A clinical 3D pointing test differentiates spatial memory deficits in dementia and bilateral vestibular failure.

BACKGROUND: Deficits in spatial memory, orientation, and navigation are often neglected early signs of cognitive impairment or loss of vestibular function. Real-world navigation tests require complex setups. In contrast, simple pointing at targets in a three-dimensional environment is a basic sensorimotor ability which provides an alternative measure of spatial orientation and memory at bedside. The aim of this study was to test the reliability of a previously established 3D-Real-World Pointing Test (3D-RWPT) in patients with cognitive impairment due to different neurodegenerative disorders, bilateral vestibulopathy, or a combination of both compared to healthy participants. METHODS: The 3D-RWPT was performed using a static array of targets in front of the seated participant before and, as a transformation task, after a 90-degree body rotation around the yaw-axis. Three groups of patients were enrolled: (1) chronic bilateral vestibulopathy (BVP) with normal cognition (n = 32), (2) cognitive impairment with normal vestibular function (n = 28), and (3) combined BVP and cognitive impairment (n = 9). The control group consisted of age-matched participants (HP) without cognitive and vestibular deficits (n = 67). Analyses focused on paradigm-specific mean angular deviation of pointing in the azimuth (horizontal) and polar (vertical) spatial planes, of the preferred pointing strategy (egocentric or allocentric), and the resulting shape configuration of the pointing array relative to the stimulus array. Statistical analysis was performed using age-corrected ANCOVA-testing with Bonferroni correction and correlation analysis using Spearman's rho. RESULTS: Patients with cognitive impairment employed more egocentric pointing strategies while patients with BVP but normal cognition and HP used more world-based solutions (pBonf 5.78 × 10-3**). Differences in pointing accuracy were only found in the azimuth plane, unveiling unique patterns where patients with cognitive impairment showed decreased accuracy in the transformation tasks of the 3D-RWPT (pBonf < 0.001***) while patients with BVP struggled in the post-rotation tasks (pBonf < 0.001***). Overall azimuth pointing performance was still adequate in some patients with BVP but significantly decreased when combined with a cognitive deficit. CONCLUSION: The 3D-RWPT provides a simple and fast measure of spatial orientation and memory. Cognitive impairment often led to a shift from world-based allocentric pointing strategy to an egocentric performance with less azimuth accuracy compared to age-matched controls. This supports the view that cognitive deficits hinder the mental buildup of the stimulus pattern represented as a geometrical form. Vestibular hypofunction negatively affected spatial memory and pointing performance in the azimuth plane. The most severe spatial impairments (angular deviation, figure frame configuration) were found in patients with combined cognitive and vestibular deficits.

Comparison of Various Smoothness Metrics for Upper Limb Movements in Middle-Aged Healthy Subjects.

BACKGOUND: Metrics for movement smoothness include the number of zero-crossings on the acceleration profile (N0C), the log dimensionless jerk (LDLJ), the normalized averaged rectified jerk (NARJ) and the spectral arc length (SPARC). Sensitivity to the handedness and movement type of these four metrics was compared and correlations with other kinematic parameters were explored in healthy subjects. METHODS: Thirty-two healthy participants underwent 3D upper limb motion analysis during two sets of pointing movements on each side. They performed forward- and backward-pointing movements at a self-selected speed to a target located ahead at shoulder height and at 90% arm length, with and without a three-second pause between forward and backward movements. Kinematics were collected, and smoothness metrics were computed. RESULTS: LDLJ, NARJ and N0C found backward movements to be smoother, while SPARC found the opposite. Inter- and intra-subject coefficients of variation were lowest for SPARC. LDLJ, NARJ and N0C were correlated with each other and with movement time, unlike SPARC. CONCLUSION: There are major differences between smoothness metrics measured in the temporal domain (N0C, LDLJ, NARJ), which depend on movement time, and those measured in the frequency domain, the SPARC, which gave results opposite to the other metrics when comparing backward and forward movements.

Route effects in city-based survey knowledge estimates.

