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.

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: 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/iPhone App: NumberOne Brain

NumberOne Brain app

NumberOne Brain app on iTunes (free)

What it is: A matching game where you are asked to locate a target number on a board tiled with several numbers (5-10 of them, see screen image #1). Very simple, but it gets more and more complex as you play: you have to learn to ignore competing stim to find the number you need.

Screen Image #1

As you can see from the screen image at a maximally simple point in the game (the start), the tiles are spaced so there's only one per column. Visual complexity is increased by adding more tiles to choose from, and/or lining them up to have more than one per column. Also, proximity of visually similar number tiles (to the target number) can add complexity, as can the extent of similarity between the tiles (so instead of maximally different from the target number as in the screen image, you may get 101, 110, 1, 211 and 11). The colors of the tiles may also work to draw your attention away from the correct answer, and at a more difficult level an incorrect tile may compete for your attention by shaking a bit. Possibly there's something in the sound as well, but I never play games like this with sound on. Either way, this is a great way to exercise your focus and quite fun as well.

Screen Image #2

How we can use it in Tx: There are several difficulty options available for this game, and as usual I recommend the simplest: "easy". All game play gets more complicated the better you do during the round though. Also, as usual I recommend playing this without the sound unless you have a pt with very high fxn that could use the extra competing stim.

One thing to keep in mind about this game is that, although a fairly simple concept and pretty fun to play, it is timed and graded, although as of March 2013 the grading can be turned off per new update. A round lasts a certain length, and you lose seconds when making mistakes, and I think gain some if have a good run. Here's an example of the summary that shows up at the end of a round if grading is not turned off (screen image #2). Some of the data is worth having, and may even be useful to us for keeping track of progress. However, the school-like grading of "brain level" is not for use in therapy (the original version of this app I reviewed did not allow grading to be switched off, and that's where the screen image is from). The new version does allow you to avoid this grading, which is a huge bonus for our uses! A great thank you to the developers for this, and their update re the matter on this post!

Goals we can target with this app: Attention, focus, following directions, scanning and visual field neglect goals, and of course memory goals (I suggest a way to focus on memory below). A pt with severe symbolic dysfunction may benefit from number matching as well, but they may need too much time for each match to get any real use out of this game. Worth a try.

Some specific examples: There's not really a lot of things you can vary in playing this game. You can vary the level of cues provided to help pt find matching tiles, and you can focus on specific results and/or progress. So for example:

1. If you're working on scanning and field neglect then accuracy becomes an important goal, and you should consider the number of mistakes per round. However, you should also pay attention to how many of those mistakes were due to competing stim from the dominant side.

2. If you're working on focus/attention, pay closer attention to what kind of competing stim interfered most (was it color, was it motion, was it placement, etc.).

3. Here's an idea for how to work on memory goals: Every time a new target number appears, after the pt has looked at it, pause the game (the screen will turn black, covering up the playing board). Check for immediate recall of the target number. If appropriate, distract the pt with something and then check for delayed recall. Then go back to the board, let the pt find the match, and do the same for the next target number (or skip one or two numbers, then pause for the following one to check recall). If you want to up the difficulty, upon pause ask to recall the current target number and the previous one.

4. Brain-training: for the regular (not rehab-patient) population, this game can provide great training for attention and focus, reflexes, scanning, and to some extent memory. For this population the graded summary may be a great motivator to do better each time you play.

iPhone/iPad app: Speed Match

Speed Match App

Speed Match on iTunes ($0.99, sometimes free)

What it is: a game where you are presented with two columns of 5 icons, and you have to remove them by matching icons from each column. Sometimes there's a few icons that are the same in both columns, sometimes only one (as in the screen shot here). Once you've matched and removed all the icons you win the round.

While playing, you can swipe a tile off the board from either column as needed, and these tiles are replaced by different ones. There is no "punishment" for doing this except for wasting time if you do it too often. There are no untimed rounds, sadly. There are several levels: you get the same total time to complete the rounds (4 minutes) and with each level you have a larger number of tiles to clear. The easiest is 25 tiles, then 50, 100, 125 and 150.

Screen Shot

As I mentioned already, all levels are timed. Additional challenges include that you can only mismatch 3 times (see 1 of the 3 spaces under the time left in the screen shot is lit up); once you mismatch 3 times the round ends. Waiting too long between matches will also cost a "mismatch" light. There are also several selections of tile styles, but I think the ones in the screen shot (the default ones) are probably easiest.

