Daniel Stålhammar

The Reaction Level Scale (RLS 85)

SummaryThe Reaction Level Scale (RLS 85) is a “coma scale” for the direct assessment of overall reaction level in patients with acute brain disorders. It is devised for reliable use even in the management of patients who are difficult to assess, such as intubated patients and patients with swollen eyelids. We here present the manual of the RLS 85 and the guidelines for its use. The underlying concepts as well as limitations are outlined. Condensed information of known reliability and validity is presented. A training scheme for presumed observers (doctors, nurses and assistant nurses) is outlined. It is suggested that users of the RLS 85 refer to these guidelines and in scientific reports clearly state any deviations from this present manual in order to facilitate valid comparisons between different studies and different groups of patients.

Epidemiology of traumatic brain injury: a population based study in western Sweden.

Background – This study on traumatic brain injury (TBI) is based on prospective and retrospective population based data from a head injury register in Borås.

Mild traumatic brain injuries: the impact of early intervention on late sequelae. A randomized controlled trial

SummaryBackground. Positive results from early clinical intervention of mild traumatic brain injury (MTBI) patients by rehabilitation specialists have been reported. Various treatments have been used, but few controlled studies are published. We hypothesised that early rehabilitation of selected MTBI patients would reduce long term sequelae.Method. A randomised controlled trial with one year follow-up. Among 1719 consecutive patients with MTBI, 395 individuals, 16–60 years of age, met the MTBI definition. Exclusion criteria were: previous clinically significant brain disorders and/or a history of substance abuse. The control group (n = 131) received regular care. The intervention group (n = 264) was examined by a rehabilitation specialist. 78 patients were mainly referred to an occupational therapist. The problems were identified in daily activities and in terms of post-concussion symptoms (PCS), an individualised, tailored treatment was given. Primary endpoint was change in rate of PCS and in life satisfaction at one-year follow-up between the groups.Findings. No statistical differences were found between the intervention and control groups. Patients who experienced few PCS two to eight weeks after the injury and declined rehabilitation recovered and returned to their pre-injury status. Patients who suffered several PCS and accepted rehabilitation did not recover after one year.Interpretation. In this particular MTBI sample, early active rehabilitation did not change the outcome to a statistically-significant degree. Further studies should focus on patients with several complaints during the first 1–3 months and test various types of interventions.

Assessment of responsiveness in acute cerebral disorders

SummaryA new scale for assessment of overall responsiveness, the Reaction Level Scale (RLS 85), which has been shown to have better reliability than the Glasgow Coma Scale (GCS), has been tested in four neurosurgical departments regarding inter-observer agreement and coveragei. e. the proportion of patients that could be assessed by the scale. In a carefully designed study 51 observers pairwise performed 164 tests on 88 patients. Reliability was studied by the Kappa method, which is defined as inter-observer agreement corrected for agreement by chance. The inter-observer agreement measured as overall Kappa was good (K=0.69 ±0.05) and there were no significant differences between the departments, professional categories or aetiologies. Regarding the separate RLS 85 levels the Kappa values were above 0.65, except for withdrawing (K=0.51) and flexor responses (K=0.55). There was good inter-observer agreement on coma (K=0.71).In conclusion, the RLS 85 proved to be easily learnt, it showed full coverage without pseudoscoring, and it was used in a consistent way by doctors, nurses and assistant nurses of four different neurosurgical departments in two Scandinavian countries.

Experimental brain damage from fluid pressures due to impact acceleration. 2. Pathophysiological observations.

The significance of the intracranial acceleration pressure pattern at impact to the intact skull in production of brain damage is discussed, particularly as regards the contre‐coup pressures. A rigid fluid‐filled cylinder was connected to the skull cavity of rabbits; the cylinder was impacted and the intracranial contents acted as a contre‐coup end. The pressure pattern was also modified by injection of small quantified air volumes. The pathophysiological effects of “experimental brain concussion” with vasomotor and respiratory disturbances which occurred were related to the contre‐coup pressures produced, particularly the magnitude of subatmospheric pressures and the duration of late positive pressures. Some implications on their significance for brain tissue flow are discussed.

EXPERIMENTAL BRAIN DAMAGE FROM FLUID PRESSURES DUE TO IMPACT ACCELERATION. 1. Design of Experimental Procedure

The significance of the intracranial acceleration pressure pattern at impact to the intact skull in production of brain damage is discussed particularly as regards the contre‐coup pressures. Sudden pressure changes within the cranial cavity of the rabbit were studied by means of a new impact acceleration model. The rabbit skull was connected with a cylinder. Impact acceleration was applied to the model with the skull contents serving as a “contre‐coup end”. Skull deformation was minimized by reinforcement of the skull vault. Acceleration, velocity and displacement of the system were recorded at various sites and could be predicted within wide ranges. Simultaneous recordings were also made of the pressure changes in the skull cavity and cylinder contents. By adjusting the acceleration course and by introducing a quantified air bubble (50, 100, 150 mm3) at the impact of the cylinder, it was possible to produce and vary an intracranial pressure pattern of “contre‐coup type”, including predictable subatmospheric transients. The mechanics of the intracranial pressure changes and displacements are discussed. The method seems to be suitable for studying the relations between brief negative‐positive pressure variations (about 5 ms) of “contre‐coup type” and pathological alterations similar to those reported in other head injury models and in human head trauma.

Manual operacional da escala de nível reativo (RLS 85)

The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical pratice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and abscence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical practice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and absence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.

Operational manual of the reaction level scale (RLS85)

The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical pratice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and abscence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical practice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and absence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.

Manual of the Reaction Level Scale (RLS85): a version in Portuguese

The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical pratice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and abscence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical practice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and absence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.