Ankylosing Spondylitis — DVA claim example

Diagnostic Assessment — Ankylosing Spondylitis

Example 1 of 1 · fictitious patient (Veteran AR)

Diagnostic Assessment

Ankylosing Spondylitis

BOP Code: 40 of 2021 (Ankylosing Spondylitis)
RH Code: 39 of 2021 (Ankylosing Spondylitis)

ADF History

Veteran AR, date of birth 03 February 1983, Royal Australian Navy, Marine Technician (Propulsion), enlisted 14 January 2002, medically discharged 20 November 2019. Operational service: Middle East Area of Operations (North Arabian Gulf), aboard a frigate, 12 September 2006 to 20 March 2007 (warlike); Middle East Area of Operations (maritime security), aboard a frigate, 04 February 2016 to 28 August 2016 (non-warlike).

Occupational History

As a marine technician the veteran maintained diesel engines, gas turbines, pumps and shafting in hot, noisy and confined machinery spaces, working in awkward and stooped postures, climbing vertical ladders and lifting heavy components by hand. Sea postings involved a six-hours-on, six-hours-off watch rotation, disrupted sleep and long periods without access to dental or specialist medical care.

Ship's companies on long deployments have limited space for exercise, a high-calorie galley diet and, in the period of his service, a strong smoking culture on the upper deck. Dental officers were not embarked on all ships, so dental disease often went untreated until return to port.

Engine room work exposed the veteran to heat stress, diesel exhaust, oil mist and vibration, and to sudden heavy lifting during breakdowns and damage-control exercises. Medical care at sea was provided by a ship's medical officer or a medical sailor with limited diagnostic facilities, and specialist investigation was usually deferred until the ship returned to its home port.

History

Veteran AR, a Royal Australian Navy marine technician, developed periodontitis during warlike service in the North Arabian Gulf in 2006-07 and then inflammatory back pain from 15 July 2007, leading to a diagnosis of HLA-B27 positive ankylosing spondylitis in 2008. The disease worsened markedly during a 2016 Middle East deployment, when he was a current smoker, obese, had untreated periodontitis and could not do his prescribed exercises or start biological therapy at sea.

