The 10 Levels of Ranchos Los Amigos OTs Should Know

Do you love watching movies as much as I do?

If so, I am sure you have seen the moment in Hollywood movies, when a person has a car accident or a fall, and magically wakes up from their coma. They are immediately able to form a coherent sentence to their loved one and can climb right out of bed. A nearby nurse then screams for the doctor to come quickly, and the patient is immediately discharged. 

Unfortunately, occupational therapists are well aware that it is never that simple. Working in any neurological unit will quickly alert you to the fact that we have levels of consciousness.

A patient who has sustained a brain injury may have a low level of alertness initially, but usually as time passes, his level of consciousness or alertness improves.

If you’re wondering what tool you can use to track their cognitive and behavioral progress post brain injury, then wonder no more! Ranchos Los Amigos is my ‘go to’ assessment in a neurological unit. 

What is the Ranchos Los Amigos?

The Ranchos Los Amigos Scale-Revised (RLAS-R) is an outcome measure one can use in patients with brain injuries. It is a tool to rate an individual’s cognitive and behavioral patterns. It gives an indication on what stage of recovery the patient is in.

This scale records ten stages of recovery.

Take note: there used to be only 8 stages, however, they realized that the tool was not providing an accurate scale of progression towards the end of recovery, so another 2 stages were added.

As a result, there are now a total of 10 levels. We recommend printing out or saving the updated, revised version of the Ranchos Los Amigos Scale, especially if you have a high caseload of patients with brain injuries.

Let’s examine the 10 different levels: 

Level 1: No response (total assistance)

• No observable change in patient in response to different stimuli

Level 2: Generalized response (total assistance)

• Generalized reflex response to painful stimuli (may be delayed response). May involve movement or non-purposeful vocalization
• Response to auditory stimuli with increased/decreased activity
• Response is the same irrespective of type or location of stimulus

Level 3: Localized response (total assistance)

• Inconsistent following of simple instruction
• Responds specifically to the type of stimulus
• Begins to visually track objects within their visual field
• Presents with reaction to visual, auditory and painful stimuli
• Can be restless: pulling out tubes or drips

Level 4: Confused/Agitated (maximum assistance)

• More alert, and mood may be labile
• May be able to perform familiar motor activities (sitting, standing, walking) but it is non-purposeful
• Often doesn’t cooperate in occupational therapy session
• Incoherent verbalizations

Level 5: Confused, Inappropriate, Non-agitated (maximum assistance)

• Disoriented to time, place and person
• Severe impairment in recent memory and is unable to learn new information
• No longer agitated
• Sustains attention for very brief periods of time
• With structure and cuing: can engage in familiar tasks
• Follows simple instructions

Level 6: Confused, Appropriate (moderate assistance)

• Inconsistent orientation
• Starting to vaguely remember some staff members
• Supervision needed in ADLs
• Poor insight into abilities 

Level 7: Automatic, Appropriate (minimal assistance)

• Oriented
• Can sustain attention in highly familiar tasks for 30 minutes with minimal assistance
• Carry over with new learning
• Carries out ADLs independently
• Supervision required at home and in community activities

Level 8: Purposeful, Appropriate (standby assistance) 

• Can sustain attention in familiar task for 1 hour
• Able to recall past and recent events
• Can use external memory strategies for recall
• Can carry out familiar work, leisure, ADL and IADL activities with standby assistance
• Aware of impairments
• Poor frustration tolerance, may be irritable and/or depressed

Level 9: Purposeful, Appropriate (standby assistance)

• Can shift between different tasks for 2 hours
• Can carry out unfamiliar work, leisure, ADL and IADL activities with stand by assistance with assistance when requested
• Still requires stand by assistance for anticipating problems, responding to other’s needs and feelings, and self-monitoring appropriate social engagement

Level 10: Purposeful, Appropriate (modified independent)

• Able to hand variety of tasks in all environment, but may require breaks
• Independent in work, leisure, ADL and IADL tasks, but may requires increased time and/or use of compensatory strategies
• Appropriate social interactions
• May have periodic periods of depression

You can find an even more detailed explanation of each level from the Shepherd Center here. 

Who can use the Rancho Los Amigos Scale?

This tool is user friendly for the whole multidisciplinary team. Having a scale that is not OT-specific helps make interdisciplinary conversations easier.

This allows for more effective communications, as mentioning a patient’s level will allow a fellow health care provider to get a clearer idea of the patient’s impairments, abilities, and prognosis. 

Why You Should Use the Rancho Levels in Occupational Therapy

• The Ranchos Los Amigos Scale is quick to administer. 
• It doesn’t necessarily have to be done with your patient present. If you know them well enough, you can even score your patient after your session is done.
• It is used by the entire medical team.
• Designed for patients with brain injuries.
• It is helpful in tracking your patient’s progress.

Alternative Outcome Measures You Can Use

Glasgow Coma Scale

The Glasgow Coma Scale is yet another free outcome measure commonly used in people with low levels of consciousness. It is used in acute medical settings with any medical or trauma patient.

The benefit of the Ranchos Los Amigos Scale is that it’s been specifically designed for the community with brain injuries, and unlike the Glasgow Coma Scale, it can be used throughout your patient’s rehabilitation state with ongoing re-assessments and not just the initial assessment. 

Coma Recovery Scale

Like Ranchos Los Amigos, the Coma Recovery Scale is also a free outcome measure that has different scales to measure levels of consciousness in patients with neurological conditions. What is interesting about this scale, is that the 6 subscale items are arranged hierarchically to reflect brainstem, subcortical, and cortically-mediated behaviors.

The sub-scales are grouped into: auditory, visual, motor, oromotor, communication and arousal. 

Other outcome measures to consider: Creative Ability and Galveston Orientation and Amnesia Test (GOAT)

Helping Family Understand the Ranchos Los Amigos Scale

As I have progressed through my career as an occupational therapist, I have learned to never underestimate the power of educating my patients and their loved ones. It can, however, be challenging at times to explain medical terms in an easy to understand manner.

Brain Line has created a wonderful resource where the Ranchos Los Amigos levels are described in non-medical terms. It provides a guide for the family on what to expect from their loved one at each level. This can help family members understand the different levels of consciousness, and feel reassured that their family member’s behavior is “normal” according to the level they are at.

It also provides some guidance on how to interact with and support their loved one according to their Ranchos Los Amigos level. It will therefore be beneficial for the OT to let the family know what Ranchos Los Amigos level their loved one is on. 

_______________

To conclude, the Ranchos Los Amigos Scale is an excellent multidisciplinary tool that occupational therapists can use when working with individuals with brain injuries.

Use this scale to place your patient on a level to track their progress, guide your intervention, and educate your patient and their family members.