International Journal of Chronic Obstructive Pulmonary Disease Dovepress

open access to scientific and medical research

Open Access Full Text Article

ORIGINAL RESEARCH

Evaluation of the Individual Activity Descriptors of

International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ on 27-Sep-2022

the mMRC Breathlessness Scale: A Mixed Method

Study
Janelle Yorke 1,2 , Naimat Khan 1,3 , Adam Garrow 1 , Sarah Tyson 1 , Dave Singh 1,3 , Jorgen Vestbo 1,4
,
Paul W Jones 5
1
Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; 2Christie Patient Centred Research, The Christie NHS
Foundation Trust, Whittington, Manchester, UK; 3Medicines Evaluation Unit, Wythenshawe, Manchester, UK; 4Department of Respiratory Medicine,
Wythenshawe Hospital, Manchester, UK; 5St George's Hospital, University of London, London, UK

Correspondence: Janelle Yorke, Tel +44920 264411, Email [email protected]

For personal use only.

Purpose: The modified-Medical Research Council (mMRC) breathlessness scale consists of five grades that contain of a description
of different activities. It has wide utility in the assessment of disability due to breathlessness but was originally developed before the
advent of modern psychometric methodology and, for example contains more than one activity per grade. We conducted an evaluation
of the mMRC structure.
Patients and Methods: Cognitive debriefing was conducted with COPD patients to elicit their understanding of each mMRC
activity. In a cross-sectional study, patients completed the mMRC scale (grades 0–4) and an MRC-Expanded (MRC-Ex) version
consisting of 10-items, each containing one mMRC activity. Each activity was then given a 4-point response scale (0 “not at all” to 4
“all of the time”) and all 10 items were given to 203 patients to complete Rasch analysis and assess the pattern of MRC item severity
and its hierarchical structure.
Results: Cognitive debriefing with 36 patients suggested ambiguity with the term “strenuous exercise” and perceived severity
differences between mMRC activities. 203 patients completed the mMRC-Ex. Strenuous exercise was located third on the ascending
severity scale. Rasch identified the mildest term was “walking up a slight hill” (logit −2.76) and “too breathless to leave the house”
was the most severe (logit 3.42).
Conclusion: This analysis showed that items that were combined into a single mMRC grade may be widely separated in terms of perceived
severity when assessed individually. This suggests that mMRC grades as a measure of individual disability related to breathlessness contain
significant ambiguity due to the combination of activities of different degrees of perceived severity into a single grade.
Keywords: psychometrics, Rasch analysis, patient reported outcomes, qualitative, scale development

Introduction
Breathlessness is a complex subjective sensation that is common and debilitating in patients with Chronic Obstructive
Pulmonary Disease (COPD). Breathlessness is an important predictor of exercise tolerance1 and both factors have been
shown to influence patients’ health status at all levels of COPD severity.2 Breathlessness can be quantified directly using
scales such as the Borg and Visual Analogue Scales (VAS) or indirectly through its impact on physical activity.3,4 The
modified-Medical Research Council (mMRC) breathlessness scale classifies the disability associated with breathlessness
by identifying different levels of activities that induce or are restricted by breathlessness.5
The MRC breathlessness scale was first published in 1959 by Fletcher et al based on their study of respiratory symptoms
experienced by Welsh coal miners in the 1940s.5 It was originally developed as an epidemiological tool for studies of the
general population, but over many decades has morphed into a tool that is applied at an individual patient level. The
questionnaire is frequently used in COPD as breathlessness is a crucial symptom in this condition.3 The original version of
the MRC consists of scale ranges from grade 1 to 5. The mMRC version is now used which is similar in wording for each

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 2289–2299 2289

Received: 16 May 2022 © 2022 Yorke et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
Accepted: 17 August 2022 php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
Published: 15 September 2022 permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
 Yorke et al Dovepress

