con coef f ic i ent s between the

short and long scales were all reported above .95. Internal

consistency scores, for the present study, ranged from .82

to .94 for the four cycles (see Table 1) . Little & Fenman

(178%) in their study of Veteran 's Administration (VA)

psychiatric inpatients described the short form of the FOMS

as having concurrent validity due to the instruments abil it y

to "detect diagnostic differences, clinical setting

differences , and c 1 in ical changes" (p. 46) .

Procedure

Fatients who met the criteria for the study were

approached by the Cl in ical Nurse Special ist (CNS) and

consent was obtained . At the time of consent, the patient

was randomized by the Froject Director to the experimental

or control group via a computer program. The Demographic

(Juestionnaire , the KFS , and the FOMS were administered to

the participant by the CNS or the nurse in charge in that

particular setting on entrance into the study and before the

in it i at ion of the first course of chemotherapy. The FHS

Çuest i onnaire was completed by each participant between the

first and second cycles of chemotherapy. The KFS, FHS, and

FOMS were again administered to each participant at each

subsequent cycle of chemotherapy, approximately every 3 to 4

weeks for four successive treatments. Time to complete this

information was approximately 15-20 minutes.

Data fanal ysis

Data were analyzed util izing an IBM FC and the

statistical analysis program CRUNCH. A Fearson Froduct

Moment Correl at ion was done to determine the relationship

between physical function ing and mood state at each time

point. A cone-way anal ys is of variance (ANOVA) was done to

determine differences over time for KFS, PHS, TMD scores and

+ or each D+ the 6 subscal es Of the FON15 . Fost-hoc

contrasts, using the Schef fe test were used to identify

significant differences between KFS, FHS, and FOMS subscales

scores Over time . Independent group t-tests were computed

to determine differences in physical function ing and mood

state between individual s witH breast cancer and those with

other types of cancer ; between men and women ; and between

ind i v i dual switH no evidence of metast as is and those with

evidence of metast as is .

Chapter V: Results

Sample Demograph its

Fart icipants were primarily caucasian (80%) ,

middle-aged ( mean 52 years, range 22 to 82, 5 - D - 13.3) , with

two years of college education . The majority of the

participants were female (68.5%) , married/partnered ( ò 17. ) ,

with 20% l i v i ng al One - The most common cancer diagnosis was

breast cancer (42.5%) , foll owed by lung cancer (15%) , then

ovarian (8.6%) , b 1 adder (7. Q%) , Non-Hodgk in 's lymphoma

(5.5%) , Hodgk in 's lymphoma (4.7%) , and col on cancers (3.0%) .

The number of patients with metastasis was (7%) . (See Table

2)

Study Furpose 1 : Rel at ionship Between Physical FLunction ing

and Mood State

Mean scores and standard deviations as wel 1 as the

standardized Chronbach * = Alpha for each of the scal es used

in this study are found in Table 1 .

The mean KFS scores, at each time point , were all above

80. A one-way ANOVA demonstrated that the changes in KFS

scores over time were not statistical l y sign if i cant (F (3, 51 )

= .51 p. 3. .. Q5, Figure 2) . These data indicate that patients

carried out normal act i v i ties with some effort and showed

only minor signs and symptoms of their disease .

The FHS scores ranged from 22 to 23 throughout the four

time periods. Une-way ANOVA demonstrated that the changes

in FHS scores over time were not statistical l y sign if i cant

(F (3,57) = 1.8, p. 3. .. Q5, Figure 3) . Since the highest

29

possible score on the FHS is 27, these data , along with the

KFS scores suggest that the participants exhibited a high

degree of physical function ing through four consecutive

cycles of chemotherapy.

Total Mood List Lurbance scores ranged from 18 - 2 to 14. '7.

A cone-way ANOVA, demonstrated that the changes in TMD scores

over time were not statistical l y sign if i cant (F (3,53) = .75,

p > . Q5, Figure 10) . However, TMD scores were highest at

Time 1 , suggesting that patients were the most distressed at

the in it i at ion of chemotherapy.

Each cº-f the subscal es Of the FOMS were eval Llated for

changes over time using a one-way ANOVA . Tension scores

decreased significantly cºver time (F (3,55) = 1 1 . 88, p.

= . QQQQ) , with the post-hoc Scheffe test indicating that the

highest tension scores were measured at T 1 (p = . QQQ3, Tab e

4, Figure 4) . Fat 1 gue scores increased sign if i cantly over

time (F (3,54) = 3.02, p = . Q312) , with the post-hoc Scheffe

test indicating that the lowest fatigue scores were reported

at T 1 (p = .03% 1 , Figure 8.) . Confusion scores decreased

over time (F (3,57) = 4.61 , p = .003%) with the post-hoc

Schef Fe test indicating that the l owest conf Lisi On scores

were reported at T3 (p = . QQ61 , Figure ?) .

