1. The issue for the tribunal is whether the respondent is liable for the applicant's incapacity for work and medical treatment expenses since compensation payments ceased on 9 January 1997. It is agreed by the parties that the applicant's claim for permanent impairment is not a matter for this tribunal's consideration.
2. It is not disputed that the applicant had a work related injury in 1983. The respondent admitted liability for the applicant's absences from work, and for the absences arising out of the aggravation to her injury in 1985, but does not now concede that compensation was properly payable after July 1986. Compensation was ceased on the grounds that the applicant's condition arose not from the head injury in 1983, but from an independent psychological condition which gave rise to fibromyalgia. The respondent's case is that the applicant's work-related condition resolved in 1986 when Dr Andrews, consultant neurologist, noted that the applicant was probably fit for work as a cleaner (T23, p.87). The applicant's task of satisfying the tribunal of the connection between the 1983 incident and the continuation of her neck complaints is assisted by the respondent's continued acceptance of liability until 1996 (McDonald v Director General of Social Security [1984] FCA 57; (1984) 1 FCR 354 at para.9), though the respondent submits that nothing turns on the respondent's continued payment in error of compensation after 1986.

1. The tribunal obtained little assistance from the applicant's evidence. In answering questions put to her in cross-examination about her medical history she had difficulty recalling names of treating or examining practitioners, and dates of events. There were also numerous discrepancies in her evidence. We are satisfied, however, that the applicant attempted to give her evidence to the best of her recollection. All observers have noted, as did the tribunal, that through language, educational, cultural and psycho-social limitations, Mrs Lovrinovic is a poor historian. Relying as the treating doctors and examining specialists must - in the general absence of clinically observable symptoms - on the patient's subjective descriptions, it is inevitable that inaccuracies will occur. In particular, from the documentation available to the tribunal, it is apparent that some of the doctors were not aware of Mrs Lovrinovic's long history of unexplained pain and undue concern with bodily health; of a gap of almost two years between the reported injury and aggravation, during which she appeared never to have complained to any of her doctors of continuing headaches or neck pain; or of the significant proportion of her employment during which she was absent from the work place after 1985.
2. Where the applicant's evidence is at variance with that of the documented records such as doctors' clinical notes, the tribunal accepts the documentary evidence. The records of dates of events and complaints of pain reported by the applicant at the time are likely to be more accurate than the applicant's recollection now of such dates and matters. Thus, we accept that the applicant's first attendance on a doctor after the incident at work of 13 May 1983, was upon Dr Gavranic on 30 May 1983. We also accept that the applicant did not attend any doctor in relation to her neck condition between 17 November 1983 and 12 September 1985. More generally, because of the considerable documentary evidence placed before the tribunal, it is useful first to summarise the applicant's medical and work history as reflected in those documents.

1. From the clinical notes of Doctors Gavranic (Exhibit 4), and Cochrane/Rosendahl (Exhibit 5), it is apparent that, from 1978 at least, Mrs Lovrinovic was suffering gynaecological problems and chronic lower back pain (concerning which latter complaint, interestingly, Dr Gavranic records in his note of 5 February 1982 her denying that it happened at work). Mrs Lovrinovic underwent an hysterectomy in 1980. However, her lower back pains continued. In the same entry of 5 February 1982, Dr Gavranic recorded a 'long history of lumbar back aches - very complex. Wants to keep going until she can get long service leave'. Again on 29 November 1982, Dr Gavranic noted 'painful back and tired aching muscles - wants a rest'.
2. This is consistent with the applicant's oral evidence that, prior to joining the CCAE in 1978, she was generally in good health and had no complaints of neck pain. She mentioned having some low back pain before her 1983 head injury at work, which she attributed to her abdominal and other problems.
3. In relation to the applicant's back problems, which do not appear to be connected with the abdominal problems, the tribunal accepts that they were not persisting, and may have related to her long history of heavy work as a cleaner. She makes no claim that there is an ongoing work-related problem in relation to her lower back.
4. In 1983 Mrs Lovrinovic continued to complain to Dr Gavranic of vague stomach pains before and after the head injury. In June 1983 a barium enema showed negative. On 29 July 1983, Dr Gavranic reported 'ovarian trouble, right lower abdomen pain for months, constipation, nervous very upset'. Again on 5 September 1983, 'abdominal pain continues'; and 26 October 1983, 'epigastric pain'. Interestingly also, for the first time in this medical history Dr Gavranic notes, on 11 October 1983, 'very good for chronic pain syndrome'; inviting the inference that he had already classified Mrs Lovrinovic as displaying that history, though only four months after the head injury, and presumably based on the much longer 7-plus years' history of unexplained pain. Dr Gavranic's notes also record his last observation of neck pain on 17 November 1983 as 'better' (Exhibit 4).
5. For the next 14 months Mrs Lovrinovic appears not to have consulted Drs Gavranic, Cochrane or Newcombe at all. The next recorded consultation is with Dr Cochrane on 25 February 1985, when she complained of 'chest pain'. Then, on 12 September 1985, she returned to Dr Gavranic who certified her as having 'acute and chronic neck pain - recurring problem following injury at work May 1983' (T5, p.7). This record is consistent with the applicant's claim that neck pain had continued since the 1983 accident. He recorded on 17 September 1985 'still painful L side'; and 24 September 1985 'looks drawn and tired, pain on some neck movements, told that I'm not taking on w/c & she should see another doctor' (Exhibit 4). Accordingly, Mrs Lovrinovic returned to Dr Cochrane on 27 September 1985 when he recorded 'still complaining of neck trouble' (Exhibit 5).
6. Most of the subsequent medical history directly concerns the 'fibromyalgia' of the upper torso. However, in early 1991 (after a gap of 18 months) Mrs Lovrinovic consulted Dr Cochrane for the last time before Dr Rosendahl took over that practice. Dr Cochrane, on 11 February 1991, recorded 'severe chest pain'; and, on 20 February 1991, 'mammogram lumpy breasts, hypercholesterolemia, severe chest pain, low back pain, neck pain, ?osteoarthritis spine' (Exhibit 5). Later, in September 1993, Dr Jeans performed a cholecystectomy, appendicectomy and abdominal wall repair; noting, on 30 September 1993, 'constipation'. Again, on 10 January 1996, Dr Jeans reported 'gastritis, liver lesion'. Throughout this period of more than 10 years, Mrs Lovrinovic underwent many tests and scans, almost all of which showed no significant abnormalities (T23, T57, T103).
7. The history above raised the question of whether the undiagnosed abdominal pain was an early indication of susceptibility to a psychosomatic pain disorder at a time prior to the 1983 work accident. However, the evidence is that the applicant worked without complaints until the incident at work in 1983. There is little evidence to suggest she had difficulties at home or unhappiness which might have contributed to, or catalysed, the development of fibromyalgia prior to this time, (if, as Dr McGill in his oral evidence suggests, unhappiness is a trigger for such a condition). The 1983 incident at work was significant, at least to Mrs Lovrinovic. She reported it and consulted Dr Gavranic 17 days later because of pain (T14). On the material available there is not sufficient evidence to satisfy the tribunal that symptoms of the fibromyalgia condition were evident prior to the incident in 1983.

