Diagnostic Assessment — Fibromyalgia
Example 1 of 1 · fictitious patient (Veteran AF)
Diagnostic Assessment
Fibromyalgia
BOP Code: 108 of 2021 (Fibromyalgia)
RH Code: 107 of 2021 (Fibromyalgia)
ADF History
Veteran AF, date of birth 14 June 1974, Australian Army, Vehicle Mechanic (Craftsman), enlisted as an Army Apprentice 15 January 1990 at the age of 15, medically discharged 20 November 2015. Operational service: East Timor, 12 October 1999 to 18 April 2000 (warlike); Iraq, 10 May 2006 to 20 November 2006 (warlike); Afghanistan, 15 February 2010 to 30 September 2010 (warlike).
Occupational History
As a vehicle mechanic the veteran recovered and repaired wheeled and armoured vehicles in workshops and in the field, working for long periods bent over engine bays, lying under vehicles on concrete and gravel, lifting wheels, packs and components of 25 to 50 kilograms, and using impact tools. Field and deployed workshops involved extreme heat, dust, long shifts, disrupted sleep and poor field hygiene, with recurrent gastrointestinal infections.
Recovery mechanics on operations travelled with combat logistics patrols and were exposed to improvised explosive devices, indirect fire and vehicle roll-overs. Apprentices of the period entered the Army at 15 and 16 years of age and lived in barracks supervised by adult instructors and senior apprentices, in a culture in which bastardisation and physical and sexual abuse of junior apprentices occurred and were rarely reported.
Members who were abused as junior apprentices often did not disclose it for decades, and the psychological effects were frequently reactivated by later operational trauma. Chronic inflammatory conditions acquired on deployment, such as reactive arthritis after dysentery, could restrict members to light duties for years, with weight gain and deconditioning.
History
Veteran AF, a vehicle mechanic in the Australian Army who enlisted as a 15-year-old apprentice and was abused by an adult instructor in 1990, developed reactive arthritis and then HLA-B27 positive ankylosing spondylitis after dysentery on warlike service in Iraq in 2006, and survived an improvised explosive device strike in Afghanistan in June 2010. Fibromyalgia began on 01 March 2011, was diagnosed by a rheumatologist on 14 September 2011, and worsened markedly by May 2014 while he was posted to a remote base without access to multidisciplinary pain management.
Timeline
- 15 Jan 1990 — The veteran enlisted as an Army Apprentice at the age of 15 years and 7 months and began training at an Army apprentice school in Victoria. The entry medical examination recorded no musculoskeletal or psychological history and a normal examination. Weight 64 kg, height 1.78 m. "fit, no significant history"
- 22 Mar 1990 — He attended the apprentice school medical centre with bruising across the back and buttocks and a laceration to the scalp, which he attributed to an initiation. A later Defence Abuse Response Taskforce finding accepted that from February to June 1990 an adult corporal instructor repeatedly beat him, forced him to stand in cold showers for hours and sexually assaulted him on at least three occasions in the barracks, while he was aged 15. The instructor threatened him with discharge if he reported it. "bruising back, initiation, aged 15"
- 03 Aug 2006 — On warlike service in Iraq the veteran was admitted to the role 2 medical facility with bloody diarrhoea and fever; stool culture grew Shigella flexneri. Two weeks later he developed painful swelling of both knees and the left ankle, bilateral conjunctivitis and buttock pain, and reactive arthritis was diagnosed. He completed the deployment on restricted duties. "Shigella dysentery, reactive arthritis"
- 21 Aug 2007 — A rheumatologist diagnosed ankylosing spondylitis following the reactive arthritis, on the basis of inflammatory back pain, positive HLA-B27, a raised CRP of 34 mg/L and bilateral sacroiliitis on MRI. Despite full-dose NSAIDs the disease remained active (BASDAI 6.4), and adalimumab was commenced on 11 February 2008 and continued thereafter. He was placed on permanent restrictions excluding heavy recovery work. "ankylosing spondylitis, HLA-B27 positive"
- 18 Jun 2010 — On warlike service in Afghanistan the recovery vehicle in which the veteran was travelling struck an improvised explosive device. The vehicle was thrown onto its side and the crew commander was seriously injured. The veteran was briefly concussed, sustained bruising of the back and shoulders, and was treated at the role 2 facility and returned to duty after five days. "IED strike, concussed, back bruising"
- 08 Feb 2011 — At his periodic health examination after return from Afghanistan the veteran reported back stiffness from his ankylosing spondylitis, controlled on adalimumab, and some disturbed sleep, but no widespread pain, fatigue or tenderness. The medical officer recorded a normal examination apart from reduced lumbar flexion. Weight 91 kg, BMI 28.7. A post-deployment psychological screen recorded intrusive memories of the June 2010 blast and of his abuse as an apprentice, and he was referred for counselling. "no widespread pain, BMI 28.7"