In Order to determine i f there was a rel at i Cºnship

between physical function ing and mood state , Fearson 's

Froduct Moment Correl at ions were performed between KFS

scores and TML scores, and FHS scores and TML scores at each

time point . Sign if i cant negative correl at i ons were found at

each time point between KFS and TMD ( al 1 p & . Q01) and

between PHS scores and TML. scores (all p < .. QQ1 ) , indicating

that at each time period as KFS and FHS scores decreased the

TML scores increased . Thus as physical function decreased ,

the persons in this study also experienced increased mood

dist Lurbance . (See Table 3)

To determine if any of the subscal e scores on the FOMS

correl ated with either the KFS scores or the FHS scores , a

correl at i cºn matrix was done using the Fearson 's Froduct

Moment Correl at i On Coef + i C i ent . (See Table 3)

All subscale scores on the FOMS ( i . e. , tension ,

depression , anger , f at i gue, vigor, and confusion ) at T 1 and

T2 were sign if i cantly correl ated with KFS and FHS scores

(all scores p < .. Q1 ) . At T3, all subscal e scores on the

FOMS were significantly correlated with KPS scores except

for anxiety and confusion (all p < .. Q.5) . FHS scores were

only significantly correl ated with fatigue, vigor, and TMD

(all p < .. Q1 at T3) . At T4 KFS scores were significantly

correlated with all subscale scores on the FDMS ( p < .. Q.5) .

At Time 4 FHS scores were all sign if i cantly correl ated with

subscale scores on the FDM5 except + or confusion (all p &

. Q.5) . The relationship between the two measures of physical

function l ng ( i.e., KFS and FHS) were also sign if i cantly

correl ated (r. = .55 to . 6 1 , a 1 1 p < .. Q 1 ) .

Study Furpose 2 : Relationship Between flae and Physical

Funct 1 on ing and Mood State

31

To determine if anv subscale scores on the PDMS, TML.

scores, KFS scores, cr FHS scores correl ated with age , a

correl at 1 on matrix was done L1s i ng the Fears on 's Product

Moment Correl at i on Coefficient . The mood state subscal es cº-f

tension and fatigue were sign if i cantly correl ated with age

at the first two cycles of chemotherapy (T 1 and T2 ) . At T 1 ,

older participants reported less tension (r. = - . 1% , p =

. Q4) ; but at T2 more fatigue (r. =- .25 , p = . Q2) . Fhysical

function in g (FHS scores) were correlated with age at cycles

3 and 4 (T3 and T4) . Older individual = reported a decrease

in PHS scores (r. = - .22 , p = . Ç5; and r = - .24, p = . Q4) at

T3 and T4 respectively.

Study Furpose 3 : Lifference in Physical Functionina and

Mood State Between Type of Cancer . Gender ... and Metastasis.

Independent group T-tests were done to determine if

there was a difference in physical + Linction in G and mood

state between individual s with breast can cer versus

individual s with other types of cancer ; between males and

femal es; and between individual s with no evidence of

metast as is and those with evidence of metast as is .

a . Results showed that individual s with breast cancer had

sign if i cantly higher K.FS and FHS scores at all four cycles

than ind 1 v i dual s with Cther types of cancer , suggest ing a

higher level of physical function i ng in breast cancer

patients. (See Tab i e 5.) There were no sign 1 + 1 cant

d if + erences in TNTLI scores between in Ci i v i Gula 1 = with breast

32

cancer and individual s with other types of cancer or in any

of the FOMS subscal e scores .

b - Women had higher KFS ( t = 3.25, p = . ØØ 16) and PHS

scores ( t = 2.1Q , p = . Q4) than men at T2, but less vigor (t.

= -2.28, p = . Q265) than men at T3, suggesting that at T2,

women had a higher level of physical function ing than men .

c - Sign if i cant differences in KFS and FHS scores and FDMS

scores were demonstrated in patients with evidence of

metastasis compared to individual s without evidence of

metastasis. (See Table 6) At T 1 , patients with metastasis

2 2 , p = .0312)2had significantly lower KFS scores ( t = -2.

and were more fatigued ( t = 2.33, p = . Q243) . At T2

patients with metastasis had significantly more confusion (t.

= 2.67, p = . QQ'7) and lower FHS scores ( t = -2. 17, p =

.0323) than patients without metastasis. There were no

significant differences found at T3 in any of the study

Variables. At T4, patients with metastasis had

sign if i cantly more fatigue ( t = 2.62, p = . Q1 Q8) and greater

TMD ( t = 2.34, p = .0223) than patients without metastasis.

33

Chapter VI : Discussion

Significance

The results of this study demonstrate a relationship

between decreases in physical function in g (as measured by

KFS and FHS) and increases in overal l mood disturbance (as

measured by the PDMS) during all four cycles of

chemotherapy. Fatigue, vigor , and TMD scores were highly

correl ated with KFS and PHS scores at all 4 cycles of

chemotherapy, indicating that as physical function ing

decreased , patients were more fatigued , and experienced

greater mood disturbance . The find ings of this study add to

the work of Cell a , Drofilamma, & Holl and et al . , (1987) and

Tayl or et al., (1985) in establishing a relationship between

physical function ing and mood state in patients undergoing

cancer treatment. However, the causal relationship between

def ic its in physical function ing and increases in total mood

disturbance cannot be determined from these data .

The range of mean scores of KFS (81 - 3-82 - 4) and FOMS

( 14. 7-18.2) were consistent with other study findings

that measured performance status and mood state in oncol ogy

patients (Dodd, 1788; Bukberg, Penman , & Hol 1 and , 1784:

Derogat is , Abel of f , & Mel isaratos, 1777; Cassil eth et al.,

1786 ; and McCork le & Benol iel , 1983) . While one might think

that patients undergoing chemotherapy might experience

changes in their ability to function or changes in their

mood , these data , as well as data from previous studies

(McCork 1 e & Benol i e ] , 1983; and Cassil eth et al . , 1784)

34

suggest that patients with a diagnosis of cancer or

undergoing cancer treatment continue to function wel 1 with

minimal changes in their cºveral l mood .

