MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; review of medical assessment of single Medical Assessor; whether injuries caused by the motor accident give rise to a whole person impairment (WPI) that is greater than 10%; physical injuries from motor accident; mild traumatic brain injury, along with injuries to the cervical spine, lumbar spine, and right shoulder; injuries to left shoulder, hands, left foot, and toes determined to not be caused by the motor accident; no evidence of cognitive impairment was detected; WPI assessment of 0% for brain injury in accordance with clinical dementia rating (CDR); inconsistency in shoulder movements; Held - total 2% WPI; certificate of medical assessor revoked.

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

1. revokes the certificate of Medical Assessor Ian Cameron dated 25 January 2025;
2. certifies the following injuries caused by the motor accident give rise to a permanent impairment of 2% which is not greater than 10%:
   • Head- mild traumatic brain injury, small microhaemorrhage of left temporal lobe
   • Cervical spine - soft tissue injury
   • Lumbar spine - soft tissue injury
   • Right shoulder - soft tissue injury, aggravation of pre-existing injury, and

1. certifies the following injuries WERE NOT caused by the motor accident:
   • Left shoulder injury
   • Injury to both hands - sensory change in the fingers (numbness and tingling in the left and right hand involving the middle, ring, and little fingers); weakness in the muscles of the hands, weakness and stiffness in both arms.
   • Left Foot - sensory changes in left foot.

1. Ms Mary Roxanas, (the claimant) is a 48-year-old female who suffered injury on

2 May 2020 as a result of a motor vehicle accident. 2. A claim was lodged upon Insurance Australia Limited t/as NRMA Insurance (the insurer) who is the insurer of the vehicle considered to be at fault. The insurer has a liability to pay statutory benefits and/or damages under the Motor Accident Injuries Act 2017 (MAI Act). 3. The issue in dispute between the parties is whether the "degree of permanent impairment as a result of the injury caused by the motor accident is greater than 10%."[1] 4. This is a review of a medical assessment pursuant to s 7.26 of the MAI Act. The medical assessment the subject of this review was conducted by Medical Assessor Ian Cameron. He issued a certificate dated 25 January 2025. The Medical Assessor certified that injuries caused by the motor accident: * Head injury - mild traumatic brain * Cervical spine - soft tissue injury * Lumbar spine - soft tissue injury * Right and left shoulders - soft tissue injury * Right thigh - lateral femoral cutaneous nerve injury

give rise to a permanent impairment of 9% which is not greater than 10%.

1. He certified the following injuries referred for assessment were not caused by the motor accident:
   • Injury to both hands - sensory change in the fingers (numbness and tingling in the left and right hand involving the middle, ring, and little fingers); weakness in the muscles of the hands, weakness and stiffness in both arms
   • Left foot - sensory changes in left foot
   • Left toes - sensory changes in left toes

1. The claimant sought a review of the medical assessment in accordance with s 7.26 of the MAI Act (review). On 2 April 2025, the President's delegate determined that there was reasonable cause to suspect the medical assessment was incorrect in a material respect. As such the review application was accepted and referred to a Review Panel (the Panel).
2. A review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission.[2]
3. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned: s 7.26(6).
4. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application: Rule 128 of the Rules.
5. The Panel issued interim directions dated 10 January 2025 requiring the parties to lodge paginated and indexed bundles of all documents relied upon. The parties lodged bundles in compliance with those directions.
6. Following an initial preliminary conference, the Panel issued directions dated 28 May 2025 advising that it required the claimant to attend a re-examination with Medical Assessor Tai Tak Wan on 3 July 2025. The claimant attended the examination, and details are set out below.
7. The Panel reconvened via teleconference on 18 July 2025 to discuss the clinical examination findings of Medical Assessor Tai Tak Wan, and the material relied upon by the parties. A further teleconference was held on 8 September 2025. These reasons have been prepared by all three Panel members as a collective adopting the clinical examination findings of Medical Assessor Tai Tak Wan.

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).
2. The Guidelines are issued pursuant to s 10.2 of the MAI Act. The Guidelines adopt the fourth edition of the American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[3]

1. Causation of injury is addressed from cl 6.5 of the Guidelines. Whilst the clauses are set out in respect of permanent impairment they are relevant to a dispute as to threshold injury.[4] Clause 6.6 and 6.7 provide:

"6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:

1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.

2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'

This, therefore, involves a medical decision and a non-medical informed judgement.

6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes."

1. In determining the issue of causation, the Panel is to also have regard to s 5D of the Civil Liability Act 2002 (CL Act).[5]

(1) A determination that negligence caused particular harm comprises the following elements;

(a) that the negligence was a necessary condition of the occurrence of the harm (factual causation), and

(b) that it is appropriate for the scope of the negligent person's liability to extend to the harm so caused (scope of liability).

(2) In determining in an exceptional case, in accordance with established principles, whether negligence that cannot be established as a necessary condition of the occurrence of harm should be accepted as establishing factual causation, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party.

(3) If it is relevant to the determination of factual causation to determine what the person who suffered harm would have done if the negligent person had not been negligent -

(a) the matter is to be determined subjectively in the light of all relevant circumstances, subject to paragraph (b), and

(b) any statement made by the person after suffering the harm about what he or she would have done is inadmissible except to the extent (if any) that the statement is against his or her interest.

(4) For the purpose of determining the scope of liability, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party."

1. Medical Assessor Ian Cameron examined the claimant on 17 January 2025. In a certificate and reasons dated 25 January 2025, the Medical Assessor found that the injury to both hands-sensory changes in fingers, weakness in the muscles of the hands and weakness and stiffness in both arms, sensory changes in left toes and left foot were not caused by the subject accident. He assessed 0% WPI for the brain injury (0% WPI both using CDR scale and emotional and behavioural function). He assessed the cervical spine as DRE category II due to non-verifiable radicular complaints, resulting in a 5% WPI. The lumbar spine was assessed as DRE category I, and thus 0% WPI. Medical Assessor Cameron assessed 0% WPI for both right and left shoulders, and 0% WPI for right thigh- lateral femoral cutaneous nerve injury.

