iOS App: HOOK

HOOK App

Hook on iTunes ($0.99, sometimes free)

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

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

Screen Shot 1

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

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

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

Screen Shot 2

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

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

Screen Shot 3

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

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

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

Some specific examples:

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

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

iOS App: RGB Express - Mini Truck Puzzle

RGB Express App

RGB Express on iTunes ($2.99, sometimes free)

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

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

Screen Shot 1

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

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

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

Screen Shot 2

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

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

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

Some specific examples:

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

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

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

iOS App: Winky Think Logic Puzzles

Winky Think Logic App

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

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

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

Screen Shot 1

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

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

Screen Shot 2

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

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

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

Some specific examples:

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

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

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

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

Android and iOS app: Constant Therapy

Constant Therapy App

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

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

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

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

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

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

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

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

Expanding the scope of reviewed apps

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

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

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

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

iOS App: ICOON Global Picture Dictionary

ICOON App

ICOON App on iTunes ($0.99, sometimes Free)

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

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

Screen Shot 1

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

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

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

Screen Shot 2

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

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

Some specific examples:

Screen Shot 3

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

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

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

iOS app: Missing Link

Missing Link App

Missing Link on iTunes (free)

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

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

Screen Shot 1: Easy Level

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

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

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

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

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

Some specific examples:

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

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

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