(a) this Certificate of Determination and Statement of Reasons;

(b) Application to Resolve a Dispute and attachments;

(c) Reply and attachments, and

(d) applicant's Application to Admit Late Documents and attachments dated

24 April 2025.

A brief statement is attached setting out the Commission's reasons for the determination.

1. Brenda Millard (the applicant) suffered an accepted injury in the nature of carpal tunnel syndrome to her right arm, with a deemed date of injury of 20 February 2019.
2. As a result of that injury, the applicant underwent carpal tunnel release in March 2019. Shortly after this procedure, the applicant claims she developed symptoms consistent with and diagnosed as a Complex Regional Pain Syndrome (CRPS) attributable to her injury. She seeks payment of permanent injury compensation in relation to her right upper limb injury, including the alleged CRPS.
3. The respondent denies liability in relation to the CRPS, alleging the applicant's condition does not meet the criteria for such an injury, and if it does, the applicant's independent medical examiner (IME) has failed to assess the CRPS in accordance with the SIRA Guidelines, and accordingly there is no medical dispute arising from a valid claim for permanent impairment.

1. The parties agree that the following issues remain in dispute:

(a) whether the applicant suffered CRPS, and

(b) if so, whether the claim for permanent impairment compensation in relation to the CRPS has been validly made.

PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION

1. I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.
2. The parties attended a hearing before me on 2 May 2025. At the hearing, the applicant was represented by Mr Morgan of counsel instructed by Ms Pearce. The respondent was represented by Mr Stiles of counsel instructed by Ms Palamara.

1. The following documents were in evidence before the Personal Injury Commission (Commission) and considered in making this determination:

(a) Application to Resolve a Dispute (the Application) and attachments;

(b) Reply and attachments, and

(c) applicant's Application to Lodge Additional Documents (ALAD) and attachments dated 24 April 2025.

1. There was no oral evidence called at the hearing.

Whether the applicant suffered complex regional pain syndrome (CRPS)

1. After sustaining the accepted carpal tunnel injury, the applicant underwent release surgery at the hands of Dr Baba in approximately May 2019.
2. Following her return to work from this procedure, the applicant began to notice pins and needles persisting and worsening. She was referred to pain specialist Dr Nazha, who diagnosed CRPS.
3. The applicant's claim in relation to CRPS was initially accepted, and she returned to work 15 hours per week for some time. After undergoing a number of tests at the hands of Dr Nazha, including as an inpatient at hospital, Dr Nazha recommended the insertion of a pain stimulator, which the applicant underwent.
4. In her initial statement, the applicant described receiving only mixed relief from the pain stimulator.
5. The applicant made a permanent impairment claim on 16 January 2024 arising out of the diagnosis of CRPS, based upon the views of her Independent Medical Examiner (IME) A/Prof Hope.
6. By dispute notice dated 24 May 2024, the CRPS condition was denied. In denying the presence of the CRPS, the respondent relied on the opinion of its IME, Dr Smith, who opined there were no signs of trophic changes in the applicant's right hand or any sign of CRPS in the right upper limb. Dr Smith reported the applicant's symptoms likely emanate from her cervical spine, and to the extent she had symptoms arising from carpal tunnel syndrome, they had resolved following the release procedure undertaken by Dr Baba.
7. The applicant's treating pain specialist, Dr Nazha has diagnosed her as suffering from CRPS. Dr Nazha has provided no fewer than 29 reports variously to the applicant's general practitioner (GP), to Dr Baba, to the respondent's insurer and to the applicant's solicitors. Those reports span a period from January 2020 to December 2024.
8. In his first report to Dr Baba dated 14 January 2020, Dr Nazha opined the applicant's condition was as follows:

"Brenda does present with almost certain neuropathic pain with features of CRPS. Thankfully, she does not show a full blown CRPS picture and is rather on the mild spectrum. I do not have the results of the nerve conduction studies present. However, she states her nerve conduction studies were consistent with median nerve entrapment. However, her nerve conduction studies appear to show the left hand being more severe which is less symptomatic than the right."

