iOS App: HOOK

HOOK App

Hook on iTunes ($0.99, sometimes free)

What it is: A simple, minimalist, puzzle game of sequentially unraveling "hooks". There are 50 levels, with a slight increase in complexity as you move up. The interface is aesthetically pleasing and elegant. There's no time limits, menus, or statistics. If you make a mistake it simply restarts. Higher levels allow 3 mistakes before the level restarts.

For each puzzle you need to find the sequence in which each hook needs to be removed (otherwise they block each other) and then trace the hook back to its starting point where the removal is initiated. Once you initiate removal of a hook, the animation of it drawing in helps visualize the process. As each hook is removed, its entire path disappears. I find this process of solving each level especially rewarding. The next step may still be complex, but it's slightly simplified by previous success.

Screen Shot 1

In Screen Shot 1 you can see a simple level - level 4 (the first level where there is interaction among the hooks; in previous levels you can remove the hooks in any order). You can see the black circle that you press to initiate removal, and the hooks to be removed. You can see where a hook would block another one if it's removed in the wrong sequence (the one that curves upward, if it's removed before the hook whose point is wedged in the curve, would be caught in place).

How we can use it in Tx: The game-play is so simple, there's not much to plan. Just let your client solve the puzzle. I suggest always starting with the first levels because they help train for what to look for, and get a user adjusted to how the controls in the puzzle work (press the dot, watch the hook pulled in towards it).

The levels get more complex gradually, and the complexity is built in very clever ways. First more and more hooks are added so unraveling becomes more complicated. Screen

Screen Shot 2

Shot 2 shows an example of a slightly more complex puzzle level (level 12), where there are 6 hooks, and some are layered. The two hooks with starting points at the farthest to the left part of the puzzle can be removed first. So you can see the problem solving becomes not just more complex, but acquires more steps: you have to figure out which hooks are removable without being blocked by other hooks, and then you have to trace back their origins.

In more advanced levels the origin point also becomes less straightforward: more than one hook might be triggered by the same origin point, and other complexities are introduced as well, such as wireless activation of hooks and hinges that can be rotated to adjust which hook is activated. Screen Shot 3 of level 34 has an example of all of these added complexities: Note that there is only one activation point (the black circle) which is "wireless", and you have to adjust which hook gets activated by rotating the hinges. So the hook removal must still be sequential, and in this level the sequence is relatively simple with only 4 hooks to control, but the problem solving complexity is shifted to which hook is activated.

Screen Shot 3

There are no directions to follow - you learn the game-play as you work the levels. So we get to work on a skill that we rarely get a chance to address directly: the skill of learning. All the while using an elegant interface that clearly favors mature users over childish animation and distractions.

The music is relaxing, but I personally would still prefer to mute it and focus on levels of cuing I need to provide to my client. I would encourage the client to verbalize as much of the problem solving as possible, to better discern the breakdowns so I could provide targeted support for the needed skills, and help build up strategies. Since there are many levels and they go up in complexity gradually, allowing one to build success through practice before new obstacles are introduced, I imagine that - choosing wisely and knowing when to stop - frustration on the part of your client will be kept to a minimum.

Goals we can target in Tx with this app: Attention and memory goals, planning, reasoning, sequencing, problem solving. While I argue that most apps I review have some utility for addressing memory, this one in particular directly addresses learning. Short term/working memory is taxed in the problem solving process: One can trace a hook from its switch to its end and figure out a sequence for solving the puzzle, which as to be mentally manipulated and thereafter retained long enough to follow through. And as one gets better at solving the maximally simple puzzles, the complexity slowly builds, utilizing the strategies developed for earlier levels. Solving these puzzles also heavily depends, obviously, on visuospatial reasoning. As such, any field neglect will hamper one's progress, so cuing can be provided to draw attention to the neglected side.

Some specific examples:

1.  Allow your client to verbalize a solution to a puzzle. E.g., "I would pull in this hook first because nothing is in its way, and then it would also get out of the way of this second hook, and then I can pull that one in". Discuss it a little to build up context and assist with memory encoding & consolidation. Then after a short delay return to the puzzle for your client to implement (or have to re-generate) their solution (retrieval of memory or strategy; capitalizing on procedural memory).

2. Since the switch to pull in the hook and the hook itself are almost always in different visual fields (left/right, up/down) almost any puzzle would require scanning the full field, even the very first levels with just one or two hooks with no interactions between them. When the cause is on one side, and the effect on the other, tracking is key. For lateral neglect, therefore, even the simplest first puzzles should work.

iOS App: RGB Express - Mini Truck Puzzle

RGB Express App

RGB Express on iTunes ($2.99, sometimes free)

What it is: A simple puzzle game where you plan a route for the game pieces: Trucks that deliver same colored packages to same colored houses. You start at the truck, you map a path through the via point(s) to pick up packages, to the destination house. Trucks can't use the same road twice (neither theirs nor each other's). After you map a path for each truck you hit "play" to watch them drive.

The screen Shots show an example of one puzzle at a simple/mod complexity level. Screen Shot 1 is the starting position, and in Screen Shot 2 you see how the puzzle is solved: you draw the path of each truck to pick up the appropriately colored package and deliver it to the appropriately colored house without using the same road twice by either truck. Once you draw the solution, you press "play" and the truck driving and picking up/delivering packages is animated. Previous levels had one truck and many possible solutions, and subsequent levels may have more trucks/colors, and more than one package per truck resulting in more complicated routing and fewer possible solutions. There is no time limit to solving the puzzles, and you can redraw the paths until you're ready to hit "play" and test them.

Screen Shot 1

How we can use it in Tx: There are 3 key features of this puzzle game that benefit its use for treatment activities. First, it doesn't involve a time limit for solving each puzzle. The time limit, to me, is what eliminates many puzzle apps from being used in Tx. We want to challenge our clients in the skills we are working on, not frustrate them. More importantly, we want them to take the time to USE those skills and improve them.

The second useful feature of this app for Tx is its gradual increase in complexity. Unlike many puzzles that get too complex for most cog patients within just a handful of levels, this one increases the problem solving task slowly, and the increased complexity is focused on the reasoning aspects - that is, the exact skills we want challenged are the ones slowly increasing in complexity. Again, not the time limit or the distractions, but the specific spatial reasoning tasks: more complex routing for planning, more via points, additional colors to match, and eventually sequencing how many packages can be carried at once.

