Statement of Principles concerning peripheral neuropathy (Balance of Probabilities) (No. 73 of 2023)

This Statement of Principles (No. 73 of 2023) is a determinative instrument made by the Repatriation Medical Authority under subsection 196B(3) of the Veterans’ Entitlements Act 1986 (the VEA) that sets out the medical and exposure factors which, on the balance of probabilities, will establish a connection between peripheral neuropathy (and death from peripheral neuropathy) and a person’s relevant service. The instrument commenced on 25 July 2023 (s 2) and expressly repeals the earlier Statement of Principles concerning peripheral neuropathy No. 75 of 2014 (s 4). It applies to claims where section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 (MRCA) applies (s 5). The instrument therefore functions as a technical, evidentiary grid relied on by decision makers assessing entitlement under the VEA or MRCA to determine whether peripheral neuropathy is connected with service.

Mechanically, the instrument does several things. It defines the meaning of peripheral neuropathy for the purposes of the VEA/MRCA claims process (s 7(2)), including required clinical features and exclusions. It identifies that death from peripheral neuropathy is included where neuropathy contributed to a terminal event (s 7(3)). It sets out the evidentiary threshold and medical-scientific basis: the Authority is of the view that, on available medical‑scientific evidence, it is more probable than not that peripheral neuropathy can be related to relevant service (s 8). It then lists the discrete factors, one or more of which must exist before a decision maker may conclude, on the balance of probabilities, that the condition is connected with service (s 9). Those factors include diseases, exposures, substance use disorders, specified drugs and clinical management events, with precise timing and exposure windows. The Schedule contains definitions and detailed specified lists that operationalise those factors, including numeric exposure thresholds and specific drug names.

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RMA Australian Government Coat of Arms

Statement of Principles

concerning

PERIPHERAL NEUROPATHY (Balance of Probabilities)

(No. 73 of 2023)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 23 June 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1 Name

This is the Statement of Principles concerning peripheral neuropathy (Balance of Probabilities) (No. 73 of 2023).

2 Commencement

This instrument commences on 25 July 2023.

3 Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4 Repeal

The Statement of Principles concerning peripheral neuropathy No. 75 of 2014 (Federal Register of Legislation No. F2014L01137) made under subsection 196B(3) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

6 Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7 Kind of injury, disease or death to which this Statement of Principles relates

(1) This Statement of Principles is about peripheral neuropathy and death from peripheral neuropathy.

Meaning of peripheral neuropathy

(2) For the purposes of this Statement of Principles, peripheral neuropathy:

(a) means a non-traumatic pathology of the peripheral nerves that supply the upper or lower limbs, and producing:

(i) symptoms; and

(ii) signs or electrodiagnostic evidence (electromyography or nerve conduction studies);

of impaired motor, sensory or autonomic functioning; and

(b) includes mononeuritis multiplex; and

(i) autoimmune nodopathies associated with autoantibodies against nodal and paranodal proteins;

(ii) chronic immune sensory polyradiculopathy and chronic immune sensory and motor polyradiculopathy;

(iii) chronic inflammatory demyelinating polyneuropathy and its variants;

(iv) complex regional pain syndrome;

(v) Guillain-Barre syndrome;

(vi) hereditary neuropathies;

(vii) isolated mononeuropathies of the upper or lower limbs including carpal tunnel syndrome, meralgia paraesthetica, Morton metatarsalgia, tarsal tunnel syndrome, and ulnar neuropathy at the elbow;

(viii) motor neurone disease (amyotrophic lateral sclerosis);

(ix) multifocal motor neuropathy;

(x) neuralgic amyotrophy;

(xi) neurogenic thoracic outlet syndrome; and

(xii) peripheral manifestations of brain or spinal cord pathology including cerebrovascular accident, traumatic brain injury, cerebral tumours, multiple sclerosis, myelopathy, myelitis or cauda equina syndrome.

Note 1: Peripheral nerves include motor, sensory and autonomic nerves extending from the nerve roots to the sensors or actuators.

Note 2: Symptoms of peripheral neuropathy include tingling, numbness, pain, weakness and sweating dysfunction.

Note 3: non-traumatic is defined in the Schedule 1 – Dictionary.

Death from peripheral neuropathy

(3) For the purposes of this Statement of Principles, peripheral neuropathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's peripheral neuropathy.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8 Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that peripheral neuropathy and death from peripheral neuropathy can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.

9 Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, peripheral neuropathy or death from peripheral neuropathy is connected with the circumstances of a person's relevant service:

(1) having amyloidosis at the time of the clinical onset of peripheral neuropathy;

Note: amyloidosis is defined in the Schedule 1 - Dictionary.

(2) having chronic liver disease at the time of the clinical onset of peripheral neuropathy;

(3) having chronic renal failure at the time of the clinical onset of peripheral neuropathy;

Note: chronic renal failure is defined in the Schedule 1 - Dictionary.

(4) having sarcoidosis at the time of the clinical onset of peripheral neuropathy;

(5) having an endocrine disease from the specified list of endocrine diseases at the time of the clinical onset of peripheral neuropathy;

Note: specified list of endocrine diseases is defined in the Schedule 1 - Dictionary.

(6) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of peripheral neuropathy;

Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.

(7) having a systemic vasculitis from the specified list of forms of systemic vasculitis at the time of the clinical onset of peripheral neuropathy;

Note: specified list of forms of systemic vasculitis is defined in the Schedule 1 - Dictionary.

(8) having an infection from the specified list of infections at the time of the clinical onset of peripheral neuropathy;

Note: specified list of infections is defined in the Schedule 1 - Dictionary.

(9) having a haematological or lymphoproliferative disorder from the specified list of haematological or lymphoproliferative disorders at the time of the clinical onset of peripheral neuropathy;

Note: specified list of haematological or lymphoproliferative disorders is defined in the Schedule 1 - Dictionary.

(10) having a malignant neoplasm, other than non-melanotic malignant neoplasm of the skin, at the time of the clinical onset of peripheral neuropathy;

(11) having a neurological paraneoplastic syndrome at the time of the clinical onset of peripheral neuropathy;

(12) having a critical illness within the 30 days before the clinical onset of peripheral neuropathy;

Note: critical illness is defined in the Schedule 1 - Dictionary.

(13) having severe alcohol use disorder at the time of the clinical onset of peripheral neuropathy;

Note: severe alcohol use disorder is defined in the Schedule 1 - Dictionary.

