Applied Neuropsychology: Adult

ISSN: 2327-9095 (Print) 2327-9109 (Online) Journal homepage: http://www.tandfonline.com/loi/hapn21

Oral adaptation of the trail making test: A practical

review

Tobias Kaemmerer & Patrick Riordan

To cite this article: Tobias Kaemmerer & Patrick Riordan (2016): Oral adaptation
of the trail making test: A practical review, Applied Neuropsychology: Adult, DOI:
10.1080/23279095.2016.1178645

To link to this article: http://dx.doi.org/10.1080/23279095.2016.1178645

Published online: 24 May 2016.

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 APPLIED NEUROPSYCHOLOGY: ADULT
http://dx.doi.org/10.1080/23279095.2016.1178645

Oral adaptation of the trail making test: A practical review

Tobias Kaemmerera and Patrick Riordanb
a
St. Louis Veterans Administration Medical Center, St. Louis, Missouri, USA; bPsychology Department, Hines Veterans Administration Hospital,
Hines, Illinois, USA

ABSTRACT KEY WORDS

Despite being one of the most widely used measures in clinical neuropsychology, the Trail Making Assessment/diagnosis; test
Test is highly reliant on intact vision and motor functioning. Given that these capacities are often construction; tests
compromised in patients requiring neuropsychological evaluation, various authors have proposed
methods for adapting the Trail Making Test for oral administration. To date, a number of
administration and score transformation methods have been proposed. We reviewed the existing
literature on oral adaptation of the Trail Making Test in order to provide recommendations for
practicing clinicians wishing to use the measure, and to highlight directions for future research.
Downloaded by [University of Nebraska, Lincoln] at 05:52 25 May 2016

The Trail Making Test (TMT) has been an integral mea-
sure throughout the history of clinical neuropsychology.
Although various conceptualizations of the constructs
underlying performance on this pair of tasks have been
proposed, the TMT has been widely recognized as an
important test of executive functioning in the neuropsy-
chologist’s test library. Test usage surveys have shown
the TMT to be one of the most frequently employed neu-
ropsychological measures (e.g., Rabin, Barr, & Butler,
2005). Furthermore, given its relatively straightforward
instructions and limited time demands (particularly in
comparison to other tests of executive functioning),
the TMT can be an especially useful measure with geria-
tric populations. Despite its considerable utility, the
demands of the TMT are such that obtaining valid data
is inherently dependent upon intact vision and motor
functioning. However, geriatric patients, individuals
with a history of stroke, and other patient populations
commonly referred for neuropsychological evaluation
often suffer from visual and/or motor limitations that
preclude standard administration of the test.
Given the value of the TMT and the fact that standar-
dized administration is not feasible for many individuals,
a variety of authors have proposed methods for oral
administration of the TMT. While the core concepts of
adapting the TMT for oral administration are straight-
forward and have remained relatively consistent across
published literature, the specific instructions for admin-
istration, score transformation, and interpretation of the
obtained results have varied across studies. The current
review aims to briefly summarize the available research
on the oral TMT, make recommendations for optimal
use of the oral TMT based on existing literature,
summarize important considerations and limitations in
the use of the oral TMT, and highlight areas for future
research.
Research on the oral TMT
To date, a range of studies have addressed oral adapta-
tions of the TMT in clinical and research contexts.
Approximately two decades ago, Ricker and Axelrod
(1994) formally introduced an oral adaptation of the
TMT. Healthy participants (N ¼ 58) from three age
groups (two younger adult groups and one older adult
group) were administered both the traditional written
TMT and an oral version of the TMT. They found that
the ratio of written-to-oral completion times for TMT-
A and TMT-B did not significantly differ between age
groups, suggesting that, among healthy individuals,
there is a consistent, age-independent relationship
between written and oral performance of this measure.
Building on their previous work, Ricker, Axelrod, and
Houtler (1996) analyzed oral TMT performance among
85 patients who had suffered recent (<3 weeks prior)
anterior or posterior cerebral infarction. The TMT was
administered to each patient in both its written and oral
form within a larger battery of tests. Oral TMT-B raw
scores were transformed to written equivalents using
the ratio previously established by the authors (i.e.,
written TMT-B ¼ oral TMT-B X 2.44; Ricker & Axelrod,
1994). The written equivalents were then