When studying wayfinding in urban environments, researchers are often interested in obtaining measures of participants' survey knowledge, i.e., their estimate of distant locations relative to other places. Previous work showed that distance estimations are consistently biased when no direct route is available to the queried target or when participants follow a detour. Here we investigated whether a corresponding bias is manifested in two other popular measures of survey knowledge: a pointing task and a sketchmapping task. The aim of this study was to investigate whether there is a systematic bias in pointing/sketchmapping performance associated with the preferred route choice in an applied urban setting. The results were mixed. We found moderate evidence for the presence of a systematic bias, but only for a subset of urban locations. When two plausible routes to the target were available, survey knowledge estimates were significantly biased in the direction of the route chosen by the participant. When only one plausible route was available, we did not find a statistically significant pattern. The results may have methodological implications for spatial cognition studies in applied urban settings that might be obtaining systematically biased survey knowledge estimates at some urban locations. Researchers should be aware that the choice of urban locations from which pointing and sketchmapping are performed might systematically distort the results, in particular when two plausible but diverging routes to the target are visible from the location.

Different approaches to test orientation of self in space: comparison of a 2D pen-and-paper test and a 3D real-world pointing task.

Spatial orientation is based on a complex cortical network with input from multiple sensory systems. It is affected by training, sex and age as well as cultural and psychological factors, resulting in different individual skill levels in healthy subjects. Various neurological disorders can lead to different patterns or specific deficits of spatial orientation and navigation. Accordingly, numerous tests have been proposed to assess these abilities. Here, we compare the results of (1) a validated questionnaire-based self-estimate of orientation/navigation ability (Santa Barbara Sense of Direction Scale, SBSODS) and (2) a validated pen-and-paper two-dimensional perspective test (Perspective Taking Spatial Orientation Test, SOT) with (3) a newly developed test of finger-arm pointing performance in a 3D real-world (3D-RWPT) paradigm using a recently established pointing device. A heterogeneous group of 121 participants (mean age 56.5 ± 17.7 years, 52 females), including 16 healthy volunteers and 105 patients with different vestibular, ocular motor and degenerative brain disorders, was included in this study. A high correlation was found between 2D perspective task and 3D pointing along the horizontal (azimuth) but not along the vertical (polar) plane. Self-estimated navigation ability (SBSODS) could not reliably predict actual performance in either 2D- or 3D-tests. Clinical assessment of spatial orientation and memory should therefore include measurements of actual performance, based on a 2D pen-and-paper test or a 3D pointing task, rather than memory-based questionnaires, since solely relying on the patient's history of self-estimated navigation ability results in misjudgments. The 3D finger-arm pointing test (3D-RWPT) reveals additional information on vertical (polar) spatial performance which goes undetected in conventional 2D pen-and-paper tests. Diseases or age-specific changes of spatial orientation in the vertical plane should not be clinically neglected. The major aim of this pilot study was to compare the practicability and capability of the three tests but not yet to prove their use for differential diagnosis. The next step will be to establish a suitable clinical bedside test for spatial memory and orientation.

Power Spectrum of Acceleration and Angular Velocity Signals as Indicators of Muscle Fatigue during Upper Limb Low-Load Repetitive Tasks.

Muscle fatigue is a risk factor for developing musculoskeletal disorders during low-load repetitive tasks. The objective of this study was to assess the effect of muscle fatigue on power spectrum changes of upper limb and trunk acceleration and angular velocity during a repetitive pointing task (RPT) and a work task. Twenty-four participants equipped with 11 inertial measurement units, that include acceleration and gyroscope sensors, performed a tea bag filling work task before and immediately after a fatiguing RPT. During the RPT, the power spectrum of acceleration and angular velocity increased in the movement and in 6-12 Hz frequency bands for sensors positioned on the head, sternum, and pelvis. Alternatively, for the sensor positioned on the hand, the power spectrum of acceleration and angular velocity decreased in the movement frequency band. During the work task, following the performance of the fatiguing RPT, the power spectrum of acceleration and angular velocity increased in the movement frequency band for sensors positioned on the head, sternum, pelvis, and arm. Interestingly, for both the RPT and work task, Cohens' d effect sizes were systematically larger for results extracted from angular velocity than acceleration. Although fatigue-related changes were task-specific between the RPT and the work task, fatigue systematically increased the power spectrum in the movement frequency band for the head, sternum, pelvis, which highlights the relevance of this indicator for assessing fatigue. Angular velocity may be more efficient to assess fatigue than acceleration. The use of low cost, wearable, and uncalibrated sensors, such as acceleration and gyroscope, in industrial settings is promising to assess muscle fatigue in workers assigned to upper limb repetitive tasks.

Developmental Changes in the Magnitude of Representational Momentum Among Nursery School Children: A Longitudinal Study.

