A clinical guide to assessment of navigation impairment: Standardized subjective and objective instruments and normative data.

OBJECTIVE: Problems with finding one's way around are frequently reported by neurological patients. However, no dedicated standardized tools exist to assess whether such reports indicate navigation impairment or not. We provide a standardized three-step method to assess navigation ability in neurological patients, based on two recently developed diagnostic tools and normative data. The objective of this method is to assess navigation ability in detail, to allow for appropriate rehabilitation training for navigation impairment. METHOD: A population-based sample of 7150 Dutch individuals (age 18-89) filled out the Wayfinding Questionnaire (WQ), to assess their self-reported navigation ability and level of spatial anxiety. Additionally, the participants completed the Leiden Navigation Test (LNT), a brief digital test consisting of five subtasks, assessing distinct domains of navigation ability. Both the WQ and LNT can be found online, free of charge. RESULTS: Normative data stratified by gender and age are reported for each of the three subscales of the WQ, and for each of the five subtasks of the LNT. CONCLUSIONS: Based on performance data of a very large population-based sample of participants, navigation performance of neurological patients with specific navigation complaints can be assessed in three steps. First, we recommend to inquire about potential problems concerning navigation. Next, in case of navigation complaints, the extent of potential navigation impairment can first be measured with the WQ. Lastly, if impaired scores are found, the LNT can provide objective verification of the perceived impairment, as well as insight into which navigation domains are affected. Such insight will allow for prediction of the practical consequences of the impairment and can be used for informed and tailored rehabilitation.

Infant walking experience is related to the development of selective attention.

Previous studies have shown that the way in which infants perceive and explore the world changes as they transition from crawling to walking. Infant walking onset generally precedes advances in cognitive development such as accelerated language growth. However, the underlying mechanism explaining this association between walking experience and cognition is largely unknown. Selective attention is a key factor underlying learning across multiple domains. We propose that the altered visual input that infants obtain as they transition to walking relates to selective attention development and that advances in selective attention may potentially explain previously reported advances in other cognitive domains. As a first step in testing this hypothesis, we investigated how walking experience relates to selective attention. In Study 1, performance of 14-month-old crawlers, novice walkers, and expert walkers was compared on a visual search eye-tracking task (N = 47), including feature and conjunction (effortful) items. Walkers outperformed crawlers on the task in general, and effortful search was enhanced in expert walkers as compared with novice walkers, after controlling for crawling onset and general developmental differences occurring before walking onset. In Study 2, earlier walking onset was related to better visual search performance in 2-year-olds (N = 913). The association appeared to be due to the difference between the 10% latest walkers and the early/average walkers. Taken together, the results of these studies show that walking experience relates to advances in selective attention. This association shows a specific timing in development; it is mainly seen relatively close to the age of walking onset.

Spatial navigation performance in people with multiple sclerosis-a large-scale online study.

OBJECTIVE: Spatial navigation has a crucial function in daily life activities, and is therefore strongly linked to quality of life, autonomy, and mobility. Navigation has been shown to be frequently impaired after forms of acquired brain injury, but the impact of MS on navigation ability has yet to be studied. A better understanding of potential navigation problems in this population could improve patient care. Therefore the aim of the current study was to measure objective and subjective navigation performance in people with MS. METHODS: Performance of a large sample of people with MS (N = 359) was compared to a group of matched controls. Additionally, the impact of ambulation and self-reported cognitive performance was studied within the MS sample. Participants filled out the Wayfinding Questionnaire, the patient-reported Expanded Disability Status Scale and the Multiple Sclerosis Neuropsychological Screening Questionnaire for self-report measures. Objective navigation performance was measured with an online navigation test using a virtual environment. RESULTS: Results indicate a lower subjective as well as objective performance in people with MS compared to healthy controls, and a substantial contribution of self-reported cognitive performance on navigation ability. CONCLUSIONS: These findings indicate that spatial navigation can be a significant problem in people with MS, especially in people with MS with other cognitive impairments.

