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More often than not Ive observed that convenient sons why this is so. Testing large numbers of normal
approximations bring you closest to comprehending subjects is perceived as less interesting than testing
the true nature of things.
diseased patients. If the test is uncomfortable or pos-
Haruki Murakami sibly hazardous, it may be more difficult to recruit
normal subjects than patients, and institutional re-
Most of the tests employed in electrodiagnostic view bodies may be reluctant to grant approval for
medicine depend upon normative data for their in- normative studies. External funding agencies are
terpretation. No matter how meticulously a neuro- usually not eager to pay the costs of gathering nor-
physiological test procedure is carried out, its inter- mative data. Many young academic physicians be-
pretation is problematic unless there exists a body of lieve, correctly, that compiling normative data is not
valid normative data against which each patient re- the best strategy for career advancement. Conse-
sult may be compared. As new and more refined tests quently, the acquisition and analysis of normative
are developed, each demands its own base of nor- data have received less attention than they deserve.
mative values for clinical decision making. And yet, The purpose of this article is to review some of
clinicians and clinical scientists devote less attention the statistical principles governing the compilation
to normative data than to other aspects of test devel- and use of normative data in medicine; to critique
opment and implementation. There are several rea- some widely used approaches to normative data
gathering; and to recommend standards for quality
and implementation of normative databases that will
From the Department of Neurology and Neurological Sciences, Stanford
University School of Medicine, Stanford, California; and the Department of facilitate diagnostic clinical applications. The em-
Rehabilitation Medicine, University of Washington School of Medicine, phasis will be upon electrodiagnostic medicine, with
Seattle, Washington.
examples drawn specifically from the discipline, but
Address reprint requests to American Association of Electrodiagnostic
Medicine, 21 Second Street S.W., Suite 103, Rochester, MN 55902.
many of the principles to be considered apply
equally well to diagnostic testing in other medical
Accepted for publication August 1, 1996.
specialties. The intent is to make the reader into a
CCC 0148-639X/97/010004-11
1997 American Association of Electrodiagnostic Medicine. Published
better informed and more critical consumer of
by John Wiley & Sons, Inc. normative data, and to encourage investigators to
FIGURE 1. Frequency distribution curves for a hypothetical Gaussian variable (above) and one with strong positive skew (below). For the
Gaussian distribution, the numbers to the right indicate representative frequency values, and those to the left indicate the area under the
curve for each increment of z-score (standard deviation). For the skewed distribution, the vertical bars indicate the values corresponding
to 2.5 standard deviations about the mean; because of the erroneous Gaussian assumption, too many cases fall above the upper limit,
and the lower limit is not meaningful.
FIGURE 3. Frequency distributions of hypothetical variables (below) and their corresponding cumulative frequency distributions (above),
illustrating the percentile method. A shows the regular sigmoid cumulative curve corresponding to the symmetrical Gaussian distribution
in B. The median (and mean) corresponds to the 50th percentile. The positively skewed, bimodal distribution in D yields the cumulative
freqency distribution in C. Note that the quintiles (20th percentile points) are highly nonuniform.