(14) consuming at least 300 kilograms of alcohol within the 10 years before the clinical onset of peripheral neuropathy;

Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.

(15) inhaling, ingesting or having cutaneous contact with a chemical from the specified list of chemicals (short term exposure);

(a) on at least 30 occasions within a continuous period of 6 months before the clinical onset of peripheral neuropathy; and

(b) where exposure has ceased before the clinical onset of peripheral neuropathy, then that onset occurred within 3 months of cessation;

Note: specified list of chemicals (short term exposure) is defined in the Schedule 1 - Dictionary.

(16) inhaling, ingesting or having cutaneous contact with a chemical from the specified list of chemicals (long term exposure):

(a) on more days than not for at least 1 year before the clinical onset of peripheral neuropathy; and

(b) where exposure has ceased before the clinical onset of peripheral neuropathy, then that onset occurred within 3 months of cessation;

Note: specified list of chemicals (long term exposure) is defined in the Schedule 1 - Dictionary.

(17) having a severe substance use disorder involving inhalation of a substance from the specified list of substances at the time of the clinical onset of peripheral neuropathy;

Note: severe substance use disorder and specified list of substances are defined in the Schedule 1 - Dictionary.

(18) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) within the 30 days before the clinical onset of peripheral neuropathy;

Note: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary.

(19) having an episode of acute cholinergic poisoning from exposure to an organophosphorus compound or a carbamate insecticide within the 2 months before the clinical onset of peripheral neuropathy;

Note: acute cholinergic poisoning and organophosphorus compound are defined in the Schedule 1 - Dictionary.

(20) being poisoned with an agent from the specified list of agents, as demonstrated by clinical, haematological or biochemical evidence, within the 30 days before the clinical onset of peripheral neuropathy;

Note: specified list of agents is defined in the Schedule 1 - Dictionary.

(21) having a nutritional deficiency as specified at the time of the clinical onset of peripheral neuropathy;

Note: nutritional deficiency as specified is defined in the Schedule 1 - Dictionary.

(22) having hypophosphataemia while undergoing total parenteral nutrition at the time of the clinical onset of peripheral neuropathy;

(23) taking a drug from the specified list of drugs that cannot be ceased or substituted, at the time of the clinical onset of peripheral neuropathy;

Note: specified list of drugs that cannot be ceased or substituted is defined in the Schedule 1 - Dictionary.

(24) taking a drug that cannot be ceased or substituted and which is associated in the individual with the clinical onset of peripheral neuropathy during drug therapy and either:

(a) the improvement of peripheral neuropathy within 3 months of discontinuing or tapering drug therapy; or

(b) the redevelopment of peripheral neuropathy on rechallenge with the same drug or another drug from the same class of drugs; and

where the drug was being taken at the time of the clinical onset of peripheral neuropathy;

(25) taking a drug from the specified list of drugs at the time of the clinical onset of peripheral neuropathy;

Note: specified list of drugs is defined in the Schedule 1 - Dictionary.

(26) taking a drug which is associated in the individual with the clinical onset of peripheral neuropathy during drug therapy and either:

(a) the improvement of peripheral neuropathy within 3 months of discontinuing or tapering drug therapy; or

(b) the redevelopment of peripheral neuropathy on rechallenge with the same drug or another drug from the same class of drugs; and

where the drug was being taken at the time of the clinical onset of peripheral neuropathy;

(27) being treated with cisplatin within the 6 months before the clinical onset of peripheral neuropathy;

(28) having bariatric surgery within the 5 years before the clinical onset of peripheral neuropathy;

Note: bariatric surgery is defined in the Schedule 1 - Dictionary.

(29) having vitamin B6 (pyridoxine) hypervitaminosis at the time of the clinical onset of peripheral neuropathy;

Note: vitamin B6 (pyridoxine) hypervitaminosis is defined in the Schedule 1 - Dictionary.

(30) undergoing stem cell or bone marrow transplantation before the clinical onset of peripheral neuropathy;

(31) having acute carbon monoxide poisoning, with a carboxyhaemoglobin level of over 20 percent, within the 30 days before the clinical onset of peripheral neuropathy;

(32) having amyloidosis at the time of the clinical worsening of peripheral neuropathy;

Note: amyloidosis is defined in the Schedule 1 - Dictionary.

(33) having chronic liver disease at the time of the clinical worsening of peripheral neuropathy;

(34) having chronic renal failure at the time of the clinical worsening of peripheral neuropathy;

Note: chronic renal failure is defined in the Schedule 1 - Dictionary.

(35) having sarcoidosis at the time of the clinical worsening of peripheral neuropathy;

(36) having an endocrine disease from the specified list of endocrine diseases at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of endocrine diseases is defined in the Schedule 1 - Dictionary.

(37) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.

(38) having a systemic vasculitis from the specified list of forms of systemic vasculitis at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of forms of systemic vasculitis is defined in the Schedule 1 - Dictionary.

(39) having a haematological or lymphoproliferative disorder from the specified list of haematological or lymphoproliferative disorders at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of haematological or lymphoproliferative disorders is defined in the Schedule 1 - Dictionary.

(40) having a malignant neoplasm, other than non-melanotic malignant neoplasm of the skin, at the time of the clinical worsening of peripheral neuropathy;

(41) having a neurological paraneoplastic syndrome at the time of the clinical worsening of peripheral neuropathy;

(42) having a critical illness within the 30 days before the clinical worsening of peripheral neuropathy;

Note: critical illness is defined in the Schedule 1 - Dictionary.

(43) having severe alcohol use disorder at the time of the clinical worsening of peripheral neuropathy;

Note: severe alcohol use disorder is defined in the Schedule 1 - Dictionary.

(44) consuming at least 300 kilograms of alcohol within the 10 years before the clinical worsening of peripheral neuropathy;

Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.

(45) inhaling, ingesting or having cutaneous contact with a chemical from the specified list of chemicals (short term exposure);

(a) on at least 30 occasions within a continuous period of 6 months before the clinical worsening of peripheral neuropathy; and

(b) where exposure has ceased before the clinical worsening of peripheral neuropathy, then that worsening occurred within 3 months of cessation;

Note: specified list of chemicals (short term exposure) is defined in the Schedule 1 - Dictionary.