However, tension , depression , anger , confusion , and TMD

mean scores were highest at T 1 , suggest ing that in it i at ing

chemotherapy is a stressful event. These f indings are

similar to the findings of Musc i & Dodd (1990) and Llodd

(1790) . Ferhaps when patients recovered from their in it i al

+ ear of the unknown and over time become more knowledgeable

of the experience of receiving chemotherapy, the initial

tension and confusion dissipated .

Results of this study indicate that older individual s

reported more positive mood states, such as a lower tension

scores, at the in it i at ion of chemotherapy. However , as time

went on , older individual s reported a decrease in the level

of physical function ing. These f indings are consistent with

results from other studies that also found that increased

age was associated with better mood , but a decrease in

physical + Lunction in g (Cassil eth et al . , 1984; and Ganz ,

Schaq ... & Heinrich , 1985) . It could be that as one grows

Ol der , an individual experiences more i l l n ess and has ■ nore

contact with the health care system. Therefore, prior

experience may hel D to decrease tens 1 on level s when a new

1 | 1 ness strikes (Ganz , Schag, & Heinrich , 1785) . However,

it is well documented in the l iterature that physical

+ Lunction i ng general l y decreases as one ages , ( Mages &

Mendel sohn , 1979; and Ganz , Schag, & Heinrich , 1985) not

35

only from ill ness or treatment, but as a result of natural

aging .

Breast cancer patients reported significant i y higher

level s of physical function ing at all four time periods than

patients with other types of cancers. No studies known to

date have documented this find in g . Gender could be a

confounding variable in these f indings , although women on 1 y

had a higher level of physical function ing than men at T2 .

At Time 1 , patients with metastasis started of f with a

decrease in physical function ing (KFS) and reported

sign if i cantly more fatigue than patients without evidence of

metastasis, probably due to the metastatic disease process.

Froblems in physical function ing (FHS) persisted at T2 and a

new symptom of confusion emerged in patients with evidence

of metast as is . There were no sign if i cant differences at T3

between the two groups. Although patients with metastasis

reported significantly more mood disturbance (TML) at T4,

these scores did not change between the two groups until T4 .

Fatients with metastasis were also significantly more

fatigued at T4 than those with no evidence of metastasis.

These results support f indings from other studies (Cassil eth

et al . , 1784; Musci & Dodd, 17% and McCork le & Benol iel ,

1983) that metastatic d 1 sease produces more physical

symptoms. However , the results do not show that patients

with metast as is have greater mood dist Llrbance al drig with a

decrease in physical function in g (Tayl or , et al . , 1985; and

Cell a , Orc-fi amma, & Hol 1 and et al . , 1987) .

36

Limitat i cons

A limitation in this study and of the larger study , is

the attriticn rate of the sample over time. The sample size

at T 1 was 127 and at T4 was 7Q , which makes general ization

of these study 's findings difficult. A total of 41 patients

dropped out of the study by T4 . (See Table 7.) One could

speculate that these patients were the sick est. However , it

is important to note that the patients remain i ng in the

study at T4 (n 70) , still reported a significant amount of

+ at i gue and conf Lisi on . Another l imitat i on D+ the larger

study , which effects this study, is that the majority of

Datients were women (68%) and the most common d 1 agnosis was

breast cancer (42%) , which i imits the general ization of the

f indings to other cancer populations.

Although the FHS was highly correl ated with the KFS

scores in this sample of oncol ogy patients, further studies

are needed before def in it i ve conclusions can be made on the

val idity of this instrument for Lise in an oncol ogy

popul at 1 on . One would expect that there would be a larger

degree of variabil it y in FHS scores in on cology patients,

especial l y those receiving chemotherapy due to the multiple

side effects of ten experienced . Fernaps the scoring of the

FHS should be expanded to all ow for more discrimination in

physical function ing to increase the sensitivity of the

scal e.

Cell a , Urof i amma , & Hol l and et al - , ( 1987) , Tayl or et

al . , (1985) , and Cassil eth et al . , ( 1786) have criticized

37

the PDMS as possibly missing a subset of the cancer

population due to the low level s of distress among cancer

patients in general . It would seem that persons facing a

l i fe-threatening i l l ness would demonstrate greater mood

disturbance. Cl in ical ly, the author has found that many

cancer patients do seem to take their disease and treatment

in stri de . In this study however, there was a wide

dispersion of FOMS subscale scores which provided the

opportunity for significant correl at ions to be demonstrated

even at T4, when the sample had dropped to 70. However , all

of the subscal e scores of the PDMS had large standard

deviations, suggest ing that there may be a small subset of

patients who experienced greater mood disturbance than the

group mean would suggest .

Impl ications for Fractice

Results of this study emphasize the need for health

professional s, especial l y nurses, to make ongoing

assessments of physical function ing and mood disturbance

using the patient 's self-report of the situation . Standard

self-report measurements of performance status and mood

state such as KPS, PHS, and FOMS could be implemented in the

inpatient and outpatients settings to determine changes in

Datient 's mood state and physical function ing , and to

determine changes over time . In future studies , it would be

important , even in light of the attrition at T4, to

determine how long this fatigue and confusion persisted .