grade but consists of scale ranges from grade 0 to 4. It is important to note that it does not measure breathlessness directly,
unlike other scales such as the Borg scale. Rather it measures the degree of activity at which a person gets breathlessness (such
as “with strenuous exercise”) or limits what a person can do (such as “too breathless to leave the house”). It consists of five
grades (1 to 5) that contain statements describing a range of physical limitations associated with breathlessness.
There is an assumption that the mMRC Grades are Guttman scaled6 in which a person who fulfils the criteria for
Grade 4, should also fulfil the criteria for Grade 3, 2 etc. Except for MRC Grade 0 (“not troubled by breathlessness
except on strenuous exercise”), each grade consists of two different activity descriptions. For example, the components of
Grade 4 include “too breathless to leave the house” or “breathless when dressing”; reflecting potentially large differences
in activity level. To our knowledge the comparability of different mMRC grade components has not been previously
subjected to rigorous testing.
The mMRC breathlessness scale has good discriminative ability and is a simple method of categorising patients with
COPD in terms of their disability7,8 and survival.9 Thus, it is recommended for use as a marker of disability in
international COPD guidelines10,11 and used to assess suitability for pulmonary rehabilitation in the UK.10 However,
due to the wide spread of severity between MRC grades it is too insensitive to detect relevant changes in activity
limitation due to breathlessness following an intervention.3 Despite the widespread use of the scale, there has been little
work to evaluate its psychometric properties, particularly the effect of combining different activity descriptions within the
mMRC grades and the ordering of the grade severity. It is important to confirm whether the different components within
each grade represent the same level of exertion. This study aimed to examine the content and construct validity of the
MRC scale using cognitive debriefing with COPD patients and modern psychometric techniques. Specific objectives
included: i) to determine how patients with COPD understand and interpret each mMRC grade descriptor; ii) to
determine if patient responses to individual mMRC activities meet the requirements for Guttman scaling; and iii) to
measure the similarity of scores between different activity descriptors within a single mMRC grade.

Methods
We used both qualitative and quantitative approaches to explore patients understanding more fully of the mMRC
descriptors and to quantify the hierarchical structure of the scale. To achieve this, the study was conducted in two phases:
Phase 1: cognitive debriefing to ascertain patients’ comprehension and views of each mMRC activity and Phase 2:
application of descriptive statistics and Rasch analysis to assesses the performance of each mMRC grade component.
This study complies with the Declaration of Helsinki and ethical approval for was provided by the National Research Ethics
Committee for Greater Manchester East (ref: 12/NW/0608). This study was conducted between January 2013 – July 2015.
In each phase of the study, the participants were identified from a research database of COPD patients (n>800)
recruited from primary care and hospital clinics; these patients had volunteered to participate in research studies at the
Medicines Evaluation Unit, adjacent to Wythenshawe Hospital (South Manchester). Potential participants for each study
phase were contacted by telephone to ascertain their interest in taking part. If interested, a study information pack was
mailed to the patient and a suitable time to attend the research facility for consenting and data collection was agreed
which were completed on the same day. Participants were paid a nominal fee for taking part in the study.

Inclusion and Exclusion Criteria

Inclusion criteria were: male and female patients aged 40 years or older diagnosed with COPD by General Practitioner or
respiratory specialists using established criteria.12 Airflow limitation was graded according to post-bronchodilator Forced
Expired Volume in 1 second (FEV1) spirometry. Patients with FEV1 ≥ 80% predicted were classified as Global Initiative
for Chronic Obstructive Lung Disease (GOLD) Grade 1 (Mild), 50% ≤ FEV1 <80% predicted Grade 2 (Moderate); 30%
≤ FEV1 <50% predicted Grade 3 (Severe) and FEV1 <30% predicted Grade 4 (Very Severe).12 Patients were excluded if
they had a medically confirmed and documented chest infection in the previous three months or any other respiratory
illness such as asthma, cystic fibrosis, and lung cancer.

2290 https://doi.org/10.2147/COPD.S372318 International Journal of Chronic Obstructive Pulmonary Disease 2022:17

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Yorke et al

Data Collection
Phase 1
The initial phase involved cognitive debriefing13 in a focus group with patients diagnosed with COPD. The groups were
facilitated by two of the authors both with qualitative research experience (JY & AG), audio-recorded and transcribed
verbatim. Participants were presented with a list of 10 items, each consisting of an individual activity from the original
MRC questionnaire (Table 1). Firstly, participants were asked to describe their understanding of the meaning of each item
and their experience of it. Next, they were asked to comment on whether or not the combination of items within the
mMRC grades was logical and appropriate and if such combinations reflected their experience (eg “Do the items ‘I am
too breathless to leave the house’ and ‘I am breathlessness when dressing/undressing’ represent a similar experience?”
and “What are your thoughts regarding the combination of different descriptors within each grade?”).

Phase 2
In Phase 2, a sample of COPD patients was asked to complete the mMRC breathlessness scale (grades 0 to 4) by placing
a tick in the box next to the grade that best described their current experience. They also completed the MRC-expanded
(MRC-Ex) version made up of the 10 MRC activities created for the purposes of this study (Figure 1). Each item used
a 4-point response scale (0 “not at all” to 4 “all of the time”). Participants were instructed to complete both questionnaires
during a study specific visit to the research facility in random order.

