Reference Determination Content
Suggested draft · fictitious patient
Chronic Pain Syndrome
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A ship's medical record by the medical officer, a frigate in the Middle East, dated 16 April 2008;
- An MRI lumbar spine report by the radiologist, dated 22 April 2008;
- An operation report by the neurosurgeon, dated 3 February 2009;
- A psychiatric assessment by the consultant psychiatrist, dated 10 June 2009;
- A neurosurgical review and MRI report by the neurosurgeon, dated 8 October 2009;
- A pain medicine consultation by the pain medicine specialist, dated 14 December 2009;
- A multidisciplinary pain assessment by the pain medicine specialist, psychiatrist, physiotherapist and psychologist, dated 18 March 2010;
- A ship's medical record by the medical officer, a frigate in the Middle East, dated 22 June 2015;
- A pain medicine consultation and MRI whole spine report by the pain medicine specialist, dated 10 August 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 January 1999 and 30 June 2019
Chronic Pain Syndrome
You have stated that your condition was caused by:
- 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
- having a chronic musculoskeletal or neuropathic pain condition at the time of the clinical onset of chronic pain syndrome
- undergoing surgery to the affected region within the one year before the clinical onset of chronic pain syndrome, with persistent post-surgical pain
- 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
- experiencing a severe psychosocial stressor within the five years before the clinical onset of chronic pain syndrome
- having sleep disturbance on at least three nights per week for at least the three months before the clinical onset of chronic pain syndrome
- taking an opioid analgesic on a daily basis for at least the three months before the clinical onset of chronic pain syndrome
- having concussion or traumatic brain injury before the clinical onset of chronic pain syndrome
- being physically inactive or deconditioned because of injury or illness for at least the three months before the clinical onset of chronic pain syndrome
- 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
Diagnosis: Chronic Pain Syndrome
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 May 2025, and is supported by a multidisciplinary pain assessment by the pain medicine specialist, psychiatrist, physiotherapist and psychologist, dated 18 March 2010.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Balance of Probabilities (reasonable satisfaction) - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- 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
- having a chronic musculoskeletal or neuropathic pain condition at the time of the clinical onset of chronic pain syndrome
- undergoing surgery to the affected region within the one year before the clinical onset of chronic pain syndrome, with persistent post-surgical pain
- 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
- experiencing a severe psychosocial stressor within the five years before the clinical onset of chronic pain syndrome
- having sleep disturbance on at least three nights per week for at least the three months before the clinical onset of chronic pain syndrome
- taking an opioid analgesic on a daily basis for at least the three months before the clinical onset of chronic pain syndrome
- having concussion or traumatic brain injury before the clinical onset of chronic pain syndrome
- being physically inactive or deconditioned because of injury or illness for at least the three months before the clinical onset of chronic pain syndrome
- 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
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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 on 14 December 2009.
The diagnosis was made on 18 March 2010 after a multidisciplinary assessment by a pain medicine specialist, psychiatrist, physiotherapist and psychologist. You 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.
This has then led to further investigations and the diagnosis of your condition of Chronic Pain Syndrome. I have accepted your condition of Chronic Pain Syndrome.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your peacetime service.
I have therefore accepted that this condition is related to your service with effect from 1 December 2009.
Chronic Pain Syndrome (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 May 2025;
- A ship's medical record by the medical officer, a frigate in the Middle East, dated 16 April 2008;
- An MRI lumbar spine report by the radiologist, dated 22 April 2008;
- An operation report by the neurosurgeon, dated 3 February 2009;
- A psychiatric assessment by the consultant psychiatrist, dated 10 June 2009;
- A neurosurgical review and MRI report by the neurosurgeon, dated 8 October 2009;
- A pain medicine consultation by the pain medicine specialist, dated 14 December 2009;
- A multidisciplinary pain assessment by the pain medicine specialist, psychiatrist, physiotherapist and psychologist, dated 18 March 2010;
- A ship's medical record by the medical officer, a frigate in the Middle East, dated 22 June 2015;
- A pain medicine consultation and MRI whole spine report by the pain medicine specialist, dated 10 August 2015.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 January 1999 and 30 June 2019
Chronic Pain Syndrome (Worsening)
You have stated that the worsening of your condition was caused by:
- sustaining a further physical injury to the affected region within the three months before the clinical worsening of chronic pain syndrome
- having a clinically significant psychiatric disorder at the time of the clinical worsening of chronic pain syndrome
- 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
- inability to obtain appropriate clinical management for chronic pain syndrome
Diagnosis: Chronic Pain Syndrome (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 May 2025, and is supported by a multidisciplinary pain assessment by the pain medicine specialist, psychiatrist, physiotherapist and psychologist, dated 18 March 2010.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Balance of Probabilities (reasonable satisfaction) - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- sustaining a further physical injury to the affected region within the three months before the clinical worsening of chronic pain syndrome
- having a clinically significant psychiatric disorder at the time of the clinical worsening of chronic pain syndrome
- 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
- inability to obtain appropriate clinical management for chronic pain syndrome
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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 on 14 December 2009.
The diagnosis was made on 18 March 2010 after a multidisciplinary assessment by a pain medicine specialist, psychiatrist, physiotherapist and psychologist. You 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.
After the condition arose, it was worsened during your service. On 22 June 2015, aboard a frigate on deployment in the Middle East, you slipped on a wet ladder and fell about two metres onto your back and right hip. Posttraumatic stress disorder and major depressive disorder from your 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. You 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. While at sea from February to early August 2015 you had no access to your 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.
This has then led to further investigations and the diagnosis of your condition of Chronic Pain Syndrome (Worsening). I have accepted your condition of Chronic Pain Syndrome (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 10 August 2015.