The results of these measures could be eval uated by the

physician and the nurse to determine and facil it ate

intervent ions directed toward the needs of the patient .

Research studies on cancer, chemotherapy, self-care ,

survival , and coping with the side effects of chemotherapy

should continue to include measurements of physical

+ Linct i on in g and emot i cnal status to further define the

relationship between physical and emotional health .

Research is also needed to determine the best measure (s) of

physical function in g and emotional status that are

reflective of the chemotherapy patient experience.

39

References

Bukberg , J . , Penman , D . , & Holl and , J. C. ( 1784) .

Depression in hospital ized cancer patients.

Psychosomatic Medicine , 46 (3) ; 199-212.

Cassil eth , B. R. , Lusk: , E. J. , Strouse, T. B. , Mill er, D.S. ,

Brown , L.L. , Cross, F. A. , & Tenaglia, A. N. (1984) .

F’sychosocial status in chronic ill ness. New England

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The relationship of psychol ogical distress, extents of

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Cancer, 6.5 , 1864-1866 .

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F’sychol og 1 cal cop in g mechanisms and survival time in

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M - , Dibble ; S. , Hudes , M., Hauck: , W., & Kato, F.

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University of Cal if ornia, National Institutes

of Health .

Felton , B.J., & Revenson , T.A. (1984) . Coping with

chronic ill ness : A study of ill ness controll ability and

the influence of coping strategies on psychol ogical

adjustment - Journal of Consul ting and Clinical

F’sychol pay. , 52 (3) , 343-353.

41

Fol k man, S. , Lazarus, R. S. , Dunkel –Schetter , C. , Del Ong is ,

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encounter : Cognitive appraisal , cop in g , and encounter

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Psychol cay, 50 (5) , 7%2-1003.

Frank. -Stromborg & Wright . (1984) . Ambulatory cancer

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Fre idenbergs ... I . , Gordon , W . , Hibbard , M . , Levine . L. ,

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International Journal of Psychiatry, 11(4) , 393-32? -

Goodman , M . ( 178%) . Managing the side effects of

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5 (2) (Suppl - 1) , 27–52.

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in cancer patients. Cancer , 53 (Suppl - 10 ) ,

2236-2242.

Holl eb , A.I. (Ed.) (1986) - The famerican Cancer Society

Cancer Book: . New York : Doubleday and Company.

Karnofsky, [ . , 3. Burchenal , J . ( 194%) . The cl i ni cal

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Factors that influence the therapeutic response .

Factors that influence the therapeutic response in

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In G.U. Coelho , D. A. , Hamberg , & J. E. Adams (Eds.) ,

Cop in a and adaptation - New York : Basic Books .

Lazarus, R. S. , & Fol k man , S. (1784) . Stress ,

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Little , D . , & Fenman , E. ( 178%) . Measuring sub acute mood

changes using the profile of mood states and visual

anal Ogue scales. Fºsychopathol cºsy. , 22, 42-47.

Love , R. R. , Leventhal , H . , Easter l ing , D.V., & Nerenz ,

D. R. ( 178%) . Side effects and emotional distress

during cancer chemotherapy. Cancer , 6.3, 604-6 12.

Mages , N. L. , & Mendel sohn , G. A. ( 177%) . Ef + ects D+

cancer on patients l i ves: A person ol og ical approach .

In B. C. Stone , F - Cohen , & N.E. Adler (Eds.) , Heal th

p =ychol cogy (pp. 255-284) . San Francisco :

Josey-Bass.

McCork, l e, R., & Quint-Benol iel , J . (1983) . Symptom

di stress, current concerns and mood disturbance after

diagnosis of l i fe-threaten i ng disease - Social Science

Medic ine, 17 (7) , 431-438.

A / I

43

McCorkle, R. (1786) . Evaluation of cancer management ,

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McNair , D . , Lorr, M . , & Dropp 1 eman, L. (1971) . EITS

Manual for the Prof i le of Mood States - San Diego -

Educational and Industrial Test ing.

Mor , V . , LaLiberte, L. , Morris, J. N. , & Wiemann , M .

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Cancer , 53, 2002-2007.

Morris, T., Greer, H.S., & White, P. (1977) .

F’sychosocial and social adjustment to mastectomy.

Cancer, 4Q, 2381-2387.

Musc i , E. C. , & Dodd, M . J. ( 1 190 ) . Pred ict in g sel f -care

with patients and family members affective states and

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Rogert ine, G. N. , Van Kammen, D.F., Fox , B.H., Locherty,

J. P. , Rosenblatt, J. E. , Boyd , 5 - C - , & Bunney, W. E.

( 177%) . Fsychol cog i cal factors in the progrids is of

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F’sychosomatic Medicine , 41 (B) ; 847-655.

Schag, C. C. , Heinrich , R. L. , & Ganz , F - A - (1983) . Cancer

inventory of problem situations: An instrument for

assess in G can cer patient ‘s rehabil it at i on needs .

Journal of F =ychosºcial Uncol Gay 1(4) .

1 1-24.

44

Schag, C. C. , Heinrich , R. L. , & Ganz , F. A. ( 1 °84) .

Karnofsky performance status revisited : Reliability,

validity, and guidel ines. Journal of

Clinical Uncol ogy. , 2.(3) ; 187-173.

Shacham , 5. (1983) . A shortened version of the profile

Of mood states - Journal of Personal it y fassessment. ,

47 (3) , 305-306.

