Rancho Los Amigos Scale-Revised (RLAS-R)

Behavioral Presentation

• No response to external stimuli (sounds, sight, touch, movement)
• Appears to be in a deep sleep; does not outwardly respond to pain or sensory stimulation
• Limiting factor: arousal

Therapy Approach

Session structure: Short sessions (10–15 minutes), multiple times per day if tolerated. Rest periods between sessions.

Primary approach: Systematic multimodal sensory stimulation — auditory, tactile, olfactory, visual, and proprioceptive input presented one modality at a time with rest periods between. Familiar stimuli are more likely to elicit responses than novel ones: family voices, preferred music, meaningful scents.

Physical: Passive ROM for contracture prevention, skin integrity checks, positioning for arousal and aspiration precaution.

Family education: Teach family what to bring (favorite music, familiar scents), how to provide meaningful stimulation, and what types of responses to watch for and document.

Assessment: Administer CRS-R to establish baseline and guide goal writing. Document all behavioral observations systematically.

Goal direction: Elicit any localized or stimulus-specific behavioral response.

Behavioral Presentation

• Responds inconsistently and non-purposefully to external stimuli
• Responses are often the same regardless of the type of stimulus
• May become more or less physically active in response to stimulation
• Sleeps much of the time

Therapy Approach

Session structure: Short sessions with rest between modalities. Minimize background noise during sessions.

Primary approach: Continue multimodal sensory stimulation. Begin documenting which stimuli elicit responses and whether responses vary by modality — this data helps differentiate generalized from localized responding over time. Familiar stimuli remain preferred.

Communication: Begin attempting informal yes/no assessment (eye blink, hand squeeze, head nod) even if responses are inconsistent. Document all observations.

Physical: Passive and active-assisted ROM, positioning, skin integrity.

Family education: Instruct family to observe and log responses they notice across the day. Family-observed responses at rest can be clinically significant.

Assessment: CRS-R serial administration (minimum 5 sessions per evaluation period). Serial documentation allows tracking of trajectory.

Goal direction: Demonstrate stimulus-specific responses; elicit any purposeful or localized movement.

Behavioral Presentation

• Responds inconsistently and specifically to stimuli — responses are directly related to the type of stimulus (e.g., withdraws or vocalizes to pain)
• Responds more to familiar people than strangers
• Awake a greater amount of the time; beginning to turn toward sounds or look at objects

Therapy Approach

Primary approach: Shift toward structured stimulation targeting localization. Begin single-step command-following trials with adequate wait time (up to 30 seconds).

Communication: Assess for reliable yes/no: eye blink, thumb up, gaze shift, head nod. If any consistent signal emerges, begin developing a binary communication system with SLP. AAC evaluation is a priority at this level.

Assessment: CRS-R is critical at this level to distinguish VS from MCS — both can present as Level III on the Rancho. The distinction carries significant prognostic and ethical implications.

Family education: Teach family how to give adequate wait time and interact purposefully rather than with rapid, continuous stimulation.

Goal direction: Consistent localization to familiar stimuli; emerging command following on CRS-R; establish at least one reliable yes/no signal.

Behavioral Presentation

• Hyperactive state with bizarre and non-purposeful behavior
• Agitation originates from internal confusion, not the external environment
• Absent short-term memory; may only recall events prior to the injury
• May act aggressively, attempt to remove restraints or tubes, or crawl out of bed
• Talking may be incoherent and unrelated to surroundings

Therapy Approach

Session structure: Short, frequent sessions (10–15 minutes). End sessions before agitation escalates rather than pushing through.

Approach: Reduce environmental stimulation during sessions (close door, dim lights, minimize people in the room). One-step commands only. Familiar, meaningful tasks are more effective than standardized testing. Consistent routine and predictable structure reduce agitation.

Safety: Agitation at this level originates from internal confusion — restraints can worsen it. Assess line and tube safety, document behavioral triggers, and coordinate a consistent behavioral management plan with nursing across the team.

Interaction style: Do not argue, correct, or confront. Redirect calmly. Avoid overstimulating or demanding environments.

Family education: This is a phase of recovery, not a permanent state. Teach family how to de-escalate, what triggers to avoid, and that agitation is neurological rather than intentional.

Goal direction: Tolerate a 10-minute structured session; reduce agitation frequency or duration; follow one-step commands with redirection.