Data Analysis
Statistical analyses were conducted using SPSS Statistics for Windows, Version 20.0. Armonk, NY. The Polytomous
Rasch model was applied using RUMM2030 programme (www.eumlab.com). In a Rasch model, severity associated with
any given item (ie “strenuous exercise”) is measured in “logits” – which is the log odds of a patient of a given level of
activity limitation, as assessed by their response to all the items combined, having a 50% chance of responding positively
to that item.

Phase 1
Focus group meetings were recorded, transcribed, and analysed using a modified thematic analysis approach.14 Thematic
analysis is a method for describing data across, for example, interviews or focus groups, to describe data through the
generation of themes. Our modified approach analysed data across the different focus-group sets to describe participants
perceptions and understanding of the mMRC descriptions; we did not move to the next step of theme generation.

Phase 2
Descriptive statistics summarised demographic details and compared participant’s self-allocation to an mMRC grade with
their responses to the 10-item MRC-Ex. In particular, we assessed whether patients scored positively for items in the
MRC-Ex that indicated more severe disability than their response on the mMRC grading.
Rasch analysis allowed several scale assumptions to be tested. It is an advanced psychometric methodology that is
closely related to item-response theories.15,16 The Rasch model is based on a probabilistic relationship between people

Table 1 mMRC Breathlessness Scale

Grade Degree of Breathlessness Related to Activities

0 Not troubled by breathlessness except on strenuous exercise1

1 Short of breath when hurrying2 or walking up a slight hill3

2 Walks slower than contemporaries on level ground because of breathlessness4, or has to stop for breath when walking at own pace5

3 Stops for breath after walking about 100 metres6 or after a few minutes on level ground7

4 Too breathless to leave the house8, or breathless when dressing9 or undressing10

Notes: Each number represents a single activity descriptor (n=10). Reproduced from Chest. Volume: 93. Mahler DA, Wells CK. Evaluation of clinical methods for rating
dyspnea. Page numbers: 580–586, copyright (1988), with permission from Elsevier.1

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 https://doi.org/10.2147/COPD.S372318

2291
DovePress

Powered by TCPDF (www.tcpdf.org)

 Yorke et al Dovepress

Not troubled by breathlessness Not at all Some of the time Most of the time All of the time
except with strenuous exercise

Short of breath when hurrying Not at all Some of the time Most of the time All of the time

Short of breath when walking up Not at all Some of the time Most of the time All of the time
a slight hill

Walking slower than people of Not at all Some of the time Most of the time All of the time
the same age on the ground level
because of breathlessness
Walking slower than people of Not at all Some of the time Most of the time All of the time
the same age on the ground level
because of breathlessness

Have to stop for breath when Not at all Some of the time Most of the time All of the time
walking at my own pace

Stop to breathe after walking Not at all Some of the time Most of the time All of the time
about 100 yards (100 metres) on
the level

Stop to breathe after walking for Not at all Some of the time Most of the time All of the time
a few minutes on level ground

Too breathless to leave the Not at all Some of the time Most of the time All of the time
house

Breathless when dressing Not at all Some of the time Most of the time All of the time

Breathless when undressing Not at all Some of the time Most of the time All of the time

Figure 1 MRC-Expanded version.

who complete a questionnaire and the items on that questionnaire. In the context of a breathlessness scale, we would
expect that a person with very severe breathlessness would be more likely to affirm any given item than another person
who had no difficulties with their breathing. Using this methodology it is possible to separately model the level of
breathlessness (i.e its severity) exhibited by the respondents and the level of breathlessness assessed by the individual
items. By doing so, items can be ordered on a continuum of breathlessness severity using a linear logit scale. A higher
logit value indicates a greater severity of breathlessness.6,16 Individual item fit was assessed using a chi-squared statistic
to compare the difference between the observed responses and those expected by the model. The presence of any item-
trait interaction was tested using a chi-square test to assess whether all items perform consistently, regardless of overall
mMRC-Ex grade severity (determined by p>0.05) (16).
Rasch analysis was used to assess the ordering of item severity of MRC-Ex items. Individual item fit was assessed to
determine if all 10 item descriptors met the requirements of a unidimensional scale. In the context of this study, Rasch fit
statistics were used to examine the measurement properties of the MRC-Ex and extrapolate these to the original mMRC
grade to highlight measurement anomalies with its individual items rather than to present the MRC-Ex as a new scale for
the assessment of breathlessness in COPD.

