Name: traditional trail making test modified into brand-new assessment tools: digital and walking trail making test
Uploaded: 2019-11-23T14:30:00
Description: Watch this Scientific Journal Video about Traditional Trail Making Test Modified into Brand-new Assessment Tools: Digital and Walking Trail Making Test at JoVE.com

The authors thank Xiaode Chen for digital technology support.

The development of the dTMT and initial application was approved by The Seventh Medical Center of PLA Army General Hospital Review Board. Subjects signed approved informed consent documents prior to testing TMT.
1. General Method Development
<ol>
	<li>Use a tablet (e.g., Microsoft Surface Pro 2) with high-quality inertial sensors embedded within the device and a compatible electronic pen (Figure 1).</li>
	<li>Use the Intelligent Device for Energy Expenditure and...

<ol>
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B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Utilization+rates+of+ecologically+oriented+instruments+among+clinical+neuropsychologists.">Utilization rates of ecologically oriented instruments among clinical neuropsychologists.</a> The Clinical Neuropsychologist. 21 (5), 727-743 (2007).</li><li>Sacco, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+a+paper-pencil+version+and+computerized+version+for+the+realization+of+a+neuropsychological+test:+the+example+of+the+trail+making+test.">Comparison between a paper-pencil version and computerized version for the realization of a neuropsychological test: the example of the trail making test.</a> Journal of Alzhemier's Disease. 68 (4), 1657-1666 (2019).</li><li>Faria, C. A., Alves, H. V. D., Charchat-Fichman, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+most+frequently+used+tests+for+assessing+executive+functions+in+aging.">The most frequently used tests for assessing executive functions in aging.</a> Dementia &amp; Neuropsychologia. 9 (2), 149-155 (2015).</li><li>Lezak, M. D., Howieson, D. D., Loring, D. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Neuropsychological assessment. 4th ed. , 317-374 (2004).</li><li>Lu, J. C., Guo, Q. H., Hong, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trail+making+test+used+by+Chinese+elderly+patients+with+mild+cognitive+impairment+and+mild+Alzheimer'+dementia.">Trail making test used by Chinese elderly patients with mild cognitive impairment and mild Alzheimer' dementia.</a> Chinese Journal Clinical Psychology. 14 (2), 118-120 (2006).</li><li>Lee, S., Lee, J. A., Choi, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Driving+Trail+Making+Test+part+B:+a+variant+of+the+TMT-B.">Driving Trail Making Test part B: a variant of the TMT-B.</a> Journal of Physical Therapy Science. 28 (1), 148-153 (2016).</li><li>Bastug, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oral+trail+making+task+as+a+discriminative+tool+for+different+levels+of+cognitive+impairment+and+normal+aging.">Oral trail making task as a discriminative tool for different levels of cognitive impairment and normal aging.</a> Archives of Clinical Neuropsychology. 28 (5), 411-417 (2013).</li><li>Perrochon, A., Kemoun, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Walking+Trail-Making+Test+is+an+early+detection+tool+for+mild+cognitive+impairment.">The Walking Trail-Making Test is an early detection tool for mild cognitive impairment.</a> Clinical Interventions in Aging. 9, 111-119 (2014).</li><li>McIntyre, R. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+THINC-Integrated+Tool+(THINC-it)+screening+assessment+for+cognitive+dysfunction:+validation+in+patients+with+major+depressive+disorder.">The THINC-Integrated Tool (THINC-it) screening assessment for cognitive dysfunction: validation in patients with major depressive disorder.</a> The Journal of Clinical Psychiatry. 78 (7), 873-881 (2017).</li><li>Schott, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trail+Walking+Test+zur+Erfassung+der+motorisch-kognitiven+Interferenz+bei+&#228;lteren+Erwachsenen.">Trail Walking Test zur Erfassung der motorisch-kognitiven Interferenz bei &#228;lteren Erwachsenen.</a> Zeitschrift f&#252;r Gerontologie und Geriatrie. 48 (8), 722-733 (2015).</li><li>Thompson, M. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+utility+of+the+Trail+Making+Test+practice+time.">Clinical utility of the Trail Making Test practice time.</a> The Clinical Neuropsychologist. 13 (4), 450-455 (1999).</li><li>Mahurin, R. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trail+making+test+errors+and+executive+function+in+schizophrenia+and+depression.">Trail making test errors and executive function in schizophrenia and depression.</a> The Clinical Neuropsychologist. 20 (2), 271-288 (2006).</li><li>Klaming, L., Vlaskamp, B. N. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Non-dominant+hand+use+increases+completion+time+on+part+B+of+the+Trail+Making+Test+but+not+on+part+A.">Non-dominant hand use increases completion time on part B of the Trail Making Test but not on part A.</a> Behavior Research Methods. 50 (3), 1074-1087 (2017).