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.

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.).

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: Writers App

Writers App

"Writers App" app in iTunes (usually $0.99, sometimes free)

What it is: An application to help authors plan a story/novel. A place to enter notes about characters, places, the plot, individual chapters, etc., and to keep it in an organized database. It is very intuitive to use, and does not require each field to have content.

You start out by adding a story (you can work on several at once, each with its own entry). For each story you then add relevant details: a title, information about the story (synopsis, premise, plot), chapters, characters, places, and there's room for further notes. You can add as many characters (or chapters, or places) as you want. For each character there are fields for name, general info (role, occupation), attributes such as strengths and weaknesses, habits, biography, hobbies, personality, and physical characteristics (hair, age, eyes, etc.), and of course further notes. Each entry for "Places" also expands to the name of place, about it, environment, description, characteristics and further notes.

So as you can see, it's structured but has a lot of fields and room for freestyle notes. There's no customization for the fields (I'm sure future updates will include this; it is always something users request once they start using an app like this). There's also no way to include pictures, and I'm not sure there ever will be, but if needed that can be added via export: Currently there's only one way to export, which is to email yourself the list: whatever level you export from, will include the info on that level and below it. So if you export from one character's view, you will only get the info for that character; if you export from the main story level, you will get everything you have entered for the entire story (all the characters, places, etc.). The emailed text can be copied and pasted into a simple document, and if needed pictures can be added. Format nicely and print.

How we can use it in Tx: This is a great tool to keep track of characters and plot twists for an author in the planning stages of their great novel... And for us, it's a great tool to help pts slowly put together their own life story. While there are a few fields in this application that won't play a role (and may confuse a pt if they are doing this independently) I think this is a great tool to use *with* the SLP to work on reminiscing, map out one's family members, one's life story, and even better--all of these. Since the information is so well fragmented into characters, places, story... we can concentrate on one section at a time (for several sessions, as needed). And the best part is that the resulting information from these sessions can be printed for the patient to keep.

This may not be the perfect app for doing this, but it's a nice start. And it lets you keep a list of what the pt has already contributed, go over it in future sessions, and proceed from there. And of course this can also be achieved with just a pad and paper, or any number of note-taking apps (some that also allow pictures and sound attachments). But I like the organization of this one that makes this open-ended task into a structured exercise, easier to follow through with and to pick up where you left off in future sessions.

Goals we can target with this app: Memory goals mostly, and since it uses a pt's personal information about their life and family, one hopes there's increased motivation to participate in the task. Sequencing and categorization, attention and question/answer goals are addressed almost inherently as part of the task, and there could be added focus on these goals as needed. For example, a pt could be asked to recall something from grade school, something from high school, something from college (if they attended) or military service (or whatever else they did after HS) and work on sequencing these stories into chapters (which came first in life, which later). Orientation is also addressed as part of discussing previous events, younger age, different locations (that was then, this is now).

Some specific examples:

1. Reminiscing: for a pt that isn't able to remember a lot about their own life, you can create a chapter for certain decades (20's, 30's, 40's, 50's, 60's...) and think of famous characters from each era (Marilyn Monroe, Shirley Temple, Churchill, Charlie Chaplin, etc.). and famous events... If you don't remember much from your grade school history classes you can do some minimal research online and find enough famous events and people for each decade within minutes, surely. Or you can do the research together with your pt, and let them participate and recall some of these milestones. I had a pt who had a really hard time remembering anything about his own life, with LTM and STM goals. I brought in a reminiscing task with pictures of famous events or people from various decades, and we went through them. My pt said he won't remember any of it when we started, but as we went through my list he did in fact recall quite a few of the events and people, and had a few bits of information to contribute about them, some even from personal experiences. It was a very successful session that left both of us smiling.

2. External memory cues: work on a pt's family tree using this app by adding each family member as their own character. Go over each character on multiple occasions trying to get pt to recall additional attributes; maybe add descriptions based on photos in the pt's room... You can get additional info from visiting family members if possible. Just have fun with it. And this is certainly something you will want to export, format, and print for the pt when you are done.

3. Write a pt's life story, especially if it's a pt who has lived in several places. Write a chapter for each time in their life (as I mention above, one for grade school, one for high school, etc.) and again, let them fill in bits and pieces over several sessions (give the specifics recalled previously and ask for more detailed info, e.g. "so last time we talked about your time in the army and you mentioned you were stationed in Italy. How long were you there?").

iPhone app: MouthOff

MouthOff App

MouthOff app in iTunes (currently free)

What it is: Purely entertainment, and yet it has been the most used app on my work iPod lately. This app has 58 reactive cartoon mouths. You pick a mouth, hold your iPhone or iPod Touch in front of your mouth, and talk (laugh, scream, whatever). The mouth moves in reaction to the sounds you make... or in reaction to any noise in a room, so in a loud room the mouths will move a lot. But in a quieter room it will match movements to your sound and make it look like the cartoon mouth is doing your talking.

