Understanding Traumatic Brain Injury, Part 2

While Mark was at McKay Dee Hospital, I was introduced to the Glasgow Coma Scale (GCS), which is used to measure the depth of a coma. When Mark moved to Western Rehab they used the Rancho Los Amigos Scale, also known as the Level of Cognitive Functioning Scale (LCFS). The treatment team used this scale as a guide for his therapy plan. Their strategy changed as Mark progressed from one level to the next. They believed Mark would have to go through each level, without skipping one to progress. Consequently, the team was always encouraging and working to get Mark to the next level. I don’t believe Mark ever went through the dreaded Level IV. I did see other patients go through this level and it was upsetting, not only for the patient and family, but for all who witnessed the confusion and agitation.

Each person with a brain injury moves through the cognitive levels at various speeds. Some patients will be discharged from the hospital prior to progressing through all ten levels. I brought Mark home at cognitive level VI.

Level I – No Response: Patient needs total assistance and appears to be in a deep sleep or coma and does not respond to any external stimuli.

Level II – Generalized Response: Patient needs total assistance, but moves around. Movement doesn’t seem to have a purpose or consistency. This reaction may be due to deep pain. Patient may open their eyes, but does not seem to be focused on anything in particular.

Level III – Localized Response: Patient needs total assistance, but begins to move their eyes and look at specific people and objects. They turn toward or away from loud voices or noise. The patient may follow a simple command such as, “squeeze my hand.”  Responses are inconsistent and directly related to the type of stimulus.

Level IV – Confused and Agitated: Patient needs maximal assistance. They are very confused and agitated about where he or she is and what is happening in the surroundings. At the slightest provocation, the patient may become very restless, aggressive or abusive, verbally and/or physically. The patient may enter in incoherent conversation in reaction to inner confusion, fear or disorientation. Safety and deficit awareness are important issues.

Level V – Confused, Inappropriate, Nonagitated: Patient needs maximal assistance. They are confused and do not make sense in conversations. They may be able to follow simple directions. Stressful situations may provoke some upset, but agitation is no longer a major problem. Patients may experience some frustration as elements of memory return. Follows tasks for 2-3 minutes, but is easily distracted by environment.

Level VI – Confused, Appropriate: Patient needs moderate assistance. Speech makes sense and they are able to do simple things such as dressing, eating and brushing teeth. Although patients know how to perform a specific activity, they need help discerning when to start and stop. Learning new things may also be difficult. The patient’s memory and attention are increasing and they are able to attend to a task for 30 minutes.

Level VII – Automatic, Appropriate: Patient needs minimal assistance and can perform self-care activities and is usually coherent. Behavior is appropriately in familiar settings and shows carry-over for new learning at a lower than normal rate. They may have difficulty remembering recent events and discussions. If physically able, patient can carry out routine activities, but has difficulty with rational judgments, calculations and solving multi-step problems. Patient may not realize this and needs supervision for safety.  Patient initiates social interactions, but judgment remains impaired.

Level VIII – Purposeful, Appropriate: Patient needs stand-by assistance, but is independent for familiar tasks in a distracting environment for a short period of time. He or she acknowledges impairments, but has difficulty self-monitoring. Emotional issues such as depression, irritability and low frustration tolerance may be observed.

Level IX – Purposeful, Appropriate: Patient needs stand-by assistance on request, but is able to shift between tasks for two hours. They require some assistance to adjust to life demands. Emotional and behavioral issues may be of concern.

Level X – Purposeful, Appropriate: Patient is modified independent and is goal directed, handling multiple tasks and independently using assistive strategies. Prone to breaks in attention and may require additional time to complete tasks.

Resources: http://www.tbims.org/combi/lcfs/lcfs.pdf , https://www.jhsmh.org/LinkClick.aspx?fileticket=8hAd-OqTIQ0%3D&tabid=298

I hope this information is helpful in understanding the recovery process from traumatic brain injury. Did you or your loved one go through each level? At what level were they released from the hospital?

Understanding Traumatic Brain Injury, Part 1

Shortly after the car accident, the hospital informed me of an ongoing weekly class they held in the evening to help family members understand Traumatic Brain Injury (TBI). It was informative, helpful and overwhelming. I attended the classes every week only because it was information I needed, but it was definitely not wanted information. To be honest, I hated the class. It was frightening and discouraging. I wanted Mark’s recovery to be like the ones portrayed in the movies, where a person in a coma just one day wakes. I didn’t realize there was a measurement to the depth of a coma and there would be a process for waking up. After all, we do it every morning with little thought. It was difficult to throw out the mentality that you’re either comatose or not and realize there are levels or stages.

At first I was introduced to the Glasgow Coma Scale (GCS), which is used to measure the depth of a coma. “The GCS rates three aspects of functioning: eye opening, motor response and verbal response. Individuals in deep coma score very low on all these aspects of functioning, while those less severely injured or recovering from coma score higher. A GCS score of 3 indicates the deepest level of coma, describing a person who is totally unresponsive. A score of 9 or more indicates that the person is no longer in coma, but is not fully alert. The highest score (15) refers to a person who is fully conscious.” http://www.msktc.org/tbi/factsheets/Understanding-TBI/What-Happens-During-Injury-And-In-Early-Stages-Of-Recovery

I. Eye Opening
1 = No eye opening
2 = Eyes open to pain
3 = Eyes open to speech
4 = Spontaneous eye opening
II. Verbal Response
1 = No sounds
2 = Incomprehensible sounds
3 = Inappropriate words and jumbled phrases consisting of words
4 = Confused, yet coherent, speech
5 = Alert and oriented
III. Motor Response
1 = No response
2 = Extensor response, abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain.
3 = Abnormal flexion, posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest.
4 = Withdraws from unpleasant or painful stimuli
5 = Localizes to unpleasant or painful stimuli
6 = Obeys commands fully

The final score is determined by adding the values of I+II+III. This number helps medical practitioners categorize the four possible levels for survival, a lower number indicating a more severe injury and a poorer prognosis.

Mark’s highest score for the first seven weeks was 4: Eye Opening 2 + Verbal Response 1+ Motor Response 1 = 4.

Mild TBI Symptoms – score 13-15

Moderate Disability score 9-12:

  • Loss of consciousness greater than 30 minutes
  • Physical or cognitive impairments which may or may not resolve
  • Benefit from rehabilitation

Severe Disability score 3-8:

  • Coma: unconscious state. No meaningful response, no voluntary activities

 Vegetative State score less than 3:

  • Sleep wake cycles
  • Arousal, but no interaction with environment
  • No localized response to pain

 Persistent Vegetative State:

  • Vegetative state lasting longer than one month

 Brain Death:

  • No brain function
  • Specific criteria needed for making this diagnosis

Resource: http://www.traumaticbraininjury.com/symptoms-of-tbi/glasgow-coma-scale/

When he moved to Western Rehab, they used a Rancho Los Amigos Scale or Level of Cognitive Functioning Scale (LCFS) which I’ll save for part 2.

Did you find this information helpful? What has been your experience or understanding of TBI?