Rancho Los Amigos Scale: Roadmap for Brain Injury Recovery

Understanding brain injuries can be overwhelming for patients, families, and caregivers alike because every brain injury follows a different recovery path. In this episode, “Rancho Los Amigos Scale: Roadmap for Brain Injury Recovery,” Tracie Lemus, RN, CCM, National Medical Catastrophic Nurse Consultant at MEC, breaks down the vital tool that healthcare professionals use to track cognitive and behavioral rehabilitation after brain trauma.

Tracie shares her perspective about how the Rancho Los Amigos Scale helps monitor recovery progress, determine appropriate treatment plans and timing, and facilitate coordination among the various specialists involved in a patient's care journey. This knowledge empowers healthcare teams to create more targeted rehabilitation strategies tailored to each patient's current cognitive and behavioral functioning. It includes:

• Tracking recovery progress through ten distinct levels, enabling better treatment planning and communication among medical team members.
• Valuable context for the often confusing and unpredictable nature of brain injury recovery.
• Factoring in both the patient’s state of consciousness and need for assistance with daily cognitive and physical functions.
• Projected timelines to help everyone involved understand where a patient currently stands and what challenges and progress might lie ahead.

Listen now to gain key insights into the Rancho Los Amigos Scale assessments, which offer a roadmap through the complex journey of brain injury rehabilitation by breaking down recovery into distinct, observable stages in the realm of neurological healing.

Chapters

• 0:00 Introduction to Expert Insights

Transcript

Speaker 1: 0:02

Hello, this is MEC Connect Expert Insights, a companion series to our main MEC Connect podcast for Midwest employers' casualty. I'm Sarah Hance and in these Expert Insights episodes, you'll hear from subject matter experts as they share practical tips and strategies on a variety of topics related to workers' comp and claims management. Today, tracy Lemus, national Catastrophic Medical Consultant, will discuss the Rancho Los Amigos Brain Injury Scale. Now let's hear from Tracy.

Speaker 2: 0:34

As a certified medical case manager, I've worked with many brain injured people over the years, from minor injuries to more complicated ones, and the thing I have learned the most is that literally every brain injury is different. So today I am happy to provide some information on the Rancho Los Amigos scale. This scale is a standardized measurement tool that is used to rate how people with brain injury are recovering. The Rancho scale, as it is frequently referred to, can measure an individual's abilities, or what they can do, as well as impairments or what they can't do or are not doing so well. The Rancho Scale can also help healthcare professionals to determine an appropriate treatment plan, like when a person is ready for different levels of rehab. It can also facilitate communication among the different treating healthcare professionals, like physical therapists, occupational therapists, speech and then different MD specialties. There are 10 levels of recovery noted in the scale, and each level describes a general pattern of recovery, with a focus on cognition and behavior.

Speaker 2: 1:37

Cognition refers to a person's thinking and memory skills. Behaviors describe how an individual acts in daily situations, so the Rancho scale takes into account the state of consciousness as well as the person's reliance on the assistance they need to carry out their daily cognitive and physical functions. I do want to note, though, that each patient will progress at their own rate. Some people will pass through each of the levels at a fast rate, for example, if they have a brain injury that is less severe, while others may only hit a certain level and fail to move forward. A physical or occupational therapist can determine a Rancho scale score. They should have received training in order to do this, as training and practice are important to be accurate. There are many factors that need to be considered when assigning a level of cognition, as each person's brain is different. There are a range of abilities within each of the levels is different. There are a range of abilities within each of the levels on the scale, and not every one fits perfectly into one particular level. Some individuals can demonstrate behaviors of more than one level at a time. The goal of recovery, or upward movement, is to see the same responses at different times of the day, consistent with all the people involved in their care, so not all of these levels will always be accomplished while a person is impatient, at different times of the day, consistent with all the people involved in their care. So not all of these levels will always be accomplished. While a person is impatient, they can continue to move through the scale in a home and or outpatient type of environment. We'll talk about the 10 levels on the Rancho scale. Level 1 is more severe, but both cognition and behaviors improve as you move upward through the stages up to 10.

Speaker 2: 3:04

Level one is where they're comatose, appears like they're sleeping, no response to sounds, touch or movement. At level two, they're more of a semi-comatose stage. They can have a generalized response to painful stimuli and they may respond to repeated sounds, touch or movement, but all of these responses may be significantly delayed. Level three they may appear to be more alert, can show withdrawal or vocalization to painful stimuli and they may turn toward or away from the sound. They may pull on tubes or restraints, respond inconsistently to simple commands, but they also might show signs of knowing family or friends. The next levels can be some of the more difficult ones for family, friends and caregivers. At level four, they are more alert but they're in a heightened state of activity. There are purposeful attempts to remove restraints or tubes. They may kick, bite, fall out of bed very difficult sometimes to contain. They may have absent short-term memory. They can overreact due to confusion and may say inappropriate things, tell inappropriate stories or even stories that aren't true. They have a short attention span and basically are unable to cooperate with any kind of treatment efforts.