One other thing: this game is optimized for the iPhone/iPod screen sizes, but works really well in x2 mode on the iPad. I recommend only using the larger iPad screen in Tx.

How we can use it in Tx: I have written the developers and asked if they'd consider adding an untimed mode that could be used for practice or younger players in general, and our target population in particular. But until such a mode is added, I envision using the easiest level (matching 25 tiles) and setting realistic goals of how many tiles to remove before the clock runs out rather than expecting a pt to clear the board completely. You can vary the level of support provided to reach the goal. You can also make it maximally simple by finding a match yourself, and then touching the pair-able tile on one side, and asking the pt to find that tile on the other side. But remember, to play this you can't select tiles, you have to be actively/continuously touching both at the same time (however, you can be touching one side and take time before touching the other side; the tile will be removed once both sides are touched).

Goals we can target with this app: attention and focus, following directions, problem solving, scanning and visual field neglect, and of course memory.

Some specific examples:

1. For memory goals, the therapist can find a pair-able tile, bring it to the pt's attention and ask for the pair, then cover the tile up (thereby "selecting" the tile by touching it, so when the paired tile is touched it is removed) for the pt to find the matching tile from memory. Set a goal for how many tiles you want matched before the round ends (either due to time running out or 3 errors).

2. For visual field neglect just playing this game and having to simultaneously touch tiles from both sides is a great activity. A variation could be having the ST find the pairs and, like in #1 above, pointing out a tile on the pt's stronger visual side (but not covering it up like in #1, just pointing at it) and having the pt find the corresponding tile on the neglected side.

3. To target problem solving make a goal that involves removing unmatchable tiles while looking for matches. For example, tell the pt to remove 2 tiles they consider in their way every time they are stuck looking for a match. On the go reasoning is required to make these decisions (play the game for a bit and you'll see yourself).

4. To target direction following the ST, again, can be the one locating the matches, and communicating which tiles to touch to the pt. This information can be communicated by describing the tile (shape, color) or their location in the column (at the very top, halfway down, etc.) or both. This will take quite a bit of time so don't expect to clear too many tiles before time runs out. Maybe if an untimed mode is added.... :-)

4. Brain-training: for the regular (not rehab-patient) population, this game can provide great stimulation for attention/focus, memory, reflexes, scanning, decision-making and prioritizing. It's kind of addicting, but for short bursts of game playing (not one of those games you'll find yourself wasting your whole day on).

iPad/iPhone App: NxtApp

NxtApp App

NxtApp on iTunes ($0.99, free sometimes)

What it is: A mental math puzzle where you have to find the next number in a sequence using basic math. For example, you may get the following screen: 5, 8, 11, 14, ___ and you have to solve for the missing number. Using simple math (in this case addition) and logic you deduce that the missing number is 17 (each number is the sum of the previous number + 3). The missing number in the sequence is not always the final one, it can be any of the numbers.

In each round you get 10 sequences to solve, although instead of just counting how many you solved correctly (which would have been much better) the round stops with the first error. But it lets you restart the round immediately so it's not a huge problem... it just means that if you want an accuracy % you'll need to keep track manually. There is a timer that runs while the sequence is being solved, but thankfully there does not appear to be a limit to how long one takes.
 
There are several categories of level difficulty: The first listed is "beginner" but it's actually a link to a different app from the same seller, intended for kids. The next level is called category 1, and it includes additions (+) and subtractions (-), category 2 multiplications (x) and divisions (÷), category 3 can have x, + or -, category 4 has powers, +, and -, category 5 has powers and x, category 6 is more powers and 7 is mystery. So as you can tell, the task gets more complex with each category.

How we can use it in Tx: When it's a game like this, simply have your pt play the game and adjust your cuing as needed. For most pts the most appropriate category would probably be 1 (limited to + and - math operations). For most pts when the operation that makes the sequence is adding or subtracting more than single digits (for example a sequence such as 2, 13, 24, 35 where each number is the previous + 11) they may need a pen and paper to calculate. And pts with reasoning goals may need additional cuing to determine what to calculate (to subtract the preceding number from the one that follows it).

Goals we can target with this app: Problem-solving, reasoning and specifically math goals, obviously sequencing goals, direction following and focus (focusing on a math problem in competing noise is quite the task), and of course memory--especially working memory--if the pt can do at least some of the task in their head (thereby having to retain the numbers and operations in memory).