(46) inhaling, ingesting or having cutaneous contact with a chemical from the specified list of chemicals (long term exposure):

(a) on more days than not for at least 1 year before the clinical worsening of peripheral neuropathy; and

(b) where exposure has ceased before the clinical worsening of peripheral neuropathy, then that worsening occurred within 3 months of cessation;

Note: specified list of chemicals (long term exposure) is defined in the Schedule 1 - Dictionary.

(47) having a severe substance use disorder involving inhalation of a substance from the specified list of substances at the time of the clinical worsening of peripheral neuropathy;

Note: severe substance use disorder and specified list of substances are defined in the Schedule 1 - Dictionary.

(48) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) within the 30 days before the clinical worsening of peripheral neuropathy;

Note: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary.

(49) having an episode of acute cholinergic poisoning from exposure to an organophosphorus compound or a carbamate insecticide within the 2 months before the clinical worsening of peripheral neuropathy;

Note: acute cholinergic poisoning and organophosphorus compound are defined in the Schedule 1 - Dictionary.

(50) being poisoned with an agent from the specified list of agents, as demonstrated by clinical, haematological or biochemical evidence, within the 30 days before the clinical worsening of peripheral neuropathy;

Note: specified list of agents is defined in the Schedule 1 - Dictionary.

(51) having a nutritional deficiency as specified at the time of the clinical worsening of peripheral neuropathy;

Note: nutritional deficiency as specified is defined in the Schedule 1 - Dictionary.

(52) having hypophosphataemia while undergoing total parenteral nutrition at the time of the clinical worsening of peripheral neuropathy;

(53) taking a drug from the specified list of drugs that cannot be ceased or substituted, at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of drugs that cannot be ceased or substituted is defined in the Schedule 1 - Dictionary.

(54) taking a drug that cannot be ceased or substituted and which is associated in the individual with the clinical worsening of peripheral neuropathy during drug therapy and either:

(a) the improvement of peripheral neuropathy within 3 months of discontinuing or tapering drug therapy; or

(b) the clinical worsening of peripheral neuropathy on rechallenge with the same drug or another drug from the same class of drugs; and

where the drug was being taken at the time of the clinical worsening of peripheral neuropathy;

(55) taking a drug from the specified list of drugs at the time of the clinical worsening of peripheral neuropathy;

Note: specified list of drugs is defined in the Schedule 1 - Dictionary.

(56) taking a drug which is associated in the individual with the clinical worsening of peripheral neuropathy during drug therapy and either:

(a) the improvement of peripheral neuropathy within 3 months of discontinuing or tapering drug therapy; or

(b) the clinical worsening of peripheral neuropathy on rechallenge with the same drug or another drug from the same class of drugs; and

where the drug was being taken at the time of the clinical worsening of peripheral neuropathy;

(57) being treated with cisplatin within the 6 months before the clinical worsening of peripheral neuropathy;

(58) having bariatric surgery within the 5 years before the clinical worsening of peripheral neuropathy;

Note: bariatric surgery is defined in the Schedule 1 – Dictionary.

(59) having vitamin B6 (pyridoxine) hypervitaminosis at the time of the clinical worsening of peripheral neuropathy;

Note: vitamin B6 (pyridoxine) hypervitaminosis is defined in the Schedule 1 – Dictionary.

(60) undergoing stem cell or bone marrow transplantation before the clinical worsening of peripheral neuropathy;

(61) having acute carbon monoxide poisoning, with a carboxyhaemoglobin level of over 20 percent, within the 30 days before the clinical worsening of peripheral neuropathy;

(62) inability to obtain appropriate clinical management for peripheral neuropathy before the clinical worsening of peripheral neuropathy.

10 Relationship to service

(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2) The factors set out in subsections 9(32) to 9(62) apply only to material contribution to, or aggravation of, peripheral neuropathy where the person's peripheral neuropathy was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11 Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1) if a factor referred to in section 9 applies in relation to a person; and

(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary

Note: See Section 6

1 Definitions

In this instrument:

acromegaly means a chronic disease of adults resulting from hypersecretion of growth hormone after closure of the epiphyses.

acute cholinergic poisoning means symptoms and signs due to the inhibition of acetylcholinesterase enzyme activity which occur within 24 hours following exposure. These symptoms and signs include bradycardia, miosis, lacrimation, salivation, bronchorrhea, bronchospasm, urination, emesis and diarrhoea.

amyloidosis means the accumulation of insoluble fibrillar proteins in organs or tissues of the body such that vital function is compromised.

Note: Diseases that can be associated with amyloidosis include myeloma and chronic inflammatory diseases or chronic infectious diseases, such as inflammatory bowel disease, rheumatoid arthritis and tuberculosis.

bariatric surgery means weight reduction surgical procedures including gastrojejunostomy, gastric stapling, vertical banded gastroplasty and gastrectomy with Roux-en-Y anastomosis.

chronic renal failure means:

(a) having a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or

(b) a need for renal replacement therapy (dialysis or transplantation) for treatment of complications of decreased glomerular filtration rate which would otherwise increase the risk of morbidity and mortality; or

critical illness means septicaemia, acute respiratory distress syndrome, acute renal tubular necrosis, disseminated intravascular coagulation, multiple organ failure, or a clinical condition requiring mechanical ventilation support, excluding ventilation during surgery.

DSM-5-TR means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.

inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) means:

(a) decanting or spraying;

(b) cleaning or maintaining equipment used to apply;

(d) handling or sawing timber treated with;

(e) being in an environment shrouded in dust from timber treated with; or

(f) using cutting oils contaminated with;

one of the following chemicals:

(a) 2,4,5-trichlorophenoxyacetic acid;

(b) 2,4,5-trichlorophenoxypropionic acid;

(d) 2-(2,4,5-trichlorophenoxy)-ethyl 2,2-dichloropropionate;

(e) o,o-dimethyl-o-(2,4,5-trichlorophenyl)-phosphorothioate;

(f) pentachlorophenol;

(g) 2,3,4,6-tetrachlorophenol;

(h) 2,4,6-trichlorophenol;

(i) 1,3,5-trichloro-2-(4-nitrophenoxy)benzene;

(j) 2,4-dichloro-1-(4-nitrophenoxy)benzene; or

(k) 2,4-dichloro-1-(3-methoxy-4-nitrophenoxy)-benzene.