Speaker 2: 4:13

At level five, they're alert and can follow simple commands. Most of the time they can wander randomly. They're usually not agitated, but they can become agitated in response to external stimulation and or lack of environmental structure, and this is shown throughout all levels with a brain injury. They can go one moment from being agitated to not agitated to agitated again. In level five, their short-term memory is impaired, attention to any task could be limited. There's absent goal-directed problem solving and self-monitoring. They're not really able to learn new information, but they may be able to perform previously learned tasks when structured and or they get cues that are provided to them. They may have difficulty starting an activity or can get stuck on a specific task. They're seldom aware of their limitations and they may not understand the purpose of rehab. And it's not uncommon for them to request to go home. You hear that a lot. They perseverate on going home.

Speaker 2: 5:08

The next few levels are where family, friends and or caregivers are starting to see the improvements. At least I feel that way. At level six, they're usually more functional, oriented to person and time and place, but just inconsistent. Remote memory has more depth and detail than recent memory. It can be easier to learn information at this stage, but details can be forgotten. There is improvement in basic care needs. They can follow simple commands more consistently and they can keep attention on a task for about 30 minutes. They may have trouble connecting thoughts with specific words or they do say things without thinking. They're unaware of impairments, disabilities and safety risks. They're still at moderate assist at this level, but you can see that they're more functional and that they have some improvement in their cognitive status. I feel like this is where again, where family and friends are starting to see their progression a little more.

Speaker 2: 5:58

At level seven, they're consistently orientated to person and place within highly familiar environments. Most daily activities are done automatically when the tasks have structure, concentration, judgment and problem solving, though still may be difficult. They need minimal supervision for safety and routine home and community activities, but safety is still a concern, as they may feel better, but they still lack judgment in some activities. When something is new, complex or different from the normal routine, it can really upset the apple cart, so to speak. They may have unrealistic planning for the future, unable to think about consequences of a decision or action, and they could be unaware of others' needs and feelings and not able to recognize inappropriate social interaction behavior. Again, we see the improvements as we move upward on the scale. But keep in mind with brain injuries it can fluctuate and people at this level are still usually not able to live independently.

Speaker 2: 6:53

Level eight is consistently oriented to person, place and time. They can independently attend to and complete familiar tasks for one hour. They can use assistive memory devices like cell phones and calendars to recall daily schedules and to-do lists. At this level they may not need supervision Once activities are learned and they can be independent at home and in the community. They think about consequences of a decision or action with minimal assistance, but they still can't overestimate or underestimate their ability. So that is something that they still need assistance with. They can acknowledge others' needs and feelings and they can respond appropriately with minimal assistance. They can recognize and acknowledge inappropriate social interaction behavior while it is occurring and take corrective action. But they also can have a low frustration tolerance and can be easily angered, argumentative, self-centered and uncharacteristically dependent or independent. Again, that is something that goes up and down the scale with a brain injury.

Speaker 2: 7:51

Level nine they can independently shift back and forth between tasks and they can complete them accurately for at least two consecutive hours. They're aware of knowledge impairments in their disabilities when they interfere with task completion and they can take appropriate corrective action. They still may require some assistance to anticipate a problem before it occurs and take action to avoid it. They're able to think about consequences of decisions or actions with assistance, accurately estimate abilities, but they still require that assistance to adjust to task demands. They can acknowledge others' needs and feelings and they can respond appropriately. Again, with minimal assistance they could still be easily irritable and have low frustration tolerance.

Speaker 2: 8:33

So as we have moved along, you have seen where they're able to maintain task activities for longer periods of time. It was 30 minutes and then we got up to two hours. So a lot of forward progress. And the later levels have to do with the same tasks but just more improvement as far as their ability to take corrective actions versus needing additional assistance. The last couple of levels, like the first couple of levels, are quite close, like with level 10, it's basically all the components of level 9, but the person is more independent in the task and can adjust to demands independently. They can anticipate impacts on ability to complete daily living tasks and will take action to avoid problems before they occur. They're able to recognize the needs and feelings of others and automatically respond in an appropriate manner. So social interaction behavior is consistently appropriate. So I wanted to say thank you for listening today. I hope you learned something new. Traumatic brain injury can be a complex topic and I hope you feel like our review of the Rancho Los Amigos scale has been helpful.

Speaker 1: 9:37

Thank you for tuning in to MEC Connect Expert Insights. Here at MEC, we focus on what matters most worker recovery and better claims outcomes. Our skilled people, proven processes and innovative technology achieve measurable results and creates lasting value. We hope you found Tracy's insights on the Rancho Los Amigos scale valuable. Stay tuned for more from MEC Connect and more expert insights. Thanks for listening.