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What Are the 10 Traumatic Brain Injury Recovery Stages?

physical therapist working with man on traumatic brain injury recovery stages and relearning to walk

Traumatic brain injury recovery can be a long and challenging process. One common tool used to classify and describe different stages of TBI recovery is the Rancho Los Amigos Scale.

This scale outlines ten stages of recovery that survivors typically experience based on the level of cognitive function that they attain. These stages serve only a general guide. Not every person will experience each stage in identical ways, and each survivor will recover at a different pace.

To better understand what the recovery process might look like, this article will cover each of the major traumatic brain injury recovery stages survivors may experience based on the Rancho Los Amigos Scale. We’ll also discuss techniques that can promote an optimal recovery.

Early Stages of Traumatic Brain Injury Recovery

Here are the initial stages of recovery that survivors may experience during the first few weeks following traumatic brain injury.

Stage 1. Coma (No Response, Total Assistance)

After a severe brain injury, your loved one may remain in a coma for some time. Comas are considered the first stage of traumatic brain injury recovery, as they can actually allow the brain to begin its healing process without interruption. A coma may be a direct result of one’s brain injury or can be medically induced to help minimize swelling and intracranial pressure following traumatic brain injury.

Described as the deepest state of unconsciousness, individuals who are in a coma are observably unresponsive to their environment and cannot wake up, even when stimulated.

The defining characteristics of a coma are:

  • No eye movement or opening
  • Lack of speech or other forms of communication
  • No purposeful movement

Most comas only last for a couple of weeks. After that, survivors may progress to the next stage of recovery.

Stage 2. Vegetative State (Generalized Response, Total Assistance)

Comas and vegetative states are often believed to be the same, but they are actually two separate states of consciousness.

The primary difference between comas and vegetative states are the neurological responses the survivor displays. In a coma, individuals are completely unresponsive. In a vegetative state, the survivor has regained some of their reflexes.

Survivors in a vegetative state may sometimes appear to be awake. Their eyes may open and close, and they can even react to pain and loud noises. However, they are not yet truly conscious. Rather these reactions, which are often delayed, are caused by autonomic responses of the brain that are still intact or have begun to heal themselves.

If a person begins to react and communicate in a purposeful way, they have entered the next stage of recovery: the minimally conscious state.

Stage 3. Minimally Conscious State (Localized Response, Total Assistance)

doctors giving oxygen to man in minimally conscious stage of traumatic brain injury

When in a minimally conscious state, survivors may drift in and out of consciousness. Unlike the vegetative state, individuals in this stage of recovery now have a limited awareness of their surroundings.

At this stage, a doctor might prescribe medicines to help stimulate the brain and help the survivor fully regain consciousness.

Once individuals consistently respond to instructions and can communicate verbally and/or nonverbally, they have reached the fourth stage of traumatic brain injury recovery.

Stage 4. Post-Traumatic Amnesia (Confused/Agitated, Maximal Assistance)

Post-traumatic amnesia refers to the stage of recovery when the brain is in a severe state of amnesia.

It involves both retrograde amnesia (the inability to remember past events) and anterograde amnesia (the inability to form new memories). In other words, the person has no memory of where they are or how they got there, nor can they remember day-to-day events.

During this stage, the person may appear erratic and even display aggressive or inappropriate behavior. That is because, immediately after emerging from a state of unconsciousness, survivors lose their inhibition. This is especially common after frontal lobe damage.

Post-traumatic amnesia is considered resolved once a person can consistently remember day-to-day events. At that time, doctors will typically recommend survivors go to a rehab facility or return home to continue pursuing recovery.

Later Stages of Traumatic Brain Injury Recovery

therapist helping traumatic brain injury patients relearn how to walk as part of the later stages of recovery

The initial four stages of recovery usually only take a few months to pass through. However, there are still six more stages survivors may experience as they continue on their recovery journey.

Below is a brief summary of the last six stages of brain injury recovery:

Stage 5. Confused/Inappropriate, Non-agitated (Maximal Assistance)

In this stage, a person has trouble focusing and is still confused by their surroundings. Their responses to questions and commands are inaccurate and may not make sense.

Stage 6. Confused/Appropriate (Moderate Assistance)

At this stage, survivors can follow commands and carry on short conversations, though they still have memory problems and cannot focus very well. They lack awareness of their impairments or safety concerns.

Stage 7. Automatic/Appropriate (Minimal Assistance)

Once survivors reach this stage of recovery, they can follow a strict schedule and complete daily routines with supervision. However, they still have trouble initiating activities and planning ahead. They cannot yet live independently.

Stage 8. Purposeful/Appropriate (Standby Assistance)

Survivors’ self-awareness and memory have greatly improved by this stage. They still have impairments with social interaction and reaction times, and are troubled by unexpected situations, but are developing ways to cope. They can even live on their own with minimal help from others.

Stage 9. Purposeful/Appropriate (Standby Assistance on Request)

At level nine, survivors are able to recognize and respond to the needs of others. They generally are able to complete familiar and unfamiliar daily activities, asking for help as necessary.

Stage 10. Purposeful/Appropriate (Modified Independent)

By this final stage of recovery, survivors are functionally independent and have essentially made a full recovery. They can handle multiple tasks at once, initiate new tasks, plan ahead, and adjust to unexpected circumstances. Their cognition is still a little slower average, but they have learned how to compensate.

Unfortunately, not every traumatic brain injury survivor will progress through all of these recovery stages. Some survivors of severe TBI may stall at levels 7 or 8, or at any other level depending on their injury. However, there are methods to help encourage a fuller recovery from brain injury.

How to Progress Through the TBI Recovery Stages

The key to progressing through the ten brain injury recovery stages lies in activating neuroplasticity. This term refers to the brain’s ability to repair neural connections and reassign functions to other undamaged portions of the brain. It is neuroplasticity that allows people to regain functions even after a devastating injury.

Therapy is usually strongly encouraged during the early stages of recovery because neuroplasticity is activated through intensive repetition of therapeutic activities and exercises. Oftentimes, survivors will participate in physical, occupational, and speech therapy to address multiple areas of recovery.

Even after returning home, it is crucial to continue practicing skills learned during therapy. If you struggle with remembering your exercises, ask your therapist to provide a home program handout to use as a guide. There are also home therapy devices, such as FitMi, that can walk you through common exercises in a more stimulating and engaging manner.

Want 25 pages of TBI recovery exercises in PDF form? Click here to download our free TBI Rehab Exercise ebook now (link opens a pop up for uninterrupted reading)

How Long Will It Take to Reach the Last Recovery Stage?

According to most experts, the majority of brain injury recovery occurs within the first two years. After two years:

  • 90% of moderate to severe TBI survivors live in a private residence
  • 50% of moderate to severe brain injury survivors can drive again, with some adaptations
  • 70% of moderate to severe TBI survivors are functionally independent

However, if you do not achieve these milestones within two years, there is still hope. In fact, recent research shows that there is the potential for recovery even after the first two years.

For example, a study that followed TBI survivors for a decade found that even at the 10-year mark, some were still improving their function.

Since recovery may continue, it’s crucial for survivors to continue pursuing therapy and other treatments.

Understanding Traumatic Brain Injury Recovery Stages

Hopefully this guide to traumatic brain injury recovery stages has helped you understand what your recovery journey may look like.

If you feel stuck in a particular stage, don’t give up hope. It’s common to experience plateaus during recovery, but these plateaus do not have to be permanent. If you continue pursuing therapy, eventually you may start to make progress again and achieve a more optimal recovery.

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15 Things Every TBI Survivor Must Know

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