Rancho Los Amigos Scale Scores Research Articles

Effect of Transcranial direct current stimulation (tDCS) on altered conscious patients after traumatic brain injury & cerebrovascular accident: A randomized clinical control trial

Background & Objective: Traumatic brain injury and cerebrovascular accidents can result in altered levels of consciousness. This study is aimed at finding the effect of transcranial direct current stimulation (tDCS) on the level of consciousness in these patients. Methods: A total of 100 patients admitted to the neurological ICU of the hospital were screened and 40 subjects after satisfying inclusion criteria were recruited within the first one to two weeks of injury. They were randomly divided into two groups after written consent from a caretaker, Group A (experimental) (n=20) and Group B (control) (n=20) by computerized randomization. Group A received Anodal tDCS to the motor area (C3/C4 ipsilesional), sensory area (P3/P4 ipsilesional) and left dorsolateral prefrontal cortex (F3) according to the 10/20 EEG montage for two sessions of 20min/day for 7 consecutive days and routine physiotherapy. Group B only received routine physiotherapy similar to Group A. Glasgow coma scale (GCS) and Rancho Los Amigos scale (RLAS) was taken pre and post- intervention to assess the level of consciousness. Results: The pretest and post- test GCS and RLAS scores in groups A and B showed statistical significance at p<0.01. The differences of mean GCS and RLAS between pretest and posttest in group A showed better improvement than that of group B. The results were statistically significant at p<0.01. The effect size was large, calculated by Cohen’s d. Conclusion: The tDCS can be effective in improving GCS and RLAS in altered consciousness patients in the acute period after injury. It is non-invasive, cost-effective with minimal contraindications, and doesnot interfere with other modalities in the intensive care unit.

Predicting Outcome of Acquired Brain Injury by the Evolution of Paroxysmal Sympathetic Hyperactivity Signs.

In this multi-center study, we provide a systematic evaluation of the clinical variability associated with paroxysmal sympathetic hyperactivity (PSH) in patients with acquired brain injury (ABI) to determine how these signs can impact outcomes. A total of 156 ABI patients with a disorder of consciousness (DoC) were admitted to neurorehabilitation subacute units (intensive rehabilitation unit; IRU) and evaluated at baseline (T0), after 4 months from event (T1), and at discharge (T2). The outcome measure was the Glasgow Outcome Scale-Extended, whereas age, sex, etiology, Coma Recovery Scale-Revised (CRS-r), Rancho Los Amigos Scale (RLAS), Early Rehabilitation Barthel Index (ERBI), PSH-Assessment Measure (PSH-AM) scores and other clinical features were considered as predictive factors. A machine learning (ML) approach was used to identify the best predictive model of clinical outcomes. The etiology was predominantly vascular (50.8%), followed by traumatic (36.2%). At admission, prevalence of PSH was 31.3%, which decreased to 16.6% and 4.4% at T1 and T2, respectively. At T2, 2.8% were dead and 61.1% had a full recovery of consciousness, whereas 36.1% remained in VS or MCS. A support vector machine (SVM)-based ML approach provides the best model with 82% accuracy in predicting outcomes. Analysis of variable importance shows that the most important clinical factors influencing the outcome are the PSH-AM scores measured at T0 and T1, together with neurological diagnosis, CRS-r, and RLAS scores measured at T0. This joint multi-center effort provides a comprehensive picture of the clinical impact of PSH signs in ABI patients, demonstrating its predictive value in comparison with other well-known clinical measurements.

Is Robotic Gait Training Feasible in Adults With Disorders of Consciousness?

To investigate the feasibility and safety of robotic-assisted gait training (RAGT) in adults with disorders of consciousness (DoC). Inpatient rehabilitation hospital. Four adult male patients with traumatic brain injury and DoC. Subjects participated in RAGT with body weight support for 5 to 20 minutes, over 1- to 2-week periods. Primary measures included vital signs, walking parameters, pain, arousal, and Agitation Behavior Scale scores. Additional data included Modified Ashworth Scale, Coma Recovery Scale-Revised, and Rancho Los Amigos Scale scores. All participants safely completed at least one session of RAGT with body weight support with safe vital signs and low agitation levels. Two adverse events occurred (increased somnolence and pain due to harness placement), which were not considered severe. All subjects emerged out of DoC at which point research protocol was stopped. Findings suggest inpatient-based RAGT may be safe and feasible to consider when developing a therapy plan of care in adults with DoC.

