Diagnostic Assessment — Chronic Pain Syndrome
Example 1 of 1 · fictitious patient (Veteran AG)
Diagnostic Assessment
Chronic Pain Syndrome
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran AG, date of birth 22 September 1980, Royal Australian Navy, Boatswain's Mate (boarding party member, later Leading Seaman), enlisted 14 January 1999, medically discharged 30 June 2019. Operational service: East Timor, 02 February 2000 to 18 June 2000 (warlike); Middle East Area of Operations aboard a frigate, 10 January 2008 to 28 July 2008 (warlike); Middle East Area of Operations aboard a frigate, 05 February 2015 to 05 August 2015 (returned early to Australia for medical review).
Occupational History
As a boatswain's mate the veteran handled mooring lines, anchors, cables and boats, rigged replenishment-at-sea gear, ammunitioned the ship by hand and lifted stores of 20 to 40 kilograms in confined spaces and on steep ladders. As a boarding party member he climbed rope and caving ladders from rigid-hulled inflatable boats onto moving vessels in heavy seas, wearing body armour, a helmet and equipment of about 25 kilograms.
Seamen in these roles are at high risk of falls on wet decks and ladders, crush and impact injuries, and repetitive spinal loading in awkward postures. Watch rotations and operational tempo cause chronic sleep disruption, and boarding operations expose members to threats of violence, which carries a risk of psychological injury.
History
Veteran AG, a boatswain's mate and boarding party member in the Royal Australian Navy, fell from a boarding ladder during warlike service in the Middle East on 16 April 2008, sustaining an L4/5 disc herniation and a concussion, and developed chronic pain syndrome on 01 December 2009 after spinal surgery, sustained opioid treatment, posttraumatic stress disorder, insomnia and marital breakdown. The condition worsened markedly in 2015 after a further fall on a ship's ladder during a second Middle East deployment.
Timeline
- 16 Apr 2008 — During a boarding of a suspect vessel in the northern Arabian Gulf on warlike service the veteran fell about four metres from a caving ladder into the rigid-hulled inflatable boat, landing on his back and striking his helmeted head on the gunwale. He was dazed with amnesia for several minutes and had severe low back pain radiating into the left leg. The ship's medical officer recorded concussion and left L5 radicular signs, and he was transferred ashore for imaging. "fall from ladder, concussion, sciatica"
- 22 Apr 2008 — MRI of the lumbar spine showed a large left paracentral L4/5 disc extrusion compressing the traversing L5 nerve root. He was placed on restricted duties ashore, with no lifting, climbing or sea time, and remained largely inactive on light duties until 2010. Paracetamol with codeine was replaced by oxycodone in June 2008 for uncontrolled pain. "L4/5 extrusion, restricted duties"
- 03 Feb 2009 — A neurosurgeon performed a left L4/5 microdiscectomy for persisting radicular pain and weakness. Leg pain improved partially, but low back pain persisted and he described burning in the left leg. Controlled-release oxycodone 20 mg twice daily (60 mg oral morphine equivalent per day) was continued after surgery. "L4/5 microdiscectomy, ongoing pain"
- 10 Jun 2009 — A psychiatrist diagnosed posttraumatic stress disorder related to the boarding fall and to an armed confrontation during an earlier boarding in March 2008, with comorbid major depressive disorder. He reported difficulty getting to sleep and waking with pain five to six nights a week since mid-2008. His wife had left the family home in May 2009, and divorce proceedings followed. Sertraline and fortnightly psychology were commenced. "PTSD and depression, poor sleep"
