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Trail Making Test
Please visit this website for more information about the instrument: Trail Making Test
NeuroRehab Supplemental - Highly Recommended
Recommendations for Use: Indicated for studies requiring a measure of executive functioning (Trail Making Part B) and/or processing speed (Trail Making Parts A and B).
It is not recommended for use in patients with significant graphomotor dysfunction.
Supplemental - Highly Recommended: Huntington's Disease (HD) - for Cognitive Assessment
Supplemental: Mitochondrial Disease (Mito)
Short Description of Instrument
Summary/Overview of Instrument: The first part of Trail Making Test (TMT) test, TMT-A, requires the participant to rapidly sequence numbers from 1 through 25, with the score being the time to complete the task. The second part, TMT-B, is a more difficult cognitive flexibility task requiring the participant to follow a sequential pattern while shifting cognitive sets, sequencing from 1 to 13 while switching between numbers and letters (i.e., 1-A-2-B-3-C,…), with the score being the time to complete the task. The utility and psychometric properties of the Trails B are so well accepted that it is one of the few measures that it is used across neurologic and psychiatric clinical and research patient populations.
Constructs measured: Psychomotor speed and executive functions
Generic vs. disease specific: Generic
Intended use of instrument/purpose of tool: The Trail Making Test is a measure of psychomotor speed, visual scanning, and executive ability (set-shifting).
Means of administration: Paper and pencil is standard, computerized is available but less validated
Location of administration (clinic, home, telephone): Clinical setting
Intended respondent (patient, caregiver): Patient
# of items: N/A
# of subscales and names of sub-scales: N/A
Comments/Special Instructions
The Trail Making Test was developed as a standalone instrument but is also included in the Delis-Kaplan Executive Function System (D-KEFS).
NeuroRehab-Specific: Trail Making Test A&B may be preferred because it is non-proprietary and has available representative norms, demographically-corrected. DKEFS Trail Making Test is another version (proprietary) that may be considered for use if the additional trials that capture motor speed and visual scanning are warranted.
Scoring and Psychometric Properties
Scoring: Scoring of Parts A and B are reported as the number of seconds required to complete the task. Higher scores indicate worse performance. Performance varies by age and education, as well as racial/ethnic background, and thus demographically corrected normative standards are used to classify patient performance. Errors affect the patient's score only in that the correction of errors is included in the completion time for the task. If a patient has not completed each part after five minutes, the test should be discontinued. In addition to the direct scores, the B-A difference score, the B:A ratio, and the B-A/A proportional score have also been used as indicators of certain cognitive operations (e.g., executive functions specific to Part B) or specific markers of brain damage (Sanchez-Cubillo et al., 2009). Note: Parts A & B must be completed together and in the correct order for test administration to be valid.
Standardization of scores to a reference population: Raw scores (time to complete) are converted to scaled scores (0-19). Scale score is converted to t score by sex, education, age, and ethnicity. Norms are from the Expanded Halstead-Reitan Battery (Heaton et al., 2004).
Psychometric Properties:
Test-retest or intra-interview (within rater) reliability (as applicable): For intervals of 3 weeks to 1 year, test-retest reliability is moderate to high for Part A (r=0.36-0.79) and Part B (r=0.44-0.89) (Bornstein et al., 1987; Matarazzo et al., 1974, Dikmen et al., 1999).
Inter-interview (between-examiner) reliability (as applicable): Inter-examiner reliability has been found to be high for both Part A (r=0.94) and Part B (r=0.90).
Statistical methods used to assess reliability: Correlational analyses and reliability coefficients.
The HD Cognitive Assessment Battery (HD-CAB) is designed specifically for use in late premanifest and early HD clinical trials. This six-test assessment battery which includes the Trail Making B test was found be sensitive to disease status and reliable in an observational study in 105 control, 103 premanifest-HD, and 55 early-HD participants (Stout et al., 2014).
Content validity: Part A and B correlate moderately (r=0.31) (Heilbronner et al., 1991).
Construct validity: Subtests correlate with visual search tasks (Ehrenstein et al., 1982). In a study by Sanchez-Cubillo and colleagues (2009), results suggested that the TMT-A mainly requires visuoperceptual abilities, while the TMT-B requires "primarily working memory and secondarily task-switching ability".
