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Rancho Los Amigos (RLA) Levels of Cognitive Functioning — Classification, Assessment & Level-Wise Physiotherapy Management

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What is the RLA Scale?

• Original scale (1972): 8 levels (Hagen, Malkmus & Durham)
• Revised scale (1997): 10 levels (adds Levels IX and X)
• Levels I–X range from No Response → Purposeful/Appropriate (Modified Independent)

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Overall Assessment Framework in TBI/RLA Patients

A. Neurological / Medical Assessment

B. Physical / Physiotherapy Assessment

C. Psychosocial Assessment

• Behavioral disturbances (agitation scoring: Agitated Behavior Scale – ABS)
• Caregiver burden
• Social support network
• Pre-morbid function

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RLA Scale — Full 10-Level Classification

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Level-Wise Physiotherapy Management

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🔴 LEVEL I — No Response

• Prevent secondary complications
• Maintain joint range and skin integrity
• Provide sensory stimulation

• Positioning: Proper supine/side-lying positioning with pressure-relieving mattress; head of bed 30°
• Passive Range of Motion (PROM): All joints 2–3× daily to prevent contractures
• Chest Physiotherapy: Postural drainage, percussion, vibration, suctioning (if intubated); manual hyperinflation
• Sensory Stimulation Programme (Coma Stimulation):
  • Auditory: familiar voices, music
  • Tactile: textures, temperature
  • Olfactory: familiar scents
  • Visual: light/movement
• Splinting: Resting hand splints, AFO (ankle-foot orthosis) to prevent foot drop
• Skin care: Regular 2-hourly turns; inspection for pressure sores
• Tilt table: Gradual head-up tilt for autonomic regulation (begin at 30°, progress to 70–80°)

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🔴 LEVEL II — Generalized Response

• Same as Level I, with initial attempts at stimulation-response observation
• Monitor changes in response to guide progression

• Continue all Level I interventions
• Enhanced multi-sensory stimulation — increase variety and duration
• Tilt table progression: Increase angle as tolerated
• Supported sitting in bed/chair for short periods (15–20 min) with full support
• Monitor vital signs continuously during positional changes
• Team communication: Document any new responses to stimuli

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🔴 LEVEL III — Localized Response

• Maximize responsiveness
• Begin functional positioning
• Improve arousal

• Continue PROM and positioning
• Wheelchair seating: Begin supported upright sitting in wheelchair (with head support if needed)
• Tilt table: Progress to 60–80° daily
• Purposeful stimulation: Use familiar objects, patient's name, structured auditory cues
• Functional tasks: Attempt simple command-based AROM (e.g., "squeeze my hand")
• Begin oral motor stimulation if safe (dysphagia assessment)
• Involve family in stimulation programme with education
• Goal: 30 minutes upright sitting tolerance

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🟡 LEVEL IV — Confused-Agitated

• Ensure safety
• Reduce agitation while maintaining physical function
• Gradual increase in purposeful activity

• Positioning: Structured chair/wheelchair sitting to orient to environment
• PROM and gentle AROM — guided, not forced
• Sensory regulation: Avoid overstimulation; offer calming proprioceptive input (firm joint compression, weighted blankets)
• Functional mobility: Bed mobility training with verbal cueing only
• Splinting: Continue AFO and hand splints
• Safety: Side rails, supervised transfers only
• Avoid: Complex tasks, multiple therapists simultaneously, overcrowded environments

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🟡 LEVEL V — Confused-Inappropriate, Non-Agitated

• Improve attention span
• Introduce structured functional tasks
• Begin basic mobility training

• Structured therapy sessions: Consistent routine, same time, same therapist, same location
• Attention training: Short, simple tasks; immediate feedback
• Bed mobility: Rolling, bridging, supine-to-sit (with moderate assist)
• Sitting balance training: Supported and unsupported static sitting; trunk stabilization
• Standing: Standing frame/tilt table progressed to standing with full assistance
• Transfers: Sit-to-stand training with maximal assist
• Gross motor activities: Reaching, weight shifting
• Memory aids: Simple written/pictorial schedules introduced
• Limit: Complex or multi-step tasks; frequent redirection needed
• Caregiver education: Consistent cueing strategies