Some specific examples:

1. For memory goals, play this game with the therapist looking at the screen and the pt having to solve the sequence either mentally or (more likely since some of the operations are a little harder) by writing the sequences down but from memory. That is, open a new sequence problem and read it to the pt all at once ("5, 8, 11, blank, 17"). The pt then has to remember all 5 numbers and repeat them before writing them down. If the pt couldn't repeat the sequence correctly immediately after it's read out, the therapist can read it again, and the pt can repeat it again. Repeat as needed until the correct sequence is repeated back, and then have the pt write it down. You can vary this task and make it easier by only reading out 3 or 4 numbers at a time. This way you are working on retaining lists of numbers (and subsequently writing them down) as part of a larger task making the list-repeating feel a little less rote.

2. For reasoning, sequencing and math goals simply play the game and choose the level of cuing your pt needs. The math required to solve each puzzle is fairly basic, but the logic and reasoning skills to figure out how to solve it may be rather difficult for many of our pts. Whichever of these goals is yours, pay attention to the cuing needed for that specific skill (i.e., your pt may need max cues to figure out which numbers to subtract or add to figure out the answer, and what to do with the answer when it's figured out, but may be able to independently carry out the actual math operation once it's determined).

3. Brain-training: for the regular (not rehab-patient) population, this is a great math and logic puzzle to train your mental math abilities. Try to beat the clock and do it quickly or aim for accuracy over speed.

iPad app: CountBattle

CountBattle App

CountBattle app on iTunes ($0.99, sometimes free)

What it is: A very simple sequencing game: you get circles numbered consecutively from 1 to 15, and you simply have to tap them in order, the main objective being to do it the fastest you can. There's 3 levels (easy, normal and hard). The easy level spreads the numbered circles throughout the screen and doesn't move them. Normal and hard levels involve random repositioning of the circles as you play. If you tap outside a circle or in the wrong order, you get moved back one number (so if you were on "7" and tapped "13" by mistake, you're now on "6").

You can play on your own, or two people can simultaneously play in split screen. See screenshots on right. The first screenshot shows the game with one player; the numbers that have been selected in order are dimmed, and the ones still to be tapped are brighter. The screenshot below it shows the game in split screen, where two sequences of 1-15 numbers are presented, one in reddish tones, one in bluish.

How we can use it in Tx: I envision it as a useful activity for any number of executive function, field neglect and aphasia related goals. For most patients you'd probably use the easy level (where numbers stay put) and full screen ("one player"). For more advanced patients you could use the normal level where numbers reposition randomly. Since there's no time limit on this task (you try to get the best time possible, but there's no limit in how long one takes) the more difficult level--while definitely a complex task--is still usable. You can also up the complexity of the task by asking the pt to play in split screen ("2 players") in easy mode (numbers don't move around).

Goals we can target with this app: scanning, sequencing, number recognition, field neglect, direction following, focus, and divided attention.

Some specific examples:

1. For a divided attention goal select 2 players for a split-screen task, and set it on easy level. The numbers for each side of the screen point towards the edge they are near (see the screenshot on the right: the two sets of numbers are right-side-up for the side of the screen they are on). Decide how you want to play the game (either set the iPad in a way that all the numbers are on their sides, but none are upside down, or let one of the colors be upside down and count that as another level of complexity for this task). Ask the pt to proceed on both sets at the same pace (so tap "1" on blues, then "1" on reds; then "2" on blues, then "2" on reds, etc.). A more complex version would be to do a few at a time (in 3's for example, doing 1-3 on blues, same on reds, then 4-6 on each, etc.). There's many variations.

2. For a simple scanning (or sequencing, or number recognition) task ask the pt to play the game in simplest mode (easy level, 1 player) and then try to beat their own time on a 2nd or 3rd attempt.

3. Brain-training: for the regular (not rehab-patient) population, playing any of these levels, trying to get the best time, is good scanning and memory practice. The non-disordered player is likely to scan the screen quickly and mental-note where the numbers are so as to play faster. I find it fun and challenging myself.

iPad/iPhone app: Hemispheres

Hemispheres App

Hemispheres app in iTunes (regularly $0.99, sometimes free)

What it is: Solve simple math problems while mixing two colors together. On their own, each of these tasks is simple, but carrying them out at the same time is quite a bit less simple, as your brain must switch between the two problems, simultaneously engaging the logical/math and creative hemispheres. Talk about split attention task! This task is timed, which ups the difficulty level.