CONTACT Patrick Riordan, Ph.D patrick.f.riordan@gmail.com Psychology Department, Hines Veterans Administration Hospital, Mail Code 116/B Hines,
IL 60141.
© 2016 Taylor & Francis
 2 T. KAEMMERER & P. RIORDAN
demographically corrected using the norms established
by Heaton, Grant, and Matthews (1991). For the written
TMT-B, neither raw scores nor demographically cor-
rected T-scores were significantly different between
groups (though the T-score difference approached sig-
nificance). However, the transformed oral TMT-B scores
(both raw and demographically corrected T) were sig-
nificantly different between groups, with the anterior
lesion group showing greater impairment, suggesting
greater sensitivity of the oral version of the test to frontal
lobe dysfunction. Furthermore, oral TMT-B scores were
significantly correlated with the percentage of persevera-
tive errors on the Wisconsin Card Sorting test (WCST),
providing some evidence of the concurrent validity of
the oral TMT as an executive measure.
Abraham, Axelrod, and Ricker (1996) evaluated
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written and oral TMT performance in a mixed clinical
sample of adult patients (N ¼ 112) undergoing neurop-
sychological evaluation. Oral TMT-B performance was
observed to correlate with written TMT-B performance
in the expected direction. Consistent with previous find-
ings, oral TMT-B performance was significantly slower
among the older patients, yet the ratio of written-to-oral
TMT-B did not differ as a function of age. In addition,
the written-to-oral TMT-B ratio did not differ signifi-
cantly as a function of written TMT-B performance or
motor function as assessed by dominant hand finger-
tapping. Thus, the authors argued that the oral TMT
is a valid tool for the assessment of executive skills in
clinical populations regardless of age, motor speed, or
level of cognitive flexibility.
Pointing to previous factor analyses showing that the
traditional written TMT taps rapid visual search and
visuospatial sequencing (e.g., Fossum, Holmberg, &
Reinvang, 1992), Oliveira-Souza et al. (2000) sought to
determine the extent to which TMT-B also uniquely
measures the ability to switch between conceptual sets.
The authors found a strong positive correlation (r ¼ .59)
between the written and oral forms of TMT-B among 55
healthy adults and argued that, given the lack of visuo-
motor components of oral TMT-B, this strong corre-
lation supports the notion that cognitive set-shifting is
an important aspect of performance on part B of this
measure regardless of administration modality.
Kowalczyk, McDonald, Cranney, and McMahon
(2001) evaluated the convergent and divergent validity
of the written and oral forms of the TMT. Both forms
were administered within the context of a broader
battery of tests among 16 older adults with dementia
and 60 healthy controls. Oral TMT performances had
a significant positive correlation with each other and
with both parts of the written TMT, WAIS-R Digit
Symbol subtest, and COWAT, supporting the
convergent validity of the oral TMT as a measure of
cognitive flexibility. The oral form was not related to
visual or motor skills, providing divergent validity for
the oral adaptation of the measure. Performance on
both the written and oral forms of the TMT was influ-
enced by age, gender, education, and general intellectual
ability, and both forms were sensitive to cognitive
decline in dementia. While written TMT raw scores
(time to completion) were more highly correlated with
tests of cognitive flexibility (e.g., WAIS-R Digit Symbol
subtest) than oral TMT raw scores, the use of difference
(B-A) and ratio (B/A) scores for both forms reduced
these differences. Thus, the authors argued that the
use of difference or ratio scores may reduce the poten-
tial differences caused by the different administration
modalities.
Ruchinskas (2003) evaluated the utility of the oral
TMT in a sample of 86 older general medical and neuro-
logic inpatients and 30 healthy controls. Mean education
was relatively low across the study (i.e., less than high
school among the clinical groups and 12.5 years among
healthy controls). The author found moderate correla-
tions between oral TMT-B and Mini-Mental State Exam
(MMSE) scores as well as moderate education effects for
oral TMT-B. In addition, oral TMT-B was significantly
correlated with number of perseverations on other execu-
tive tasks administered (e.g., Luria’s “rampart” design;
alternating motor sequencing tasks). High failure rates
on oral TMT-B were observed among the general medical
(42%) and neurologic (61%) inpatients using a cutoff of
300 seconds or 5 errors. The author concluded that the
oral TMT is a fair measure of general cognitive integrity
but suggested caution in its utilization among older medi-
cal patients and those with lower levels of education.
Notably, this study also found limited evidence of clinical
utility for oral TMT-A, with significantly different mean
time to completion scores observed across control and
neurologic impairment groups.
In response to a lack of formal validity studies and
available normative data for the oral TMT, Mrazik,
Millis, and Drane (2010) evaluated performance on both
the written and oral versions of the TMT among 81
healthy adults. The authors found a strong correlation
(r ¼ .62) between the written and oral forms of TMT-
B, but weak correlations between oral TMT-A and both
parts of the written TMT. While oral TMT-A was not
significantly correlated with any demographic factors,
oral TMT-B was significantly correlated with age (but
not education or gender) in their sample. The authors
argued that oral TMT-A is not an equivalent task to writ-
ten TMT-A given the weak correlations observed, noting
that this is likely due to the simplicity of the oral version,
which is essentially an overlearned counting task that