Results
Phase 1
36 patients took part in six focus groups, each including 2–9 participants. Their characteristics are shown in Table 2. With
the exception of mMRC Grade 0 (strenuous exercise), participants were able to describe the meaning of each individual
activity (Table 3). There was a consensus that combining items within a mMRC grade was not logical, particularly the
combination of descriptors located in Grade 4. In general, participants viewed the mMRC scale as quick and easy to use
but questioned the appropriateness of combining different grade components.

2292 https://doi.org/10.2147/COPD.S372318 International Journal of Chronic Obstructive Pulmonary Disease 2022:17

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Yorke et al

Table 2 Participant Characteristics for Phase 1

Focus Groups
(n=36)

Male n (%) 18 (50.0)

Age mean (SD) 68.3 (5.2)

BMI mean (SD) 27.2 (4.8)

Current smokers n (%) 11 (30.6)

COPD duration in years (SD) 7.4 (5.2)

GOLD Grade 1 n(%) 1 (2.8)

GOLD Grade 2 n(%) 12 (33.3)

GOLD Grade 3 n(%) 15 (41.7)

GOLD Grade 4 n(%) 3 (8.3)

Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary
disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Table 3 Focus Group Comments for Each MRC Grade

mMRC Grade mMRC Activity Descriptor Cognitive Debriefing Comments

0 Not troubled by breathlessness except on strenuous exercise Participants were unsure as to what constitutes strenuous exercise.
The item did not relate to some people: “Can’t do strenuous
exercise”
“What is strenuous exercise – gardening, carrying heavy bags?”;
“When you are putting strain on yourself?”; “Does it mean going to
the gym or does it mean getting dressed? But I don’t consider
getting dressed strenuous exercise – unless you have COPD”

1 Short of breath when hurrying on the level OR Short of breath Consensus that this should be 2 items
walking up a slight hill “Hurrying on the level is not the same as walking up hill – walking
up hill is more strenuous”
“You’re going to walk up hill more slowly anyway”
“If you’re hurrying, you get stressed because you’re trying to hurry
and you can’t, rather than if you’re walking uphill and it’s just
strenuous”

2 Walks slower than people of the same age on the ground level Agreement that these are two different experiences
because of breathlessness OR have to stop for breath when “What is a regular pace?”
walking at my own pace “Depends on speeds”
“Age has nothing to do with it. It’s either breathlessness or
whatever, but not age”

3 Stop to breathe after walking about 100 yards (100 metres) on “Depends on speed”
the level OR Stop for breath after walking for a few minutes on “Getting breathless after 100 yards is a different experience from
level ground walking for a few minutes”

4 Breathless when dressing Agreement that these are two different experiences
Breathlessness when undressing “All of us have said that we get breathless when we’re getting
Too breathless to leave the house dressed or showering but it doesn’t stop us leaving the house”
“Depends on the weather – if you are too breathless to go out
there’s not a lot you can do but you can carry on putting on clothes
after resting”

Abbreviation: mMRC, modified Medical Research Council ws.

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 https://doi.org/10.2147/COPD.S372318

2293
DovePress

Powered by TCPDF (www.tcpdf.org)

 Yorke et al Dovepress

Phase 2
203 patients with a confirmed diagnosis of COPD completed the questionnaires. Their characteristics are shown in
Table 4. There was a good spread of patients across the five mMRC grades (0: 9.9%; 1: 31.5%; 2: 19.7; 3: 21.6%; 4:
11.3%) enabling comparisons to be made across the full range of possible disabilities.
The first stage of analysis included an assessment of patients’ responses to the original mMRC grading compared with
their responses to the MRC-Ex (Table 5). For each mMRC grade a proportion of patients also responded positively to
experiencing a more severe level of disability on the MRC-Ex at least “some of the time”. For example, 20 patients were
in mMRC Grade 0 yet most also experienced breathlessness during activities that were assigned to other mMRC grades
such as such as Grade 1 (“going up a slight hill”; 15/20 and “hurrying on the level”; 14/20), even MRC grade 4 (dressing/
undressing; both 4/20); none of the 20 “Grade 0” participants responded that they were too breathless “to leave the
house”. For MRC-Ex items 1, 3, 5, 6, 7, 8, 9 and 10, a proportion of patients indicated they did not experience an item at
least “some of the time”, despite responding positively to the relative MRC grade. For example, of the 23 patients in
mMRC Grade 4, 30% (7/20) responded “not at all” to the MRC-Ex item “too breathless to leave the house”. For mMRC
Grade 3 13% (7/56) patients responded “not at all” to its corresponding items MRC-Ex 6 and 7.