Claimant's review submissions dated 25 February 2025

1. It is submitted that Medical Assessor Cameron was in error by referencing Table 11 of the AMA4 Guides, when such table relates to the upper extremity and has nothing to do with the lower extremity injury (thigh).
2. The claimant submits that cl 6.104 of the Guidelines provides guidance on assessing peripheral nerve injury to the lower extremity. It is then submitted:

"Additionally, and in any event, it is unclear how "25% is multiplied by 1% for sensory impairment..." is in keeping with the clauses 6.58 and 6.60 of the guidelines (even if they applied, which they don't).

The Assessor has quite plainly failed to assess the claimant in accordance with the guidelines. This is a failure to properly carry out his statutory task. It must give rise to reasonable cause to suspect that the error is incorrect in a material respect."

1. In respect of the cervical spine, it is submitted that the Medical Assessor was in error by not addressing other criteria necessary for an assessment of radiculopathy that complies with

cl 6.138 of the Guidelines. 2. It is submitted that his reasons are internally inconsistent with the Medical Assessor stating that there were no signs of non-verifiable radicular symptoms, yet he elsewhere states that ulnar sensory symptoms in both hands can be interpreted as non-verifiable radicular complaints. 3. It is also noted the Medical Assessor said there was no difference in circumference of the upper extremities but says nothing about whether there was atrophy even if there was no difference in circumference. It is further submitted that other signs referred to in cl 6.138 of the Guidelines are not address.

Insurer review submissions in reply dated 19 March 2025

1. The insurer submits that the alleged errors of the Medical Assessor is simply a manifestation of the claimant's disagreement of the Medical Assessor's findings. In support of their position, the insurer refers to the opinion of Dr Bodel who provided a report to the claimant's representatives. It is noted that Dr Bodel had not been informed or assessed an impairment of the right thigh. It is further noted that Dr Bodel also assessed a DRE Category II impairment.

1. The Panel issued interim directions requiring the parties to each lodge a single bundle of documentation relied upon. The parties have complied with such direction and the Panel has considered the material provided. This includes a bundle lodged by the claimant on 2 May 2025 consisting of 917 pages - "Roxanas Claimant's_index_and_Bundle_of_Documents_review_of_Medical_Assessment" and a bundled lodged by the insurer on 23 May 2025 consisting of 216 pages - "2025.05.23 Roxanas - Insurer's Review Bundle (WPI - Physical)."
2. Whilst not every document has been referenced within these reasons, the certificate and reasons have been prepared in the context of the Panel having considered all documentation.
3. The claimant lodged a further application to lodge additional documents on or around

20 August 2025. The Panel notes the description of the material confirms it is a statement of the claimant dated 19 August 2025. The insurer does not consent to the inclusion of this material. The insurer notes that the medical assessment had already taken place and therefore should not be allowed. It is also suggested that the claimant complains about the assessment process within the statement. The insurer submits: "...while the complaints made could be very genuine, they are actually irrelevant to the assessment process because the claimant's injuries must be assessed as she presented on the day of the assessment." 4. Whilst the Review Panel has not read the statement, it is abundantly clear that it goes to complaints as to the medical assessment examination. The grievances are not something within the jurisdiction of the Review Panel to deal with. The Panel agrees that the material has been prepared and served after the medical assessment, and the injuries are to be assessed as the claimant presented on the day of the assessment. 5. The Review Panel has therefore not considered the additional material lodged by the claimant in the application of 20 August 2025.

Application for personal injury benefits dated 15 May 2020.

1. In an application for personal injury benefits dated 15 May 2020 (claim form) the claimant describes her injuries as:

"... whiplash and associated pain since the accident: I have experienced headaches, stiff neck, soreness in my back, neck, head and shoulder as well as a limited range of movement in my right arm and shoulder. My neck movement is also limited, particularly when turning my head to the right or when tilting it to the left...".

Pre-existing injuries include, "... a previous car accident in 1999. In that car accident I received whiplash injuries, which do not impact my daily life, but which leave me with a stiff neck if I sit for too many hours position - this can be relieved by stretching and exercise... In February 2019, I had suffered an injury to my right shoulder: a SLAP tear caused by dislocation. However, I was discharged by the physiotherapist 6 months prior to the car accident and have had no residual pain or discomfort from that injury since being discharged by the physiotherapist...".

1. In a referral letter to Dr Jayeshkumar Parikh dated 27/1/2020, Dr Kong Chung, a neurologist, asked for a nerve conduction studies, as the claimant complained of ulnar 3 fingers sensory disturbance of varying severity and left lateral 3 toes altered sensation after the subject motor vehicle accident (MVA). He also suspected these were concussion related, and wanted to rule out general neuropathy, compressive neuropathy such ulnar neuropathy at the elbow.
2. In a report dated 13 November 2020, Dr Chung stated the background was, "Whiplash injury in her 20s, but able to lead a normal life following that. History of joint hypermobility with various joint subluxation during pregnancy, and dislocated right shoulder last year. Episodic migraine with aura...". [my comment: that suggested that the migraine with aura was pre-existing.]
3. Dr Chung then stated that:

"... Emma had a motor vehicle accident on 2 May 2020. Her body and neck rotated maximally to the right looking for oncoming traffic, with view to turn left onto a slipped lane. She was hit behind on the driver side by a learner driver..... Upon impact the immediate sensation was something wrong with her neck. She developed a headache on the same day of the accident which intensified over the following few days. Everything above the neck was pounding with trigger/sensitive point over the right occipital area.. For the first 2 weeks she suffered significant headache, which was exacerbated by even short duration of working on computer. This has improved. Prolonged sitting either with work or social interaction would exacerbate headache.... She took sick leave for about 4 days following the car accident. Additional symptoms include dizziness, 'enormous pain' body sized up and stayed locked, and disturbance in vision mostly in the periphery. 'words swim around' when tired/after long day at work. Though symptoms are improving. Her difficulties now are fluctuating residual pins an needle sensation around ulnar 3 fingers on both sides, lateral 3 toes on the left, while right foot is spired. She has received input from physiotherapist and chiropractor, had dry needling. Reportedly suffered C1 vertebral rotational injury, which rotated 4", No analgesia requirements, usually managed by exercise or listen to her to body when to rest...".