1. In a report to the applicant's GP dated 8 May 2020, Dr Nazha,

"advised [the applicant] that it is early days and to do her best to engage in the CRPS management strategy. It is imperative now that she avoids passive physiotherapy that she was engaging in before and it was not resulting in any significant benefit and could possibly have been harming her."

1. At this point, Dr Nazha noted the applicant had been approved for a trial of percutaneous electrical nerve stimulation therapy.
2. By August 2020, the applicant was consulting a complex pain psychologist and had received her initial assessment. Dr Nazha indicated the applicant would benefit from the implantation of a peripheral nerve stimulator. However, she was reluctant to have the procedure.
3. On 20 October 2020, Dr Nazha again provided a report to the applicant's GP. The applicant had not heard from the insurer as to whether the proposed treatment for CRPS had been approved.
4. By 12 November 2020, the applicant was presenting to Dr Jane Standen for pain management strategies for CRPS of the right upper limb. Dr Standen noted the applicant had a number of treatments trialled for CRPS, which was a provisional diagnosis.
5. Dr Standen described the applicant as having increasing pain and disability associated with CRPS of the right hand. Dr Standen recommended active rehabilitation and engagement with a physiotherapist with expertise in the management of CRPS. She stated the applicant should also consider inpatient admission of low dose ketamine infusions together with hand physiotherapy, the possible implantation of a peripheral nerve stimulator to better manage neuropathic pain and also consider the trial of medicinal cannabis.
6. On 9 June 2021, Dr Nazha reported to the applicant's GP that the respondent's insurer had declined a request for a trial of the peripheral nerve stimulator and accordingly the applicant's CRPS and secondary deconditioning had widened. According to Dr Nazha:

"It is unacceptable that Brenda has been put into this position whereby she has been denied treatment that is appropriate to treat her condition. Previously, we have endeavoured to utilise a technology that was far more suited to her pain being relatively more localised with less invasive therapy via utilising the micro stimulator. Unfortunately, due to the insurer not providing approval for a treatment that is reasonable and necessary [sic], she has therefore seen significant deterioration in her clinical state. Her deterioration can be directly attributable to the insurer denying this request."

1. By September 2021, the applicant had a trial spinal cord stimulator inserted and had noted some benefit from it. At this time, Dr Nazha sought approval from the respondent to proceed with implantation of a permanent stimulator. By December 2021, approval for the permanent spinal cord stimulator had been obtained. The applicant described her pain had reduced in severity by approximately 70% during the trial, and it was the best she had felt in two years, with increased range of motion in her hand and fingers together with improved sleep and an ability to engage in domestic duties which she had not been able to do when her condition was at its worst.
2. The applicant underwent insertion of the spinal cord stimulator in approximately February 2022. On 29 March 2022, Dr Nazha reported to the applicant's GP that the applicant was healing well after the insertion of the device, which she was using properly and with which she was not having any issues.
3. In a report to the applicant's GP on 4 May 2022, Dr Nazha noted the applicant had been having issues with persistent nausea, headache and with her bowel movement. The applicant stated that when her stimulator was switched off, her nausea, headaches and bowel issues dramatically resolved. Accordingly, she was provided with a new programme by the cord stimulator technician with a lower energy burden.
4. After a further follow-up on 31 May 2022, Dr Nazha recommended further fine tuning of the device. Dr Nazha recommended repositioning of the stimulator battery. That procedure was approved in or about August 2022. Following this repositioning, Dr Nazha reported by February 2023 the applicant was not having significant relief, though her pain had changed somewhat in nature.
5. On 9 February 2023, Dr Nazha provided a report to the respondent. In that report, Dr Nazha confirmed the diagnosis of CRPS as a result of the applicant's work injury.
6. Dr Nazha continued to provide regular reports following consultations with the applicant throughout 2023 and 2024. In his report to the applicant's solicitors dated

