Ranchos Los Amigos


Article Author:
Katherine Lin


Article Editor:
Michael Wroten


Editors In Chief:
Michael Labanowski


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/29/2019 11:59:18 PM

Introduction

 The Rancho Los Amigos Scale (RLAS), also known as the Ranchos Scale, is a widely accepted medical scale used to describe the cognitive and behavioral patterns found in brain injury patients as they recover from injury. It was originally developed by the head injury team at the Rancho Los Amigos Hospital in Downey, California to assess patients emerging from a coma.[1][2][3]

It is often used in conjunction with the Glasgow Coma Scale during the initial assessment of a brain injury patient. However, unlike the Glasgow Coma Scale, it is used throughout the recovery period and not limited to the initial assessment. It takes into account a patient’s state of consciousness as well as their reliance on assistance to carry out their cognitive and physical functions.[4][5][6][4]

The original scale consisted of eight levels, with level 1 representing the lowest level of function and level 8, the highest level of function. As a patient progresses to higher levels, they demonstrate improved cognitive and behavioral states and move toward greater independence. Individuals move through the different levels in a sequential pattern. However, the amount of time spent in each level and the maximum level achieved is variable among individuals. Individuals can also demonstrate an overlap of behaviors between two different levels and they can skip levels during their recovery.

The original scale has since been revised and is known as the Rancho Los Amigos Revised Scale (RLAS-R). One of the limitations of the original eight level scale was that it did not accurately reflect the individuals with higher levels of recovery. Two more levels were added to the initial eight level Ranchos Scale to create a more comprehensive ten level scale named the Rancho Los Amigos Revised Scale (RLAS-R). Each level will be further described in detail below.

Level I: No Response: Total Assistance

  • No response to external stimuli            

Level II: Generalized Response: Total Assistance

  • Responds inconsistently and non-purposefully to external stimuli
  • Responses are often the same regardless of the stimulus

Level III: Localized Response: Total Assistance

  • Responds inconsistently and specifically to external stimuli
  • Responses are directly related to the stimulus, for example, patient withdraws or vocalizes to painful stimuli
  • Responds more to familiar people (friends and family) versus strangers

Level IV: Confused/Agitated: Maximal Assistance

  • The individual is in a hyperactive state with bizarre and non-purposeful behavior
  • Demonstrates agitated behavior that originates more from internal confusion than the external environment
  • Absent short-term memory

Level V: Confused, Inappropriate Non-Agitated: Maximal Assistance

  • Shows increase in consistency with following and responding to simple commands
  • Responses are non-purposeful and random to more complex commands
  • Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates
  • If action or tasks is demonstrated individual can perform but does not initiate tasks on own
  • Memory is severely impaired and learning new information is difficult
  • Different from level IV in that individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli.

Level VI: Confused, Appropriate: Moderate Assistance

  • Able to follow simple commands consistently
  • Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks
  • Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns 
  • Responses may be incorrect secondary to memory impairments but appropriate to the situation

Level VII: Automatic, Appropriate: Minimal Assistance for Daily Living Skills

  • Oriented in familiar settings
  • Able to perform daily routine automatically with minimal to absent confusion
  • Demonstrates carry over for new tasks and learning in addition to familiar tasks
  • Superficially aware of one’s diagnosis but unaware of specific impairments
  • Continues to demonstrate lack of insight, decreased judgment and safety awareness
  • Beginning to show interest in social and recreational activities in structured settings
  • Requires at least minimal supervision for learning and safety purposes.

Level VIII: Purposeful, Appropriate: Stand By Assistance

  • Consistently oriented to person, place and time
  • Independently carries out familiar tasks in a non-distracting environment
  • Beginning to show awareness of specific impairments and how they interfere with tasks, however, requires standing by assistance to compensate
  • Able to use assistive memory devices to recall daily schedule
  • Acknowledges other’s emotional states and requires only minimal assistance to respond appropriately 
  • Demonstrates improvement of memory and ability to consolidate the past and future events
  • Often depressed, irritable and with low frustration threshold

Level IX: Purposeful, Appropriate: Stand By Assistance on Request

  • Able to shift between different tasks and complete them independently
  • Aware of and acknowledges impairments when they interfere with tasks and able to use compensatory strategies to cope
  • Unable to independently anticipate obstacles that may arise secondary to impairment
  • With assistance able to think about consequences of actions and decisions
  • Acknowledges the emotional needs of others with stand by-assistance.
  • Continues to demonstrate depression and low frustration threshold

Level X: Purposeful, Appropriate: Modified Independent 

  • Able to multitask in many different environments with extra time or devices to assist
  • Able to create own methods and tools for memory retention
  • Independently anticipates obstacles that may occur as a result of impairments and take corrective actions
  • Able to independently make decisions and act appropriately but may require more time or compensatory strategies
  • Demonstrate intermittent periods of depression and low frustration threshold when under stress
  • Able to appropriately interact with others in social situations

Function

The Rancho Los Amigos Scale-Revised (RLAS-R) is a ten level descriptive scale that provides a standardized measure that healthcare professionals can use to understand a brain injury patient's abilities, impairments, and prognosis better, as they move through the stages of recovery. It facilitates communication among treating healthcare professionals and aids in treatment planning.[7]

Clinical Significance

The RLAS-R is often used in conjunction with the Glasgow Coma Scale (GCS) to provide an early assessment of cognitive function in brain injury patients. Differing from the GCS, the RLAS-R is helpful in evaluating a patient's recovery beyond the initial emergence from coma. Earlier screening of cognitive function plays an important role in the prediction of recovery outcomes and facilitates rehabilitation planning in a clinical setting.[8][9][10]

The Ranchos Los Amigos Scale was shown to have high inter-rater reliability and concurrent, predictive value. It is often used in conjunction with the GCS.