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🟡 LEVEL VI — Confused-Appropriate

• Functional mobility with assist
• Improve balance and endurance
• Begin ADL participation

• Sit-to-stand and standing balance: Progress from maximum to moderate assist; static → dynamic standing
• Gait training: Begin parallel bars → walking frame → quad cane → standard cane
• Balance exercises: Weight shifting, tandem standing, cone reach tasks
• Endurance training: Gradual aerobic activity (cycle ergometer, treadmill with support)
• ADL retraining: Bed-to-chair, grooming, dressing practice (co-managed with OT)
• Stair climbing: Begin with railing and moderate assist
• Cognitive-physical integration: Simple obstacle courses, directional tasks
• Memory strategies: Diary, checklists, orientation board used during therapy
• Group therapy: Begin in small, structured groups

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🟢 LEVEL VII — Automatic-Appropriate

• Independent mobility in familiar environments
• Community mobility preparation
• Improve higher-level balance and coordination

• Gait training: Progress to outdoor surfaces, uneven terrain, ramps, elevators
• Balance: Dynamic balance training — perturbation training, dual-task activities (walking while talking)
• Endurance: Structured aerobic programme; 20–30 min moderate intensity exercise
• Coordination: Fine and gross motor activities; ball skills, sport-specific tasks
• Functional reach and manipulation: Complex ADL tasks
• Community re-integration: Supervised community ambulation
• Driving assessment referral if appropriate
• Group therapy: Structured group exercise; social interaction
• Patient education: Insight training, error recognition
• Neuropsychological feedback for lack of initiation/insight

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🟢 LEVEL VIII — Purposeful-Appropriate

• Return to full functional independence
• Community participation
• Vocational/leisure rehabilitation

• Advanced balance: Single-leg stance, eyes closed, foam surface
• High-level gait: Running, sport-specific activities, agility drills
• Return-to-work programme: Functional capacity evaluation (FCE)
• Ergonomic training: Workplace-specific activities
• Sports rehabilitation if applicable
• Home exercise programme (HEP): Independent, self-managed
• Cognitive-physical dual tasks: Complex walking tasks, memory while exercising
• Fatigue management: Energy conservation strategies
• Patient education: Full insight into residual deficits; coping strategies

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🟢 LEVEL IX — Purposeful-Appropriate (Standby Assistance)

• Transition to community independence
• Self-monitoring and self-correction

• Supervised community outings: Buses, shops, public spaces
• Fall prevention programme: Home hazard assessment, vestibular exercises
• Self-monitoring strategies: Checklist usage, self-correction during tasks
• Advanced endurance and sport: Individual rehabilitation goals
• Telerehabilitation or outpatient follow-up
• Finalize home exercise programme

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🟢 LEVEL X — Purposeful-Appropriate (Modified Independent)

• Maintenance of function
• Long-term community participation
• Prevention of secondary complications (e.g., deconditioning, falls)

• Independent home exercise programme
• Gym-based or community fitness
• Annual review: Re-assessment for any functional decline
• Peer support groups / community reintegration programmes
• Driving, vocational, and recreational goals

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Summary Table: RLA Levels — Key Physiotherapy Focus

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Key Principles Across All Levels

1. Neuroplasticity-based rehabilitation — repetition, task specificity, and progressive overload drive cortical reorganization
2. Interdisciplinary team approach — PT, OT, SLP, neuropsychology, nursing, social work
3. Family/caregiver education at every level
4. Goal-setting: SMART goals, Patient-Specific Functional Scale (PSFS)
5. Re-assessment: Regular re-evaluation using RLA level, FIM, BBS, TUG to track progress and revise goals
6. Fatigue management — brain injury fatigue is real and limits therapy tolerance; schedule rest breaks
7. Avoid over-stimulation at lower levels; progressively increase cognitive-motor challenge at higher levels

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Clinical Note: RLA level determines the approach to therapy — not the intensity alone. A patient at Level IV needs environmental control and safety; a patient at Level VIII needs challenge and complexity. Matching intervention to cognitive level is the cornerstone of TBI rehabilitation.