- 14 Dec 2009 — A pain medicine specialist recorded pain that had spread since 01 December 2009 from the lower back and left leg into the whole lower back, both buttocks, both legs and the thoracic spine, with allodynia over the left leg, pain scores of 8 out of 10 most days, marked pain behaviour, fear of movement and withdrawal from social activity. He could sit for no more than 20 minutes and walk for no more than 200 metres. The specialist referred him to a multidisciplinary pain programme. "widespread pain, allodynia, disability"
- 18 Mar 2010 — After multidisciplinary assessment by a pain medicine specialist, psychiatrist, physiotherapist and psychologist, chronic pain syndrome was diagnosed. The pain had persisted for nearly two years, was out of proportion to the structural findings, and was associated with central sensitisation, opioid tolerance, depression, sleep disturbance and severe functional limitation. Brief Pain Inventory interference score 7.4, Pain Disability Index 52 out of 70. "chronic pain syndrome, BPI 7.4"
- 22 Jun 2015 — Aboard a frigate on a second Middle East deployment the veteran slipped on a wet ladder between decks, falling about two metres and landing on his back and right hip. Thoracolumbar and hip pain flared severely. Oxycodone was increased by the ship's medical officer to 40 mg twice daily (120 mg oral morphine equivalent per day). No pain specialist, psychologist or physiotherapist was available at sea. "ladder fall at sea, opioids increased"
- 10 Aug 2015 — After he was returned to Australia for review, a pain medicine specialist documented clinical worsening of the chronic pain syndrome, with pain now involving the whole spine, both hips and both legs, average pain 9 out of 10, Brief Pain Inventory interference 8.9 and Pain Disability Index 64 out of 70. Repeat MRI showed a new L3/4 annular fissure. Posttraumatic stress disorder symptoms had also worsened, and he was medically downgraded. "CPS worsened, BPI 8.9"
Symptoms
At onset the veteran had constant pain spreading beyond the operated L4/5 level into both legs, both buttocks and the thoracic spine, with burning and allodynia in the left leg, pain scores of 8 out of 10, poor sleep, fatigue, fear of movement and withdrawal from family and social activity. He could not sit, stand or walk for more than short periods and could not perform seagoing duties.
He now reports widespread spinal and limb pain every day, broken sleep, low mood and poor concentration. He cannot work, needs help with heavy household tasks and has stopped fishing and coaching junior football. He attends a pain clinic, a psychologist and a physiotherapist, and he is being weaned from opioids.
Imaging
- 22 Apr 2008 — MRI lumbar spine: "Large left paracentral L4/5 disc extrusion with caudal migration, compressing the traversing left L5 nerve root. Mild L5/S1 disc desiccation."
- 08 Oct 2009 — MRI lumbar spine with contrast: "Post left L4/5 microdiscectomy. Enhancing epidural fibrosis around the left L5 nerve root. No recurrent disc herniation."
- 10 Aug 2015 — MRI whole spine: "Stable L4/5 post-surgical fibrosis. New L3/4 posterior annular fissure with a small central protrusion. Mild thoracic spondylosis T6 to T9."
- 10 Aug 2015 — X-ray right hip: "No fracture. Normal joint space."
Onset Date
The most likely date of onset of this condition is 01 Dec 2009.
At that date the veteran was serving full time ashore on restricted duties at a naval base in Australia, ten months after an L4/5 microdiscectomy for the disc injury sustained on warlike service in the Middle East on 16 April 2008. He was taking controlled-release oxycodone 60 mg oral morphine equivalent per day, had posttraumatic stress disorder and depression, was sleeping poorly and was going through a divorce.
This date is appropriate because the neurosurgical review of 08 October 2009 recorded pain confined to the lower back and left leg in the distribution expected after the surgery, without spread, allodynia or the pain behaviour later seen, and the pain medicine specialist on 14 December 2009 documented that the spread and allodynia had begun on 01 December 2009. It falls within uninterrupted full-time service.