Iodine-based Dual-Energy CT of Traumatic Hemorrhagic Contusions: Relationship to In-Hospital Mortality and Short-term Outcome.

BackgroundTraumatic hemorrhagic contusions are associated with iodine leak; however, quantification of leakage and its importance to outcome is unclear.PurposeTo identify iodine-based dual-energy CT variables that correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.Materials and MethodsIn this retrospective study, consecutive patients with contusions from May 2016 through January 2017 were analyzed. Two radiologists evaluated CT variables from unenhanced admission head CT and follow-up head dual-energy CT scans obtained after contrast material-enhanced whole-body CT. The outcomes evaluated were in-hospital mortality, Rancho Los Amigos scale (RLAS) score, and disability rating scale (DRS) score. Logistic regression and linear regression were used to develop prediction models for categorical and continuous outcomes, respectively.ResultsThe study included 65 patients (median age, 48 years; interquartile range, 25-65.5 years); 50 were men. Dual-energy CT variables that correlated with mortality, RLAS score, and DRS score were iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusion. The single-energy CT variable that correlated with mortality, RLAS score, and DRS score was hematoma volume at follow-up CT. Multiple logistic regression analysis after inclusion of clinical variables identified two predictors that enabled determination of mortality: postresuscitation Glasgow coma scale (P-GCS) (adjusted odds ratio, 0.42; 95% confidence interval [CI]: 0.2, 0.86; P = 0.01) and iodine quantity in pseudohematoma (adjusted odds ratio, 1.4 per milligram; 95% CI: 1.02 per milligram, 1.9 per milligram; P = 0.03), with a mean area under the receiver operating characteristic curve of 0.96 ± 0.05 (standard error). For RLAS, the predictors were P-GCS (mean coefficient, 0.32 ± 0.06; P < .001) and iodine quantity in contusion (mean coefficient, -0.04 per milligram ± 0.02; P = 0.01). Predictors for DRS were P-GCS (mean coefficient, -1.15 ± 0.27; P < .001), age (mean coefficient, 0.13 per year ± 0.04; P = .002), and iodine quantity in contusion (mean coefficient, 0.19 per milligram ± 0.07; P = .02).ConclusionIodine-based dual-energy CT variables correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.© RSNA, 2019Online supplemental material is available for this article.See also the editorial by Talbott and Hess in this issue.

The body participating: a qualitative study of early rehabilitation participation for patients with severe brain injury and low level of consciousness

Background: The literature on participation in rehabilitation by those with the most severe acquired brain injury is very sparse.Objectives: The aim of this study was to explore how physiotherapists promote the participation of patients with severe brain injury in therapeutic and daily-life situations in early rehabilitation.Methods: In a qualitative study employing phenomenological philosophy, several video-recorded sessions of patients with a Rancho Los Amigos Scale score of 3-4 were analysed. Empirical themes were identified by four different investigators through individual and consensus-based analyses. The results were theoretically stated and supported.Results: In an effort to achieve patient participation, the following four themes seemed to be significant: 1) consciously encountering the patient in the moment, 2) the employment of concepts surrounding the interaction between body and environment, 3) timing and flow of the activities and 4) comprehensive bodily support, guidance and facilitation of the activity and participation in daily-life skills.Conclusions: The dynamic use of these four themes seemed to enrich early rehabilitation interventions for patients with severe brain injury and low level of consciousness in terms of their participation and functioning in everyday life.

