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Administration and interpretation of Trail Making Test

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Administration and interpretation of the
Trail Making Test
Christopher R Bowie & Philip D Harvey
Department of Psychiatry, Mount Sinai School of Medicine, 1425 Madison Ave., Box 1230, New York, New York 10029, USA. Correspondence should be addressed to
P.D.H. (philipdharvey1@cs.com).
Published online 21 December 2006; doi:10.1038/nprot.2006.390
Measurement of cognitive functions is an increasingly important goal for clinicians and researchers. Many neuropsychological test
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols
batteries are comprehensive and require specialized training to administer and interpret. The Trail Making Test is an accessible
neuropsychological instrument that provides the examiner with information on a wide range of cognitive skills and can be completed in
5–10 min. Its background, psychometric properties, administration procedures and interpretive guidelines are provided in this protocol.
INTRODUCTION
The Trail Making Tests (TMTs) are popular neuropsychological
instruments used either alone as a screening instrument for
detecting neurological disease and neuropsychological impairment
or as part of a larger battery of tests. The tests are believed to
measure the cognitive domains of processing speed, sequencing,
mental flexibility and visual–motor skills. The most commonly
used version of the test, the TMT, was developed from the Taylor
number series test, which required the subject to connect
numbers sequentially from 1 to 50. It was revised by Partington
and Leiter and included in the Army Individual Test Battery1
as well as the Halstead–Reitan Neuropsychological Battery2 in its
current form3.
The most widely used version of the TMT comprises parts A and
B. In part A, the subject uses a pencil to connect a series of 25
encircled numbers in numerical order. In part B, the subject
connects 25 encircled numbers and letters in numerical and
alphabetical order, alternating between the numbers and letters.
For example, the first number ‘‘1’’ is followed by the first letter ‘‘A,’’
followed by the second number ‘‘2’’ then second letter ‘‘B’’ and so
on. The numbers and letters are placed in a semi-random fixed
order, in such a manner as to avoid overlapping lines being drawn
by the examinee. The primary variables of interest are the total time
to completion for parts A and B. A cutoff time of 300 s is generally
used to discontinue test administration and is therefore the typical
maximum score. Specific cutoffs have been suggested based on total
time to complete the practice versions of the tests4.
Errors on the TMT do not directly contribute to the scoring and
are generally not tallied. The effect of errors is realized on the total
time to complete the test, as the examiner stops the examinee and
returns him or her to the last correct response. Although some
studies have found that patient populations, such as those with
head injury, are more prone to make errors in shifting from letters
to numbers, these findings are of limited clinical value5.
Part A is generally presumed to be a test of visual search and
motor speed skills, whereas part B is considered also to be a test of
higher level cognitive skills such as mental flexibility6, although
there has been some debate over the ability of these tests to measure
discrete cognitive domains. Aside from the additional cognitive
demands of switching mental sets, the structure of part B places
more demands on visual search; even when removing the switching
component, part B is more difficult because the distance between
PROTOCOL
stimuli is greater and there are more visually interfering stimuli
than part A7. However, other work has established part B as a
measure of executive control via its correlation with other tests of
executive function that do not require motor components8. Within
the executive functioning domain, part B appears to be a measure
of cognitive flexibility, rather than a measure of the ability to
maintain a cognitive set9. Still, several studies have cautioned
against inferring a frontal lobe deficit based on part B performance,
based on a lack of discrimination between patients with frontal lobe
disease and healthy individuals10 when performing this test.
Performance on the TMT is considered a robust correlate of
overall measures of intelligence11,12 and a particularly sensitive
indicator of neurological impairment13. Normal, healthy adults
often show declines in cognitive performance across a number of
cognitive domains with aging and the TMT follows a pattern
similar to most tests that have a motor speed component. In an
elderly sample, increased times to complete both parts A and B
were found in the absence of motor or sensory deficits14, which
suggests that the TMT is sensitive to normal age-related declines in
concentration, vigilance and visuo-spatial ability that occur in later
life. Age, education and occupation are related to performance on
the TMT, and separate norms have been presented with these
sociodemographic factors in mind15.
Although the use of localizing discrete areas of neurological
dysfunction is not the primary goal of modern neuropsychological
assessment, there is evidence that cognitive tasks are a function of
semi-discrete regions. Early work using electroencephalography
implicated frontal lobe activation during performance on the
TMT16. Using a verbal adaptation of the TMT, Moll et al.17
found that the set shifting component of alternating letters of the
alphabet and consecutive numbers activated the left dorsolateral
prefrontal cortex and supplementary motor area/cingulate sulcus,
which are areas postulated to be sensitive to executive functioning,
particularly cognitive flexibility. Zakzanis et al.18 adapted the TMT
for use in functional magnetic resource imaging with a visual stylus.
This study, like the verbal adaptation of Moll et al., revealed greater
activation of not only left dorsolateral prefrontal cortex during part
B but also the precentral gyrus, cingulate gyrus and medial
frontal gyrus, suggesting both motor control and cognitive flex-
ibility are important for performance on part B. The TMT is
sensitive to subcortical white matter hyperintensities in healthy
NATURE PROTOCOLS | VOL.1 NO.5 | 2006 | 2277
 PROTOCOL