For the injury factor, the three months before onset run from 01 Sep 2009 to 01 Dec 2009; persistent pain from the 2008 injury was present throughout. For the surgery factor, the one year before onset runs from 01 Dec 2008 to 01 Dec 2009 and includes the microdiscectomy of 03 Feb 2009. For the psychiatric factor, the two years before onset run from 01 Dec 2007 to 01 Dec 2009; posttraumatic stress disorder and depression were diagnosed on 10 Jun 2009. For the stressor factor, the five years before onset run from 01 Dec 2004 to 01 Dec 2009 and include the armed boarding confrontation of March 2008, the fall of 16 Apr 2008 and his separation in May 2009. For the sleep, opioid and inactivity factors, the three months before onset run from 01 Sep 2009 to 01 Dec 2009, during which he had insomnia five to six nights a week, took oxycodone daily and remained on restricted, largely sedentary duties. For the occupational loading factor, the ten years before onset run from 01 Dec 1999 to 01 Dec 2009 and cover more than eight years of seagoing boatswain's mate and boarding duties. The concussion of 16 Apr 2008 preceded onset.
For the worsening factors, the period after onset runs from 01 Dec 2009 to the documented worsening on 10 Aug 2015. The three months before the worsening run from 10 May 2015 to 10 Aug 2015, which include the ladder fall at sea on 22 Jun 2015, during which he took oxycodone at 60 mg and then 120 mg oral morphine equivalent per day, and during which his posttraumatic stress disorder remained active and under treatment.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Chronic Pain Syndrome (ICD-10-AM R52.2, other chronic pain), with a primary pain generator in the lumbar spine after the L4/5 disc injury and microdiscectomy, and with central sensitisation. No Statement of Principles has been determined for chronic pain syndrome.
Chronic pain syndrome describes pain that persists beyond the expected time of tissue healing, usually more than three to six months, and that has become a condition in its own right. Changes in the nervous system, known as central sensitisation, amplify pain signals, so pain spreads beyond the original injury, normally painless touch becomes painful and pain is out of proportion to the structural findings. It is accompanied by sleep disturbance, low mood, anxiety, fear of movement, deconditioning and loss of function, and it is perpetuated by psychological trauma, poor sleep, long-term opioid use and further injury.
The veteran's condition followed a disc injury and concussion on warlike service in 2008 and spinal surgery in 2009, in the setting of posttraumatic stress disorder, depression, insomnia, opioid treatment and inactivity. It began on 01 December 2009, was diagnosed on 18 March 2010 and worsened after a further fall at sea in 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
01 December 2009.
When did the veteran first present to a health / medical provider for this condition?
14 December 2009.
When was the condition confirmed / formally diagnosed?
18 March 2010.
When did the veteran first present to you (or your practice) for this condition?
19 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 on 18 March 2010 after a multidisciplinary assessment by a pain medicine specialist, psychiatrist, physiotherapist and psychologist. The veteran had pain for nearly two years, well beyond the expected healing time of the disc injury and surgery, which had spread beyond the operated level to both legs, both buttocks and the thoracic spine, with allodynia and hyperalgesia indicating central sensitisation. Imaging showed post-surgical fibrosis but no lesion that could explain the extent of the pain.
The pain was associated with sleep disturbance, depression, fear of movement, opioid tolerance, deconditioning and severe functional limitation, with a Brief Pain Inventory interference score of 7.4 and a Pain Disability Index of 52 out of 70. These findings meet the accepted clinical criteria for chronic pain syndrome. The documented worsening on 10 August 2015 was measured on the same instruments, with the interference score rising to 8.9 and the disability index to 64.
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.
No Statement of Principles has been determined for chronic pain syndrome, so the Statements of Principles do not limit the factors that can be considered. The claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, applied to the veteran's service. The recognised causes below are drawn from the pain medicine literature and are set out in Statement of Principles style.
Legislation: the clinical onset of this condition was on 01 December 2009, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The initiating injury occurred on warlike service in the Middle East in 2008, and the worsening followed a fall at sea during a further Middle East deployment in 2015; the condition itself began during peacetime service ashore. For conditions with Statements of Principles, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service, and the same beneficial approach is applied here.
Each factor must be related to the person's 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.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having a significant physical injury to the affected region, with pain persisting for at least the three months before the clinical onset of chronic pain syndrome; — MET
- On warlike service in the Middle East on 16 April 2008 the veteran fell about four metres from a boarding ladder and sustained a large left L4/5 disc extrusion compressing the L5 nerve root, shown on MRI on 22 April 2008. Low back and left leg pain persisted continuously from the injury to the onset, including throughout the three months from 01 September 2009 to 01 December 2009.