- 22 Mar 2011 — At the garrison health centre the veteran described widespread aching pain in the neck, both shoulders, upper and lower back, both arms and both legs since the start of March 2011, with exhausting fatigue, unrefreshing sleep, poor concentration and headaches. The ankylosing spondylitis was assessed as quiescent on adalimumab, with a normal CRP. Weight 93 kg, BMI 29.4. His periodic health examination of 08 February 2011 had recorded no widespread pain. "widespread pain since early March"
- 14 Sep 2011 — A rheumatologist diagnosed fibromyalgia after more than six months of chronic widespread pain. The widespread pain index was 11 with pain in all five regions, and the symptom severity scale score was 7. Inflammatory markers were normal, MRI showed no active sacroiliitis or spinal inflammation, and thyroid function, creatine kinase and vitamin D were normal. Amitriptyline 10 mg at night, graded exercise and referral to a multidisciplinary pain program were recommended. "fibromyalgia, WPI 11, SSS 7"
- 12 May 2014 — After sixteen months posted to a remote base in northern Australia, where no pain specialist, rheumatologist, psychologist or exercise physiologist was available and the pain program referral could not be taken up, the veteran reported marked worsening. The widespread pain index was 15 and the symptom severity scale score 10. He was downgraded medically and was later medically discharged. "worse, WPI 15, SSS 10"
Symptoms
At onset the veteran had chronic aching and burning pain in the neck, shoulders, arms, upper and lower back and legs, with tenderness to touch, exhausting fatigue, unrefreshing sleep, morning stiffness distinct from his ankylosing spondylitis, poor concentration and memory, headaches and irritable bowel symptoms. The pain was present on most days, in at least four of the five regions, and was not explained by his inflammatory arthritis, which was quiescent.
He now reports constant widespread pain, flares after physical exertion and cold weather, severe fatigue, poor sleep, cognitive difficulties and low mood. He cannot sustain physical work and limits standing and walking. The symptoms worsened markedly in 2013 and 2014 while he could not access multidisciplinary care.
Imaging
- 21 Aug 2007 — MRI sacroiliac joints: "Bilateral active sacroiliitis with bone marrow oedema and early erosions, consistent with axial spondyloarthritis."
- 05 Sep 2011 — MRI sacroiliac joints and whole spine: "Chronic changes of sacroiliitis without active inflammation. No active spinal inflammation, no structural lesion to account for widespread pain."
Onset Date
The most likely date of onset of this condition is 01 Mar 2011.
At that date the veteran was serving full time as a vehicle mechanic in a combat service support battalion in Australia, five months after returning from warlike service in Afghanistan. He was taking adalimumab for ankylosing spondylitis, was on restricted duties and had gained weight. From the start of March 2011 he developed widespread aching pain, fatigue and unrefreshing sleep.
This date is appropriate because his periodic health examination of 08 February 2011 recorded no widespread pain, and at his first presentation on 22 March 2011 he dated the widespread pain to the start of March 2011. The pain then persisted for more than three months, and the diagnosis was confirmed on 14 September 2011.
For the category 1A stressor factor, the 1 year before onset runs from 01 Mar 2010 to 01 Mar 2011; the improvised explosive device strike of 18 June 2010 on warlike service in Afghanistan falls within it. For the severe, chronic medical condition factor, the 2 years before onset run from 01 Mar 2009 to 01 Mar 2011; ankylosing spondylitis, diagnosed on 21 August 2007 and treated with adalimumab from 11 February 2008, was present and active throughout that period. The severe childhood abuse occurred from February to June 1990, before onset. The ankylosing spondylitis and his overweight status, with a BMI of 29.4, were present at onset on 01 Mar 2011.
For the worsening factor, the period after onset runs from 01 Mar 2011 to the documented worsening on 12 May 2014, including his posting to a remote base from January 2013, during which multidisciplinary pain management could not be obtained.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Fibromyalgia (ICD-10-AM M79.7), under the Statements of Principles concerning fibromyalgia, Balance of Probabilities No. 108 of 2021 and Reasonable Hypothesis No. 107 of 2021.
Fibromyalgia is a syndrome of chronic widespread pain with associated somatic symptoms, including fatigue, unrefreshing sleep and cognitive difficulty, that persists for at least three months. It is thought to reflect altered central processing of pain, with amplified sensitivity to pain signals. It commonly follows physical or psychological trauma and often coexists with inflammatory arthritis, sleep disturbance and mood disorders. It is diagnosed clinically using the widespread pain index and symptom severity scale.
