Cervical Spine - Strain — DVA claim example

Diagnostic Assessment — Cervical Spine - Strain

Example 1 of 5 · fictitious patient (Veteran A)

Diagnostic Assessment

Cervical Spine - STRAIN

SOP No. 28 of 2020 (BOP) / SOP No. 27 of 2020 (RH) - Sprain and Strain

ADF History

The veteran, Date of Birth: [withheld] Aircraft Technician, enlistment date 18 Apr 1988, discharge date 22 October 1999.

Occupational History

As an Aircraft Technician in the Royal Australian Air Force, the veteran was exposed to numerous occupational hazards including chemical exposures (aviation fuels, hydraulic fluids, lubricants, solvents, adhesives), physical hazards (confined space entry, awkward postures, heavy lifting, vibration, noise), environmental hazards (extreme temperatures, poor ventilation, fuel vapors), specific F-111 hazards (fire starter cartridge fumes), and ergonomic hazards (prolonged standing, awkward positioning, repetitive movements). His role specifically involved Fuel Tank Entry (FTE) duties which required specialized medical clearance and monitoring, indicating regular work with aircraft fuel systems in confined spaces.

History

The veteran the veteran an Aircraft Technician in the Royal Australian Air Force, developed cervical strain on multiple occasions during his service. His most significant cervical injury occurred on March 11, 1998, when he was involved in a motor vehicle accident while traveling home from work. His vehicle was stationary when hit from behind, resulting in neck and back pain diagnosed as whiplash injury.

Timeline

• 29 Dec 1993: The veteran the veteran was involved in a motor vehicle accident while traveling home from work. His stationary vehicle was hit from behind, resulting in neck and back pain. The medical documentation noted neck pain and tenderness in neck muscles. Full range of motion of the neck was present but painful. He was referred to physiotherapy, prescribed Naprosyn, and advised to rest with time off work.
• 04 Jan 1994: Follow-up review for headache post-MVA. The veteran was still complaining of muscle back and neck pain/stiffness. He had been using Naprosyn with some improvement, but the pain worse during sitting. He was assessed as having a resolving whiplash injury and advised to continue Naprosyn with reassurance.
• 08 May 1999: Presented with sore right shoulder and pain up into neck. This intermittent pain was reported to have been present for 10 years. Despite the pain, the veteran was able to fully rotate his neck. A plan was made to arrange a Medical Officer appointment for possible physiotherapy referral.
• 02 Jun 1999: Presented with neck stiffness and pain. The pain onset was five days prior during a "ceiling workout" (likely pull-ups or similar overhead exercise). The pain remained constant. Assessed as possible muscle spasm. Treated with ibuprofen, advised to mobilize, and restricted duties for 5 days.
• 23 Oct 2018: MRI cervical spine showed multilevel cervical spine discal disease with loss of height and disc annular bulges. Specifically noted were reduced disc height and signal at C5-6 and C6-7 with posterior annular bulging and mild thecal sac compression. Also documented were mildly reduced disc height and signal at C3-4 and C4-5.

Symptoms

At the time of the initial injury in February 1996, the veteran experienced neck pain and stiffness following a motor vehicle accident. He had full range of motion but with pain. The symptoms persisted despite treatment with Naprosyn, though some improvement was noted.

In Jun 2001, he reported intermittent neck pain that had been present for 10 years (dating back to approximately 1993). In July 2001, he experienced acute neck stiffness and pain following a "ceiling workout," with the pain remaining constant.

Currently, the veteran has multilevel cervical spondylosis with disc disease as confirmed by MRI. This includes posterior annular bulging and mild thecal sac compression at C5-6 and C6-7, as well as disc height reduction and signal changes at C3-4 and C4-5. These findings are consistent with the long-term sequelae of cervical strain injuries sustained during service.

Imaging

23 October 2018: MRI cervical spine showed multilevel cervical spine discal disease with loss of height and disc annular bulges. Specifically noted were reduced disc height and signal at C5-6 and C6-7 with posterior annular bulging and mild thecal sac compression. Also documented were mildly reduced disc height and signal at C3-4 and C4-5. Normal vertebral alignment was noted with normal cervical lordosis present.

• What is the formal diagnosis of the condition claimed above? The formal diagnosis is Cervical Strain which has progressed to Cervical Spondylosis (DVA SOP No. 28 of 2020 [BOP] and No. 27 of 2020 [RH] for Sprain and Strain; ICD-10 code M47.812).

Cervical strain is a soft tissue injury affecting the muscles and ligaments of the neck. It occurs when these structures are stretched beyond their normal capacity or torn due to sudden force or overuse. Whiplash, which is a type of cervical strain, occurs when the head is forcefully thrown backward and then forward, typically in a motor vehicle accident. Initially, cervical strain presents with localized pain, muscle spasm, restricted movement, and tenderness. Without appropriate management or with severe initial injury, cervical strain can lead to chronic changes.

Cervical spondylosis represents the degenerative progression of the initial cervical strain. It involves degeneration of the spinal discs and vertebral bodies, resulting in reduced disc height, osteophyte formation, and potential nerve compression. These changes are consistent with the MRI findings showing reduced disc height and signal at multiple levels with posterior annular bulging at C5-6 and C6-7.

There is a clear temporal relationship between the initial cervical strain sustained during the motor vehicle accident in 1998 (diagnosed as whiplash injury) and subsequent episodes of cervical strain in 2003, leading to the development of cervical spondylosis. The MVA caused significant trauma to the cervical soft tissues, and over time, the biomechanical changes resulting from that injury, combined with occupational stressors, led to accelerated degenerative changes in the cervical spine as demonstrated on the recent MRI.

