Statement of Principles concerning fibromyalgia (Reasonable Hypothesis) (No. 107 of 2021)

The core concept is the definition of fibromyalgia itself. Section 7(2) requires chronic widespread pain persisting for at least three months, meeting three criteria: a WPI of at least 7 with an SSS of at least 5, or a WPI from 4 to 6 with an SSS of at least 9; pain present in at least 4 of 5 specified body regions (left upper, right upper, left lower, right lower, axial); and the pain and symptoms not being better accounted for by another medical or psychiatric condition. Pain in the jaw, chest and abdomen does not count toward the four regions but does count toward the WPI score (0-19). The SSS (section 1 of the Schedule) is the combined total of the severity of three symptoms (fatigue, waking unrefreshed, cognitive symptoms) scored 0-3 each, plus the sum (0-3) of the number of three additional symptoms (headaches, lower abdominal pain or cramps, depression) present in the past six months. This definition is borrowed from the 2016 American College of Rheumatology criteria (not cited but evident from the scoring). It is a shift from the earlier SoP which used a simpler clinical description.

The six factors in section 9 are the minimum required to raise a reasonable hypothesis. They are: (1) experiencing severe childhood abuse before the clinical onset; (2) being overweight or obese (BMI of 25 or greater) at the time of clinical onset; (3) having an autoimmune inflammatory condition which is associated with the development of arthritis at the time of clinical onset; (4) experiencing a category 1A stressor within the one year before clinical onset; (5) having a severe, chronic medical condition for at least the two years before clinical onset; and (6) inability to obtain appropriate clinical management for fibromyalgia.

Each defined term is critical. Severe childhood abuse (Schedule) means serious physical, emotional, psychological or sexual harm, or serious neglect, whilst a child under 16 years, perpetrated by a parent, care provider, an adult who works with or around the child, or any other adult in contact with the child. Category 1A stressor (Schedule) means a life-threatening event, being subject to a serious physical attack or assault including rape and sexual molestation, or being threatened with a weapon, held captive, kidnapped or tortured. Severe, chronic medical condition (Schedule) means an illness that substantially impacts functioning, requires ongoing daily or almost daily management under a registered practitioner with specific assistance (activities of daily living, bed rest, drug therapy, nursing care, etc.), and is of a type that does not usually resolve, is rarely cured, or may progress to a life-threatening illness. Examples given include chronic kidney disease requiring dialysis, severe psoriasis, and poorly controlled asthma, COPD, diabetes or epilepsy.

Relevant service (Schedule) is defined to mean operational service, peacekeeping service, hazardous service, or British nuclear test defence service under the VEA, and warlike or non-warlike service under the MRCA. This is a broad category that excludes peacetime service under the VEA unless it falls under one of the specified types.

The primary group affected are veterans and members of the Australian Defence Force who have rendered relevant service and who develop fibromyalgia or die from it. This includes veterans who served in operational areas, peacekeeping missions, hazardous service (e.g., certain training or deployment environments), British nuclear test defence service, and warlike or non-warlike service under the MRCA. The SoP also applies to their dependants claiming death benefits under the VEA or MRCA. It directly affects the Repatriation Commission and the Military Rehabilitation and Compensation Commission as the decision-making bodies that adjudicate claims. The Veterans’ Review Board and the Administrative Appeals Tribunal must apply the SoP when reviewing decisions.

Medical practitioners who assess and diagnose fibromyalgia for veterans are also affected. They must now apply the specific scoring criteria from the SoP, not merely a clinical judgment of chronic widespread pain. This imposes an additional administrative burden: a practitioner must calculate the WPI (19 body parts) and the SSS (0-12) and confirm that pain is present in at least 4 of the 5 regions, and that another medical or psychiatric condition does not better account for the symptoms. The definition excludes conditions such as chronic fatigue syndrome, lupus, or rheumatoid arthritis if those diagnoses better explain the pain.