1. Panel comment: all the complaints cannot easily be explained by organic pathology such as possibility of a very small haemorrhage in the brain, suggesting psychosocial pictures (yellow flags) especially when NCS/EMG was totally normal.
2. On examination, Dr Chung reported that, "... she denies flashbacks... Neurology examination is largely normal, apart from possible trigger point, and subject appendicular sensory changes. I suspect she suffered concussion, followed by post-concussion syndrome and ? post-traumatic stress disorder [PTSD]... Background episodic migraine and joint hypermobility. ... I recommend MRI brain and whole spine and nerve conduction studies..."
3. In a reported dated 15 February 2021 and an attached results of a nerve conduction study and needle EMG [NCS/EMG] Dr Parih, a neurologist, stated he did the NCS/EMG on the day, and found no electrophysiological evidence for a median or ulnar neuropathy, plexopathy, radiculopathy or myopathy on either side.
4. In a report dated 17 March 2021, Dr Chung stated that the claimant continued to complain significant headache, 20-25 days a month, with ongoing appendicular sensory disturbance. She recounted two episodes of migrainous phenomenon, one of which with debilitating headache during time of stress, the other episode visual aura. He believed that balancing probability, the left temporal lobe microhaemorrhage was due to concussion from the MVA.
5. In a report dated 31 May 2021, Dr Chung stated that, "... Emma attended clinic today... Daily headaches since ... early March... some improvement in PTSD following input from psychologist. Unfortunately she has experienced recent significant psychosocial stressors from family members health issues, and financial concerns...chronic migraine complicated by trigger point, PTSD and recent psychosocial stressor...". He then suggested venlafaxine, melatonin and Sandomigran treatments.
6. In a report dated 17 November 2022, Dr Daniel Farbodmanesh, a rehabilitation physician of Sydney Pain Management Centre stated he reviewed the claimant on the day. She complained frequent migraine headaches and pain around the cervical region radiating to right occiput and parietal region. The neck pain radiated to right upper limb with paraesthesia of the upper limb. The pin and needles in her hand can at times bilateral and may interrupt her sleep. Pain in the lumbar region can radiate to the right lower limb. He opined that

"... Overall Ms ... Roxanas most likely suffers from... occipital neuralgia as well as migrainous headaches following a motor vehicle accident as well as a elements of whiplash injury. She also presents with facetogenic headache and cervical pain with radiation to her right upper limb. She may also have AC joint pathology or subacromial bursitis..." 7. In a report dated 20 June 2023, Dr Farbodmanesh stated the claimant complained metallic taste in mouth with Topamax. Her migraine headaches usually happen two or three times a month. He suggested to try Duloxetine and arrange a bilateral C2 and third occipital nerve block. 8. In an operation record dated 1 August 2023, Dr Vahid Mohabbati stated a "right C3/4, C4/5 facet joint Medial branch block" was performed on the day at Sydney Pain Day Surgery. 9. In an operation record dated 15 August 2023, Dr Vahid Mohabbati stated a "right C2 Dorsal Root Ganglion and 3rd occipital nerve block" was performed on the day at Sydney Pain Day Surgery. 10. In a report dated 20 September 2023, Dr Farbodmanesh stated that "... following the right C3/4 and C4/5 medial branch blocks Mary did not have any migraine headache, temporary good relief... I have arranged... right C3/4 and C4/5 medial branch radiofrequency ablation [RFA] ... Endone... 20 tablets...". 11. In a report dated 18 October 2023, Dr Farbodmanesh stated that,"...Mary had the... RFA on 3rd October 2023... has been experiencing a pain flare following the ablation. Mary also reported a burning sensation around the right shoulder... I have commenced her Palexia SR ... and Palexia IR...continue with Panadol and Nurofen,,, a compound cream with ... Ketoprofen, Lignocaine, cyclobenzaprine and Pregabalin...". 12. The Panel has reviewed multiple certificate of capacity/certificate of fitness (CoC), issued by her GP Dr Jung-Yoon Huh. 13. In a report dated 11 February 2022, Dr Melissa Hughes, a neuropsychologist, stated she examined the claimant on 8 February 2022 at the request of claimant's solicitor. Dr Hughes administered the usual battery of tests. Based on history, demographics and current psychometric data, she estimated the premorbid functioning in the Superior range. She concluded that the claimant sustained a mild traumatic brain injury (TBI) in the motor accident, with a background of migrainous headache. The current cognitive performance, both verbal and visual abilities including reasoning and general knowledge were in the Superior to very superior range. However, the assessment indicated heightened anxiety. Her cognitive symptoms pertain to attentional fluctuations appeared to be related to mood state and pain rather than a permanent organic neurological injury. Although protracted the headaches appear to be reducing through her current treatments being physical therapy and psychological therapy. The claimant has the cognitive capabilities to embark on any career she chooses and does not show impairment which could impact her future income. Using the CDR rating, Dr Hughes assessed 5% WPI for the brain injury + 2% WPI for treatment. 14. In a "claimant's statement" (document A3) dated 28 June 2024, the claimant's solicitor confirmed that the claimant had a motor accident in 1997, sustaining a whiplash type injury, which resolved in a few months. The claimant sustained an injury to the right shoulder in March 2019 when she brushed her hair. Soon after that she received a forceful hug from her son which increased her pain. She was reviewed by Dr Perko, orthopaedic surgeon on

29 April 2019, who reviewed an MRI and noted a small labral tear, which was treated physiotherapy for six months. It also stated that the claimant had a subsequent MVA on