The third useful feature of this app for Tx is the ability to self correct: One can draw the possible routing solution, and if one determines there's a problem with it, one can redraw it before pressing the "play" button to animate the solution. So your client doesn't only get a chance to take their time planning a solution, they can produce a visual plan and determine its value before proceeding. This isolates some of the steps in problem solving and allows you as therapist to work on the component skills that require help and not merely the overall macro skill. The benefit of this aspect to Tx cannot be overstated. It is very rare to find a fun, motivating, task that allows us a glimpse into the micro component skills of reasoning.

Screen Shot 2

Although I don't list it as one of key beneficial features, there's one more thing I like about this app: It's simple and while it has use of color (necessary to the puzzle) and some animation, the color and animation are not distracting to the user. It doesn't feel inappropriately childish

So to use this in Tx you just let your client play the game, preferably on a large screen of an iPad or iPad mini. I usually have the sound on muted, and offer cuing as needed. Keep track of how much cuing was required to solve a puzzle, and what was most difficult (matching colors, drawing a path to destination and via points, addition of more via points or addition of more trucks, determining correctness of solution before hitting "play", etc.).

Goals we can target in Tx with this app: Planning a route for each truck via the point where the "package" is picked up to the destination (the house) requires problem solving, spatial reasoning, planning and scanning. Other skills engaged in solving these puzzles involve direction following, use of full visual field (as such, it can be useful to tasks targeting visual field neglect of various etiologies), sequencing (e.g., the order of packages before reaching the destination while avoiding the path of other trucks), focus/attention, categorization (colors, stopping points, destinations), and--as I always suggest--memory (e.g., to carry out the plan one comes up with to solve the puzzle). Also, as mentioned above, this task breaks up some of the components of problem-solving and allows you a glimpse into what specific component (planning, carry through, etc.) may need the most work.

Some specific examples:

1. For a lower functioning client you may want to work on recognizing a solution rather than generating one. Start at the lower levels with simpler road paths (like the one in the screen shots) and one truck picking up one package (one path to draw, one via point, one destination). Draw a route and ask if it's the shortest route to the destination. Draw one that passes the destination before the via point, and ask if that will work as a solution. Press "play" to determine if it works or not.

2. If you determine which increased challenge leads to the most errors (e.g., more complicated map or more via points or more trucks/colors) you can skip along to the levels that increase challenges in other areas but not the specific one causing problems so your client can continue to be challenged but not overwhelmed.

I also recommend doing these on your own so you can access all the levels in Tx because, as with most puzzles like this, advanced levels are unlocked as you complete previous ones. So make sure you have access to various levels that doesn't depend on your current client's progress.

iOS App: Winky Think Logic Puzzles

Winky Think Logic App

Winky Think Logic Puzzles App on iTunes ($2.99, sometimes free)

What it is: A collection of 180 logic puzzles that involve very simple to mod difficulty levels. The puzzles all consist of variously shaped and colored tiles that need to be positioned in specific spots. Sometimes it's as simple as moving a tile to its designated spot, sometimes several tiles to several spots, and sometimes there's obstacles to overcome and sequencing to determine. Solutions require single - to - multi steps to reach, with skills that tap into shape and color recognition, path determination, figuring out the outcome of various objects in the puzzles, etc.

Screen Shot 1 shows a simple level where you have to choose the correct shape to move to the center. Screen Shot 2 shows a simple level where there's some restriction on movement, and more than one target shape - so one has to move the tiles in sequence to place them. Subsequent levels include some additional problem solving. It never gets too difficult and it's pretty fun. If you get stuck, you can restart a level at any point - there's no timer and no points to lose; you just keep solving until it's solved.

Screen Shot 1

How we can use it in Tx: There's no settings to consider except whether or not you want music. If you are working on focus and need some distracting stim, you can keep the music on.

The levels are made more complex by the addition of obstacles, and multi-step solutions to the puzzle. A few levels require the use of more than one finger--I'd skip those levels in therapy unless you have a very highly functioning and dexterous individual. There's also a few levels at the end of the game where very precise movement is required (the obstacles cannot be "touched" by the tiles); I'd skip those as well as they may just frustrate more than help. But overall, levels are realistically solvable, especially with some cuing.

Screen Shot 2

You get to move up levels as you solve them (solve one, get to move on to subsequent levels) but once solved, you can reuse the levels. So, I would recommend solving ahead (as far as you plan to use with any client; or all 180 puzzles - it's fun). That way you can skip over levels that aren't appropriate for a particular client, and not worry about any subsequent levels being locked. Otherwise, just choose levels and play.

One issue that may arise is that solving some of the levels may require dexterity beyond the ability of your client. In such cases you can either skip that level, or split the task into parts that would still provide experience with the problem solving and the planning: the client may solve the puzzle by making a plan (e.g., for screen shot 2, figure out the sequence in which tiles need to be dragged into the track), and then verbalizing directions for someone else (likely the clinician) to carry out the plan. Then the dexterity of maneuvering the tiles would be left to the participant without deficits in this area.

Goals we can target in Tx with this app: Direction following, problem solving, reasoning, symbolic dysfunction, visual field neglect or other visual-field dysfunctions (like hemianopsia--to get used to scanning back and forth to compensate), sequencing, sorting, focus/attention, categorizing, planning, and of course spatial reasoning. And of course, as per my usual logic, memory.

Some specific examples:

1. As noted above, if you have a client who lacks the dexterity to maneuver the tiles in any or all levels, you can separate the task into manageable bits and remove the part that requires skill beyond your client's reach: the client can make a plan to solve the puzzle, verbalize it (or discuss it), then provide directions for another person to carry it out. The clinician, or another client if you're working in a group, can maneuver the tiles.

