Speech-language pathologists (SLPs) provide rehabilitative services to patients who have sustained a traumatic brain injury (TBI). The main focus of this rehabilitation is cognitive-communication therapy.

Cognition is a person’s ability to think, process information, remember and recall events, pay attention, solve problems, demonstrate awareness of his surroundings and self, as well as plan and organize.

Therefore, cognitive-communication is the way a person uses these skills, along with language, to communicate.

Following TBI, some or all of these skills may have changed as a result of the person’s injury. The SLP will evaluate the person with TBI to determine their strengths and areas for improvement and develop an individualized cognitive-communicative therapy plan.

Family Guide to the Rancho Scale

One important part of the recovery process involves the use of the Rancho Los Amigo Scale, or Rancho Levels of Cognitive Functioning. This scale is used by SLPs and other rehabilitation specialists to identify, document, and communicate patient progress.

As a person recovers from a TBI, they move through a predictable pattern of recovery. The person demonstrates behaviors and cognitive-communicative abilities that change and improve over time.

The scale detailed below has eight levels. Rancho levels I-III describe behaviors and abilities that are severely affected by the TBI, whereas the highest levels, Level VIII+, describes mild deficits.

A person with TBI usually progresses from a lower level to a higher level as the TBI improves through participation in therapy.

The Rancho scale is a predictable pattern of behaviors and abilities and is a guide -- although the pattern is the same, there can be much variation among individuals. Speech therapy and rehabilitation can help patients move to the next stage when they are ready.

Select a link below to learn how patients react at a certain level of cognition and how friends and family can help support the patient at each stage of recovery.

• Level I
• Level II
• Level III
• How can family and friends help patients at Levels I, II, and III?
• Level IV
• How can family and friends help patients at Level IV?
• Level V
• How can family and friends help patients at Level V?
• Level VI
• How can family and friends help patients at Level VI?
• Level VII
• Level VIII
• How can family and friends help patients at Levels VII and VIII?
• Levels VIII+
• How can family and friends help patients at Levels VIII+?

Level I: No Response

Behaviors

• Appears to be in a deep sleep
• Will not respond to sounds, sights, touch, or movement

Level II: Generalized Responses

Behaviors

• Responds inconsistently to sounds, sights, touch, and movement
• Responses may vary, not occurring every time and often delayed
• Responses may be the same regardless of the stimulus type or location, such as when a loud noise is presented or a bright light is shined in the eyes

Level III: Localized Responses

Behaviors

• May be awake on and off throughout the day
• Will move more spontaneously
• Reactions to various stimuli will be more specific
• May withdraw from pain, blink when presented with strong light, or turn toward or away from sound
• May begin to respond inconsistently to yes/no questions as well as simple instructions

How can family and friends help Levels I, II, and III patients?

• Use a normal tone of voice when speaking
• Speak calmly and slowly
• Have one person talk at a time
• Talk about the present, positive things, or home events
• Use the person’s name when talking
• Tell the person what you are about to do (“I’m going to brush your hair.”)
• Limit periods of stimulation/activity to 5-10 minutes
• Turn on the TV for short periods of time (5-10 minutes)
• Limit the number of visitors to two to three people at a time
• Keep the room calm and quiet; avoid over-stimulation (loud noises, too many people, bright lights, etc.)
• Bring in personal items (favorite lotion, music, posters)
• Do not speak in front of the person as if he/she were not there

Level IV: Confused and Agitated Responses

Behaviors

• Becomes more alert and active
• Shows unusual and inappropriate behavior
• Focus becomes basic, physical needs
• May scream out, be verbally abusive, behave aggressively, or attempt to remove restraints
• Speech is often confused or the content may be inappropriate
• Attention span is very short
• Memory and the ability to process information are impaired
• Begins to take some independent action, but is usually very dependent and needs significant help to maintain safety and meet basic needs

How can family and friends help a Level IV patient?

