Concussions: Post-Traumatic Amnesia May Indicate More Severe Injury, Longer Recovery

Two types of amnesia

An athlete can experience two types of post-traumatic amnesia (PTA) after a concussion: anterograde (reduced ability to form new memories) and/or retrograde (partial or total loss of the ability to recall events before injury). Anterograde amnesia is considered an important indicator of more serious injury and may be associated with slower recovery.

Anterograde amnesia is characterized by a reduced ability to form new memories after a brain injury, which may lead to decreased attention and inaccurate perception. Anterograde memory is frequently the last function to return after the recovery from a loss of consciousness (LOC). Following the recovery of consciousness patients may be unable to recall little or anything that occurred for days, weeks, or even months after their injury.

Retrograde amnesia (RGA) is characterized by the partial or total loss of the ability to recall events that occurred during the period prior to brain injury. RGA may extend backwards for seconds, minutes, hours, days, months or even years depending on the severity of the injury. The symptoms of retrograde amnesia may improve over time.¹

Testing for amnesia

When checking for amnesia on the sports sideline, the Sport Concussion Assessment Tool 2 (SCAT2) - issued in conjunction with the Concensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008² - calls for asking an athlete the following questions (the modified so-called "Maddocks questions"):

1. At what venue are we today?
2. Which half is it now?
3. Who scored last in this match?
4. What team did you play last week/game?
5. Did your team win the last game?

Testing for PTA

When conducting a more thorough examination for anterograde amnesia deficits, the Zurich consensus statement recommends that the team physician or ATC conduct three cognitive assessment tests:

1. An orientation test: What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now?
2. An immediate memory test: using random, unrelated words, reading each word at a rate of one word per second, and asking the athlete to recall the words both immediately and after a delay (not informing the athlete of the delayed testing until after tests 2 and 3 below, and choosing a different set of words each time the test is performed at follow-up exams);
3. A concentration test in which the athlete is asked to recite backwards two sets of increasingly long strings of digits, and then recite the months of the year in reverse order starting with the last month.

Anterograde amnesia: may predict slower recovery

Until the early 2000's, the most widely followed concussion management guidelines relied heavily on loss of consciousness (LOC) and PTA to determine the severity, or grade, of a concussion and return to play. Many considered the duration of PTA the best indicator of traumatic brain injury severity and the most dependable factor in predicting outcome, even in mild cases.

Beginning in 2001 with the Vienna international consensus statement on concussion in sport, and continuing with the Second Consensus Statement on Concussion In Sport of the 2nd International Conference on Concussion in Sport in Prague in 2004, the trend was away from using PTA in predicting a slower recovery:

• Studies suggested that the nature, severity, and duration of clinical post-concussion symptoms such as headache, dizziness, confusion (mental fogginess), disorientation, and blurred vision are more common than amnesia, and may be more important than the presence or duration of amnesia alone:
  • A 2000 study of 1003 concussions sustained by high school and college football players reported that amnesia was present in only 27% of all cases.
  • 2011 study³ of concussions sustained by high school football players reported that RGA was present in 25% of all cases.
• Studies have also shown that, because RGA varies with the time of measurement after injury, and because athlete often hears peers, family, and coaches discuss events surrounding the injury - making it more likely that they will subsequently falsely report remembering more about the injury - it is a poor measure of injury severity.⁴

By the time the Zurich consensus statement on concussion statement³ was issued in May 2008, however, there was  "renewed interest" in the role of anterograde amnesia as a surrogate measure of injury severity.  The Zurich statement therefore includes anterograde amnesia as a "'modifying' factor" that may predict the potential for prolonged or persistent concussion symptoms and influence concussion investigation and management.  Noting that retrograde amnesia "varies with the time of measurement post-injury," the statement continues the expert  trend in the 2000s viewing it as "poorly reflective" of concussion severity.

The American Academy of Pediatrics' 2010 clinical report on concussions,⁵ concurs, stating that, "[a]long with LOC, [anterograde] amnesia may be an important indicator of more serious injury." 

A 2011 study³ by researchers at the University of Pittsburgh found  that PTA and retrograde amnesia were not predictive of protracted recovery (21 days or more to return to play), which the authors said may be because they are part of the normal acute response to a concussion and resolve relatively quickly with little lasting effects. Their findings "should be interpreted cautiously", they said, "as previous research had supported retrograde amnesia and PTA as predictors of poor concussion outcomes (although not protracted recovery times per se). 

For the most comprehensive, up-to-date concussion information on the Internet, click here.

1. Reddy CC, Collins MW, Gioia GA. Adolescent sports concussion. Phys Med Rehabil Clin N Am. 2008;19(2):247-269. 

2. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 20090: 43:i76-i84

3. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR.  Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players?  Am. J Sport Med 2011;20(10):DOI:10.1177/0363546511410655 (published June 28, 2011 online ahead of print)(accessed November 5, 2011)

4. CollinsMW. Update: concussion. Presented at the American Orthopaedic Society for Sports Medicine 2009 annual meeting; July 9-12, 2009; Keystone, CO.

5. Halstead, M, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents"  Pediatrics. 2010;126(3):597-615.

Revised November 6, 2011