Rancho Levels and Neuro-Rehabilitation Review

Key Terminology in Neuro-Rehabilitation

• Arousal: Defined as the physiological and psychological state of being awake. It indicates that the Reticular Activating System (RAS), autonomic nervous system, and endocrine system are functioning, even if they are performing at a low level or incorrectly.

• Consciousness: A state of being aware and alert. It is not defined specifically by cognitive abilities but is assessed through tools like the JFK Coma Recovery Scale (JFK-CRS) to evaluate responses to stimuli.

• Responses:

  • Primitive Responses: Involuntary movements of organs or body parts that typically disappear as the Central Nervous System (CNS) matures. Their presence in adults indicates a loss of descending inhibitory control. Examples include sucking, rooting, and grasping reflexes.

  • Reflexive Responses: Involuntary movements occurring immediately following a stimulus. These generally do not involve consciousness or intention. They are categorized into three classes:

    • Primitive.

    • Superficial: Examples include abdominal and Babinski reflexes.

    • Deep Tendon (DTR): Examples include pectoral, biceps, triceps, knee, and Achilles reflexes.

  • Generalized Responses: These are undifferentiated responses elicited without higher cortical control. The patient shows the same or similar response to all stimuli. Examples include changes in vital signs, eye blinking, increased muscle tone, reflexive posturing, or generalized body movements.

  • Localized Responses: These are differentiated, purposeful, and intentional movements involving higher cortical control. Different stimuli elicit different responses. Examples include turning the head toward a speaker, moving a specific body part, following guided movement, or spontaneous anticipatory movement. Note: These responses may be delayed by $20-30\,\text{seconds}$.

• Consistency thresholds:

  • Inconsistent: A response occurring less than $80\%$ of the time following stimulus presentation.

  • Consistent: A response occurring greater than $80\%$ of the time following stimulus presentation.

Reflexive and Abnormal Posturing

• Decorticate Posturing (Flexor):

  • Presentation: Flexion of the Upper Extremities (UE) with extension of the neck and Lower Extremities (LE). Arms move inward toward the "cord."

  • Pathophysiology: Indicates upper midbrain damage occurring above the Red Nucleus. The Red Nucleus is disinhibited, facilitating UE flexion. The Lateral Corticospinal Tract is affected; while it usually facilitates flexion, the damage prevents the signal from passing correctly, resulting in LE extension.

• Decerebrate Posturing (Extensor):

  • Presentation: Rigid extension of the trunk and limbs with Internal Rotation (IR) of the limbs. Arms are shaped like "e's."

  • Pathophysiology: Indicates upper pontine damage below the Red Nucleus. There is a disconnect at the midbrain/cerebellum level. Because the tracts that facilitate flexion (including signals from the Red Nucleus) are unavailable, extension overrides everything. This is considered more severe than decorticate posturing.

• Opisthotonus: A severe form of decerebrate posturing characterized by a severely arched spine and cervical extension. The heels tilt back such that only the back of the head and the heels contact the ground.

• Fencing: A brief period of decorticate or decerebrate posturing of the UEs where forearms flex or extend and stay in the air. Often seen after a concussion or as a preliminary position in severe Traumatic Brain Injury (TBI). It represents a brainstem-level reactivation of the Asymmetrical Tonic Neck Reflex (ATNR).

Objective Measures and Scale Administration

• Scale Administration: Rancho levels are typically assigned by skilled therapists in neurocognitive assessment, often Speech-Language Pathologists (SLP) or Neuropsychologists. In Model Systems centers, all rehab providers may assist. Timing matters, as some activities stimulate the RAS more than others, and the time of day affects performance.

• Rancho Los Amigos Level of Cognitive Functioning Scale (RLCFS/RLA/LOFS):

  • Consists of $8$ levels (original) or $10$ levels (Revised LOFS).

  • Provides insight into the course of recovery but is not a predictor of long-term outcome.

  • Correlates with $24\,\text{hour}$ Glasgow Coma Scale (GCS), length of Post-Traumatic Amnesia (PTA), and coma duration.

  • Patients may skip stages, fluctuate between two levels, or emerge slowly.

• JFK Coma Recovery Scale (JFK-CRS):

  • Hierarchically arranged: reflexive $\rightarrow$ subcortical $\rightarrow$ volitional cortical mediated responses.

  • Used to identify emergence from Disorders of Consciousness (DOC).

  • To emerge from Unresponsive Wakefulness Syndrome (UWS) into a Minimally Conscious State (MCS), a patient must achieve above reflexive activity in all $6$ subcategories.

  • To be considered fully conscious (emerged from MCS), a patient must show cortically mediated motor or verbal responses (functional object use or accurate communication).

Complications During Disorders of Consciousness (Rancho I-III)

• Dysautonomia (Storming):

  • Symptoms: Increased body temperature (sweating), increased Respiratory Rate (RR), increased Blood Pressure (BP), increased Heart Rate (HR), posturing, hypertonia, and teeth grinding.

  • Triggers: Often elicited by overstimulation.

  • Management: Cooling blankets, ice packs, monitoring vital signs, medications for hypertensive crises, and reducing stimulation.

• Heterotopic Ossification (HO):

  • Risk Factors: Coma lasting >2\,\text{weeks}, immobilization, increased muscle tone, and local tissue trauma.

  • Timing: Greatest risk in the first $3-4\,\text{months}$ post-injury.

  • Common Sites: Hip, elbow, shoulder, knee.