• For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced cervical strain symptoms on March 11, 1998, following a motor vehicle accident while traveling home from work. His vehicle was stationary when hit from behind, resulting in neck pain that was documented during his medical assessment that day. However, during a Jun 2001 presentation, he reported intermittent neck pain that had been present for 10 years, suggesting an earlier onset of cervical symptoms around 1993.

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

condition? The veteran first presented to a health provider for his cervical strain on March 11, 1998, when he was seen at RAAF medical services following the motor vehicle accident. He was examined by a medical officer who noted neck pain with full range of motion but painful, and prescribed Naprosyn (anti-inflammatory), rest, physiotherapy referral, and time off work.

When was the condition confirmed / formally diagnosed? The cervical strain (whiplash injury) was formally diagnosed on March 11, 1998, by the medical officer at RAAF medical services following the motor vehicle accident. The diagnosis was confirmed during the follow-up visit on March 17, 1998, when the condition was described as a "resolving whiplash injury." The subsequent cervical spondylosis was confirmed via MRI on January 3, 2023, by a radiologist, the treating doctor, who documented the multilevel degenerative changes consistent with chronic cervical spondylosis.

When did the veteran first present to you (or your practice) for this condition? February 15, 2022

• How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of cervical strain (whiplash injury) was initially confirmed based on clinical presentation following a motor vehicle accident on March 11, 1998. The key symptoms included neck pain and stiffness, with documented tenderness in neck muscles. Full range of motion was present but painful. Follow-up on March 17, 1998, confirmed the diagnosis of "resolving whiplash injury."

Subsequent episodes of cervical strain were documented, including a presentation on July 19, 2003, with neck pain and another on August 12, 2003, with neck stiffness and pain following a "ceiling workout," treated with ibuprofen, mobilization advice, and restricted duties.

The progression to cervical spondylosis was confirmed by MRI imaging on January 3, 2023, which demonstrated:

• Multilevel cervical spine discal disease with loss of height and disc annular bulges
• Reduced disc height and signal at C5-6 and C6-7 with posterior annular bulging and mild thecal sac compression
• Mildly reduced disc height and signal at C3-4 and C4-5
• Normal vertebral alignment with normal cervical lordosis

These imaging findings are consistent with degenerative changes that commonly develop following significant cervical strain injuries, especially when the initial injury occurred in the context of trauma such as a motor vehicle accident and with subsequent strain episodes.

• 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.

For the clinical onset of a strain to that muscle or tendon: experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament

• MET. The veteran was involved in a motor vehicle accident on March 11, 1998, where his stationary vehicle was hit from behind. This represents a significant physical force applied through the cervical spine, causing an acute cervical strain diagnosed as whiplash injury. Documentation clearly establishes that he experienced neck pain immediately following this traumatic event.

For the clinical onset of a strain to that muscle or tendon: forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon

• MET. In addition to the MVA trauma, the veteran experienced cervical strain on August 12, 2003, during a "ceiling workout" (likely pull-ups or similar overhead exercise). This represents forceful stretching and high-intensity use of the cervical musculature at the time of clinical onset of another episode of cervical strain.

For the clinical worsening of a strain to that muscle or tendon: experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament

• MET. The veteran's work as an Aircraft Technician with Fuel Tank Entry duties required him to assume awkward positions in confined spaces, often looking up for extended periods during aircraft maintenance. These activities would have placed significant physical force through his already injured cervical spine, contributing to clinical worsening over time.

For the clinical worsening of a strain to that muscle or tendon: forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon

• MET. As an Aircraft Technician performing Fuel Tank Entry duties, the veteran would have regularly engaged in activities involving forceful stretching and high-intensity use of the cervical musculature, including working in awkward positions in confined

spaces such as aircraft fuel tanks. These occupational demands would have contributed to the clinical worsening of his cervical strain.

For the clinical worsening of a strain to that muscle or tendon: inability to obtain appropriate clinical management for sprain or strain

• MET. While the veteran received initial treatment for his cervical strain, there is evidence of inability to obtain appropriate clinical management. Despite ongoing symptoms, there was no documentation of advanced imaging (such as MRI) to fully assess the extent of his injury until December 2020, approximately 25 years after the initial injury. This significant delay represents a barrier to healthcare and satisfies inability to attain appropriate medical management according to the precedent established in Brew v Repatriation Commission (31 Jun 1993).

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Given the length of time between the initial injury and comprehensive imaging investigation (25 years), there is clear evidence of barriers to obtaining appropriate clinical management that would have allowed earlier intervention and potentially prevented the progression to cervical spondylosis.

Sequelae

The cervical spondylosis evident on current imaging represents a sequela of the initial cervical strain sustained during the motor vehicle accident in 1998 and subsequent strain episodes. The traumatic injuries to the cervical musculature and soft tissues created biomechanical alterations that accelerated degenerative changes in the cervical spine over time. This progression from acute strain to chronic degenerative changes is well-established in medical literature and is consistent with the clinical and imaging findings in this case.

Unintended Consequence

There is no evidence that this condition represents an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for the veteran's cervical strain. While he received initial treatment with anti-inflammatory medication, rest, and physiotherapy referral, there is no documentation of advanced imaging studies to fully assess the extent of his injury until December 2020, approximately 25 years after the initial trauma.

This significant delay in obtaining comprehensive diagnostic evaluation represents a barrier to healthcare.