"The development of Complex Regional Pain Syndrome (CRPS) following surgical intervention, such as carpal tunnel release, is a well-documented phenomenon. CRPS is a multifactorial condition often precipitated by trauma, surgery or nerve injury. Brenda's CRPS symptoms are medically attributable to her carpal tunnel release for the following reasons:

• Temporal relationship: Brenda's CRPS symptoms began approximately six weeks after her carpal tunnel release in March 2019. Initially, she experienced significant symptom improvement post-surgery. However, she subsequently developed hallmark features of CRPS, including dysesthesia, vasomotor changes, pseudo motor abnormalities and pain that extended beyond the typical distribution of the median nerve. The timing strongly suggests a causal link between the surgery and the onset of her condition.
• Surgical trauma as a trigger: Surgical interventions, particularly in anatomically sensitive areas such as the carpal tunnel, can sensitise the central and peripheral nervous systems, resulting in a cascade of pathological changes characteristic of CRPS. The nature of Brenda's surgical history, coupled with the persistence and escalation of her symptoms post-surgery, supports this mechanism.
• Symptoms consistent with CRPS: Brenda's clinical presentation, including burning pain, autonomic changes (temperature and colour variations), trophic changes (brittle nails, absence of hair growth) and motor dysfunction (partial fist like contracture of the fingers) aligns with the Budapest diagnostic criteria for CRPS. These symptoms emerged following her carpal tunnel release, directly linking the two events.
• Exclusion of other causes: No other identifiable traumatic or pathological events between the surgery and the onset of symptoms can explain the development of her CRPS. Therefore, it is reasonable to conclude that the surgical intervention acted as the precipitating factor."

1. When specifically asked, Dr Nazha opined the applicant's CRPS had developed consequentially and directly as a result of her work-related injury and subsequent carpal tunnel release. He provided detailed reasons as to why this was the case. Dr Nazha concluded the applicant's CRPS was directly attributable to her work-related carpal tunnel syndrome and the subsequent release surgery.
2. For the respondent, IME Dr Smith opined the applicant's condition was more likely caused by degenerative disease in her cervical spine which had not been treated. In his report dated

22 March 2024, Dr Smith stated there was no evidence of CRPS. Dr Smith stated that having seen the applicant twice, he had not seen "any objective evidence of her having CRPS".