</li><li>Christidi, F., Kararizou, E., Triantafyllou, N., Anagnostouli, M., Zalonis, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Derived+trail+making+test+indices:+demographics+and+cognitive+background+variables+across+the+adult+life+span.">Derived trail making test indices: demographics and cognitive background variables across the adult life span.</a> Aging, Neuropsychology, and Cognition. 22 (6), 667-678 (2015).</li><li>Dahmen, J., Cook, D., Fellows, R., Schmitter-Edgecombe, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+analysis+of+a+digital+variant+of+the+Trail+Making+Test+using+machine+learning+techniques.">An analysis of a digital variant of the Trail Making Test using machine learning techniques.</a> Technology and Health Care. 25 (2), 251-264 (2017).</li><li>Woods, D. 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C., Jones, J. L., Ashton-Miller, J. A., Alexander, N. B., Giordani, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Executive+function+and+gait+in+older+adults+with+cognitive+impairment.">Executive function and gait in older adults with cognitive impairment.</a> The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 63 (12), 1350-1355 (2008).</li><li>Zhang, K., Werner, P., Sun, M., Pi-Sunyer, F. X., Boozer, C. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measurement+of+human+daily+physical+activity.">Measurement of human daily physical activity.</a> Obesity Research. 11 (1), 33-40 (2003).</li><li>Zhang, K., Pi-Sunyer, F. X., Boozer, C. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improving+energy+expenditure+estimation+for+physical+activity.">Improving energy expenditure estimation for physical activity.</a> Medicine and Science in Sports and Exercise. 36 (5), 883-889 (2004).</li><li>Gorelick, M. L., Bizzini, M., Maffiuletti, N. A., Munzinger, J. P., Munzinger, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Test-retest+reliability+of+the+IDEEA+system+in+the+quantification+of+step+parameters+during+walking+and+stair+climbing.">Test-retest reliability of the IDEEA system in the quantification of step parameters during walking and stair climbing.</a> Clinical Physiology and Functional Imaging. 29 (4), 271-276 (2009).</li><li>Nordin, E., Moe-Nilssen, R., Ramnemark, A., Lundin-Olsson, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Changes+in+step-width+during+dual-task+walking+predicts+falls.">Changes in step-width during dual-task walking predicts falls.</a> Gait and Posture. 32 (1), 92-97 (2010).</li><li>Liebherr, M., Weiland-Breckle, H., Grewe, T., Schumacher, P. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cognitive+performance+under+motor+demands+-+On+the+influence+of+task+difficulty+and+postural+control.">Cognitive performance under motor demands - On the influence of task difficulty and postural control.</a> Brain Research. 1684, 1-8 (2018).</li><li>Herold, F., Hamacher, D., Schega, L., M&#252;ller, N. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thinking+while+moving+or+moving+while+thinking+&#8211;+Concepts+of+motor-cognitive+training+for+cognitive+performance+enhancement.">Thinking while moving or moving while thinking &#8211; Concepts of motor-cognitive training for cognitive performance enhancement.</a> Frontiers in Aging Neuroscience. 10, 228 (2018).</li><li>Kim, H., Hsiao, C. P., Do, Y. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Home-based+computerized+cognitive+assessment+tool+for+dementia+screening.">Home-based computerized cognitive assessment tool for dementia screening.</a> Journal of Ambient Intelligence &amp; Smart Environments. 4, 429-442 (2012).</li><li>Mancini, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trunk+accelerometry+reveals+postural+instability+in+untreated+Parkinson's+disease.">Trunk accelerometry reveals postural instability in untreated Parkinson's disease.</a> Parkinsonism &amp; Related Disorders. 17 (7), 557-562 (2011).</li><li>Ozinga, S. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+evaluation+of+postural+stability+in+Parkinson's+disease+with+mobile+technology.">Three-dimensional evaluation of postural stability in Parkinson's disease with mobile technology.</a> NeuroRehabilitation. 41 (1), 211-218 (2017).</li><li>Fellows, R. P., ahmen, J., Cook, D., Schmitter-Edgecombe, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multicomponent+analysis+of+a+digital+Trail+Making+Test.">Multicomponent analysis of a digital Trail Making Test.</a> Clinical Neuropsychologist. 31 (1), 154-167 (2017).</li><li>Au, R., Piers, R. 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Traditional paper-pencil TMT has been well used worldwide for more than 50 years. However, digital TMT is advantageous. First, traditional TMT is considered as an executive function tool, while both dTMT and WTMT have aspects reflecting motor ability besides cognitive function. Considering that the cognitive-motor dual task has gained great attention in recent years26, digital technologies can provide researchers with more information on this integrated task compared with the traditional TMT<sup c...

