Rancho Los Amigos Scale

The Rancho Levels, as they are called, are an assessment tool or scale that does not require cooperation from the patient. Rather; they are based on observation of the patient as he responds to environmental stimuli. They provide a clear description of the various behavioral stages a brain injury victim will experience as he begins to progress through recovery toward rehabilitation.

The Rancho Levels are most useful in the first weeks or months following the injury. The speed at which progression from level to level will occur cannot be predicted. And just as the rate of progression cannot be predicted, the level of plateau cannot be predetermined.

An understanding of the characteristics of each of the eight Rancho Levels is helpful when families and professionals must deal with the behaviors demonstrated by patients following head injury. The descriptions listed below provide insight into the expected progression during recovery and rehabilitation.

I. No Response

Patient appears to be in a deep sleep and is unresponsive to stimuli.

II. Generalized Response

Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Reflexes are limited, and often the same, regardless of stimuli presented.

III. Localized Response

Patient responses are specific but inconsistent, and are directly related to the type of stimulus presented, such as turning head toward a sound or focusing on a presented object. He may follow simple commands in an inconsistent and delayed manner.

IV. Confused-Agitated

Patient is in a heightened state of activity and severely confused, disoriented and unaware of present events. His behavior is frequently bizarre and inappropriate to his immediate environment. He is unable to perform self-care. If not physically disabled, he may perform automatic motor activities such as sitting, reaching and walking as part of his agitated state, but not necessarily as a purposeful act.

V. Confused-Inappropriate, Non-Agitated

Patient appears alert and responds to simple commands. More complex commands, however, produce responses that are non-purposeful and random. The patient may show some agitated behavior it is in response to external stimuli rather than internal confusion. The patient is highly distractible and generally has difficulty in learning new information. He can manage self-care activities with assistance. His memory is impaired and verbalization is often inappropriate.

VI. Confused-Appropriate

Patient shows goal-directed behavior, but relies on cuing for direction. He can relearn old skills such as activities of daily living, but memory problems interfere with new learning. He has a beginning awareness of self and others.

VII. Automatic Appropriate

Patient goes through daily routine automatically, but is robot like with appropriate behavior and minimal confusion. He has shallow recall of activities, and superficial awareness of, but lack of insight to, his condition. He requires at least minimal supervision because judgment, problem solving, and planning skills are impaired.

VIII. Purposeful Appropriate

Patient is alert and oriented, and is able to recall and integrate past and recent events. He can learn new activities and continue in home and living skills, though deficits in stress tolerance, judgment, abstract reasoning, social, emotional and intellectual capacities may persist.

NEXT: Brain Injury Prognosis.

Understanding Subtle Brain Injury

The concussions that disable, are almost always more symptomatic at 24 hours, than at the 2-4 hour time frame when injured persons are evaluated in the emergency room. Brain injury symptoms escalate over the first 24 hours, because brain injury involves a cascade of events. It is critical that if you are still symptomatic the day after your injury, go back to the same Emergency Room, don’t wait for a doctors appointment. It is critical that the Emergency Room personnel see that the symptoms still persist or have gotten worse.

View Our Video Series on Concussions