For Individuals/Families

Rancho Los Amigos Scale

Health care teams use the Rancho Los Amigos Scale to describe a person’s recovery from a brain injury. (The scale is named after the hospital in the United States where it was created.)

Each level describes general patterns of response. However, it is important to note that each person will recover differently. People with brain injury:

  • may not pass through all levels
  • may skip levels
  • may never be at the lower levels—or may never reach the upper levels
  • do not usually move quickly and clearly from one level to another. They may be in more than one level at the same time.

Find out more about how you can support your family member in these stages of recovery.

The Scale

Level I. No Response

Person appears to be in a deep sleep and is unresponsive to stimuli.

Level II. Generalized Response

Person reacts inconsistently and non-purposefully to stimuli in a nonspecific manner. Reflexes are limited and often the same, regardless of stimuli presented.

Level III. Localized Response

Person’s responses are specific but inconsistent, and are directly related to the type of stimulus presented, such as turning head toward a sound or focusing on a presented object. The individual may follow simple commands in an inconsistent and delayed manner.

Level IV. Confused-Agitated

Person is in a heightened state of activity and severely confused, disoriented, and unaware of present events. Behaviour is frequently bizarre and inappropriate to the immediate environment. She/he is unable to perform self-care. If not physically disabled, the person may perform automatic motor activities such as sitting, reaching and walking as part of this agitated state, but not necessarily as a purposeful act.

Level V. Confused-Inappropriate, Non-Agitated

Person appears alert and responds to simple commands. More complex commands, however, produce responses that are non-purposeful and random. The person may show some agitated behaviour, but it is in response to external stimuli rather than internal confusion. Is highly distractible and generally has difficulty in learning new information. Can manage self-care activities with assistance. The person’s memory is impaired and verbalization is often inappropriate.

Level VI. Confused-Appropriate

Person shows goal-directed behaviour, but relies on cueing for direction. Can relearn old skills such as activities of daily living, but memory problems interfere with new learning. She/he has a beginning awareness of self and others.

Level VII. Automatic-Appropriate

Person goes through daily routine automatically, but is robot-like with appropriate behaviour and minimal confusion. Has shallow recall of activities, and superficial awareness of, but lack of insight into, his/her condition. Person requires at least minimal supervision because judgment, problem solving, and planning skills are impaired.

Level VIII. Purposeful-Appropriate

Person is alert and oriented, and is able to recall and integrate past and recent events. Can learn new activities and continue in home and living skills, though deficits in stress tolerance, judgment, abstract reasoning, social, emotional, and intellectual capacities may persist.

Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972.