Sensitivity to Change/Ability to Detect Change (over time or in response to an intervention): In published cross-sectional (Stout et al., 2011) and internal analyses (PREDICT-HD), Parts A and B are sensitive to impairments in premanifest-HD participants, especially Part B in individuals who are closer to an expected diagnosis. Unpublished internal analyses of 7-year longitudinal data (PREDICT-HD) show differences in rates of longitudinal change in premanifest-HD participants on both subtests, but especially Part A, compared to gene negative participants.
Cross sectionally, the TRACK-HD study found that healthy control participants performed significantly better than both the early-HD and the premanifest-HD groups. Longitudinally, the TRACK-HD study found significant differences in rates of change for early-HD compared to control participants but did not find significant differences in rates of change for premanifest-HD compared to control participants. Note that HD involves declines in motor speed and executive functions, all of which are tapped into by the Trail Making Test. Therefore, performances on the Trail Making Test may reflect any of these domains.
The TRACK-HD premanifest-participants may be less likely to show cognitive effects than the PREDICT-HD premanifest participants because 1) they are further from estimated onset based on CAG repeat length and age (Langbehn et al., 2004) and 2) they are potentially less progressed in actuality because the TRACK-HD study excluded premanifest participants based on UHDRS motor scores >= 5. Cognitive tests will be more effective metrics in studies of premanifest-HD when the focus is on participants that are close to onset.
Known Relationships to Other Variables (e.g., gender, education, age): Performance declines with IQ and educational level (Diaz-Asper et al., 2004; Clark et al, 2004; Hester et al., 2005).
Diagnostic Sensitivity and Specificity, if applicable (in general population, HD population- premanifest/ manifest, other disease groups): Well-established in multiple disease groups. (See Strauss et al., 2006 or Mitrushina et al., 2005 for details.) O'Rourke et al. (2011) showed sensitivity to detect differences between prodromal HD and gene negative control participants.
Strengths: Parts A and B are sensitive in cross-sectional and longitudinal studies of prodromal HD, mild TBI, HIV-related neurocognitive disorders, multiple sclerosis, epilepsy, and age-related neurodegenerative disorders. They are non-proprietary. Task has been assessed at sites in the United States, Canada, United Kingdom, Australia, Germany, and Spain.
Weaknesses: The examiner must carefully monitor a participant's performance to accurately detect errors and correct them as quickly as possible. The reliability of test administration can vary by examiner's reaction time in noticing errors and pointing them out, which introduces imprecision. More severe motor impairment may influence results. Participants who are very cognitively impaired may not be able to complete the task, which must be dealt with statistically (e.g., set a maximum time for non-completers, such as 300 seconds). Distribution of raw scores (reaction time) are typically skewed at the group level, requiring transformation or use of normative scores.
Availability: In the Public domain, may be photocopied, though there are versions available for purchase.
Special Requirements for administration: Stopwatch.
Administration Time: 10 minutes.
Key Reference:
Reitan RM. Validity of the Trail Making test as an indicator of organic brain damage. Percept Mot Skills. 1958;8:271-6.
Additional References:
Chen P, Ratcliff G, Belle SH, Cauley JA, DeKosky ST, Ganguli M. Cognitive tests that best discriminate between presymptomatic AD and those who remain nondemented. Neurology. 2000 Dec 26;55(12):1847-53.
Clark MS, Dennerstein L, Elkadi S, Guthrie JR, Bowden SC, Henderson VW. Normative verbal and non-verbal memory test scores for Australian women aged 56-67. Aust N Z J Psychiatry. 2004 Jul;38(7):532-40.
Corrigan JD, Hinkeldey NS. Relationships between parts A and B of the Trail Making Test. J Clin Psychol. 1987 Jul;43(4):402-9.
Ehrenstein WH, Heister G, Cohen R. Trail Making Test and visual search. Arch Psychiatr Nervenkr (1970). 1982;231(4):333-8.