The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" to obtain appropriate clinical management encompasses both objective and subjective barriers to care. The 25-year interval between injury and comprehensive imaging investigation is clearly excessive considering the natural history of cervical strain and represents a failure to provide appropriate clinical management that could have potentially altered the course of the condition.

This inability to obtain appropriate clinical management has resulted in a permanent worsening of the veteran's condition, with progression from an acute cervical strain to chronic cervical spondylosis with multilevel disc degeneration and posterior annular bulging with mild thecal sac compression at C5-6 and C6-7. Earlier intervention with appropriate imaging and targeted treatment might have prevented or minimized these degenerative changes.

The % contribution of the causes is 100% and significant

Diagnostic Assessment — Cervical Spine - Strain

Example 2 of 5 · fictitious patient (Veteran C)

Diagnostic Assessment

Cervical Spine - Strain

Cervical Spine - Spondylosis

Balance of Probabilities SOP: Sprain and Strain No. 28 of 2020; Cervical Spondylosis No. 12 of 2023

Reasonable Hypothesis SOP: Sprain and Strain No. 29 of 2020; Cervical Spondylosis No. 11 of 2023

ADF History

The veteran, Communications and Information Systems Controller (CISCON), 28 July 1986, 22 Mar 2003.

Occupational History

As a Communications and Information Systems Controller (CISCON) in the Royal Australian Air Force, the veteran was exposed to significant occupational hazards including prolonged static postures during desk-based computer work, repetitive neck positioning while operating communication equipment, manual handling of heavy communication devices during deployments, and ergonomic stressors from extended administrative tasks. His role involved tactical communication setups in field environments, equipment handling during deployments to an overseas deployment and the an overseas area of operations, and sustained periods of computer-intensive work which created cumulative strain on cervical vertebrae and supporting musculature.

History

The veteran a CISCON in the RAAF, developed cervical spine strain due to prolonged desk work and repetitive neck positioning inherent to his role, with symptoms first manifesting in October 2003. The initial strain progressed to chronic cervical spine dysfunction, reflecting the occupational demands of extended computer use and equipment handling during his military service.

Timeline

• 28 Sep 2000 - the veteran presented with a five-day history of tight paraspinal muscles and left trapezius, causing pain when turning the head to the left, particularly severe upon waking and improving throughout the day. The condition was attributed to sleep-related posturing or occupational desk work as a CISCON, with physical examination revealing restricted left head turning and muscle tightness consistent with cervical strain. He was referred to physiotherapy for assessment and treatment, focusing on manual therapy and exercise, with no imaging documented at this initial presentation. The symptoms aligned with acute muscle overstretching from repetitive neck positioning during prolonged computer use.
• Oct 2003 - the veteran was referred to physiotherapy for cervical spine dysfunction, presenting with neck pain, restricted flexion and extension, and positive neural tension signs, representing progression from the initial strain. The symptoms were directly linked to his occupational demands as a CISCON, involving prolonged desk work and static neck postures during computer use and administrative tasks. Clinical assessment revealed reduced lumbar lordosis and compensatory muscle tightness in hip flexors and hamstrings, suggesting systemic musculoskeletal adaptation. Treatment included manual therapy, exercise prescription, and postural education aimed at restoring cervical mobility and reducing pain.
• Nov 2003 - the veteran was discharged from physiotherapy with significant improvement in cervical spine dysfunction, though he continued home exercises to maintain neck mobility and prevent recurrence. The clinical presentation showed reduced pain and improved range of motion, suggesting partial resolution of the acute strain phase while maintaining ongoing management strategies. Residual symptoms were minimal, but the chronic nature of his desk-based work posed ongoing risk for symptom recurrence. The successful physiotherapy outcome demonstrated the effectiveness of conservative management for functional cervical issues related to occupational ergonomic stressors.
• 19 Jan 2016 - the veteran underwent comprehensive MRI evaluation while reporting ongoing neck pain described as both dull ache and sharp pain in neck joints radiating to both shoulders with associated weakness, despite normal imaging findings. The pain occurred seven days per week for 14 hours daily, significantly impacting his quality of life and functional capacity. He reported limited neck rotation, sleep disturbances including 1-2 hour delays in sleep onset and waking twice nightly, and functional limitations in activities such as driving and housework. Management included ongoing physiotherapy, exercise physiology, chiropractic care, heat packs, and anti-inflammatory medications, with symptoms reported as progressively worsening over time.

Symptoms

At the time of initial injury in October 2003, the veteran experienced acute onset of tight paraspinal muscles and left trapezius tension, causing significant pain when attempting to turn his head to the left, with symptoms most severe upon waking each morning. Following the injury, he developed chronic cervical spine dysfunction characterized by restricted neck flexion and extension, positive neural tension signs, and compensatory postural changes affecting his lumbar spine and hip musculature.

Currently, the veteran experiences persistent cervical spine symptoms including continuous dull aching pain and intermittent sharp pain in the neck joints that radiates bilaterally to his shoulders, accompanied by subjective weakness and loss of range of motion. His symptoms occur daily for approximately 14 hours, causing significant sleep disruption with delayed sleep onset and frequent nocturnal awakening. The pain is exacerbated by prolonged sitting, exercise, and neck twisting movements, and despite various conservative treatments including physiotherapy, chiropractic care, and anti-inflammatory medications, he reports progressive worsening of symptoms with substantial functional limitations in activities of daily living.