1. Turning now to the applicant's work history following the injury of 13 May 1983, based on the medical certificates and reports, it is apparent that she worked full-time (including 6 months on light duties) for a total of 2 years and 10 months out of the 9 years and 2 months until invalidity retirement. She had only two and a half days off work between the accident on 13 May 1983 and 13 September 1985. She had 6 weeks off at that point, followed by a month back at work, then approximately 21 months off until she returned to light duties full-time on 7 September 1987. She continued full-time on light duties until 10 March 1988 when she once again was declared unfit for work for a total of 16 months. On 21 July 1989 she commenced part-time light duties on rehabilitation. Over the next 10 months she undertook several rehabilitation attempts, managing to work for about half the time. Finally she ceased work permanently on 14 May 1990, exactly 7 years after the original accident, and was retired 2 years and 2 months later on 16 August 1992. Thus Mrs Lovrinovic worked full and part-time for just over 4 years in the 7 years until ceasing work permanently.

1. The applicant suffered a musculo-ligamentous strain (Dr Newcombe, 8 January 1986, T19), or soft tissue injury to the neck (Dr Cochrane, 10 October 1985, T5, p.11) when she hit her head in the 1983 incident at work. It seems that she developed chronic neck pain over the next two years (Dr Gavranic, 12 September 1985, T5, p.7). The pain continued and extended to total body pain incorporating illness behaviour and depression (Dr Chase, 28 August 1991, T67).
2. The treating and examining doctors agree that the applicant's relevant symptoms are headaches, generalised widespread pain over her neck, shoulders, arms, thoracic and lumbar spine, and thighs, and depression. Examination by the treating and examining doctors reveals essentially full and free movement of upper and lower limbs, neck and lumbar spine. On some occasions mild pain was reported at the limits of passive movement (movements made with the assistance of the doctor). All relevant scans and tests report essentially normal results. Thus there is no detectable organic source of the reported pain. The doctors variously labelled the applicant's symptoms as fibrositis (Dr Cassar, 27 May 1987, T34); or fibromyalgia (Ms Cursley, 17 August 1994, T85; Dr McGill, 1 October 1996, T99; Dr White, 17 January 1997, T103), DSM-IV pain disorder, (Dr Knox, 9 April 1997, T105) or chronic widespread pain syndrome, (Dr Champion, 23 June 1997, T10).
3. Whatever label is attached to the condition, it is one involving widespread musculo-skeletal pain, a diagnosis of fibromyalgia, or chronic pain disorder, receiving general support of the medical practitioner's who examined or treated the applicant. The respondent's medical experts accept that the applicant's complaints of pain are genuinely felt, without accepting the applicant's attribution of her symptoms to her 1983 injury. The general view is that the applicant's condition is permanent. She is unlikely to return to work. Whether the applicant's current pain disorder or fibromyalgia was caused, or was contributed to in a material degree, by the incident at work in 1983, requires an analysis of the various medical opinions in the light of the relevant facts, matters and circumstances surrounding the applicant's medical, work and personal history.