The condition followed severe abuse as a 15-year-old apprentice in 1990, ankylosing spondylitis that developed after dysentery on warlike service in Iraq in 2006, and an improvised explosive device strike in Afghanistan in 2010. It began on 01 March 2011, was diagnosed on 14 September 2011 and worsened by 12 May 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
01 March 2011.
When did the veteran first present to a health / medical provider for this condition?
22 March 2011.
When was the condition confirmed / formally diagnosed?
14 September 2011.
When did the veteran first present to you (or your practice) for this condition?
07 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 14 September 2011, after more than six months of chronic widespread pain. The widespread pain index was 11, with an associated symptom severity scale score of 7, meeting criterion (a)(i), and pain was present in all five of the specified regions, meeting criterion (b). The pain and symptoms were not better accounted for by another condition: the ankylosing spondylitis was quiescent with a normal CRP, MRI on 05 September 2011 showed no active inflammation, and thyroid function, creatine kinase and vitamin D were normal, meeting criterion (c). This meets the Statement of Principles definition of fibromyalgia.
The clinical course was consistent with the diagnosis: widespread pain, fatigue, unrefreshing sleep and cognitive symptoms, with diffuse tenderness and normal investigations. The worsening was documented on 12 May 2014 with a widespread pain index of 15 and a symptom severity scale score of 10.
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 01 March 2011, 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, including the abuse at the apprentice school in 1990 and the remote posting from 2013. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006, where the dysentery that led to his inflammatory arthritis occurred, and in Afghanistan in 2010, where he experienced the improvised explosive device strike.
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 Fibromyalgia, No. 108 of 2021
Causative factors
Factor 9(1): experiencing severe childhood abuse before the clinical onset of fibromyalgia; — MET
- From February to June 1990, while serving as an Army Apprentice aged 15, the veteran was repeatedly beaten, subjected to prolonged cold-shower punishments and sexually assaulted on at least three occasions by an adult corporal instructor responsible for his supervision. This was serious physical, psychological and sexual harm to a child aged under 16 years, perpetrated by an adult who worked with him. The medical centre record of 22 March 1990 documents the injuries, and the Defence Abuse Response Taskforce accepted the abuse. It occurred during his service and 21 years before the onset of fibromyalgia on 01 March 2011.
Factor 9(2): being overweight or obese at the time of the clinical onset of fibromyalgia; — MET
- The veteran weighed 93 kg at a height of 1.78 m, a BMI of 29.4, at his presentation on 22 March 2011, three weeks after onset, and his BMI had been above 25 since 2008. The weight gain followed the permanent restrictions on physical activity imposed for his service-related ankylosing spondylitis and a course of prednisolone during flares in 2007.
Factor 9(3): having an autoimmune inflammatory condition which is associated with the development of arthritis at the time of the clinical onset of fibromyalgia; — MET
- The veteran had HLA-B27 positive ankylosing spondylitis, diagnosed by a rheumatologist on 21 August 2007 with bilateral sacroiliitis on MRI, and treated continuously with adalimumab from 11 February 2008. Ankylosing spondylitis is an autoimmune inflammatory condition associated with the development of arthritis. It was present at the onset of fibromyalgia on 01 March 2011, and it followed reactive arthritis after Shigella dysentery contracted on service in 2006.
Worsening factors
Factor 9(4): inability to obtain appropriate clinical management for fibromyalgia; — MET
- After diagnosis on 14 September 2011 the rheumatologist recommended a multidisciplinary pain program, graded exercise with an exercise physiologist and psychological therapy. From January 2013 the veteran was posted to a remote base in northern Australia where none of these services was available, the pain program referral lapsed, and requests for travel to attend treatment were declined because of unit commitments. By 12 May 2014 the widespread pain index had risen from 11 to 15 and the symptom severity scale score from 7 to 10. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management, and it contributed to the worsening.
Reasonable Hypothesis — Statement of Principles concerning Fibromyalgia, No. 107 of 2021
Causative factors
Factor 9(1): experiencing severe childhood abuse before the clinical onset of fibromyalgia; — MET
- The veteran was physically, psychologically and sexually abused by an adult instructor from February to June 1990 while serving as a 15-year-old apprentice, before the onset of fibromyalgia on 01 March 2011. The abuse sensitised his stress responses, and his psychiatrist recorded that memories of it were reactivated by the life-threatening events of his warlike service in Afghanistan in 2010, in the year before the fibromyalgia began.