tends to yield a restricted range of scores. In contrast,
they highlighted the strong relationship between the
written and oral forms of TMT-B, noting that this may
reflect a shared dependence on mental flexibility and
divided attention. Of note, the written-to-oral TMT-B
ratios observed were lower than those previously
reported (2.1 vs. 2.44) and, unlike in previous studies,
variable across age groups. Thus the authors cautioned
against the use of a uniform conversion factor to predict
performance on the written version based on oral TMT
performance. Finally, the authors aptly noted a lack of
clarity about how the examiner is to respond when an
examinee makes an error during oral TMT performance
and addressed this by providing simple, scripted
instructions.
Bastug et al. (2013) evaluated the discriminative and
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concurrent validity of the oral TMT in older patients
with mild cognitive impairment (MCI), Alzheimer’s
disease (AD), and healthy controls (HC). The oral
TMT-A discriminated between AD and MCI, but not
MCI and HC. Oral TMT-B discriminated between all
groups (time to completion: AD > MCI > HC). Neither
part of the oral TMT correlated with age, but oral
TMT-B completion time negatively correlated with edu-
cation. Strong correlations were observed between the
oral TMT (both parts) and other neuropsychological
measures including Clock Drawing, WAIS-R Digits
Backward, and the written TMT. The authors concluded
that the oral TMT (especially part B) is a valid tool for
measuring different levels of cognitive impairment, parti-
cularly when visual or motor deficits are present. They
noted that, in comparison to its written counterpart,
the oral version of the TMT takes less time to administer,
is less affected by the aging process, and can be adminis-
tered via telephone (as in Mitsis et al., 2010). Of note, the
authors recommended the use of oral TMT-B or combi-
nation scores (e.g., A þ B) instead of the oral TMT-A.
Finally, given that the written and oral versions of the
TMT are not identical, they argued in favor of developing
independent normative data for the oral TMT instead of
converting oral TMT scores to written TMT scores.
Unlike many other popular neuropsychological mea-
sures, the TMT has been used sparsely within functional
neuroimaging studies, most likely because the physical
aspects of the traditional, paper and pencil administra-
tion are not conducive to fMRI. As a result, multiple
authors have devised adaptations of the TMT more suit-
able for fMRI research (e.g., Allen, Owens, Fong, &
Richards, 2011; Moll, de Oliveira-Souza, Moll, Bramati,
& Andreiuolo, 2002; Zakzanis, Mraz, & Graham, 2005).
Corresponding investigations have helped to elucidate
the neural underpinnings of TMT performance and have
generally aligned with previous data suggesting
APPLIED NEUROPSYCHOLOGY: ADULT 3
significant recruitment of ventral and dorsal visual path-
ways and dorsolateral and medial prefrontal cortices
(Allen et al., 2011; Moll et al., 2002). Nevertheless, overall,
oral adaptations have received a minimal amount of
attention in the functional neuroimaging research.
Clinical studies
Although the instructions for administering, transform-
ing, and scoring oral adaptations of the TMT have not
been fully standardized, a number of clinical studies
have employed the oral TMT and provide further evi-
dence of its considerable value across a range of popula-
tions. A 2002 study by Chiaravalloti and DeLuca (2002)
used oral adaptations of TMT A & B in a comparison of
neuropsychological test performances across individuals
with MS and healthy adults, given that motor deficits
associated with MS could artificially impair perfor-
mance on the written administration. In 2006, Bennett
and colleagues used oral TMT-B as a measure of
executive functioning in a study assessing functional
and neuroimaging correlates of neuropsychological test
performance in the very elderly. Grober et al. (2008)
used an oral adaptation of TMT-B in order to control
for motor impairment in a study assessing screening
methods for early dementia. Cercy, Simakhodskaya, &
Elliott (2010) developed a brief cognitive screening
instrument for use with psychiatric patients in emerg-
ency medical settings that included oral adaptations of
TMT A & B. Notably, they found improved classi-
fication accuracy for identifying cognitive impairment
after removing the oral TMT-A results from their com-
posite score and only including oral TMT-B. In a study
of hypotensive patients with spinal cord injury, Jegede
et al. (2010) used oral adaptations of oral TMT A & B
and found performance differences across SCI patients
with and without hypotension on oral TMT-A. In
2010, Mitsis et al. used the oral adaptation of TMT A
& B in a study of telephone-based cognitive assessment
in the elderly. In comparison to in-person assessment,
they found statistically significant performance differ-
ences for written versus oral TMT-A but not B. A
2012 study of patients with ALS by Jelsone-Swain et
al. (2012) used a ratio score of performance on oral
TMT-A and oral TMT-B to account for processing
speed differences across participants, in which they
found significant group differences between ALS
patients and healthy controls on oral TMT-B raw scores,
but not oral TMT-B/oral TMT-A ratios.
Given its status as a well-established test of executive