How we can use it in Tx: There is no easy or relaxed level, so expect pts to only be able to get through the first couple of problems (the game ends with the third error on either side; running out of time counts as an error as well). But even a couple of rounds of this game can be useful, and it's definitely something to use with higher functioning pts.

Goals we can target with this app: Attention, focus, math, and to a certain extent visual field neglect since the problems presented by the app are side-by-side, so attention to each side is needed. It is definitely a worthy brain-training tool as well.

Some specific examples: Since this app only has one level and the tasks are timed, there is not really a way to make the task simpler. Therefore, I would be weary of giving it to pts working on the very simple or basic skills. I would target pts with more advanced goals.

1. The most obvious use is for a split-attention task for higher functioning individuals with mild executive function deficits. Set as goal trying to get through as many of the problems as possible (i.e., get the highest possible score).

2. For field neglect goals, instruct the pt to focus on the weaker side's problem (e.g., for left neglect have them only solve the left-sided problem, ignoring the one on right). This will make for a short round, as concentrating only on one side will ensure the other side will run out of time and add to the count of errors, ending the round after 3. But solving 3 problems on the weak side with competing stimulus from the strong side is actually not a bad task, especially since the game can be restarted as many times as wanted (so you can ask to solve the 3 problems at a time, x5 for the entire activity).

3. Brain-training: for the regular (not rehab-patient) population, switching between the hemisphere-heavy tasks makes for a great exercise of multitasking, prioritizing, attention and focus skills.

iPad/iPhone app: Numbers Addict Free

Numbers Addict App

Numbers Addict Free app in iTunes

What it is: A simple matching and adding game that could not be more fun (or addicting for that matter). It's reminiscent of Tetris, where balls with numbers (each number has its own color so it's easier to recognize) are stacked along a grid of 5 columns, 8 rows. You can see the next 3 balls that need to be stacked (see screen shot below).

There are 3 difficulty levels, and the "easy" one has no time limit: the balls don't drop until you place them, but a new row of balls appears at the bottom every few rounds. You have to match by number to pop them (remove them from the grid), and you need that number of balls to pop them. So you need two 2's, three 3's, four 4's, etc. to clear them. The first levels start with 1-5, and after a few completed levels you get the 6, then the 7, up to 9. You can also move two balls together to create a ball of the sum: if you move the "2" to the "1", it becomes a light blue "3" ball. The sum has to be within the limit of the highest number on that level (so on a level where you only have 1-5, you cannot make a 6 or above). You're scored by total number popped, so six 6's will give you a higher score than two 2's. There's also a paid ad-free version of this game.

Screen Shot Level 1

How we can use it in Tx: Assume you will only use the "easy" relaxed level that has no time limit, and most likely only the first few rounds of it (where you don't have to match anything above a 5). And let the pt play this game (preferably on a larger device like an iPad). Cue as needed, depending on your goals. In the specific examples section below I make some suggestions.

Goals we can target with this app: Attention and focus, following directions, math, problem-solving, scanning, sequencing, and sorting are the main ones.

Specific examples:

1. If you want to target sorting and/or visual neglect and scanning, direct the pt to sort the numbers in adjoining columns (so only put the 1's in the first column, the 2's in the second, and the 3's in the third... etc.). For added complexity ask the pt to predict when a column will get cleared (e.g., when you add the 4th "4" ball to its stack).

2. To target higher level reasoning and math, for higher functioning pts, make the game's goal to add together as many balls as possible (e.g., drag the middle "4" to the "1" below it in the screen shot to create a "5") to direct attention to the more complex possibilities within the game playing than just matching numbers and colors.

3. For a cool scanning and problem solving task ask the pt to fill up the grid with balls allowing as few as possible to pop. It's not possible to control this altogether because every few balls that are placed a new line of balls appears from below, and some of those may create a match. But the pt's task would be to go for the lowest score possible by placing the balls under their control in a way that doesn't allow two 2's or three 3's, etc. This would be a scanning-intensive task.

4. Brain-training: this is also a great app in general for exercising one's multitasking, math, problem solving, reflexes, planning ahead, prioritizing, attention and focus skills.

Neuroplsticity and Brain Training

This is a short post, not about specific apps, but all of them in general. Sort of an added goal for this blog.