• Frequently remind the individual of the day and time
• Explain what is happening to the person
• Expect the person to be forgetful -- you may need to repeat answers several times
• Demonstrate patience
• Limit distractions and stimulation
• Remain calm and provide a safe environment
• Limit the number of visitors to two to three people at a time
• Allow the individual to move to the extent that is physically safe
• Reduce stimuli (sights, sounds, activity) in the environment if the individual becomes agitated or restless
• Keep the room quiet and calm (close doors, keep TV off, do not have secondary conversations in the room)
• Simplify words you use when talking, decrease rate of speech, speak naturally

Level V: Confused and Inappropriate Responses

Behaviors

• Appears more alert
• Follows simple commands
• May become agitated with too much external stimulation
• Some long-term memory is beginning to return (information about events before the accident)
• Short-term memory is severely impaired
• May try to fill gaps in memory by making things up
• May have difficulty starting or completing everyday tasks
• Will likely have difficulty meeting basic needs without significant assistance

How can family and friends help a Level V patient?

• Repeat information as needed
• Remind the individual of basic information (day, date, and time)
• Use memory aids to help the person remember information
• Keep instructions short and simple
• Provide structure to help complete basic tasks
• Limit the number of visitors to two to three people at a time
• Give the individual frequent rest breaks
• Correct tactfully, do not argue
• Encourage independence

Level VI: Confused and Appropriate Responses

Behaviors

• Follows simple directions but may become confused by changes in routine
• Can complete basic activities such as eating, dressing, and bathing with help
• Should be able to remember who they are, where they are, and the date
• Attention span has increased
• There is some understanding of the rehabilitation program
• May show impulsive behavior and unrealistic thinking and expectations
• May have trouble organizing thoughts and activities

How can family and friends help a Level VI patient?

• Allow the individual to do daily activities as much as possible
• Provide instruction and encouragement
• Encourage problem solving and independence by talking the person through it step by step
• Bring photos and items from home to help with memory
• Continue to remind of the time, day, and current events
• Provide close supervision with activities (safety issues continue to be a concern)

Level VII: Automatic and Appropriate Responses

Behaviors

• Behavior is more appropriate
• Remembers time and place
• Performs daily routines with little or no confusion but may have limited memory of what occurred
• Performs routine self-care without help
• May still have problems with judgment, safety, and planning
• Verbalizes needing to do a particular activity; however, will have trouble initiating the steps to carry out the plan
• Able to learn new information, but at a slower rate than before the injury

Level VIII: Purposeful and Appropriate Responses

Behaviors

• Responds correctly and learns, though slower than prior to the injury
• Memory has improved, but may still be slightly impaired
• No longer requires supervision, can be independent at home, and can possibly relearn higher level tasks such as driving and job training
• May have a decreased capacity to fully reason, tolerate stress, and use good judgment in emergency situations
• Some physical, language, or cognitive problems may still exist; however, they will likely not be noticeable to people who did not know the person prior to their injury

How can family and friends help Level VII and Level VIII patients?

• Encourage independence with self-care and simple activities
• Talk to the individual as an adult, using normal (not simplified) language
• Respect the person’s independence
• Use humor appropriately -- the individual may not understand and take the joke literally
• Provide support to the person when they are making decisions -- reasoning and judgment may still be impaired
• Encourage continued treatment
• Check with the person’s physician prior to returning to tasks such as driving and working
• Talk about their feelings and ways you can provide support
• Seek additional counseling and services as needed -- living with brain injury is a lifelong process

Level VIII+: Purposeful and Appropriate Responses

Behaviors

• Moves between tasks with little difficulty
• Can use memory devices to recall daily events, personal schedules and “to do” lists with some assistance
• Awareness of the impairment is present and the person can acknowledge how it interferes with completing a task
• Assistance will be needed to anticipate a problem and take corrective action
• May become irritable and easily frustrated
• Manages multiple tasks in a variety of environments, but may require breaks to recover
• Can perform personal and work goals
• Able to consider the consequences of personal decisions, but may require more time to determine appropriate courses of action
• Responds appropriately in social situations and recognizes the needs and feelings of others

How can family and friends help patients at Level VIII+?

• Provide emotional support and encouragement
• Give freedom to make choices; however, be prepared to give assistance
• Continue to encourage asking for help when needed

The scale is adapted from “The Family Guide to the Rancho Levels of Cognitive Functioning” from the Rancho Los Amigos National Rehabilitation Center.