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Trail Making Test (TMT), Delis-Kaplan Executive Function System (D-KEFS)
Availability
Please click here for more information: Trail Making Test
Classification
Supplemental - Highly Recommended: Sport-Related Concussion (SRC)
Basic: Acute, Moderate and Mild Traumatic Brain Injury (TBI)
Supplemental: Stroke, Epidemiology TBI
Exploratory: Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)
Short Description of Instrument
Summary/Overview of Instrument: The first part of Trail Making Test (TMT) test, TMT-A, requires the subject 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 subject 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.
 
Construct 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.
 
Means of administration (paper and pencil, computerized): Written
 
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 that is available for use outside of D-KEFS.
Scoring
Scoring: Scoring of Parts A and B are reported as the number of seconds required to complete the task. Higher scores indicate greater impairment. Performance varies by age and education, and thus 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 both parts after five minutes, it is unnecessary to continue the test. 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 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 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, Matarazzon et al., 1974, Dikmen et al., 1999).
 
Inter-interview (between-rater) reliability (as applicable): Interrater 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.
 
HD Cognitive Assessment Battery (HD-CAB) is a cognitive battery 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 subjects (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) suggested that the TMT-A mainly requires visuoperceptual abilities, while the TMT-B requires "primarily working member 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, 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 on both subtests, but especially Part A, compared to gene negatives.
Cross sectionally, the TRACK-HD study found that healthy controls 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 controls, but did not find significant differences in rates of change for premanifest HD compared to controls.
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 subjects based on UHDRS motor scores > 5. Cognitive tests will be more effective metrics in studies of premanifest HD when the focus is on subjects 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 controls.
Rationale/Justification
Strengths: Parts A and B are sensitive in cross-sectional and longitudinal studies of prodromal HD. Task has been tested 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. 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 noncompleters).
 
Availability: In the Public domain, May be photocopied, though there are versions available for purchase.
 
Special Requirements for administration: Stopwatch.
 
Administration Time: 10 minutes.
References
Key Reference:
Reitan RM. Validity of the Trail Making test as an indicator of organic brain damage. Percept Mot Skills. 1958;8:271-276.
 
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 ;55(12):1847-1853.
 
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;38(7):532-540.
 
Corrigan JD, Hinkeldey NS. Relationships between parts A and B of the Trail Making Test. J Clin Psychol. 1987;43(4):402-409.
 
Ehrenstein WH, Heister G, Cohen R. Trail Making Test and visual search. Arch Psychiatr Nervenkr (1970). 1982;231(4):333-338.
 
Erickson T. (2013). Trail Making Test - Administration Procedures of Errors. Presentation at the National Association of Psychometrists Annual Conference October 18-19, 2013, San Diego, CA. Available at: NAPnet.org.
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. (2004). Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery: Demographically Adjusted Neuropsychological Norms for African American and Caucasian Adults. Retrieved from http://www4.parinc.com/Products/Product.aspx?ProductID=RCNAAC
 
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):251-258.
 
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):106-109.
 
Lezak MD, Howieson DB, Bigler ED, Tranel, D. (2012). Neuropsychological Assessment (5th Edition ed.). New York: Oxford University Press.
 
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):271-288.
 
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. (2005). Handbook of Normative Data for Neuropsychological Assessment 2nd Edition. New York: Oxford University Press.
 
Moses JA Jr. Test review-Comprehensive Trail Making Test (CTMT). Arch Clin Neuropsychol. 2004;19(5):703-708.
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):567-579.
 
Reitan RM (1979). Manual for Administration of Neuropsychological Test Batteries for Adults and Children.
Reitan RM & Wolfson D. (1993). The Halstead-Reitan neuropsychological test battery: Theory and clinical interpretation (2nd ed.). New York: Neuropsychology Press.
 
Reynolds CR. (2002). Comprehensive Trail Making Test: Examiner's manual. Austin, TX: PRO-ED.
Sánchez-Cubillo I, Periáñez JA, Adrover-Roig D, Rodríguez-Sánchez JM, Ríos-Lago M, Tirapu J, Barceló 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):438-450.
 
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):1281-1288.
 
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. (2006). Comprehensive Trail Making Test (CTMT) A Compendium of Neuropsychological Tests (pp. 557-561). New York: Oxford University Press.
 
Specialty Automated Systems Corporation offers an online version of the Trail Making Test. For more information, visit: Trail Making Test
 
Tombaugh TM. (2006). Trail Making Test A and B: Normative data stratified by age and education. Arch Clin Neuropsychol. 2004;19(2):203-314.
 
Document last updated June 2021