Table 4 Participant Characteristics – Phase 2

COPD (n=203)

Male n (%) 128 (63.1)

Age (years) 64.8 (7.5)

BMI mean (SD) 27.6 (5.2)

Current smokers n (%) 66 (32.5)

Pack years median (IQR) 41 (27 to 57)

COPD duration in years (SD) 7.5 (5.3)

mMRC scale n (%)

1 20 (9.9)

2 64 (31.5)

3 40 (19.7)

4 56 (27.6)

5 23 (11.3)

GOLD n(%)

Grade 1 28 (13.8)

FEV1% predicted (%) mean (SD) Min & Max 87.7 (5.6) Min 80.0-Max 100.1)

Grade 2 83 (40.9)

FEV1% predicted (%) mean (SD) Min & Max 64.0 (7.9) Min 51.1-Max 78.9)

Grade 3 50 (24.6)

FEV1% predicted (%) mean (SD) Min & Max 43.3 (4.5) Min 34.2-Max 49.9)

Grade 4 15 (7.4)

FEV1% predicted (%) mean (SD) Min & Max 23.9 (3.4) Min 21.9-Max 28.6)
Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; mMRC, modified
medical research council; GOLD, Global Initiative for Chronic Obstructive Lung Disease; FEV1, Forced
Expired Volume in 1 second.

2294 https://doi.org/10.2147/COPD.S372318 International Journal of Chronic Obstructive Pulmonary Disease 2022:17

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Yorke et al

Table 5 mMRC Grade and Corresponding MRC-Ex Responses

mMRC Grade MRC-Exploded Item mMRC Grade 1 mMRC Grade 2 mMRC Grade 3 mMRC Grade 4 mMRC Grade 5

n = 20 n = 64 n = 40 n = 56 n = 23

Yes* No# Yes* No Yes* No Yes* No Yes* No

(%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

MRC 0 1.Strenuous exercise 15 (75) 5 (25) 64 (100) 0 39 (97) 1 (3) 54 (96) 2 (4) 20 (87) 3 (13)

MRC 1 2. Hurrying on level 14 (70) 6 (30) 64 (100) 0 40 (100) 0 56 (100) 0 23 (100) 0

MRC 1 3. Slight hill 15 (75) 5 (25) 62 (97) 2 (3) 40 (100) 0 56 (100) 0 23 (100) 0

MRC 2 4. Slower than cotemporaries 2 (10) 18 (90) 43 (67) 21 (33) 40 (100) 0 56 (100) 0 23 (100) 0

MRC 2 5. Stop walking at own pace 2 (10) 18 (90) 38 (59) 26 (41) 33 (87) 5 (13) 53 (95) 0 22 (96) 1 (4)

MRC 3 6. 100 yards/metres 1 (5) 19 (95) 24 (38) 40 (62) 29 (73) 11 (27) 54 (96) 2 (4) 22 (96) 1 (4)

MRC 3 7. Few minutes 1 (5) 19 (95) 16 (25) 48 (75) 27 (68) 13 (32) 51 (91) 5 (9) 21 (91) 2 (9)

MRC 4 8. Leave the house 0 20 (100) 5 (8) 59 (92) 5 (13) 35 (87) 24 (43) 32 (57) 16 (70) 7 (30)

MRC 4 9. Dressing 4 (20) 16 (80) 20 (31) 44 (69) 25 (63) 15 (37) 49 (88) 7 (12) 22 (96) 1 (4)

MRC 4 10. Undressing 4 (20) 16 (80) 17 (27) 47 (73) 23 (58) 17 (42) 45 (80) 11 (20) 22 (96) 1 (4)
#
Notes: *Responded on the MRC-Ex at least “some of the time”. Responded on the MRC-Ex “not at all”. Bold numbers indicate the proportion of patients affirming a grade
of the mMRC. This shows that for each mMRC grade a proportion of patients also responded positively to experiencing a more severe level of disability on the MRC-Ex at
least “some of the time”.

Rasch analysis was used to determine the severity location (measured in logits) for each MRC-Ex item and to test
whether its severity matched the ordering according to mMRC grades (Table 6). The mildest item was “breathless when
going up a slight hill” (logit −2.76) and “too breathless to leave the house” was the most severe item (logit 3.422). MRC-
Ex item 1 (“strenuous exercise”) was located third on the ascending severity scale with a logit of −1.389. mMRC Grade 4
components “breathless when dressing” (MRC-Ex 9) and “breathless when undressing” (MRC-Ex 10) were much milder
(at least 2 logits) than “too breathlessness to leave the house” (MRC-Ex 8). The level of information provided by each
item at different levels of breathlessness is plotted in Figure 2.