MRCA means the Military Rehabilitation and Compensation Act 2004.

non-traumatic means a disease mechanism not being damage due to blunt trauma, penetrating trauma, compression trauma, traction, thermal trauma, electrical trauma, ionising radiation, the effect of a space occupying lesion, or entrapment of a nerve or nerve root.

nutritional deficiency as specified means having clinical or biochemical evidence of a deficiency of one of the following:

(a) copper;

(b) vitamin B1 (thiamine);

(d) vitamin B12 (cobalamin); or

(e) vitamin E.

organophosphorus compound means an agent used to inhibit acetylcholinesterase, and includes Novichok nerve agents and the organophosphate pesticides chlorpyrifos, dichlorvos, diisopropyl phosphofluoridate, EPN (ethyl p-nitrophenyl theonobenzenephosphonate), ethyl parathion, fenthion, isopenphos, leptophos, malathion, merphos, methamidophos, mevinphos, mipafox (diisopropyl phosphorofluoridate), omethoate, parathion, phosphamidon/mevinphos, phenyl saligenin phosphate, trichlorfon, trichlornat and TOCP (tri-ortho-cresyl phosphate).

peripheral neuropathy—see subsection 7(2).

relevant service means:

(a) eligible war service (other than operational service) under the VEA;

(b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

severe alcohol use disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5-TR):

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 6 of the following, occurring within a 12-month period:

Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following:

(i) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or

(ii) a markedly diminished effect with continued use of the same amount of alcohol.

K. Withdrawal, as manifested by either of the following:

(i) the characteristic withdrawal syndrome for alcohol; or

(ii) alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

The definition of severe alcohol use disorder excludes acute alcohol intoxication in the absence of alcohol use disorder.

Note: DSM-5-TR is also defined in the Schedule 1 – Dictionary.

severe substance use disorder means a disorder of mental health characterised by a problematic pattern of use of a substance leading to clinically significant impairment or distress, as manifested by at least 6 of the following criteria (derived from DSM-5-TR), occurring within a 12-month period:

The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
Craving, or a strong desire or urge to use the substance.
Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home.
Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
Important social, occupational or recreational activities are given up or reduced because of substance use.
Recurrent substance use in situations in which it is physically hazardous.
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following:

(i) a need for markedly increased amounts of the substance to achieve intoxication or desired effect; or

(ii) a markedly diminished effect with continued use of the same amount of the substance.

Note: DSM-5-TR is also defined in the Schedule 1 - Dictionary.

specified list of agents means:

(a) a polychlorinated biphenyl;

(b) brevetoxin;

(d) cobalt;

(e) colloidal silver;

(f) diethylene glycol;

(g) dimethylamine borane;

(h) fruit of the Buckthorn shrub (Karwinskia humboldtiana);

(i) inorganic arsenic;

(j) inorganic lead;

(k) mercury;

(l) methyl bromide;

(m) N-3-pyridyl methyl-N’-p-nitrophenyl urea (Vacor);

(n) saxitoxin;

(o) tetrodotoxin;

(p) thallium salts;

(q) trichloropropane; or

(r) tri-ortho-cresyl phosphate.

specified list of autoimmune diseases means:

(a) antiphospholipid syndrome;

(b) coeliac disease;

(d) mixed connective tissue disease;

(e) rheumatoid arthritis;

(f) Sjögren syndrome;

(g) systemic lupus erythematosus; or

(h) systemic sclerosis (scleroderma).

specified list of chemicals (long term exposure) means:

(a) acrylamide monomer at an oral dose rate of >0.001 mg/kg/day;

(b) allyl chloride;

(d) carbon disulphide at an inhaled concentration of >0.3 ppm;

(e) ethylene oxide at an inhaled concentration of >1 ppm;

(f) methyl bromide at an inhaled concentration of >0.02 ppm;

(g) methyl n-butyl ketone (MNBK) at an inhaled concentration of >0.6 ppm; or

(h) n-hexane at an inhaled concentration of >0.6 ppm.

specified list of chemicals (short term exposure) means:

(a) acrylamide monomer at an oral dose rate of >0.01 mg/kg/day;

(b) 1-bromopropane at an inhaled concentration of >1 ppm or an oral dose rate of >0.001 mg/kg/day;

(d) dimethylaminopropionitrile;

(e) ethylene oxide at an inhaled concentration of >5 ppm;

(f) methyl bromide at an inhaled concentration of >0.02 ppm;

(g) methyl n-butyl ketone (MNBK) at an inhaled concentration of >0.6 ppm; or

(h) n-hexane at an inhaled concentration of >0.6 ppm.

specified list of drugs means

(a) amiodarone;

(b) arsenic trioxide;

(d) bortezomib;

(e) brentuximab vedotin;

(f) carfilzomib;

(g) cycloserine;

(h) dichloroacetate;

(i) disulfiram;

(j) fludarabine;

(k) fluoroquinolone antibiotics, excluding topical formulations;

(l) ipilimumab;

(m) isoniazid;

(n) itraconazole;

(o) linezolid;

(p) methotrexate;

(q) metronidazole;

(r) misonidazole;

(s) nitrofurantoin;

(t) pemetrexed;

(u) platinum compounds;

(v) pomalidomide;

(w) statins;

(x) taxanes;

(y) thalidomide;

(z) trastuzumab;

(aa) trastuzumab emtansine;

(bb) vigabatrin;

(cc) vinca alkaloids; or

(dd) zalcitabine (ddC).

specified list of drugs that cannot be ceased or substituted means:

(a) 5-fluorouracil;

(b) acitretin;

(d) auranofin;

(e) aurothioglucose;

(f) benznidazole;

(g) brigatinib;

(h) chloramphenicol;

(i) chloroquine;

(j) chlorprothixene;

(k) colchicine;

(l) crizotinib;

(m) cytosine arabinoside;

(n) dapsone;

(o) daptomycin;

(p) didanosine (ddI);

(q) encorafenib;

(r) entrectinib;

(s) eribulin mesylate;

(t) etanercept;

(u) ethambutol;

(v) etoposide;

(w) etravirine;

(x) gemcitabine;

(y) glutethimide;

(z) griseofulvin;

(aa) hexamethylmelamine;

(bb) hydralazine;

(cc) hydroxychloroquine;

(dd) infliximab;

(ee) interferon alpha;

(ff) ixabepilone;

(gg) leflunomide;

(hh) lenolidamide;

(ii) levodopa;

(jj) lithium;

(kk) lorlatinib;

(ll) mefloquine;

(mm) nitrous oxide with prolonged use over 24 hours;

(nn) nifurtimox;

(oo) peginterferon alpha-2a;

(pp) perhexiline maleate;

(qq) phenytoin;

(rr) podophyllin;

(ss) ponatinib;

(tt) procarbazine;

(uu) sorafenib;

(vv) stavudine (d4T);

(ww) sulphasalazine;

(xx) suramin;

(yy) telbivudine;

(zz) teniposide;

(aaa) teriflunomide;

(bbb) tioguanine; or

(ccc) voriconazole.

specified list of endocrine diseases means:

(a) acromegaly;

(b) diabetes mellitus;

(d) hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism; or

(e) thyrotoxicosis.

