Recovery after brain injury is a process that occurs in stages. Some people move quickly through the stages, while others make slow, but steady gains.
The Rancho Los Amigos’ Levels of Cognitive Functioning, called the Ranchos Scale, is one scale that measures improvement. There are 8 stages or recovery.
You may find this scale helpful to follow your loved one’s progress. Progress through the levels may not happen all at once. A person may return to a lower stage because of fatigue, frustration or other changes during the day. Watch for changes towards the next higher stage. It may be frustrating when you do not see changes from day to day. Remember, gradual progress over time is more important.
|Level I:||No Response||The person is in a coma and may appear to be asleep.
They may be restless.
He or she does not respond to sounds, sights, touch or movement.
|How to Help during Level I and II Recovery:
|Level II:||Generalized Response||The person is semi-comatose. He or she begins to respond to sounds, sights, touch or movement.
Response is slow, inconsistent or occurs after a delay.
The person responds or mimics what is heard, seen or felt.
Responses may include:
|Level III:||Localized Response||The person appears more alert.
He or she reacts to what is seen, heard or felt. For example, the person may follow you with his or her eyes or turn the head towards sound.
When the person feels pain, an arm or leg may move, and he or she may cry out.
The person may follow simple commands, like “close your eyes.”
The person may show signs of knowing family or friends.
|How to Help during Level III Recovery:
Responses may not always be the same in Level III recovery.
A person may be able to follow a command or voice a response one day, but not the next day. Be patient. The person may be as frustrated as you are.
|Level IV:||Confused and Agitated||This stage can be difficult for families and friends.
The person may not understand what is happening (gets confused) and be scared.
He or she may try to remove all restraints, kick, hit or bite others, pull out tubes and crawl out of bed.
They may overreact due to confusion by screaming or say things that are not appropriate. He or she may make up stories to overcome internal confusion and fear.
Often, the person’s attention span is very short and he or she may lack short term recall.
Memory may be limited only to past events.
The person may be focused on basic needs like eating, going to
the bathroom, or dressing and need help with these activities.
|How to Help during Level IV Recovery:
|Level V:||Confused and Inappropriate||During this stage of recovery, the person is not as explosive or combative.
The person is more alert and can follow simple commands most of the time.
Complex or multiple step commands may lead to frustration and upset.
Attention to any task may be limited.
Long term memory of past events may be better than short term recall of daily events.
To fill in the gaps of memory, the person may make up stories.
He or she may have confusion due to problems learning or organizing information.
Most days, common activities of daily living, such as eating or dressing, can be done with few problems. However, the person may have difficulty starting an activity or get stuck on one step of a task.
Step by step instructions for specific tasks are very helpful.
The person is also seldom aware of his or her limitations. As a result, a person may not understand the purpose of rehabilitation. He or she is better able to understand physical injury than problems with thinking or memory.
It is not uncommon to hear requests to leave the hospital, or “go home.”
|How to Help during Level V Recovery:
|Level VI:||Confused and Appropriate
|At this stage, a person’s behaviour is more functional.
He or she can remember time, events of the day and major life events.
There is improvement in the care of basic needs. The person can follow simple commands more consistently and can keep attention for 30 minutes on a task.
It is easier to learn information at this stage, but details may be forgotten. For example, the person may remember talking with a family member, but forget what was said.
Response time to finish activities may still be slow.
May have trouble connecting thoughts with specific words or say things without thinking.
|How to Help during Level VI Recovery:
|Automatic and Appropriate||At this stage, most daily activities are done automatically when tasks have structure. Concentration, judgment and problem solving may be difficult.
Safety is a concern. The person may feel “better” but lacks judgment for some activities. For example, driving a car is not recommended.
When something is new, complex or different from the normal routine, it can lead to upset. Learning new information is possible, but it takes time and practice to retain.
During this stage, counselling for work or school may be appropriate.
|How to Help during Level VII Recovery:
|Level VIII:||Purposeful and Appropriate
|At this stage, the person has purpose in daily living.
He or she can recall and integrate past and present.
Carryover for new learning is evident.
The person needs no supervision once activities are learned and can be independent at home and in the community.
The person may continue to show decreased abilities, reasoning, judgment, stress tolerance, and emotional and intellectual capacity compared to pre-injury, yet be functional in society.
|How to Help during Level VIII Recovery:
The Ranchos scale is © Copyright 2004 – April 23, 2012. The Ohio State University Wexner Medical Centre.
"Pediatric neuro-rehabilitation cannot be delivered in isolation. The needs of the child have to be looked at both holistically and within the context of the family unit. Parents need to be empowered to be parents in post-acute pediatric neuro-rehabilitation following brain injury"
"Different 'experts' involved in pediatric neuro-rehabilitation come from different organisational cultures which causes conflict and has a negative effect on the outcomes for the child."
"More play increases brain plasticity and makes for better recovery post brain injury"
"When someone has a brain injury, early access to local, specialist rehabilitation is crucial to ensure the maximum recovery and make significant savings to the state in health costs"
"We are medical practitioners. The real experts are the parents. Over the last 35 years they have taught me everything I know"
"Poor parenting styles affects children's behavior; increases their learning disability; and has a negative impact on emotions; anxiety; anger management post brain injury"
"Parent-supported interventions after pediatric ABI bring reductions to the cost to society"
"Rehabilitation interventions can lead to positive outcomes for children and their families if delivered in the familiar home environment and applied to everyday situations"
"New parenting support intervention showed how parenting style is related to executive dysfunction in children and young people post brain injury. With support parents cope better so the child has a better recovery"
"We would like to see earlier identification and support for children with brain injuries to help them succeed in school."