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.

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.