Trail Making Test (TMT)

A literature search was conducted to identify all relevant publications on the psychometric properties of the Trail Making Test (TMT) involving patients with stroke.
Floor/Ceiling Effects

In a study by Mazer, Korner-Bitensky and Sofer (1989) that investigated the ability of perceptual testing to predict on-road driving outcomes in patients with stroke, part A of the TMT was found to have significant ceiling effects. For this reason, Part A was excluded from study results as it was deemed too easy for participants when evaluating the ability of the TMT to predict on-road driving test outcomes. No ceiling effects for part B were found.


Internal consistency:
No studies were identified examining the internal consistency of the TMT in patients with stroke.

Matarazzo, Wiens, Matarazzo and Goldstein (1974) examined the test-retest reliability of the TMT and other components of the Halstead Impairment Index with 29 healthy males and 16 60-year old patients with diffuse cerebrovascular disease. Adequate test-retest reliability was found for both Part A and Part B of the TMT in the healthy control group (r=0.46 and 0.44 respectively), as calculated using Pearson correlation coefficients. Excellent and adequate test-retest reliability was found for Part A and Part B of the TMT respectively (r=0.78 and 0.67), among participants with diffuse cerebrovascular disease.

Goldstein and Watson (1989) investigated the test-retest reliability of the TMT as a part of the Halstead- Reitan Battery in a sample of 150 neuropsychiatric patients, including patients with stroke. Test-retest correlations were calculated using Pearson Correlation Coefficients for the entire sample and for the sub-group of patients with stroke. Excellent test-retest reliability for both Part A and Part B were found (0.94 and 0.86 respectively) in the sub-group of patients with stroke; and adequate reliability for the entire participant sample (0.69 and 0.66 respectively).

No studies were identified examining the intra-rater reliability of the TMT in patients with stroke.

No studies were identified examining the inter-rater reliability of the TMT in patients with stroke.


O’Donnell, MacGregor, Dabrowski, Oestreicher & Romero (1994) examined the face validity of the TMT in a sample of 117 community-dwelling patients, including patients with stroke. The results suggest that the TMT is a complex test that involves aspects of abstraction, visual scanning and attention.

No studies were identified examining the concurrent validity of the TMT.

Mazer, Korner-Bitensky and Sofer (1998) examined the ability of the TMT and other measures of perceptual function to predict on-road driving test outcomes in 84 patients with subacute stroke. For Part B of the TMT, a cut-off score of < 3 errors demonstrated high positive predictive value (85%) and low negative predictive value (48%) for successful completion of driving evaluation. The Motor Free Visual Perception Test (MFVP) and the TMT Part B, when combined, demonstrated the highest predictive value for on-road driving test outcome. Participants who scored poorly on both the MFVP and TMT Part B had 22 times the likelihood of failing the on-road evaluation.

Devos, Akinwuntan & Nieuwboer (2011) conducted a systematic review to identify the best determinants of fitness to drive following stroke. The TMT Part B was evaluated in 2 studies (Mazer et al., 1998 and Mazer et al., 2003) and found to be one of the best predictors of passing on-road driving evaluation tests (effect size = 0.81, p<0.0001). In addition, when using a cutoff score of 90 seconds, the TMT Part B had a sensitivity of 80% and a specificity of 62% for detecting unsafe on-road performance. In a subsequent systematic review by Marshall et al. (2007), the TMT was, again, found to be one of the most useful predictors of fitness for driving post-stroke.

O’Donnell et al. (1994) examined the convergent validity of the TMT and four other neuropsychological tests: Category Test (CAT), Wisconsin Card Sort Test (WCST), Paced Auditory Serial Addition Task (PASAT), and Visual Search and Attention Test (VSAT). The study involved 117 community-dwelling adults, including patients with stroke. Poor to adequate correlations were found between the TMT and the other measures (CAT r=0.38; WCST r=0.31; PASAT r=0.44; VAST r=0.30), using Pearson product-moment correlations.

Known groups:
Reitan (1955) examined the ability of the TMT to differentiate between patients with and without organic brain damage, including patients with stroke. Highly significant differences in mean and sum scores were found between the two groups (p<0.001) on both parts of the TMT, suggesting that the TMT is able to different between patients with and without brain damage.

Corrigan and Hinkeldey (1987) examined the relationship between Part A and Part B of the TMT. Data was collected from the charts of 497 patients receiving treatment at a rehabilitation centre. Patients with traumatic brain injury and stroke comprised a large majority of the sample. A difference (B-A) and a ratio (B/A) score were calculated. The difference score was highly correlated with intelligence and severity of impairment and only moderately correlated with age, education and memory functioning. The B/A ratio appeared to show greatest sensitivity to differences in cerebral lateralization of damage.