Sites such as Lumosity are becoming popular with the general population for training their brain and enhancing attention and memory performance, as well as focus, organization, problem-solving, learning new things, etc. These sites and apps are based on research into neuroplsticity, and boast success stories from customers about their improved cognitive skills since starting the "workouts". As such, I decided to go back and re-tag my older posts where I discuss apps that could be used for this kind of brain training (tagging them as "brain-training") and adding a note to the "examples" section at the bottom for each app that could be useful for the purpose of enhancing cognitive function in normal adults. Whatever "normal" means...

I also went back and tagged apps relevant to brain-training with this icon.

iPad/iPhone app: Match Panic

Match Panic app

Match Panic app in iTunes (was free for a while, now $1.99)

What it is: It is a matching game, where various tiles queue up in the middle of the screen, and you tap the right or the left to match them. Each level starts with just two tile images (see screen image #1), and every two levels or so one more is added at some point in the level (see screen image #2). It is timed, so if you don't finish a level in 30 seconds, you get a score but you don't move up to the next level (that is the only consequence). If a tile is matched to the wrong side, it turns into a sad face for a second (and costs a second of your allotted time).

Screen image #1

There's powerups too, which may add or reduce complexity of the task as they may affect the queue, e.g., by turning all visible tiles to the same shape, or "blowing up" the next few tiles in the queue, reducing the number of total tiles to be matched for that level. Powerups are a reward for a high scoring round, so a slow player isn't going to encounter this complication often. Don't let the "panic" in the app's name fool you: it's only panicky if you are gung ho about moving up levels and matching quickly. If you're playing the game in a more casual manner, there's nothing in particular that rushes you (other than the fact that the timer may run out before the level is finished, but if your goal is to play one level, no big).

Screen image #2

How we can use it in Tx: Pretty much assume you will only use the first 1-4 levels of this game, although there's nothing specific you have to do to select this. Just keep the goals simple. Turn off the sound so there's no "countdown" sound at the end of a level, and trust me, the music is super annoying anyway. It is designed to make the game feel more urgent (gives it that "panicky" flare) so it's best avoided.

This type of visual matching to right/left is a fairly good exercise for lateral neglect issues. This task is very similar to some divided attention activities that involve canceling a specific word or letter from a pageful of words/letters. Following directions is built-in, and memory plays a role as matching is easiest if one remembers the tiles on each side instead of having to compare each tile. As the number of tile shapes increases, so does the complexity of each of these tasks, including memory.

Goals we can target in Tx with this app: Following directions, sequencing, sorting, focus/attention, divided attention, scanning, visual neglect, and of course memory. This is also a great app for brain-training for the general population.

Some specific examples: Although this is a simple one-dimensional activity, I think it can be used in a variety of ways for different fxn levels and goals. Here are some examples.

1. For a slow, focused approach, possibly for a lower-fxn pt, prioritize accuracy of matching rather than total tiles matched, and ask the pt to take their time but send the fewest possible tiles to the wrong side. Let the progress be as slow as it needs to be, and set as goal for the task a limited number of tiles (10 or 20, for example). Have the pt count out each tile that is matched, and keep track of how many were initially matched incorrectly (then you can calculate % accuracy easily).

2. For a more advanced pt you can prioritize overall completion: Don't count how many were matched incorrectly (although that will play a role as each incorrect match reduces the level's time) and ask the pt to go through as much of the queue as possible in the allotted time. Calculate accuracy by points scored (since it's difficult to calculate percent of queue completed--you only see a piece of the queue at a time with no hint as to how much of it is still to come; if they ever add a % completed counter to this game it would be even better for Tx).

3. For visual neglect goals prioritize the neglected side, and ask the pt to say out loud the tile on that side each time it is encountered. So for example, focusing on the left side of the level in Screen image #1, each time a cactus is encountered have the pt say "cactus" before touching the left side. That way, not only is matching required on the weaker side, but it's also emphasized verbally.

4. Brain-training: This app is also great for normally (or close to normally) functioning individuals who want to get some cognitive training. This kind of thing is now popular with sites such as Lumosity, with more popping up. Everyone wants a piece of this neuroplasticity performance training. And if you feel the need for brain training, an app like this matching one will certainly do the trick as an attention-enhancing activity much like those offered on the paid "brain training" sites.

iPad/iPhone app: Success Story

Success Story App

Success Story from iTunes (free for a while)

What it is: A FUN (and kind of addicting) time management game. These types of games usually involve playing a role of a cook or waiter purveyor of some sort of goods or services, and your task is to complete your customers' requests (e.g., cook specific dishes to order, or arrange ingredients in a sequence) to make a specified profit and move up to next level. As requests become a little more intricate, and customers can get pissy if you don't deliver on time and walk away, you have to prioritize the steps to complete your tasks. That's the "time management" aspect of these games. I have long considered these types of games optimal for Tx for both adults and children, but the problem is that these games are often overly complex with too many steps to negotiate in too little time. My motto, which I keep repeating here, is that if it goes from fun to frustrating too fast, it's not useful as a Tx tool.

