Response Categories

• No response - Patient does not react in any observable way to the sensory input provided
• Generalized response - Patient's response to sensory input is not specifically related to the input, and may be delayed an inconsistent or the same for all sensory input, such as total body movements and autonomic nervous system (ANS) responses - increased heart rate, changes in skin color or temperature, breathing changes, etc.
• Localized response - Patient's response to sensory input is specific to the input, but may be delayed and demonstrate some inconsistency.

Input	Generalized	Localized
Tactile  Pinprick  Ice  Light Touch	Mass body flexion or extension patterns.      Autonomic nervous system (ANS) changes, i.e.: Increased respiration Decreased respiration Increased muscle tone Perspiration Flushing or other skin changes Moaning Crying Any generalized responses below	Movement of extremity away from stimulus Pushing stimulus away Turning towards stimulus
Vestibular  Rolling/rocking  Movement to sit	Increased arousal Decreased arousal Increased muscle tone Extensor patterning Any generalized response above or below	Eye opening Head turning in direction of movement
Visual  Light  Mirror/face	Change in pupil size Blink Any generalized responses above or below	Turning head Closing eyes Focusing, tracking
Auditory  Clap, ring bell,  Voice, call patient's name, 1-Step command	Blinking, startle response Increased arousal Grimace Increased movement Calming effect	Turning head to stimulus Opening eyes Attempt to follow command
Olfactory  Vanilla, banana,  Familiar scent,  Mustard	Increased arousal Decreased arousal	Swallowing Lip-tongue movements Eye opening
Gustatory  Sweet, salty, sour  solution  Lemon swab	Whole body response Change in level of arousal	Tongue movements Licking lips Swallowing Eyes open Head turning

WARNING SIGNS OF SENSORY OVERLOAD

• Flushing
• Perspiring
• Prolonged increase in respiration rate
• Agitation
• Closing of eyes
• Sudden decrease in level of arousal
• Increase in muscle tone

Response Scales

AROUSAL 4-Maintains for 16-30 minutes 3-Maintains for 15 minutes 2-Maintains for 3-5 minutes 1-Maintains <3 minutes 0-None	VISUAL 6-Object recognition 5-Near-point tracking (8 in.) 4-Distant tracking (4 feet) 3-Fixes (any interval) 2-Blink to threat 1-Blink to light 0-None
AUDITORY 4-Replicable movement to command 3-Movement to command 2-Head/eye turn to stimulus 1-Blink to noise 0-None	ORAL-MOTOR/GUSTATORY 3-Swallow reflex present 2-Spontaneous oral movement 1-Bite reflex 0-None
MOTOR RESPONSE 5-Automatic motor response 4-Localizing 3-Flexion withdrawal 2-Abnormal flexion 1-Extension 0-None	COMMUNICATION 2-Mouths/verbalizes words 1-Incomplete vocalization 0-None
OLFACTORY 2-Turn head away from/toward stimulus 1-Facial grimace 0-None

Patterns of Arousal

• Persistent Vegetative State (PVS - in coma 3-6 months after trauma)
  • A syndrome of wakeful unresponsiveness in which patients are neither conscious or in a coma.
  • Neocortical damage prevents conscious thought, but the brainstem continues the motor functions, such as breathing, sleep-wake cycles, coughing, etc.
  • There is no cerebral cortical function (purposeful responding, following commands, or speaking), but the patient can respond at a subcortical level (i.e. eye opening, visual tracking, postural reflexes, grasp reflex, etc.)

  These patients may be admitted to a rehab program for a trial period of therapy and to properly evaluate positioning and equipment needs, such as a bed, wheelchair, etc.

• Early Stages of Recovery
  • Often characterized by inconsistency of response to stimulation, which may be affected by time of day, position, and type of input.
  • Chart and post the patient's responses, so family and rehab team members can document the type of stimulus, patient response, and time of day to determine patterns that indicate increased levels of arousal throughout the day
  • Capitalize on the documented periods of alertness and provide meaningful input in the hope of expanding this state.

• Level III of RLAS - Localized Response
  • Increase the frequency, variety, consistency, and rate of response with the goal of expanding the patient's response and channeling responses into simple activities
  • Perform a stimulation oriented program on patients who can attend to an activity, follow simple verbal or demonstrated commands, and use objects - e.g. catching or throwing a ball, matching activities, 1-piece puzzles, simple self-care activities. Progress to a structure oriented program when the patient progresses to Level IV.