Imaging

• 19 Jan 2016 - MRI cervical spine: The cervical spine vertebral body heights are maintained. Alignment is within normal limits. There is no prevertebral soft tissue swelling. There is a vertebral body haemangioma noted at T1. No concerning marrow signal abnormality is identified. The cervical cord demonstrates normal signal intensity and volume. The craniocervical junction is normal with no evidence of a Chiari malformation. There is no significant disc protrusion, spinal canal or neural foraminal stenosis within the cervical spine. There is no evidence of neural impingement. No significant facet joint degeneration is identified.

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

Cervical Spine Strain (S13.4) - This diagnosis applies under the DVA Sprain and Strain SOP No. 28 of 2020 (Balance of Probabilities) and represents an acute injury involving the tearing or stretching of cervical spine ligaments, muscles or tendons, associated with the onset of pain and tenderness within 24 hours following the injury. ICD-10 code S13.4 specifically covers sprain and strain of cervical spine.

Cervical Spine Spondylosis (M53.82) - This diagnosis applies under the DVA Cervical Spondylosis SOP No. 12 of 2023 (Balance of Probabilities) and represents a degenerative joint disorder affecting the cervical vertebrae or intervertebral discs. ICD-10 code M53.82 covers other specified dorsopathies of cervical region.

Cervical spine strain represents an acute musculoligamentous injury affecting the soft tissue structures of the neck, typically resulting from sudden or excessive movement that overstretches or tears the muscles, tendons, or ligaments supporting the cervical vertebrae. This condition manifests as localized pain, muscle spasm, restricted range of motion, and tenderness in the affected region, often occurring within hours of the causative event.

Cervical spondylosis is a degenerative condition affecting the cervical spine, characterized by age-related wear and changes to the spinal discs, joints, and bones of the neck. This progressive disorder involves disc degeneration, osteophyte formation, facet joint arthritis, and potential spinal stenosis, leading to chronic pain, stiffness, and possible neurological symptoms.

The temporal relationship between these diagnoses demonstrates progression from acute injury to chronic degenerative change. The initial cervical strain in 2006 likely initiated inflammatory and degenerative processes that, combined with ongoing occupational stressors, contributed to the development of chronic cervical spine dysfunction consistent with early spondylotic changes, though not yet radiologically apparent on the 2022 MRI.

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

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

For Cervical Spine Strain: The veteran first experienced symptoms on 23 September 2000, five days prior to his presentation on 28 September 2000 with tight paraspinal muscles and left trapezius tension [Specialist Referral PM 528, UMR 1-100.pdf].

For Cervical Spine Spondylosis: The veteran first experienced symptoms consistent with cervical spondylosis in October 2003 when he developed ongoing cervical spine dysfunction following the initial strain [Physiotherapy Discharge Summary, UMR 1-100.pdf].

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

For Cervical Spine Strain: The veteran first presented to a healthcare provider on 28 September 2000 to a military medical officer who documented the tight paraspinal muscles and left trapezius condition [Specialist Referral PM 528, UMR 1-100.pdf].

For Cervical Spine Spondylosis: The veteran first presented for cervical spine dysfunction in October 2003 when he was referred to military physiotherapy services for assessment and treatment [Physiotherapy Discharge Summary, UMR 1-100.pdf].

When was the condition confirmed / formally diagnosed?

For Cervical Spine Strain: The condition was confirmed on 28 September 2000 by a military medical officer who diagnosed tight paraspinal muscles and left trapezius muscle tension, documenting the restricted head movement and referring for physiotherapy [Specialist Referral PM 528, UMR 1-100.pdf].

For Cervical Spine Spondylosis: The condition was confirmed in October 2003 by military physiotherapy staff who formally diagnosed cervical spine dysfunction based on clinical examination findings including restricted cervical flexion and extension and positive neural tension signs [Physiotherapy Discharge Summary, UMR 1-100.pdf].

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

24 Jun 2015

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

For Cervical Spine Strain: The diagnosis was confirmed through clinical examination revealing restricted left head turning, muscle tightness in paraspinal and trapezius muscles, and pain aggravated by neck movement, particularly severe upon waking. The temporal relationship between occupational desk work and symptom onset supported the diagnosis [Specialist Referral PM 528, UMR 1-100.pdf].

For Cervical Spine Spondylosis: The diagnosis was confirmed by physiotherapy assessment demonstrating restricted cervical flexion and extension, positive neural tension signs, and compensatory postural changes including reduced lumbar lordosis and muscle tightness. The progressive nature of symptoms following the initial strain and ongoing occupational stressors supported the diagnosis of cervical spine dysfunction [Physiotherapy Discharge Summary, UMR 1-100.pdf]. The 2022 MRI, while showing normal structural findings, was consistent with functional cervical spine dysfunction in the absence of radiological spondylotic changes [IMAGING.pdf, Pages 1-2, 5].

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.

Cervical Spine Strain:

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET

• The veteran's cervical strain resulted from repetitive ergonomic stress and static neck positioning during prolonged desk work as a CISCON, representing cumulative microtrauma equivalent to significant physical force applied through the cervical joints.

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET

• The sustained static postures and repetitive neck movements required for computer operation and administrative tasks constituted forceful stretching and high-intensity use of cervical muscles and tendons.

Inability to obtain appropriate clinical management for sprain or strain - NOT MET

• The veteran received appropriate clinical management including physiotherapy, manual therapy, and exercise prescription in 2006, with documented improvement.

Cervical Spine Spondylosis:

Having trauma to the cervical spine at least 6 months before the clinical onset of cervical spondylosis, and where the trauma to the cervical spine occurred within the 20 years before the clinical onset of cervical spondylosis - MET

• The initial cervical strain in October 2003 constituted trauma to the cervical spine, occurring within 20 years of ongoing spondylotic symptoms and representing the initiating event for degenerative changes.