Lawyers, advocates, and claims consultants who assist veterans must now be familiar with the precise definitions in the Schedule. For example, a veteran who experienced childhood abuse but not the specific types listed (e.g., perpetrated by a sibling of similar age who is not a care provider) may not satisfy factor (1). Similarly, a veteran who was overweight (BMI 25+) at clinical onset must prove that weight status existed at the precise time of onset, not merely some years earlier. The definition of “being overweight or obese” is linked to BMI which means weight (kg) divided by height (m) squared - a simple calculation but one that requires contemporaneous records.

The SoP also indirectly affects veterans who served before the diagnosis criteria were formalised. They will now need retrospective evidence of the WPI, SSS, and region count, which may be difficult to obtain years after the original diagnosis. This can shift the evidentiary burden from the Commission to the claimant, making successful claims more dependent on medical record completeness than on the likely causal link to service.

The SoP imposes no direct duties on veterans, but in practice claimants must satisfy the existence of at least one factor from section 9 and demonstrate that the factor is related to relevant service under section 10(1). The duty is on the decision-maker to apply the SoP in accordance with its terms. The instrument confers a right on a veteran to have their claim assessed using the factors; decision-makers cannot impose additional factors not listed. However, this is a limited right because the factors are exhaustive: if a veteran’s condition clearly resulted from a service-related cause not listed (e.g., a specific toxic exposure not captured by the six factors), the instrument operates to reject the claim at the reasonable hypothesis stage, subject to any other applicable SoP.

Section 10(2) creates a special rule for factor (6) (inability to obtain appropriate clinical management). It applies only to material contribution to, or aggravation of, fibromyalgia where the person’s fibromyalgia was suffered or contracted before or during (but did not arise out of) the person’s relevant service. This means that if fibromyalgia first arose during service, the inability factor cannot be used to link the initial onset to service; it can only be used for a worsening of a pre-existing condition. That is a nuance often overlooked.

Section 11 incorporates other SoPs by reference. If a factor refers to an injury or disease for which another SoP exists (e.g., autoimmune inflammatory condition with arthritis - which itself must satisfy a definition in another SoP), then the factors in that other SoP apply as in force from time to time. This creates a cascading system where a veteran may need to satisfy not only the fibromyalgia SoP but also the SoP for the underlying condition. For example, factor (3) requires an autoimmune inflammatory condition associated with the development of arthritis. If that condition is rheumatoid arthritis, the veteran must also meet the factors in the rheumatoid arthritis SoP to establish that condition is service-related. This can multiply the evidentiary burden.

The RMA has the duty to determine the SoP based on sound medical‑scientific evidence (section 8). The instrument recites that the RMA is of the view that such evidence exists. That view is not reviewable in the merits review of a specific claim, but the existence of the SoP is conclusive as to the minimum factors.

This SoP does not itself contain penal provisions. It does not impose fines or imprisonment. Its effect is to determine whether a veteran is entitled to compensation under the VEA or MRCA, which involves payments of pensions or lump sums. The enforcement mechanism is the refusal or grant of the claim. If a claimant misrepresents facts to satisfy a factor (e.g., falsely claiming a childhood abuse history or fabricating medical evidence), they may be liable for criminal offences under the Criminal Code (Cth) for social security fraud, or under the VEA for false statements. However, those penalties are not in this instrument.

The primary cost to the government is the financial outlay if claims are accepted. The SoP is designed to restrict claims: only those who satisfy one of the six factors can succeed at the reasonable hypothesis stage. The RMA’s choice to require a minimum WPI/SSS score excludes many people with chronic pain who do not meet the strict numeric threshold. This reduces the pool of eligible claimants and hence the fiscal liability. From a free-market perspective, this is a supply-side restriction on benefits: the government controls the definition of the condition and the causal factors, reducing the moral hazard of spurious claims but also potentially undercompensating veterans with genuine service-related pain that does not fit the RMA’s template.

The SoP also creates an enforcement burden on the Department of Veterans’ Affairs (DVA) to verify the existence of factors. For example, verifying “severe childhood abuse” requires investigation of records that may be decades old, confidential, or unrecorded. The definition requires the harm to be perpetrated by a specific set of adults; abuse by other children or strangers (outside the “adult in contact” category) is excluded. DVA must police this boundary, which can lead to intrusive inquiries into a veteran’s childhood history. This is a cost to both the veteran (privacy intrusion) and the state (administrative resources).