1. In considering the linkage between the applicant's pain disorder and her work injury, we turn first to the medical opinions, bearing in mind that, in the absence of observable symptoms, the treating doctors have had to rely on Mrs Lovrinovic's subjective reports of incidents and symptoms.
2. Dr Gavranic first examined Mrs Lovrinovic 17 days after the injury on 30 May 1983. He understandably linked the symptoms complained of with the injury, diagnosing post-traumatic soft tissue pain (T14). Subsequently, on 27 September 1985, he linked her claimed aggravation 'as attributable to the (May 83 injury), which in turn is consistent with the after-effects of the stated injury ("knocking my head")', having seen her on 12 September 1985 when he recorded a recurring neck pain (T5, p.7), and persisting pain on 17 September 1985 and 24 September 1985.
3. Dr Cochrane first examined Mrs Lovrinovic relevantly 4 weeks after the injury on 9 June 1983. He opined that the injury was 'probably a form of whiplash' (Exhibit 5). When she continued to complain of neck pain, he referred her to Dr Newcombe, neurosurgeon. Subsequently, Mrs Lovrinovic returned to Dr Cochrane on 27 September 1985 after being turned away by Dr Gavranic. Dr Cochrane apparently accepted that, notwithstanding the passage of more than two years since he had referred her to Dr Newcombe, the persisting symptoms, which were still much the same, resulted from the original injury. By 20 November 1985 Dr Cochrane was noting that Mrs Lovrinovic was a 'depressed lady' (Exhibit 5).
4. Dr Newcombe saw Mrs Lovrinovic on 25 August 1983 and also accepted the injury as causing the pain. He concluded that she was suffering from 'occipital neuralgia due to strain of C1/2 joints' (T9). On 8 January 1986 he reported to Dr Cochrane, having seen Mrs Lovrinovic again following the 'aggravation' in September 1985. He recorded that her 'neck pain has continued' and concluded that 'Although it is now two years since her injury, it seems more reasonable to interpret it as a musculo-ligamentous strain' (T19).
5. Dr Andrews, consultant neurologist, saw Mrs Lovrinovic approximately monthly between 25 January 1986 and 10 September 1986. In his report of 20 August 1986 (T23), he describes 'continuing neck, shoulder, arm pain and headaches', but he was apparently unaware of the two-year gap in complaint of symptoms. He diagnosed 'facet joint dysfunction' and observed that 'It seems likely to me that she is exaggerating the extent of her disabilities.' When Dr Andrews declined to give Mrs Lovrinovic a medical certificate for more than one month at a time in September 1986, she returned to Dr Cochrane who obliged (T5, p.27). Dr Andrews later provided a medico-legal report dated 20 March 1998 (Exhibit 2), not realising that he had treated the applicant 12 years previously. In that report he noted the 'consensus diagnosis is regional pain syndrome or fibromyalgia, with or without depression' and observed that 'fibromyalgia is a psychosomatic disorder'. He noted that 'The bump to the back of the head was minor.' He was doubtful that it had 'caused any residual problems in the cervical spine. There is no evidence of a facet joint or disc rupture in the cervical region so injury to the neck that could have occurred at the time was presumably soft tissue in nature and would have resolved over 6-12 month period.' (During his oral evidence to the tribunal, his attention was drawn to the apparent conflict between that latter opinion and his earlier treatment of her in 1986 when she had already apparently been suffering the neck pains for 3 years. He agreed that, with hindsight, there must have been something more complex than simple soft tissue pain at work.) In his March 1998 report (Exhibit 2), Dr Andrews concluded that he saw 'no connection now between the original injury and the so-called fibromyalgia syndrome', noting that Mrs Lovrinovic did not exhibit 'all the features of fibromyalgia in the sense that there are parts of the syndrome missing.' In short, Dr Andrews concluded in March 1998 that there was no connection between the applicant's present condition and the injury of 13 May 1983. However, the confliction with his earlier recognition and treatment of apparently continuing pain since the original injury, diagnosed at that time as 'assumed facet joint dysfunction', begs instead the conclusion that something more complex than simple soft tissue injury was at work, and that, whatever the disorder, it was linked at least temporally with the original injury. Accordingly, the tribunal discounts Dr Andrews' March 1998 conclusion of 'no connection'.
6. A CMO examined Mrs Lovrinovic on 26 June 1986 (T21), receiving her simplified and self-serving history which, not unexpectedly, presumed the causal link with the original injury. That history omitted mention of the 2-year gap in reported pain, claiming instead a history of continuous and worsening neck pain. The CMO diagnosed 'neck pain' and found her unfit for work until 18 August 1986.
7. Another CMO examined Mrs Lovrinovic on 11 August 1986 (T22). This CMO referred to the history recorded by the previous CMO, and noted 'No evidence of any pathology has been found despite intensive investigation. Fit for continued employment, 4h/d lighter duties.' (However, Dr Andrews had already certified her unfi_t_ for that month of August). This CMO examined the applicant again on 12 October 1987 (T41), finding no organic basis for Mrs Lovrinovic's complaints, noting that she found work helpful in reducing her depression, assessing her fit for light duties and recommending persistence with the work trial.
8. Mr Petroni, clinical psychologist, saw Mrs Lovrinovic on 28 February 1987 and reported 'I find it difficult to see a causal relationship between the bump on the head and the expressed pain. More likely to be RSI variety and therefore possibly containing some functional element' (Exhibit 5). That is, Mr Petroni was seeing a psychological problem rather than an organic one.
9. Dr Cassar, consultant physician, first reported on Mrs Lovrinovic on 27 May 1987 (T34). He also recorded her simplified history, but more cautiously merely noted her claim of 'disability based on injury at work'. He also recorded that 'With the passage of time aching moved into the lower back', noting that the 'chronically aching neck and back is based on fibrositis'. He observed that 'There are symptoms ... and other features of psychiatric and personality disturbance ...'. He found her unfit for work. Later, on 13 July 1987 (T38), he concluded that the 'trigger appears to have been injury at work as a cleaner in May 1983.' On 28 July 1987 (T39) he found the applicant 'totally incapacitated both from a physical and psychiatric point of view'. In reporting to Dr Cochrane on 26 November 1987 he diagnosed Mrs Lovrinovic's problem as 'soft tissue disability from injury May 83, the soft tissue complaint being diagnosed as fibrositis' (T42). Finally he provided a medical certificate on 19 April 1988 (T43) recording a 'relapse in fibrositis in Feb 88' and declaring Mrs Lovrinovic 'totally incapacitated'.
10. A further CMO examined the applicant on 13 July 1987 (T32) and diagnosed cervicalgia, finding her fit to gradually return to light duties commencing with 4 hours per day.
11. Dr Adam, in the absence of Dr Cochrane**,** provided medical certificates (T5, pp. 31-33) for work unfitness from March to May 1988. On those medical certificates she recorded 'pain in neck and back related to work', probably continuing the long-standing linkage presumption established by Dr Cochrane in 1983.
12. A further CMO examined the applicant on 16 June 1988 (T44), diagnosing 'cervicalgia and lumbalgia (80/20)' and confirming her fitness to 'continue 4h/d light duties'; although at this time Dr Cassar had already declared her 'unfit' and continued to so certify, along with Dr Corry, for the next 12 months until 26 June 1989, when Dr Corry declared her fit to undertake a rehabilitation program (T5, p.44). At this point Mrs Lovrinovic made several attempts over the next 10 months to return to work, beginning on 10 July 1989, with Drs Cochrane and Corry variously certifying her unfit for differing periods, until 15 May 1990 when Dr Cochrane - and subsequently Drs Corry, Cassar and finally another CMO - declared her permanently unfit.
13. Dr Corry first examined Mrs Lovrinovic in February 1986 when he assessed her as suffering from 'tension neck syndrome precipitated by the minor trauma of her head injury but the major etiological factor is anxiety and chronic pain behaviour', (letter to Dr Cochrane dated 20 February 1986 and quoted by Dr Rosendahl in his letters of 4 August 1994 at T80-T82). Again on 14 August 1986, in commenting on a negative cervical myelogram result, he observed that 'she doesn't seem too eager about getting better'. Mrs Lovrinovic was referred to Dr Corry again on 2 February 1989, and he continued to see her regularly until 4 May 1990 when he first raised the possibility of medical retirement for her. In his letter of that date (T54) he recorded 'persisting myofascial pains in the neck and upper limb girdle', 'developing some significant neurotic symptoms and appears to becoming increasingly depressed', and concluded that 'her symptoms are permanent with continuing work disability.' On 29 May 1990 Dr Corry wrote to Comcare summarising the position as he saw it 'which is dated historically to an injury at work in May 1983', and recommending consideration of medical retirement (T57).
14. A CMO examined the applicant on 8 August 1990 (T58), recorded a summary of the history of injury and headaches (continuing the presumed causal link of his predecessors), diagnosed 'cervicalgia, lumbalgia and reactive depression (35/35/35)', and certified Mrs Lovrinovic 'permanently unfit'.
15. Dr Chase, occupational health physician, assessed Mrs Lovrinovic on 16 August 1991 and reported on 28 August 1991 (T67). She observed that Mrs Lovrinovic 'suffers total body pain'. In her conclusions she said that:

... it is not credible that she suffered any ongoing disability as a result of the incident in 1983;

... the pain would have settled over several weeks;

... she has incorporated illness behaviour into her daily life;

Some of her pain is simple muscle fatigue. Any activity will result in exercise myalgia. In addition she is clinically depressed and this also exaggerates any pain perception;

1. Dr Knox, consultant psychiatrist, first assessed the applicant on 9 August 1994 (T83) at the request of Dr Rosendahl. His summary of her history was very general and consequently imprecise. He observed that:

she now manifests the rather typical secondary low grade depression and helplessness one sees in chronic pain patients;

I don't doubt that there are some psychological components to her condition;

I didn't feel that she presented with a depression as such;

I believe there is some significant underlying physical condition ... to degenerate into this type of unhappy state following relatively minor injuries.

1. Later, on 9 April 1997 (T105) at the request of the applicant's solicitors, Dr Knox concluded that:

Despite the uncertainty regarding the true etiology of Mrs Lovrinovic's condition, there would seem little doubt that her suffering and incapacity has flowed directly from the triggering accident causing neck injury.

I believe that secondary stresses arising from her pain, incapacity, inability to earn, and arguments with family members have all fuelled a deterioration in her psychological health ... there has been significant secondary emotional disturbance by way of depression and also, I believe, a component of anxiety.

Were the fibromyalgia to have developed separately from the head injury of 1983, as suggested by Dr McGill, I believe we would have seen evidence of this condition prior to the 1983 accident.

My own view is, however, that the fibromyalgia, or - speaking psychiatrically - Pain Disorder, arose directly out of the accident of 1983.

1. Dr Knox agreed with Dr Corry that the applicant had a chronic pain condition arising from psychological factors. Such a disorder is identified in DSM-IV as: 'Pain Disorder associated with both psychological factors and a general medical condition'. The tribunal believes that the criteria for this disorder fit Mrs Lovrinovic's condition quite accurately.
2. Ms Cursley, physiotherapist, also responded to Dr Rosendahl's request on 17 August 1994 (T85). She noted that Mrs Lovrinovic 'suffered whiplash injury to the cervical area at the time of the original accident. This may well have led to the development of myofascial trigger points ... probably indicat(ing) that she is now suffering from fibromyalgia.'
3. Dr Brook, consultant rheumatologist, also responded to Dr Rosendahl's request on 4 October 1994 (T86). Rather unhelpfully, he concluded a 'diagnosis of regional pain syndrome. From the history it sounds as though this has complicated a neck injury in an accident in 1983.'
4. Dr McGill, consultant rheumatologist, examined the applicant for Comcare, reporting on 10 October 1996 (T99). He noted 'There is no abnormal physical condition. ... That constellation of symptoms and signs, in the absence of physical disease, is labelled fibromyalgia'; 'I do not believe that her current symptoms are related to her previous employment'; 'I think her fibromyalgic symptoms would probably have been the same whether or not she had previously worked as a cleaner with CCAE'. Later, in a further report to Comcare on 3 March 1998 (Exhibit 1), Dr McGill confirmed his opinion that the suggestion that 'the minor physical insult in May 1983 led to her widespread symptoms and feelings of depression in subsequent years is implausible.' (During his oral evidence to the tribunal, Dr McGill agreed that, if there were no symptoms in any area before the injury, then the etiology he described would be atypical.)
5. Dr White, consultant neurologist, examined the applicant at the request of her solicitors and reported on 17 January 1997 (T103). He provided a useful summary of Mrs Lovrinovic's history as follows:

history of pain following a moderate blow to the head;

Her pain has continued to become worse despite cessation of work;

has developed a regional pain syndrome with subsequent development of a symptom complex consistent with a diagnosis of fibromyalgia syndrome;

1. In response to a specific question concerning causal relationship, Dr White opined 'There appears to be a temporal relationship between her injury and subsequent development of pain. This appears to be more than coincidence although it is difficult to prove the causal relationship.' Subsequently, in a further report to the applicant's solicitors dated 10 July 1998 (Exhibit A), Dr White confirmed his opinion that 'there is a direct connection with her work. I do not see how it can be discounted given the fact that she had always previously been active and that her deterioration clearly associates in time and place with the work injury.'
2. Dr Champion, rheumatologist, examined Mrs Lovrinovic on 7 March 1997 and reported to her solicitors on 23 June 1997 (T107). He is the only specialist who offered a medical explanation of a minor trauma leading to a chronic widespread pain syndrome. His explanation has apparently received relatively recent recognition by the medical fraternity and is obviously not yet widely accepted. Nevertheless, it appears to closely parallel that of Dr Knox (and Dr Corry), differing only in the emphasis on the neurological role rather than a psychological one. The history recorded by Dr Champion was the usual (by that stage) generalised one with several errors of detail, none of which however detracted from his subsequent analysis. He did record, in passing, a significant comment by Mrs Lovrinovic that she attributed her worsening condition to her belief that she 'damaged her head'. (This probably reflects a comment purportedly made by Dr Gavranic when Mrs Lovrinovic first consulted him after the accident, intimating that she had injured a very important part of her head, which injury could have been very serious. The same concern was apparently expressed to Dr Snowdon by Mrs Lovrinovic, which could indicate a significant psychological trigger in her mind.) Dr Champion reported that his examination had identified features 'characteristic of secondary allodynia (implying central sensitisation of nociception).' He opined that 'The chronic pain state has no doubt been importantly contributed (to) by psycho-social factors.' He then concludes:

It is likely that that direct blow caused a primary sensitisation of nociception in the occipito-parietal region of her skull and in her cervical spine. The eventual spread of pain to the shoulders and arms, and to her back and legs, appears to have been the result of the apparent central sensitisation of nociception and influenced by psycho-social factors which may operate through reduced effectiveness of descending pain modulation systems

Dr Champion then debunks the fibromyalgia syndrome label, stating that 'It has no meaningful information content.' He goes on to state that:

The increasing evidence is that some individuals are particularly susceptible to central sensitisation of nociception after injury, leading to widespread chronic pain state. There is a variable contribution from psychogenic mechanisms to this chronic pain state. Some would argue that it is mainly psychogenic (as does Dr McGill) while others, including myself, note the significance of the secondary allodynia and emphasise to a great extent the neuro-physiological mechanisms.

He quotes 'a recent study' that indicates that 'injuries to the cervical spine in particular are especially liable to provoke these kinds of chronic pain disorders.' Dr Champion finally concludes:

In summary, Mrs Lovrinovic has unfortunately sustained a chronic pain state with important psychosocial consequences precipitated by, and largely caused by, an injury at work in May 1983. If there was no such injury I very much doubt that she would have gone on to a chronic pain state such as has occurred during the last 14 years.

1. Dr Snowdon, consultant psychiatrist, examined the applicant on 2 July 1998 and reported to the respondent's solicitors on 10 August 1998 (Exhibit 3). His lengthy recorded history reflected the generalised account which had become well established in Mrs Lovrinovic's mind but necessarily also reflected the omissions and inaccuracies of detail seen in earlier histories. Dr Snowdon's report also focused on some family, domestic and cultural aspects which, at the least, suggested some possible psychological triggers for aversity to work; and from which Dr Snowdon inferred early signs of psychosomatic pain, depression and anxiety. In reviewing Mrs Lovrinovic's psychological history, Dr Snowdon disagrees with the applicability of the fibromyalgia diagnosis in her case and, indeed, with the utility of such a diagnosis anyway. He observes that 'The fact is that this lady, even in 1994, essentially had unexplained pain with accompanying depression.' (Moreover, on his own analysis, Dr Snowdon might have taken that date much further back to the early 1980s or even 1978 in respect of lower abdominal pain. Indeed, in his oral evidence to the tribunal he did just that.) In making a diagnosis, Dr Snowdon stated 'Her neck pain is extremely bizarre and quite unexplainable in physical terms.' He then concludes:

It would appear almost certain that this lady's neck pain is not of physical origin and is not, I feel, even an exaggeration of a physically-originated pain. It is quite common for there to be, especially on the background of depression, an exaggeration of pain through increased muscle tension, especially in the region of the neck. In Mrs Lovrinovic's case, however, I feel that the pain is almost entirely conversion in origin; that is, originating entirely in psychological factors.