Short Digital Spatial Memory Test Detects Impairment in Alzheimer's Disease and Mild Cognitive Impairment.

BACKGROUND: Impairment in navigation abilities and object location memory are often seen in early-stage Alzheimer's Disease (AD), yet these constructs are not included in standard neuropsychological assessment. We investigated the differential ability of a short digital spatial memory test in mild AD dementia and mild cognitive impairment (MCI). METHODS: 21 patients with AD dementia (66.9 ± 6.9; 47% female), 22 patients with MCI (69.6 ± 8.3; 46% female) and 21 patients with subjective cognitive decline (SCD) (62.2 ± 8.9; 48% female) from the Amsterdam Dementia Cohort performed the Object Location Memory Test (OLMT), consisting of a visual perception and memory trial, and the Virtual Tübingen (VT) test, consisting of a scene recognition, route continuation, route ordering and distance comparison task. The correlations with other cognitive domains were examined. RESULTS: Patients with mild AD dementia (Z: -2.51 ± 1.15) and MCI (Z: -1.81 ± 0.92) performed worse than participants with SCD (Z: 0.0 ± 1.0) on the OLMT. Scene recognition and route continuation were equally impaired in patients with AD dementia (Z: -1.14 ± 0.73; Z: -1.44 ± 1.13) and MCI (Z: -1.37 ± 1.25; Z: -1.21 ± 1.07). Route ordering was only impaired in patients with MCI (Z: -0.82 ± 0.78). Weak to moderate correlations were found between route continuation and memory (r(64) = 0.40, p < 0.01), and between route ordering and attention (r(64) = 0.33, p < 0.01), but not for the OLMT. CONCLUSION: A short digital spatial memory test battery was able to detect object location memory and navigation impairment in patients with mild AD dementia and MCI, highlighting the value of incorporating such a test battery in standard neuropsychological assessment.

The Influence of Stimuli Valence and Arousal on Spatio-Temporal Representation of a Route.

This study assesses the influence of valence and arousal of element/landmarks along a route on the spatio-temporal representation of the route itself. Participants watched a movie of a virtual route containing landmarks with high arousal and positive (HP) or negative valence (HN), or landmarks with low arousal and positive (LP) or negative valence (LN). Afterwards, they had to (a) imagine walking distances between landmarks, (b) indicate the position of the landmarks along the route, (c) judge the spatial and temporal length of the route, and (d) draw the route. Results showed that the tasks were differentially influenced by the valence and arousal levels. Specifically, participants were more accurate in representing distances between positive, rather than negative, landmarks and in localizing positive high arousing landmarks. Moreover, the high arousing landmarks improved performance at the route drawing task. Finally, participants in the negative and low arousing conditions judged the route as being metrically and temporally longer than participants in positive and high arousing conditions. These results are interpreted in the light of theories about the effects of emotions on memory processes and the "feelings-as-information" theory. In brief, the results support the idea that representations of a route reflect a combination of cognitive and emotional processes.

Quality of self-reported cognition: effects of age and gender on spatial navigation self-reports.

Subjective measures of cognitive abilities are often used in various environments, such as clinical, experimental, and professional settings. Here, we assess the quality of such measures, specifically looking into the impact of age and gender. Spatial navigation ability will be used as an exemplary case, given its large individual variation and relevance to the healthy aging process. With a navigation experiment and a self-report questionnaire, the objective and subjective navigation performance of 7150 participants (age 18-89 years) was measured. Results showed the participants provided informative estimates of their cognitive performance. However, strong systematic biases were present related to age and gender. Overestimation increased with increasing age. Overestimation was also found for males, whereas underestimation was found for females. Consideration of such biases is recommended when implementing self-report measures of cognition and considering the potential impact these biases may have on cognitive functioning itself.

Healthcare Professionals' Acceptance of Digital Cognitive Rehabilitation.

