Understanding the Rancho Brain Injury Scale

Brain Injury
doctor discusing rancho brain injury scale with patient

Cognitive skills describe the core skills the brain uses in abstract and critical thinking, paying attention, reasoning, learning and remembering. When the brain is injured, some of these skills may be lost or changed. The Rancho Los Amigos scale (RLAS), also known as the Rancho brain injury scale, is a tool used by a rehabilitation team to evaluate the cognitive and behavioral patterns in traumatic brain injury patients during recovery.

What is the Rancho Scale?

The Rancho scale was developed by the head injury department at Rancho Los Amigos Hospital in Downey, California, to assess the status of patients coming out of a coma. Now the scale is widely used to rate a patient’s recovery following a brain injury. It is helpful in determining a patient’s rehabilitation needs.

Originally, there were eight levels of cognitive functioning based on the typical stages, or levels, of recovery after a brain injury. The scale has been revised to include two additional levels. This updated scale is known as the Rancho Los Amigos Revised Scale, or RLAS-R.

Rancho Brain Injury Scale Levels

Identifying where a patient falls on the scale is helpful in preparing a treatment program based on the individual’s current abilities. How far and how quickly a patient progresses on the scale depends on the location of the brain damage, the severity of damage and the length of time that has passed since the brain injury occurred. Not every patient will achieve all levels.

The levels are defined as:

Level I: No Response

  • At this level a person does not respond to sounds, sights, touch or movement. They require total assistance.

Level II: Generalized Response

  • Begins to respond to sounds, sights, touch or movement; however, the response is inconsistent and without purpose.
  • Responses may be the same even with different stimuli.
  • Response time may be delayed and subtle such as rapid breathing, sweating or moaning.
  • Continues to require total assistance.

Level III: Localized Response

  • Responds directly to specific stimuli, such as withdrawing from painful stimuli or turning toward a sound.
  • May be awake at periods during the day.
  • Reactions may be inconsistent or delayed.
  • Responds better to family and friends than strangers.
  • May be able to follow simple commands inconsistently.
  • The eyes may follow an object.
  • Still requires total assistance.

Level IV: Confused and Agitated

  • Alert but in a highly agitated state.
  • Confused and overreactive. May scream, hit or curse.
  • Exhibits non-purposeful movements such as reaching, sitting or climbing out of bed.
  • May show aggressive behavior.
  • May have extreme mood swings not prompted by an event.
  • No short-term memory.
  • Difficulty following directions.
  • May be able to perform basic functions such as dressing or feeding themselves but require much assistance.

Level V: Confused and Inappropriate

  • Short attention span.
  • Continues to be confused.
  • Agitation is reduced in general, although may become agitated in response to external stimulation.
  • Does not initiate activities without prompting. Requires step-by-step instructions to complete everyday tasks such as brushing teeth.
  • Recent memory impairment. May not remember why they are in the hospital or current routines.
  • Difficulty learning new tasks.
  • Has memory impairment. May fill in memory blanks with false information, known as confabulation.
  • Requires maximum assistance.

Level VI: Confused and Appropriate

  • Memory and thinking improve but may still experience bouts of confusion. Remote memory remains better than recent memory.
  • Can follow simple directions but has difficulty learning new tasks.
  • More aware of physical condition than cognitive issues.
  • Attention span increases.
  • Able to perform most daily tasks—brush teeth, dress, feed self, comb hair, and so on, with assistance.

Level VII: Automatic and Appropriate

  • Overall oriented to environment and people. May not grasp time without help.
  • Able to follow a schedule, if set.
  • Can feed self and dress without assistance.
  • Difficulty paying attention with distractions around.
  • Poor judgment and decreased understanding of safety so still requires supervision.
  • Unable to discern inappropriate social behavior.
  • Self-focused. Unaware of the needs of others.
  • Unrealistic when it comes to future plans and ability to carry them out.

Level VIII: Purposeful and Appropriate

  • Oriented to people, surroundings and time.
  • Aware of thinking and memory problems.
  • Able to do some problem-solving.
  • May continue to have poor judgment in some situations and can become overwhelmed in difficult or stressful situations.
  • Carries out learned tasks with no assistance.
  • May be depressed or irritable and can anger easily.

Level IX: Purposeful and Appropriate

  • Able to move between tasks and complete them accurately for a minimum of two consecutive hours.
  • Can follow daily schedule with help of lists and memory devices.
  • Aware of impairments and limitations and can correct issues when they occur but unable to anticipate problems ahead of time.
  • Aware of the feelings of others but, at times, needs assistance to respond appropriately.
  • May continue to experience depression, frustration and irritability.

Level X: Purposeful and Appropriate

  • Can successfully multitask in all environments but may need breaks.
  • May require extra time but able to start and finish a variety of tasks.
  • Recognizes needs of others and responds appropriately.
  • Behaves appropriately in social situations.
  • Can create own methods to prompt memory.
  • Aware of the consequences of actions/decisions, but may require more time compensatory strategies to make the right choice.

The content of this site is for informational purposes only and should not be taken as professional medical advice. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding any medical conditions or treatments.