The SoP operates under the VEA and the MRCA. Section 5 states that it applies to a claim to which section 120A of the VEA or section 338 of the MRCA applies. Section 120A VEA provides that the standard of proof for claims concerning operational service is reasonable hypothesis (for the claimant) unless the Commission is satisfied beyond reasonable doubt that there is no sufficient ground for determining that the injury is service-related. Section 338 MRCA contains a similar provision. The SoP is the tool for determining whether a reasonable hypothesis exists. If the claimant’s circumstances do not match any factor, the hypothesis is not reasonable, and the claim fails unless the Commission is satisfied (rarely) that the condition is service-related by some other route not covered by the SoP.

Section 120A(3) VEA requires the RMA to determine a SoP for a disease if there is sound medical‑scientific evidence that it can be related to service. The fibromyalgia SoP is one such determination. It interacts with other SoPs for conditions that are associated with fibromyalgia. For example, if a veteran has post-traumatic stress disorder (PTSD) and fibromyalgia, the PTSD may be a factor under the fibromyalgia SoP only if it qualifies as a severe, chronic medical condition (factor 5) or if a PTSD-related stressor qualifies as a category 1A stressor within one year before clinical onset (factor 4). But PTSD also has its own SoP; the emotional or cognitive symptoms from PTSD may not automatically meet the SSS definition for fibromyalgia, because the fibromyalgia SoP requires the SSS to be assessed independently.

Section 11 of the SoP explicitly provides that if a factor refers to another injury or disease with its own SoP, that other SoP applies. So if a claimant relies on factor (3) - autoimmune inflammatory condition with arthritis - they must also satisfy the SoP for that specific arthritis condition (e.g., rheumatoid arthritis or ankylosing spondylitis). This creates a system of stacked SoPs, each with its own definition and factors. A veteran with fibromyalgia secondary to a service-related rheumatoid arthritis must prove the rheumatoid arthritis is service-related under the rheumatoid arthritis SoP, and then use that as the factor for the fibromyalgia SoP. This multiplies the complexity and cost of claim preparation.

The SoP also interacts with the general law of evidence. The definitions in the Schedule are legal definitions, not medical ones. A medical practitioner may diagnose fibromyalgia using other criteria (e.g., 1990 ACR criteria), but the SoP’s criteria are binding for the claim. Similarly, the definition of severe childhood abuse is a legal definition, and clinical judgment may not align with its scope.

The SoP repeals the Statement of Principles concerning fibromyalgia No. 13 of 2014 (F2014L00016) made under subsection 196B(2) of the VEA. The current instrument is No. 107 of 2021, made on 22 October 2021, and commenced on 22 November 2021. The change in numbering suggests that numerous SoPs are issued each year. The 2014 version had a different factor set; the new version updates the medical definition of fibromyalgia to the 2016 ACR criteria (as reflected in the WPI and SSS scoring), and changes the factors. Notably, the earlier SoP may have had a different definition of stressor or omitted the “inability to obtain appropriate clinical management” factor. Practitioners should be careful not to rely on the older SoP.

The instrument also updates the ICD-10-AM code reference (M79.7) and ties the meaning of fibromyalgia to the Tenth Edition (effective 1 July 2017). Future amendments to the ICD codes may require a new SoP. The RMA has the power to revoke or amend SoPs at any time under section 196B(2). Given that the 2014 SoP lasted 7 years, a similar period might be expected before the next revision. The amendment history is unavailable in the source itself, but the repeal clause indicates that only one prior version exists (No. 13 of 2014). There may have been earlier versions before 2014 that were repealed and replaced by No. 13, but they are not mentioned.

The source does not list any cases. However, the SoP is a legislative instrument and is subject to judicial review. The Federal Court and the Administrative Appeals Tribunal have often considered whether the RMA properly determined a SoP or whether a factor should extend beyond its definition. For example, past litigation on the meaning of “severe childhood abuse” in other SoPs may inform interpretation here. The factor for “category 1A stressor” has been litigated in the context of PTSD SoPs; the definition here is identical. Similarly, the definition of fibromyalgia using the 2016 ACR criteria may face challenge if it excludes veterans with widespread pain that does not meet the specific scoring thresholds but is nevertheless clinically diagnosed.