Factor 9(2): being overweight or obese at the time of the clinical onset of fibromyalgia; — MET
- The veteran's BMI was 29.4 at onset. His weight rose from 82 kg in 2006 to 93 kg in 2011 after the inflammatory arthritis that followed dysentery on warlike service in Iraq forced permanent restrictions on exercise, and after the back and shoulder injuries from the improvised explosive device strike in Afghanistan in June 2010 limited his activity further.
Factor 9(3): having an autoimmune inflammatory condition which is associated with the development of arthritis at the time of the clinical onset of fibromyalgia; — MET
- Ankylosing spondylitis developed after reactive arthritis triggered by Shigella dysentery contracted on warlike service in Iraq on 03 August 2006. It was diagnosed on 21 August 2007 and treated with adalimumab, and it was present at the onset of fibromyalgia on 01 March 2011.
Factor 9(4): experiencing a category 1A stressor within the 1 year before the clinical onset of fibromyalgia; — MET
- On 18 June 2010, on warlike service in Afghanistan, the recovery vehicle in which the veteran was travelling struck an improvised explosive device and was thrown onto its side, seriously injuring the crew commander. This was a life-threatening event, a category 1A stressor. It occurred within the 1 year before onset, which runs from 01 March 2010 to 01 March 2011.
Factor 9(5): having a severe, chronic medical condition for at least the 2 years before the clinical onset of fibromyalgia; — MET
- The veteran's ankylosing spondylitis, which arose from reactive arthritis after dysentery on warlike service in Iraq, was a severe, chronic medical condition: it was active despite full-dose NSAIDs, with a BASDAI of 6.4, required continuous biologic therapy with adalimumab from 11 February 2008, caused persistent pain and stiffness, and led to permanent duty restrictions. It was present throughout the 2 years before onset, from 01 March 2009 to 01 March 2011.
Worsening factors
Factor 9(6): inability to obtain appropriate clinical management for fibromyalgia; — MET
- From January 2013 to May 2014 the veteran was posted to a remote base without access to a pain specialist, rheumatologist, psychologist or exercise physiologist, and the multidisciplinary pain program recommended in September 2011 could not be obtained. The fibromyalgia worsened, with the widespread pain index rising from 11 to 15 by 12 May 2014. The condition arose from his warlike service, and the absence of treatment while he remained in service amounts to an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The fibromyalgia is a sequela of the veteran's accepted ankylosing spondylitis, which arose from dysentery on warlike service in Iraq, and of the psychological effects of the abuse he suffered as an apprentice and the improvised explosive device strike in Afghanistan. The fibromyalgia has in turn contributed to chronic insomnia, depressive symptoms and physical deconditioning.
Unintended Consequence
Met. The course of prednisolone given in 2007 for flares of service-related inflammatory arthritis, and the permanent activity restrictions imposed by Defence medical officers, contributed to the weight gain that left him overweight at onset. This is an unintended consequence of treatment provided by the Commonwealth during his service.
Inability to Attain Appropriate Medical Management
MET. After the diagnosis on 14 September 2011 the veteran was referred for a multidisciplinary pain program, exercise physiology and psychological therapy. From January 2013 he was posted to a remote base where none of these services existed, and requests for travel to attend treatment were declined because of unit commitments, so for sixteen months he received only amitriptyline. The widespread pain index rose from 11 to 15 and the symptom severity scale score from 7 to 10 by 12 May 2014. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a posting that prevents access to the recommended treatment, with no alternative provided, amounts to an inability to obtain appropriate clinical management, and it contributed to the worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 15 Jan 1990, Entry medical examination, Army recruiting medical officer
- 22 Mar 1990, Medical centre treatment record, Apprentice school medical officer
- 03 Aug 2006, Role 2 admission record, Medical officer, Iraq
- 21 Aug 2007, Specialist report and MRI sacroiliac joints, Rheumatologist and radiologist
- 11 Feb 2008, Biologic therapy commencement letter, Rheumatologist
- 18 Jun 2010, Role 2 treatment record and incident report, Medical officer, Afghanistan
- 08 Feb 2011, Periodic health examination, Medical Officer, Garrison health centre
- 22 Mar 2011, Outpatient health record, Medical Officer, Garrison health centre
- 05 Sep 2011, MRI sacroiliac joints and whole spine, Radiologist
- 14 Sep 2011, Specialist report, Rheumatologist
- 12 May 2014, Outpatient health record and medical employment review, Senior Medical Officer
- Defence Abuse Response Taskforce finding letter
- Statement of Principles concerning Fibromyalgia (Balance of Probabilities) No. 108 of 2021, Repatriation Medical Authority
- Statement of Principles concerning Fibromyalgia (Reasonable Hypothesis) No. 107 of 2021, Repatriation Medical Authority
