The key word, here, is "begins," as recovery is a multi-stage
process, which typically continues in a variety of ways for months and years.
An essential concept that must be emphasized is that,
as with everything related to TBI, recovery will not be the same for
any two people with TBI. The respective stages of recovery that are
typical when considering the population as a whole may in any one
individual overlap, one stage with the next, or one or more stages
may be skipped altogether.
The progress seen during the immediate recovery period
in individuals with severe to moderate TBI is often tracked using
the Rancho Los Amigos Scale, which specifies eight levels -- rising
from the depths of coma to return to awareness and purposeful activity.
These levels of recovery of functioning reflect processes within the
brain, as it heals, stabilizes and reorganizes itself (to some extent).
Although the Rancho scale assumes that recovery will
pass through eight stages, a small percentage of people with severe
injuries remain 'stuck' at Levels I to III for months or years. They
remain in coma or in what is referred to as a 'vegetative state' and
fail to return to purposeful, appropriate functioning.*
Rancho Los Amigos Scale
Level I (No Response). The individual is in deep coma and does not
respond to any stimuli at all -- neither loud sounds, voices nor pain.
Level II (Generalized Response). The person still sleeps
most of the time, but has periods of brief wakefulness. He or she
responds, often inconsistently and without purpose, to stimuli such
as a pinch. Responses and movements are largely reflexive.
Level III (Localized Response). The person is alert
for lengthier periods. He or she still reacts inconsistently to commands,
but his or her responses are related to the type of stimulus
presented. For example, objects brought into the person's visual field
will produce visual focusing while noises will produce a listening
response.
Level IV (Confused and Agitated). As the individual's
awareness increases, his or her behaviors bespeak his or her confusion
and sense of disorganization. Aggressive and/or silly behavior is
seen, along with verbal abuse, agitated actions and incoherent speech.
The person's attention span is too short to allow full cooperation
in treatment programs; and the person is unable to independently undertake
basic tasks such as eating and grooming.
Level V (Confused, Inappropriate, Not Agitated). Simple
commands are now followed consistently, the person's long-term memory
is returning and she or he can now carry out routine, over-learned
skills such as eating. However, individuals at Level V have difficulty
with complex commands, short-term memory, learning new skills and
concentrating for more than a few minutes.
Level VI (Confused, Appropriate). The individual begins
to show goal-directed behavior, but typically still needs direction.
The individual is more aware of specifics, for example, his or her
deficits, family members and so forth. The person can carry out more
tasks independently and carries over relearned skills from one occasion
to the next.
Level VII (Automatic, Appropriate). The individual performs
daily routines automatically, without his or her previous confusion,
and is better able to learn new skills, although slower than before
injury. The person still has poor short-term memory; judgment and
problem-solving are still impaired.
Level VIII (Purposeful, Appropriate). The person's abilities
have recovered to the point where he or she is able to function once
more in his or her home and community. Impairments in cognitive, social
and emotional functioning, to a greater or lesser extent, are likely
to continue in comparison to pre-injury levels.
* Although 'vegetative' is still used by some to refer to individuals
in long-term coma, it is now considered sub-standard usage by many,
as its connotations can create needless pain for families of individuals
who are in a coma. To those who eschew this term, these individuals
are still human beings deserving respect, not 'plant-like' labels.