  • Signs/Symptoms: Redness, warmth, swelling, decreased Range of Motion (ROM), hard end-feel, and pain.

  • PT Management: Gentle ROM, positioning, and modalities (heat, ice, or iontophoresis).

  • Medical Management: Diphosphates to inhibit calcium phosphate; surgical excision (usually $12-18\,\text{months}$ post).

• Seizures:

  • Affects $12-50\%$ of individuals with severe brain injury.

  • Diagnosed via EEG and managed with anticonvulsants.

Examination, Physical Exam, and Observations

• Chart Review: Focus on Mechanism of Injury (MOI), GCS scores at the scene/ER, medications, and surgical history.

• Family Interview: Determine likes/dislikes, social history (prognosis factor), and familiar memories to be used in treatment.

• Review of Systems: Vital signs (may be the only response in severe BI), skin integrity, and entry posture.

• Arousal Assessment: Eye opening, tracking, blinking to threat, and eye movement (nystagmus, convergence/divergence).

• Physical Exam Focus:

  • Response to Sensory Stimulation: Auditory, visual, and tactile.

  • Motor Control: Spontaneous vs. purposeful movement; quality (isolated vs. synergistic).

  • Positional Responses: Monitor for autonomic changes, nystagmus, or tone changes during rolling, sitting, or position changes.

  • Specific Protocols:

    • Eye Opening: Measure time eyes are open in $5\,\text{minute}$ increments.

    • Command Following: All caregivers use one common motor command.

    • Agitated Behavior Scale (ABS): Monitors agitation throughout the day.

Cognitive Domains and Executive Function

• Attention:

  • Sustained: Continuous repetitive activity without cues (e.g., eating).

  • Selective: Staying on task despite distractions (e.g., conversation at a restaurant).

  • Alternating: Switching between tasks (e.g., $5\,\text{minutes}$ of one task, then switching).

  • Divided: Simultaneous task completion (e.g., walking and talking).

• Memory:

  • Explicit: Conscious effort to remember.

  • Implicit: Unconscious memory (procedural, classical conditioning, priming).

• Executive Function: Includes focusing attention, setting goals, problem-solving, verbal reasoning, and metacognition (thinking about thinking).

Detailed Rancho Levels and Treatment Strategies

Rancho I (Coma / No Response)

• Definition: Absence of sleep-wake cycles; no eye opening; no purposeful motor response; no language comprehension.

• Clinical Picture: GCS <8; usually lasts <4\,\text{weeks}; requires artificial life support.

• Primary Problems: Decreased arousal/attention, decreased motor control, limited ROM.

• Treatment: Sensory feedback (visual, auditory, olfactory, tactile, vestibular), positioning (tilt table), and PROM to prevent contractures.

• Guidelines: $15-20\,\text{minute}$ sessions in a quiet room; allow $20\,\text{seconds}$ for a response.

Rancho II (UWS / Generalized Response)

• Definition: Sleep/wake cycles present; spontaneous eye opening; autonomic functions may return; no command following.

• Prognosis: Poor if recovery from UWS takes >3\,\text{months} (anoxic) or >12\,\text{months} (TBI).

• Treatment: Same as Level I, focusing on eliciting any response (vital sign change, roving eye movement) and initiating movement like rolling.

Rancho III (MCS / Localized Response)

• Definition: Localized but inconsistent (<80\%) responses; begins to track objects/people; aroused for parts of the day.

• Goals: Improve consistency of response, establish a basic communication system, and increase activity tolerance.

• Treatment: Similar sensory input but expecting more purposeful responses; use FES cycles or AAROM.

• Guidelines: $30\,\text{minute}$ sessions; allow $10-15\,\text{seconds}$ for response; can move to a gym setting.

Rancho IV (Confused - Agitated)

• Definition: Akathisia, heightened response to stimuli, mood swings, unable to cooperate, no short-term retention.

• Treatment Key Points: Minimize distractions, maintain a daily routine, use error-less learning, and allow energy consumption to relieve internal agitation (e.g., walking, treadmill).

• Behavioral Management: Remain calm during outbursts; use internal motivators.

Rancho V (Confused - Inappropriate)

• Definition: Non-oriented, easily distracted, short attention span, and poor memory.

• Treatment Key Points: Use simple repetitive tasks and long-term memories (family photos); do not teach unnecessary tasks; provide frequent rests.

Rancho VI (Confused - Appropriate)

• Definition: Goal-directed with external drive; inconsistent orientation; $30\,\text{minute}$ attention span.

• Treatment Key Points: Multi-step tasks; introduce error-ful learning; use memory diaries/books; focus on sequencing and organization.

Rancho VII (Automatic - Appropriate)

• Definition: Able to go through routine without external drive; needs structure; inflexible thinking.

• Treatment Key Points: Encourage self-assessment; community re-integration; high-level balance with distractors.

Rancho VIII (Purposeful - Appropriate)

• Definition: Able to complete new learning; aware of and responsive to the environment; shifts tasks for $2\,\text{hours}$.

• Treatment Key Points: Decrease structure; increase self-responsibility; scavenger hunts; planning public transportation trips.

Rancho IX and X

• Rancho IX: Purposeful/Appropriate; Stand-by Assistance. Independently shifts tasks; recognizes limits but requires help to anticipate problems; lower frustration threshold.

• Rancho X: Purposeful/Appropriate; Modified Independent. Handles multiple tasks simultaneously; anticipates limits and adjusts; recognizes the needs/feelings of others; behavioral issues only under high stress.