older adults19. Part A is a sensitive in vivo measure of drug effects
on the temporal and parietal cortex in Alzheimer disease20, and
both parts A and B are sensitive to the effects of cocaine on frontal
white matter21.
Alternate versions of the TMT have been developed to extend the
applicability of the test across age ranges and to accommodate
verbal and visual obstacles. An intermediate form of the TMT was
developed for use in children aged 9–14, and consists of 15 stimuli
for both parts A and B. The Color Trails Test22 was developed to
accommodate testing in subjects with language difficulties,
although there is some evidence that the part B equivalent of this
test is not compatible with the original TMT part B23, particularly
in younger and less educated subjects24. An oral version of the test
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols
been developed and are found to have excellent psychometric
properties26.
The TMT has excellent interrater reliability3 but, like many
neuropsychological instruments, it is somewhat susceptible to
practice effects. At shorter intervals, such as 6 weeks, large practice
effects may be found27. However, unlike other tests for which there
is a component of ‘‘learning how to take the test,’’ such as the
Wisconsin Card Sorting Test, the TMT does not evidence practice
effects across larger time intervals such as 1 year28, and possibly as
short as 6 months29,30. Alternate forms of reliability are quite high,
ranging from 0.78 (ref. 31) to 0.92 (ref. 32).
In PROCEDURE, we present verbatim instructions to an

examiner, such as would be used in a clinical assessment or in a

was developed25 and may distinguish between spatial and motor clinical trial. The exact text of the instructions spoken to the
components from sequencing deficits when used in conjunction examinee, as used in several previously published clinical trials, is
with the TMT. Equivalent alternate forms of the adult TMT have presented in italics.

MATERIALS
HUMAN subjects ! CAUTION Informed consent must be obtained and the EQUIPMENT SETUP
investigation performed according to National and Institutional Regulations. TMT forms (Available from Psychological Assessment
EQUIPMENT Resources Inc.).
. Stopwatch with a second hand Both parts A and B of the TMT have practice forms on one side of a single
. Pencil page and the formal test on the alternate side.

PROCEDURE
Part A
1| Place the part A sheet, practice side up, flat on the table in front of the subject.

2| Provide the subject with a pencil and say: ‘‘On this page (point to 1) are some numbers. Begin at number 1 (point to ‘‘1’’)
and draw a line from one to two (point to 2), two to three (point to 3), three to four (point to 4), and so on, in order, until
you reach the end (point to the circle marked ‘END’). Draw the lines as fast as you can. Do not lift the pencil from the paper.
Ready. Begin.’’

3| Provide any necessary instructions and feedback to the subject to elicit successful performance. If a subject makes an error,
say ‘‘stop’’ and refer to Table 1.
? TROUBLESHOOTING
4| After successful completion of the practice trial, turn the page over and present the test.

5| Tell the subject ‘‘On this page are more numbers. Do this the same way you did the practice. Begin at number one
(point to 1) and draw a line from one to two (point to 2), two to three (point to 3), three to four (point to 4), and so on, in
order, until you reach the end (point to 25). Remember, work as fast as you can. Ready, begin.’’

6| Start timing and continue timing even if the subject makes errors until the subject reaches the end.
7| Write the total seconds on the test sheet.

