Psychometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with neck pain

OBJECTIVE: To examine selected psychometric properties of these instruments in a cohort of patients with mechanical neck pain. DESIGN: Cohort design of 78 subjects completing self-report measures of pain, disability, and the Fear-Avoidance Beliefs Questionnaire Work (FABQW) and Physical Activity (FABQPA) subscales, as well as the Tampa Scale of Kinesiophobia (TSK) at baseline and a 2-day follow-up. Intraclass correlation coefficients were used to calculate test-retest reliability, and Cronbach's alpha was used to calculate internal consistency. Concurrent validity was analyzed between the FABQPA, FABQW, TSK, pain, and disability using Pearson correlation coefficients and hierarchical linear regression modeling. RESULTS: The FABQPA and FABQW subscales exhibited substantial test-retest reliability, whereas the TSK exhibited moderate reliability. Internal consistency was high for all measures. The FABQW subscale was the only measure that significantly contributed to the regression model for both pain and disability in this group of patients with neck pain. CONCLUSIONS: Whereas the reliability and internal consistency of all measures ranged between moderate and substantial, the results of this study suggest weaker relationships between measures of fear and avoidance beliefs and pain/disability among patients with mechanical neck pain than has been reported among patients with low-back pain.     

Pain-Related Fear in Adults Living With Chronic Pain: Development and Psychometric Validation of a Brief Form of the Tampa Scale of Kinesiophobia

ObjectiveTo develop and validate a brief version of the Tampa Scale of Kinesiophobia (TSK) while preserving content validity in a mixed chronic pain population.DesignCross-sectional study.SettingTertiary care interdisciplinary chronic pain clinic.ParticipantsAdults with chronic pain (N=933; mean age, 53.5±15.7 years; 63% women).InterventionNot applicable.Main Outcome MeasureTSK-11 measured at intake. Self-reported data from a patient registry were extracted from November 2017 to October 2019.ResultsAn exploratory factor analysis identified a 2-factor structure from the TSK-11 and item reduction resulted in a 7-item TSK (TSK-7) with 61.2% explained variance and Cronbach's alphas of 0.76 and 0.70 for each of the 2 factors. To maximally reduce the number of items without affecting internal consistency, a 5-item TSK (TSK-5) with 72% explained variance was also explored. Strong correlations were found between the newly developed brief TSK versions and TSK-11 (r>0.93), suggesting good concurrent validity. TSK-11, TSK-7, and TSK-5 had similar convergent validity with moderate correlations for pain catastrophizing (r=0.57, 0.58, 0.54), depression (r=0.45, 0.46, 0.42), pain interference (r=0.43, 0.44, 0.40), and pain acceptance (r=–0.57, –0.59, –0.55).ConclusionsThese 2 brief versions of the TSK may help to simplify questionnaires across chronic pain centers where multiple outcome measures are used for a complete biopsychosocial assessment of patients.     

Kinesiophobia in chronic fatigue syndrome: assessment and associations with disability

OBJECTIVES: To investigate aspects of the validity of the total scores of the Tampa Scale for Kinesiophobia (TSK), Dutch Version, which was modified to make it an appropriate questionnaire for the assessment of kinesiophobia (fear of movement) in chronic fatigue syndrome (CFS) patients (the Dutch TSK-CFS), and, using this assessment tool, to examine the associations between kinesiophobia, exercise capacity, and activity limitations and participation restrictions in patients with CFS. DESIGN: Prospective observational studies. SETTING: An outpatient fatigue clinic. PARTICIPANTS: In the first study, 40 patients fulfilling the 1994 US Centers for Disease Control and Prevention (CDC) criteria for CFS were enrolled. The sample of the second study consisted of 51 CDC-defined patients with CSF. INTERVENTIONS: Not applicable.Main outcome measures Study 1: Subjects completed a set of questionnaires; the Utrechtse Coping List (UCL), the Dutch TSK-CFS, and the Dutch Baecke Questionnaire of Habitual Physical Activity. Study 2: All patients completed 2 questionnaires (Chronic Fatigue Syndrome Activities and Participation Questionnaire [CFS-APQ], Dutch TSK-CFS) and performed a maximal exercise stress test on a bicycle ergometer. The heart rate was monitored continuously by use of an electrocardiograph. Metabolic and ventilatory parameters were measured through spirometry. RESULTS: Study 1: The Cronbach alpha coefficient for the individual item scores on the TSK-CFS was .80. The total scores on the Dutch TSK-CFS showed a statistically significant correlation with both the avoidance/abide subscale of the UCL (Spearman rho=.35, P=.029) and the total score of the Baecke Questionnaire (rho=-.45, P=.004). Study 2: The total scores on the Dutch TSK-CFS showed a statistically significant correlation with the total scores on the CFS-APQ (rho=.39, P=.004). No statistically significant associations were observed between the exercise capacity parameters and the total scores on the Dutch TSK-CFS. CONCLUSIONS: These results provide evidence for the internal consistency and the convergent and congruent validity of the scores obtained by use of the Dutch TSK-CFS. Kinesiophobia appears to be associated with activity limitations/participation restrictions but not with exercise capacity in patients with CFS.     

