Updating The PCRS MRC Breathlessness Score Web Page

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021Updating the PCRS MRC breathlessness score web pageReason for updateInternational respiratory colleagues use the PCRS MRC breathlessness scale web page. Theyhave asked via the IPCRG whether the page can be developed to give additionally adviceabout what to ask and how to ask the question in a clinical setting in order to best facilitatea correct response. The current page includes the scale but not the question that pre-emptsthe response.Why PCRS?A Google search for ‘MRC scale’ results in the PCRS page sitting in the first position and weknow from google analytics that it is also the most viewed PCRS web page. It seems thatover recent years the PCRS website has become the preferred or default place for peoplewanting to know about the MRC scale.https://www.pcrs-uk.org/mrc-dyspnoea-scale1

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021As the PCRS page is the first place that most people will now find or go to for downloadingthe MRC score it would be the ideal place to add this new element of the resource. Theneed to use the MRC scale remains as much as ever and so keeping this page relevant willhelp maintain the PCRS digital profile also.What does the page currently provide?The page provides a table that links the grading 1 to 5 with the 5 levels of breathlessnessthat a patient can report that they are experiencing. It also provides references and amention that a newer modified version is now recommended by GOLD (p9) and thereference seen below.2

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021What does the page currently not provide?Information about how to ensure the answers elicited are reliable and consistent.What do the references behind the PCRS version and mMRC version say?The material on the PCRS page is sourced from the MRC / UKRI ale-mrc-breathlessness-scale/The original reference for the MRC scale is: Adapted from Fletcher CM. The clinical diagnosis of pulmonary emphysema—anexperimental study. Proc R Soc Med e ‘MRC’ questionnaire was first published in 1960 under the approval of the MRCCommittee on the Aetiology of Chronic Bronchitis. A new revised version was published in1966. The committee subsequently disbanded and the responsibility for it was passed to thenewly formed MRC Committee for Research into Chronic Bronchitis who again revised it in1976. When this committee disbanded, the responsibility for the questionnaire passed tothe Committee on Environmental and Occupational Health (CEOH) who reviewed it andissued what remains to be the most recent version 1986.3

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021The Questionnaire on Respiratory Symptoms was designed to be used in large scaleepidemiological studies only (100-1000 people). The MRC/UKRI site states that it cannot beused on an individual basis.However, this is now a well-established method of recording perceived respiratory disabilityand is part of guidelines and quality improvement schemes in primary care such as QOF.The latest 1986 version of the questionnaire provides some advice about how to ask thequestion to what was anticipated to be research subjects. However, the paper does notprovide a specific phrase about how to introduce the MRC breathlessness scale and elicit to-interviewers/The original paper by Fletcher – noting that the context was the assessment of male minersin the 1950s - states:(RE: Breathlessness) Such a subjective and comparative symptom cannot be assessed by anysingle simple question, such as "How breathless are you on exertion?" for the answer willlargely depend upon the patient's habits and activities, and the effect of age in diminishingexercise tolerance is very great as many of us are painfully aware so that we cannot safelycompare a man's present with his previous abilities.The standard questions which we have for some years employed in the PneumoconiosisResearch Unit to establish clinical grades of breathlessness are as follows:Grade 1: Is the patient's breath as good as that of other men of his own age and build atwork, on walking, and on climbing hills or stairs?Grade2: Is the patient able to walk with normal men of own age and build on the level butunable to keep up on hills or stairs?Grade 3: Is the patient unable to keep up with normal men on the level, but able to walkabout a mile or more at his own speed?Grade 4: Is the patient unable to walk more than about 100 yards on the level without arest?Grade 5: Is the patient breathless on talking or undressing, or unable to leave his housebecause of breathlessness?The reference for the GOLD mMRC version is stated as the 1960 paper in the BMJ, again byFletcher 98438/?page 1It is important to note that in both these papers, Fletcher is communicating in a ‘letters to ajournal’ style which was typical of that era and they do not attempt to describe validationmethodology.Fletcher states: “In recent years a more or less standard questionary has been adopted bymost investigators in this field and it has been shown that with appropriate care , systematicerrors in diagnosis may be kept small.”4

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021The breathlessness questionnaire was part of a wider ‘questionary’ agreed by a committee“whose members had had considerable experience in the use of respiratory questionaries infield work.”The questionary also included questions on smoking, occupation, residence as well as entryoptions for sputum volume, lung function test and radiology results.The 1966 version of the questionnaire can be o-interviewers-1966/The preamble, instruction for questioning and 3 elements of the current MRC scale are seenbelow:Can PCRS provide some pragmatic / consensus-based advice?It is clear that the MRC breathlessness scale originated for a different purpose andpopulation and disease process than it is currently being used for, has not been validated forthe primary care surgery annual assessment purpose but clearly has real world validity as itis such a downloaded and used measure. The addition of ‘I’ statements in the GOLDmodified version transforms the intended approach into something more patient-centricthan the original version.Other COPD scores such as the validated COPD assessment test CAT score are now wellestablished and have clearer instruction on use, but the MRC score remains popular andindeed was further modified by the British Lung Foundation as a patient facingbreathlessness assessment test.5

Paper 4MRC ScalePCRS Education Committee Meeting: 19 March 2021There may therefore be an opportunity to further support to practising clinicians to use thistest more reliably and encouraging consistency in approach.For example, the BLF site does give some helpful patient centred advice about the test:What will happen when I see my doctor?You may not actually feel out of breath when you see your doctor - you’ll be sitting downand may have only walked a short distance. So, think about how you’ll describe yourbreathlessness. If you’d find it useful, you could bring someone with you who can helpdescribe your breathlessness.Your doctor should show you the MRC breathlessness scale to help describe how breathlessyou get.This test does not recognise other aspects of breathlessness – such as how you think or feelabout getting out of breath.The MRC scale shows what your breathlessness stops you doing. Your grade is the one thatdescribes you when you’re at your best.The BLF test provides some important considerations such as about pre-consult planning,patient cognition and confidence to report from a written resource, how the media ispresented, what the test is asking about and what it isn’t asking about.There is an opportunity for PCRS to add value to the MRC breathlessness scale clinical utilitythrough pragmatic, consensus-based advice from a team of patient representatives, multiprofessional current users of the scale and those experienced in developing questionnairessuch as the British Lung Foundation/Asthma UK partnership.Other issues to consider if taking into account an international audience In most countries GOLD is the guideline used/adapted and PCRS also uses a GOLDadapted guide but they tend to use mMRC not MRC. Here is another commonlyaccessed paper that talks about bothversions. 095219MRC grade 3 mMRC grade 2 are important cut offs in terms of the usual point ofreferral to PR but also internationally when people look at GOLD and categorise asABC or D‘Competitor’ sources of MRC aledoc.pdfNoel Baxter 2020-01-126

MRC Scale PCRS Education Committee Meeting: 19 March 2021 1 Updating the PCRS MRC breathlessness score web page Reason for update International respiratory colleagues use the PCRS MRC breathlessness scale web page. They have asked via the IPCRG whether the page can be developed to give additionally advice