Representational momentum (RM) is a well-known phenomenon that occurs when a moving object vanishes suddenly and the memory of its final or vanishing position is displaced forward in the direction of its motion. Many studies have shown evidence of various perceptual and cognitive characteristics of RM in various daily aspects, sports, development, and aging. Here we examined the longitudinal developmental changes in the displacement magnitudes of RM among younger (5-year-old) and older (6-year-old) nursery school children for pointing and judging tasks. In our experiments, the children were asked to point at by their finger (pointing task) and judge the spatial location (judging task) of the vanishing point of a moving stimulus. Our results showed that the mean magnitudes of RM significantly decreased from 5- to 6-year-old children for the pointing and judging tasks, although the mean magnitude of RM was significantly greater in the 5-year-old children for the pointing task but not for the judging task. We further examined the developmental changes in RM for a wide range of ages based on data from the present study (5-year-old children) and our previous study (7- and 11-year-old children and 22-year-old adults). This ad hoc examination showed that the magnitude of RM was significantly greater in 5-year-old children than in adults for the pointing and judging tasks. Our findings suggest that the magnitude of RM was significantly greater in young children than in adults and significantly decreased in young children through adults for the pointing and judging tasks.

Virtual navigation in healthy aging: Activation during learning and deactivation during retrieval predicts successful memory for spatial locations.

Spatial navigation and spatial memory are two important skills for independent living, and are known to be compromised with age. Here, we investigate the neural correlates of successful spatial memory in healthy older adults in order to learn more about the neural underpinnings of maintenance of navigation skill into old age. Healthy older adults watched a video shot by a person navigating a route and were asked to remember objects along the route and then attempted to remember object locations by virtually pointing to the location of hidden objects from several locations along the route. Brain activity during watching and pointing was recorded with functional MRI. Larger activations in temporal and frontal regions during watching, and larger deactivations in superior parietal cortex and intraparietal sulcus during pointing, were associated with smaller location errors. These findings suggest that larger evoked responses during learning of spatial information coupled with larger deactivation of canonical spatial memory regions at retrieval are important for effective spatial memory in late life.

Different strategies in pointing tasks and their impact on clinical bedside tests of spatial orientation.

Deficits in spatial memory, orientation, and navigation are often early or neglected signs of degenerative and vestibular neurological disorders. A simple and reliable bedside test of these functions would be extremely relevant for diagnostic routine. Pointing at targets in the 3D environment is a basic well-trained common sensorimotor ability that provides a suitable measure. We here describe a smartphone-based pointing device using the built-in inertial sensors for analysis of pointing performance in azimuth and polar spatial coordinates. Interpretation of the vectors measured in this way is not trivial, since the individuals tested may use at least two different strategies: first, they may perform the task in an egocentric eye-based reference system by aligning the fingertip with the target retinotopically or second, by aligning the stretched arm and the index finger with the visual line of sight in allocentric world-based coordinates similar to using a rifle. The two strategies result in considerable differences of target coordinates. A pilot test with a further developed design of the device and an app for a standardized bedside utilization in five healthy volunteers revealed an overall mean deviation of less than 5° between the measured and the true coordinates. Future investigations of neurological patients comparing their performance before and after changes in body position (chair rotation) may allow differentiation of distinct orientational deficits in peripheral (vestibulopathy) or central (hippocampal or cortical) disorders.

Evidence of movement variability patterns during a repetitive pointing task until exhaustion.

Human movement is characterized by its variability: the same task is never performed twice in exactly the same way. This variability is believed to play a functional role in movement performance and adaptability, as well as in preventing musculoskeletal damage. This article focuses on the time-evolution of movement variability throughout a repetitive pointing task until exhaustion. The kinematics of 13 subjects performing the pointing task is analyzed. Principal Component Analysis of joint angles identifies joint coordinations for each pointing cycle, and cycle-by-cycle comparison highlights movement variability. Non-supervised clustering reveals that subjects adopt successive coordination patterns at an intra-individual level. Inter-individual variability is characterized by the number and type of such patterns: from 3 to 5 patterns, mobilizing the trunk, the shoulder and the upper limbs differently. Movement variability exists even in a seemingly basic and constrained task. It appears in the very early stages of fatigue onset, and may correspond to adaptative coordination responses throughout task performance. This observation should encourage workstation designers to better account for movement variability in order to preserve operators' health and safety.

Evaluation of Child-Computer Interaction Using Fitts' Law: A Comparison between a Standard Computer Mouse and a Head Mouse.