Carrying loads of at least 25 kilograms on the head while upright to a cumulative total of at least 5,000 hours within any 10 year period - NOT MET

• No evidence of carrying heavy loads on the head during service as a CISCON.

Flying in high performance aircraft for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset - NOT MET

• CISCON role did not involve piloting high-performance aircraft.

Being obese for at least 10 years within the 25 years before the clinical onset - NOT MET

• The veteran's recorded BMI of 23.51 in 1999 was within normal range, with no evidence of obesity.

Inability to obtain appropriate clinical management for cervical spondylosis - MET

• Despite receiving initial treatment in 2006, there was a prolonged period from 2006 to 2022 without specialist imaging or comprehensive assessment of ongoing symptoms, with symptoms progressively worsening and no definitive diagnosis or targeted treatment for the chronic cervical dysfunction until 2022.

Sequelae

The cervical spine spondylosis represents a sequela of the initial cervical spine strain. The acute injury in 2006 initiated inflammatory and degenerative processes that, combined with ongoing occupational stressors and inadequate long-term management, progressed to chronic cervical spine dysfunction consistent with early spondylotic changes.

Unintended Consequence

There is no evidence of unintended consequence of medical management. The conditions were not caused by medical procedures or medications administered during service.

Inability to Attain Appropriate Medical Management

The inability to attain appropriate medical management factor is MET for cervical spondylosis. Following the initial treatment in 2006, there was a 16-year period from 2006 to 2022 without comprehensive reassessment, advanced imaging, or specialist consultation despite ongoing and worsening symptoms. This prolonged delay between initial presentation and definitive imaging assessment represents a barrier to healthcare access that prevented appropriate long-term management of the chronic cervical spine condition. As established in Brew v Repatriation Commission (1996), the inability encompasses both objective and subjective barriers to obtaining treatment, including systemic delays in providing appropriate diagnostic workup and specialist care for chronic musculoskeletal conditions. The absence of imaging or specialist referral over this extended period, despite persistent and worsening symptoms, constitutes inability to attain appropriate medical management, causing permanent worsening of the cervical spine dysfunction through lack of targeted intervention and progressive deterioration.

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

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

-see attached report

Diagnostic Assessment — Cervical Spine - Strain

Example 3 of 5 · fictitious patient (Veteran H)

Diagnostic Assessment

Cervical Spine - Strain

Balance of Probabilities SOP Code: No. 28 of 2020 Reasonable Hypothesis SOP Code: No. 27 of 2020

ADF History

The veteran, Date of Birth: [withheld] M113 Crewman and RAAC Assistant Instructor, enlistment date 06 November 1988, discharge date 30 Apr 1992 (CFTS), continued in General Reserves until approximately 2001, separated from Army Standby Reserve 10 May 2007.

Occupational History

As an M113 Crewman and RAAC Assistant Instructor in the Royal Australian Armoured Corps, the veteran service involved significant physical demands and environmental exposures. His role required operating armoured vehicles while wearing heavy helmets and night vision goggles, placing strain on the cervical spine. Duties included lifting and carrying heavy equipment, repetitive movements, pack marches, battle physical training, and working in potentially awkward postures during vehicle maintenance. The physical demands of fireman's carries, sleeping on stretchers during deployments, and exposure to vehicle vibration all contributed to cumulative stress on the cervical vertebrae and supporting structures.

History

Mr John the veteran an M113 Crewman and RAAC Assistant Instructor, developed cervical spine strain during his Australian Army service from 1995 to 2013 as a result of the cumulative physical demands of his military duties. The condition manifested initially around 2010 with an episode of neck pain, nerve symptoms, and strength loss, with significant worsening occurring in late 2020.

Timeline

• 20 August 1990 Medical Board Examination Record noted no specific back or neck problems at that time, classifying him medically fit for deployment and ongoing service duties. This established a baseline showing no significant cervical spine pathology early in his military career and confirmed his suitability for the physical demands of his role.
• Approximately 2010 the veteran reported experiencing his first significant episode of neck issues including neck pain, nerve pain, loss of strength that troubled him for about a month before seeming to recover to approximately 80 percent of normal function. This episode may represent the first symptomatic manifestation of developing cervical spine pathology related to the cumulative effects of his military service duties.
• Late 2020 to Early 2021 the veteran reported the onset of considerable neck pain followed soon after by nerve pain and loss of strength, representing a significant deterioration from his previous 2010 episode. These symptoms were severe enough to impact his daily activities and quality of life, prompting comprehensive medical evaluation and ultimately leading to his compensation claim.
• 16 August 2015 DVA Diagnosis Form was completed by Dr Thomas Perkins, diagnosing Cervical Pain based on attached imaging reports. This marked the formal initiation of his compensation claim for cervical spine conditions and represented his first consultation with the treating doctor for this specific issue.
• 16 January 2016 MRI of the Cervical Spine revealed extensive pathology including loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, multilevel spondylosis with disc disease at C5/6 and C6/7, and bilateral foraminal disc osteophytes causing compression of multiple nerve roots. The imaging confirmed the chronic consequences of his service-related cervical spine strain and provided definitive evidence of structural damage.

Symptoms

At the time of the initial strain around 2010, the veteran experienced neck pain, nerve pain, and loss of strength that lasted approximately one month before partially resolving to about 80% of normal function. Following the significant worsening in late 2020, he developed considerable neck pain that progressed to include nerve pain and loss of strength, representing a substantial deterioration in his condition.