Psychometric properties of the Fear-Avoidance Beliefs Questionnaire in patients with neck pain

OBJECTIVES: To translate the Fear-Avoidance Beliefs Questionnaire and investigate the validity and reliability of the Chinese version of the questionnaire in patients with neck pain. DESIGN: Observational cross-sectional and prospective study. SETTING: Physiotherapy outpatient departments. SUBJECTS: Four samples with 476 consecutive adult patients with neck pain from four physiotherapy centres. METHODS: The original questionnaire was translated into Chinese by forward and backward translation and reviewed by a panel of experts. The subjects completed the Chinese version of the fear-avoidance questionnaire, Northwick Park Neck Pain Questionnaire, Medical Outcomes 36-Item Short-Form Health Survey and their pain intensity was measured using an 11-point pain numerical rating scale. They were observed and measured at the beginning of physiotherapy, at week 3 and at week 6 after treatment began. RESULTS: The questionnaire had very good content validity and test-retest reliability with an intraclass correlation coefficient of 0.81 and Cronbach's alpha coefficient of 0.90. Spearman's correlation coefficients between fear-avoidance and the neck pain questionnaire, the health survey (physical), health survey (mental) and pain scale were 0.56, 0.45, 0.36 and 0.34, respectively. The standard response mean and effect size at week 6 were 0.38 and 0.32, respectively. Factor analysis yielded three factors which accounted for 61.6% of the total variance of the questionnaire. CONCLUSION: The Fear-Avoidance Beliefs Questionnaire is a valid and reliable tool for patients with neck pain. It has been shown to demonstrate very good content validity, a high degree of test-retest reliability and internal consistency, good construct validity and medium responsiveness.     

Pain-Related Fear Contributes to Self-Reported Disability in Patients With Foot and Ankle Pathology

Lentz TA, Sutton Z, Greenberg S, Bishop MD. Pain-related fear contributes to self-reported disability in patients with foot and ankle pathology.

Objective

To determine the unique influence of pain-related fear of movement on foot and ankle disability, after accounting for pain, demographic, and physical impairment variables.

Design

Cross-sectional study using retrospective chart review.

Setting

Outpatient rehabilitation clinic.

Participants

Referred sample of subjects with foot- and ankle-related disability (N=85, 40 men; mean age, 33y; range, 16-77y).

Interventions

Not applicable.

Main Outcome Measures

Lower Extremity Functional Scale (LEFS), Shortened Tampa Scale of Kinesiophobia (TSK-11).

Results

Hierarchical regression analysis determined the proportions of explained variance in disability (LEFS). Demographic variables were entered into the model first, followed by pain intensity and range-of-motion (ROM) deficit, and finally, TSK-11. Demographics collectively contributed 9% (P=.015) of the variance in disability scores. Pain intensity and overall ROM deficit contributed an additional 11% (P<.001) of the variance, and TSK-11 scores contributed an additional 14% (P<.001). In the overall model, age (β=−.29, P=.004), chronicity of symptoms (β=.23, P=.024), ROM deficit (β=−.28, P=.003), and TSK-11 (β=−.41, P<.001) explained 34% of the variance in the LEFS score (P<.001).

Conclusions

Age, chronicity of symptoms, ROM deficit, and TSK-11 scores all significantly contributed to baseline foot and ankle self-reported disability. Pain-related fear of movement was the strongest single contributor to disability in this group of patients.     

Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia

The Tampa Scale for Kinesiophobia (TSK) is one of the most frequently employed measures for assessing pain-related fear in back pain patients. Despite its widespread use, there is relatively little data to support the psychometric properties of the English version of this scale. This study investigated the psychometric properties of the English version of the TSK in a sample of chronic low back pain patients. Item analysis revealed that four items possessed low item total correlations (4, 8, 12, 16) and four items had response trends that deviated from a pattern of normal distribution (4, 9, 12, 14). Consequently, we tested the psychometric properties of a shorter version of the TSK (TSK-11), having excluded the six psychometrically poor items. The psychometric properties of this measure were compared to those of the original TSK. Both measures demonstrated good internal consistency (TSK: alpha=0.76; TSK-11: alpha=0.79), test-retest reliability (TSK: ICC=0.82, SEM=3.16; TSK-11: ICC=0.81, SEM=2.54), responsiveness (TSK: SRM=-1.19; TSK-11: SRM=-1.11), concurrent validity and predictive validity. In respect of specific cut-off scores, a reduction of at least four points on both measures maximised the likelihood of correctly identifying an important reduction in fear of movement. Overall, the TSK-11 possessed similar psychometric properties to the original TSK and offered the advantage of brevity. Further research is warranted to investigate the utility of the new instrument and the cut-off scores in a wider group of chronic pain patients in different clinical settings.     

Psychometric Properties of the Community Integration Questionnaire Adjusted for People With Aphasia

Dalemans RJ, de Witte LP, Beurskens AJ, van den Heuvel WJ, Wade DT. Psychometric properties of the community integration questionnaire adjusted for people with aphasia.

Objectives

To describe the feasibility of the Community Integration Questionnaire (CIQ) adjusted for use in people with aphasia and to report its psychometric properties in people with aphasia (internal consistency, factor analysis, test-retest reliability, convergent validity).

Design

A cross-sectional, interview-based psychometric study. Test-retest reliability was evaluated in 20 people (minimal to severe aphasia) by 2 different interviewers within a 2-week period.

Setting

Community.

Participants

In total 490 stroke survivors with (minimal to severe) aphasia were approached, of which 165 (34%) participants returned the answering letter. Participants (N=150) agreed to take part and were interviewed using a structured interview format.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire (CIQ), Frenchay Aphasia Screening Test, Barthel Index, Dartmouth Coop Functional Health Assessment Charts (COOP)-World Organisation of Family Doctors (WONCA) Charts, Life Satisfaction Questionnaire.

Results

A total of 150 stroke survivors with aphasia completed the CIQ adjusted for people with aphasia. The CIQ adjusted for people with aphasia was a feasible instrument. Results showed good internal consistency for the CIQ total (standardized Cronbach α=.75), excellent test-retest reliability (intraclass correlation coefficient=.96), moderate correlations with the Barthel Index, the COOP-WONCA, and the Life Satisfaction Questionnaire with regard to construct validity. Significant relations were found with regard to age and aphasia severity.

Conclusions

The CIQ adjusted for people with aphasia seems to be an adequate instrument to assess participation in people with aphasia.     

Clinical Outcomes for Patients Classified by Fear-Avoidance Beliefs and Centralization Phenomenon

Werneke MW, Hart DL, George SZ, Stratford PW, Matheson JW, Reyes A. Clinical outcomes for patients classified by fear-avoidance beliefs and centralization phenomenon.

Objectives

To (1) determine the prevalence of pain pattern classification subgroups (centralization, noncentralization, and not classified) observed during the initial evaluation of patients experiencing high versus low Fear-Avoidance Beliefs Questionnaire for physical activity (FABQ-PA) scores, (2) examine the association between discharge pain intensity and functional status (FS) outcomes based on FABQ-PA and pain pattern subgroups, and (3) compare minimal clinically important improvement for FS and pain intensity for FABQ-PA and pain pattern classification subgroups.

Design

Observational cohort design.

Setting

Suburban hospital-based outpatient rehabilitation clinic.

Participants

Consecutive patients with low back syndromes (N=238, mean ± SD, 59.1±17.0y; minimum=20, maximum=91).