functioning without significant time demands, the tra-
ditional TMT has also been utilized as a subtest within
multiple brief cognitive screening batteries designed to
 4 T. KAEMMERER & P. RIORDAN
simplify and improve detection of cognitive impairment
in specific disease processes (e.g., the Alzheimer’s
Disease Centers’ Uniform Data Set Neuropsychological
Test Battery, Weintraub et al., 2009; the American
College of Rheumatology neuropsychological battery
for systemic lupus erythematosus, Kozora, Ellison, &
West, 2004). The oral adaptation of the TMT has also
been utilized for such purposes, particularly in cognitive
screening batteries designed for use with populations
with significant motor impairments. For instance, the
Edinburgh Cognitive and Behavioral Amyotrophic
Lateral Sclerosis Screen (ECAS; Abrahams, Newton,
Niven, Foley, & Bak, 2014) has been shown to have high
sensitivity (85%) and specificity (85%) in the detection
of cognitive impairments characteristic of ALS patients
(Niven et al., 2015). While the ECAS version of the
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OTMT uses its own unique administration and scoring
procedures (e.g., raw score ¼ number of correct trials vs.
time to completion), the subtest preserves the basic
OTMT structure and procedure of verbally alternating
between numbers and letters, from “1-A” through
“12-L.” Because the raw score equals the number of
correct trials and not the time to completion as in the
traditional OTMT, the ECAS version appears to place
more emphasis on set-shifting ability/accuracy without
the speed component.
Recommendations for use of oral trails based
on research to date
Given the lack of consistent standardization and find-
ings across studies of the oral TMT, caution should be
taken in administration and interpretation of the mea-
sure. At the same time, the TMT has well-documented
utility and is not easily substituted for in cases of visual
and/or motor impairment. Furthermore, the existing
research literature provides clear instructions for the
administration of the adapted measure, considerable
evidence for concurrent and divergent validity, and
reasonably consistent conversion factors to transform
oral TMT scores for interpretation with written TMT
norms. Based on the available research literature, the
following recommendations are made for best current
use of the oral adaptation of the TMT:
1. Although multiple authors have noted the limited
clinical utility of oral TMT-A (e.g., Bastug et al.,
2013) and some have suggested omitting it, adminis-
tration of both A and B trials is recommended for
oral adaptation of the measure in order to maximize
consistency of administration. Furthermore, existing
studies have provided limited evidence of potential
clinical utility for oral TMT-A (e.g., Ruchinskas,
2003), as well as potential utility of oral TMT B/A
ratio scores. At the same time, the preponderance
of available evidence clearly indicates that establish-
ing a uniform conversion factor for oral TMT-A to
written TMT-A is not possible, and that oral TMT-
A cannot be meaningfully interpreted as an analogue
form of written TMT-A.
2. Early research did not delineate specific instructions for
administration of the oral TMT and for standardized
management of examinee errors. However, adding to
the initial instructions provided by Ricker and Axelrod
(1994), Mrazik et al. (2010) added standardized instruc-
tions for management of errors. Given the comprehen-
siveness of these instructions and the normative
database associated with them, their use is recom-
mended in clinical applications and future research:
Introductory Instructions (from Ricker & Axelrod,
1994, pp. 48–49).
Oral TMT-A: “I would like you to count from 1 to 25
as quickly as you can 1, 2, 3, and so on. Are you ready?
Begin.”
Oral TMT-B: “Now I would like you to count again,
but this time you are to switch between number and let-
ter, so you would say 1-A-2-B-3-C, and so on, until I say
‘stop’. Are you ready? Begin.”
Correction Instructions (from Mrazik et al., 2010,
p. 238).
If the patient makes an error on Part A, the examiner
is to reorient them to the last correct number by saying:
“You last said ‘[specific number],’ please continue from
there.”
If the patient makes an error on Part B, the examiner
is to reorient them to the last correct pair by saying:
“You said‘[specific number] [specific letter];’ Continue
from there.”
3. Although early studies on the oral TMT appeared to
suggest that a uniform conversion factor for oral
TMT-B is sufficient (e.g., Ricker & Axelrod, 1994),
subsequent research has provided compelling evi-
dence that use of age-adjusted conversion ratios
may be more appropriate. Until more comprehensive
normative data specific to the oral TMT are pub-
lished, clinicians are likely best served by considering
both the uniform oral TMT-B conversion factor of
2.44 proposed by Ricker and Axelrod (1994), as well
as the age- specific oral TMT-B conversion factors
established by Mrazik et al. (2010), which are
summarized below:20–39: 1.7 29–49: 1.8 39–59: 1.9
49–69: 2.2 59–79: 2.3 69–90: 2.3
Given that there are currently no standardized rules
governing when to administer the TMT in oral versus
written form, examiners must rely on clinical judgment
to decide which approach will allow for the most
valid assessment of the core underlying constructs