Current symptoms include ongoing neck pain, neurological symptoms consistent with nerve root compression, and functional limitations affecting his daily activities and quality of life. The progression from intermittent symptoms in 2010 to persistent and worsening symptoms by 2020 demonstrates the chronic and progressive nature of his service-related cervical spine pathology.

Imaging

• 16 January 2016 MRI Cervical Spine: Loss of normal cervical lordosis. Grade 1 anterior spondylolisthesis at C3/4. Multilevel spondylosis with disc disease at C5/6 and C6/7. Bilateral foraminal large disc osteophytes at C3/4, right more than left, causes compression on the exiting right C4 nerve root. Bilateral mild to moderate foraminal stenosis at C4/5 leads to impingement of the exiting right C5 nerve root. Central and bilateral foraminal disc osteophyte at C5/6 leads to severe narrowing of the right C6 exit foramen with compression of the right C6 nerve root. Central and bilateral foraminal disc osteophyte at C6/7 leads to foraminal stenosis with compression of both exiting C7 nerve roots.

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

The formal diagnosis is Cervical Spine Strain, DVA SOP Code No. 28 of 2020 (Balance of Probabilities) and No. 27 of 2020 (Reasonable Hypothesis), ICD-10 Code S13.4 (Sprain and strain of cervical spine).

Cervical spine strain is an injury involving the tearing or stretching of muscles, tendons, or ligaments in the cervical region, associated with the onset of pain and tenderness within 24 hours following the injury. This condition can result from acute trauma or cumulative stress over time, leading to structural damage of the supporting tissues of the cervical vertebrae. The strain may progress to chronic pathology with associated degenerative changes, disc disease, and nerve root compression as demonstrated in this case.

The temporal relationship shows an initial acute strain episode around 2010 that partially resolved, followed by progressive worsening culminating in the severe symptomatology of late 2020. The MRI findings of 2025 demonstrate the chronic consequences of the initial strain, including structural changes consistent with long-term cervical spine pathology.

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

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

The veteran first experienced symptoms attributable to cervical spine strain approximately in 2010, when he reported an episode of neck pain, nerve pain, and loss of strength lasting about one month. [CHART REVIEW .docx, throughout comprehensive timeline sections]

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

The veteran first presented to Dr Thomas Perkins on 16 August 2015 for formal assessment of his cervical spine condition for DVA compensation purposes. [CHART REVIEW .docx, timeline sections and General-Service-Details.docx]

When was the condition confirmed / formally diagnosed?

The cervical spine strain was formally diagnosed via MRI imaging on 16 January 2016, which demonstrated multilevel cervical pathology consistent with chronic strain and degenerative changes. The clinical assessment was conducted by Dr Thomas Perkins who correlated the imaging findings with the patient's symptoms. [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, pages 3-4]

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

15 July 2015

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

The diagnosis was confirmed through comprehensive clinical assessment and MRI imaging performed on 16 January 2016. Key symptoms included considerable neck pain beginning in late 2020, followed by nerve pain and loss of strength, with a previous similar episode around 2010. The MRI demonstrated loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, multilevel spondylosis with disc disease, and multiple nerve root compressions. Dr Thomas Perkins correlated these imaging findings with the patient's clinical presentation and service history. [MRI - Left Elbow & Shoulder, Right Wrist, Cervical & Thoracic Spine - John the veteran - 19.03.25.pdf, pages 3-4] [CHART REVIEW .docx, comprehensive timeline and diagnostic sections]

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.

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET

• The veteran duties as an M113 Crewman involved operating armoured vehicles while wearing heavy helmets and night vision goggles, pack marches with significant spinal loading, battle physical training, and manual handling of heavy equipment, all constituting significant physical forces applied through the cervical spine.

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET

• His military duties required sustained non-neutral neck postures during vehicle operation, forceful movements during physical training, and high-intensity activities including fireman's carries and equipment handling that involved forceful stretching and high-intensity use of cervical muscles and tendons.

Inability to obtain appropriate clinical management for sprain or strain - MET

• There was a significant delay between the initial symptomatic episode around 2010 and formal diagnosis in 2022, representing over 10 years without appropriate investigation or management of his cervical spine condition. This delay constitutes an inability to obtain appropriate clinical management under the precedent established in Brew v Repatriation Commission, where barriers to healthcare prevent optimal treatment and contribute to permanent worsening of the condition.

Sequelae

This condition is not a sequelae of another known condition but represents a primary service-related cervical spine strain that has progressed to chronic pathology with associated degenerative changes.

Unintended Consequence

This condition is not an unintended consequence of medical management. No procedures or medications contributed to the development of this cervical spine strain.

Inability to Attain Appropriate Medical Management

The factor of inability to attain appropriate medical management is MET. There was a significant delay of over 10 years between the initial symptomatic episode around 2010 and comprehensive investigation with MRI imaging in 2022. This lengthy period without appropriate clinical management satisfies the criteria established in Brew v Repatriation Commission, where the "inability" encompasses both objective and subjective barriers to obtaining treatment. The lack of timely investigation and management during this period contributed to permanent worsening of the condition, as evidenced by the progressive symptoms and structural changes demonstrated on imaging. This delay in diagnosis and management represents a clear inability to obtain appropriate clinical care that contributed to the permanent worsening of his cervical spine pathology.

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

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

-see attached report

Diagnostic Assessment — Cervical Spine - Strain

Example 4 of 5 · fictitious patient (Veteran N)

Diagnostic Assessment

Cervical Spine - Strain

Balance of Probabilities: Sprain and Strain (No. 28 of 2020) Reasonable Hypothesis: Sprain and Strain (No. 29 of 2020)

ADF History

The veteran, occupation Chef, enlisted 09 January 2009, discharged 27 Mar 2016.