With technological possibilities in healthcare steadily increasing, more tools for digital cognitive rehabilitation become available. Acceptance of such technological advances is crucial for successful implementation. Therefore, we examined technology acceptance specifically for this form of rehabilitation in a sample of healthcare providers involved in cognitive rehabilitation. An adjusted version of the Technology Acceptance Model (TAM) questionnaire was used, including the subscales for perceived usefulness, perceived ease of use, subjective norm (toward use), and intention to use, which all contribute to actual use of a specific technology. Results indicate a generally favorable attitude toward the use of digital cognitive rehabilitation and positive responses toward the TAM constructs. Only for subjective norm, a neutral mean response was found, indicating that this could pose a potential obstacle toward implementation. Potential differences between subgroups of different age, gender, and professional background were assessed. Age and gender did not affect the attitude toward digital cognitive rehabilitation. Occupational therapists showed lower scores than healthcare psychologists and physiatrists with regard to perceived usefulness, possibly linked to a difference in operational and managerial tasks. The findings of his study stimulate further implementation of digital cognitive rehabilitation, where the role of subjective norms should be specifically considered.

The Effectiveness of Home-Based Training Software Designed to Influence Strategic Navigation Preferences in Healthy Subjects.

One approach to the rehabilitation of navigation impairments is to train the use of compensatory egocentric or allocentric navigation strategies. Yet, it is unknown whether and to what degree training programs can influence strategic navigation preferences. In validating this approach, the key assumption that strategic preference can be changed by using a navigation training was assessed in a group of healthy participants (n = 82). The training program consisted of a psychoeducation session and a software package that included either allocentric or egocentric navigation exercises in virtual environments. Strategic navigation preference, objective and self-reported spatial abilities were assessed in pre- and post-training sessions. Based on their pre-training strategic preference, participants received either the egocentric training (n = 19) or the allocentric training (n = 21) version of the training. These participants engaged in four training sessions over a period of 2-3 weeks. The second group of participants did not use the training software (n = 43) and served as a control group. The results show that 50% of participants that received the egocentric training shifted from an allocentric to and an egocentric strategic preference. The proportion of participants that switched their strategic preference as a result of the allocentric training was identical to this proportion in the control group (19%). The training did not affect objective and self-reported navigation abilities as measured in the pre- and post-training sessions. We conclude that strategic navigation preferences can be influenced by using home-based training in healthy participants. However, using the current approach, only a preference shift from an allocentric to an egocentric navigation strategy could be achieved. The effectiveness of this navigation strategy training should next be assessed in relevant patient populations.

Cognitive processing of spatial relations in Euclidean diagrams.

The cognitive processing of spatial relations in Euclidean diagrams is central to the diagram-based geometric practice of Euclid's Elements. In this study, we investigate this processing through two dichotomies among spatial relations-metric vs topological and exact vs co-exact-introduced by Manders in his seminal epistemological analysis of Euclid's geometric practice. To this end, we carried out a two-part experiment where participants were asked to judge spatial relations in Euclidean diagrams in a visual half field task design. In the first part, we tested whether the processing of metric vs topological relations yielded the same hemispheric specialization as the processing of coordinate vs categorical relations. In the second part, we investigated the specific performance patterns for the processing of five pairs of exact/co-exact relations, where stimuli for the co-exact relations were divided into three categories depending on their distance from the exact case. Regarding the processing of metric vs topological relations, hemispheric differences were found for only a few of the stimuli used, which may indicate that other processing mechanisms might be at play. Regarding the processing of exact vs co-exact relations, results show that the level of agreement among participants in judging co-exact relations decreases with the distance from the exact case, and this for the five pairs of exact/co-exact relations tested. The philosophical implications of these empirical findings for the epistemological analysis of Euclid's diagram-based geometric practice are spelled out and discussed.

Large-scale assessment of human navigation ability across the lifespan.