How we can use it in Tx: For the most part, I use it for motivation, and frankly, to de-crabbify even the most annoyed nurses or CNAs at my SNF. This can make every person laugh out loud with delight. Sometimes the tasks we do with our patients are tedious... especially when it comes to mostly OMEs or airway protection exercises... this can just make it fun. But, being that it reacts to sound--and the louder the sound the bigger the reaction--it CAN be used for Tx with voice patients to work on volume and duration mostly. As such, it can be used much like the bla | bla | bla sound-reactive app I discuss in a previous post (see the bla | bla | bla post from 3/11/11) which lately I've been using with an MS patient with some great results.

Goals we can target with this app: I'm sticking with motivation building as an important goal (if not one I actually write for a pt); also voice, dysarthria, phonation, intonation and prosody with, for example, MS or PD patients.

Some specific examples: I think you'll see that everyone gets a kick out of this. Lately I've been walking into pts' rooms with this app in front of my mouth and just giving them a giggle before we get started. But here's a couple more ideas.

1. Play with one of the cartoon mouths with the pt to determine its maximum reaction (open mouth or tongue out, or whatever else it may be for the particular cartoon). Then have the pt look at the screen and repeat words trying to get the maximum response to either each syllable or to the stressed syllable. Write a goal for % volume at word or syllable level.

2. A more amusing variation on the first suggestion: have the pt do the same but instead of looking at the screen watching the mouth, have them hold the device in front of their own mouth in front of a mirror.

3. I feel this app can come in handy for OMEs... but I haven't quite put my finger on how yet. It'll come to me later this week I'm sure.

iPhone/iPad app Dragon Dictation (Free)

Dragon Dictation Free App

Dragon Dictation for iPhone/iPad/iPod-touch from iTunes

What it is: A rather well known application that translates speech to text. You speak into it, and it gives you a text version of what you said. I've noticed that sometimes it recognizes raised intonation as questions, but normally, I just say "question mark" or "comma" if I want those included in the text. It is quite good and amazingly accurate if you speak clearly with relatively little background noise. It lets you easily bring up a keyboard if anything needs to be corrected, and even has drop down choices for some common homophones (like if it wrote "do" and you select it, it may automatically suggest "due" instead). The application also makes up a database of names in your address-book to help recognize these in your speech and spell them right. You can then export the speech you dictated into a text message, an email, some of the social networking programs, or lets you copy it for pasting (like into a note or whatever else you choose).

How we can use it in Tx: In some ways, this application is a measure of clarity and intelligibility. Granted, the clarity and intelligibility for this app needs to be superior to what would be required in normal conversation, but that's not a bad thing for treatment purposes. A patient that is working on intelligibility, volume, or slowing down their speech can practice with this app. Whether the patient is working on word-, phrase- or sentence- level, they can practice saying a list of words or phrases to see how many of the dictated words were clear enough for the application to transcribe. Makes it pretty easy to quantify progress as well. It is also quite delightful how good this app is at transcribing speech, which helps build motivation. This is a good companion to the Bla | Bla | Bla sound reactive app which helps work on volume and timing (see my write-up of the Bla | Bla | Bla app from March 11, 2012).

Goals we can target in Tx with this app: Intelligibility, pacing (especially slowing speech down at sentence or conversation level), volume, phoneme accuracy... and well, most dysarthria related goals. My PD patients have found it challenging but fun.

Some specific examples:

1. For word-level intelligibility or phoneme accuracy goals, start with a list of common words that target the phonemes in question, or a range of phonemes. I suggest dividing your list up by syllable length (so have a list of monosyllabic words, disyllabic, and longer). Have pt pronounce each word, and quantify success by how many trials got transcribed accurately. You can have each word said 5 times, and find % that were transcribed correctly, or just do the full list with each word once, and take % of correct words from the whole list. The transcription errors produced by the app should also help highlight the problem areas, especially for monosyllabic words (if a word is longer and one or two phonemes are off target, the app may still figure out what word it is, but shorter words rely on less context and more accurate production to transcribe). As such, you could use this app for evaluation purposes (an informal look at what sounds may be toughest for a patient, if so indicated).

2. For sentence-level pacing goals, have pt read a sentence or paragraph into the app and check on % of the sentence that was correctly transcribed into text. The feedback to the patient is very quick, and it may be helpful to see a visual of just how much of one's speech is misunderstood due to fast speaking. Putting pauses between words will up accuracy very quickly, and that would also be a good visual for the patient.