2. You can use this as a break between other tasks, or as its own task for a certain part of your session. To document skill and progress I would keep track of the cuing required and the number of steps that were needed to solve each puzzle to determine the difficulty of the task at each level. You might also note if the multi steps were homogenous: That is, were they the same step each time, as in sequencing the order like the puzzle in screen shot 2, or heterogeneous steps, as when one tile needs to be put on a spot that opens an obstacle or has to be maneuvered to a spot that allows it to change colors. I would consider heterogeneous steps more complex. For someone with symbolic dysfunction, you 'd want to also keep track of how many colors and/or shape choices were provided and how much cuing they needed to pick the correct shape/color (e.g., in the puzzle shown in screen shot 1).

3. Memory: you can show the solution to a min/mod difficult puzzle, and then ask your client to re-solve the puzzle using their reasoning and their memory of your solution. See, I can ALWAYS involve memory goals.

All in all, I think you can have a lot of fun with this puzzle both for direct Tx and for a motivating and useful break between other tasks you have planned.

Android and iOS app: Constant Therapy

Constant Therapy App

Apps: iPad Constant Therapy app on iTunes (free)
Android Constant Therapy app on Google Play (free)
Website: constanttherapy.com

What it is: A Speech Therapy tool for Cognitive-Communicative rehab. The app includes a large variety of language and cognitive tasks that can be customized to complexity level of your clients. It is free for clinicians, researchers and students; clients have to buy a subscription.

Here is how it works: As a clinician you would have this app on your device (again, for you an account is free). When you have a client with cog-com goals, you would create an account for them on your device (this is all still free). You would choose appropriate tasks customized to your client's diagnosis and severity, functional needs and skills.

The variety of their tasks is extremely satisfying. For language they have tasks for auditory compr, naming, writing, reading and sentence planning; for cognition they have attention, visual processing, mental flexibility, memory, problem solving and executive skill tasks. This list does not do justice to the variety and creativity of these tasks. I'm not sure the exact number but I counted 34 language tasks and 31 cognition tasks. To get a better idea very quickly, I urge you to hop over to this page and just glance at these tasks (when you mouse-over any task, it shows you a screen shot): http://constanttherapy.com/constant-therapy-tasks.

In Tx: The program allows you to select which tasks to use with your client, and at the level of each task you can adjust the complexity. You then get a baseline for each task for the individual client, and the program continues to keep track of progress (as well as usage). There's too many activities that address a large variety of goals to go into detail here. What I can say is that the activities I've seen and tried are created almost exactly how I would have conceptualized them, and I found it was very intuitive how to explain the clinical justification for spending time on these to patients and their families. Also, CT's website discusses Evidence Based Practice (EBP) implementation.

Outside Tx: You can select the tasks you want as "homework" for your client. This is where their own subscription becomes beneficial: The clients that can continue to complete these tasks outside of the therapy session can purchase a subscription (http://constanttherapy.com/pricing). They should do it using the account you create for them in session, so that the homework you assign can show up in their account, and their progress with tasks in sessions and on their own can be tracked (from within the account of the clinician that originally created their login). This extends your therapy outside the session: you, the SLP, are making clinically-informed choices re which tasks are most appropriate and beneficial, and are able to modify your decision based on progress feedback. Very few tools allow this kind of flexibility for clinicians to address patient needs beyond the therapy session.

My experience: I've used it only with adults for both cognitive and language intervention. I found it extremely age-appropriate, interesting and motivating. My clients seemed to enjoy the tasks, and I can't say enough about the ability to track progress in such an individualized (per client, per goal, per task) manner. A few outpatients have purchased a subscription and they (and their spouses) report good motivation to work on tasks at home.

Bottom line: I can absolutely recommend this program/service to both clinicians and clients. For the clinician, you will find this to be one of your most used apps on your tablet. For the client, based on the prices in 2014-2015 the feedback I've received is that it is well worth it.

Expanding the scope of reviewed apps

I started this blog to help sift through available low-cost resources when I realized that I'll be paying out of pocket for Tx materials in a medical/rehab SLP setting. As such, I looked beyond the apps developed specifically for SLPs mostly because of their price tags, but also because the general apps that are free or cheap were often ignored in SLP blogs on technology and small device apps.

Listing apps that are targeted at the general population, I developed an organization that included description of the app in question, how it can be used in treatment, specific goals that it may help target, and some examples of its use or goal-specific tasks.

I've come close to running out of general apps to review (that aren't similar to previously reviewed apps). I shall therefore add some SLP-specific apps to the catalog of reviews. I will attempt a similar organization suggesting specific uses and goals (based on client diagnosis and disorders, as well as specific goals for Tx) and add my thoughts on each app's value for $.

One of the first apps/services I will look at is Constant Therapy (http://constanttherapy.com/), which is free for clinicians and students, but not free for clients/users. I've used it with several clients who went on to buy subscriptions to the service, and I can definitely recommend it for cog goals. Check back for a full review in a (near) future blog entry.

iOS App: ICOON Global Picture Dictionary

ICOON App

ICOON App on iTunes ($0.99, sometimes Free)

What it is: Aimed at travelers ICOON provides a pictorial phrase book for the purpose of cross-language communication. It is simple to use and includes 12 categories that range from the basic/every-day (Hygiene, Health, Clothing, Food) to the travel-related (Measurements, World and Accommodation).

Screen Shot 1 shows a view of the categories, which is on the first screen of this app. Screen Shot 2 shows the view from inside a category ("Hygiene"), and Screen Shot 3 a specific item (toothbrush and toothpaste from the "Hygiene" category).

Screen Shot 1

How we can use it in Tx: When it comes to language goals,
pictures are always useful. Pictures divided into relevant categories are even more useful as one can make decisions about complexity level of vocabulary tasks based on context.

For word-finding goals, vocabulary that is relevant to the immediate environment of your client or is basic for their ADLs (e.g., food, hygiene, clothing) would be easiest. Emotions and Leisure a little more difficult, and Travel and World categories likely most
complex.

Language goals can be addressed in a variety of ways including confrontational naming, categorizing (top-down starting with the category and thinking of items then going over them, or bottom-up starting with items and determining categories). Pictures can replace word lists for motor speech and intelligibility practice. The picture lists easily lend themselves to various Q/A tasks, from simplest y/n to more open ended.

Screen Shot 2

The app could also be used to assess appropriateness of AAC using pictures. Does your client recognize the pictures? Are they able to read the category names? Their AAC needs are not likely to be fully met with this app (unless there is no symbolic dysfunction, and your client is only limited d/t voice issues) but you will be able to assess needs and abilities to determine what AAC app WOULD work if any.

