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The Rancho Los Amigos Scale

    The Rancho Los Amigos scale was developed at the Rancho Los Amigos Hospital in California by the Head Injury Treatment team.  This scale is useful to therapists and families to help understand the behavior and progression of the head injury survivor as he goes through rehabilitation.  These levels are applicable in the first weeks or months following the injury and are not intended to predict improvement over the long term.

    Progress is rapid at first.  The patient will move between the levels quickly.  However, as the months go by, progress will slow and at some point the patient may seem to plateau around level VI or VII.  The level at which the patient plateaus cannot be predicted beforehand.  Patients may also have characteristics of more than one level at a time.

Level 1 - NO RESPONSE: Does not respond to voices, sounds, light, or touch; appears in a deep sleep.

Level 2 - GENERALIZED RESPONSE: Limited, inconsistent, non-purposeful responses; first reaction may be to deep pain; may open eyes but will not seem to focus on anything in particular.

Level 3 - LOCALIZED RESPONSE: Inconsistent responses but purposeful in that reacts in a more specific manner to stimulus; may focus on a presented object; may follow simple commands.

Level 4 - CONFUSED, AGITATED: Heightened state of activity; confusion; unable to do self-care; unaware of present events. Reacts to own inner confusion, fear, disorientation; excitable behavior may be abusive or aggressive.

Level 5 - CONFUSED, INAPPROPRIATE, NON-AGITATED: Appears alert; responds to commands; follows tasks for 2-3 minutes but easily distracted by environment; frustrated; verbally inappropriate; does not learn new information.

Level 6 - CONFUSED APPROPRIATE: Follows simple directions consistently; needs cueing; can relearn old skills; serious memory problems but improving; attention improving; self-care tasks performed without help; some awareness of self and others.

Level 7 - AUTOMATIC APPROPRIATE: If physically able, can carry out routine activities but may have robot-like behavior, minimal confusion, shallow recall; poor insight into condition; initiates tasks but needs structure; poor judgement, problem-solving and planning skills; overall appears normal.

Level 8 - PURPOSEFUL APPROPRIATE: Alert, oriented; recalls and integrates past events; learns new activities and can continue without supervision; independent in home and living skills; capable of driving; defects in stress tolerance, judgment; abstract reasoning persist; many function at reduced levels in society.

References:
Lake Erie Institute of Rehabilitation, 137 West Second Street, Erie, Pennsylvania, 16507

Mitiguy, J.S., Thompson, G.T., & Wasco, J. (1990). Understanding Brain Injury. Massachusetts: New Medico Head Injury System.

National Head Injury Foundation. "Coma: Its Treatment and Consequences."

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