Part B
8| Place the test sheet for part B, sample side up, flat on the table in front of the subject, in the same position as the sheet
for part A was placed.

9| Say ‘‘On this page are some numbers and letters. Begin at number one (point) and draw a line from one to A (point to A),
A to two (point to 2), two to B (point to B), B to three (point to 3), three to C (point to C), and so on, in order, until you
reach the end (point to circle marked END). Remember, first you have a number (point to 1), then a letter (point to B), and so
on. Draw the lines as fast as you can. Ready. Begin.’’

10| Provide any necessary instructions and feedback to the subject to elicit successful performance. If a subject makes an error,
say ‘‘stop’’ and refer to Table 1.
? TROUBLESHOOTING

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 PROTOCOL

11| After successful completion of the practice trial, turn the page over and present the test for part B.

12| Tell the subject: ‘‘On this page are both numbers and letters. Do this the same way as the practice. Begin at number one
(point to 1) and draw a line from one to A (point to A), A to two (point to 2), two to B (point to B), B to three (point to 3),
three to C (point to C), and so on, in order, until you reach the end of the test (point to the end). Remember, you have to start
with a number (point to 1), then a letter (point to B) and so on. Do not skip around, but go from one circle to the next in the
proper order. Draw the lines as fast as you can. Ready. Begin.’’
13| Start timing and continue timing even if the subject makes errors until the subject reaches the end.

14| Write the total seconds on the test sheet.

 TIMING
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

The administration time will generally range from 5 to 10 min.

? TROUBLESHOOTING
Troubleshooting advice can be found in Table 1.

TABLE 1 | Troubleshooting table.

Problem Solution
Subject lifts pencil Instruct the subject to keep the pencil in contact with the paper and move on to the next circle

Subject asks for feedback Instruct the subject to finish the test; encourage to continue but do not provide qualitative feedback

Subject does not understand directions Repeat directions as necessary. If the subject still does not understand, guide the subject’s hand with
the eraser of the pencil and verbalize the instructions as you move the subject’s hand through the
practice items, then have the subject attempt again. If it is evident that the subject cannot complete
the test, enter a maximum score of 300 s and note ‘‘unable to perform’’

Subject lifts the paper Instruct the subject to keep the paper oriented vertically

Subject attempts to erase response Instruct subject to put a dash through their line and continue from the last number

Subject becomes inattentive or tries to Ask the subject to finish the test first
leave

Subject starts with the wrong circle Tell the subject that they started with the wrong circle and point to circle 1

Subject skips a circle Return the subject to the skipped circle and say this number (or letter) comes after (preceding stimulus)

Subject connects the wrong circle Cross out the erroneous line and provide immediate feedback, either in terms of ascending connections
for part A or alternation for part B

ANTICIPATED RESULTS
As mentioned above, the primary variables of interest are the total time to completion for both parts A and B. Some clinicians
and researchers also calculate a B–A difference or a B/A ratio, which may provide an index of the level of interference by the
addition of the flexibility component of part B.
Early attempts at establishing cutoff scores indicative of disease are rarely used clinically owing to lack of specificity.
Instead, normative scores are calculated based on the performance of healthy populations (see refs. 3,33) for comprehensive
normative data stratified by age, gender and education level and (ref. 34) for norms using regression-based approaches.
Comparing timed tests to healthy populations is potentially troublesome, however, given the potential for extraordinarily large
(and a mathematically impossible number of persons scoring outside of these ranges in diseased populations) standard scores
(i.e., z-scores). For example, a 19-year-old with a score of 300 s on part B would have a z-score of 16.5 based on normative
data3. As a z-score of 3.0 represents less than 0.5% of people, scores outside of this range are essentially meaningless.
Therefore, raw scores may be more meaningful for interpretation and tracking changes at this level of impairment.
Impairments on either or both parts of the TMT are likely to be found in conditions associated with cognitive impairment.
The degree of injury following traumatic brain injury is sensitive to both parts of the TMT, as well as the interaction between