Navigation ability is particularly sensitive to aging. Evidence of aging patterns is largely restricted to comparing young adults and elderly and limited in the variety of navigation tasks used. Therefore, we designed a novel task battery to assess navigation ability in a very large, representative sample (N = 11,887, 8-100 years). The main aim was to measure navigation ability across the lifespan in a brief, yet comprehensive manner. Tasks included landmark knowledge, egocentric and allocentric location knowledge, and path knowledge for a route and survey perspective. Additionally, factors that potentially contribute to navigation ability were considered; gender, spatial experience and spatial anxiety. Increase in performance with age in children was found for allocentric location knowledge and for route-based path knowledge. Age related decline was found for all five tasks, each with clearly discernible aging patterns, substantiated the claim that each task distinctively contributes to the assessment of navigation ability. This study provides an in depth examination of navigation ability across dissociable functional domains and describes cognitive changes across the lifespan. The outcome supports the use of this task battery for brief assessment of navigation for experimental and clinical purposes.

How age relates to spatial navigation performance: Functional and methodological considerations.

Aging effects have often been reported for spatial navigation performance. Moreover, navigation performance is thought to be an early marker of pathological aging. Yet, the cognitive complexity of navigation and large individual variation in healthy population make it difficult to pinpoint the precise aging mechanisms involved. We performed a systematic literature review with specific attention to functional dissociation between the tasks used and methodological characteristics. The literature search resulted in 39 articles in which age comparisons were made for large-scale navigation measures. Outcomes were categorized into the domains of landmark, location (egocentric and allocentric), and path knowledge (route and survey). Results indicate that clear functional dissociation exists between these navigation knowledge domains. Aging effects are found for path knowledge most convincingly, while landmark and egocentric location knowledge are frequently omitted in assessment. The participant samples reported often neglect adult, middle aged participants, while this group could be highly informative to the aging process as well. Moreover, having a clear image of age-related performance across the lifespan could be a valuable addition towards the early detection of pathological aging through navigation performance.

The Effect of Stereoscopic Augmented Reality Visualization on Learning Anatomy and the Modifying Effect of Visual-Spatial Abilities: A Double-Center Randomized Controlled Trial.

Monoscopically projected three-dimensional (3D) visualization technology may have significant disadvantages for students with lower visual-spatial abilities despite its overall effectiveness in teaching anatomy. Previous research suggests that stereopsis may facilitate a better comprehension of anatomical knowledge. This study evaluated the educational effectiveness of stereoscopic augmented reality (AR) visualization and the modifying effect of visual-spatial abilities on learning. In a double-center randomized controlled trial, first- and second-year (bio)medical undergraduates studied lower limb anatomy with stereoscopic 3D AR model (n = 20), monoscopic 3D desktop model (n = 20), or two-dimensional (2D) anatomical atlas (n = 18). Visual-spatial abilities were tested with Mental Rotation Test (MRT), Paper Folding Test (PFT), and Mechanical Reasoning (MR) Test. Anatomical knowledge was assessed by the validated 30-item paper posttest. The overall posttest scores in the stereoscopic 3D AR group (47.8%) were similar to those in the monoscopic 3D desktop group (38.5%; P = 0.240) and the 2D anatomical atlas group (50.9%; P = 1.00). When stratified by visual-spatial abilities test scores, students with lower MRT scores achieved higher posttest scores in the stereoscopic 3D AR group (49.2%) as compared to the monoscopic 3D desktop group (33.4%; P = 0.015) and similar to the scores in the 2D group (46.4%; P = 0.99). Participants with higher MRT scores performed equally well in all conditions. It is instrumental to consider an aptitude-treatment interaction caused by visual-spatial abilities when designing research into 3D learning. Further research is needed to identify contributing features and the most effective way of introducing this technology into current educational programs.

Memory-related perceptual illusions directly affect physical activity in humans.

Perceptual illusions help us understand deficits in human perception, but they also have the potential to serve as treatment methods; e.g., to alleviate phantom limb pain. Treatment effects are usually the direct result of a mismatch between false visual feedback and somatosensory/proprioceptive feedback. We aimed to influence physical activity (walking distance) using a memory-related perceptual illusion that relies on a mismatch between a spatially manipulated virtual reality environment and a weakness of memory for a similar, previously experienced environment. Participants' main task was to reproduce a baseline distance three times, by walking on a treadmill while moving through a virtual reality environment. Depending on condition, the environment was either stretched or compressed relative to the previous session, but participants were not informed about these manipulations. Because false, suggestive information can lead to alterations in memory, especially when conveyed through 'rich' forms of media such as virtual reality, we expected each manipulation to alter memory for the previous environment(s) and we hypothesized that this would influence walking distance. The results for the first time showed that memory-related perceptual illusions can directly affect physical activity in humans. The effects we found are substantial; stretching previously experienced virtual environments led participants to almost double their initial walking distance, whereas compressing the environments resulted in about half of the initial distance. Possible clinical applications arising from these findings are discussed.

