RANCHO Los Amigos Scale

This scale is commonly used by both medical and rehabilitation providers to measure and track cognitive recovery after traumatic brain injury. It is a 10-point scale, although many medical professionals only use the first eight levels. All levels are defined below:

Level I No Response: Appears to be in a deep sleep and does not outwardly respond to pain or stimulation of the senses.

Level II Generalized Response: Will sometimes respond to stimulation by becoming more or less physically active. The person's reaction may be the same to pain, noise, a visual stimulus or any other stimulation encountered. He or she will continue to "sleep" much of the time.

Level III Localized Response: Is awake a greater amount of the time and reacts more to what is happening around him or her. For example, the person may begin to turn toward sounds such as a door closing or to look at objects. Also, the person may begin to recognize familiar faces.

Level IV Confused, Agitated: Behavior may appear bizarre and out of character at this stage. The individual may act aggressively and attempt to remove restraints, tubes, or crawl out of bed. Talking may be incoherent and not related to anything around them. The person has a hard time remembering current events and may only recall what happened prior to the accident.

Level V Confused, Inappropriate, Not Agitated: More alert and beginning to follow simple directions. Situations or activities that are unfamiliar or difficult may trigger restless behavior or outbursts, but this happens less frequently. Concentration improved, but redirection is still needed. Poor memory from moment to moment.

Level VI Confused, Appropriate: Now follows simple directions consistently. Beginning to show awareness of the injury and may become frustrated or annoyed when they can't do things they could before the injury. Confused and disoriented at times. Attends activities for up to 30 minutes.

Level VII Automatic, Appropriate: Appears appropriate and normal on the surface. Goes through daily routine automatically, but may have little recollection of what has been happening day to day or week to week. Improving awareness. Lack of insight and judgment for safety.

Level VIII Purposeful-Appropriate, Standby Assistance: Oriented to person, place, time and space. Able to complete familiar activities in a distracting environment for short periods of time. Uses memory device with help. May still require supervision for some familiar executive tasks. Depression, irritability, and frustration common.

Level IX Purposeful-Appropriate, Standby Assistance at Request: Able to shift attention back and forth between activities without help. Uses memory device independently. Assistance with problem solving. Occasional help for socially acceptable behavior. Periods of depression, irritability and low tolerance for frustration.

Level X Modified Independence: Completes activities from before injury independently with extra time and compensatory techniques. Requires periodic breaks for fatigue. Anticipates and independently solves problems. May still have periods of depression and frustration especially when tired, under stress, or sick.

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