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Physiotherapy Management in
Head Injury Based on
RLA Scale
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.
Introduction (Contd…)
 an evaluation tool
 consists ten levels
 progress of each patient depends on the
severity, location and duration since brain
injury
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
The Cognitive Process
MEMORY
EXECUTIVE
FUNCTIONING
PROBLEM
SOLVING
REASONING
CATEGORIZ
ATION
SEQUENCING
ASSOCIATION
ORIENTATION
ATTENTION
COGNITIVE
PROCESS
Level I - No Response:
Total Assistance
Complete absence of observable change in
behavior when presented
Visual
auditory
Tactile
proprioceptive
vestibular
painful stimuli
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
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
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
Intervention (Contd…)
 Physical return does not mirror the RLA scale of
cognitive behaviour
 When entering a new stage previous stage
behaviours may be demonstrated
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
Low Level Management (Contd…)
Evaluation
 Passive ROM
 Spontaneous activity
 Posture and primitive reflexes
 Eye opened/ closed
 Vocalization
 Muscle tone
 Reflexes
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
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
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
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
Mid Level Management (Contd…)
Evaluation
 Functional mobility
 Balance
 Range of motion
 Strength/ Motor control
 Tone
 Sensation
 Reflexes
Mid Level Management (Contd…)
Cognitive Function
 Orientation
 Attention
 Memory
 Insight
 Safety awareness
 Alertness
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
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?
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
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
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
Mid Level Management
(Level V –VI)
No more agitation, can follow simple
commands fairly consistently & carry
over present
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
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
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?
 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
 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
 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…)
 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
 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…)
 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
 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…)
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
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?
Questions…
Physiotherapy Management in Head Injury Based on RLA Scale

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Physiotherapy Management in Head Injury Based on RLA Scale

  • 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
  • 5.
  • 6.
  • 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?