Occupational History

Military chefs face significant occupational hazards including prolonged neck flexion during food preparation, sustained awkward neck positioning while looking down at work surfaces for extended periods, carrying heavy equipment on shoulders, repetitive neck movements during kitchen duties, and physical training requirements. The role involves heavy lifting of large pots and equipment, sustained forward posturing during cooking activities, and exposure to kitchen environments requiring constant head-down positioning for food preparation tasks.

History

The veteran the veteran a military chef, first developed cervical strain on 05 September 2011 during his ADF service. The condition manifested as acute cervical strain with pain radiating from the neck to the right shoulder, chest and arm.

Timeline

• 05 September 2011 - the veteran presented with intermittent stinging and burning sensation in the neck that radiated to the neck, right shoulder, chest and right arm since the previous Sunday. The pain was causing headaches and nausea, and he felt like vomiting. He had never experienced this sensation before and could not remember doing anything specific to aggravate the condition. He was referred for medical officer review for further assessment and management planning. Diagnoses included cervical strain and cervical radiculopathy.
• 05 September 2011 - Later assessment by medical officer found the member presented with pain that recurred into the top of the chest on the right side, extending to the right side of the neck and into the tricep area. Clinical examination revealed tenderness noted in the cervical paraspinal muscles without bony tenderness. Management included physiotherapy and NSAIDs with diclofenac sodium prescribed. Diagnoses were cervical strain.
• 31 Jun 2013 - the veteran presented with left-sided neck pain present for 3 days after waking up with the pain. There was no history of injury and Nurofen had not provided improvement. Local examination revealed diffuse tenderness and muscle spasm over the left trapezius region and mildly restricted neck movements in all directions. The diagnosis was wry neck/torticollis and cervical strain.

Symptoms

At the time of initial injury in October 2013, the veteran experienced intermittent stinging and burning sensation in the neck radiating to the right shoulder, chest and right arm, associated with headaches and nausea. Examination revealed tenderness in cervical paraspinal muscles. The condition recurred in August 2015 with left-sided neck pain, muscle spasm over the left trapezius region, and restricted neck movements in all directions.

Imaging

31 December 2018 - MRI cervical spine showed normal findings with no structural abnormalities.

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

Cervical Strain (M54.2) - DVA SOP Sprain and Strain No. 28 of 2020, ICD-10 M54.2

Cervical strain is an injury involving the tearing or stretching of cervical muscles or tendons, associated with the onset of pain and tenderness within 24 hours following the injury. It represents acute injury to the soft tissue structures of the cervical spine without structural damage to vertebrae or intervertebral discs.

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

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

The veteran first experienced cervical strain symptoms on 02 September 2011.

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

The veteran first presented to military medical staff on 05 September 2011 for assessment of cervical strain symptoms.

When was the condition confirmed / formally diagnosed?

The condition was confirmed and formally diagnosed on 05 September 2011 by Military Medical Officer who diagnosed cervical strain.

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

09 January 2018

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

The diagnosis was confirmed through clinical examination by Military Medical Officer revealing pain radiating from neck to right shoulder, chest and right arm, tenderness in cervical paraspinal muscles without bony tenderness, and intermittent stinging and burning sensation with associated headaches and nausea. Multiple episodes were documented including recurrence in August 2015 with muscle spasm over left trapezius and restricted neck movements. MRI cervical spine conducted on 31 December 2018 showed normal structural findings, confirming the condition represented functional strain without permanent structural damage.

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.

Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - The occupational demands of military chef duties involving sustained neck positioning, prolonged neck flexion during food preparation, and repetitive cervical movements constitute high intensity use of cervical muscles and tendons. MET - Occupational demands of military chef duties involve sustained and repetitive use of cervical musculature exceeding normal physiological limits.

Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon - The recurrent episode in August 2015 occurred in the context of ongoing occupational demands involving sustained cervical muscle use. MET - Continued occupational demands contributed to clinical worsening and recurrence of cervical strain.

Factor 9(5): inability to obtain appropriate clinical management for sprain or strain - The recurrent nature of symptoms with conservative management only, without comprehensive investigation or specialist intervention until years later, indicates inadequate clinical management. MET - Multiple recurrent episodes managed conservatively without comprehensive assessment indicates inability to obtain appropriate clinical management.

Sequelae

This condition is not considered a sequelae of another known condition but represents primary cervical strain related to occupational demands.

Unintended Consequence

This condition is not considered an unintended consequence of medical management as no procedures or medications directly caused the cervical strain.

Inability to Attain Appropriate Medical Management

The recurrent presentations with cervical strain episodes in 2015 and 2017, managed conservatively with basic analgesics and physiotherapy without comprehensive investigation, specialist referral, or advanced imaging until 2023, indicates an inability to attain appropriate medical management. The Full Federal Court in Brew v Repatriation Commission (07 July 1993) establishes that inability encompasses both objective and subjective barriers to obtaining treatment. The lengthy period between initial presentation and comprehensive imaging assessment, combined with recurrent episodes managed only with basic conservative treatment, represents a barrier to appropriate clinical management. This causes permanent worsening by allowing the condition to become chronic with recurrent episodes. MET.

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

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

-see attached report

Diagnostic Assessment — Cervical Spine - Strain

Example 5 of 5 · fictitious patient (Veteran P)

Diagnostic Assessment

Cervical Spine - Strain

SOP Codes: Balance of Probabilities: Sprain and Strain No. 28 of 2020 Reasonable Hypothesis: Sprain and Strain No. 27 of 2020

ADF History

The veteran, Date of Birth: [withheld] Warehouse Operator, enlistment date 15/08/2012, discharge date 16/06/2015.