Goals we can target in Tx with this app: Language goals
including word-finding, categorizing, question/answer and descriptions, speech goals that address dysarthria, apraxia and anything that affects intelligibility, and AAC (specifically to help assess needs and appropriateness).

Some specific examples:

Screen Shot 3

1. I recently had a client who has an existing Dx of severe expressive aphasia as well as a Dx for severe dementia. I have been working with her on pictures, and she is now able to generate around 30% (on a good day) of simple vocab from pictures. I show her a picture and ask what it is. I try to keep the pictures for each session from within the same category to help with context. If she is not able to generate the word, I give her a choice ("is this a toothbrush or a comb?"). She is able to reply with >90% accuracy. When we started she had <50% acc just repeating words. Her ability to express her needs has increased, and I have been able to educate staff re strategies to communicate with her (to ask her y/n questions as she demonstrates fairly high accuracy answering these).

2. S/P stroke client with expression limited to yes and no and conflicting reports of accuracy re same. These every day vocab pictures were useful in determining the severity of his symbolic dysfunction and helped determine that he is appropriate for an AAC device, and is able to navigate across categories to find his needs.

3. Used this app for a short task in a session with a high functioning language client presenting with mild word-finding issues at conversation level. This app was used to provide stim to jump-start conversations on a variety of topics.

iOS app: Missing Link

Missing Link App

Missing Link on iTunes (free)

What it is: A puzzle where 3 words are presented with missing letters, and solving the puzzle requires filling in the blanks to find these words. The main clue you get is that in all 3 words the same string of letters is missing.

There are 3 difficulty levels: easy, medium and hard. At easy level there's usually 2 letters missing (see Screen Shot 1), 3 at medium level, and at hard level there's shorter words with 3 blanks, so a larger part of the word is obscured.

Screen Shot 1: Easy Level

The layout is clean enough, even with the ads that pop up at the top in the free version. It resembles
an old-style typewriter (with sounds to match) and is obviously directed at adult populations.

How we can use it in Tx: As far as language goals go, even at simple level this is not the easiest game because the target words aren't the most common. As such, I would use this app for the higher functioning language client, stick to the simplest level and provide a lot of cues.

As far as reasoning goals go, the directions are simple (find 2 letters that would complete all 3 words) and yet not automatically familiar (there's not a lot of games/puzzles like this) so you have a chance to work on direction-following, and on recall of directions from one puzzle to the next. In this context, you can work with mod impaired clients as long as they don't have comorbid symbolic dysfunction.

Cuing could involve recognizing letter/sound combinations in English (e.g., if you have a verb like "keel" in screen shot 1, followed by blank-blank-g, familiarity with English should make one think of the "-ing" ending); or cuing could involve clues towards guessing the words themselves (e.g., "what's another word for 'airplane'?"). You can enter letters (even wrong ones) and ask the client whether they recognize each entry as a word. Word-recognition is an important aspect of symbolic dysfunction, although normally I'd choose simpler and shorter words for such a task unless the client was pretty high functioning.

Goals we can target in Tx with this app: Language goals involving reading, word-finding, symbolic dysfunction and intelligibility (see example 3 below); memory/recall goals related to direction following and sequencing, as well as reasoning goals.

Some specific examples:

1. Higher functioning client with language goals, you can solve the puzzle providing cues as needed (start with sound/letter familiarity cues as discussed above, then add word definition hints if needed). Once solved request client form a sentence with each word, followed by one sentence using all 3 (it can be silly, as long as it's grammatically correct).

2. For client with language goal, after solving the 3 words, have them make a list of 3-5 additional words that contain the string of letters missing from the current puzzle.

3. For a client with intelligibility goals, the simple level puzzles in this app provide great practice word lists since they are mostly 2 or more syllables long. So, solve the puzzle for fun, then use the words for intelligibility strategies practice, and to make sentences (silly sentences are really great for intelligibility practice because they lack context and thus have greater dependency on each word being heard and understood).

Android, Windows and iOS app: 4 Pics 1 Word

4 Pics 1 Word App

4 Pics 1 Word for Windows RT, for Android devices on Google Play, and for iOS devices from iTunes (all are free at this time). Also available for Nook from Barnes and Noble, and for Kindle from Amazon (these cost $0.99, and possibly are from a different developer).

What it is: A simple puzzle that presents 4 pictures that have one word in common, and you have to guess what that word is. See screen shot below where the target word is "sweet".

The gameplay is simple. Just start it and it presents 4 pictures on the screen (beautiful and high resolution), 12 letters, and blanks for each letter of the target word. Figure out what word the 4 pictures have in common and fill in the answer. You can turn off the sound if you want (although it's not annoying, just sound effects for when you select letters) and you can turn off the notifications re "buying" hints and such. As you progress through the puzzle, you win "coins" with each correct answer, and then you can purchase hints with these coins. Players can also buy these "coins" via in-app purchase.

How we can use it in Tx: Solve the puzzles with your client, providing cues as needed. You can talk about each picture of the 4 presented per puzzle, ask questions and elicit replies. In many cases the target word has more than one meaning (e.g., "sign" where it could be a noun or a verb) which provides context for some great language intervention. Solving the puzzles is great, but the path to solving each puzzles provides context for some useful interaction.

The main problem with this app is that you can't go back to puzzles you've solved (unless you remove the app and reinstall it, presumably). The puzzles do get progressively more difficult but very gradually and not by much. It's not optimal but for now you can use it until it's too difficult for your population, then reinstall and start from the beginning. And hopefully down the road, there will be a setting to go back to solved puzzles/restart the progress. On the other hand, it's free so expectations for greater customization are rather low.

Goals we can target in Tx with this app: Language goals that involve word-finding and naming are addressed rather straightforwardly, but there's also good use of repetition and Q/A that can be useful in addressing apraxia and dysarthria goals. Describing and discussing the 4 pictures presents a great opportunity to practice verbal expression. Reasoning is addressed with solving the puzzles, and focus/attention can be addressed as well (presenting 4 different pictures to solve for one word would require some cuing for focus for quite a few of my current clients). A client with lateral neglect may benefit from having to give equal attention to all 4 pictures to solve the puzzle. And you can always address memory goals with recall of pictures.