Cause 2: having a chronic musculoskeletal or neuropathic pain condition at the time of the clinical onset of chronic pain syndrome; — MET
- At onset the veteran had chronic mechanical low back pain from the L4/5 disc injury and a left L5 radiculopathy with burning neuropathic pain, with epidural fibrosis around the L5 nerve root on MRI on 08 October 2009. Both conditions arose from the boarding fall of 16 April 2008 and were present on 01 December 2009.
Cause 3: undergoing surgery to the affected region within the one year before the clinical onset of chronic pain syndrome, with persistent post-surgical pain; — MET
- A left L4/5 microdiscectomy was performed on 03 February 2009, within the one year before onset, from 01 December 2008 to 01 December 2009, for the disc herniation sustained on warlike service. Low back pain and burning left leg pain persisted after surgery, and epidural fibrosis was shown on MRI in October 2009.
Cause 4: having a clinically significant psychiatric disorder, including posttraumatic stress disorder or depressive disorder, within the two years before the clinical onset of chronic pain syndrome; — MET
- A psychiatrist diagnosed posttraumatic stress disorder and major depressive disorder on 10 June 2009, within the two years before onset, from 01 December 2007 to 01 December 2009. The disorders arose from an armed confrontation during a boarding in March 2008 and from the fall of 16 April 2008, both on warlike service, and required sertraline and fortnightly psychology.
Cause 5: experiencing a severe psychosocial stressor within the five years before the clinical onset of chronic pain syndrome; — MET
- Within the five years before onset, from 01 December 2004 to 01 December 2009, the veteran was threatened with a weapon during a boarding in March 2008, was injured in the fall of 16 April 2008, lost his seagoing career prospects, and separated from his wife in May 2009, followed by divorce proceedings and loss of daily contact with his children. The stressors were documented by his psychiatrist and arose from, or were caused by the consequences of, his service.
Cause 6: having sleep disturbance on at least three nights per week for at least the three months before the clinical onset of chronic pain syndrome; — MET
- From mid-2008 the veteran had difficulty getting to sleep and waking with pain and nightmares on five to six nights a week, recorded by his psychiatrist on 10 June 2009 and continuing throughout the three months before onset, from 01 September 2009 to 01 December 2009. The insomnia resulted from his service-related back injury and posttraumatic stress disorder.
Cause 7: taking an opioid analgesic on a daily basis for at least the three months before the clinical onset of chronic pain syndrome; — MET
- The veteran took oxycodone daily from June 2008, as controlled-release oxycodone 20 mg twice daily (60 mg oral morphine equivalent per day) from February 2009, prescribed by Defence-funded clinicians for his service-related back injury. This continued throughout the three months before onset, from 01 September 2009 to 01 December 2009, and the pain medicine specialist recorded opioid tolerance and features of opioid-induced hyperalgesia.
Cause 8: having concussion or traumatic brain injury before the clinical onset of chronic pain syndrome; — MET
- In the fall of 16 April 2008 on warlike service the veteran struck his helmeted head on the boat's gunwale and was dazed, with amnesia for several minutes, recorded as concussion by the ship's medical officer. This preceded the onset on 01 December 2009.
Cause 9: being physically inactive or deconditioned because of injury or illness for at least the three months before the clinical onset of chronic pain syndrome; — MET
- From 16 April 2008 the veteran was restricted from lifting, climbing and sea time and remained on largely sedentary light duties ashore, recovering from his injury and surgery. Physiotherapy recorded marked loss of trunk and lower limb strength and endurance in October 2009. This inactivity continued throughout the three months before onset, from 01 September 2009 to 01 December 2009.