The primary ground for challenge would be that the RMA breached its duty under section 196B(2) to base the SoP on sound medical‑scientific evidence. If new research emerges showing that other factors (e.g., chronic infections, sleep disorders) are more strongly linked to fibromyalgia, veterans might argue the SoP is too restrictive. But the High Court has given the RMA wide latitude. The 2021 SoP may have been issued in response to earlier AAT decisions that found the 2014 SoP difficult to apply. Practitioners should search for decisions on the 2014 SoP for guidance on how the AAT interprets the factors.

Several provisions can trap the unprepared.

Definition of fibromyalgia: Section 7(2) requires an assessed WPI and SSS. Many medical reports will state a diagnosis of fibromyalgia without these scores. Such a report is insufficient for the SoP. The claimant must obtain a specific assessment, often from a rheumatologist, that calculates the scores and confirms pain in at least 4 of the 5 regions. The exclusion of jaw, chest and abdomen from the region count but their inclusion in the WPI is a common source of error.

Severe childhood abuse: The definition requires the perpetrator to be a parent, care provider, an adult who works with or around the child, or any other adult in contact with the child. Abuse by a sibling who is a minor or by a non-adult does not count. Also, the abuse must be “severe” and defined as serious harm; less serious mistreatment is excluded. The note in factor (1) cross-references the definition, but many claimants may not realise that abuse by a grandparent who was not a care provider may still fit “any other adult in contact with the child”, which is broad but still requires some contact.

Category 1A stressor within 1 year: Factor (4) requires the stressor to occur within the 1 year before the clinical onset. This is a strict temporal window. If the stressor occurred 13 months before onset, it does not count. Also, “category 1A stressor” is narrower than a general stressor. It excludes events like witnessing trauma, verbal threats without a weapon, or non-physical harassment. The definition requires a life-threatening event, serious physical attack/threat, or captivity/torture. Many service-related stressors (e.g., handling dead bodies, constant fear of attack) may not qualify.

Severe, chronic medical condition for at least 2 years: The condition must have existed for at least 2 years before the clinical onset of fibromyalgia. It must also meet the strict criteria of substantial impact, daily management under a registered practitioner, and be of a type that does not usually resolve. The examples given are all serious (dialysis, severe psoriasis, poorly controlled asthma, etc.). Common conditions like hypertension or mild diabetes that are well-controlled are unlikely to satisfy the definition. The factor requires on-going daily or almost daily management with specific items; mere medication without supervision may not suffice.

Inability to obtain appropriate clinical management: Factor (6) is limited by section 10(2) to material contribution or aggravation where fibromyalgia was suffered or contracted before or during service but did not arise out of service. This means it cannot be used to claim the initial onset of fibromyalgia itself. For example, if a veteran had fibromyalgia before enlisting and was unable to get treatment because of their posting, that could support a worsening claim. But if fibromyalgia first appeared after a service event, this factor is not available.

Relationship to service: Section 10(1) requires the factor itself to be related to the relevant service. So even if a veteran has severe childhood abuse, that abuse must be related to their service (e.g., abuse occurred during service? No, childhood abuse occurs before service - how can it be related to service? The SoP does not say the factor must arise out of service; it must be “related to” service. This is a subtle point: the factor may be a pre-service condition that, because of service, becomes relevant? Actually, the standard interpretation is that the factor must exist as a consequence of service. For childhood abuse, the abuse must have happened as a result of the service (unlikely). More likely, the factor is a personal characteristic like overweight/obese; that must be related to service (e.g., weight gain due to service conditions). This is a gotcha: many claimants will have a factor that is not service-related, and the claim will fail.

Multiple factors: The SoP requires only one factor to exist, but the factor must be related to service. If a veteran has both factor (1) (childhood abuse) and factor (4) (stressor), but neither is service-related, the claim fails.

Terminal events: Death from fibromyalgia includes death from a terminal event contributed to by fibromyalgia. The terminal events listed are pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function. If a veteran with fibromyalgia dies from a drug overdose or suicide, it may not fall under these events unless fibromyalgia contributed to the suicide in a way that led to one of those events, which is tenuous.