Dr Snowdon then goes on to conclude that 'Mrs Lovrinovic is susceptible to developing a pain disorder in the absence of significant physical origin.' In discussing causation, Dr Snowdon suggests that the injury of 13 May 1983 was a psychological, rather than physical, trigger for her 'susceptibil(ity) to developing chronic pain' precipitating the presented pain picture; adding that 'this lady's continuing pain is due to psychological, domestic and cultural factors', not from any 'originat(ing) physical condition'. He then summarises his conclusion concerning causation, stating:

I do not feel, on the balance of probabilities, that this lady's condition is due to her employment, and any continuing aggravating factors are also unrelated to employment.

1. It is apparent that the various opinions on causation can be divided into three groups for simplification. Firstly the two general practitioners and the neurosurgeon who treated and reported on Mrs Lovrinovic following her injury in 1983 (Drs Gavranic, Cochrane and Newcombe) linked the reported neck and shoulder pain and headaches with the injury. Indeed, it would be virtually impossible for the tribunal to ignore the evidence of that reported pain never being complained of before the injury, and being complained of consistently and continually following the injury at least until 17 November 1983, (to Dr Gavranic). Similarly, the five CMOs were never really concerned with causation, simply accepting the applicant's recounted history, and assessing current fitness for employment. As well, Drs Adam and Rosendahl merely continued to treat their patient following Dr Cochrane's example; and Dr Cassar, Dr Brook and Ms Cursley simply accepted the history as referred.
2. The second group is made up of those who specifically commented on causation and accepted as at least a reasonable probability a direct link with the 1983 injury. This group includes Drs Corry, Knox, White and Champion. They all acknowledge a temporal and locational link between the injury and the subsequent chronic pain, and recognise the absence of such specific pain prior to the injury. Drs Corry and White accept the fibromyalgia label as adequately descriptive of the patient's pain; while Dr Knox, emphasising the psychological element, identifies the disease as a DSM-IV one - Pain Disorder; and Dr Champion prefers a neurological explanation with psycho-social elements. All see the same symptoms and causal factors; and all acknowledge the work injury of 1983 as the triggering factor.
3. The third group includes Drs Andrews, Chase, McGill, Snowdon and Mr Petroni. As commented above, the tribunal discounts Dr Andrews' opinion of 20 March 1998 because it is inconsistent with his own observations in 1986 when he accepted that Mrs Lovrinovic was still experiencing pain associated with her injury after 2 1/2 years, although he did express concern that she may have been exaggerating 'the extent of her disabilities'. Mr Petroni, clinical psychologist, simply had difficulty relating an apparently minor injury nearly four years previously with the presented symptoms. However, as commented in passing by Dr Champion, 'perhaps that was not entirely his role' (T107). Obviously Drs Chase and McGill shared the same scepticism as Dr Petroni, neither accepting the plausibility of a link between the minor injury and the subsequent chronic general pain, nor offering any alternative explanation for the sequence of events. The nearest Dr Chase (an occupational health physician) came to an explanation was 'It is probable that her pains are a result of the normal body ageing, and she has incorporated illness behaviour into her daily life for other secondary gains ... Her disability has no physical basis.' Similarly Dr McGill recognised the 'constellation of symptoms and signs' as 'fibromyalgia', but found 'no underlying physical condition'. He concluded that 'her fibromyalgic symptoms would probably have been the same at this stage whether or not she had previously worked as a cleaner with the CCAE' (T99). Unfortunately, this hypothesis ignores the reality of the temporal link with the subsequent pain, as remarked on by Dr Knox. Finally, Dr Snowdon, appears to be at the extremity of this group, diagnosing a 'conversion' disorder, with the neck pain being 'too bizarre for it to originate in any physical condition'. Indeed, in his oral evidence, he seemed to take the 'conversion disorder' back to a time before the injury of May 1983, although the tribunal has difficulty with that proposition because of the historical absence of neck pain prior to the injury. However, it is interesting to note that, in his oral evidence, Dr Snowdon appeared to back away from this 'extreme' position and move to a position closely resembling that of Dr Knox, (a fellow consultant psychiatrist), wherein Dr Snowdon conceded that a minor injury could lead to an exaggerated response if there was present a psychological predisposition to the development of chronic pain.
4. It is apparent that the diagnoses are largely only descriptive of the symptoms, without offering any explanation of cause or etiology. Most doctors are content with 'fibromyalgia' (or variations thereof), without really addressing the cause. Dr Andrews rejects the fibromyalgia label because of the absence of some features of the syndrome, but offers no real alternative. Dr Knox views the case as principally a psychological one with, however, an element of medical condition. He gives the case a specific DSM-IV label. Dr Snowdon goes further, denying any medical condition and opting instead for a 'conversion disorder' 'originating entirely in psychological factors'. Finally, only Dr Champion sees an organic neurological problem which he describes as 'central sensitisation of nociception after injury and influenced by psycho-social factors'. In short, all doctors agree that a chronic widespread pain syndrome is present, induced principally - or at least influenced - by non-organic psychological factors. Only Dr Champion sees a neurological explanation for the pain causation; which view, however, is not inconsistent with the likely influence of psychological factors on the patient's susceptibility to a chronic pain state.
5. From all the foregoing it is clear that there is substantial medical agreement that Mrs Lovrinovic suffers a fibromyalgic-type constellation of symptoms which have no underlying organic basis. Further, it seems agreed that, whatever the etiology, Mrs Lovrinovic's pain condition is largely a result of psycho-social factors. It is also clear that there is no adequate, widely accepted explanation of the mechanism by which psychological factors can reflect in chronic pain; nor even how a physical trauma can lead to such pain. Yet such cases are apparently relatively common. In short, the medical world does not yet understand this problem. There are obviously many doctors who, in the absence of a demonstrable explanation, remain sceptical that a minor injury could lead to a major pain syndrome. Nevertheless, there are those who see these cases frequently and accept their reality without having a good understanding of the physical and psychological factors at work.