Interventions

Interventions were designed to match patient classification by fear-avoidance level and pain pattern.

Main Outcome Measures

Two outcome measures were assessed: patient self-reported FS and pain intensity. FS was assessed by using computerized adaptive testing methods. Maximal pain intensity was assessed by using an 11-point numeric pain scale: 0 (no pain) to 10 (worst imaginable pain).

Results

There were no differences (χ₂²=3.7, P=.16) in proportion of patients classified by pain pattern experiencing high or low fear-avoidance beliefs. After controlling for the effect of available risk-adjustment variables, only dual-level classification subgroups, symptom acuity, payer type, and intake FS or pain intensity were associated with discharge FS or pain outcomes. The highest proportion of patients achieving minimal clinically important improvement in pain and FS were reported by the following patient subgroup: centralization and low fear.

Conclusions

Pain pattern and FABQ-PA characteristics impacted rehabilitation outcomes. We recommend that both factors be considered when managing patients with low back pain in an effort to optimize rehabilitation outcomes.     

The Chronic Pain Acceptance Questionnaire (CPAQ)-further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia

Acceptance of pain and distress has lately appeared as an important factor in determining peoples’ ability to restore functioning in the presence of chronic pain. Although treatments based on cognitive behaviour therapy are beginning to incorporate acceptance strategies, there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Chronic Pain Acceptance Questionnaire (CPAQ) was originally constructed as part of the development of an acceptance oriented treatment approach for pain patients. A revised 20-item version of the instrument with two subscales has shown adequate reliability and validity. In the present study, a Swedish translation of CPAQ was evaluated with 611 participants reporting chronic pain and symptoms of whiplash associated disorders. This study sought to further assess the psychometric properties of the instrument and to investigate its relation to another important measure of pain adjustment, the Tampa Scale of Kinesiophobia. Due to low intercorrelations with other items, item 16 was excluded. Exploratory and confirmatory factor analyses supported the previously suggested two-factor solution. Furthermore, the internal consistencies were good for the subscales (activities engagement and pain willingness) as well as the total scale. Hierarchical regression analyses illustrated strong relations with criteria variables (e.g. disability and life satisfaction). In general, the activities engagement subscale contributed more than pain willingness to the prediction of criteria variables. Furthermore, results illustrated that CPAQ explained more variance than the Tampa Scale of Kinesiophobia in pain intensity, disability, life satisfaction, and depression.     

Evaluation of Cognitive Behavioral Interventions and Psychoeducation Implemented by Rehabilitation Specialists to Treat Fear-Avoidance Beliefs in Patients With Low Back Pain: A Systematic Review

Objectives

To systematically locate, critically appraise, and synthesize the available evidence regarding the effectiveness of cognitive behavioral therapies (CBTs) and psychoeducation that can be implemented by rehabilitation specialists to treat fear-avoidance beliefs in patients with acute, subacute, and chronic low back pain (LBP).

Psychometric properties of the Tampa Scale of Kinesiophobia (TSK-11) among older people with chronic pain

Abstract

Objectives: The study aimed to test the construct validity, factor structure and reliability of the 11-item version of the Tampa Scale for Kinesiophobia (TSK-11, Swedish version) among older people (65+) with chronic pain. Design: Methodological study. Subjects: 433 participants with chronic pain (mean age 74.8, 65–98 years) completed postal questionnaires. 264 of the participants completed a test–retest assessment. Methods: Construct validity was evaluated through corrected item-total correlations. Convergent validity was analyzed by correlations with activity/activities of daily living (ADL) dependence, pain intensity and physical activity (all of which are constructs related to kinesiophobia according to fear-avoidance theories). Factor structure was tested through confirmatory factor analysis. Reliability was assessed with Cronbach’s α and test–retest reliability, analyzed by intra-class correlation coefficient (ICC) and weighted κ coefficient analysis. Results: Evidence of convergent validity was shown by significant positive correlations with activity/ADL dependence (r?=?0.20) and pain intensity (r?=?0.31), and a significant negative correlation with physical activity (r?=??0.38). Confirmatory factor analysis showed that both one- and two factor-solutions were possible. Cronbach’s α coefficients ranged between 0.74 and 0.87. Test–retest analysis showed strong agreement regarding ICC (r?=?0.75, 95% confidence interval 0.64–0.82). The weighted κ coefficients for the individual items showed fair to moderate reliability. Conclusion: The Swedish version of TSK-11 had acceptable construct validity, factor structure, and reliability and, hence, can be considered suitable for older people with chronic pain.     