Spiegel , Li . (1986) . Fsychosocial intervent ions with

cancer Patients - Journal of Psychosocial Uncol day,

3 (4) , 83–75.

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Dosik , G.M., & Leibowitz, R. L. (1985) . I l l ness-related

and treatment-related factors in psychol ogical

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Weisman , A. L. . , & Worden , J. W. (1976–1977) . The

existential plight in cancer : Sign if i cance of the first

109 days - International Journal of Psychiatry in

Medic line , 7 (1) , 1 - 15.

45Table 1

-Ileigriotive and Pºughomºtrio Propºrtiºn of Yariablº_

INSTRUMENT DRTR STRNDRRDIZED MERNCOLLECTION CHRONBQCH"S

IIMES Bll-PHB

Kornofsky Performance Soo leCKPSD

Physiod 1 Health StotusCPHS)

8 3 ; ;Profile of Mood States CPOM8Dtension-anxiety

depression-dejection

cºnger-hostility

vigor-dotivity

fatigue-inertio

confusion-bewilderment

9 3

Total Mood Disturbance CTMD)

9 3

- - i :

; ;

; ;Note. Inoppliocble data are represented by --.

Toble 2

-Demographic charactariation of Patients (N = 1272–

Chorooteristics N %

TESTRETszycarºtkanas Ezz-82; suTI3:35Education : M = 114 years CRonge = 7-20; SD = 2.95.)

GENDER

Female 87 (58.5

Mole 10 31.5

MRRITRL STRTUS

Morried 78 61.1%

Divorced 20 15.8

Never Morried 16 12.6

Uidowed 8 6.3

Separated 2 1.6

RRCE

Coucasion 102 80.3

Others 25 19.7

EMPLOYMENT

Retired 23 20.6

Full Time 24 19.0

Discbility 21 16.7

Leave of Rbs oence-

15 11.9

Port Time 8 6.3

CRNCER DIRGNOSIS

Brecast 5\} 102.5

Lung 19 15.0

Ovorion 11 8.7

Blodder 9 7.1

Lumphomo 7 5.5

Hodgkin's 6 1.7

Colon 1, 3.2

METRSTQTIC DISEQSE

Yes 97 79.0

No 25 21.0

47Table 3

-Paarson Correlations. Between Philaigal fungtioning and Mood State

Tension Depression Rnxiety Fatigue Vigor Confusion Mood

TIRETIKPS -0.3095 -0.1%223 -0.3950 -0.5770 0.4818 -0.4322 -0.5351

n = 117 0.0007 0.0000 O.0000 0.0000 0.0000 0.0000 0.0000

PHS -0.3000 -0.1%361 -0.31%.71 -0.1%008 (J.M. 193 -0.3482 -0.14558

in s 99 0.0026 0.0000 0.0001} 0.0000 0.0000 0.0001} 0.0000

TIME 2KPS -0.147.10% -0.4693 -0.3911 -0.04823 (0.14853 -0.04601 -0.5793

n = 88 0.0000 0.0000 0.0002 0.0000 0.0000 0.0000 0.0000

PHS -0.2801 -0.14331, -0.2592 -0.37.17 D.2738 -0.3236 -0.1%021

in s 38 0.0082 0.0000 0.0153 0.0001} 0.009! 0.0015 0.0001

TIME 3KPS -0.3525 -0.2738 -0.4337 (0.13361 -0.1%033

n = 80 0.0013 0.01140 0.0001 0.0001 (J.0002

PHS -0.3388 (0.3076 -0.2522

in s 31 0.0020 0.0052 0.0231

TIME 14KPS -0.3483 -0.320.1 -0.2625 -0.4181 0.2743 -0.3526 -0.4261

in s 68 0.0036 0.0078 0.0305 0.0003 0.0236 (0.0030 0.0003

PHS -0.3310 -0.3169 -0.2798 -0.37.11% (J.321.1% -0.3969

in s 69 0.0055 0.0080 D.01.99 0.001" (19.0071 0.0003

Tøble tº 48

-significant Changas in Mood states over Ilma

Post - hoo

M SD F 2 Comparison Scheffe

Tension 1 8.1 5.5 11.9 .0000 1 > 2 .00032 5.5 U.2 C3,55) 1 > 3 .00003 S.3 1.0 1 > \} .00001% 5.2 14.7