Note: acromegaly is also defined in the Schedule 1 – Dictionary.

specified list of forms of systemic vasculitis means:

(a) Behçet disease;

(b) eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome);

(d) granulomatosis with polyangiitis (Wegener granulomatosis);

(e) Henoch-Schonlein purpura (IgA vasculitis);

(f) microscopic polyangiitis;

(g) mixed cryoglobulinaemia; or

(h) polyarteritis nodosa.

specified list of haematological or lymphoproliferative disorders means:

(a) acute lymphoblastic leukaemia/lymphoblastic lymphoma;

(b) acute myeloid leukaemia;

(d) chronic myeloid leukaemia;

(e) Hodgkin lymphoma;

(f) hypereosinophilic syndrome;

(g) monoclonal gammopathy;

(h) myeloma;

(i) non-Hodgkin lymphoma;

(j) polycythaemia vera; or

(k) Waldenström macroglobulinaemia.

specified list of infections means:

(a) Borrelia burgdorferi (Lyme disease);

(b) Clostridium botulinum (botulism);

(d) cytomegalovirus;

(e) hepatitis B virus;

(f) hepatitis C virus;

(g) human immunodeficiency virus;

(h) Mycobacterium leprae (leprosy); or

(i) Treponema pallidum (tertiary syphilis).

specified list of substances means:

(a) methyl n-butyl ketone (MNBK);

(b) n-hexane;

(d) petrol.

terminal event means the proximate or ultimate cause of death and includes the following:

(a) pneumonia;

(b) respiratory failure;

(d) circulatory failure; or

(e) cessation of brain function.

VEA means the Veterans' Entitlements Act 1986.

vitamin B6 (pyridoxine) hypervitaminosis means:

(a) having taken least 100 milligrams of vitamin B6 per day for a continuous period of at least 12 months; or

(b) having clinical or biochemical evidence of vitamin B6 hypervitaminosis.

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Statement of Principles

concerning

PERIPHERAL NEUROPATHY (Balance of Probabilities)

(No. 73 of 2023)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 23 June 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1 Name

This is the Statement of Principles concerning peripheral neuropathy (Balance of Probabilities) (No. 73 of 2023).

2 Commencement

This instrument commences on 25 July 2023.

3 Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4 Repeal

The Statement of Principles concerning peripheral neuropathy No. 75 of 2014 (Federal Register of Legislation No. F2014L01137) made under subsection 196B(3) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

6 Definitions

Central legal and medical concepts are defined and anchored in the instrument. Peripheral neuropathy is defined narrowly for the purposes of claims under the VEA and MRCA. The definition requires three elements: a non‑traumatic pathology of peripheral nerves supplying the upper or lower limbs; the presence of symptoms together with signs or electrodiagnostic evidence (electromyography or nerve conduction studies); and resulting impairment of motor, sensory or autonomic function (s 7(2)(a)(i)-(ii)). The instrument explicitly includes mononeuritis multiplex and excludes a set of named conditions such as Guillain‑Barré syndrome, hereditary neuropathies, isolated mononeuropathies (for example carpal tunnel), chronic inflammatory demyelinating polyneuropathy, complex regional pain syndrome and peripheral manifestations of central nervous system pathology (s 7(2)(b)-(c)). The Schedule explains non‑traumatic as excluding injuries from blunt, penetrating, compression or traction trauma, thermal or electrical trauma, ionising radiation, space‑occupying lesions, or entrapment of a nerve or nerve root.

The causation model is the balance of probabilities. The Authority states that on the available medical‑scientific evidence it is more probable than not that peripheral neuropathy can be related to relevant service (s 8). The instrument then provides an exhaustive list of discrete factors, any one of which, if present and related to relevant service, is sufficient to establish connection on the balance of probabilities (s 9). These factors are both predisposing or aggravating conditions (for example amyloidosis, chronic liver disease, chronic renal failure, sarcoidosis, endocrine and autoimmune diseases), and exposure or treatment events (for example specified chemical exposures, prescribed drugs, cisplatin treatment, bariatric surgery, stem cell transplantation). Some factors are framed by timing windows relative to clinical onset or clinical worsening of neuropathy. For drugs, the instrument distinguishes between drugs that cannot be ceased or substituted (a specified list) and other specified drugs; in many cases evidence of temporal association and dechallenge/rechallenge is required (for example improvement within three months of stopping or re‑occurrence on rechallenge).

Relationship to service is a two‑stage concept. First, the instrument requires that one or more of the factors in s 9 must exist (s 9). Second, the factor must be related to the relevant service rendered by the person (s 10(1)). A further constraint is placed on factors in subsections 9(32) to 9(62): they apply only to material contribution to or aggravation of peripheral neuropathy where the neuropathy was suffered or contracted before or during (but did not arise out of) the person’s relevant service (s 10(2)). Finally, where a factor refers to an injury or disease already the subject of another Statement of Principles, that other Statement’s factors apply in accordance with its terms (s 11). The Schedule contains granular definitions and lists (for example specified chemicals, agents, drugs, infections, haematological disorders) that convert general factor headings into discrete, verifiable items.

The instrument affects claimants to whom section 120B of the VEA or section 339 of the MRCA applies (s 5). Practically, that means veterans, former members and serving members (as defined by the VEA and MRCA) who lodge claims alleging that peripheral neuropathy, or death from peripheral neuropathy, is connected with their relevant service. The RMA’s Statement is used by administrative decision makers when assessing connection for entitlement purposes under those Acts. The instrument also affects medical practitioners and allied health professionals who provide evidence in support of claims, because claimants must establish clinical onset, signs or electrodiagnostic confirmation, and the presence and timing of the listed factors.

