aVOR app, developed by H. MacDougall, S. Rogers, A. Bradshaw, and L. McGarvie
Description and Purpose: The aVOR app is an educational app intended to aid in understanding the vestibular system. The aVOR app can be found online (available at https://itunes.apple.com/us/app/avor/id497245573?mt=8) or by searching for "aVOR" in the iTunes App Store. The app is a virtual human vestibular system that allows visualization of basic vestibular anatomy. The user has the option to specify several vestibular pathologies including benign paroxsymal positional vertigo canal hypo-function (individual or multiple canals), and nonspecific cerebellar disease. The aVOR app is free. aVOR is only available on the iTunes App Store, requires iOS 3.2 or later, and is compatible with iPhone, iPad, and iPod touch. The information provided in this review was current as of September 28, 2014.
Audience: The app authors suggest an intended audience including college-level students and medical professionals. aVOR is also ideal for health care providers to use for educating individuals with vestibular pathology about their disease.
Content: There are 11 individual pages in the app. The first 5 pages instruct the user about different finger actions, which change the orientation of the viewed head/vestibular apparatus and the fixation point of the eyes. Semicircular canal anatomy is provided on pages 6 and 7, which is helpful for showing patients the location and orientation of the vestibular apparatus with respect to the head and eyes. Pages 8 and 9 indicate paired canal planes and the direction for canal excitation. These pages are particularly useful for individuals learning canal-specific head impulse testing. Color coding for excitation (red) and inhibition (blue) easily demonstrates the push/pull mechanism of semicircular canal pairs. Users are able to select specific pathologies for the app to emulate on the settings page. A canalith repositioning treatment can be simulated by moving an iPhone or apple tablet allowing the user to visualize the "otoconia" traveling through the semicircular canal. Other beneficial features include (1) the eye monitor can be turned on or off; (2) users can specify acute or compensated pathology; (3) corrective saccades can be specified as covert, overt, or delayed; and (4) the fixation reference point can either be head or world centered.
Organization/Structure/Ease of Use: The app starts with an introduction to finger controls, which change the orientation and position of the head on the screen. Triple tapping re-centers the head, and the gaze fixation point can also be specified. aVOR is easy to use and provides a basic understanding of how a healthy vestibular semicircular canal system generates eye movements and how eye movements change when the vestibular system is impaired.
Usefulness: aVOR is useful as a vestibular education tool for health care providers and their patients. More experienced vestibular clinicians may benefit from "Test Mode" in which a random pathology is selected and the user must "diagnose" the pathology on the basis of the behavior of the eyes in response to head (tablet) movements. A working knowledge of vestibular physiology is necessary to translate the app into patient education.
Reviewed by Eric Anson, MPT
University of Maryland
College Park, MD
Metronome version 3.1, developed by ONYX Apps
Description and Purpose: This app serves as a metronome that can be played from one's phone while treating patients with various movement disorders. The use of a metronome can be an effective treatment option during gait training. This app has many features that make it easy to use from both the clinician and the client point of view. It is available in the App Store and requires iOS 7.0 or later and is compatible with Apple products. It is 18.8 MB in size. This version (3.1) is free and was most recently updated on June 15, 2014.
Audience: This app is a tool for use with any patient or client who has symptoms such as hypokineisa or difficulty in scaling their movements. The metronome offers an auditory cue to facilitate speed and fluidity of movement. Because the app provides a beat, the patient can match their stepping to the beat during gait training. A patient could download and use this app while at home to assist in improving their speed of movement.
Content: The metronome can be used as an audio or visual aid to assist in gait training by providing an audible beat and visual cue that a patient can match while ambulating. I have found this to improve gait speed and decrease the number of freezing episodes a patient may have while ambulating.
Organization/Structure/Ease of Use: The clinician can adjust the beats per minute (bpm) of the metronome by either tapping a plus or minus sign or with a swipe control. Alternatively, the "Tap" button can be used to manually tap out a beat to better match the patient's capabilities. The maximum tempo is 240 bpm. The metronome is preset to a 4/4 beat. A different swipe control can also be used to adjust the volume of the sound of the metronome. There are preset time limits (1, 2, 3, 5, 10, 15, 20, or 30 minutes), or the metronome can be set to beat continuously. The time limit is in a countdown format. There is an additional feature of adding a visual cue to the auditory cue. The metronome can be set so that the flash from the camera matches the beat. Also, there is the option of a small light to flash around the play/pause button. There is even the option to use both of these visual features combined during use of the app.