Translation,Cross-Cultural Adaptation,and Psychometric Properties of the Chinese Version of the Surgical Fear Questionnaire

PurposeTo translate the Surgical Fear Questionnaire into Chinese, to culturally adapt, and test the validity and reliability of the Chinese version of the Surgical Fear Questionnaire.DesignThe translation and cultural adaptation process followed Sousa's guidelines, including the evaluation of this scale by the selected participants and content validity measurement by experts. A cross-sectional design was employed to the psychometric properties evaluation phase.MethodsA convenience sample of 336 participants from three hospitals was recruited between July 2019 and December 2019. Internal consistency reliability, construct validity, and convergent validity with the Hospital Anxiety and Depression Scale were analyzed.FindingsConfirmatory and exploratory factor analyses of the Chinese version of the Surgical Fear Questionnaire yielded a two-factor solution, with each factor comprised of four items, which were the same as the original English scale. The Chinese version showed a moderate correlation with the two domains of the Hospital Anxiety and Depression Scale. Cronbach's alpha and McDonald's Omega in the present sample showed excellent internal consistency.ConclusionsThe Chinese version of the Surgical Fear Questionnaire is a reliable and valid instrument to assess the fear before surgical procedures under general anesthesia.     

Kinesiophobia Is Associated With Pain Intensity and Disability in Chronic Shoulder Pain: A Cross-Sectional Study

ObjectiveKinesiophobia is a clinically relevant factor in the management of chronic musculoskeletal pain. The aim of this study was to explore the cross-sectional association between kinesiophobia and both pain intensity and disability among individuals with chronic shoulder pain.MethodsA total of 65 participants with chronic unilateral subacromial shoulder pain were recruited from 3 primary care centers. The Shoulder Pain and Disability Index assessed pain intensity and disability. The Tampa Scale for Kinesiophobia short form assessed the presence of kinesiophobia. A linear multivariable regression analysis evaluated the potential association between kinesiophobia and range of movement free of pain with pain intensity and disability. The analysis was adjusted for sex and age.ResultsIn the linear multivariable regression analysis, only greater kinesiophobia (standardized β = 0.35, P < .01) and sex (standardized β = -0.29, P < .01) contributed to explain 19% of the variance in shoulder pain and disability scores.ConclusionThis cross-sectional study provides preliminary evidence about the association between kinesiophobia and pain intensity and disability among individuals with chronic shoulder pain. However, our findings only contributed to explain 19% of the variance in shoulder pain and disability scores.     

Psychometric Properties of the Disorders of Consciousness Scale

Objective

To provide evidence for psychometric properties of the Disorders of Consciousness Scale (DOCS).

Design

Prospective observational cohort.

Settings

Seven rehabilitation facilities.

Participants

Patients (N=174) with severe brain injury.

Interventions

Not applicable.

Main Outcome Measure

DOCS.

Results

Initial analyses suggested eliminating 6 items to maximize psychometrics, resulting in the DOCS-25. The 25 items form a unidimensional hierarchy, rating scale categories are ordered, there are no misfitting items, and differential item functioning was not found according to sex, type of brain injury, veteran status, and days from onset. Person separation reliability (.91) indicates that the DOCS-25 is appropriate for individual patient measurement. Items are well targeted to the sample, with the difference between mean person and item calibrations less than 1 logit. DOCS-25 Rasch measures result in a 62% gain in relative precision over total raw scores. Internal consistency is very good (Cronbach α=.86); interrater agreement is excellent (intracIass correlation coefficient=.90) for both the DOCS-25 and the sensory subscales. The DOCS-25 total measure, but not subscale measures, correlates with the Glasgow Coma Scale and the Coma/Near-Coma Scales and distinguishes significantly between vegetative and minimally conscious states, indicating concurrent validity.

Conclusions

The DOCS-25 is psychometrically strong. It has excellent measurement precision and captures a broad range of patient function, which is critical for capturing recovery of consciousness. The sensory subscales are clinically informative but should not be reported as separate measures. The Keyform synthesizes clinical observations to visualize response patterns with potential for informing clinical decision-making. Future studies should determine sensitivity to change, examine issues of rater severity, and explore the usefulness of the Keyform in clinical practice.     