Fotigue 1 5.9 13.6 3.02 .0312 1 ( 1) .03912 7.0 5.2 C3.5%)3 7.2 1.1%º 7.7 1.7

Confusion 1 1.2 3.7 lº.61 .0039 1 ) 3 .00612 3.3 3.6 C3,57)3 2.0 2.4%1% 3.7 3.5

Touble 5

-significant Diffarangas in Individuals with Bragat Cangar

—and Thoas with Qther Lupes of Canoer

M SD t dº 2

Time 1KPS Breast 87.1 11.0 3.33 123 .0011

Other 78.9 15.2

Time 2KPS Breast 85.1 9.7 2.80 91% .00053

Other 110.3

PHS Broost 214.1 2.1% 10.5 95 .0000Other 21.0 1.1

Time 3KPS Breast 80%.9 10.3 2.60% 83 .0099

Other 12.0

PHS Breast 23.6 2.8 2.35 82 .02.13Other 22.0 3.3

Time i■PHS Brecast 21.0 2.5 3.09 (35 .003

Other 21.9 3.2

50Table @

-significant Differengºs Batiusan Individuals with Hataºtaºis–

and Those without Metastasis

M SD t d'■ 2

Time 1KPS Metastosis 81.6 14.3 -2.22 136 .0312

No Met astosis 87.6 11.8%

Fatigue Metostosis 6.1% 5.3 2.33 147 .0233No Metostosis 13.1 3.9

Time 2PHS Metostasis 22.1 13.0 -2.17 92 .0323

No Metastosis 24.1 2.1

Confusion Metostosis 19.3 10.1 2.67 90 .0090No Metostosis 1.8 1.8

Time !Fotigue Metostosis 3.3 19.7 2.62 66 .01.08

No Metostosis 13.8 3.1

TMD Metostosis 18.2 21.9 2.31% 63 .0223No Metostosis 13.0 10.1%

51Table 7

-statistics of Individuals unable to complate four Month studiº

■ º % Reds on

1. 5 0.0 Too busu2. 7 S.S Rodication treatments3. 5 14.0 Chemotherapu discontinued Cno response)1%. 8 6.0 Too ill5. 6 5.0 Expired6. 3 2.0 Psychological problems7. 7 5.5 Other reosons

Total tº 1 32.0

Notº. Rt Time 1, the total number of patients - 127.

52

Figure 1 . Lazarus & Folk man 's Stress, Appraisal , and Cop ing

Theoretical Framework with Study Variables

Cognitive appraisal of the person toward his/her cancer

and of the chemotherapy experience can affect the

individual ‘s perception of physical function ing and mood

state at each cycle of chemotherapy.

53

Causal Antecedents

Time 1

Nied i at i ng Processes

Time 2, 3, 4

Immediate

E++ ects

Time 2, 3, 4

Ferson Variables :

Fer:f Ormance Status

Functional Status

Modd State

Cognitive Appraisal

of Chemotherapy

Experience

Perf Cºrmance

Status

Functional

Status

Mood State

–

54

Figure 2. Changes in Karnofsky Performance (KFS) Scores

Over Time

There were no sign i Fi cant changes in KFS scores over

time (F (3,61 ) = .51 1 , p = . 68.

55

Elb■ OOSEKONV/WHO-IHEdAXIS-HONHVO!

–0■ 2-0■ 7|-09-001

EHOOS

5 6

Figure 3. Changes in Fnysical Health Status (FHS) Scores

Over Time

There were no sign if i cant d 1 + + erences in FHS scores

over time (F (3,57) - 1 E 5 D. - - 1 4

57

----08ST).LVLSHLTV/EHTVOISAHc|

EHOOS

F 1 gure 4 . Changes in Tension Scores Over Time

Tension scores ( subscal e Of the FOMS) decreased

significantly over time (F (3,55) = 1 1.88, p = . Q000) , with

the post-hoc Scheffe test indicating that the highest

tension scores were measured at T 1 (p = . QQQ3) .

59

+0]+Z||--171

NOISNELLEHOOS

60

Figure 5. Changes in Depression Scores Over Time

There were no sign i + i cant differences in depression

scores (a subscale of the FOMS) over time (F (3,54) = .82

= . 49 ) .

D.

61

NOISSEE|d|E|C.EHO3)S

Figure & . Changes in Anger Scores Over T 1 me

There were no sign if i cant d if + erences in anger scores

(a sub scal e Df the FOMS) Over time (F (3,54) .3% , p = . 76 ) .

wº

/(r-, -

s

63

HEISONV/-01

EHOOS

64r

Figure 7 . Changes in Vigor Scores Over Time

There were no sign if i cant changes in v i g or scores ( a-

subscale of the FDMS) over time (F (3,54) = 2.5 , p = . Q6) .

65

EHOOS

66

Figure 8 - Changes in F at i gue Scores Over Time

Fat i gue scores ( a sub scal e c-f the FOMS) increased

significantly over time (F (3,54) = 3. Q2, p = . Q312) , with

the post-hoc Sche+fe test indicating that the lowest fatigue

scores were reported at T 1 (p = .03% 1 ) .

67

ETSOLLVE

EEOC)S

68

Figure 2. Changes in Confusion Scores Over Time

Conf Lisi On scores (a sub scal e dif the FOMS) decreased

over time (F (3,57) = 4.61 , p = . QQ3%) , with the post-hoc

Schef + e indicating that the l owest confusion scores were

reported at T3 (p = . QQ61 ) .

69

NOISTEINOSOEHOOS

70

F i gure 1 Q - Changes in Total Plood dist Lurbance (TMI) Scores

Over Time

There were no sign if i cant ci i f + erences in TML scores (a

summary measure , adding the sub scale scores of the FUP15,

negatively weigning vigor ) (F (3,53) = .75 , p = .42) .

71

--09

EKONVERHTISICICIOOWTVILO1

EHOOS

1.

2.

3.

5.

Who currently lives at home with you? 73

Name- - -

Sex Age Relationship

Self

How many children are there in the family?

What is your current partner status?

Married. . . . . . . . . . . . . . . . . . . . . . . 1 Separated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Widowed. . . . . . . . . . . . . . . . . . . . . . .2 Never married. . . . . . . . . . . . . . . . . . . . . . . . . .5Divorced. . . . . . . . . . . . . . . . . . . . . .3 Not married but living together. . . . . . . .6

What is the highest grade or year you completed in regular school, vocationalschool, college or graduate professional training? (circle highest grade oryear completed and indicate if diploma/degree was obtained.)