Usefulness: Because it is an app it is used on the phone, and it can be carried in the hand to make use of the visual features. If only the auditory features are needed it can be placed in the pocket. With the swipe controls for both volume and beat, it is easy to adjust the metronome for each patient's needs. Also, because the beat frequency is adjustable, it is possible to use this to track a patient's progress during the course of treatment. The preset time limits can also be used to track a patient's progress in terms of distance ambulated or the number of repetitions completed in a given time limit. For example, documentation could state: "The patient can now ambulate 200 feet at 80 bpm in 5 minutes." Progress could then be noted in subsequent sessions in terms of distance or increased bpm.
Reviewed by Suzanne Trojanowski, PT, DPT, NCS
Senior Physical Therapist
Sinai-Grace Hospital
Detroit, MI
iGotBalance, developed by Interactive Medical Productions, LLC
Description and Purpose: iGotBalance is an app designed to measure and improve postural stability by means of a simple game. The app registers movement by using the accelerometer capabilities of the smartphone. The goal for the user is to minimize movement of the phone to sustain a marble-shaped icon centered over a bull's-eye. The device is held in the hand during various standing positions/tasks that challenge postural stability. The "game" feature encourages the user to register online through http://www.ustabilize.com to track progress over time, to challenge friends, or to see a leaderboard listing of the all-time best scores. iGotBalance is a 2014 updated version of Ustabilize, an app introduced in 2011. The iGotBalance app was tested on the iPhone 5s. The app size is 9.1 MB, and pro pack version costs $1.99. The information in this review is current as of September 8, 2014.
Audience: This app is targeted as a stability game for use by the client.
Content: Depending on ability level, the user has the option of assuming various seated or standing positions with eyes opened or closed, with the smartphone held close to the body directly over the navel, or with outstretched arms directly in front of the body or out to the side. On the basis of the difficulty of the position chosen and the total time the target is centered (with the goal to maintain motionless stability as long as possible), a "stability score" is generated for each trial.
Organization/Structure/Ease of Use: Conceptually, this app is a great idea. It could provide helpful biofeedback while clients independently perform various balance training exercises that focus on minimizing postural sway. However, there were several challenges when using the app. The icon target movement is extremely sensitive, making it very difficult to sustain the marble on the bull's-eye. When the phone is placed flat on a level surface, there is a spontaneous drift of the icon off of the target, even after recalibration of the accelerometer feature of the phone. In addition, due to the sensitivity of the game, there may be a tendency to better stabilize the phone by making small adjustments to hand position instead of by minimizing postural sway. There are no explicit instructions to keep the target centered by adjusting postural sway. This would likely not be obvious without specific instruction from a therapist. In addition, to actually see the screen of the phone when it is held close to the body, the user needs to sustain the head in forward flexion, which is less than optimal for postural training. When the phone is held at arm's length, seeing the screen to use visual feedback is also difficult, if not impossible. For trials with eyes closed, the app has an option to provide vibration as the biofeedback cue, but the vibration is only triggered at the outer edge of the bull's-eye, immediately preceding the timer stopping, which does not allow the user to make postural corrections in a timely manner.
Usefulness: In its current state, this app is likely too challenging for the majority of clients who require the use of physical therapy to remediate postural stability issues. In addition, the app does not offer clear instructions, and the lowest difficulty setting appears too sensitive. The developers should consider improving the vibration feature, as well as offering a feature that could utilize a laptop or external monitor for visual feedback to allow the smartphone to be held against the body without the user needing to look at it.
Cost: A free version of the app offers only 1 task (single-limb standing) with eyes opened or closed and various arm positions. If one upgrades to the "Pro Pack" for $1.99, access is then gained to the additional tasks of sitting, standing with feet apart or together, and tandem standing.
Reviewed by Jeffrey Hoder, PT, DPT, NCS
Assistant Professor
Emory University, Division of Physical Therapy
Atlanta, GA