Employers and third parties can be affected when their records are used to prove exposure or the occurrence of specified events. For example, the instrument requires precise evidence as to chemical exposures, either short term (30 occasions in a continuous 6 month period) or long term (on more days than not for at least one year), with set windows for time from cessation to clinical onset or worsening (three months) (ss 9(15)-(16), 9(45)-(46) and Schedule lists). Occupational health records, maintenance logs, pesticide application records, or timber handling logs may therefore become material. Where the claimant alleges inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by TCDD (dioxin), the Schedule specifies detailed modes of exposure such as decanting, spraying, cleaning application equipment, being sprayed, handling treated timber, or dust exposure (Schedule).

Medical product manufacturers and prescribers may be implicated by the lists of drugs. The instrument contains two lists of drugs: specified list of drugs (which includes numerous chemotherapeutic agents, some antibiotics, statins, taxanes, vinca alkaloids and others) and a separate list of drugs that cannot be ceased or substituted (a different set with drug names). Where the drug was being taken at the time of clinical onset, and if the individual demonstrates improvement within three months of discontinuation (or recurrence on rechallenge), a connection can be established under several factors (for example ss 9(24), 9(26), 9(54), 9(56)). This places evidentiary emphasis on clinical records showing prescription, dosing, cessation and objective response.

Decision makers and advisers (lawyers, advocates and health assessors) must also be operationally affected. The Statement requires specific forms of evidence,clinical onset date, electrodiagnostic studies, biochemical or haematological proofs for poisoning, GFR thresholds for chronic renal failure, GGT or liver disease documentation, and DSM‑5‑TR derived criteria for severe alcohol or substance use disorder,so advisers will need to structure claims to produce that evidence and to address timing and relation to service. Finally, the RMA and the Department administratively face record assessment and potentially higher evidentiary burdens in cases where records are incomplete, in which case the timing of onset and service linkage will be contested.

The instrument itself does not create duties or rights in the sense of imposing criminal sanctions. Rather, it prescribes a deterministic evidentiary framework that administrative decision makers must apply when determining whether peripheral neuropathy or death from peripheral neuropathy is connected with relevant service for the purposes of entitlements under the VEA and MRCA. The RMA made the Statement under its statutory power (s 3), and decision makers use it to determine connection under the specified sections in the principal Acts (s 5). The claimant’s right is to have an entitlement decision informed by this Statement where the claim falls within s 120B VEA or s 339 MRCA.

Operational duties fall on medical practitioners, claimants and decision makers to produce and assess the evidence that the Statement requires. The claimant must show that the condition meets the instrument’s definition of peripheral neuropathy, specifically a non‑traumatic pathology with symptoms and either signs or electrodiagnostic evidence (s 7(2)). For many factors, claimants must supply clinical, haematological or biochemical evidence,for example, poisoning by a specified agent demonstrated by clinical, haematological or biochemical evidence within the 30 days before clinical onset (s 9(20)), or acute carbon monoxide poisoning with a carboxyhaemoglobin level over 20 per cent within 30 days before onset (s 9(31)). Chronic renal failure is defined by glomerular filtration rate thresholds or the need for dialysis or transplantation over set periods (Schedule).

Where the claimant alleges a factor that is disease‑related (for example a specified autoimmune disease, endocrine disease, infection or haematological disorder), the Statement requires that that disease was present at the time of clinical onset or clinical worsening. For drug‑related factors that require dechallenge/rechallenge evidence, the claimant has, effectively, the burden of proving temporal association and response to withdrawal or rechallenge (ss 9(24), 9(26), 9(54), 9(56)). Decision makers have the duty to treat this Statement as the governing Statement of Principles and to apply it, but the Statement also cross‑references other Statements of Principles where factors refer to injuries or diseases already covered (s 11). That creates a duty to consult and apply the terms of those other Statements where relevant.

Claimants retain procedural rights under the VEA and MRCA to lodge claims, to have evidence considered, and to seek review and merits review as provided by those Acts. The Statement does not alter those statutory review mechanisms, but it materially affects the evidentiary standard and the content of medical evidence required to establish connection. The RMA’s authority is to determine the Statement; it does not itself decide individual claims. Rights to benefits therefore remain within the statutory adjudication frameworks; the Statement is an interpretive tool with binding status for decision makers applying the connection tests under the VEA and MRCA.

This Statement of Principles does not create criminal offences, civil penalties or administrative fines. It is a technical instrument used by adjudicators to determine entitlement under the VEA and MRCA. The instrument’s legal force flows from the RMA’s statutory power to determine Statements of Principles under subsection 196B(3) of the VEA (s 3). Enforcement in the conventional punitive sense does not arise from the Statement itself. Instead, the operational enforcement mechanism is administrative: decision makers will rely on the Statement to decide whether to accept a claim as connected with service. That decision then triggers entitlement streams, or denial, under the VEA or MRCA.

Because the Statement prescribes criteria and timing requirements, its practical enforcement effect is to set thresholds that must be met by claimants’ evidence. For example, certain exposures must be shown within strict temporal windows (for instance, acute cholinergic poisoning within two months of clinical onset, s 9(19); inhalation or contact with TCDD‑contaminated chemical agents within 30 days before onset, s 9(18)). Where claimants cannot meet those windows or cannot produce the biochemical, haematological, electrodiagnostic or occupational evidence the Statement requires, decision makers can lawfully find there is no connection and deny the claim. The instrument therefore functions as a gatekeeper to benefits rather than as a penal device.

There are also indirect enforcement consequences. Where a claim is accepted because it satisfies a specified factor and timing, the State will incur liability for entitlements under the VEA or MRCA. Conversely, if a claim is denied based on this Statement, the claimant may exercise statutory review and appeal rights in the principal Acts. The Statement does not itself prescribe the appeals process. Any procedural sanctions for misleading information or fraud in a claim arise under the VEA/MRCA administrative frameworks, not from this Statement. Readers should not infer that the Statement imposes obligations that attract separate fines; its purpose is evidentiary definition and administrative guidance for entitlement determination.

This instrument is an interpretive, evidentiary instrument that interacts directly with the VEA and MRCA. It applies to claims to which s 120B of the VEA or s 339 of the MRCA apply (s 5), meaning it is invoked when a decision maker is determining whether a disease or death is connected with service under the statutory tests in those Acts. The Authority made the Statement under the enabling provision of the VEA (s 3), so it sits subordinate to the primary legislation and operates within the statutory decision frameworks and review processes contained in those Acts.