18 April 2022, sustaining "mild aggravation of her cervical spine injury". Several medicolegal reports were discussed, including those of Dr Hughes, Dr O'Neil, Dr Bodel, Dr Teychenne and Dr McIntosh. 15. The Panel also reviewed a "Statement of Emma Roxanas" (Document A5) dated 28 June 2024. 16. The Panel has reviewed the report of Dr McIntosh dated 19 October 2023. 17. The Panel has reviewed the reports of Dr Perko, the treating orthopaedic surgeon, dated

11 April 2019, 29 April 2019 related to the claimant's pre-existing right shoulder injury when she brushed her hair and then a forceful hug from her 10 year son. An MRI scan a small labral tear, more postero-inferior. He advised a rehabilitation programmes. 18. The Panel has reviewed the report of Dr O'Neil, a neurologist, dated 16 September 2022. He assessed no TBI and no WPI for cervical spine symptoms. 19. The Panel has reviewed the reports of Dr Wallace, an orthopaedic surgeon, dated 8 August 2022 and 28 November 2023. The way he did the pre-existing condition deduction for cervical spine was incorrect according to MAG. 20. The Panel has reviewed the report of Dr Synnott, a psychiatrist, dated 12 October 2022. 21. The Panel has reviewed the report of Dr Bodel, orthopaedic surgeon, dated 21 December 2022. He assessed WPI as: Cervicothoracic spine - 5%. Lumbosacral spine - 5%, Right shoulder - 6%, Left shoulder - 2%. 22. The Panel has reviewed the reports of Dr Paul Teychenne. Dr Teychenne diagnosed the claimant as having sustained an incomplete cervical cord lesion as a result of the subject accident. He assessed 25% WPI for nervous system injuries. The Panel found that his physical findings and conclusions were very different from those of other medical reports. The Panel also noted that currently he is not an authorised health practitioner with reference to the motor accident injuries.

1. The below is the clinical examination findings of Medical Assessor Tai Tak Wan who examined the claimant in his rooms in Fairfield on 3 July 2025.
2. The claimant is 48-years-old. She attended the assessment alone. The assessment, including history taking, cognitive functions assessment and physical examination, lasted for two hours.

1. The following injuries were referred by the Personal Injury Commission for assessment:
   • Head Injury - mild traumatic brain injury - left temporal lobe microhaemorrhage, post-concussion syndrome, memory loss, difficulty with activities of daily living including. concentration and work
   • Cervical Spine - C1 vertebral rotation injury, incomplete cervical cord lesion.
   • Lumbar spine - Injury to lower back.
   • Shoulders - Injury to both shoulders, stiffness and weakness.
   • Injury to both hands - sensory change in the fingers (numbness and tingling in the left and right hand involving the middle, ring, and little fingers); weakness in the muscles of the hands, weakness and stiffness in both arms.
   • Left Foot - sensory changes in left foot.
   • Left Toes - sensory changes in left toes.
   • Right Thigh - sensory change in the right thigh - numbness.

Pre-Accident Medical History and Relevant Personal Details

1. Ms Mary Roxanas, 48-years-old, a manager of Department of Climate Change and Energy Environmental and Water (DCCEEW) (working three days per week). She said she was the Director of DCCEEW before the subject MVA, working four days a week, 9am to 10pm. It is mainly a desktop job although she sometimes does site visits.

1. She has the following significant history:
   • 1997, driver in a MVA. She stopped at a stop sign but hit by an inexperienced driver from behind. Airbag not deployed. She exchanged details with the other driver. She did not go hospital. She received physio for three months. She did not take any time off the work
   • 2019 March, injured right shoulder, and was told to have 'SLAP tear'. She consulted a shoulder specialist (orthopaedic surgeon) but could not name him. MRI was done, and was treated conservatively.
   • Appendectomy at age 9
   • Adenoid surgery at age 6
   • Hiatus hernia for 2 months
2. She said she was "strange reaction" to some opioids, "colours look different" and gets sleepy.

1. She was born in NSW, Australia.
2. She said her high school performance was average, and best subject in school was Music, and worst subject was Maths. She studied violin at The Conservatorium High School. She took the HSC exam but could not tell her HSC scores or ATAR score. She has a Bachelor degree in Arts (Sydney University), then a master degree in English literature (Cambridge University). She worked as a professional violist for four years and the as an office manager (while in United Kingdom) for five years. She then returned to Australia to study and got a 'Juris Doctor' form UTS (it is a master's degree in law for people without a primary law degree). She then works in the government as a public servant.
3. She lives with her husband (40 years old software engineering), a 18-year-old daughter and a 17-year-old son, in a one storey house with no steps.
4. She goes to gym three times a week.
5. She is a non-smoker and a non-drinker. She denied taking any recreational drugs.
6. She drives an automatic car.

History of the Motor Accident (from the claimant)

1. Ms Roxanas said that on 2 May 2020, a Saturday, at about 1:15 pm, she was a restrained driver of a vehicle which was stationary before a give-way sign, waiting to turn left to a slip lane. There was a headrest in her car seat. According to her statement (document A5) husband Daniel, was the passenger. She said "he was mildly injured but now recovered". She was leaning forward and turned her to the right side, looking at the traffic. Unfortunately, her car was hit by another vehicle from behind on the right back corner. Her car was pushed forward but did not hit any object. She was able to exit the car by herself, and exchanged details with the other driver, who was a learner driver (and had a passenger in the car). She said police did come but ambulance did not come. (She said because the COVID the ambulance service was 'locked down'.) Her car was not drivable after the MVA, and towed, but later repaired. There was no loss of consciousness (LOC). She called a relative to take her home. She said she felt a bit unwell after the accident but did not go to hospital or consult her GP on the day ('because of the COVID'). She consulted a female GP two days later.