Table 6 Logit (Severity) Location for Each mMRC Component

mMRC Grade MRC-Ex Item Severity (Logit)

1 3. slight hill −2.76

1 2. hurrying on flat −2.519

0 1. strenuous exercise −1.389

2 4. same age −0.847

2 5. own pace 0.043

3 6. 100 metres 0.427

3 7. few minutes 1.051

4 9. dressing 1.1

4 10. undressing 1.472

4 8. leave house 3.422

Abbreviations: mMRC, modified Medical Research Council; MRC-EX, Medical Research Council
Extended.

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 https://doi.org/10.2147/COPD.S372318

2295
DovePress

Powered by TCPDF (www.tcpdf.org)

 Yorke et al Dovepress

Figure 2 Individual item information plot for MRC-Ex.

The MRC-Ex 10-items did not fit the Rasch model (chi-square = 11.2, p <0.00001). This was due to one item – “not
troubled by breathlessness except on strenuous exercise” (MRC-EX item 1) which demonstrated significant mis-fit to the
model due to a high positive fit residual, indicating that the item does not reliably discriminate between respondents at
any level of breathlessness (item residual +7.2, p = 0.00004) (Figure 3) leading it to provide very little information at all
levels of breathlessness. The removal of this item resulted in overall fit of the remaining 9 items to the Rasch model (chi-
square = 21.5, p = 0.25).

Figure 3 Item characteristic curve – MRC-Ex 1 “Not troubled by breathlessness except on strenuous exercise”.

2296 https://doi.org/10.2147/COPD.S372318 International Journal of Chronic Obstructive Pulmonary Disease 2022:17

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Yorke et al

Discussion
The aim of this study was to examine the performance of different components of the mMRC breathlessness scale and to
determine the appropriateness of combining different activity descriptors within each grade. To our knowledge, this is the
first mixed method analysis to examine the validity of presenting more than one activity descriptor within the mMRC
grades and its Guttman scaling properties in patients with COPD.
The results from both Phases 1 and 2 bring into question the hierarchical structure of the mMRC scale. Notably,
mMRC grade 0 presents a number of measurement challenges. Firstly, some patients stated that the term was difficult to
place in context of their current experience because they did not undertake strenuous exercise. For others, the description
was confusing as it could cover a very broad spectrum of activities. This ambiguity is likely to have resulted in some
patients being allocated to Grade 0 whilst also responding positively to an MRC-Ex item that denoted greater disability.
Rasch analysis confirmed that patients were not responding to this item in the intended manner, resulting in item “mis-
fit”; when this item was removed the remaining item-set demonstrated good fit to the Rasch unidimensional model.
Rasch analysis also demonstrated that this item did not denote the mildest breathlessness – it was positioned third on the
MRC-Ex severity scale. These results highlight mMRC grade 0 as an anomaly. It is difficult for patients to comprehend,
has poor measurement properties and its logit value does not represent the lowest level of activity limitation.
The mMRC grades 1 to 4 contain more than one activity that it is assumed evoke the same level of disability due to
breathlessness, however there was a consensus during focus group meetings that the inclusion of more than one activity
in a single mMRC grade was unhelpful and confusing. Compared to other grades, grade 1 components (“hurrying on the
flat” and “walking up a slight hill”) demonstrated the closest logit severity level – they were less than 0.2 logits apart.
Interestingly, one focus group participant associated the term “hurrying” with being stressed as opposed to representing
breathlessness due to physical exertion/walking quickly. This brings into question the comparability of these two grade
components. However, of the 64 participants located in mMRC grade 1, all responded positively to MRC-Ex item 2
(“hurrying up a hill”) and only two responded “not at all” to MRC-Ex item 3 (“slight hill”).
During cognitive interviewing, the activities contained in both Grade 2 and 3 were also perceived as representing different
levels of disability associated with breathlessness. There was also some confusion about what each descriptor meant, as each
experience was dependent on different factors such as speed/pace of walking. This made it challenging for participants to
come to firm agreement on the meaning of each description. There was approximately 0.5 logit difference between each
component in grade 2 and grade 3, which is large for items that are meant to reflect the same degree of severity.6,15,16
The largest mismatch between grade components was seen within mMRC grade 4. Patients agreed that there was little
difference in activity limitation due to breathlessness when “dressing or undressing”, although during cognitive debrief­
ing some expressed more concern with morning-time activities which is related to getting dressed; however, the
difference in logits was minimal. The perceived impact of COPD on morning activities has previously been shown to
be substantial.17,18 The main concern with Grade 4 was the descriptor “too breathless to leave the house”. There was
a clear consensus that breathlessness associated with dressing/undressing represented a lower level of disability than
being unable to leave the house. Such views were supported by the results of MRC-Ex Rasch analysis in which “too
breathless to leave the house” was located at the severe end of the scale and much higher (two logits) than the dressing
items. Combining of these descriptors into one MRC grade is inappropriate.
Based on our analyses, the main concerns relate to the extreme ends of the MRC questionnaire: “strenuous exercise”
and “too breathless to leave the house”. As most COPD patients are symptomatic, strenuous exercise does not fit well
with the application of the mMRC questionnaire to this population. In addition, combining items in Grade 4 is illogical as
is the use of “too breathless to leave the house” when respondents are completing the questionnaire at a venue outside
their house. As patients can attend a focus group interview for research purposes, they can clearly leave the house.
This study leaves a question hanging - what are the implications of this study? The mMRC scale is extremely widely
used and is incorporated into guidelines for the management of individual patients; however this study has shown that it
has significant weakness at both a qualitative and a quantitative level. Part of the problem lies with mMRC grade zero
and the unavoidable conclusion from this study is that this grade is unreliable. The other nine activities, when used
individually, have good measurement properties and also moderately good properties when activities are grouped as into