No formal school: O

Grade school/junior high: l 2 3 4 5 6 7 8

High school/vocational/trade: 9 10 1 1 12. . . . . . . . . . . Diploma: Yes No

College/specialized training: Degree or13 14 15 16. . . . . . . . . . . Diploma: Yes No

Graduate professional training:

17 18 19 20 or more.... Degree: Yes No

Please circle your religious preference at the present time:

a Protestant d Other (specify)b Catholic e NoneC Jewish

74

10.

11.

12.

Full timeNo changeFull time

Change inPart time

No changePart time

change in

in status

Statu S

in status

Statu S

iPlease circle your current employment status:

Leave of absence

DisabilityNot employedRetiredOther

Please circle your partner's current employment status:

a

b

Full timeNo changeFull timeChange inPart time

No changePart time

Change in

in status

Statu S

in status

Status

iLeave of absenceDisabilityNot employedRetired

Not applicable

If you have been previously or are currently employed, what do/did you do?

What type of work did/does your partner do?

Circle the number that best describes your ethnic group:

Asian or Pacific Islander..... 1American Indian. . . . . . . . . . . . . . .2Black. . . . . . . . . . . . . . . . . . . . . . . . .3Caucasian/White. . . . . . . . . . . . . . .4

Eurasian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Hispanic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Family has mixed ethnic background. . . . . 7Other (specify) 8

Circle the number that best describes your partner's ethnic group:

Asian or Pacific Islander. . . . .American Indian. . . . . . . . . . . . . . .Black. .

l23

Caucasian/White. . . . . . . . . . . . . . .4

Eurasian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Hispanic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Family has mixed ethnic background. . . . . 7

8Other (specify)Not applicable . . . . . . . . .9

Please look at the list below and circle the letter next to the amount thatcomes closest to your family's total income last year.

a

bC

Less than$10,000 –$30,000 –

$10,000$29,999$49,999

de

f

$50,000 – $69,999Over $70,000No answer

76

INSTRUCTIONS: PLEASE CIRCLE THE PERCENTAGE THAT BEST DESCRIBES YOUR ABILITIESAT THE PRESENT TIME.

13. I feel normal, I have no complaints or symptoms.-

100

I am able to carry on normal activities; I have 90minor signs or symptoms of my illness.

It takes a bit of effort to engage in my normal 80activity.

I can care for myself; but am unable to carry on 70normal activity or to do active work.

I require occasional assistance, but am able 60to care for most of my personal needs.

I require a considerable amount of assistance, 50and frequent medical care.

I require special care and assistance 40

I feel severe disabled and need to be hospitalized 30

PHYSICAL HEALTH STATUS 78

INSTRUCTIONS: PLEASE CIRCLE THE ANSWER THAT BEST DESCRIBES YOUR CURRENT ABILITIES.

At the current time:

39. Are you able to drive a car?(Circle One)

No, because of my health. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - Answer 40No, for some other reason. . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - Go to 41Yes, able to drive a car. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - Go to 41

40. How long have you been unable to drive a car because of your health?-

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1l

-3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

41. When you travel around your community, does someone have to assist you becauseof your health?

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l - Answer 42No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

-Go to 43

42. How long have you needed someone to assist you in traveling around yourcommunity?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

-3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

43. Do you have to stay indoors most or all of the day, because of your health?

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - Answer 44No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - Go to 45

44. How long have you had to stay indoors most or all of the day because of yourhealth?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

79Are you in bed or a chair for most or all of the day because of your health?45.

Yes. . . . . . . . . . . . . . . . . - - - - - - - - - - - e e e e e º e e - e. e. • e º e º 'º - - - - 1 - Answer 46No e e - e. e. e. e. e. e. e. e e - e. e. e. e. e. e. e. e. e. e. e. e. e. • e º e - e. e. e º 'º - e - - - - - - e - - - - 2 - Go to 47

46. How long have you been in bed or a chair for most or all of the day because ofyour health?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . e - e. e. e. e. e. e e s - e. e. e. e. e. e. e. e. ... 11 - 3 weeks. . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - - - - - - - - - 2More than 3 weeks. . . . . . . . . . . . . . . . . . . - - - - - - - - . . . . . . . . 3

47. Does your health limit the kind of vigorous activities you can do, such asrunning, lifting heavy objects, or participating in strenuous sports?

Yes. . . . . . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - Answer 48No - - - - - - - - - - - • e º 'o - e º 'o e º e - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. - - - - - - - 2 - Go to 49

48. How long has your health limited the kind of vigorous activities you can do?(Circle One)

Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l1 - 3 weeks. . . . - - - - - e e º e e - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. 2More than 3 weeks. . . . . . . . e - e. e. e. e. e. e. e. e. e. e. e. e. e. . . . . . . . . . . . . 3

49. Do you have any trouble either walking several blocks or climbing a few flightsof stairs because of your health?

Yes. . . . . . . . . . . . . . . . . . . . . . e e o e e - e. e. e. e. e. e. e. e. e. e. e. e. e. . . . . . . . . 1 - Answer 50No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e e e º e º e e s e ... 2 - Go to 51