Tamez et al. (2011) examined the effects of frontal versus non-frontal stroke and severity of stroke on TMT performance in 689 patients with stroke. The TMT, Digit Span and National Institute of Health Stroke Scale (NIHSS) were administered within 72 hours of hospital admission. Stroke severity was classified according to the NIHSS, and frontal or non-frontal lesions by CT or MRI scans. Performance on both Part A and Part B of the TMT were significantly correlated with stroke severity using the NIHSS. Patients with frontal and non-frontal lesions were found to score equally on Part A and Part B (p>0.05). Results of this study suggest that the TMT is sensitive to brain damage, however, there is little evidence to support the widely held assumption that Trails B is more sensitive to frontal lesions than Part A.

Sensitivity/ Specificity:
No studies were identified examining the specificity of the TMT in patients with stroke.


Barker-Collo, Feigin, Lawes, Senior and Parag (2000) assessed the course of recovery of attention span in 43 patients with acute stroke over a 6-month period. The TMT and other measures of attention were administered at baseline (within 4 weeks following stroke onset), 6 weeks, and 6 months after stroke. Although the responsiveness of the TMT was not formally assessed in this study, the scale was sensitive enough to detect an improvement in attention at 6 weeks and 6 months following stroke.

  • Barker-Collo, S., Feigin, V., Lawes, C., Senior, H., & Parag, V. (2010). Natural history of attention deficits and their influence on functional recovery from acute stages to 6 months after stroke.Neuroepidemiology, 35(4), 255-262.
  • Barncord, S.W. & Wanlass, R.L. (2001). The Symbol Trail Making Test: Test development and utility as a measure of cognitive impairment. Applied Neuropsychology, 8, 99-103
  • Corrigan, J. D. & Hinkeldey, N. S. (1987). Relationships between Parts A and B of the Trail Making Test. Journal of Clinical Psychology, 43(4), 402-409.
  • D’Elia, L.F., Satz, P., Uchiyama, C.I. & White, T. (1996). Color Trails Test. Odessa, Fla.:PAR.
  • Devos, H., Akinwuntan, A. E., Nieuwboer, A., Truijen, S., Tant, M., & De Weerdt, W. Screening for fitness to drive after stroke: a systematic review and meta-analysis.Neurology, 76(8), 747-756.
  • Elkin-Frankston, S., Lebowitz, B.K., Kapust, L.R., Hollis, A.M., & O’Connor, M.G. (2007). The use of the Colour Trails Test in the assessment of driver competence: Preliminary reports of a culture-fair instrument. Archives of Clinical Neuropsychology, 22, 631-635.
  • Goldstein, G. & Watson, J.R. (1989). Test-retest reliability of the Halstead-Reitan Battery and the WAIS in a Neuropsychiatric Population. The Clinical Neuropsychologist, 3(3), 265-273.
  • O’Donnell, J.P., Macgregor, L.A., Dabrowski, J.J., Oestreicher, J.M., & Romero, J.J. (1994). Construct validity of neuropsychological tests of conceptual and attentional abilities. Journal of Clinical Psychology, 50(4), 596-560.
  • Mark, V. W., Woods, A. J., Mennemeier, M., Abbas, S., & Taub, E. Cognitive assessment for CI therapy in the outpatient clinic.Neurorehabilitation, 21(2), 139-146.
  • Marshall, S.C., Molnar, F., Man-Son-Hing, M., Blair, R., Brosseau, L., Finestone, H.M., Lamothe, C, Korner-Bitensky, N., & Wilson, K. (2007). Predictors of driving ability following stroke: A systematic review. Topics in Stroke Rehabilitation, 14(1):98-114.
  • Matarazzo, J.D., Wiens, A.N., Matarazzo, R.G., & Goldstein, S.G. (1974). Psychometric and clinical test-retest reliability of the Halstead Impairment Index in a sample of healthy, young, normal men. The Journal of Nervous and Mental Disease, 188(1), 37-49.
  • Mazer, B.L., Korner-Bitensky, N.A., & Sofer, S. (1998). Predicting ability to drive after stroke. Archives of Physical Medicine and Rehabilitation, 79, 743-750.
  • Mazer, B.L., Sofer, S., Korner-Bitensky, N., Gelinas, I., Hanley, J. & Wood-Dauphinee, S. (2003). Effectiveness of a visual attention retraining program on the driving performance of clients with stroke. Archives of Physical Medicine and Rehabilitation, 84, 541-550.
  • Reitan, R.M. (1955). The relation of the Trail Making Test to organic brain damage. Journal of Consulting Psychology, 19(5), 393-394.
  • Reynolds, C. (2002). Comprehensive Trail Making Test. Austin, Tex,: Pro-Ed.
  • Ricker, J.H. & Axelrod, B.N. (1994). Analysis of an oral paradigm for the Trail Making Test. Assessment, 1, 47-51.
  • Strauss, E., Sherman, E.M.S., & Spreen, O. (2006).A Compendium of neuropsychological tests: Administration, norms, and commentary.(3rd. ed.).NY. Oxford University Press.
  • Tamez, E., Myersona, J., Morrisb, L., Whitea, D. A., Baum C., & Connor, L. T. (2011). Assessing executive abilities following acute stroke with the trail making test and digit span.Behavioural Neurology, 24(3), 177-185.