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 https://doi.org/10.2147/COPD.S372318

2297
DovePress

Powered by TCPDF (www.tcpdf.org)

 Yorke et al Dovepress

mMRC grades 1–4, but it is clear that when grouped in this way there is a loss of precision. We cannot recommend that
the 9-point scale is used, because there has been no qualitative study to identify all the candidate items for a scale of
dyspnoea-induced disability, and the analysis was not designed to identify the minimum number of items that are
required to form a such a scale. The mMRC-ex was developed to enable Rasch analysis to be performed and provide
indication of the mMRC structure. However, we recommend that such as scale is developed to help clinicians make
a reliable assessment of individual patients in routine practice; robust testing of a further modified mMRC that replaces
“strenuous exercise” and includes a one activity description for any single item may be a sensible approach to rectifying
the issues identified in this study. For clinicians, we conclude that whilst there is some value in recording the mMRC
grade, the patient should always be asked about limitation of activities that are important to them and this analysis shows
that the 9 individual mMRC items, excluding strenuous exercise, would form a helpful guide to answering the patient’s
question “What type of activity do you mean?”.
This study had a number of limitations. Participants were recruited using a database of COPD patients living in one
area of England, Greater Manchester. However, many of the sample characteristics are representative of similar COPD
cohorts of primary care patients.7 The MMRC-Ex was not developed with patient input – the researchers simply
separated each activity description and retained the same wording and nominated a scaling range for each (0–4).
Participants for both study phases attended the research clinic to complete focus groups/questionnaires and hence were
able to leave the house which is likely to have biased responses to mMRC Grade 4. We recommend further research that
explores mMRC responses with people unable to leave the house. It has been shown that gender differences in the
experience and reporting of breathlessness exists between males and females. We did not specifically examine this in our
study but would recommend that this is explored in future work examining patients’ views of the mMRC scale. We did
not include clinicians views which would be an important aspect of any follow-on study to further modify the mMRC.
In conclusion, the mMRC generally meets the criteria for hierarchical ordering however, Grade 0 (strenuous exercise)
presents as an anomaly. There was a general consensus among focus group participants that the combining of descriptors
into single mMRC grades was inappropriate and this was confirmed by quantitative analyses with large severity
difference between some categories. We recommend further development of the mMRC to address the measurement
issues identified through this study.

Acknowledgments
Thank you to all our patients who took the time to participate in this study.
The abstract of this paper was presented at the European Respiratory Society Conference ‘Evaluation of individual
activity descriptors of the MRC Dyspnoea Scale: do they add up? As a poster presentation with interim findings. The
poster’s abstract was published in “Poster Abstracts” in European Respiratory Journal 2015 46: PA681; DOI: 10.1183/
13993003.congress-2015.PA681.

Funding
The study was supported by a Innovate UK through a Knowledge Transfer Partnership. JY and JV are supported by the
NIHR Manchester Biomedical Research Centre.

Disclosure
Professor Dave Singh reports personal fees from Aerogen, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, CSL
Behring, Epiendo, personal fees from Genentech, GlaxoSmithKline, Glenmark, Gossamerbio, Kinaset, Menarini,
Novartis, Pulmatrix, Sanofi, Synairgen, Teva, Theravance, Verona, outside the submitted work. Dr Jorgen Vestbo reports
personal fees from AstraZeneca, grants from Boehringer-Ingelheim, personal fees from Chiesi, GSK, Novartis, ALK-
Abello, Teva, Boehringer-Ingelheim, outside the submitted work. Professor Paul W Jones reports he is an employee of
GlaxoSmithKline, outside the submitted work. The authors have no other conflicts of interest in relation to this work.