Some specific examples: Just a couple of examples of the less straightforward uses of the puzzle.

1. Memory goals: after discussing each of the 4 pictures and, hopefully, solving the puzzle, turn off the device and recall the 4 images. Start by cuing with the common word, then provide additional cues as needed.

2. Homographs/homonyms: address the various meanings of the target words as they come up in the puzzle. Since it will be as part of the puzzle-solving activity, and since the differing meanings of the words are in most cases what make the puzzle (e.g., in the screen shot above the actual taste of something vs. a synonym for "cute"), you'll have a great opportunity for this type of activity in  context (rather than a rote list of words as part of a structured task).

iPad app: Move & Match

Move & Match App

Move & Match app on iTunes (US $1.99)

What it is: Listed in the "Education" category, this app lets you create elements on a background and move them around freely. Elements can only be rectangular, but they can hold photos/pictures or words, they can be custom sized (as can the text within), they have a variety of background colors, and they can be cloned. If this description doesn't do much for your imagination, look at the screen images of examples I threw together really quickly (or look at the developers' examples of uses in iTunes via the link above).

Within the app you make a project file for each exercise that you create, and hence can build yourself a nice database of go-to tasks for a variety of goals. The developers also have a selection of pre-created projects that you can download off Dropbox directly into the app and use (this is accessible via the "i" information screen within the app).

Screen Image 1: Closed paragraph

How we can use it in Tx: This app allows easy creation of a host of closed-exercises that require either filling in the blank from provided choices (like in Screen Image 1), multiple choice answers, any kind of matching, or word/sentence building. For cogn goals you can create sequencing and sorting tasks. If you take the time you can build some useful visuospatial/executive function tasks such as completing a pattern or an analogy (you'd need to create some images externally--via an image editor and then get the pictures on your iPad first). I discuss some of these suggestions in the "specific examples" section below. But really, the possibilities are endless... just about anything you do with worksheets that involves multiple choice can be replicated and expanded on using this app!

Goals we can target in Tx with this app: Language and word finding goals through a variety of fill-in-blank, closed paragraph, matching, word/sentence building or multiple choice tasks. Higher level cogn goals like planning, sequencing and reasoning. Sequencing and sorting either words, numbers or images (e.g., photographs of various stages of some activity, just like photo sorting cards but all in one screen). You can make simple math problems with multiple choice answers (there's actually a few of these ready-made and freely available from the developers already). You can create a background monthly calendar with fill-in elements to work on orientation and recall.

Screen Image 2: Sequencing photos and/or text

Some specific examples:

1. Sequencing/sorting: As I mention above, you can take photos of various stages of an activity (e.g., doing laundry, heating up a pizza, making ice cubes, etc.). You can import pictures from your album which means you can use your camera or do image searches online, save them to album, and use them from album. Once you have enough steps to sequence you just let the client move them around into the correct order. You can also make text elements to sort or sequence (e.g., months, numbers, days of the week, or steps of an activity listed in text instead of as photos). See Screen Image 2 of a quick and dirty example where I use photos I took for another app I reviewed recently, but also added text that can be moved and reordered.

2. For language goals you can create just about any matching exercise you can come up with. Antonyms, synonyms, definitions, pictures of items and their names... etc.

Screen Image 3: Categorizing text and/or images

3. Categorizing task: create a few headings (e.g., furniture, food, countries, etc.) and a bunch of words or images that fit in each of these and have your client drag the words around to place them under the appropriate category name. See Screen Image 3 for a quick and dirty example I made for this task. The images I just downloaded after a very quick google search, and, you can see at the bottom of the screen the elements waiting to be sorted.

4. Scanning activity: create a whole bunch of elements (icons or words or letters or numbers or even just squares with colors) and direct your client to find (and, for example, move to a specific side of the screen) all the elements that fit some set of criteria (e.g., all the blue squares, or all the blue squares with "r").

Screen Image 4: Calendar

5. Orientation/recall: use an image of a calendar (in my example in Screen Image 4 I used a weekly view of the iPad Calendar that was blank) and add some elements that can be moved around (visitors, routines like therapy and meals, etc.). Work on today, or recall yesterday. I like the weekly view for this because it has all this room to hold the collection of elements while the client decides if to use them and where to put them in the daily list.

There's just too many things you can do with this app to list them all... Since these projects can be saved and shared, maybe if there's enough SLPs using this app we can have our own section on the developer's Dropbox down the road... or find some other way to share amongst ourselves. I know I plan to create a whole load of projects in this app, and although some may take great time and effort, I know I'll use them a lot.

iPad app: Kokako 123 Audio and Visual Training

Kokako 123 App

Kokako 123 Audio and Visual Training app on iTunes (free)

What it is: Described as a game to "help auditory/visual training". This app's description on iTunes specifies that it is not intended to replace therapy, but to go hand in hand with it by providing repetitive practice to enhance skills. It definitely is targeted at children, but manageably so.

The game only does one thing: it gives a series of cards with numbers one at a time (see screen image 1) and asks the user to repeat them by using the keypad to enter each number below its card. One of the best things about it is that the user can choose what order to put the numbers in (same order they were presented from left to right, or backwards from right to left, or random).

Screen Image 1

Settings for this game include choices for how many cards will be presented (from 1 to 8; the example in the screen shots has 4 cards), and for how to present the cards (visually by flipping them over, auditory presentation where you can choose one of two male voices, or both visual and auditory). There is also a setting for how much time to space in ms between cards as they are presented.

Screen Image 2

Once user puts in the sequence and presses "go" feedback re accuracy is presented. As you can see in screen image 2, feedback includes which cards were correct, how long the turn took, and a count of how many turns were correct (screen shot 2 says "0" because not all 4 numbers were correct).

The themes are rather childish (you can choose car, flower or star; I have it set to the least annoying star) and there's a happy or sad star that comes up at the end of each turn. Not overwhelming, but nevertheless, it's there.

How we can use it in Tx: Set the activity to fit your client's needs in terms of how many numbers to remember (start with 3, and increase complexity to 4, 5 or even 6 if you think it's appropriate for your client's level).

