Abstract
The Trail Making Test (TMT) is widely used for assessing executive function, frontal lobe abilities, and visual motor skills. Part A of this pen-and-paper test (TMT-A) involves linking numbers randomly distributed in space, in ascending order. Part B (TMT-B) alternates between linking numbers and letters. TMT-B is more demanding than TMT-A, but the mental processing that supports the performance of this test remains incompletely understood. Functional MRI (fMRI) may help to clarify the relationship between TMT performance and brain activity, but providing an environment that supports real-world pen-and-paper interactions during fMRI is challenging. Previously, an fMRI-compatible tablet system was developed for writing and drawing with two modes of interaction: the original cursor-based, proprioceptive approach, and a new mode involving augmented reality to provide visual feedback of hand position (VFHP) for enhanced user interaction. This study characterizes the use of the tablet during fMRI of young healthy adults (n = 22), with half of the subjects performing TMT with VFHP and the other half performing TMT without VFHP. Activation maps for both TMT-A and TMT-B performance showed considerable overlap between the two tablet modes, and no statistically differences in brain activity were detected when contrasting TMT-B vs. TMT-A for the two tablet modes. Behavioral results also showed no statistically different interaction effects for TMT-B vs. TMT-A for the two tablet modes. Tablet-based TMT scores showed reasonable convergent validity with those obtained by administering the standard pen-and-paper TMT to the same subjects. Overall, the results suggest that despite the slightly different mechanisms involved for the two modes of tablet interaction, both are suitable for use in fMRI studies involving TMT performance. This study provides information for using tablet-based TMT methods appropriately in future fMRI studies involving patients and healthy individuals.
Highlights
Since its development by U.S Army psychologists in the latter stages of the second world war, the Trail Making Test (TMT) has become one of the most widely used neuropsychological (NP) tools for assessing brain dysfunction in diverse patient populations (Halstead, 1947; Morris et al, 1987; Dikmen et al, 1990; Buchanan et al, 1994; Ashendorf et al, 2008; McKhann, 2011)
Subjects who performed without visual feedback of hand position (VFHP) had completion times of 39.7 (11.7) s and 48.9 (11.1) s for TMT-A and TMT-B, respectively; those who performed with VFHP had analogous values of 46.2 (11.3) and 53.2 (9.8) s
A Wilcoxon signed-rank test was conducted between completion times for TMT with VFHP (B-A) and without VFHP (B-A), and in an analogous manner for the by TMT-A completion time (B/A) ratio
Summary
Since its development by U.S Army psychologists in the latter stages of the second world war, the Trail Making Test (TMT) has become one of the most widely used neuropsychological (NP) tools for assessing brain dysfunction in diverse patient populations (Halstead, 1947; Morris et al, 1987; Dikmen et al, 1990; Buchanan et al, 1994; Ashendorf et al, 2008; McKhann, 2011). In TMT-A, the patient is presented with encircled numbers from 1 to 25 randomly distributed on a sheet of paper, and they are instructed to link the numbers in ascending order In TMT-B, a second sheet includes both encircled numbers and letters that the patient must link in alternating ascending order The difference between the completion times for TMT-A and TMT-B (i.e., “B-A”) is frequently used to remove the speed element from the test evaluation, and ratio scores such as B/A (Corrigan and Hinkeldey, 1987) and (B-A)/A (Stuss et al, 2001; Bowie and Harvey, 2006) have been employed to assess a variety of cognitive impairments (Bowie and Harvey, 2006)
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