The Rancho Los Amigos Scale (RLAS), also known as the Ranchos Scale, is a widely accepted medical scale used to describe cognitive and behavioral patterns in patients with brain injury as they recover. It was originally developed by the head injury team at the Rancho Los Amigos Hospital in Downey, California to assess patients emerging from a coma. It is often used in conjunction with the Glasgow Coma Scale during the initial assessment of a brain injury patient. However, unlike the Glasgow Coma Scale, it is used throughout the recovery period and not limited to the initial assessment. It takes into account a patient’s level of consciousness as well as their reliance on assistance with cognitive and physical functions. The original scale consisted of 8 levels, with level 1 representing the lowest level of function and level 8 the highest. As a patient progresses to higher levels, they demonstrate improved cognitive and behavioral states and move toward greater independence. Individuals move through the different levels in a sequential pattern. However, the time spent in each level and the maximum level achieved vary among individuals. Individuals can also demonstrate overlap in behaviors across different levels and skip levels during their recovery. The original scale has since been revised and is known as the Rancho Los Amigos Revised Scale (RLAS-R). One limitation of the original 8-level scale was that it did not accurately reflect individuals at higher levels of recovery. Two more levels were added to the initial 8-level Ranchos Scale, creating a more comprehensive 10-level scale, the RLAS-R. Each level is further described in detail below. No response to external stimuli . Responds inconsistently and non-purposefully to external stimuli. Responses are often the same regardless of the stimulus. Responds inconsistently and specifically to external stimuli. Responses are directly related to the stimulus, for example, the patient withdraws or vocalizes to painful stimuli. Responds more to familiar people (friends and family) than to strangers. The individual is in a hyperactive state with bizarre and non-purposeful behavior. Demonstrates agitated behavior that originates more from internal confusion than the external environment. Absent short-term memory. Shows an increase in consistency with following and responding to simple commands. Responses are non-purposeful and random to more complex commands. Behavior and verbalization are often inappropriate, and the individual appears confused and often confabulates. If action or tasks are demonstrated, an individual can perform, but does not initiate tasks on their own. Memory is severely impaired, and learning new information is difficult. Different from level IV in that the individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli. Able to follow simple commands consistently. Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face); however, unable to retain learning for new tasks. Demonstrates increased awareness of self, situation, and environment, but is unaware of specific impairments and safety concerns . Responses may be incorrect secondary to memory impairments, but appropriate to the situation. Oriented in familiar settings. Able to perform daily routine automatically with minimal to absent confusion. Demonstrates carry over for new tasks and learning in addition to familiar tasks. Superficially aware of one’s diagnosis but unaware of specific impairments. Continues to demonstrate a lack of insight, decreased judgment, and safety awareness. Beginning to show interest in social and recreational activities in structured settings. Requires at least minimal supervision for learning and safety purposes. Consistently oriented to person, place, and time. Independently carries out familiar tasks in a non-distracting environment. Beginning to show awareness of specific impairments and how they interfere with tasks, however, requires standing by assistance to compensate. Able to use assistive memory devices to recall daily schedule. Acknowledges others’ emotional states and requires only minimal assistance to respond appropriately . Demonstrates improvement in memory and the ability to consolidate past and future events. Often depressed, irritable, and with a low frustration threshold. Able to shift between different tasks and complete them independently. Aware of and acknowledges impairments when they interfere with tasks and can use compensatory strategies to cope. Unable to independently anticipate obstacles that may arise secondary to impairment. With assistance, one can think about the consequences of actions and decisions. Acknowledges the emotional needs of others with stand-by assistance. Continues to demonstrate depression and a low frustration threshold. Able to multitask in many different environments with extra time or devices to assist. Able to create own methods and tools for memory retention. Independently anticipates obstacles that may occur as a result of impairments and takes corrective actions. Able to independently make decisions and act appropriately, but may require more time or compensatory strategies. Demonstrate intermittent periods of depression and low frustration threshold when under stress. Able to appropriately interact with others in social situations.
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