Behavioral Presentation

• Increasing consistency with following and responding to simple commands
• Responses are non-purposeful and random to more complex commands
• Behavior and verbalization often inappropriate; frequently confused and confabulates
• Can perform tasks when demonstrated but does not initiate independently
• Memory severely impaired; new learning is difficult
• Less agitated than Level IV; unfamiliar or difficult situations may still trigger outbursts

Therapy Approach

Session structure: Structured sessions with frequent breaks. Consistent, distraction-reduced environment. Predictable daily routine.

Primary approach: Begin basic ADL tasks at maximum assistance using errorless learning — structure tasks so the patient succeeds rather than practicing errors. Demonstrated tasks are better tolerated than verbal instruction alone.

Cognition: New learning is severely impaired; do not expect carryover of newly introduced information. Begin formal cognitive screening if tolerated (ACE, Orientation Log).

Communication: Verbal output is often inappropriate or confabulatory — do not correct aggressively. Use yes/no format when assessing preferences or comprehension.

Goal direction: Purposeful participation in basic ADLs with maximal assistance; tolerate 15–20 minute session with structured breaks; follow simple two-step commands.

Behavioral Presentation

• Follows simple commands consistently
• Retains learning for familiar pre-injury tasks (e.g., brushing teeth, washing face) but unable to retain new learning
• Increased awareness of self, situation, and environment; unaware of specific impairments and safety concerns
• Responses may be incorrect due to memory impairment but appropriate to the situation
• Beginning to recognize the injury; may become frustrated or annoyed when unable to do things they could before
• Attends to activities for up to 30 minutes

Therapy Approach

Primary approach: Functional ADL tasks — procedural memory is often preserved at this level, so familiar pre-injury routines can be performed even when new learning is impaired. Capitalize on this.

Cognition: Introduce new tasks and compensatory strategies slowly; expect slow acquisition and inconsistent carryover. Begin explicitly targeting safety awareness — the patient is becoming more independent but often lacks insight into impairments.

Emotional: Patient is beginning to recognize the injury and may express frustration, grief, or denial. Acknowledge and validate. Family education on emotional processing is important at this level.

Goal direction: Complete familiar ADLs with moderate assistance; demonstrate basic safety awareness; sustain attention for 30 minutes in a structured session.

Behavioral Presentation

• Oriented in familiar settings; performs daily routine automatically with minimal confusion
• Demonstrates carryover for new tasks as well as familiar tasks
• Superficially aware of diagnosis but unaware of specific impairments
• 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

Therapy Approach

Patients at this level are more typical of step-down or early acute rehabilitation than acute ICU.

Focus: Building insight into specific impairments and safety awareness. Introduce compensatory strategies for memory and executive function. Structured social and recreational engagement.

Goal direction: Independence in familiar ADLs with minimal supervision; begin using memory compensation devices with assistance.

Behavioral Presentation

• 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
• Able to use assistive memory devices to recall daily schedule
• Acknowledges others’ emotional states; requires minimal assistance to respond appropriately
• Often depressed, irritable, and with low frustration threshold

Therapy Approach

Patients at this level are more typical of inpatient rehabilitation than acute ICU.

Focus: Advanced compensatory strategy training; independent memory device use. Shift toward community-based and role-based activities. Address depression, emotional regulation, and fatigue management.

Goal direction: Independence in familiar tasks in distracting environments for short periods; independent use of memory device with prompting.

Behavioral Presentation

• Able to shift between tasks and complete them independently
• Aware of impairments when they interfere; able to use compensatory strategies
• Unable to independently anticipate obstacles from impairments
• With assistance, able to consider consequences of actions and decisions
• Continues to demonstrate depression and low frustration threshold

Therapy Approach

Patients at this level are more typical of outpatient rehabilitation.

Focus: Executive function and problem-solving training. Anticipatory planning — learning to predict and plan for obstacles before they occur. Community reintegration and work/school preparation. Depression and frustration management.

Goal direction: Independently use compensatory strategies; anticipate obstacles with minimal assistance.

Behavioral Presentation

• Able to multitask in multiple environments with extra time or assistive devices
• Creates own methods and tools for memory retention
• Independently anticipates obstacles from impairments and takes corrective action
• Able to make independent decisions; may require more time or compensatory strategies
• Intermittent periods of depression and low frustration threshold, particularly when tired, under stress, or ill

Therapy Approach

Patients at this level are primarily seen in outpatient or community settings.

Focus: Vocational, academic, and community role reintegration. Fatigue management and pacing strategies. Ongoing emotional support — depression and frustration may persist intermittently even at this level.

Goal direction: Modified independence across environments with self-generated compensatory strategies; periodic breaks for fatigue management.