Timeline

• 15 Aug 2006 — Pre-deployment periodic health examination at the fleet base health centre. No back pain or stiffness, full spinal range of movement, normal chest expansion. Smoker of 15 cigarettes a day since 2002. BMI 26.2. Dental check showed mild gingivitis only. Fit for sea service. "no back pain, fit for sea"
• 04 Dec 2006 — Consultation with the ship's medical officer during warlike service in the North Arabian Gulf. The veteran reported bleeding, swollen gums and bad breath for several weeks. No dental officer was embarked. He was given chlorhexidine mouthwash and told to see a dentist on return to Australia, about four months away. "bleeding gums, no dental officer"
• 28 Mar 2007 — Post-deployment dental examination by a naval dental officer. Generalised chronic periodontitis with probing depths of 5 to 7 mm, bleeding on probing and 20 to 30 per cent horizontal bone loss on bitewing radiographs. A course of deep scaling and root planing was commenced. Still smoking 15 to 20 cigarettes a day. "chronic periodontitis, 5-7 mm pockets"
• 03 Aug 2007 — At the base health centre the veteran described low back and buttock pain since 15 July 2007, worse in the second half of the night and in the morning, with morning stiffness lasting over an hour, improving with exercise and not with rest. Pain alternated between the buttocks. Examination showed reduced lumbar flexion (modified Schober 3.5 cm) and tenderness over both sacroiliac joints. He was started on naproxen with good relief. "inflammatory back pain, morning stiffness"
• 30 Aug 2007 — Dental review after the first course of deep scaling. Periodontitis persisted, with residual probing depths of 5 to 6 mm and bleeding on probing at multiple sites. Further treatment was planned but interrupted by sea time. The dental officer recorded that the periodontitis had been present since before the deployment ended and was slow to respond because the veteran continued to smoke. "persisting periodontitis, 5-6 mm pockets"
• 11 Jan 2010 — Periodic health examination. Weight 98 kg, height 1.79 m, BMI 30.6, up from 26.2 in 2006. The veteran attributed the weight gain to back pain limiting his running and to limited exercise opportunities during sea postings. Still smoking 15 to 20 cigarettes a day. Ongoing naproxen with partial control of morning stiffness. Advised on weight loss and smoking cessation. "BMI 30.6, still smoking"
• 21 Feb 2008 — A rheumatologist reviewed him with HLA-B27 positive serology, a CRP of 18 mg/L and pelvic X-rays showing bilateral grade 3 sacroiliitis. MRI of the sacroiliac joints of 07 November 2007 had shown bilateral bone marrow oedema. The rheumatologist diagnosed ankylosing spondylitis meeting the modified New York criteria and prescribed daily stretching, range of motion and aerobic exercises and continued naproxen. BASDAI 3.1. "HLA-B27 positive, grade 3 sacroiliitis"
• 14 Apr 2015 — Rheumatology review. Disease had been moderately controlled on naproxen and exercise (BASDAI 3.4, CRP 6 mg/L) but lumbar X-rays showed early syndesmophytes at L1/2 and L2/3. BMI 32.4. Still smoking. The rheumatologist recommended a tumour necrosis factor inhibitor if disease activity rose, and recorded two failed attempts to stop smoking while at sea. "BASDAI 3.4, early syndesmophytes"
• 14 Apr 2016 — On non-warlike service in the Middle East the ship's medical officer recorded increasing back pain, morning stiffness of two hours and night waking. The veteran had been unable to do his prescribed exercises because of six-on, six-off watches, ship motion and no space. Gums were bleeding and periodontal treatment had been interrupted when the ship sailed. Biological therapy could not be started at sea. "unable to exercise at sea"
• 12 Sep 2016 — Rheumatology review two weeks after return. BASDAI 7.2, ASDAS-CRP 3.9, CRP 38 mg/L, modified Schober 2.0 cm, new right heel enthesitis and a first episode of left anterior uveitis treated by an ophthalmologist on 01 September 2016. MRI showed new active inflammation in the thoracolumbar spine. Adalimumab was commenced. BMI 32.8. Still smoking. "BASDAI 7.2, CRP 38, adalimumab"

Symptoms

At onset the veteran had inflammatory low back and alternating buttock pain, worse in the second half of the night and the morning, with morning stiffness of more than an hour that eased with exercise. After onset he developed reduced spinal movement and fatigue, controlled in part by naproxen and exercise. After the 2016 worsening he had severe pain and stiffness, night waking, heel enthesitis and an episode of anterior uveitis.

Between onset and the 2016 worsening his symptoms fluctuated, with flares lasting several weeks during sea postings when he could not exercise, and partial remission ashore with daily stretching and swimming. Each flare was accompanied by bleeding gums when dental treatment lapsed.

He now reports constant thoracolumbar pain and stiffness, morning stiffness of about 90 minutes despite adalimumab, reduced ability to turn his head and trunk, fatigue, poor sleep, and difficulty sitting, bending, lifting and driving for long periods.

Imaging

• 07 Nov 2007 — MRI sacroiliac joints: "Bilateral periarticular bone marrow oedema of the sacroiliac joints on STIR sequences, consistent with active sacroiliitis."
• 21 Feb 2008 — X-ray pelvis: "Bilateral grade 3 sacroiliitis with erosions, sclerosis and joint space irregularity."
• 14 Apr 2015 — X-ray lumbar spine: "Squaring of the lumbar vertebral bodies and early marginal syndesmophytes at L1/2 and L2/3."
• 12 Sep 2016 — MRI whole spine and sacroiliac joints: "New active inflammatory lesions at the anterior vertebral corners from T10 to L2 and active bilateral sacroiliitis. Progression of syndesmophytes."

Onset Date

The most likely date of onset of this condition is 15 Jul 2007.

At that date the veteran was a marine technician serving full time aboard a frigate alongside in Australia, four months after returning from warlike service in the North Arabian Gulf. From that date he had persistent inflammatory back pain with prolonged morning stiffness, which he reported at the base health centre on 03 August 2007.