Dr Smith stated there was no relationship between the applicant's employment and her carpal tunnel syndrome (a somewhat bold conclusion given the respondent had long accepted liability for it). 3. In his report dated 18 April 2023, Dr Smith was of the view the applicant was embellishing her symptoms, without providing detailed or compelling reasons as to why this is the case. In the face of a four year course of treatment by a pain specialist and associated pain management team, including an appropriately qualified psychologist, it is extremely difficult to accept this conclusion. 4. For the respondent, Mr Stiles submitted on balance the applicant had not established the presence of CRPS, and in any event even if such a condition was present, a claim had not been properly made because of the manner in which her IME, A/Prof Hope had categorised her condition by reference to the tables in the relevant impairment guidelines to which he had referred. 5. Mr Morgan noted this denial of liability was not raised by the respondent in its dispute notice. However, he nevertheless dealt with the substance of it at the hearing. On balance, I propose to address the issue substantively. 6. Mr Stiles relied on the requirement in the WorkCover Guidelines to establish CRPS. He noted the examining doctor must include a finding that the applicant had reached maximum medical improvement and that the part of the body being assessed must be dealt with in line with the guidelines. 7. The respondent submitted A/Prof Hope had not assessed the applicant in accordance with the appropriate guidelines. Mr Stiles submitted A/Prof Hope had failed to make reference to the diagnostic criteria found at 17.1 of the Guidelines. Rather, Mr Stiles noted A/Prof Hope had assessed in accordance with AMA 5, rather than the guidelines themselves which require an examiner to set out whether the applicant's CRPS falls within Type 1 or Type 2. 8. Mr Stiles criticised A/Prof Hope for not dealing with the criteria, particularly points two and three and therefore submitted there was no relevant diagnosis to support either a finding of CRPS or any whole person impairment arising from it. 9. This being so, Mr Stiles submitted there was in fact no medical dispute referable to a Medical Assessor. 10. Mr Stiles made similar criticism of the reports of Dr Nazha. However, it should be noted he is a treating doctor and was not providing an assessment for the purposes of whole person impairment under the worker's compensation system. 11. In reply, Mr Morgan noted the requirement under the Guidelines are that the claim must be made "in line with" the Guidelines, meaning they must be consistent with or have regard to the relevant paragraphs, but it was not necessary to refer to specific parts of them. 12. Mr Morgan noted that an examination of the relevant aspects of AMA5 and paragraph 17.1 of the Guidelines reveals an identical recitation of the various indicia for CRPS. He submitted Dr Nazha and his report to the applicant solicitors essentially recited the terms of table 17.1 and found the applicant satisfied the requirements of it. Mr Morgan submitted nothing turned on this question and again noted the s 78 notice indicated there was no CRPS but did not deny a valid claim for it having been made. 13. On balance, I am satisfied A/Prof Hope has dealt with the relevant diagnostic criteria for CRPS found at page 17.1 of the relevant guides, as has Dr Nazha, on whom the applcaint also relies to establish the presence of the condition. 14. Having found CRPS, A/Prof Hope in my view then applied the relevant assessment of the right upper extremity in accordance with the appropriate Guidelines. Mr Morgan submitted, and I accept, that once there were findings consistent with the criteria to establish CRPS, it is necessary to refer back to the relevant chapter of the Guidelines in order to assess whole person impairment, and this was the process A/Prof Hope had undertaken. 15. I find in favour with this submission. As noted, the respondent took no issue with the applicant having made a valid claim until these proceedings. Nevertheless, Mr Morgan dealt with the substance of that argument, and in my view defeated it. 16. I also accept A/Prof Hope's rebuttal of Dr Smith's opinion as being at odds with the facts. The applicant's right upper limb was symptom free until she developed carpal tunnel syndrome. The right upper limb surgery to release that carpal tunnel syndrome was work related and CRPS developed thereafter. I accept A/Prof Hope's finding that there is no cervical pathology in play. 17. In my view, the balance of the medical evidence in this matter is overwhelming. Dr Nazha has provided many reports over nearly half a decade of treating the applicant. His diagnosis has been consistent, and in my view is supported by the applicant having received some benefit from the chord stimulator being inserted to ease irrelevant and neuropathic symptoms. One would expect that if the seat of her problems was the cervical spine, she would not have received benefit from the cord stimulator being placed to treat her right upper extremity symptoms. 18. As a treating specialist, Dr Nazha's opinion is entitled to considerable weight, unless it can be shown it contains an error sufficient to render it unpersuasive, or an incorrect history is provided. Neither is the case here. Rather, Dr Nazha's reports provide a continuous and thorough recitation of the applicant's symptoms over many years, along with a consistent diagnosis of CRPS. I accept his evidence as extremely persuasive. 19. Dr Smith's opinion stands alone. He makes reference to the applicant's symptoms as being consistent with cervical spine pathology and goes so far as to state that any such pathology would not be work related as it would be degenerative in nature. He does so without reference to any radiological investigation or by providing a factual basis for this opinion. In my view, his opinion does not stand up against the weight of the treating and IME evidence put forward by the applicant. 20. I am comfortably satisfied in the balance of probabilities the applicant has discharged the onus of proving that she suffers from CRPS, and that this condition is as a consequence of her accepted work-related injury. 21. As such, the applicant's right upper extremity, including the CRPS, will be the subject of a referral to a Medical Assessor to determine her degree of whole person impairment.

1. For the above reasons, the Commission will make the findings and orders set out on page one of the Certificate of Determination