Memory for novel and familiar environments relies on the hippocampus: A case study on a patient with a right anteromesial temporal lobectomy.

While the hippocampus has been ascribed a prominent role in navigation ability, it is still a subject of debate whether it contributes to learning novel environments only or to remembering familiar environments as well. We attempt to shed light on this issue by reporting on a patient who developed complaints of severe difficulties with navigation after she underwent a right anteromesial temporal lobectomy. A standard neuropsychological assessment revealed only a visuospatial working memory deficit. Clear evidence for problems with novel environments were found on a virtual route learning test. Two real-world tests were used to investigate her ability to recall familiar environments. The first test was based on the area she grew up in (and still visits regularly) and the second test concerned her current place of residence which she never visited prior to the surgery. While her landmark recognition in general was accurate, she showed notable difficulties with indicating their locations on a map and with giving accurate route descriptions between them for both real-world environments. This pattern of findings suggests that the hippocampus is not only important for navigation in novel environments, but also for familiar environments learned long ago.

A Usability Study of a Serious Game in Cognitive Rehabilitation: A Compensatory Navigation Training in Acquired Brain Injury Patients.

Acquired brain injury patients often report navigation impairments. A cognitive rehabilitation therapy has been designed in the form of a serious game. The aim of the serious game is to aid patients in the development of compensatory navigation strategies by providing exercises in 3D virtual environments on their home computers. The objective of this study was to assess the usability of three critical gaming attributes: movement control in 3D virtual environments, instruction modality and feedback timing. Thirty acquired brain injury patients performed three tasks in which objective measures of usability were obtained. Mouse controlled movement was compared to keyboard controlled movement in a navigation task. Text-based instructions were compared to video-based instructions in a knowledge acquisition task. The effect of feedback timing on performance and motivation was examined in a navigation training game. Subjective usability ratings of all design options were assessed using questionnaires. Results showed that mouse controlled interaction in 3D environments is more effective than keyboard controlled interaction. Patients clearly preferred video-based instructions over text-based instructions, even though video-based instructions were not more effective in context of knowledge acquisition and comprehension. No effect of feedback timing was found on performance and motivation in games designed to train navigation abilities. Overall appreciation of the serious game was positive. The results provide valuable insights in the design choices that facilitate the transfer of skills from serious games to real-life situations.

Lateralized pointing does not cause a cognitive bias.

Lateralized pointing has been shown to cause not only a shift in visuo-motor midline, but also a shift in non-lateralized spatial attention. Non-lateralized cognitive consequences of lateralized pointing have been reported for local and global visuospatial processing. Here, we evaluate these findings and examine this effect for categorical and coordinate spatial relation processing, for which the attentional processes are thought to be highly similar to local and global visuospatial processing, respectively. Participants performed a commonly used working memory task to assess categorical and coordinate spatial relation processing. Lateralized pointing with either the left or the right hand, to either the left or the right side was introduced as a manipulation, as well as a new control condition without any pointing. Performance on the spatial relation task was measured before and after pointing. The results suggest that non-lateralized consequences of lateralized pointing cannot be generalized to other cognitive tasks relying on attentional processing. Further examination of lateralized pointing is recommended before drawing further conclusions concerning its impact on non-lateralized cognition.

A systematic investigation of navigation impairment in chronic stroke patients: Evidence for three distinct types.