Cause 10: undertaking heavy physical work involving repeated lifting, carrying or climbing with loads of at least 20 kilograms, for a cumulative period of at least 2,000 hours within the ten years before the clinical onset of chronic pain syndrome; — MET
- Between January 1999 and April 2008 the veteran served at sea as a boatswain's mate, handling mooring lines and cables, ammunitioning the ship by hand and carrying stores of 20 to 40 kilograms up and down ladders, and climbing boarding ladders in about 25 kilograms of equipment. His divisional records show more than 1,800 sea days, and these duties exceeded 2,000 hours within the ten years before onset, from 01 December 1999 to 01 December 2009.
Worsening factors
Worsening 1: sustaining a further physical injury to the affected region within the three months before the clinical worsening of chronic pain syndrome; — MET
- On 22 June 2015, aboard a frigate on deployment in the Middle East, the veteran slipped on a wet ladder and fell about two metres onto his back and right hip. MRI on 10 August 2015 showed a new L3/4 annular fissure. The injury occurred within the three months before the worsening, from 10 May 2015 to 10 August 2015.
Worsening 2: having a clinically significant psychiatric disorder at the time of the clinical worsening of chronic pain syndrome; — MET
- Posttraumatic stress disorder and major depressive disorder from his 2008 service persisted and were documented as worsening during the 2015 deployment, with a PCL-5 score of 58 on 10 August 2015, at the time of the worsening.
Worsening 3: taking an opioid analgesic at an average daily morphine equivalent dose of at least 60 milligrams for at least the three months before the clinical worsening of chronic pain syndrome; — MET
- The veteran took controlled-release oxycodone at 60 mg oral morphine equivalent per day, increased on 22 June 2015 to 120 mg oral morphine equivalent per day by the ship's medical officer, throughout the three months before the worsening, from 10 May 2015 to 10 August 2015. The pain specialist recorded escalating tolerance and hyperalgesia.
Worsening 4: inability to obtain appropriate clinical management for chronic pain syndrome. — MET
- While at sea from February to early August 2015 the veteran had no access to his pain medicine specialist, psychologist, physiotherapist or multidisciplinary pain programme, and after the fall of 22 June 2015 the only available treatment was an increase in opioid dose. Specialist review was not possible until 10 August 2015, by which time the condition had measurably worsened. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The chronic pain syndrome is a sequela of the veteran's accepted conditions: the L4/5 disc injury and left L5 radiculopathy from the boarding fall on warlike service in 2008, the microdiscectomy performed for them, the concussion, and his posttraumatic stress disorder, depression and insomnia.
Unintended Consequence
Met. The chronic pain syndrome is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the microdiscectomy, which left epidural fibrosis around the L5 nerve root, and the long-term opioid treatment, which produced tolerance and opioid-induced hyperalgesia and was escalated at sea in 2015 (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. During his 2015 deployment at sea the veteran could not access his pain medicine specialist, psychologist, physiotherapist or multidisciplinary pain programme, and after his fall on 22 June 2015 the only treatment available was a doubling of his opioid dose. His Brief Pain Inventory interference score rose from 7.4 to 8.9 and his Pain Disability Index from 52 to 64. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent access to the treatment a condition requires amount to an inability to obtain appropriate clinical management. The interruption of his multidisciplinary programme by his posting to sea is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 16 Apr 2008, Ship's medical record, Medical Officer, a frigate in the Middle East
- 22 Apr 2008, MRI lumbar spine report, Radiologist
- 03 Feb 2009, Operation report, Neurosurgeon
- 10 Jun 2009, Psychiatric assessment, Consultant psychiatrist
- 08 Oct 2009, Neurosurgical review and MRI report, Neurosurgeon
- 14 Dec 2009, Pain medicine consultation, Pain medicine specialist
- 18 Mar 2010, Multidisciplinary pain assessment, Pain medicine specialist, psychiatrist, physiotherapist and psychologist
- 22 Jun 2015, Ship's medical record, Medical Officer, a frigate in the Middle East
- 10 Aug 2015, Pain medicine consultation and MRI whole spine report, Pain medicine specialist
- Medical-scientific literature on the causes of chronic pain syndrome (no Statement of Principles determined)