This study evaluates and compares the suitability for child-computer interaction (CCI, the branch within human-computer interaction focused on interactive computer systems for children) of two devices: a standard computer mouse and the ENLAZA interface, a head mouse that measures the user's head posture using an inertial sensor. A multidirectional pointing task was used to assess the motor performance and the users' ability to learn such a task. The evaluation was based on the interpretation of the metrics derived from Fitts' law. Ten children aged between 6 and 8 participated in this study. Participants performed a series of pre- and post-training tests for both input devices. After the experiments, data were analyzed and statistically compared. The results show that Fitts' law can be used to detect changes in the learning process and assess the level of psychomotor development (by comparing the performance of adults and children). In addition, meaningful differences between the fine motor control (hand) and the gross motor control (head) were found by comparing the results of the interaction using the two devices. These findings suggest that Fitts' law metrics offer a reliable and objective way of measuring the progress of physical training or therapy.

Persistence of Mental Fatigue on Motor Control.

The effects of mental fatigue on both cognitive and physical performance are well described in the literature, but the recovery aspects of mental fatigue have been less investigated. The present study aimed to fill this gap by examining the persistence of mental fatigue on behavior and electrophysiological mechanisms. Fifteen participants performed an arm-pointing task consisting of reaching a target as fast as possible, before carrying out a 32-min cognitively demanding task [Time Load Dual Back (TLDB) task], and immediately, 10 and 20 min after completion of the TLDB task. During the experiment, electroencephalography was continuously recorded. The significant increase in mental fatigue feeling after the TLDB task was followed by a decrease during the 20 min of recovery without returning to premeasurement values. Brain oscillations recorded at rest during the recovery period showed an increase in both theta and alpha power over time, suggesting a persistence of mental fatigue. Arm-pointing movement duration increased gradually over time during the recovery period, indicating that behavioral performance remained impaired 20 min after the end of the cognitively demanding task. To conclude, subjective measurements indicated a partial recovery of mental fatigue following a cognitively demanding task, whereas electrophysiological and behavioral markers suggested that the effects of mental fatigue persisted for at least 20 min. While the subjective evaluation of mental fatigue is a very practical way to attest the presence of mental fatigue, electrophysiological and behavioral measures seem more relevant to evaluate the time course of mental fatigue effects.

Temporal Discrimination Thresholds and Proprioceptive Performance: Impact of Age and Nerve Conduction.

BACKGROUND: Increasing attention is payed to the contribution of somatosensory processing in motor control. In particular, temporal somatosensory discrimination has been found to be altered differentially in common movement disorders. To date, there have only been speculations as to how impaired temporal discrimination and clinical motor signs may relate to each other. Prior to disentangling this relationship, potential confounders of temporal discrimination, in particular age and peripheral nerve conduction, should be assessed, and a quantifiable measure of proprioceptive performance should be established. OBJECTIVE: To assess the influence of age and polyneuropathy (PNP) on somatosensory temporal discrimination threshold (STDT), temporal discrimination movement threshold (TDMT), and behavioral measures of proprioception of upper and lower limbs. METHODS: STDT and TDMT were assessed in 79 subjects (54 healthy, 25 with PNP; age 30-79 years). STDT was tested with surface electrodes over the thenar or dorsal foot region. TDMT was probed with needle electrodes in flexor carpi radialis (FCR) and tibialis anterior (TA) muscle. Goniometer-based devices were used to assess limb proprioception during (i) active pointing to LED markers, (ii) active movements in response to variable visual cues, and (iii) estimation of limb position following passive movements. Pointing (or estimation) error was taken as a measure of proprioceptive performance. RESULTS: In healthy subjects, higher age was associated with higher STDT and TDMT at upper and lower extremities, while age did not correlate with proprioceptive performance. Patients with PNP showed higher STDT and TDMT values and decreased proprioceptive performance in active pointing tasks compared to matched healthy subjects. As an additional finding, there was a significant correlation between performance in active pointing tasks and temporal discrimination thresholds. CONCLUSION: Given their notable impact on measures of temporal discrimination, age and peripheral nerve conduction need to be accounted for if STDT and TDMT are applied in patients with movement disorders. As a side observation, the correlation between measures of proprioception and temporal discrimination may prompt further studies on the presumptive link between these two domains.

Consecutive postural adjustments (CPAs): A kinetic analysis of variable velocity during a pointing task.