Section 11 establishes a specific mechanism for interaction with other Statements of Principles. Where a factor listed in s 9 refers to an injury or disease that is already the subject of another Statement determined under subsection 196B(3) of the VEA, then the factors in that other Statement apply according to their own terms. This creates a networked structure of Statements where cross‑references may determine the applicable presumptions and evidentiary rules. Practically, decision makers must identify whether a listed factor corresponds to another Statement and then apply that other Statement’s conditions. That avoids duplication but requires administrative cross‑checking and coordination.

The Statement’s definitions incorporate other legal references. The Schedule defines MRCA and VEA by reference to those Acts; it adopts DSM‑5‑TR criteria for severe alcohol and substance use disorder and requires measurement standards for alcohol consumption utilising the Australian standard of 10 grams of alcohol per standard alcoholic drink (Schedule notes). The instrument therefore imports diagnostic frameworks and statistical standards commonly used in medical and occupational contexts. Where statutory or regulatory regimes outside the VEA/MRCA regulate exposure limits, occupational safety or compensation (for example workers’ compensation regimes), this Statement does not displace those schemes, but an affected person may have parallel claims under other legal regimes. The Statement does not address interactions with workers’ compensation, public health laws, or tort actions; it simply sets the RMA’s position for veterans’ entitlement determinations.

The Statement also interacts implicitly with medical practice and pharmaceutical regulation. Its lists of drugs and exposure agents may interface with product labelling, pharmacovigilance records and clinical management decisions. For drugs where cessation or substitution is relevant, the Statement assumes clinicians will have recorded therapeutic choices and adverse effects. Decision makers using this Statement will therefore need to reconcile clinical records, regulatory advice and the Statement’s lists to determine whether the conditions are satisfied. The Statement does not, however, alter obligations under privacy laws in collecting medical records, nor does it authorise compulsion to obtain records beyond the powers available in the VEA or MRCA frameworks.

The instrument itself contains minimal amendment history. It expressly repeals the earlier Statement of Principles concerning peripheral neuropathy No. 75 of 2014 made under subsection 196B(3) of the VEA (s 4). The instrument was made and dated 23 June 2023 and commences on 25 July 2023 (ss 1-2). The Schedule states definitions and specified lists that operationalise the factors. There are no further amendment entries recorded within the text provided.

Because this Statement is an RMA determination under subsection 196B(3) of the VEA, future amendments would follow the same statutory process and would be reflected by a subsequent instrument that amends, replaces or repeals this Statement. The instrument contains an express cross‑reference mechanism to other Statements of Principles (s 11), which means a change to another Statement could affect how this instrument operates in specific cases where factors refer to diseases covered elsewhere. The document itself does not record prior revisions beyond the repeal of the 2014 Statement.

Practitioners should therefore treat the instrument as current as of its commencement date and monitor the Federal Register of Legislation and RMA publications for any subsequent determinations that amend these provisions or alter specified lists. Because the Statement relies on medical‑scientific evidence (s 8), new medical evidence or changes in clinical practice could prompt the RMA to revise the Statement. The absence of recorded amendment history in the instrument does not preclude later amendments; it simply reflects that, as made, this instrument superseded the 2014 Statement and stands until further determination.

The instrument does not record any litigation history within its text. It is a determinative administrative instrument and does not cite cases, judicial interpretations, or prior litigation. Consequently, there are no judicial decisions referenced in the Statement that construe its provisions or application. The instrument’s legal standing is statutory: it is made pursuant to the RMA’s power under subsection 196B(3) of the VEA (s 3), and its role is to guide administrative determinations under the VEA and MRCA.

That lack of recorded litigation history means that, as of the instrument’s text, there is no on‑face catalogue of judicial responses to its provisions included in the instrument. Practitioners seeking to understand how courts or tribunals have applied equivalent or prior Statements of Principles, or how they have interpreted the relationship between RMA determinations and statutory causation standards, will need to search administrative and judicial databases for decisions post‑dating this instrument. The instrument itself signals that it replaces the 2014 Statement (s 4), which creates an avenue for comparative analysis: prior decisions referencing the 2014 Statement may illuminate themes, but the content and thresholds in the 2023 Statement differ and therefore may produce different outcomes.

Where a claimant contests an administrative decision that applied this Statement, the review and appeal mechanisms available under the VEA and MRCA would be the procedural routes for litigation. Those decisions may give rise to judicial review or merits review applications in appropriate tribunals or courts, and subsequent case law may clarify evidentiary questions such as the meaning of “related to relevant service” for particular factors, the sufficiency of exposure evidence, or the application of the timing windows the Statement sets. The Statement as provided contains no recorded judicial interpretations; any litigation history must be assembled from external case law and follow‑on decisions.

Several features of the Statement are technical and likely to generate practical pitfalls for claimants and advisers. These are concrete evidentiary and timing traps that can determine the outcome of entitlement decisions.