50. How long have you had trouble walking several blocks or climbing a few flightsof stairs because of your health?

(Circle One)Less than 1 week. . . . . . . . - - - - - - - - - - - - - - - - - - - - - - - - - - - ... 11 - 3 weeks. . . . . . . . . . . . . . . . . . . . . . . e e º e º 'º e s e e º 'º e e . . . . 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

51. Do you have trouble bending, lifting, or stooping because of your health?

1 - Answer 52No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 – Go to 53

80How long have you had trouble bending, lifting, or stooping because of your52.health?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 3 weeks. . . . . . . . . . - - - - - - - - - - e e s e º e º e o 'º e º e º 'º - e. e. e. e. e. 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

53. Do you have any trouble either walking one block or climbing one flight ofstairs because of your health?

-

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 – Answer 54No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

-Go to 55

54. How long have you had trouble walking one block or climbing one flight of stairsbecause of your health?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1l

-3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

More than 3 weeks. . . . . . . . . e c e e s - e. e. e. e. . . . . . . . . . . . . . . . . 3

55. Are you unable to walk unless you are assisted by another person or by a cane,crutches, artificial limbs, or braces?

Yes. . . . . . . . . . . . . . . . . . . . - - - - - - e e - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. 1 - Answer 56No. . . . . . . . . . . . . . . . . . . . - - - - - - - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. 2 - Go to 57

56. How long have you been unable to walk without assistance?(Circle One)

Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l1 - 3 weeks. . . . . . e e - e. e. e. e. e. e. e. e. e. e. e - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e º 'o - e. e. 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

57. Are you unable to do certain kinds or amounts of work, housework, or schoolworkbecause of your health?

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . e - e. e. e. e. e. e. e. e. e. e. e. e. . . . . . . . 1 - Answer 58No. . . . . . . . . . . . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - - - - - - . . 2 – Go to 59

58. How long have you been unable to do certain kinds or amounts or work, housework,or schoolwork because of your health?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - l1 - 3 weeks. . . . . . . . • * * * * * * * * * * ~ * - e. e. e. e. e s - e. e. e. e. e. e. e. e. e. e. e. e. 2More than 3 weeks. . . . . . . . . . . • e º e º e - e. e. e. e. e. e. e. e. e. e. e. e. e. e. e. ... 3

81

59.

60.

Does your health keep you from working at a job, doing work around the house, orgoing to school?

1 - Answer 602 – Go to 61

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How long has your health kept you from working at a job, doing work around thehouse, or going to school?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

61.

62.

Do you need help with eating, dressing, bathing, or using the toilet because ofyour health?

1 – Answer 622 – Go to 63

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How long have you needed help with eating, dressing, bathing, or using thetoilet because of your health?

(Circle One)Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

63.

64.

Does your health limit you in any way from doing anything you want to do?

1 - Answer 642

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How long has your health limited you in doing things you want to do?(Circle One)

Less than 1 week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2More than 3 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

POMS 83

INSTRUCTIONS: PLEASE CIRCLE THE NUMBER THAT BEST DESCRIBES HOW YOU HAVE BEENFEELING DURING THE PAST WEEK INCLUDING TODAY.

Not at A. little Moderately Quite Extremelyall

-a bit

14. Tense . . . . . . . . . . . 0 1 2 3 4

15. Angry - - e - e. e. e. e. 0 1 2 3 4

16. Worn out . . . . . . . . . . 0 l 2 3 4

17. Unhappy . . . . . . . . . . O l 2 3 4

18. Lively . . . . . . . . . . . 0 l 2 3 4

19. Confused . . . . . . . . . . O l 2 3 4

20. Peeved . . . . . . . . . . . O l 2 3 4

21. Sad . . . . . . . . . . . . O l 2 3 4

22. Active . . . . . . . . . . . 0 l 2 3 4

23. On edge . . . . . . . . . . 0 l 2 3 4

24. Grouchy . . . . . . . . . . 0 1 2 3 4

25. Blue . . . . . . . . . . . . 0 l 2 3 4

26. Energetic . . . . . . . . . 0- l 2 3 4

27. Hopeless . . . . . . . . . . O l 2 . 3 4

28. Uneasy . . . . . . . . . . . 0 l 2 3 4

29. Restless . . . . . . . . . . O l 2 3 4

30. Unable to concentrate . . . O l 2 3 4

31. Fatigued . . . . . . . . . . O l 2 3 4

32. Annoyed . . . . . . . . . . O l 2 3 4

33. Discouraged . . . . . . . . 0 l 2 3 4

84(Continued)

Not at A little Moderately Quite Extremelyall a bit

34. Resentful . . . . O l 2 3 4

35. Nervous . . . . . 0 1 2 3 4

36. Miserable . . . . . O l 2 3 4

37. Cheerful . . . . . O l 2 3 4

38. Bitter . . . . . . . . 0 l 2 3 4

39. Exhausted . . . . . . O l 2 3 4

40. Anxious . . . 0 l 2 3 4

41. Helpless . . . . . . 0 l 2 3 4

42. Weary . . . . . . . 0 l 2 3 4

43. Bewildered . . . . . O l 2 3 4

44. Furious . . . . . . . O l 2 3 4

45. Full of pep . . . 0 1 2 3 4

46. Worthless . . . . . 0 l 2 3 4

47. Forgetful . . . . . . 0 l 2 3 4

48. Vigorous . . . 0 l 2 3 4

49. Uncertain about things . 0 l 2 3 4

50. Bushed . . . 0 l 2 3 4

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