This date is appropriate because his pre-deployment examination on 15 August 2006 recorded no back pain and a normal spinal examination, and his first presentation with inflammatory back pain, on 03 August 2007, dates the persistent symptoms to 15 July 2007. MRI in November 2007 and X-rays in February 2008 confirmed the diagnosis. It falls within continuous full-time service.

For the periodontitis factor, the three months before onset run from 15 Apr 2007 to 15 Jul 2007. Periodontitis was present from at least 04 Dec 2006, when bleeding, swollen gums were recorded on deployment, was diagnosed with established bone loss on 28 Mar 2007 and was still present at dental review on 30 Aug 2007, so it was present throughout that window.

For the worsening factors, the documented worsening was on 12 Sep 2016, when BASDAI had risen from 3.4 to 7.2 and CRP from 6 to 38 mg/L, with new spinal inflammation on MRI, enthesitis and uveitis, requiring escalation to adalimumab. The three months before the worsening run from 12 Jun 2016 to 12 Sep 2016, and periodontitis was present continuously from 18 Jan 2016. The ten years before the worsening run from 12 Sep 2006 to 12 Sep 2016 and contain 6 years and 8 months with a BMI above 30 (11 Jan 2010 to 05 Sep 2016). He was a current smoker of about 11 pack-years at the worsening, and the inability to exercise or start biological therapy ran from 04 Feb 2016 to 28 Aug 2016.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Ankylosing Spondylitis (ICD-10-AM M45), under the Statements of Principles concerning ankylosing spondylitis, Balance of Probabilities No. 40 of 2021 and Reasonable Hypothesis No. 39 of 2021.

Ankylosing spondylitis is a chronic, progressive, systemic inflammatory disease that principally involves the sacroiliac joints and the axial skeleton. It typically begins before the age of 45 with inflammatory back pain, worse at night and in the morning and better with exercise, and is strongly associated with the HLA-B27 antigen. Inflammation at the attachment of ligaments to bone (enthesitis) leads to erosion and new bone formation, with syndesmophytes that can eventually fuse the spine. Extra-articular features include anterior uveitis, peripheral arthritis and heel enthesitis. Treatment relies on regular exercise, nonsteroidal anti-inflammatory drugs and, for active disease, biological therapy.

Periodontitis is a chronic inflammatory disease of the supporting tissues of the teeth caused by bacterial biofilm. It produces a sustained systemic inflammatory burden, and periodontal bacteria and the host response to them are recognised as possible triggers of spondyloarthritis in genetically susceptible, HLA-B27 positive people. Smoking and obesity are recognised modifiers of disease activity and treatment response.

The disease began on 15 July 2007 after periodontitis acquired on warlike service, was diagnosed by a rheumatologist on 21 February 2008 and worsened during and after operational service in the Middle East in 2016.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

15 July 2007.

When did the veteran first present to a health / medical provider for this condition?

03 August 2007.

When was the condition confirmed / formally diagnosed?

21 February 2008.

When did the veteran first present to you (or your practice) for this condition?

27 May 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by a rheumatologist on 21 February 2008 and meets the modified New York criteria: inflammatory back pain for more than three months improving with exercise and not with rest, reduced lumbar flexion (modified Schober 3.5 cm) and bilateral grade 3 sacroiliitis on X-ray. MRI on 07 November 2007 showed active bilateral sacroiliitis, HLA-B27 was positive and CRP was raised at 18 mg/L.

This is a chronic, progressive, systemic inflammatory disease principally involving the sacroiliac joints and axial skeleton, as the Statement of Principles requires. Psoriatic arthritis, reactive arthritis and fibromyalgia were excluded: there was no psoriasis, no preceding gastrointestinal or genitourinary infection, and the objective inflammatory and imaging findings are not those of fibromyalgia. Later syndesmophytes, enthesitis and uveitis confirm the diagnosis.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 15 July 2007, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service and contains only worsening factors for this condition. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the North Arabian Gulf in 2006-07, during which the periodontitis preceding onset arose, and his non-warlike service in the Middle East in 2016, during which the condition worsened. Under section 10(2) of each instrument the worsening factors apply to aggravation of the condition.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Ankylosing Spondylitis, No. 40 of 2021