Depending on the goals decide if you want the target number list presented orally or visually, and how fast. Maybe you'd like to have the client repeat each number as it is presented? That's a good memory strategy, and if you decide to go that path you may want to put in a longer delay between cards. Then have the client either tell you the sequence to enter or, if they have the dexterity, have them enter the numbers using the keypad.

What's nice is that you can also use this as a memory/mental manipulation activity and ask for the sequence backwards (since you can enter the answer in any order you want). You could also ask for the number sequence to be repeated in ascending or descending order. If you have the capability, you can enter the numbers in their correct spots; otherwise you can just enter the numbers in ascending or descending order and not worry about the game telling you the answer is incorrect--since it will flip the cards over at the end you'll be able to check accuracy that all numbers were recalled.

Goals we can target in Tx with this app: You can customize the settings and activity to target memory, immediate recall, spaced recall, working memory, attention,  and visual & auditory processing to a lesser extent.

Some specific examples:

The memory and attention activities are limited to numbers which is rather rote, so you don't want to spend too much time doing only this activity, but it can be useful for a short task or two.

1. As I mention above, if you want to work on memory and mental manipulation you can ask for the sequence of numbers to be given backwards or in ascending or descending order. If you ask for the numbers in reverse order, you can just enter them in reverse order and let the app tell you how accurate you were. If you do ascending or descending, you can just ignore the app's feedback on accuracy (since the game expects the numbers to be entered in their correct spots, not just be the correct ones) and judge for yourself when the cards are turned over whether all the numbers presented are accounted for. Should be just as effective and simple enough (except for the frowny star that will show up).

2. For spaced retrieval: you would think that you'd be able to use the running timer on the screen during the turn to space out input from output, but in fact this timer doesn't run during the turn--it merely returns the total time it took once the turn is over (and "go" is pressed). So you'll need your own watch/timer to space out this task. But otherwise, it's doable (although frankly, I'm not a fan of doing context-free numbers in this sort of activity).

3. If you are not working on mental manipulation that involves returning the numbers in a specific sequence, you can--like advised in #1 above--just ignore the accuracy of the order of the replies, and focus only on whether the client remembered all the items on the list. Again, you would not use the game's accuracy feedback for this and just keep track of it separately.

4. Brain-training: for the regular (not rehab-patient) population, this game can provide great training for memory and focus. Since you can set the game to provide you with a sequence of up to 8 numbers, with very little delay between them, visual or read, you can really set the task up to challenge anyone's function. You can also make yourself give the numbers back in ascending or descending sequence while getting them in their correct slots. And you can motivate yourself to return the answer faster each time as well.

iPad app: ScrapPad - Scrapbook for iPad (for sequencing)

ScrapPad App

ScrapPad - Scrapbook for iPad on iTunes (free!)

What it is: A sophisticated easy to use, and fun, scrapbooking application. It provides a variety of backgrounds, borders, embellishments and stickers (organized by themes like holidays, seasons, etc.). You can import images from your album (or take new ones from within the app with your camera), resize, move and rotate them however you want (except cropping--I didn't see that capability in the app; but there's native cropping in iOS already).

The app responds very smoothly to repositioning, rotating and resizing elements. You can work on the canvass with the tools at your ready or in full screen mode taking advantage of more space.

When you've made your creation you can email it, save (I'm assuming each page separately) to your album, share on FB, or send it to the app publishers to print (for a fee of course). They do not include the option to save your creation as PDF or some other format that can be read in iBooks, which is too bad for the scrapbooker, but not a big deal for our uses.

Screen Image 1

How we can use it in Tx: One obvious use for this app is to create family albums, logs, memory books and the like (much like what I wrote about in my review of My Story from 3/3/2012). I won't elaborate on that idea as it's fairly intuitive. My more interesting idea for this app though, is to use it for sequencing.

There's a few apps out there that are dedicated to sequencing tasks, where a user is presented with 3-6 step common tasks, with an image for each step, and asked to put the steps in sequence. I haven't seen any free apps for this, but here's a review from "Speaking of Apps" of a $4.99 app dedicated to sequencing called Making Sequences. It sounds great and the price tag is not too bad for a Tx-dedicated app. But it only comes with 15 sequences.

So here's what I did. I created my own sequence photos. For this review I very quickly made 2 sets of 3-step tasks (one making the bed, another folding laundry). I could have just as easily downloaded clipart. I put both of my tasks together to simulate what the screen would look like with a 6-step task (but if I was using each of these I'd have only the 3 steps of each task on the screen at a time).

I added all 6 photos to my scrapPad canvass, resized them for best fit and rotated them for proper aspect. I switched to full screen mode and basically created a space where the photos can smoothly be moved around as needed (see Screen Image 1). And there you have it: a sequence task. The reason it works so well is that (1) you can use the full screen so there's no dedicated sequencing app out there that can beat the real estate available for the task; and (2) the dragging/placing of the elements (the single photos) is so very smooth. They don't "snap to", but neither do photo cards you would use for this task if you didn't have an electronic version. There's also no music, no grading, no animation. It's just an improvement on the low-tech version in the sense that it's a lot easier to quickly make new sequences, and if you want, you can make them with images from the client's immediate environment.

Screen Image 2

One can make a page for each task, and create a "scrapbook" with as many sequencing tasks as they bother making with no limits. You can size the images to your liking (I wanted to make them as large as possible while still having enough room to move them around). You can also add titles to each page (if you want to add context; I like to ask my pts what the task is before they start sequencing, but some need the context to perform the task).

Just to show the full potential of this app (so well beyond what I'd use it for) here's a scrapbooked (albeit hideously... I'm not much for scrapbooking) version of my 6 pictures on the canvass with the tools open, and the "export" window open so you can see the options it comes with (Screen Image 2).

Goals we can target in Tx with this app: Memory/STM and orientation goals (which I didn't discuss much but they are fairly obvious), focus and direction following, spatial reasoning if you want to do some actual scrap-booking tasks, and the one I suggest it for: sequencing and sorting.

Some specific examples:

1) For sequencing--the main use of this app I recommend--snap some photos of common daily activities, even specific activities of your client if you feel it's appropriate, import them into the app and size them so all steps of the sequenced task can fit, then move to full screen and let the client order the steps. Just as I describe above. There's really no end to the possibilities.