History of Symptoms and Treatment Following the Motor Accident

1. Ms Roxanas said she sustained the following injuries from the accident:
   • Headache
   • Neck pain
   • Shoulders pain, right more than left side
   • Pain and Numbness of fingers, third, fourth, and fifth fingers
2. She was referred to see a neurologist, Dr Chung, who ordered an MRI scan. She has stopped seeing Dr Chung, because "he does not do CTP cases". She said she had not seen a brain injury specialist or attended a brain injury clinic. Apparently, she has not been assessed by a neuropsychologist.
3. She was referred to see a pain specialist Dr Farbodmanesh (according to the documentation, he actually is a rehabilitation physician but does not have a fellowship in pain medicine) in 2023 (two years ago, three years after the subject accident). She was given Mobic, Palexia, Paracetamol, Vitamin B12, Vitamin D and magnesium supplement.
4. She was referred to an interventional radiologist for injection to the neck.
5. She saw an occupational therapist in 2021, who did a telephone consultation, and advised on workstation setup.
6. She probably consulted once a vocational rehab provider on return to work (RTW) issues.
7. She has been seeing a psychologist "Kristina" since 2021, once a week, the diagnosis is post-traumatic stress disorder. She said she has not seen any psychiatrist.

Details of Any Relevant Injuries or Conditions Sustained Since the Motor Accident

1. In 2022, the claimant was a driver in another MVA, when her car was hit by a 'red P plate' driver from behind. She was wearing a seat belt; there was headrest in her car. It aggravated her headache, shoulder and neck pain. No ambulance or police came. She consulted GP a week later. She was told that she got a 'minor whiplash'. She continued the physio.

1. Her current complaints are as follows:
   • headache, 6/10 in visual analogue scale (VAS). It is an intermittent ache, like pressure, in the face and goes down the ears. There may hypersensitivity to light. She complained of 'mentally fatigue' and "emotional strained". She feels that she is now a different person. She sees a psychologist regularly.

She complained that her memory is not good since the accident, particularly the short-term memory. Her judgment is impaired according to her boss. She saw a neurologist, Dr Chong in 2022 but has since stopped seeing him;

• pain shoulders, 5/10 in VAS (she pointed to the trapezius region when asked to show me where is the pain). It is an intermittent ache and aggravated by sneezing. She believed that there is a 'nerve pain' going to under the arms. She said sometimes she cannot feel her fingers. Her coordination is poor;
• numbness in the right thigh. She said it started after RFA (radiofrequency ablation), September 2023;
• low back pain, 5/10 in VAS, more on the right side. It is an intermittent pain and is aggravated by any movement (up to 7/10 in VAS). She said she was diagnosed to have 'hypermobility' by someone, but she could not give a specific syndrome name;
• sometimes pain in both little fingers, "on and off", and
• sleep is not good, mainly due to late sleeping.

1. She said she may have constipation because she takes opioids. Sometimes bowel movement may aggravate the headache. She reported no problem in the bladder function.
2. She said at most she can sit for one hour, stand for 15 minutes and walk for 30 minutes. She can drive for one hour (automatic car with power steering).
3. She is independent in the personal hygiene care and most activities of daily living (ADL). She said her husband and children do most of the housework, although she sometimes helps.
4. She does not go to gym three times a week. She still visits friend as usual.
5. She said music is her hobby. She cannot play violin because of the neck pain, but she still sings.

1. The claimant stated that she has been taking the following medication:
   • Mobic (? Dose) 1 tab daily.
   • Palexia SR (? Dose) 1 tab several times weekly when necessary
   • Panadol osteo two tablets three times a day
   • Vitamin B12, Vitamin D, magnesium supplements
2. She said she once received physiotherapy but has ceased them now.
3. She said she sees her GP Dr Ning from time to time as necessary.
4. She once consulted a chiropractor but not now.
5. She consults her psychologist regularly.

1. Examination on 3 July 2025 showed that claimant was orientated and alert. She said she is 160cm tall, and weighs 82kg, which gave a BMI of 32, in the obese range. Significant pain behaviours were observed during the interview. She walked independently without any walking aid and she had a normal symmetrical gait. She could walk on tip-toes, on heels, and in tandem (heel-toes). She had no difficulty in squatting. She could dress and undress independently. She could get on and off the examination couch independently.
2. She is right hand dominant.
3. Examination of the head showed no conspicuous scars, swellings, or deformities. Smell sensation was normal. Visual fields tested by confrontation were normal on both eyes. There was no nystagmus or diplopia found. Pupils were equal and reactive. Visual acuity was grossly normal. There was no gross hearing loss. There were no other motor or sensory deficits in the face and head. All the cranial nerves were intact. There was no difficulty in communication, both in expression and comprehension. There were no cerebellar signs found. Romberg test was normal.

1. She scored 29/30 in Folstein Mini Mental test (MMSE). She lost one point in short term verbal memory test. She scored 5/5 in both serial 7 test and reverse spelling test. She had no problem in copying figures including three-dimensional cubes. She had no problem in alternating sequences. She drew a clock showing the current time quick and well. Regarding written arithmetic tests, she got the correct answer for addition and subtraction, but gave wrong answers to multiplication and division, saying that she normally used a calculator. She gave good answers when asked to explain some common proverbs. She gave quick and good answers when asked to give for three differences and three similarities between apple and orange.
2. In summary, no evidence of cognitive impairment was detected clinically in the mental state screening tests. The slight difficulty in short term verbal memory was within normal limits. The arithmetic test results most likely due reflected her usual ability (maths was her worst subject in school), work experience, and the fact she uses calculator for all calculation. Abstract thinking and executive function were within normal limits. Clinically I could not find any evidence of cognitive impairment from the subject accident.
3. There were no documented features of post traumatic amnesia and no evidence of loss of consciousness or concussion features after the MVA.