Enhancing Healthcare Team Outcomes

The Rancho Los Amigos Scale-Revised (RLAS-R) is a ten level descriptive scale that provides a standardized measure that healthcare professionals including nurses, therapists and physicians can use to understand a brain injury patient's abilities, impairments, and prognosis better, as they move through the stages of recovery. It facilitates communication among treating healthcare professionals and aids in treatment planning


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Ranchos Los Amigos - Questions

Take a quiz of the questions on this article.

Take Quiz
A patient with traumatic brain injury who has a Rancho Los Amigos score of 3 is being evaluated for motor control by an occupational therapist. What will the therapist observe?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with traumatic brain injury has short gross attention and no selective attention. His behaviors and verbalizations are non-purposeful and inappropriate. He is aggressive and shouts for no reason. It takes maximal assistance to perform self-care. At what Ranchos Los Amigos level is the patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What Rancho Los Amigos level should be reached before a patient with traumatic brain injury should consider driving?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a traumatic brain injury can follow simple one-step directions, has decreased information processing ability, and is not always oriented. He has awareness of basic needs, self, and family but impaired short term memory. What level has he reached on the Rancho Los Amigos scale?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has had traumatic brain injury and is at revised Rancho Los Amigos level V. What is the best treatment goal for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which Rancho Los Amigos level would benefit most from sensory stimulation treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
At what Rancho Los Amigos level would sensory stimulation be least appropriate?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
At what Rancho Los Amigos level would the practice of tasks and repetition be of most benefit?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is at Rancho Los Amigos level VIII. Which of the following would be least appropriate?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A traumatic brain injury patient is described as Level V - confused, inappropriate non-agitated: maximal assistance. What scale is being used?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has post traumatic brain injury. He is beginning to engage in goal directed behavior with familiar tasks, but requires moderate assistance for completion. He is beginning to be inconsistently oriented to person, time and place, however still continues to be confused. What level is this on the Rancho Los Amigos Cognitive Functioning Scale (RLAS)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You are called to see a patient on the inpatient brain injury unit who is exhibiting hostile behavior. He is making attempts to crawl out of bed and remove his IV lines. He is unable to be re-directed and is unable to coherently verbalize what, if anything, is specifically bothering him. He appears to be more responsive to internal stimuli and is not oriented to person, place, or time. Using the Rancho Los Amigos Scale - Revised, what is his level of cognitive function?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Ranchos Los Amigos - References

References

Al-Hassani A,Strandvik GF,El-Menyar A,Dhumale AR,Asim M,Ajaj A,Al-Yazeedi W,Al-Thani H, Functional Outcomes in Moderate-to-Severe Traumatic Brain Injury Survivors. Journal of emergencies, trauma, and shock. 2018 Jul-Sep;     [PubMed]
Hartmann A,Kegelmeyer D,Kloos A, Use of an Errorless Learning Approach in a Person With Concomitant Traumatic Spinal Cord Injury and Brain Injury: A Case Report. Journal of neurologic physical therapy : JNPT. 2018 Apr;     [PubMed]
Mandaville A,Ray A,Robertson H,Foster C,Jesser C, A retrospective review of swallow dysfunction in patients with severe traumatic brain injury. Dysphagia. 2014 Jun;     [PubMed]
Lapitskaya N,Moerk SK,Gosseries O,Nielsen JF,de Noordhout AM, Corticospinal excitability in patients with anoxic, traumatic, and non-traumatic diffuse brain injury. Brain stimulation. 2013 Mar;     [PubMed]
Yap SG,Chua KS, Rehabilitation outcomes in elderly patients with traumatic brain injury in Singapore. The Journal of head trauma rehabilitation. 2008 May-Jun;     [PubMed]
Irdesel J,Aydiner SB,Akgoz S, Rehabilitation outcome after traumatic brain injury. Neurocirugia (Asturias, Spain). 2007 Feb;     [PubMed]
Ng YS,Chua KS, States of severely altered consciousness: clinical characteristics, medical complications and functional outcome after rehabilitation. NeuroRehabilitation. 2005;     [PubMed]
Duff D, Review article: altered states of consciousness, theories of recovery, and assessment following a severe traumatic brain injury. Axone (Dartmouth, N.S.). 2001 Sep;     [PubMed]
Rader MA,Alston JB,Ellis DW, Sensory stimulation of severely brain-injured patients. Brain injury. 1989 Apr-Jun;     [PubMed]
Davis AE,Gimenez A, Cognitive-behavioral recovery in comatose patients following auditory sensory stimulation. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2003 Aug;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Clinical Neurology-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Clinical Neurology-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Clinical Neurology-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Clinical Neurology-Medical Student. When it is time for the Clinical Neurology-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Clinical Neurology-Medical Student.