NATURE PROTOCOLS | VOL.1 NO.5 | 2006 | 2279

 PROTOCOL

these parts35–38; however, neither error scores38–40 nor the interactions between parts A and B contribute to diagnostic
sensitivity of injury severity38; time to completion provides the most parsimonious and sensitive score. TMT results shortly
after injury, as part of a larger battery of tests and demographic features (e.g., age, duration of loss of consciousness) are
valid prognostic indicators of functional recovery in traumatic brain injury patients, although they do not account for a large
proportion of variance alone41–43.
Although error scores are rarely reported in the literature, they may have some utility in clinical use. Low performance on
both parts of the TMT in Alzheimer disease was reported; an analysis of error types by Amieva et al.44 attributed poor perfor-
mance to disinhibition. Stuss et al.45 found sensitivity for part B error scores. In this study of control subjects and patients
with lesions to the frontal or nonfrontal regions, all subjects who made more than one error had frontal lesions. Within the
region, inferior medial damage was not associated with part B performance and those with dorsolateral frontal lesions were
most impaired.
Moderate impairments on both parts of the test have been found in patients with bipolar I46,47 and II disorder47. A study of
© 2006 Nature Publishing Group http://www.nature.com/natureprotocols

bipolar and unipolar depressed patients found similar mild impairments on part A but evidence for a differential deficit on part
B, with the bipolar depressed patients patients performing worse48. There is preliminary evidence that TMT part B deficits in
bipolar disorder result from white matter deficits, particularly in the anterior cingulate cortex46, and deficits appear to be stable
across clinical states in bipolar disorder49.
The moderate to severe impairment often reported on part A of the TMT in schizophrenia50,51 suggests that impairments in
processing speed may mask additional impairments that could be potentially observed in the executive components of part B.
However, an interesting analysis of eye tracking and hand movements revealed inefficient strategies on part B in patients with
schizophrenia, as they tended to process the numbers and letters sequentially, rather than in a parallel fashion characteristic of
healthy subjects or patients with unipolar depression52,53. Thus, deficits may be observed across psychiatric conditions, but the
mechanism for poor performance may differ across these illnesses, with depressed patients showing slower motor speed and
schizophrenia patients demonstrating both slower motor speed and inefficient simultaneous processing strategies.
The TMT may also be used to estimate or predict functional abilities. It is correlated with driving ability54 and may be a useful
screening tool for driving readiness in combination with other measures such as driving simulators54,55. The B–A score was the
only significant predictor of driving safety errors in individuals with Parkinson disease56. Global impairments in psychosocial
functioning and occupational functioning in particular are associated with part B of the TMT in bipolar disorders47.
An additional important issue with the TMT is that, particularly for part A, it is a reliable and robust measure of processing
speed. Processing speed, measured with a variety of different tests, has been shown to be markedly impaired in many major
neuropsychiatric conditions57, and has been shown to be a potent predictor of vocational potential58. Processing speed
abnormalities may in fact underlie many other cognitive abnormalities, for a single, simple reason. Many ‘‘nontimed’’ neuro-
psychological tests have stimuli that are presented at a fixed rate. For instance, digit span tests are often presented at a rate of
one item per second and word list learning (episodic memory) tests are often presented at a rate of one word per 1.5 or 2.0 s.
If one is markedly slow in their psychomotor processing speed, ‘‘nontimed’’ tests may actually have substantial speed demands.
In fact, the largest neuropsychological study of schizophrenia ever performed, consisting of over 1,000 patients59, found that
processing speed accounts for substantial variance (460%) in global cognitive performance, whereas more complicated and
theoretically informed measures (executive functioning, vigilance and spatial working memory) accounted for relatively
minimal variance increments. Thus, one of the most important features of a simple processing speed measure like the TMT is
that it may provide a valuable point of reference on psychometric factors that influence performance on tests that appear more
‘‘sophisticated’’ and/or substantial theoretic origin.
Given the correlation of impaired TMT performance and functional outcomes, treatment of these deficits is important as it
may result in functional recovery. Parts A and B appear to be malleable with pharmacologic treatment in schizophrenia60–62.
It will be important for future research to examine how improvements relate to functional changes.

COMPETING INTERESTS STATEMENT The authors declare that they have no
competing financial interests.
Published online at http://www.natureprotocols.com
Rights and permissions information is available online at http://npg.nature.com/
reprintsandpermissions
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