For a veteran or their representative, compliance with the SoP involves gathering evidence that matches the definitions precisely.

Step 1: Obtain a medical report from a qualified practitioner (preferably a rheumatologist) that explicitly states:

• The diagnosis of fibromyalgia using the criteria in section 7(2): chronic widespread pain for at least 3 months, WPI score (0-19), SSS score (0-12), confirmation that pain is present in at least 4 of 5 specified regions, and a statement that the pain and symptoms are not better accounted for by another medical or psychiatric condition.
• The report should include the breakdown of the WPI (which body parts had pain in the last week) and the SSS (severity of fatigue, waking unrefreshed, cognitive symptoms, plus presence of headaches, lower abdominal pain/cramps, depression in past 6 months).
• The date of clinical onset (when the condition first met these criteria). This date is critical for temporal factors.

Step 2: Identify which factor(s) from section 9 the veteran can satisfy. For each factor, gather evidence linking the factor to the veteran’s relevant service.

• For factor (1) severe childhood abuse: gather police records, child protection records, medical reports of psychological harm, or credible witness statements. The abuse must be by a parent, care provider, adult who works with/around the child, or any adult in contact with the child. The abuse must have occurred before clinical onset of fibromyalgia. The abuse must also be related to service - difficult but possible if service conditions caused a re-exposure or trauma that exacerbated the abuse memory? Actually the factor itself must be related to service. Abuse usually predates service, so it is unlikely to be service-related. The better approach is to show that the abuse is indirectly linked (e.g., service made the veteran unable to cope with the abuse in a way that caused fibromyalgia). But the SoP requires the factor to be related to service - that might mean the abuse was a consequence of service (e.g., a veteran’s child was abused because of the parent’s service?). This is extremely narrow. Practitioners should focus on other factors.

• For factor (2) being overweight or obese: obtain evidence of height and weight at the time of clinical onset. This may be in service medical records. BMI calculation must be 25 or greater. If the veteran was not overweight at onset, this factor is not available.

• For factor (3) autoimmune inflammatory condition with arthritis: must have a confirmed diagnosis of such a condition (e.g., rheumatoid arthritis) at the time of clinical onset. That condition must also be service-related under its own SoP. So first establish the underlying condition as service-related, then use it as a factor.

• For factor (4) category 1A stressor within 1 year before onset: identify a specific event that meets the definition (life-threatening, serious physical attack, threat with weapon, held captive, etc.). Obtain service records, operational orders, witness statements, and a stressor statement. Ensure the event occurred within 1 year before the clinical onset date.

• For factor (5) severe, chronic medical condition: the condition must have been present for at least 2 years before fibromyalgia onset. Gather medical records showing the condition, its impact on functioning, the daily management required, and that it is of a type that does not resolve. The condition must also be related to service (e.g., service-related asthma).

• For factor (6) inability to obtain appropriate clinical management: only relevant for aggravation claims where fibromyalgia existed before or during service (but did not arise from service). Evidence of inability to access care due to service circumstances (e.g., posting to remote area, lack of specialists).

Step 3: Prepare a statement explaining how each factor relied on is related to the person’s relevant service. Section 10(1) requires this nexus. For example, if relying on being overweight, show that the weight gain was caused by service conditions (e.g., stress, lack of exercise, dietary changes). If relying on a stressor, the stressor must have occurred during service (operational, peacekeeping, etc.) or be caused by service.

Step 4: Submit the claim to DVA with all supporting evidence. The decision-maker will check each element against the SoP definitions. If the evidence does not match the definitions, the claim is likely to be rejected at the reasonable hypothesis stage. There is no discretion to accept alternative criteria.

For decision-makers (DVA officers), compliance means verifying the WPI, SSS, region count, and the exact definitions from the Schedule. They should not accept a mere diagnosis of fibromyalgia without the scoring. They must also check that any factor used is within the temporal windows and that the relationship to service is established. The SoP is binding; they cannot substitute their own view of causation. If the claimant does not satisfy any factor, the claim fails unless the decision-maker is satisfied beyond reasonable doubt that there is a causal link - a rare outcome.