Physiotherapy Management strategies in managing Head injuries based on the Rancho Los Amigos Level of cognitive functioning

1. Physiotherapy Management in
Head Injury Based on
RLA Scale

2. Introduction
The Rancho Los Amigos level of
cognitive functioning
 descriptive scale that outlines a predictable
sequence and patterns of cognitive and
behavioural recovery seen in individuals with
traumatic brain injury
 developed in the 1970s.

3. Introduction (Contd…)
 an evaluation tool
 consists ten levels
 progress of each patient depends on the
severity, location and duration since brain
injury

4. Purpose of the scale
 means of assessment that does not require the
co-operation of the patient
 description covering a wide range of behaviors
 a common descriptive vocabulary
 increased understanding of behavioural stages
seen during recovery
 Assist in establishing appropriate treatment
objectives and or referrals

7. The Cognitive Process
MEMORY
EXECUTIVE
FUNCTIONING
PROBLEM
SOLVING
REASONING
CATEGORIZ
ATION
SEQUENCING
ASSOCIATION
ORIENTATION
ATTENTION
COGNITIVE
PROCESS

8. Level I - No Response:
Total Assistance
Complete absence of observable change in
behavior when presented
Visual
auditory
Tactile
proprioceptive
vestibular
painful stimuli

9. Level II - Generalized Response:
Total Assistance
 Same regardless of type and location of
stimulation
 May be significantly delayed
Demonstrates generalized reflex
response to painful stimuli
Responds to external stimuli with
generalized gross body movement
and/or not purposeful vocalization

10. Level III - Localized Response:
Total Assistance
 Responses directly related to type of
stimulus
Painful stimuli- withdrawal /vocalization
Auditory stimuli- turns toward or away
Strong light crosses visual field - blinks
Follows moving object passed within visual
field
Discomfort- pulling tubes or restraints
Responds inconsistently simple
commands

11. Intervention
 Because the cognitive level of the patient
determines the extent to which he can be actively
involved in the treatment, the organization of
physiotherapy
 treatment information is built around the patient’s
cognitive level
 Due to diverse and complex impairments difficult
to categorize assessment and treatment from
physiotherapy standpoint

12. Intervention (Contd…)
 Physical return does not mirror the RLA scale of
cognitive behaviour
 When entering a new stage previous stage
behaviours may be demonstrated

13. Low Level Management
Goals
 Prevent Complications
 Increase patients level of interaction with the
environment
 Improve level of alertness
 Improve motor control
 Manage effects of tone
 Improve postural control
 Educate family and care gives

14. Low Level Management (Contd…)
Evaluation
 Passive ROM
 Spontaneous activity
 Posture and primitive reflexes
 Eye opened/ closed
 Vocalization
 Muscle tone
 Reflexes

15. Low Level Management (Contd…)
Treatment
 Sensory stimulation
 Auditory
 Visual
 Olfactory
 Gustatory
 Tactile
 Vestibular
 Passive range of motion
 Positioning
What family/friends can do at Cognitive
Levels I, II, and III

16. Level IV - Confused/Agitated:
Maximal Assistance
 Alert and in heightened state of activity
 Purposeful attempts to remove restraints
or tubes or crawl out of bed
 Perform motor activities such as sitting,
reaching and walking without any
apparent purpose or on request
 Absent short-term memory

17. Level IV - Confused/Agitated:
Maximal Assistance (Contd…)
 May cry out or scream out of proportion to
stimulus even after its removal
 May exhibit aggressive or flight behavior
 Mood swings present
 Unable to cooperate with treatment efforts
 Verbalizations are frequently incoherent
and/or inappropriate to activity or
environment

18. Mid Level Management
Require tremendous amount of
structure to prevent over
stimulation
Evaluation and treatment must be
modified to include activities that
are familiar and liked by the patient

19. Mid Level Management (Contd…)
Evaluation
 Functional mobility
 Balance
 Range of motion
 Strength/ Motor control
 Tone
 Sensation
 Reflexes

20. Mid Level Management (Contd…)
Cognitive Function
 Orientation
 Attention
 Memory
 Insight
 Safety awareness
 Alertness

21. Mid Level Management (Contd…)
Goals
 Maintenance or improvement of joint range
of motion
 Prevent further physical deconditioning
 Improved response to simple commands
 Prevention of agitated outburst via use of
highly structured environment

22. Mid Level Management (Contd…)
Treatment
 Work on improving the endurance rather than to attempt to
progress to more challenging skills that would require more
learning
 Remember patient is confused
 Expect no carry over
 Model calm behavior
 Be prepared with numerous activities
 Offer options
 Expect egocentricity
 What family/friends can do at this stage?