Well, you get the picture. Patient speaks into the app, the app returns with a text of what it was able to transcribe from the pt's speech. Accuracy is easily quantifiable, and suggestions can be made to improve the accuracy. Strategies are discussed, practiced, and pt tries again. Hopefully, accuracy goes up.

iPhone/iPad app Bla | Bla | Bla: A Sound Reactive App

Bla | Bla | Bla free app

Bla | Bla | Bla - Sound Reactive app Available in iTunes

What it is: 16 cute faces that react to sound, for example by opening their eyes and mouth wider, varying their reaction to correspond to the volume of the sound: The louder the sound, the greater the reaction from the faces. The length of the reaction also corresponds to the sound: The longer the sound, the longer the face is held in reaction mode. This app is free and it works on iPhone, iPad and iPod-touch. This is one of the apps that, for Tx,  works just as well on a small device (iPod or iPhone) and does not require the iPad to be useful. Oh and it's super fun to watch the faces change in response to sound!

How we can use it in Tx: While this is not a measure of clarity or intelligibility, it can be a useful visual feedback tool to show a patient how loud their speech, or part of their speech is, or how long they hold a vowel, or how much stress they put on one syllable as compared to another. I had a patient who would trail off on all but the first syllable except when using this app. And as I note above, it really is very amusing to watch the faces change: my pts enjoyed it a lot, and some liked getting to pick which face to use.

Goals we can target in Tx with this app: Intelligibility, dysarthria, stress/intonation, volume, voice, phonation, to name a few. I've used it with patients with Parkinson's, MS, and others with mild dysarthria.

Some specific examples (not an exhaustive list):

1. After going over intelligibility strategies of putting stress on each syllable and exaggerating each sound, a pt can practice a word list, starting with some automatic ones like days of the week, with the goal of getting maximum reaction from the app's faces for each syllable (not trailing off). Accuracy can be measured by how many of the words got equally strong reactions from the app's faces for each syllable.

2. For a pt with flat affect or disordered prosody, write a goal to practice phrases and mark the stressed elements with prolongation and increased volume, as measured by the reaction from this app. The list of phrases could include ones where the word emphasized is the only difference (minimal pairs with respect to prosody); e.g., "I want SOUP for lunch" vs. "I want soup for LUNCH" (the first meaning I want soup and not something else, the second one meaning I want it for lunch, not for dinner). The emphasis on the word in CAPS should be apparent from the Bla | Bla | Bla app's reaction to volume and duration. Accuracy can be measured by how many reps it took to get the reaction on the correct words.

3. For a pt with goals to increase vocal intensity, can write a goal to elicit maximum response from the app's faces to a list of words or phrases. It is easy to see what maximum response is for each included face by making a soft sound followed by a loud one and comparing the response. Then the pt can work towards getting the maximum response, which would entail speaking louder. Accuracy can be measured by what % of the pt's speech got maximum response from the app's face.

4. Pacing goals, for pts who need to work on slowing their speech, could also be addressed I think. I haven't had a chance to try this with a pt, but I imagine you could write a goal for the pt to space out the face's responses to syllables (since vowels are the loudest parts of speech, those are the ones the app's faces respond to). If speech is too quick, the face doesn't "rest" as much between reactions, so spacing these out can be a visual indicator of the speed of one's speech.

5. Another thing I haven't tried but feel could be appropriate is using this app with fluency/stuttering pts. Visual indicator of volume and speed can help pace and shape prosody. Affecting these characteristics of speech has been shown to increase fluency (using metronomes and delayed feedback all provide auditory feedback on pacing and affect prosody, but visual feedback, in the form of pointing to a word being read for example, has also been shown to be effective). Therefore using visual feedback such as this app to increase awareness of prosody and pacing to shape fluency is within supported reason, so to speak.

iPad app: My Story (free for a limited time)

My Story iPad app

My Story - Book Maker for Kids for iPad on the iTunes App Store

What it is: My Story is marketed for kids to make their own story books using photos, drawings, coloring, text, even recorded voice, and these story books can be saved and exported to iBooks, and then viewed/read like any digital book on your device.

How we can use it in Tx: The most obvious use is to create family albums and daily logs with pts that need external memory devices. While on the device it is not a resource that can be left with the pt to use on their own, it can be a productive memory aide used with the ST during sessions. Screenshots of the log can also be printed (take a screenshot by clicking the home and power buttons at the same time, and it'll save as a PNG file in your albums; then you can email it to yourself and print it on any printer) and those can be made into materials that ARE left with the pt to use independently.

Goals we can target in Tx with this app: Memory and orientation goals are the most obvious. Stories can also be created to target language, word-finding, problem solving and sequencing.

Some specific examples (not an exhaustive list):

1) Create a family album using photos of the pt's family if available (take picture of photos in pt's room, or draw stick figures for family members not yet available in photos) and name them all, listing relationship; have pt add a voice note to each member saying something unique about them (besides their name and relationship). Write a goal for pt to remember every family member's name, relationship, and some % of what s/he said about them in the voice note.

2) Create a book of a new exercise or routine learned in OT or PT sessions, with a page for each step. Move the pages around randomly and write a goal for the pt to sequence the steps correctly.

3) Create a continuous story and add a page each session; write a goal for the pt to recall 1-3 events from the current (or previous) day to add to the page.

What could you do with this app?