Associates of Physical Function and Pain in Patients with Patellofemoral Pain Syndrome

Piva SR, Fitzgerald GK, Irrgang JJ, Fritz JM, Wisniewski S, McGinty GT, Childs JD, Domenech MA, Jones S, Delitto A. Associates of physical function and pain in patients with patellofemoral pain syndrome.

Objectives

To explore whether impairment of muscle strength, soft tissue length, movement control, postural and biomechanic alterations, and psychologic factors are associated with physical function and pain in patients with patellofemoral pain syndrome (PFPS).

Design

Cross-sectional study.

Setting

Rehabilitation outpatient.

Participants

Seventy-four patients diagnosed with PFPS.

Interventions

Not applicable.

Main Outcome Measures

Measurements were self-reported function and pain; strength of quadriceps, hip abduction, and hip external rotation; length of hamstrings, quadriceps, plantar flexors, iliotibial band/tensor fasciae latae complex, and lateral retinaculum; foot pronation; Q-angle; tibial torsion; visual observation of quality of movement during a lateral step-down task; anxiety; and fear-avoidance beliefs.

Results

After controlling for age and sex, anxiety and fear-avoidance beliefs about work and physical activity were associated with function, while only fear-avoidance beliefs about work and physical activity were associated with pain.

Conclusions

Psychologic factors were the only associates of function and pain in patients with PFPS. Factors related to physical impairments did not associate to function or pain. Our results should be validated in other samples of patients with PFPS. Further studies should determine the role of other psychologic factors, and how they relate to anxiety and fear-avoidance beliefs in these patients.     

Psychometric Properties of the Tampa Scale for Kinesiophobia-11 (TSK-11)

The aim of this study was to investigate the psychometric properties of an abbreviated version of the Tampa Scale for Kinesiophobia (TSK) in a clinical sample of patients with chronic pain. Chronic pain patients (n = 276) seeking treatment at an interdisciplinary treatment center completed self-report questionnaires including the TSK-13, and 2 tests of physical functioning. Four competing models of the TSK were tested using confirmatory factor analysis. Internal consistency was assessed, as were discriminant evidence of construct validity and concurrent criterion-related validity. Incremental validity was assessed with hierarchical multiple regressions controlling for pain severity. The analyses indicated that an 11-item, 2-factor structure best fit the data. The first factor, somatic focus, consisted of 5 items, while the second factor, activity avoidance, was comprised of 6 items. The TSK-11 scales demonstrated acceptable levels of internal consistency, as well as evidence of discriminant, concurrent criterion-related, and incremental validity. Somatic focus uniquely predicted perceived disability while activity avoidance uniquely predicted actual physical performance, controlling for pain severity. The 2-factor structure of the TSK-11 was found to be a brief, reliable, and valid measure of fear of movement/(re)injury for chronic pain patients. We recommend that the TSK-11 be used in future research and in clinical settings.     

Norming of the Tampa Scale for Kinesiophobia across pain diagnoses and various countries

The present study aimed to develop norms for the Tampa Scale for Kinesiophobia (TSK), a frequently used measure of fear of movement/(re)injury. Norms were assessed for the TSK total score as well as for scores on the previously proposed TSK activity avoidance and TSK somatic focus scales. Data from Dutch, Canadian, and Swedish pain samples were used (N = 3082). Norms were established using multiple regression to obtain more valid and reliable norms than can be obtained by subgroup analyses based on age or gender. In the Dutch samples (N = 2236), pain diagnosis was predictive of all TSK scales. More specifically, chronic low back pain displayed the highest scores on the TSK scores followed by upper extremity disorder, fibromyalgia, and osteoarthritis. Gender was predictive of TSK somatic focus scores and age of TSK activity avoidance scores, with male patients having somewhat higher scores than female patients and older patients having higher scores compared with younger patients. In the Canadian (N = 510) and Swedish (N = 336) samples, gender was predictive of all TSK scales, with male patients having somewhat higher scores than female patients. These norm data may assist the clinician and researcher in the process of decision making and treatment evaluation.