1. Examination of the neck showed mild tenderness over the left trapezius area but no muscle spasm or guarding. There was no evidence of non-verifiable radicular complaints, and there were no features of radiculopathy. There were mild restrictions in active movements of the neck, but no evidence of dysmetria (asymmetrical loss of motion).
2. All the measurements are those of active movements. All the active ranges of movements (ROM) of the spine were measured using an inclinometer and a goniometer]:

1. Examination of the upper back showed mild tenderness over left scapula region but no muscle spasm or guarding. Active movements of the thoracic spine were symmetrical and within normal limits. There was no evidence of any non-verifiable radicular complaints nor radiculopathy:

1. Examination of the lower back showed very mild tenderness in the lumber region more on the right side, but no muscle spasm or guarding. There were some restrictions in active movements of the lumbar spine, but there was no evidence of dysmetria. There was no evidence of radiculopathy nor non-verifiable radicular complaints:

1. Straight leg raising was 90° in on both sides; in supine position.

1. Examination of the upper limbs showed no gross muscle wasting. Measurements of mid-arm circumference showed that the right side was 0.5cm larger than the left side, which was within the normal limits, given that she is right hand dominant. Measurement of mid-forearm circumferences the right side was 0.5cm larger than the left side, which was within the normal limits. Muscle power was normal in both upper limbs, both proximally and distally. Reflexes were normal and symmetrical in the upper limbs. She complained of subjective reduced sensation to pain and touch in both hands affecting all fingers, (right side worse than the left side), which do not follow any dermatomal or peripheral nerve distribution) and could not be confirmed by two-point discrimination tests in both upper limbs.
2. Examination of the shoulders showed tenderness in both trapezius muscle regions. No crepitation was found on moving shoulders. Active movements of right shoulders were mildly restricted. She complained some pain in the shoulder at the extreme of ranges. [All the measurements are those of active movements. Medical Assessor Wan did not test any passive movements. All the active ranges of movements (ROM) of the limbs were measured using a goniometer]:

1. Medical Assessor Wan found the measured range of motion of neck, lower back and shoulder were a bit less than the findings of Medical Assessor Cameron and other specialists, and observations when not in formal examination, such as dressing and undressing. Medical Assessor Wan presented the discrepancy to the claimant, she said it was because she had more pain on the day of re-examination. The Medical Assessor repeated the measurements of neck, lower back and shoulders, asking her to give the best efforts, but the findings were similar.
2. Examination of the elbows showed no tenderness or swelling. Active movements of the elbows were symmetrical and within normal limits.
3. Examination of the wrists and hands showed no deformity or swelling. Active movements of the wrists, hands and fingers were all symmetrical and within normal limits.

1. Examination of the lower limbs showed no gross muscle wasting. Measurement of mid-thigh circumference showed that the right side was 0.5cm larger than the right side, which was within normal limits. Measurement of mid-calf circumference were equal on both sides. Muscle power was normal and symmetrical, both proximally and distally. Reflexes were normal and symmetrical on both lower limbs. She complained some numbness in right lateral thigh after a pain procedure om 2023, but no consistent sensory impairment could be demonstration in that area. The sensation was otherwise normal in the lower limbs.
2. Examination of the hips showed no deformity or swelling. There was no tenderness over the hip regions. FABER test was normal on both sides. Active movements of the hips were normal bilaterally.
3. Examination of the knees showed no deformity, swelling or effusion. There was no crepitation on moving the knees. There was no excessive antero-posterior or medio-lateral laxity of the left knee suggesting the cruciate and collateral ligaments were intact. McMurray's test was normal on both knees, suggesting the menisci were intact. There was mild restriction in flexion of the right knee. Active movements of left knees were within normal limits.
4. Examination of the ankles showed no deformity or swelling. Active movements of the ankles and feet were symmetrical and largely within normal limits.
5. Examination of the chest and abdomen were unremarkable.

1. It has already been mentioned above, the inconsistency in the shoulder examinations.

1. The claimant brought the X-ray but no reports to the assessment, reports were found in the supporting documents.
2. Medical Assessor Wan reviewed the films and reports of the following investigations:
   • MRI brain and whole spine of 21 January 2021 taken at SAN Radiology, reported by Dr Avigdor Saks - the scan was done approximately eight months after the subject MVA, which showed no evidence of significant trauma. There was a small focus of susceptibility artefact in the anterior periphery of the left temporal lobe indicating old haemorrhage. There was no other evidence of prior haemorrhage. The radiologist concluded that the possibility of a previous left anterior temporal lobe haemorrhage was questionable.

MRI spine showed haemangiomata at T6 and T7 (Medical Assessor comment: it was an incidental finding, causally unrelated to the subject motor accident and has no clinical significance). There was minimal disc bulging C5/6 and C6/7, but no evidence of bone trauma nor epidural haematoma.

• MRI brain of 7 March 2023, taken at Spectrum medical imaging, reported by Dr Laughlin Dawes - which showed no change in the susceptibility effect in the left anterior temporal lobe. No abnormality was evident in this region on other sequences. Intracranial time-of-flight MRA was normal with no aneurysm, stenosis or vascular irregularity. The radiologist concluded that "unchanged appearance of microhaemorrhage in the left temporal pole".
• The claimant said she had a MRI cervical spine in 2025, but neither the films nor report were made available.
• In a report dated 7 March 2023, Dr Jason Wenderoth, neuro-interventionist (and a radiologist) stated that the claimant consulted him for opinion on MRI done in 2021 at SAN Radiology. Her neurologist, having reviewed the scan, felt that it was artefactual. He was unable to determine from the hard copy images whether the purported abnormality was real or an artefact, therefore arrange to repeat the imaging at Spectrum Imaging.
• In a report dated 11/5/2023, Dr Jason Wenderoth, a neuro-interventionist (and a radiologist) stated he had a phone consultation with the claimant on that day. He stated "... MRI at Spectrum... shows clear evidence of haemosiderin staining in the left temporal pole in keeping with previous haemorrhage...".

Medical Assessor comment: I have reviewed the films of both MRI of 2021 and 2023. I was not convinced that there was hemosiderin deposition which usually appeared after significant cerebral haemorrhage. Therefore, I was not convinced that there was a small haemorrhage but believed that, like Dr Chung initial thought, was an artefact. However the images of the films were small, but Dr Wenderoth had the advantage of seeing the original raw images and I believed that usually enlargement and other manoeuvre could be used to enhance the images, and he is a radiologist, I would accept his opinion.