With a rapidly aging population, dementia is considered to be a major public health concern. The number of elderly patients with dementia worldwide is about 47 million according to the World Health Organization1. Executive function impairment is not only a common type of cognitive dysfunction in aged individuals, but has been reported as a predictor of progression from mild cognitive impairment (MCI) to clinical Alzheimer&#8217;s disease (AD)2,3. As the third most widely used test in neuropsychology4, the Trail Making Test (TMT) is employed as a well-accepted tool to evaluate executive functions, especially sustained attention and set-shifting5, even in elderly patients6.
The standard TMT is a paper-pencil test consisting of two parts: tMT-A and TMT-B5. The former calls for the test-taker to draw lines connecting randomly distributed numbers (1&#8211;25) on a test paper in ascending order (1-&#62;2-&#62;3&#8230;), whereas the latter requires the test-taker to set numbers and letters (1-&#62;A-&#62;2-&#62;B&#8230;) alternatively. The performance of TMT is generally scored in the time taken to complete each part correctly7. TMT has been translated into different languages. The Chinese version of TMT was developed in 20068. Since Chinese characters are quite distinct from English letters, the Chinese version of TMT was used in our procedure.
Apart from the standard version, TMT has been modified in different ways by researchers (e.g., oral TMT9, driving TMT10, walking TMT (WTMT)11) to assess specific populations or find details under different conditions, such as driving and walking. Of note, some studies conferring different numbers compared with the standard TMT are also reported to be of high validity and reliability. For example, THINC-Integrated Tool (THINC-it) developed by the McIntyre group used 9 numbers and letters for TMT-B12; WTMT reported by Schott and colleagues used 15 numbers for TMT-A13. In the same way, many evaluating systems of TMT have been built beyond the complete time scoring, which are reported to be helpful in finding more items besides executive dysfunction, or to be accessible for participants who are not suitable to complete the standard TMT. For example, some researchers investigated the errors in TMT and found that errors in TMT-B were associated with mental tracking and working memory in patients with psychiatric disorder14. Another group from Greece suggested derived TMT scores [TMT-(B&#8722;A) or TMT(B/A)] as indices to detect impairment in cognitive flexibility across the adult life span15. Generally, alternative evaluating systems of TMT can be summarized as follows: (1) completion time analysis&#8212;TMT completion time is calculated in seconds16; (2) error analysis&#8212;different types of TMT errors are classified and quantified14; (3) intermanual differences&#8212;different abilities of completing TMT between the dominant hand and the nondominant hand are compared17; and (4) derived Trail Making Test indices&#8212;different characterizations between completing TMT-A and TMT-B are analyzed15. The alternative scoring methods provide additional information. For example, the utility of TMT error analysis could reveal cognitive deficits not traditionally captured using completion time as the sole outcome variable in patients with schizophrenia and depression14. The lack of any significant intermanual difference helped to discriminate the cognitive dysfunction from the influence of the motor disorder17. Derived TMT indices could detect impairment in cognitive flexibility across the adult life span and minimize the effect of demographics and other cognitive background variables15.
With advances in modern technology, computer-based digital applications have been increasingly integrated into traditional cognitive interventions, most of which are designed as similar to the original test as possible, rather than created as new tools. Digital or computerized TMT (dTMT) has been proven to have the potential to capture additional information, with the structure of the existing test mainly unchanged in recent years18,19.
This study aimed to introduce a computer-based Chinese version of dTMT-A and dTMT-B, as well as a WTMT. Both are modified TMTs and have been confirmed to have high sensitivity and specificity to screen patients with MCI, Parkinson&#8217;s Disease, Alzheimer&#8217;s Disease, and so forth, based on the movement of upper and lower limbs20,21. Detailed scoring methods were also presented because digital technologies incorporated into dTMT and WTMT might help capture more information compared to the paper-pencil version of TMT.

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			<td height="42" style="height:42px;width:215px;">Minisun</td>
			<td style="width:69px;">LLC</td>
			<td style="width:115px;"></td>
			<td style="width:415px;">Intelligent Device for Energy Expenditure and Activity (IDEEA)</td>
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			<td height="21" style="height:21px;width:215px;">Surface Pro 2</td>
			<td style="width:69px;">Microsoft</td>
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			<td style="width:415px;">computer</td>
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traditional trail making test modified into brand-new assessment tools: digital and walking trail making test

The Trail Making Test (TMT) is a well-accepted tool for evaluating executive function. The standard TMT was invented more than 60 years ago and has been modified into many versions. With the development of digital technologies, TMT is now modified to a digitized version. The present study demonstrated digital TMT (dTMT) performed on a computer, and Walking TMT (WTMT) on the floor. Both revealed more information compared with the traditional version of TMT.

Seven aged patients with Mild Cognitive Impairment (Elderly with MCI), seven aged subjects with Parkinson&#8217;s Disease (Elderly with PD), and seven aged healthy individuals (Healthy Elderly) were recruited, and dTMT-A, dTMT-B, WTMT-A, and WTMT-B, were performed. After the tests, data were collected and analyzed using SPSS software.
As a whole, the demographical data of participants showed that all groups were matched well in terms of age, gender, educational level, dominant hand, Clinical D...

Watch this Scientific Journal Video about Traditional Trail Making Test Modified into Brand-new Assessment Tools: Digital and Walking Trail Making Test at JoVE.com

Traditional Trail Making Test Modified into Brand-new Assessment Tools: Digital and Walking Trail Making Test

Here, we present a protocol to show how to perform two types of cognitive assessment tools derived from the paper-pencil version of the Trail Making Test.

The Trail Making Test (TMT) is a well-accepted tool for evaluating executive function. The standard TMT was invented more than 60 years ago and has been ...

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