AIM: This paper examines the postural adjustments that occur after the end of a voluntary movement (consecutive postural adjustments, CPAs). Its aim is to reinforce the theory that CPAs are necessary to counterbalance the destabilizing effect of a voluntary movement. In addition, we compared the main features of CPAs with those of anticipatory postural adjustments (APAs) in order to gather evidence that could afford new insights into postural programming. METHODS: Nine healthy adults were invited to adopt a sitting position to perform nine pointing movements at decreasing velocities. The antero-posterior component of the reaction forces was measured. Upper limb kinematics were recorded and the kinetics calculated. The main features under study included linear impulses, peak amplitudes and duration of CPAs and APAs. RESULTS: Two main results emerged from our study: the impulse produced after the end of a focal movement (CPAIx) was negative, while the impulse produced before its end (*ASPIx) was positive; their absolute values were not significantly different; when movement velocity increased, CPA impulse and peak amplitude (pCPA) increased significantly, contrary to duration (dCPA). Furthermore, APA impulse, peak amplitude and duration were all increased. CONCLUSIONS: These findings on pointing movements strengthen the hypothesis that CPAs play a role of body stabilization and that the postural chain kinetics is programmed according to focal movement velocity. Evidence on CPA obtained from healthy subjects may contribute to the further specification of the differences associated with motor impairment.

Map Learning in Normal Aging: The Role of Individual Visuo-Spatial Abilities and Implications.

OBJECTIVE: The present study analyzes the age-related differences in map learning between young and normally-aging young-old and old-old adults in relation to individual visuo-spatial factors to specify which aspects of spatial learning are susceptible to aging. METHODS: Forty young, 40 young-old and 40 old-old participants performed a series of tasks to assess their visuo-spatial working memory (VSWM) and visuo-spatial (rotation) abilities, then they studied a map. To test their recall, they graphically reproduced the map in a freehand drawing, then performed a sketch map task (which involved placing a list of landmarks on a blank layout of the map) and a pointing task (adopting aligned and counter-aligned imaginary positions). RESULTS: The results showed that age-related differences depend on the type of recall task performed: in the pointing and freehand map-drawing tasks, the young-old and old-old performed worse than the young adults; but in the sketch map task, the young-old performed as well as the young adults and only the old-old's performance was worse than that of the other two age groups. Concerning the role of individual factors, VSWM and rotation abilities were found strongly involved in the pointing task (especially for counter-aligned pointing) and the freehand map-drawing task. CONCLUSION: Overall, these results suggest that different factors related to spatial (map) learning explain age-related differences in normal aging. The implications of the present results in normal and pathological aging, and for the purposes of clinical assessments and interventions, are discussed.

Development of a version of the self-ordered pointing task: a working memory task for Brazilian preschoolers.

OBJECTIVE: Working memory is a fundamental cognitive function and is predictive of outcomes and achievement in a wide range of domains from an early age. The focus of this study was to develop a computerized Brazilian version of the Self-Ordered Pointing Task (SOPT) for preschoolers and to provide initial normative and validation data for this task. METHODS: The sample of the present study was composed of 248 children aged 3 (n = 41), 4 (n = 88) and 5 (n = 119) years from 13 private and public schools in Belo Horizonte. Children were evaluated with the SOPT and the Columbia Mental Maturity Scale (CMMS), a measure of intelligence, and their parents completed the Brazilian Criterion of Economic Classification (CCEB) to assess their SES. A subsample of parents of 184 children also filled the Child Behavior Checklist for Ages 11/2-5 years (CBCL 11/2-5), a measure of psychopathology. RESULTS: A multiple regression analysis found chronological age, intelligence, and SES to be predictive of performance on the SOPT. Furthermore, five-year olds performed better than three- and four-year olds in the task. A difference between children in private and public kindergartens also emerged. Additionally, SOPT performance was negatively correlated with Internalizing, Externalizing, and Total psychopathological problems, as well as to several other psychopathological measures as accessed by the CBCL, although the correlations were small. CONCLUSION: Taken together, this study provides initial normative and validation data for the SOPT, but further validation studies are needed.

Rewarding feedback promotes motor skill consolidation via striatal activity.

Knowledge of performance can activate the striatum, a key region of the reward system and highly relevant for motivated behavior. Using functional magnetic resonance imaging, striatal activity linked to knowledge of performance was measured during the training of a repetitive arc-tracking task. Knowledge of performance was given after a random selection of trials or after good performance. The third group received knowledge of performance after good performance plus a monetary reward. Skill learning was measured from pre- to post- (acquisition) and from post- to 24h posttraining (consolidation). Our results demonstrate an influence of feedback on motor skill learning. Adding a monetary reward after good performance leads to better consolidation and higher ventral striatal activation than knowledge of performance alone. In turn, rewarding strategies that increase ventral striatal response during training of a motor skill may be utilized to improve skill consolidation.