Worsening factors

Factor 9(1): for current smokers only, having smoked at least one pack-year of tobacco products before the clinical worsening of ankylosing spondylitis; — MET

- The veteran began smoking at recruit training in 2002 and smoked 15 cigarettes a day throughout his service, increasing to 25 a day at sea, where smoking on the upper deck was the main break from watch-keeping. He was still smoking at the documented worsening on 12 September 2016, by which time he had smoked about 11 pack-years. Smoking was recorded at every periodic health examination from 2003 to 2016, and his rheumatologist noted in 2015 that he had been unable to stop despite two attempts with nicotine replacement while at sea. He was therefore a current smoker with well over one pack-year before the clinical worsening. Smoking is associated with higher disease activity, poorer response to treatment and faster radiographic progression in ankylosing spondylitis.

Factor 9(2): inability to obtain appropriate clinical management for ankylosing spondylitis. — MET

- After diagnosis the veteran was prescribed daily ankylosing spondylitis exercises (regular stretching and range of motion exercises with aerobic exercise) and a nonsteroidal anti-inflammatory drug, and in 2015 his rheumatologist recommended a tumour necrosis factor inhibitor. During his frigate posting and his 2016 deployment he could not undertake the prescribed exercises: watch-keeping in a six-hours-on, six-hours-off rotation, ship motion and the lack of deck or gym space prevented regular stretching and aerobic exercise, as recorded by the ship's medical officer on 14 April 2016. The application for biological therapy was deferred until after the deployment because the drug could not be stored or monitored at sea. His BASDAI rose from 3.4 to 7.2 and his CRP from 6 to 38 mg/L by 12 September 2016. This is an inability to obtain appropriate clinical management, including inability to undertake prescribed ankylosing spondylitis exercises, before the worsening.

Reasonable Hypothesis — Statement of Principles concerning Ankylosing Spondylitis, No. 39 of 2021

Causative factors

Factor 9(1): having periodontitis for at least the three months before the clinical onset of ankylosing spondylitis; — MET

- During warlike service in the North Arabian Gulf aboard a frigate from 12 September 2006 to 20 March 2007 there was no embarked dental officer for six months. The ship's medical record notes bleeding, swollen gums and halitosis on 04 December 2006, and the post-deployment dental examination on 28 March 2007 diagnosed generalised chronic periodontitis, with probing depths of 5 to 7 mm, bleeding on probing and radiographic horizontal bone loss of 20 to 30 per cent, a degree of bone loss that had taken months to develop. The periodontitis was therefore present from at least 04 December 2006, more than three months before the clinical onset of ankylosing spondylitis on 15 July 2007, and the dental officer recorded it as still present at the review on 30 August 2007. Periodontitis drives systemic inflammation and is associated with the onset of spondyloarthritis.

Worsening factors

Factor 9(2): having periodontitis for at least the three months before the clinical worsening of ankylosing spondylitis; — MET

- At the pre-deployment dental examination on 18 January 2016 the veteran had recurrent generalised periodontitis with probing depths up to 7 mm. Deep scaling was started but the course was deferred because the ship sailed for the Middle East on 04 February 2016, and no dental officer was embarked. The post-deployment dental examination on 06 September 2016 recorded active periodontitis with further bone loss. The periodontitis was present continuously from 18 January 2016 to the worsening on 12 September 2016, well over the three months before the worsening, and it arose during and was left untreated because of his operational service.

Factor 9(3): for current smokers only, having smoked at least one pack-year of tobacco products before the clinical worsening of ankylosing spondylitis; — MET

- The veteran was a current smoker of about 15 cigarettes a day, rising to 25 a day at sea, from 2002 to the worsening on 12 September 2016, about 11 pack-years. His smoking increased during his operational service in the Middle East in 2006-07 and 2016, where cigarettes were cheap and smoking breaks punctuated long watches. He was still smoking at the worsening.