• X-ray right shoulder, of 11 April 2019, reported by Dr R. Kapoor - the history stated, "abnormal subluxation". It did not any abnormal findings.

1. The above clinical examination findings were discussed by the Panel in the two

post-examination teleconferences, along with the material provided by the parties. The Panel collectively agreed to adopt the clinical examination findings as part of these reasons.

1. There is no evidence of a significant head injury: there is no documented observed loss of consciousness (LOC), no documented abnormal GCS scores, no clinical evidence of PTA and no recorded PTA assessment. There were neurological signs of brain injury demonstrated. As discussed above the Panel accepted that there was a small 'microhaemorrhage in the left temporal pole". Intracranial MRA was totally normal. Although Dr Chung, the treating neurologist, mentioned "post-concussion syndrome, memory loss..." in his report, there was no documented features of concussion. The claimant complained of memory problems, especially recently, it was not confirmed by neuropsychologist report of Dr Hughes. However, there was significant psychological symptoms, as confirmed by the tests of Dr Hughes, and the complaints of memory problem, anxiety, post-traumatic stress disorder and personality changes were most likely due to the psychological injuries and her headaches. She had history of migraines even before the subject MVA, although it became more frequent, but according to the history, those headaches has improved with the treatment of Dr Chung. Therefore, the Panel assess that even we accept the very small "microhaemorrhage of left temporal lobe", it was a mild traumatic brain injury (TBI).
2. The screening mental test showed no cognitive function impairment, including no evidence of any executive function impairment, consistent with the test findings of the neuropsychological report.
3. Head injury is assessed according to the Motor Accident Guideline (MAG) paragraph 6.160 to 6.176, and Table 6.9. According to paragraph 6.160:

"... The medical assessor must consider the categories of:

(b) mental status and integrative functioning abnormalities

(d) disturbances of consciousness and awareness (permanent and episodic).

The medical assessor must select the highest rating from categories 1 to 4...."

1. In the case of the claimant, there are no aphasia or communication disorders, and no disturbances of consciousness and awareness.
2. According to 6.164, for an assessment of mental status impairment and emotional and behavioural impairment certain pre-requisite criteria should be satisfied. In the case of the claimant, there was no evidence of high-velocity vehicle impact (from history and report of Dr McIntosh). But since the Panel accepted that there might be a microhaemorrhage of left temporal lobe, it would accept that there was a possibility of significant cerebral insult. Although there was no evidence of abnormal GCS score, nor PTA, there was possibility of abnormal brain imaging. Therefore, the Panel accepted that the pre-requisite criteria had been satisfied.
3. Whole Person Impairment (WPI) of disturbances of mental status and integrative function due to brain injury sustained in the accident is assessed using the CDR (clinical dementia rating) according to paragraph 6.166 to 6.169 and Table 6.10, MAG. It is assessed as follows:
   • Memory score is questionable, as although the claimant complains of memory problem, it is not confirmed by mental status assessment, M=0.5.
   • Orientation score is none, as she is fully orientated, O=0
   • 'Judgement and problem-solving score' is none, as shown from the mental status screening and neuropsychological assessment, JPS =0
   • Community affairs score is none, as she functions independently in job, shopping and social groups, CA=0. (The Panel noted that the claimant reported that she was a Director of her unit, working four days a week, but she now works as a manager, three days a week. However apparently that is due to her frequent migraines (which are pre-existing) but not due to her cognitive impairment. Furthermore, according to MAG, pain by itself, unless in certain well-defined condition, such as trigeminal neuralgia or CRPS, does not carry any WPI. The neuropsychologist also opined that the claimant "... From a cognitive perspective, Ms Roxanas has the required capabilities to embark on any career she chooses and does not show impairments which could impact her future income..." (page 8 of Dr Hughes's report).
   • Home and hobbies score is none, as the life at home, and intellectual interests were well maintained, HH=0
   • Personal care score is none, as he is fully capable of self-care, and other secondary scores are also 0, PC=0.
4. Since all secondary categories are scored less than M score (primary category), therefore the CDR score = secondary scores =0.
5. According to Table 6.10, CDR=0 would be assessed as 0% WPI.
6. The Panel has considered the report of Dr Hughes as required by cl 6.165 of the Guidelines.
7. The claimant has depressive, anxiety and post-traumatic stress disorder features. However, the cognitive WPI is 0% and the Panel opined that the small "micro-haemorrhage of left temporal lobe" is medically unlikely to cause the psychological symptoms, but rather those psychological symptoms are due to the psychological injury. Even if the Panel assessed the emotional and behavioural impairment, using Table 3, p142, AMA4, it will be assessed as lowest end of mild limitation range, corresponding to 0% WPI, as there is no evidence of organic brain injury to explain the depression and posttraumatic stress disorder.

1. Clinically there are no evidence of "C1 vertebral rotation injury, incomplete cervical cord lesion" (only mentioned by Dr Teychenne but the Panel would put little weight on his report, see above). The Panel's findings are similar to those of Medical Assessor Cameron, and it found that there were mild to moderate but symmetrical reduced range of motion in all planes, therefore no dysmetria.
2. There was tenderness but no muscle guarding or spasm. Although the claimant complains of intermittent pain in all fingers it does not follow any dermatomal or peripheral nerve distribution, therefore there was no non-verifiable radicular complaints. (Medical Assessor Cameron's certificate has some inconsistency here: although he stated that ".... No non-verfiable radicular complaints present..." on page 4 of his certificate under the section of "Clinical Examination", on page 6 and page 8 of his certificate he stated, "....Ms Roxanas has symptoms that are consistent with non-verifiable radicular complaints...".)
3. NCV/EMG was normal. MRI spine of 21 January 2021 was essentially normal. There are no features of radiculopathy, using the criteria of radiculopathy as listed in cl 6.138 of the Guidelines: there are no loss or asymmetry of reflexes, no positive sciatic nerve root tension signs, no muscle atrophy, no muscle weakness or reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution. Therefore, currently there are no symptoms or signs to justify assessment of DRE II or III. According to Table 6.7 and Table 6.8, MAG, the Panel assessed the cervical spine injury as DRE category I. Using Table 73, page 110, AMA4, it corresponds to 0% WPI.
4. The Panel noted that Dr Farbodmanesh did arrange right C3/4 and C4/5 medial nerve block and later radiofrequency ablation of the same region, however pain complaints are not considered in DRE classification.