Designing for physically disabled users: benefits from human motion capture - a case study.

PURPOSE: The present study aimed to improve the design of an interface that may help disabled children to play a musical instrument. The main point is to integrate human motion capture in the design process. METHOD: The participant performed 20 pointing movements toward four selected locations. A three one-way analysis of variance (ANOVA) was performed in order to determine the most efficient input location. For each button position, we compared (1) the reaction time (RT), (2) the movement time (MT), and (3) the spatial variability of the movements. RESULTS: According to the results obtained for RT and MT, one position was the most efficient button location in order to produce efficient movements. CONCLUSIONS: As the case study showed, combining the 3D motion capture system and the statistical analysis led to help the designers their design methodology and crucial choices. Implications for Rehabilitation The paper point out the possibility for designers to use motion capture science to improve the efficiency of the personal interface manipulation to play musical instrument. This experiment with the disabled user allows researcher not only to propose standard procedure to characterize an interface but also to take into account the complete behaviour of the user: from the decision of the movement to the execution of the action. The discussion and the experiment with the disabled user help him to better understand its own difficulties. This kind of experimental procedure helps a lot the user in his future rehabilitation choices and decisions.

Limb Dominance and Its Effects on the Benefits of Intralimb Transfer of Learning: A Visuomotor Aiming Task.

Research has attempted to address what characteristics benefit from transfer of learning; however, it is still unclear which characteristics are effector dependent or independent. Furthermore, it is not clear if intralimb transfer shows, similarly to interlimb transfer, an asymmetry of benefits between the upper limbs. The purpose of the current study is to examine if effector independence effects emerge, as observed in interlimb transfer studies, when transfer to new effector group within the same limb occurs, and whether the pattern of intralimb transfer benefits differ between the limbs. Our results suggest that a visuomotor task transfers within both limbs, even though the transfer benefits within the limbs seem to differ. This was supported by more transfer occurring in the dominant limb than the nondominant limb. Potential control mechanisms used for intralimb transfer are discussed.

Effect of mental fatigue on speed-accuracy trade-off.

The aim of this study was to investigate the effects of mental fatigue on the duration of actual and imagined goal-directed arm movements involving speed-accuracy trade-off. Ten participants performed actual and imagined point-to-point arm movements as accurately and as fast as possible, before and after a 90-min sustained cognitive task inducing mental fatigue, and before and after viewing a neutral control task (documentary movie) that did not induce mental fatigue. Target width and center-to-center target distance were varied, resulting in five different indexes of difficulty. Prior to mental fatigue, actual and imagined movement duration increased with the difficulty of the task, as predicted by Fitts' law. Mental fatigue task induced a 4.1±0.7% increase in actual movement duration and a 9.6±1.1% increase in imagined movement duration, independently of the index of difficulty. The trial-by-trial evolution of actual and imagined movement duration remained stable with mental fatigue. The control task did not induce any change in actual and imagined movement duration. The results suggested that movement was slowed in the presence of mental fatigue, maybe due to proactive changes occurring during the preparatory state of the movement, to preserve task success.

Language development at 18 months is related to multimodal communicative strategies at 12 months.

The present study investigated the degree to which an infants' use of simultaneous gesture-speech combinations during controlled social interactions predicts later language development. Nineteen infants participated in a declarative pointing task involving three different social conditions: two experimental conditions (a) available, when the adult was visually attending to the infant but did not attend to the object of reference jointly with the child, and (b) unavailable, when the adult was not visually attending to neither the infant nor the object; and (c) a baseline condition, when the adult jointly engaged with the infant's object of reference. At 12 months of age measures related to infants' speech-only productions, pointing-only gestures, and simultaneous pointing-speech combinations were obtained in each of the three social conditions. Each child's lexical and grammatical output was assessed at 18 months of age through parental report. Results revealed a significant interaction between social condition and type of communicative production. Specifically, only simultaneous pointing-speech combinations increased in frequency during the available condition compared to baseline, while no differences were found for speech-only and pointing-only productions. Moreover, simultaneous pointing-speech combinations in the available condition at 12 months positively correlated with lexical and grammatical development at 18 months of age. The ability to selectively use this multimodal communicative strategy to engage the adult in joint attention by drawing his attention toward an unseen event or object reveals 12-month-olds' clear understanding of referential cues that are relevant for language development. This strategy to successfully initiate and maintain joint attention is related to language development as it increases learning opportunities from social interactions.