Factor 9(4): being obese for at least five years within the ten years before the clinical worsening of ankylosing spondylitis; — MET

- The veteran's BMI rose above 30 from the periodic health examination of 11 January 2010 (weight 98 kg, height 1.79 m, BMI 30.6) and was recorded at 31 to 33 at every examination through to 05 September 2016 (BMI 32.8), a period of 6 years and 8 months, all within the ten years before the worsening, from 12 September 2006 to 12 September 2016. The weight gain followed the reduced activity caused by inflammatory back pain and the limited opportunities for exercise at sea, including on his 2016 deployment. Obesity increases disease activity and reduces the response to treatment in ankylosing spondylitis.

Factor 9(5): inability to obtain appropriate clinical management for ankylosing spondylitis. — MET

- On operational service in the Middle East from 04 February 2016 to 28 August 2016 the veteran could not do his prescribed daily stretching, range of motion and aerobic exercises because of watch-keeping, ship motion and lack of space, and his biological therapy was deferred until after the deployment because it could not be stored or monitored at sea. Disease activity rose markedly during this period (BASDAI 3.4 to 7.2, CRP 6 to 38 mg/L). Earlier, during his 2006-07 warlike deployment, he had inflammatory back pain without any access to a doctor able to investigate it. This is an inability to obtain appropriate clinical management, including the inability to undertake prescribed ankylosing spondylitis exercises.

The % contribution of the causes is 100% and significant.

Sequelae

The ankylosing spondylitis has resulted in progressive thoracolumbar syndesmophytes with loss of spinal mobility, right heel enthesitis and recurrent left anterior uveitis. Chronic pain and fatigue have led to sleep disturbance and a depressive adjustment disorder. These are sequelae of the accepted condition and can be claimed in their own right when diagnosed.

Unintended Consequence

Not met. Treatment with naproxen from 2007 and adalimumab from 2016 has been appropriate and has not been shown to have caused or worsened any condition. Any future complication of this Commonwealth-provided treatment, such as gastrointestinal bleeding, renal impairment or serious infection, would be an unintended consequence of treatment of the accepted condition under section 6A of the DRCA and the equivalent provisions of the MRCA and should be claimed when it is diagnosed.

Inability to Attain Appropriate Medical Management

MET. On operational service in the Middle East from February to August 2016 the veteran could not do his prescribed daily stretching, range of motion and aerobic exercises because of six-on, six-off watch-keeping, ship motion and lack of space, and the biological therapy his rheumatologist had planned was deferred because it could not be stored or monitored at sea. His periodontal treatment was also interrupted when the ship sailed. Disease activity rose sharply over the deployment. The instruments expressly include inability to undertake prescribed ankylosing spondylitis exercises. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the operational circumstances that prevented the prescribed treatment amount to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 15 Aug 2006, Periodic health examination and dental check, Medical Officer, Fleet base health centre
2. 04 Dec 2006, Ship's medical record, Ship's Medical Officer
3. 28 Mar 2007, Post-deployment dental examination, Naval Dental Officer
4. 03 Aug 2007, Outpatient health record, Medical Officer, Base health centre
5. 07 Nov 2007, MRI sacroiliac joints, Radiologist
6. 21 Feb 2008, Specialist consultation, X-ray pelvis and pathology, Rheumatologist
7. 11 Jan 2010, Periodic health examination, Medical Officer
8. 14 Apr 2015, Specialist review and X-ray lumbar spine, Rheumatologist
9. 18 Jan 2016, Pre-deployment dental examination, Naval Dental Officer
10. 14 Apr 2016, Ship's medical record, Ship's Medical Officer
11. 01 Sep 2016, Ophthalmology consultation, Ophthalmologist
12. 06 Sep 2016, Post-deployment dental examination, Naval Dental Officer
13. 12 Sep 2016, Specialist review and MRI spine, Rheumatologist
14. Statement of Principles concerning Ankylosing Spondylitis (Balance of Probabilities) No. 40 of 2021, Repatriation Medical Authority
15. Statement of Principles concerning Ankylosing Spondylitis (Reasonable Hypothesis) No. 39 of 2021, Repatriation Medical Authority