Screen image towards end of 1st level

"Success Story" is, finally, a time management game that takes it easy; while there is a timed aspect to this game, the complexity of the tasks is built up slowly, and I feel that a large number of levels (way more than needed for Tx) are usable. In this game you are making sandwiches to order; there is a grid of 11 plates where single ingredients are presented for a time, although not all the plates are full especially in the first levels so it's easier to choose (see screen image). If an ingredient is not used after a while the plate empties and is replace with another ingredient. Customers come up to the counter (it starts with one at a time, then two, and a maximum of 3 customers at higher levels) and order sandwiches (each customer needs 3 identical sandwiches). All levels start out with one ingredient sandwiches (e.g., hamburger, or lettuce or bacon). The "order" is shown as an image so you can see what is in the requested sandwich. You click on the ingredient (e.g., hamburger) once per sandwich (so x3 for an order) and then a few desserts pop up: each customer finishes a meal with desserts. The desserts you just click on, you needn't check what the customer asked for. Complexity is slightly increased with additional ingredients (two items, but in sequence: hamburger and lettuce, or lettuce and pickles; then three items, and more) and at higher levels there is less time as customers get impatient quicker, the ingredient plates time out faster, and of course there's more ingredients per sandwich. There's a few other details like powerups and between-level mini games, some of which are memory games. Let me tell you, it may sound complicated when you read about it, but it is really fun and addicting. And the initial levels are really easy to get through as you only need to serve a portion of your customers to move up a level.

How we can use it in Tx: Let a pt play this game, going through the first 3-5 levels where at most sandwiches include 3-ingredients. This game will work on an iPhone/iPod touch, but I'd recommend only using it on iPad for patients. The tutorial section is actually very useful, and is the virtual version of full modeling of the task. If a patient can get even one customer served (shouldn't be a problem in the first few levels no matter how long one takes) it's considered successful, and they can replay the same level instead of moving to the next one. You can quantify progress by how many ingredients were picked correctly, how few were picked incorrectly (incorrect ingredients require an extra step to remove from an order), or how many customers were served.

Goals we can target in Tx with this app: Direction following (this game involves 1-, 2-, 3-, and at later levels more, step commands). The game directions do get a little easier to follow as one gets used to the game, and the difficulty is increased very slowly so there's plenty of time to enjoy the game before it gets frustrating (if ever). Problem solving in the form of prioritizing (do you finish one customer's dessert order or take care of another customer's sandwich order first so they don't leave, do you grab the power-ups or finish an order, etc.), and as such there's sequencing of steps as well as sequencing of ingredients (if a customer wants lettuce topped by pickles, they will not take pickles with lettuce on top). Scanning goals can be addressed as well since there is a grid of 11 ingredients that need to be scanned to select the required ones, and during dessert time, the player has to distinguish all the dessert ingredients in the grid and grab them. Memory goals are also addressed with some of the mini-games between levels, where the ingredient grid is turned into a tiny memory game of matching two ingredients at a time. Attention and focus can also be indirectly addressed. Categorization skills are accommodated in the part of the game where desserts are sent to customers, since this part of the step involves scanning the grid of ingredients for any dessert items (rather than looking at the specific order).

Specific examples:

1. For scanning or visual neglect write a goal to use a certain % of the ingredients on the neglected side during a level. So for example, if one is making a bacon and tomato sandwich, the 11-ingredient grid will have plates of bacon in random locations, and a player without visual neglect would normally not favor either side of the grid; so ask your pt to specifically grab available ingredients from the side they tend to neglect, and then quantify what % of bacon plates were selected from that side.

2. For memory goals, at a level where more than one ingredient is needed per sandwich, quantify how much cuing was necessary for the 2nd and 3rd sandwich for each order. That is, when a customer orders a burger, cheese, tomato sandwich, you have to make 3 of these to complete the order. The first one requires looking at the order image for each ingredient, but the next two sandwiches should be built from memory or verbal repetition. As an aside, completing these tasks is a great way to contextually practice holding an increasingly larger list of (related) items in memory using visual and verbal cues.