2298 https://doi.org/10.2147/COPD.S372318 International Journal of Chronic Obstructive Pulmonary Disease 2022:17

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Yorke et al

References
1. Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest. 1988;93:580–586. doi:10.1378/chest.93.3.580
2. Oga T, Nishimura K, Tsukino M, Hajiro T, Ileda A, Mishima M. Relationship between different indices of exercise capacity and clinical measures
in patients with chronic obstructive pulmonary disease. Heart Lung. 2002;31:374–381. doi:10.1067/mhl.2002.127941
3. Bausewein C, Farquhar M, Booth S, Gysels M, Higginson IJ. Measurement of breathlessness in advance disease: a systematic review. Respir Med.
2007;101(3):399–410. doi:10.1016/j.rmed.2006.07.003
4. Dorman S, Byrne A, Edwards A. Which measurement scales should we use to measure breathlessness in palliative care? A systematic review.
Palliat Med. 2007;21(3):177–191. doi:10.1177/0269216307076398
5. Fletcher CM, Elmes PC, Fairbairn AS, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working
population. Br Med J. 1959;2:256–266. doi:10.1136/bmj.2.5147.257
6. Pallant JF, Tennant A. An introduction to the Rasch measurement model: an example using the hospital anxiety and depression scale (Hads). Br
J Clin Psychol. 2007;46(Pt 1):1–18. doi:10.1348/014466506X96931
7. Bestall JC, Paul EA, Garrod R, et al. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with
chronic obstructive pulmonary disease. Thorax. 1999;54:581–586. doi:10.1136/thx.54.7.581
8. Stavem K, Boe J, Erikssen J. Health status, dyspnea, lung function, and exercise capacity in patients with chronic obstructive pulmonary disease.
Int J Tuberc Lung Dis. 1999;3:920–926.
9. Celli BR, Cote CG, Lareau SC, Meek PM. Predictors of survival in COPD: more than just the FEV1. Resp Med. 2008;102(Suppl 1):S27–35.
doi:10.1016/S0954-6111(08)70005-2
10. National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in
primary and secondary care. London: National Clinical Guideline Centre; 2010. Available from: Hyyp://giudeance.nice.org.uk/. Accessed August
29, 2022.
11. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary
disease – 2007 update. Can Respir J. 2007;14(Suppl B):5B–32B. doi:10.1155/2007/830570
12. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease
GOLD executive summary. Am J Respir Crit Care Med. 2013;187:347–365. doi:10.1164/rccm.201204-0596PP
13. Drennan J. Cognitive interviewing: verbal data in the design and pretesting of questionnaires. JAN. 2003;42:57–63. doi:10.1046/j.1365-
2648.2003.02579.x
14. Green J, Thorogood N. Qualitative Methods for Health Research. London: Sage Publications; 2004.
15. Rasch G. Probabilistic Models for Some Intelligence and Attainment Tests. Amsterdam: Danish Institute of Educational Research; 1960.
16. Holland P, Wainer H. Differential Item Functioning. New Jersey: Lawrence Erlbaum Associates; 2012.
17. Partridge MR, Karlsson N, Small IR. Patient insight into the impact of chronic obstructive pulmonary disease in the morning: an internet survey.
Curr Med Res Opin. 2009;25(8):2043–2048. doi:10.1185/03007990903103006
18. Roche N, Chavannes NH, Miravitlles M. COPD symptoms in the morning: impact evaluation and management. Respir Res. 2013;14:112.

International Journal of Chronic Obstructive Pulmonary Disease Dovepress

Publish your work in this journal
The International Journal of COPD is an international, peer-reviewed journal of therapeutics and pharmacology focusing on concise rapid reporting
of clinical studies and reviews in COPD. Special focus is given to the pathophysiological processes underlying the disease, intervention programs,
patient focused education, and self management protocols. This journal is indexed on PubMed Central, MedLine and CAS. The manuscript
management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.
dovepress.com/testimonials.php to read real quotes from published authors.
Submit your manuscript here: https://www.dovepress.com/international-journal-of-chronic-obstructive-pulmonary-disease-journal

International Journal of Chronic Obstructive Pulmonary Disease 2022:17 DovePress 2299

Powered by TCPDF (www.tcpdf.org)