1. Faced with such professional divergence of opinion and ambiguity, the tribunal must be satisfied that a medical hypothesis raised in the applicant's favour linking the applicant's current condition with the 1983 incident at work is one which is accepted by a body of well-regarded medical specialists. That is clearly the case here. Being satisfied that there is medical acceptance that the applicant's current condition could be so linked to the 1983 incident, for the applicant's condition to be compensable, the tribunal must then be satisfied that in the light of all the facts, matters and circumstances of the applicant's case, it is more likely than not that the 1983 work incident contributed in a material degree to her current condition and incapacity. We do so find.
2. The evidence supports the finding that Mrs Lovrinovic is susceptible to the development of chronic psychologically-based pain, given her long history of concern with non-organic pains, multiple negative tests, operations which don't resolve the complaints, and worsening state of incapacity and depression. She had no neck complaints prior to 1983. She was working uneventfully despite her other medical complaints until that time, and for a while thereafter. There is no doubt that she suffered the injury in 1983 and complained consistently and continually of its effects for at least six months.
3. A matter of concern to the tribunal, one noted by Dr Chase (T67), and referred to during the hearing, is the absence of complaint to doctors or other health supporters by the applicant concerning neck or shoulder pain and associated headaches for a period of almost two years between 17 November 1983 and 12 September 1985. During this period the documents before the tribunal indicate that Mrs Lovrinovic visited her general practitioner, Dr Cochrane, only once on 25 February 1985 complaining of chest pain, with no reference to any injury related pain (Exhibit 5). When questioned on this matter, Mrs Lovrinovic explained that she simply accepted the pain and continued working until the pain became so bad (in September 1985) that she returned to Dr Gavranic and filed a second application for compensation based on 'aggravation at work of the original injury'. This is confirmed by Dr Gavranic's acceptance at that time that Mrs Lovrinovic's neck pain was a chronic and recurring problem (T5, p.7).
4. In the absence of any further evidence, the tribunal accepts the applicant's evidence that the pain continued throughout that time, gradually becoming worse. We conclude, therefore, that while she was able to cope with the increasing level of pain, she continued working without complaint until the pain became so bad that she could no longer work with it. She describes this deterioration over time as 'an aggravation'. The tribunal accepts that the pain condition from the original 1983 injury persisted throughout 1984 and 1985, and that the applicant's work aggravated that condition at least until she went off work for a substantial period in September 1985. If it is accepted that the original injury and its aggravation either triggered a neurophsyiological process of pain reception (as per Dr Champion) or simply triggered a psychological pain response (as per Drs Knox, Corry and White), then a lapse in seeking further medical help while continuing to work would not seem to detract from the likelihood of its original causality being work-related.
5. The tribunal is unable to say for how long the work-caused aggravation to her 1983 injury lasted, and at what point psycho-social factors played a part in the development of the fibromyalgic symptoms. It is clear, however, that well before the respondent's decision to cease liability for her injury in 1996 the applicant had developed a constellation of symptoms commonly referred to as fibromyalgia. Noting a significant psychological element in the development of her current chronic pain state, we accept that the original injury and the work-caused aggravation triggered this condition, and that it developed into a DSM-IV pain disorder.
6. The applicant's complaints of pain have been generally accepted as genuine. The respondent raised the issue of credit only in relation to some specific assertions by the applicant; in particular, the fact she travelled overseas in 1986-7 to see her ill mother while claiming that she was unfit for work. As to this, the tribunal notes that she was certified unfit for work by Dr Cochrane throughout this period from before her departure overseas until some 6 months after her return. When she returned to work she was certified fit for light duties only.
7. The final consideration then which supports the tribunal's finding is the fact of temporal and locational link between the injury and the onset of neck and shoulder pain and headaches. The tribunal noted that Mrs Lovrinovic had a long and complex history of lumbar pain which pre-dated the injury. We therefore discount the continuing post-injury lumbar pain from the causal chain. However, the absence of a pre-injury history of neck pain, and the presence of a continuous post-injury history of such pain - albeit with a period in 1984-5 without formal complaint other than the applicant's own evidence - convinces the tribunal that the probability of causal link - either neurological or psychological - is reasonable. To find otherwise is made more difficult when no convincing alternative explanation for the applicant's condition has been provided by those medical specialists who expressed scepticism about the causal link.

1. The tribunal heard little by way of oral evidence about the applicant's treatment needs. In 1994 Dr Rosendahl reported that the applicant's level of function had deteriorated appreciably since she ceased her massage. He considered that the massage was of significant value and it was thus 'therapeutic' and 'curative' (T87). His opinion that it is curative, is against the weight of the medical evidence.
2. The respondent's counsel drew our attention to Dr Brooks' comments to Dr Rosendahl of 4 October 1994 where he said (Exhibit 5):

I know of no treatment which makes any difference to this condition (RPS). One can only offer symptomatic treatment and in this respect massage is I believe to be the most efficacious. However, massage does not alter the prognosis and it must be said that the massage is purely for comfort. There is no prospect that it will return her to work.