1. There is mild tenderness but no muscle guarding or spasm. There are moderate but symmetrical restrictions in active movements of lumbar spine in all planes, and therefore no dysmetria. There are no non-verifiable radicular complaints. There are no features of radiculopathy, using the criteria of radiculopathy as listed in cl 6.138 of the Guidelines: there are no loss or asymmetry of reflexes, no positive sciatic nerve root tension signs, no muscle atrophy, no muscle weakness or reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution. Therefore, currently there are no symptoms or signs to justify assessment of DRE II or III. According to Table 6.7 and Table 6.8, of the Guidelines, the Panel assessed the lumbar spine injury is Diagnosis related estimate (DRE) I. Using Table 72, page 110, AMA4, it corresponds to 0% WPI.

1. There is no weakness or 'stiffness' in the muscles of hands and arms found in the

re-examination. NCV/EMG was normal. There is no evidence of injury to both hands, and arms sustained in the subject motor accident.

1. According to claimant's description, it is possible that she sustained a soft tissue injury to the right shoulder, aggravating a pre-existing right shoulder injury.
2. The Panel accepts that, on the balance of probabilities that injury to the right shoulder was caused by the motor accident by way of aggravation of a pre-existing injury
3. There is no weakness demonstrated in upper limbs. There are mild restrictions in active movements of the right shoulders.

1. The shoulder impairments are then added together (1%+ 1%+ 1%) = 3% UEI
2. The movements of the left shoulder are normal, therefore there is no need for contralateral deduction. There is no evidence of left shoulder injury.
3. Using Table 3, p.20, AMA4, the UEI are then converted to whole person impairment (WPI). 3% UEI corresponds to 2% WPI.
4. Although there is evidence of pre-existing right shoulder injury 'SLAP tear' in March 2010, only one year before the subject motor accident, the claimant claimed that she had full recovery from that injury before the subject motor accident. The Panel believed that although there may potentially be some residual symptoms, there was insufficient information to assess the degree of right shoulder impairment present prior to the subject accident. The Panel noted that Medical Assessor Cameron found the movements of the shoulders were normal, and the claimant stated that she had more pain on the day of re-examination. According to paragraph 6.31, MAG, "... if there is no objective evidence of the pre-existing symptomatic permanent impairment, then its possible presence should be ignored...". Therefore, the Panel decided not to do deduct any amount for any pre-existing condition.
5. There was also subsequent motor accident in 2022. However, the claimant claimed that it was a minor injury. Although there was aggravation of headache, shoulder pain and neck pain, she said she continued physiotherapy and the pain and restriction in movements returned to "same level as before the subsequent accident". Since there were no detailed physical findings available in the period just before and soon after the subject motor accident, the Panel decided that it was inappropriate to make a deduction for subsequent injuries.

1. There is no evidence of sensory changes in left foot on clinical examination.

1. There is no evidence of sensory changes in left toes on clinical examination.

Right Thigh - sensory change in the right thigh - numbness

1. The claimant complained of numbness in the right lateral thigh after the procedure by the pain specialist in 2023 (the Panel suspected that was the RFA procedure), but there was no such symptoms prior to that. Medical Assessor Cameron reported sensory deficit in the distribution of lateral femoral cutaneous nerve. Medical Assessor Tai Tak Wan on examination, could not confirm that there was consistent sensory deficit in lower limbs, including pain, touch and two-point discrimination. Since the symptoms (and probably the intermittent sign) occurred approximately three years after the subject motor accident and after a medical procedure, the Panel decided that the intermittent feature (similar to the condition of Meralgia paresthetica) was not, on the balance of probabilities, causally related to the subject motor accident. Furthermore, the claimant has a BMI in the obese range, and Meralgia paresthetica is not uncommon in obese people.
2. Even in circumstances where the Panel were to accept that the Meralgia paresthetica was related to the subject motor accident, with reference to the claimant's submissions, the method used by Medical Assessor Cameron to calculate the WPI is correct. Using Table 68, the maximum sensory impairment of lateral cutaneous nerve is 1%WPI or 2% LEI (lower extremity impairment). According to cl 6.106, of the Guidelines when using Table 68, the medical assessor is to refer to Table 11a and 12a (page 48-49, AMA4 and clauses 6.658, 6.59 and 6.60). Since there is intermittent decreased sensibility, without interfering with activity, according to Table 11a, p.48, AMA4, it is classified as Grade 2, corresponding to 25% sensory deficit. The WPI is then calculated by multiplying 25% to 1% WPI, equal to 0.25% WPI which is rounded to 0% WPI.

Summary of Injuries Listed by the Parties and Caused by the Accident

1. The following injuries WERE caused by the motor accident:
   • head- mild traumatic brain injury, small microhaemorrhage of left temporal lobe;
   • cervical spine - soft tissue injury;
   • lumbar spine - soft tissue injury, and
   • right shoulder - soft tissue injury, aggravation of pre-existing injury.

Summary of Injuries Listed by the Parties and Not Caused by the Accident

1. The following injuries WERE NOT caused by the motor accident:
   • left shoulder injury;
   • injury to both hands - sensory change in the fingers (numbness and tingling in the left and right hand involving the middle, ring, and little fingers); weakness in the muscles of the hands, weakness and stiffness in both arms;
   • left foot - sensory changes in left foot;
   • left toes - sensory changes in left toes, and
   • right thigh - sensory change in the right thigh - numbness.

1. Given the assessment of whole person impairment differs from that of Medical Assessor Cameron, the certificate of 25 January 2025 is revoked. A new certificate is provided at the beginning of these reasons.

[4] See Briggs v IAG Limited t/as NRMA Insurance [2022] NSWSC 372 at [35].