Longitudinal Trajectories of Health Related Quality of Life in Danish Family Members of Individuals with Severe Brain Injury

Scant research has examined health-related quality of life (HRQoL) in family members of patients with severe brain injury, even less has been done in Scandinavian countries, and none has examined this construct longitudinally. The current study therefore used multilevel modelling to investigate the trajectories of HRQoL in 94 Danish family members of patients with severe brain injury at five time points, beginning at the patient's stay in a neuro intensive care unit through one year after injury. The family members’ HRQoL scores significantly and strongly increased over time, and Role Limitations – Emotional scores were higher when patients had high Rancho Los Amigos Scale scores at admission to early intensive rehabilitation in hospital. These results suggest that the acute and sub-acute periods after brain injury are an extremely difficult time psychologically for many families, and family-based mental health interventions during the acute and sub-acute phases are critical, especially for families who have a patient with severe deficits.

The Association of Functional Oral Intake and Pneumonia in Patients With Severe Traumatic Brain Injury

Hansen TS, Larsen K, Engberg AW. The association of functional oral intake and pneumonia in patients with severe traumatic brain injury. Objectives To investigate the incidence and onset time of pneumonia for patients with severe traumatic brain injury (TBI) in the early phase of rehabilitation and to identify parameters associated with the risk of pneumonia. Design Observational retrospective cohort study. Setting Subacute rehabilitation department in a university hospital in Denmark. Participants Patients (N=173) aged 16 to 65 years with severe TBI who were admitted during a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously. Interventions Not applicable. Main Outcome Measure Pneumonia. Results Twenty-seven percent of the patients admitted to the brain injury unit were in treatment for pneumonia; pneumonia developed in 12% of the patients during rehabilitation; the condition occurred within 19 days of admission in all but 1 patient. Of these patients, 81% received nothing by mouth. Three factors identified patients at highest risk of pneumonia: Glasgow Coma Scale score less than 9 (1 day after cessation of sedation); Rancho Los Amigos Scale score less than 3 (on admission); and no oral intake on admission. Having a tracheotomy tube and/or feeding tube was also associated with a higher occurrence of pneumonia. Conclusions Among patients with severe TBI, 27% had pneumonia at transfer from the intensive care unit. Pneumonia developed in only 12% of the participants during rehabilitation. Patients with a low level of consciousness and patients with a tracheotomy tube or feeding tube had a higher likelihood of pneumonia.

(354) Development of a pain assessment scale for patients with moderate to severe brain injury: A pilot study

Evaluation of pain in traumatic brain injury (TBI) patients with impaired cognition and communicative ability is confounded by the absence of reliable self-reporting of symptoms. Many studies have looked at pain behaviors in the confused elderly, cognitively impaired, neonatal and mild TBI (mTBI) populations, yet there have been no formal validation of methods to assess pain behavior in the moderate to severe TBI (sTBI) population. We sought to develop a method of quantifying pain levels (Behavioral Pain Scale, BPS) based on pain behaviors observed in patients with brain injuries. The study took place at an urban academic rehabilitation hospital. There were 18 nonverbal patients with varying degrees of TBI brain injury: Rancho los Amigos Scale (RAS) and Reverse Wong Baker (RWB) scale scores ranged between II-IV and 0-6, respectively. Patients were monitored for fifteen minutes by blinded and unblinded observers who rated specific behaviors. Pain behaviors were grouped into three categories: vocalization, facial behaviors, and body behaviors, all contributing to the patient’s total BPS score. The most frequently observed behaviors were limb movement (83%), facial grimacing (67%), spasms/contractures (50%), and extended eye closing (37.5%). The BPS scores correlated significantly with the RWB (rs = .590 , p = .01), but not with the RAS (p = .877) or the Glasgow scores (p = .193). Injury etiology and pain behaviors do not appear to be associated; however statistical examination with a larger sample size may prove otherwise. Preliminary development of a Behavioral Pain Score in nonverbal TBI patients shows a correlation with RWB, but not with the RAS or Glasgow scores. Further validation is warranted. Evaluation of pain in traumatic brain injury (TBI) patients with impaired cognition and communicative ability is confounded by the absence of reliable self-reporting of symptoms. Many studies have looked at pain behaviors in the confused elderly, cognitively impaired, neonatal and mild TBI (mTBI) populations, yet there have been no formal validation of methods to assess pain behavior in the moderate to severe TBI (sTBI) population. We sought to develop a method of quantifying pain levels (Behavioral Pain Scale, BPS) based on pain behaviors observed in patients with brain injuries. The study took place at an urban academic rehabilitation hospital. There were 18 nonverbal patients with varying degrees of TBI brain injury: Rancho los Amigos Scale (RAS) and Reverse Wong Baker (RWB) scale scores ranged between II-IV and 0-6, respectively. Patients were monitored for fifteen minutes by blinded and unblinded observers who rated specific behaviors. Pain behaviors were grouped into three categories: vocalization, facial behaviors, and body behaviors, all contributing to the patient’s total BPS score. The most frequently observed behaviors were limb movement (83%), facial grimacing (67%), spasms/contractures (50%), and extended eye closing (37.5%). The BPS scores correlated significantly with the RWB (rs = .590 , p = .01), but not with the RAS (p = .877) or the Glasgow scores (p = .193). Injury etiology and pain behaviors do not appear to be associated; however statistical examination with a larger sample size may prove otherwise. Preliminary development of a Behavioral Pain Score in nonverbal TBI patients shows a correlation with RWB, but not with the RAS or Glasgow scores. Further validation is warranted.

