Rancho Los Amigos Scale – Stages of Recovery After Traumatic Brain Injury

A key element in the development of a Life Care Plan is the creation of a thorough medical record summary highlighting the details of an individual’s initial injury, treatment interventions, and symptomology. The Life Care Planner must have a broad understanding of medical diagnoses and their related symptoms. The spectrum of symptoms following a traumatic brain injury (TBI) can be wide and often highly complex depending on the severity of the brain injury.

Several clinical scales have been developed to assist providers in quickly assessing and categorizing TBI patients such as the Glascow Coma Scale, Post-Traumatic Amnesia Scale, Mayo Classification System of TBI Severity, and The Ranchos Los Amigos Scale. Identifying and comprehending these scales can enable the Life Care Planner to better predict the likelihood of specific future treatment modalities and guide conversations when collaborating with treating providers.

Developed in the 1970s at the Rancho Los Amigos National Rehabilitation Center in California, the Rancho Los Amigos Scale (also known as the Rancho Los Amigos Levels of Cognitive Functioning Scale) is a widely utilized clinical tool for identifying and describing the stages of cognitive and behavioral recovery following a traumatic brain injury (TBI). This scale helps clinicians assess a patient’s current level of function and track progress throughout the rehabilitation process. It was later revised to the Revised Rancho Los Amigos Scale (RLAS-R) and contains ten levels ranging from the most severely impaired (Level 1) to near or full independent functioning (Level 10).

Listed below are the ten levels of the scale and their corresponding descriptions:

Level I: No Response – Total Assistance. The person appears in a coma-like state. There is no observable response to any external stimuli (sound, touch, pain, light, etc.). They seem asleep or unresponsive.

Level II: Generalized Response – Total Assistance Responses begin but are inconsistent, non-purposeful, and generalized (e.g., the same delayed reflex or body movement to any stimulus, like pain or sound). Responses are often the same regardless of what stimulus is applied.

Level III: Localized Response – Total Assistance Responses become more specific and directly related to the stimulus (e.g., turning head toward sound, pulling away from pain, blinking at bright light, or inconsistently following a simple command like "squeeze my hand"). Still highly inconsistent and delayed.

Level IV: Confused/Agitated – Maximal Assistance The person is alert but extremely confused and agitated. They may be hyperactive, aggressive, resistant, or emotionally volatile with rapid mood swings. Short attention span, no recent memory, uncooperative, may try to pull out tubes/restraints or wander. Speech may be incoherent or inappropriate.

Level V: Confused, Inappropriate Non-Agitated – Maximal Assistance Agitation decreases, but confusion persists. The person can follow simple commands inconsistently and may perform familiar tasks with cues, but has poor judgment, memory problems, and distractibility. Behavior is often inappropriate to the situation.

Level VI: Confused, Appropriate – Moderate Assistance The person shows more goal-directed behavior and can follow simple routines with direction. Memory and problem-solving are still impaired. They may recognize familiar people/places but remain confused about details and need supervision for safety.

Level VII: Automatic, Appropriate – Minimal Assistance for Daily Living The person functions automatically in familiar environments and routines with minimal supervision. They can perform daily activities but may still have abstract thinking deficits, reduced insight, or difficulty in new/unfamiliar situations. Judgment and problem-solving remain limited.

Level VIII: Purposeful and Appropriate – Stand-by Assistance The person is alert, oriented, and can respond appropriately most of the time. They can learn new things with some effort and have good recall. May still have mild deficits in higher-level cognition (complex planning, abstract reasoning)) but can live independently with occasional stand-by support or cueing.

Level IX: Purposeful and Appropriate – Stand-by Assistanceon Request Independent in most daily activities. Can think about consequences, plan ahead, and adjust behavior. Still may need occasional help or structure for very complex tasks, stressful situations, or when insight is challenged.

Level X: Purposeful and Appropriate – Modified Independent Fully independent in society with only minor residual deficits (if any). Can handle multiple tasks, new learning, and abstract thinking effectively. May use compensatory strategies for subtle remaining issues.

This scale focuses on awareness, behavior, functional ability, and cognition and can be assigned based on physician observation and interaction. While an individual’s exact level on the scale can fluctuate or remain permanent, comprehension of this scale can assist Life Care Planners in the early stages of Life Care Plan development and may result in more targeted and impactful discussions with treating providers during the process of obtaining future treatment recommendations.