Unveiling Trail Making Test: Visual and manual trajectories indexing multiple executive processes

TL;DR

This study introduces a computerized version of the Trail Making Test (cTMT) that measures eye and hand movements to better analyze executive functions, overcoming limitations of traditional pen-and-paper tests.

Contribution

The paper presents a novel digital cTMT that captures detailed movement data, enabling more precise analysis of executive processes and internal cognitive markers.

Findings

Performance similar to traditional TMT

Identified eye movement patterns related to task parts

Proposed internal measures as markers of working memory and inhibitory control

Abstract

The Trail Making Test (TMT) is one of the most popular neuropsychological tests in the clinical assessment of executive functions (EF) and research in a wide range of clinical conditions. In addition to its sensitivity to executive dysfunction, the TMT presents several strengths: it is simple and intuitive, it is easy to understand for patients, and has a short administration. However, it has important limitations. First, the underlying EFs articulated during the task are not well discriminated, which makes it a test with low specificity. Second, the traditional pen-and-paper version presents one trial per condition which introduces high variability. Third, only the total time is quantified, which does not allow for a detailed analysis. Fourth, it has a fixed spatial configuration per condition. In the present study we designed a computerized version of the TMT (cTMT) to overcome its main limitations. Eye and hand positions are simultaneously measured with high resolution, several trials are acquired, and spatial configuration of the targets is controlled. Our results showed a very similar performance profile compared to the traditional TMT. Moreover, it revealed similarities and differences in eye movements between the two parts of the task. Most importantly, we found an internal working memory measure of the cTMT based on hand and eye movements that showed an association to a validated working memory task. Additionally, we found another internal measure of the TMT, also based on hand and eye movements, that we propose as a potential marker of inhibitory control. Our results showed that executive functions can be studied in more detail using traditional tests combined with powerful digital setups. Finally, our study paved the way for a detailed analysis of other complex tasks used for clinical evaluation, providing a deeper understanding of the processes underlying its resolution.