Rancho Levels of Cognitive Functioning (3rd edition, 1998)

Purpose

This evaluation tool identifies patterns of recovery for people with brain injury. The scale describes behavioral characteristics and cognitive deficits associated with brain injury to help the team understand and focus on the person's abilities in designing an appropriate treatment program.

Link to Instrument

Acronym LCFS

Cost

Not Free

Actual Cost

$4.00

Cost Description

Reference card is $4.00 with a family guide available for $5.50

Diagnosis/Conditions

Brain Injury Recovery

Brain Injury

A single-item rating scale with eight levels that range from level I (no response) to level VIII (purposeful and appropriate).
Each level includes multiple cognitive and behavioral items that can be checked as present or absent during observation.

Number of Items

minutes

No specific time requirement is described.

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Karen McCulloch, PT, PhD, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 5/2012

Measurement Domain

Cognition

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association��s Multiple Sclerosis Taskforce (MSEDGE), Parkinson��s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:

Abbreviations:
HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	N/A	N/A	N/A	N/A

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	Yes	Yes	Yes	Not reported

Considerations

There is no standardized approach to score the LCFS, but its simplicity and ease in characterizing global level of recovery have resulted in common use.

The levels of cognitive functioning are most appropriate for use in the first year following brain injury, when a global description of cognitive and behavioral function may be feasible. As recovery continues and higher level function is attained, more specific neuropsychological testing is indicated to describe the nuances of cognitive and behavioral function.

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Test/Retest Reliability

Traumatic brain injury:(Gouvier et al, 1987; n=40 patients with TBI admitted to inpatient rehabilitation)

Excellent test-retest reliability (Spearman rho=.82)

Interrater/Intrarater Reliability

Traumatic brain injury: (Gouvier et al, 1987)

Excellent inter-rater reliability (average Spearman rho=.89)

Traumatic Brain Injury: (Beauchamp et al, 2001)

Adequate to excellent inter-rater reliability (r=.84, overall reliability index 0.91, k=.31)

Criterion Validity (Predictive/Concurrent)

Traumatic Brain Injury: (Gouvier et al, 1987)

Predictive validity of admission LCFS scores was examined via correlations with discharge ratings on the Stover-Zeiger scale (r=.59), Glasgow Outcome Scale (r=.57) and Glasgow Outcome Scale �CExpanded (r=.68).

Traumatic Brain Injury: (Cifu et al, 1997; n=132 patients with TBI who had been employed prior to injury; mean age=33 years old; f/u one year post injury)

Predictive validity of LCFS scores at admission and at discharge from rehabilitation and LCFS change scores were significantly higher in patients who returned to work than those who did not.

Traumatic Brain Injury:(Rao and Kilgore, 1992; n=57 admissions to inpatient brain injury rehabilitation)

Admission and discharge LCFS scores predicted 86.8% of patients who returned to work and 63.2% of those who did not.

Construct Validity

Traumatic brain injury: (Gouvier et al, 1987)

Excellent concurrent validity of LCFS with Stover-Zeiger scale was r=.92 at admission. Discharge concurrent measures of the LCFS with the Stover-Zeiger Scale was (r=.73), Glasgow Outcome Scale (r=.76) and Glasgow Outcome Scale- Expanded (r=.79).

Moderate to Severe Traumatic Brain Injury: (Mysiw et al, 1989; n=76 individuals with moderate to severe TBI in outpatient clinic; mean age= 30.5 years old (range 16-65); mean time post injury = 25 months)

LCFS ratings could discriminate between most severely involved group categories of vocational readiness (return to work, vocational training, supported work) p<.0001

Traumatic Brain Injury: (Labi et al, 1998; n=33 mean age males 38.8, women 52.2; average GCS=7.8; average LCFS=4.6)

Excellent correlation with LCFS and admission (r=.79) and discharge (r=.77) Functional Cognition Index scores.

Traumatic Brain Injury: (Hall et al, 1993; n=332 from TBI model systems database; mean age 34.5 (16) years, mean GCS 8.2 (3.7))

Adequate correlation with LCFS and indicators of injury severity: GCS (r=.329), coma duration (r=.360), length of PTA (r=.465).
Excellent correlation with Rasch transformed disability indices: DRS r=.727, FIM/FAM cognitive r=.670, FIM cognitive r=.671.

Traumatic Brain Injury:(Finch et al, 1987; n=46 patients with TBI admitted to inpatient rehabilitation, median age 38.5 years, median time from injury to admission 26 days)

Discharge LCFS was adequately correlated (r=.47) with higher level cognitive functions (abstraction, backward digit span) tested at admission.

Bibliography

Cifu, D. X., Keyser-Marcus, L., et al. (1997). "Acute predictors of successful return to work 1 year after traumatic brain injury: A multicenter analysis* 1,* 2." Archives of physical medicine and rehabilitation 78(2): 125-131.

Finch, M., Sandel, M. E., et al. (1997). "Admission examination factors predicting cognitive improvement during acute brain injury rehabilitation." Brain Inj 11(10): 713-721.

Gouvier, W. D., Blanton, P. D., et al. (1987). "Reliability and validity of the Disability Rating Scale and the Levels of Cognitive Functioning Scale in monitoring recovery from severe head injury." Arch Phys Med Rehabil 68(2): 94-97.

Hagen, C. and Malkmus, D. (1975). Levels of cognitive functioning. Hall, K. M., Hamilton, B. B., et al. (1993). "Characteristics and comparisons of functional assessment indices: Disability Rating Scale, Functional Independence Measure, and Functional Assessment Measure." The Journal of Head Trauma Rehabilitation.

Labi, M. L. C., Brentjens, M., et al. (1998). "Functional Cognition Index?: A New Instrument to Assess Cognitive Disability After Traumatic Brain Injury." Neurorehabilitation and Neural Repair 12(2): 45-51.

Mysiw, W. J., Corrigan, J. D., et al. (1989). "Vocational evaluation of traumatic brain injury patients using the functional assessment inventory." Brain Inj 3(1): 27-34.

Rao, N. and Kilgore, K. M. (1992). "Predicting return to work in traumatic brain injury using assessment scales." Arch Phys Med Rehabil 73(10): 911-916.

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