2) For sorting, download or snap photos of elements you can sort (items or animals that vary in size or number, people that vary in age, foods that vary in size or calories, whatever you can think of... just keep it clear) and create a task just like the sequencing one. Save these and over time you'll have a ton of fun sequencing and sorting activities in one place.

3) A fun STM task that allows for use of memory strategies is to create a page for a specific event or season (e.g., for Easter or a birthday). Create it with the pt, discussing the various elements you're putting in there and color decisions, etc.; make all decisions explicit and together. Then find some filler task you can do for 5-10min (whatever you think is appropriate) and return to this task: ask for recall of the creation you made together, and carefully use cues as needed to get as much recall as possible (cues can range from visual to discussing some of the decisions you made together, etc.).

iOS/Android App: Counting Dots

Counting Dots App

Counting Dots on iTunes ($0.99)
There's also a version for Androids on Google Play (same price)

What it is: It is described as a colorful counting game for kids. The colors are vibrant but crisp and clean (if nobody told me it was for children, I'd just think of the layout as modern). Popping sounds and vibrations can be shut off as well. The task is one of counting, where you can count by 1's, 5's or 10's, and you can start with any number you choose (so if you start with "5" and count by 5's you'll get 5, 10, 15, 20, etc, just like in the screen image below; and if you start with "2" and count by 5's you'll get 2, 7, 12, 17, etc.).

A player is presented with dots in various colors and sizes with numbers on them, and the task is to select them in ascending order. The game playing happens in levels of increasing number of dots. First you're given one dot. When you clear that (by selecting the one dot) you are given 2 dots. When you clear those, you are presented with 3, and so on.

The background colors and dot colors are different each turn. The dots overlap, but the correct answer is always visible (though sometimes hidden by the previous answer). The sizes vary randomly (so 80 may be tiny and 85 large; but all fully legible and selectable). If you touch the wrong dot it shakes for a split second, nothing else happens. So there's no error reporting, there's no scoring and as far as I can tell, there's no end.

How we can use it in Tx: I'd shut off sounds and vibrations in the settings, and set the difficult appropriately for each client. Here's my opinion of settings ranging from easiest to most complex given the parameters of this app:

1. Starting with 1 or any number, and counting by 1's (1, 2, 3, 4, etc.)
2. Counting by 10's, starting with 10 (10, 20, 30, 40, etc.)
3. Counting by 5's starting with 5 (5, 10, 15, 20, 25, etc.)
4. Counting by 10's starting with something other than 10, for example 3 (3, 13, 23, 33, etc.)
5. Counting by 5's starting with any number between 1 and 4, for example 2 (2, 7, 12, 17, etc.)

Using an iPad with its larger screen is probably best. Ask the patient to perform the task (select the dots in ascending order, with a greater number of dots presented each after the previous one is cleared). You can keep track of accuracy by counting errors (error stats, as I mention above, are not kept; but the incorrectly pressed dot does shake for a split second providing a quick but not distracting or discouraging visual of an error if a therapist is watching for it). Maybe stop the game either after a certain time limit (play it for 5 minutes, for example, and note how many levels have been achieved in that time) or after the pt seems to get stuck a lot (hits the wrong dot several turns in a row). Definitely try to stop before frustration sets in, but do try to get to a level that is challenging for your client.

Goals we can target with this app: Sequencing obviously, providing a range of difficulty levels for this task. Certainly math (on the simpler level, although you'd be surprised how challenging it can be to sort the dots in ascending order as you get into the higher numbers). Memory (STM, working-memory) are addressed: it is actually pretty challenging to remember where you are in the sequence once you've been playing for a while, especially with distraction of colors and sizes of the dots. Visual field neglect and scanning are incorporated as the dots are spread across the screen, and again, the colors and sizes can provide competing stim. And if there's competing stim, focus and attention play a role as well as direction following. I wouldn't spend too long on this task, but it's a nice 5 minute exercise that can address a number of goals.

Some specific examples (or in this case, rather, just notes):

1. If you are working on memory goals, then note the fluency with which the sequence is carried out. That is, to play this game smoothly the player must remember what number they are on. If, however, they forget, they can still carry the task out by scanning the screen and finding the smallest number to select. So it would be up to us to see which strategy is being used.

2. If you are working on visual neglect or scanning, note accuracy involving the weaker side compared to the stronger.

3. Patients with focus goals will probably be most distracted by size differences between the dots. You may also want to add another layer to the task, where if a smaller number has a larger circle your client must somehow acknowledge it (verbally, for example) which will provide a divided attention aspect to the exercise.

4. For a reasoning/problem-solving (and math) goal you could set up the starting number and intervals, and let the client start playing with the goal of figuring out what the sequence is counted by (1, 5, or 10). Difficulty levels for this type of exercise are similar to those listed above, although it is fairly limited in that respect.

iPad App: A Memory Game

A Memory Game App

A Memory Game on iTunes (free)

What it is: Basic memory/concentration game where you start with 20 "face down" cards, and picking 2 at a time try to match pairs. When pairs are found, they are removed from the board. It is one of the few memory/concentration game apps I've found that is not targeted at children with cute pictures of animals and such. The images are crisp and clear and definitely favor adults. There's no distractions such as unnecessary animation. Very basic, very clean, and I can't believe it's free!

Screen image 1: playing with flags

You can play the game using flags or symbols. The first is flags of countries where the card shows both the flag and the name of the country (see screen image 1). Symbols are black and white simple images such as pencil, flower, airplane, etc. (see screen image 2); they are all very clear and easy to tell apart, but there is no text or color.

As you play the game keeps track of your tries and how many pairs have been cleared. At the end of a game you're presented with a message that tells you how many moves it took you to clear the board.

How we can use it in Tx: Obviously the way to use it is let your client play this game. I would consider the flags option as the more basic, easier, level. Flag images come with context: the name of the country is provided which gives a player something to hold on to in memory. There's also colors that help visually distinguish each card. The symbols option is definitely more complex as there is no text, and there are no colors. A player would have to name the image and hold on to just that word and location to continue matching.