Bilateral craniotomies for blunt head trauma.

Development of delayed or recurrent intracranial hematomas requiring reexploration or a secondary craniotomy is well known. Patients with bilateral pathology requiring bilateral craniotomies as the initial emergency operative intervention, however, are uncommon. The lack of available literature and the large volume of head trauma seen at our institution prompted us to analyze the retrospective data on blunt head injury requiring bilateral craniotomies. Twenty patients underwent bilateral craniotomies at the University of Miami/Jackson Memorial Medical Center between January 1986 and June 1994. Ages ranged from 18 to 85 years. Mechanism of injury included motor vehicle crash (n = 4), pedestrian hit by automobile (n = 4), assault (n = 8), fall from height (n = 3), and unknown (n = 1). Epidural hematomas, acute subdural hematomas, contusions, and intracerebral hematomas were seen in varying combinations. The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 14, with a mean of 8.8 (+/-0.82 SE). Sixteen of the 20 patients survived and were discharged from the hospital. The survivors' Rancho Los Amigos Scale score on discharge ranged from 2 to 8, with a mean of 6.1 (+/-0.45 SE). A Fisher's exact test was performed to compare the outcome between the patients with mild (GCS score 13-15) to moderate (GCS score 9-12) head injury and those with severe (GCS score 4-8) head injury. It showed a statistically higher frequency of death in the severe category (p < 0.05). In conclusion, the outcome of patients with bilateral pathology requiring emergency bilateral craniotomy at initial treatment correlated well with their GCS scores at initial presentation.

Evoked Potential Assessment: Utility in Prognosis of Chronic Head Injury

Brainstem auditory evoked potentials (BAEP) and somatosensory evoked potentials (SSEP) were performed on 29 patients an average of 12.4 months after traumatic brain injury (TBI). The study purpose was to predict long-term outcome in chronic TBI patients by using multimodality evoked potentials (MEP), the Rancho Los Amigos Scale (RLAS), and other clinical parameters. Neither the BAEP nor SSEP correlated significantly with the cognitive level on the RLAS at the MEP study approximately one year after TBI (RLAS1). Only 11.7% of RLAS1 could be predicted by the combined study of BAEP and SSEP. BAEP and SSEP obtained about one year after TBI jointly had a 15% predictive power of the long-term follow-up RLAS score obtained 18 months after performance of the MEP (RLAS2). Stepwise regression analysis showed that the best predictive indicator of the status of long-term outcome was RLAS1 which alone can predict 60% of long-term outcome. The predictive value of combinations of RLAS1 and age improved prediction of long-term outcome to 66.8%, and the combination of RLAS1, age, and SSEP further increased the value to 72%. Perhaps the MEPs were relatively insensitive in reflecting the patient's adaptation to fixed neuronal damage since patients can perform higher cognitive function by adaptation through behavioral modification and cognitive retraining despite little structural improvement. This adaptation would result in a discrepancy between MEP and RLAS scores in the late chronic phase.