(i.e., cognitive processing speed, mental flexibility,
set-shifting). When the most appropriate modality for
administration is not obvious (e.g., a stroke patient with
motor and language deficits hindering both dominant
hand function and speech), the clinician may choose
to attempt administration of both forms or omit the
TMT as appropriate.
Future directions
While the existing body of literature on oral adaptations
of the TMT clearly supports judicious clinical use of the
measure, further research and development of the oral
TMT is needed. Oral adaptation of the TMT is parti-
cularly supported in the assessment of examinees who
cannot be administered the traditional written version
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due to motor impairments significantly affecting domi-
nant hand function (e.g., tremor, paresis, or peripheral
injury) and/or significant visual impairments (e.g.,
impaired eyesight, diplopia, or visual field deficit). A
more robust normative data set exclusive to the oral
TMT is desirable and would help to establish the oral
TMT as not only an alternative administration method
for the TMT, but also a potentially useful complimentary
measure that may represent a more conceptually pure
measure of executive functions.
Additionally, although research to date has clearly
illustrated the lack of stability across the oral and writ-
ten versions of TMT-A, several studies have employed
novel composite, difference, and ratio scores that may
have utility in contextualizing oral TMT-B performance.
Accordingly, even if the independent utility of oral
TMT-A performance is limited, continued inclusion of
the oral TMT-A in clinical and research contexts
appears warranted, particularly given the low adminis-
tration burden of the task and its potential utility in
screening for relevant third variables (e.g., generalized
slowing, sequencing deficits, etc.).
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