Screen image 2: playing with symbols

The flag option provides you with plenty of opportunity not only for various cuing levels, but also to practice various memory strategies. As a card is opened the flag and country that is presented can be discussed. What do you know about that country? What continent is it in? Are you familiar with that region? Have you ever been there or wanted to go there? Did you recognize the flag? Do you like the colors of the particular flag? And references can be made to the location of the card itself (e.g., this country is a southern country, and hey, it's at the top of our board... it should have been at the bottom). OK, I'm reaching here, but my point is that this simple set of images presents us with lots of opportunities to model and practice memory strategies.

Goals we can target with this app: Memory (STM and to an extent working memory) obviously; certainly some scanning/visual field neglect. Focus/attention and following directions, as well as categorizing to an extent as part of flag/country discussion.

Some specific examples: I don't know that specific examples are needed in this case: just play the game using flags option, and decide on the level of cuing you want to provide. If you are targeting specific memory strategies (like repeating or visualizing) you can write goals for implementing those strategies while playing this game. And you can use the stats provided at the end if you want to help you measure accuracy and progress.

Brain-training: For the regular (not rehab-patient) population, this game can provide great training for memory. If you want it more challenging, certainly use the symbols option over the flag one. On the other hand, with just 20 cards, this will never get TOO challenging, just fun.

iPad App: Cursive Writing HD

Cursive Writing HD app

Cursive Writing HD app on iTunes ($0.99, periodically free for a limited time)

What it is: Practice cursive writing by tracing at the level of letters (capitals or lower case), words, or sentences (where you can type your own sentence and have it presented in traceable format). There's a few settings that can be adjusted like color and thickness, but in general it's a one-trick pony: have written material presented so you can practice tracing it.

How we can use it in Tx: Decide on the complexity level you need (letter, word, sentence) and have your client practice tracing, preferably using a stylus rather than their finger. There's not a ton of different uses for this, and not a ton of pts that would need it. But right now I actually do have a pt that wants to work on her handwriting because it's harder for her to write than it used to be before her stroke. She has no problems reading, and she likes to write only in cursive. She has a hard time holding a writing utensil and pressing down enough to make clear markings on a page. Using a stylus to trace the letters on an iPad circumvents the problems with strength and gravity (where she is holding her paper up and trying to write with the pen's tip pointing up). She was used her nice handwriting and really wants to have it back. She has also forgotten how to write a few of the cursive letters (particularly capitals of some cursive letters, like Q and G). This app was just made for her.

Goals we can target with this app: Like I said, one-trick pony... so mostly writing, and as far as language goes, symbolic dysfunction to a point (if it's beyond very mild dysfunction, cursive is probably not the writing you'd work on). I think tasks can be implemented for field-neglect goals and, obviously, reading.

Some specific examples:

1. Writing: Choose the level you need to work on (letters, words, sentences) and, well, do.

2. For reading goals, if they are for very mild dysfunction with high-functioning pts, you can use this app to generate cursive sentences for pts to practice reading. Anything more severe than mild should probably not be addressed in cursive form.

3. For visual field neglect goals practicing tracing letters, words or sentences (especially sentences) may help work on both strong and neglected sides; you can assess how much cuing is needed to address the weaker side.

iPad/iPhone App: Christmas Delights

Christmas Delights App

Christmas Delights app on iTunes ($0.99, sometimes free)

What it is: An app that lets you decorate a tree, with a few choices of trees and backgrounds (additional options as part of in-app purchases, but not really necessary for our needs). The ornaments that come with this app are sufficient in variety of colors and types. The lights have a dynamic display (they light up and dim) so the effect is rewarding. The resulting decorated tree can be saved and printed or emailed (or shared on social media, as with everything else in this world these days). Here is the emailed card of the tree I decorated with the app:

How we can use it in Tx: I would turn off the sound (there's a variety of holiday themed music as background; unless you want to provide competing stimuli to work on focus, I'd keep it quiet). Then you can either let the client free-form decorate a tree and put presents under it, or you can request the client follow a particular color scheme or other directions.

Goals we can target with this app: I think this would be a great task for visual field neglect needs, especially motivating at this time of year although I imagine this would still be fun any time. You can work on direction-following (written or oral) and memory if you give one or two step directions verbally. Attention and focus, with competing stimuli if you want to keep the music on. Sequencing and sorting can be implemented (see examples below). Temporal orientation if you talk about the holidays in general.

Some specific examples:

1. For visual field neglect goals simply let the pt decorate the tree and cue as needed to avoid neglecting the weaker side.

2. For direction-following goals provide written directions at the complexity level your goal targets, and assess ability to follow them. For example, specify what type and/or color of decorations should go at the top of the tree, what in the middle, what at the bottom. Maybe specify how many rows and how many decorations per row at various heights of the tree. How many gifts and what color wrapping... etc.

3. For memory goals give directions in 1 or 2 steps at a time verbally; have the pt repeat the directions (e.g., "put a yellow ball on the tree, then a red one" or "put 2 blue bows at the top of the tree") then follow them from memory. You can control the difficulty level of the task by how many details are included in the directions.

4. For sequencing goals you can give directions that involve sequencing, for example asking a pt to put one ornament at the top, then 2, then 3 with each row towards the bottom having one more decoration than the previous row.

5. For sorting you can include requests that involve sorting ornaments by color or shape or type.

Just have fun with it. Anything is better than crossing out specific letters or numbers on a page... right?

iPad/iPhone App: Micromedex Drug Information (Free)

Micromedex Drug Info App

Micromedex Drug Information on iTunes (free)

A database of medications (generic and trade names) that includes information on 4500+ search terms. Once downloaded to your device, you can access the information offline (don't need an internet connection/wifi).

This is a great resource for information we could use, such as precautions, contraindications, common and serious adverse effects, drug interactions and loads more. It's hard to believe this app is free!

I've been using this app as a basic quick check of medications' effect on swallowing function. For example, a dysphagia pt of mine was recently put on an antidepressant that has xerostomia listed as one of its side-effects. I had noticed a slight increase in stasis, and now I have at least one explanation for why, along with a good idea of how to treat it. It's not making me an expert on medications by any means, but this information came in useful for my clinical decision making. Over time, I'm sure I'll just have a basic idea of which class of meds is relevant to my scope of practice... but for now, I can look stuff up quickly and easily on my iPhone.