3. Brain-training: this is also a great app in general for exercising one's memory, reaction time, attention and focus.

And hey, how appropriate is the name of this app for Tx purposes?!

iPad/iPhone app: Occupied

Occupied

Occupied app from iTunes ($0.99; was free for a while)

What it is: A sorting game where you have to get plane passengers to the correct, um, bathroom. The levels are timed (always a bit of a bummer for treatment's sake) but start out simple with just men and women and the two corresponding bathrooms. It doesn't require a lot of dexterity, and accuracy can be measured by how many passengers were correctly directed in the allotted time. Following levels get a little harder, first with the bathrooms themselves moving (switching sides, so sometimes the women's room is on the right, sometimes the men's, and you can see them trade places), then the passengers are all kids who need to be sorted quicker or they run off; the next level includes a third type of passenger (babies, who need to be directed to their own area) and then the bathrooms start moving on the screen so dexterity becomes an issue (as is motion sickness.. not part of the game, but what I get from trying to play at these levels). So I would recommend only the first 3 or 4 levels for Tx, which should be plenty. There are additional scenarios and more difficult level settings, but those don't interest me for therapy.

As an aside, I sent an email to the developers explaining how I plan to use their game for cognitive therapy, and why, and asking if they'd consider adding a simple, slower, or untimed set of levels for rehab purposes. Who knows, their response may be positive... although I can see how adding a set of levels for such a small specialized market may not be worth their trouble.

How we can use it in Tx: There's really only one way to use it, which is let the pts play the game. As I mention above, I'd stick with just the first 3 or 4 easy levels. The game provides feedback regarding accuracy of each completed level (% better or worse from previous attempt) which can be noted for the pt if you want, assuming it's the same pt completing the level (i.e., being compared to self and not another pt).

Goals we can target in Tx with this app: Attention, focus, scanning, reasoning, categorization, following-directions

Specific examples: Since there's only one way to use this app--that is, to play the game--there's no need for specific examples. However, goals can be worded to reflect each pt's intervention needs:

1. For a pt with left-neglect, the target of playing this game could be to match the accuracy of the right-sided sorting to that of the left side (e.g., for the first level if the men's room is on the left, then the goal would be to approximate accuracy of getting men to their destination to the accuracy of getting women to theirs).

2. For an attention goal, target overall accuracy of whatever levels are played.

3. For direction-following goals, pay attention to the amount of cuing needed to initiate and carry out each new level (since each new level involves a slight change in instructions).

4. Brain-training: this is also a great app in general for exercising one's attention, focus, and reaction time.

iPad app: Vismory (Visual Memory)

Vismory iPad app

Vismory - Visual Memory available in iTunes

What it is: Works on iPad, iphone or ipod touch. It is a memory game where you memorize a sequence of objects. It starts slow and while a quicker response will score more points, it gives the option to take your time. There are many versions of memory games for tablets and smartphones, but this one has a couple of advantages: First, in terms of number of objects to remember and time allowed to respond, quite a few of its levels can be used for players with more severe deficits (unlike many games that after a couple of easy levels amp up the difficulty or put you on a short timer, making the activities inappropriate for most patients with memory goals, going from fun to frustrating in mere seconds). In this game there are more challenging levels, but plenty of useful simple ones as well. Second, there is some mental manipulation required because it is the sequence of objects that must be recalled, not just the objects themselves. It is currently $1.99 (and worth it, I think) but every so often the price drops to free to bring in users and gather up ratings... that's when I managed to grab it, so keep a watch for if you don't want to spend any money.

How we can use it in Tx: This one's easy, just let your patient play this game, preferably on an iPad (not iPhone or iPod-touch as a larger screen will make all the difference). Practice different strategies to remember the sequence of objects in the game (you start with a very small number of objects; at first all of them are different colors so maybe repeat the colors in order... then there will be two objects that are different shapes but the same colors, so maybe repeat the object labels, and such).

Goals we can target in Tx with this app: short-term memory, working memory, sequencing.

Specific examples: Usually I end with specific examples for usage, but this app only has one function: playing the memory game, so there's not much variation in how it can be used. It's a memory and sequencing game. However, if you're targeting specific memory strategies (like repeating or visualizing) you can write goals for implementing those strategies while playing this game.

Brain training: This is also a great app in general for memory workout.