23. Level V - Confused, Inappropriate
Non-Agitated: Maximal Assistance
 Alert, not agitated
 Agitated in response to external stimulation,
and/or lack of environmental structure
 Not oriented to person, place or time
 Severely impaired recent memory
 Absent goal directed, problem solving, self-
monitoring behavior
 Unable to learn new information
 May be able to perform previously learned tasks
when structured and cues provided

24. Level VI - Confused, Appropriate:
Moderate Assistance
 Inconsistently oriented
 Able to attend highly familiar tasks in non-
distracting environment for 30 minutes with
moderate redirection
 Remote memory more depth and detail than
recent memory
 Vague recognition of some staff
 Able to use assistive memory aide with maximum
assistance
 Emerging awareness of appropriate response to
self, family and basic needs

25. Level VI - Confused, Appropriate:
Moderate Assistance (Contd…)
 Supervised for old learning (e.g. self care)
 Maximum assistance for new learning with little
or nor carry over
 Unaware of impairments, disabilities and safety
risks
 Consistently follows simple directions
 Verbal expressions are appropriate in highly
familiar and structured situations

26. Mid Level Management
(Level V –VI)
No more agitation, can follow simple
commands fairly consistently & carry
over present

27. Mid Level Management
(Level V –VI) (Contd…)
Evaluation
 Formal assessment in a concise manner
 Strength / motor control
 Tone
 Reflex
 Co-ordination
 Balance
 Postural instability
 Functional status

28. Mid Level Management
(Level V –VI) (Contd…)
Goals
 Increasing participation
 Increasing or maintaining range of motion
 Increasing physical conditioning
 Maximize mobility skills
 Treating focal motor deficits that exists

29. Mid Level Management
(Level V –VI) (Contd…)
Treatment
 Maintain structure
 Increase safety awareness
 Short instructions
 Use physical props to improve compliance
 Memory book
What family/friends can do at this stage?

30.  Consistently oriented to person and place within
highly familiar environments
 Moderate assistance for orientation to time
 Minimal supervision for new learning
 Demonstrates carry over of new learning
 Initiates and carries out steps to complete
familiar routine but shallow recall of what he/she
has been doing
 Superficial awareness of his/her condition but
unaware of specific impairments and disabilities
Level VII - Automatic, Appropriate:
Minimal Assistance for Daily Living Skills

31.  Consistently oriented to person, place and time
 Able to recall and integrate past and recent
events
 Uses assistive memory devices to recall daily
schedule
 Initiates and carries out steps to complete
routines with stand-by assistance and can modify
the plan when needed with minimal assistance
 Requires no assistance once new tasks/activities
are learned
Level VIII - Purposeful, Appropriate:
Stand-By Assistance

32.  Requires no assistance once new tasks/activities
are learned
 Aware of and acknowledges impairments and
disabilities when they interfere with task
completion but requires stand-by assistance to
take appropriate corrective action
Level VIII - Purposeful, Appropriate:
Stand-By Assistance (Contd…)

33.  Independently shifts between tasks and
completes them accurately for at least two
consecutive hours
 Uses assistive memory devices to recall daily
schedule
 Initiates and carries out steps to complete
familiar tasks independently and unfamiliar tasks
with assistance when requested
 Able to think about consequences of decisions or
actions with assistance when requested
Level IX - Purposeful, Appropriate:
Stand-By Assistance on Request

34.  Aware and acknowledges impairments and
disabilities when they interfere with task
completion and takes appropriate corrective
action but requires stand-by assist to anticipate a
problem before it occurs and take action to avoid
it
 Accurately estimates abilities but requires stand-
by assistance to adjust to task demands
 Acknowledges others' needs and feelings and
responds appropriately with stand-by assistance
Level IX - Purposeful, Appropriate: Stand-
By Assistance on Request (Contd…)

35.  Able to handle multiple tasks simultaneously in
all environments but may require periodic breaks
 Independently create and maintain own assistive
memory devices
 Independently initiates and carries out steps to
complete familiar and unfamiliar tasks but may
require more than usual amount of time and/or
compensatory strategies to complete them
 Independently think about consequences of
decisions or actions
Level X - Purposeful, Appropriate:
Modified Independent

36.  Anticipates impact of impairments and
disabilities on ability to complete daily living
tasks and takes action to avoid problems before
they occur
 Recognize the needs and feelings of others and
automatically respond in appropriate manner
 Periodic depression may occur
 May be easily irritable
 Social interaction behavior is consistently
appropriate
Level X - Purposeful, Appropriate:
Modified Independent (Contd…)

37. High Level Management
Goals
 Emphasize on community re-entry and
return to work
 Assist patient in integrating cognitive,
physical and emotional skills necessary to
function in real world
 Judgment, problem solving emphasized

38. High Level Management (Contd…)
Treatment
 Wean from excessive structure
 Help with problem solving
 Focus on function
 Sensory integration
 Movement with challenges
 Maintain performance while decreasing structure
and supervision
What family/friends can do at this stage?

39. Questions…