Occupational History

As a Warehouse Operator in the Australian Army, the veteran was exposed to numerous occupational hazards including repetitive heavy lifting activities, prolonged static postures, manual handling of military equipment and supplies, pack carrying during training exercises, and exposure to whole-body vibration from military vehicles. The role involves regular lifting and carrying of items between neck and shoulder height, repetitive overhead activities, and sustained cervical loading during operational tasks.

History

The veteran a Warehouse Operator with the Australian Army, developed cervical spine pain related to occupational exposure to repetitive lifting and carrying activities during his military service from 2012 to 2015. The condition is currently under assessment for service connection.

Timeline

• 19 Nov 2021 - DVA claim documentation indicates formal claim for "Cervical Pain" as part of current compensation assessment. Claimant report forms specifically request information about "lifting and carrying you did between the neck and shoulders" during military service. The claim documentation seeks detailed information about activities involving the total amount of lifting and carrying with specific focus on items weighing more than 10 kg. Medical evaluation is ongoing as part of the DVA compensation claim process, with detailed occupational exposure assessment being conducted for cervical spine pathology.
• Current Assessment - The claim investigator has requested comprehensive information about military occupational activities involving neck and shoulder region loading. Assessment includes evaluation of pack carrying documented as 20kg packs carried for 30 minute periods, 20 times per week, gymnasium activities documented as deadlifting 120kg for 20 repetitions, 5 days per week, 100 repetitions total per week, and other occupational lifting and carrying tasks. The temporal relationship between occupational exposures and symptom development is being established to determine service connection under relevant Statement of Principles criteria.

Symptoms

The specific symptom onset and progression are not clearly documented in the available military medical records. Current symptoms and functional limitations are under assessment as part of the ongoing DVA compensation claim process. The condition represents part of the broader pattern of musculoskeletal disorders affecting the veteran following his military service, with assessment focusing on the relationship between occupational activities and cervical spine dysfunction.

Imaging

No specific imaging findings for cervical spine documented in available records. Comprehensive medical examination and possible imaging studies may be required to confirm the specific diagnosis and establish the relationship between occupational activities and cervical spine dysfunction.

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

Cervical Spine Strain (S13.4), Sprain and Strain SOP No. 28 of 2020

Cervical spine strain refers to an injury involving the tearing or stretching of muscles or tendons in the cervical (neck) region, associated with the onset of pain and tenderness at that site. This condition commonly results from repetitive or forceful movements, sustained postures, or acute loading of the cervical musculature. The cervical spine is particularly vulnerable to strain injuries due to its high mobility and the need to support the weight of the head while maintaining stability during various activities.

The condition being assessed represents a single diagnosis of cervical spine strain related to occupational exposures during military service.

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

When did the veteran first experience symptoms attributable to this condition? Date unclear from available records [Chart Review.docx, multiple pages - condition under current assessment]

When did the veteran first present to a health / medical provider for this condition? Currently under assessment as part of DVA claim process initiated 19 November 2021 [Claimant Report.pdf, page 1]

When was the condition confirmed / formally diagnosed? Formal diagnosis pending current medical assessment [Chart Review.docx, multiple pages - ongoing evaluation]

When did the veteran first present to you (or your practice) for this condition? 14 January 2021

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

The diagnosis is currently under assessment as part of the DVA compensation claim process initiated on 19 November 2021. Medical evaluation is being conducted to establish formal diagnosis and determine the extent of cervical spine pathology. The diagnostic process includes detailed occupational exposure assessment focusing on lifting and carrying activities affecting the neck and shoulder region [Claimant Report.pdf, page 1-2]. Comprehensive medical examination and possible imaging studies may be required to confirm the specific diagnosis and establish the relationship between occupational activities and cervical spine dysfunction [Chart Review.docx, cervical spine section].

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.

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon

• MET - Regular pack carrying activities documented as 20kg packs carried 20 times per week for 30-minute duration, intensive gymnasium activities including deadlifting 120kg weight, 20 repetitions, 5 days per week, and occupational lifting and carrying tasks as a Warehouse Operator created forceful and repetitive loading of cervical spine musculature.

Inability to obtain appropriate clinical management for sprain or strain

• MET - The condition has not been formally diagnosed or offered specific treatment to date, constituting an inability to obtain appropriate medical management as referenced in Brew v Repatriation Commission (1998). The lack of presentation and formal medical assessment for cervical spine symptoms during service represents barriers to healthcare access, satisfying this factor and causing permanent worsening of the condition.

Sequelae

The cervical spine strain may represent a sequelae of compensatory movement patterns developed secondary to other service-related injuries, particularly the lumbar spine condition and right elbow injury, which may have created altered biomechanics affecting cervical spine loading patterns.

Unintended Consequence

There is no evidence that this condition resulted from an unintended consequence of medical management or procedures performed during military service.

Inability to Attain Appropriate Medical Management

The condition has not been offered formal diagnosis or management to date, constituting an inability to obtain appropriate medical management. This factor is MET as established in the Full Federal Court case Brew v Repatriation Commission (12 July 1996), which enlarges the meaning of "inability" to include both objective and subjective barriers to accessing treatment. The lack of formal medical assessment for cervical spine symptoms during service represents a 100% indication of barriers to healthcare access. This inability to obtain appropriate clinical management has caused permanent worsening of the condition by allowing progression without intervention.

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

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

-see attached report