Dr Knox noted in his report of 9 August 1994 (T83) that various treatments over the years have not been especially helpful.

1. Taking the whole of the evidence into account, it seems clear to us that the treatment recommended by Dr Rosendahl is merely for the applicant's comfort, and that it will not alter her long-term prognosis. Although continuing massage and chiropractic treatment will not return the applicant to work, is it reasonable treatment for the purposes of section 16 of the Act? Subsection 16(1) of the Act provides:

16.(1) Where an employee suffers an injury, Comcare is liable to pay, in respect of the cost of medical treatment obtained in relation to the injury (being treatment that it was reasonable for the employee to obtain in the circumstances), compensation of such amount as Comcare determines is appropriate to that medical treatment.

At section 4, the Act defines the term "medical treatment". The Act provides that:

(b) therapeutic treatment obtained at the direction of a legally qualified medical practitioner;

(d) therapeutic treatment by, or under the supervision of, a physiotherapist, osteopath, masseur or chiropractor registered under the law of a State or Territory providing for the registration of physiotherapists, osteopaths, masseurs or chiropractors, as the case may be;

"therapeutic treatment" includes an examination, test or analysis done for the purpose of diagnosing, or treatment given for the purpose of alleviating, an injury.

In Comcare v Watson (1997) 22 AAR 516 at 519_,_ Justice Finn noted that Comcare submitted that treatment:

can only be 'therapeutic' if its object is to cure a disease or injury.

Though some dictionary definitions do emphasise the 'healing or curative' connotation of the words 'therapy and therapeutic', the latters' use in this context encompasses the alleviation of the pain of an injury. This view is consistent with the section 4 definition of 'therapeutic treatment' which includes 'treatment given for the purpose of alleviating an injury.'

Justice Finn therefore found that treatment designed to alleviate, or aimed at alleviating pain arising from an injury or a disease is properly to be regarded as therapeutic treatment.

1. It is our task to objectively assess whether therapeutic massage and chiropractic treatment is reasonable given the nature of the applicant's injury for the purposes of section 16(1). In Re Jorgensen and Commonwealth (1990) 23 ALD 321 at 325, Justice Gray considered the question of reasonable medical treatment in relation to invitro fertilisation treatment. His Honour stated:

The idea of reasonableness involves objectivity. A reference to the circumstances raises subjective factors, but they are intended to be subjective factors related to the nature of the injury, and not to details of the personal life of an applicant for compensation.

Deputy President Forrest in Tiranti-Valenti and Comcare (1996) 45 ALD 478 at 480 also noted that "[t]he reasonableness of the treatment is a matter of judgment to be assessed by reference to the relevant circumstances".

1. The applicant's evidence is that following her retirement, she was in receipt of massage and chiropractic treatment. Her evidence is that she attended massage twice a week; however, following the cessation of compensation payments, she has not attended massage therapy because of financial limitations. She, however, continues to receive chiropractic care.
2. The applicant does not suggest that her proposed treatment programme alleviates her pain. It provides some relief for short periods. Dr Rosendahl in recommending that the applicant have massage therapy twice a week, notes that "massage therapy is associated with the cessation of symptoms for 48 hours or more..." (Exhibit 5). We note that Dr Cassar in his treatment recommendations dated 24 October 1996 did not recommend massage therapy as treatment for the applicant's ailment (Exhibit 5).
3. In recommending that the applicant have chiropractic care every 2 to 6 weeks Dr Rosendahl states that it has proved to be of substantial benefit (Exhibit 5). On the other hand, Dr McGill said 'the benefit she receives is likely to be via psychological support rather than any physical aspect of the massage treatment' (T99), and that 'further therapy along physical lines is likely to be counter productive by reinforcing an inappropriate sick role' (Exhibit 1).
4. Given that the applicant's pain condition is psychologically rather than physiologically produced, we agree with Dr McGill's opinion that physical therapy is inappropriate. The treatment produces temporary relief from pain with no curative effect. We also bear in mind the evidence that counselling or pain management education are likely to be ineffective (Dr Snowdon, 10 August 1998, Exhibit 3). Drs Snowdon, McGill (3 March 1998, Exhibit 1) and White (21 July 1998, Exhibit A) all suggest anti-depressant therapy is a reasonable treatment option at this stage. We accept this view.
5. Therefore, taking the nature of the applicant's injury and the whole of her circumstances into account, we do not consider that therapeutic massage and chiropractic treatment is reasonable medical treatment for the applicant to have obtained for the purposes of section 16 of the Act.

1. The tribunal sets aside the decision under review and in substitution therefor decides that:

(a) the applicant suffered an injury at work on 13 May 1983, and aggravation of that injury as a result of work during 1984 and 1985. As a consequence of the injury and aggravation she developed a chronic pain syndrome amounting to a DSM- IV pain disorder. The applicant continues to suffer a compensable condition and remains incapacitated for any work;

(b) the applicant is entitled to compensation by way of medical treatment expenses, other than massage and chiropractic treatment expenses, and to incapacity payments pursuant to sections 16 and 19 of the Act from 9 January 1997;

(c) the respondent is to pay the applicant's reasonable costs of the proceeding as a greed or taxed.

I certify that this and the 28 preceding pages are a true copy of the decision and reasons for decision herein of Senior Member Burton, and Air Marshal I B Gration, AO AFC, Member

Signed: Diane Popple.................................................