Erickson T. Trail Making Test - Administration Procedures of Errors. Presentation at the National Association of Psychometrists Annual Conference; 2013 October 18-19; San Diego, CA.
Fals-Stewart W. An interrater reliability study of the Trail Making Test (Parts A and B). Percept Mot Skills. 1992;74(1):39-42.
Heaton RK, Miller W, Taylor MJ, Grant I. Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults. 2004. Retrieved from  
Heilbronner RL, Henry GK, Buck P, Adams RL, Fogle T. Lateralized brain damage and performance on trail making A and B, Digit Span Forward and Backward, and TPT Memory and Location. Arch Clin Neuropsychol. 1991;6(4):251-8.
Hester RL, Kinsella GJ, Ong B, McGregor J. Demographic influences on baseline and derived scores from the trail making test in healthy older Australian adults. Clin Neuropsychol. 2005;19(1):45-54.
Kortte KB, Horner MD, Windham WK. The trail making test, part B: cognitive flexibility or ability to maintain set? Appl Neuropsychol. 2002;9(2):106-9.
Lezak MD, Howieson DB, Bigler ED, Tranel, D. Neuropsychological Assessment (5th Edition ed.). New York: Oxford University Press. 2012.
Mahurin RK, Velligan DI, Hazleton B, Mark Davis J, Eckert S, Miller AL. Trail making test errors and executive function in schizophrenia and depression. Clin Neuropsychol. 2006;20(2):271-88.
Matarazzo JD, Wiens AN, Matarazzo RG, Goldstein SG. Psychometric and clinical test-retest reliability of the Halstead impairment index in a sample of healthy, young, normal men. J Nerv Ment Dis. 1974;158(1):37-49.
Mitrushina M, Boone KB, Razini J, D'Elia LF. Handbook of Normative Data for Neuropsychological Assessment 2nd Edition. New York: Oxford University Press. 2005.
Moses JA Jr. Test review-Comprehensive Trail Making Test (CTMT). Arch Clin Neuropsychol. 2004 Aug;19(5):703-8.
O'Rourke JJ, Beglinger LJ, Smith MM, Mills J, Moser DJ, Rowe KC, Langbehn DR, Duff K, Stout JC, Harrington DL, Carlozzi N, Paulsen JS. The Trail Making Test in prodromal Huntington disease: contributions of disease progression to test performance. J Clin Exp Neuropsychol. 2011;33(5):567-79.
Reitan RM. Manual for Administration of Neuropsychological Test Batteries for Adults and Children. 1979.
Reitan RM & Wolfson D. The Halstead-Reitan neuropsychological test battery: Theory and clinical interpretation (2nd ed.). Tucson, AZ: Neuropsychology Press. 1993.
Reynolds CR. Comprehensive Trail Making Test: Examiner's manual. Austin, TX: PRO-ED. 2002.
Sanchez-Cubillo I, Perianez JA, Adrover-Roig D, Rodriguez-Sanchez JM, Rios-Lago M, Tirapu J, Barcelo F. Construct validity of the Trail Making Test: role of task-switching, working memory, inhibition/interference control, and visuomotor abilities. J Int Neuropsychol Soc. 2009;15(3):438-50.
Stout JC, Queller S, Baker KN, Cowlishaw S, Sampaio C, Fitzer-Attas C, Borowsky B; HD-CAB Investigators. HD-CAB: a cognitive assessment battery for clinical trials in Huntington's disease 1,2,3. Mov Disord. 2014;29(10):1281-8.
Stout JC, Paulsen JS, Queller S, Solomon AC, Whitlock KB, Campbell JC, Carlozzi N, Duff K, Beglinger LJ, Langbehn DR, Johnson SA, Biglan KM, Aylward EH. Neurocognitive signs in prodromal Huntington disease. Neuropsychology. 2011;25(1):1-14.
Strauss E, Sherman EMS, Spreen O. Comprehensive Trail Making Test (CTMT) A Compendium of Neuropsychological Tests. Oxford University Press. 2006; 557-61.
Tombaugh TN. Trail Making Test A and B: normative data stratified by age and education. Arch Clin Neuropsychol. 2004 Mar;19(2):203-14.
Document last updated March 2024