OBJECTIVE: In a recent systematic review, Claessen and van der Ham (2017) have analyzed the types of navigation impairment in the single-case study literature. Three dissociable types related to landmarks, locations, and paths were identified. This recent model as well as previous models of navigation impairment have never been verified in a systematic manner. The aim of the current study was thus to investigate the prevalence of landmark-based, location-based, and path-based navigation impairment in a large sample of stroke patients. METHOD: Navigation ability of 77 stroke patients in the chronic phase and 60 healthy participants was comprehensively evaluated using the Virtual Tübingen test, which contains twelve subtasks addressing various aspects of knowledge about landmarks, locations, and paths based on a newly learned virtual route. Participants also filled out the Wayfinding Questionnaire to allow for making a distinction between stroke patients with and without significant subjective navigation-related complaints. RESULTS: Analysis of responses on the Wayfinding Questionnaire indicated that 33 of the 77 participating stroke patients had significant navigation-related complaints. An examination of their performance on the Virtual Tübingen test established objective evidence for navigation impairment in 27 patients. Both landmark-based and path-based navigation impairment occurred in isolation, while location-based navigation impairment was only found along with the other two types. CONCLUSIONS: The current study provides the first empirical support for the distinction between landmark-based, location-based, and path-based navigation impairment. Future research relying on other assessment instruments of navigation ability might be helpful to further validate this distinction.

The link between motor and cognitive development in children born preterm and/or with low birth weight: A review of current evidence.

The current review focuses on evidence for a link between early motor development and later cognitive skills in children born preterm or with Low Birth Weight (LBW). Studies with term born children consistently show such a link. Motor and cognitive impairments or delays are often seen in children born preterm or with LBW throughout childhood and studies have established a cross-sectional association between the two. However, it is not yet clear if, and if so, how, motor and cognitive skills are longitudinally interrelated in these children. Longitudinal studies with this population including measures of motor development during the first year of life and cognitive measures at later measurement points were included. The 17 studies included usually show a link between level and/or quality of motor development during the first year of life and later cognitive skills in children born preterm and/or with LBW. However, given the small number of studies, and a possible effect of early interaction between motor and cognitive skills affecting this relation, more work is clearly needed.

Landmark Agnosia: Evaluating the Definition of Landmark-based Navigation Impairment.

OBJECTIVE: Landmark agnosia is a rare type of navigation impairment, for which various definitions have been presented. From a clinical as well as theoretical perspective, consensus on the characteristics of landmark agnosia would be valuable. In the current study we review the literature concerning landmark agnosia and present a new case study. Existing literature highlights the importance of examining familiar as well as novel landmark processing and substantial variation in performance patterns of individual patients. METHOD: We performed a case study with patient KS, a 53-year-old male, suffering from landmark agnosia, making use of elaborate neuropsychological screening and virtual reality-based tests of navigation ability. RESULTS: Our extensive examination of his impairment shows that landmark agnosia can be very narrow; in KS it is restricted to recognition of newly learned landmarks only. Also, he has no trouble recognizing familiar landmarks that are not part of a navigated route. CONCLUSIONS: The literature review shows that the right temporal lobe, and the right hippocampus in particular are the main lesion sites for landmark agnosia. Furthermore, our case study substantiates that this disorder can occur for both familiar and novel landmarks, and can affect novel landmarks in isolation from familiar landmarks. Moreover, it can occur in isolation from problems with processing route information.

Classification of navigation impairment: A systematic review of neuropsychological case studies.

The neurocognitive architecture of navigation ability has been investigated by extensively studying the navigation problems of individual neurological patients. These neuropsychological case reports have applied highly variable approaches to establish navigation impairment in their patients. This review provides a systematic and up-to-date inventory of all relevant case studies and presents an analysis of the types of navigation impairments that have been described. The systematic literature search revealed 58 relevant papers reporting on 67 neurological patients. Close analysis of their patterns of navigation performance suggests three main categories of navigation impairments. These categories are related to three types of representations that are considered highly relevant for accurate navigation: knowledge of landmarks, locations, and paths. The resulting model is intended to serve both clinical and theoretical advances in the study of navigation ability and its neural correlates.