Narrow diagnostic definition. The instrument requires not only symptoms but also signs or electrodiagnostic evidence (electromyography or nerve conduction studies) of impaired motor, sensory or autonomic function (s 7(2)(a)(i)-(ii)). Absent objective signs or tests, a claimant’s report of symptoms alone will not satisfy the definition of peripheral neuropathy for the Statement.
Extensive exclusions. Several specific neuropathic disorders are excluded, including Guillain‑Barré syndrome, hereditary neuropathies, chronic inflammatory demyelinating polyneuropathy, isolated mononeuropathies such as carpal tunnel syndrome, and peripheral manifestations of brain or spinal cord pathology (s 7(2)(c)). Careful diagnostic differentiation is required, because an incorrect or broad diagnosis may fall outside the Statement.
Timing windows and cessation rules. Many exposure factors require strict timing. Short term chemical exposure requires at least 30 occasions within a continuous 6 month period and, if exposure ceased before clinical onset, that onset must be within 3 months of cessation (s 9(15)). Long term exposure requires exposure on more days than not for at least one year, with the same 3 month post‑cessation window (s 9(16)). These temporal constraints can defeat claims where records do not show the requisite frequency or where onset is uncertain.
Different treatment and drug rules. There are separate lists for "specified list of drugs" and "specified list of drugs that cannot be ceased or substituted" in the Schedule. For many drug factors, the Statement requires either that the drug was being taken at onset, or that the drug is associated with onset demonstrated by improvement within three months of discontinuation or recurrence on rechallenge (ss 9(23)-(26), 9(53)-(56)). In practice, obtaining evidence of improvement within three months of stopping a necessary drug may be clinically impossible, particularly where the drug is essential and cessation is unsafe. The instrument does include a special category for drugs that cannot be ceased or substituted (Schedule list), where different rules apply.
High numerical thresholds. The alcohol threshold is high: consuming at least 300 kilograms of alcohol within ten years before clinical onset or clinical worsening (ss 9(14), 9(44) and Schedule note that alcohol consumption is calculated using the Australian standard of 10 grams per standard drink). Practitioners should verify that alleged consumption meets that implausibly large aggregate quantity; this involves conversion to standard drinks and corroborative records.
Clinical onset versus clinical worsening. The instrument differentiates factors present at clinical onset (ss 9(1)-(31)) and factors present at clinical worsening (ss 9(32)-(62)). Section 10(2) restricts the latter group to material contribution or aggravation of pre‑existing neuropathy suffered or contracted before or during (but not arising out of) relevant service. This means that a factor listed at 9(32)-(62) cannot be used to establish that neuropathy first arose out of service. The legal distinction between contracting/suffering in service and aggravation after service is a frequent source of dispute.
Required biochemical proof for poisonings and exposures. For specified agent poisonings, the Statement requires clinical, haematological or biochemical evidence within 30 days before clinical onset (s 9(20)). Similarly, acute carbon monoxide poisoning requires a carboxyhaemoglobin level over 20 per cent (s 9(31)). Absent such laboratory proof, the factor will not be made out.
Cross‑reference complexity. Section 11 requires that factors referring to injuries or diseases covered by other Statements be dealt with according to those Statements. This can complicate claim preparation because the decision maker must evaluate which Statement applies and apply multiple documents. Practitioners must cross‑check other Statements to determine applicable requirements.
DSM‑5‑TR criteria for severity of substance and alcohol use disorders. The Statement incorporates DSM‑5‑TR‑derived criteria for severe alcohol and severe substance use disorder in the Schedule. That requires psychiatric diagnostic evidence meeting a high threshold of at least six specified criteria within a 12 month period. Routine clinical notes that do not apply DSM‑5‑TR criteria may be insufficient.
Proof of exposure concentration. For the specified lists of chemicals, the Schedule provides numeric exposure thresholds (for example acrylamide monomer oral dose rates, inhaled concentrations in ppm for 1‑bromopropane, ethylene oxide, methyl bromide, n‑hexane, etc). Claimants must produce evidence capable of establishing those concentrations and durations, which is often technically complex and may require industrial hygiene or occupational exposure assessment evidence.

These features create concrete evidentiary requirements that are frequently challenging to meet. Failure to provide the specific laboratory, electrodiagnostic, exposure, prescription, or occupational records that the Statement requires can be fatal to a claim. Practitioners should plan evidence collection with these exacting thresholds in mind.

Compliance, in this context, means assembling and presenting the evidence the instrument requires so that a decision maker can lawfully find that peripheral neuropathy is connected with relevant service. The steps below follow directly from the Statement’s text and Schedule and are structured to meet the specific factor and timing requirements.

Confirm the claim falls within the Statement’s application. Ensure the claim is one to which s 120B of the VEA or s 339 of the MRCA applies (s 5). If not, the Statement will not govern the connection determination.
Establish the diagnosis in the terms used by the Statement. The claimant’s medical records should show that the condition meets the Statement’s definition: a non‑traumatic pathology of peripheral nerves supplying upper or lower limbs producing symptoms and signs or electrodiagnostic evidence (EMG or nerve conduction studies) of impaired motor, sensory or autonomic function (s 7(2)). Obtain and include EMG and nerve conduction study reports, and documentation excluding traumatic mechanisms as defined in the Schedule.
Identify which factor(s) in s 9 is/are relied on. The Statement requires at least one enumerated factor to be present. Carefully map clinical and documentary evidence to the exact factor wording. For disease factors, include diagnostic criteria, specialist letters, pathology and imaging where relevant (for example amyloidosis, chronic liver disease, chronic renal failure as defined in the Schedule). For infection factors, provide microbiology or serology evidence for the specified pathogens.
Meet timing windows precisely. For factors tied to clinical onset, show the date of clinical onset and the presence of the factor at that date. For exposures that specify cessation windows, prove both the exposure period and the cessation date so the three month or other windows can be tested. For "short term exposure" provide documentary proof of at least 30 occasions within a continuous 6 month period; for "long term exposure" provide records showing exposure on more days than not for at least one year (ss 9(15)-(16) and Schedule).
Provide biochemical, haematological or electrodiagnostic proof where required. For specified agent poisoning, supply relevant lab results within 30 days before clinical onset (s 9(20)). For acute carbon monoxide poisoning, provide carboxyhaemoglobin level results demonstrating >20 per cent within 30 days before onset (s 9(31)). For chronic renal failure, include GFR results, dialysis records or transplant records meeting the Schedule definition.
Document drug therapy carefully. If a specified drug or a drug that cannot be ceased is implicated, supply prescription records, pharmacy dispensing records, specialist letters, and clinical notes showing start and stop dates. Where the rule requires dechallenge/rechallenge evidence, provide documentation of clinical improvement within 3 months of discontinuation, or of recurrence on rechallenge, as applicable (ss 9(24), 9(26), 9(54), 9(56)). Where drug cessation was clinically contraindicated, document the clinical rationale and include expert opinion linking the drug to neuropathy.
For exposure to chemicals with numeric thresholds, obtain occupational hygiene assessments or expert opinions. The Schedule specifies concentrations and dose rates for many chemicals. Clinical assertions about exposure are unlikely to suffice. Collect workplace exposure assessments, monitoring data, maintenance and application logs, or expert industrial hygiene reports that can establish exposure magnitude and frequency.
For alcohol and substance use disorder factors, obtain psychiatric evidence applying DSM‑5‑TR criteria. Severe alcohol and substance use disorders are defined by DSM‑5‑TR‑derived criteria and require evidence that at least six specified criteria were met within a 12 month period. Provide psychiatric assessments, treatment records, inpatient admissions and other documentation that apply those criteria.
For TCDD contamination allegations, collect specific evidence of the modes of exposure set out in the Schedule. The Schedule lists specific activities such as decanting, spraying, cleaning equipment, being sprayed, handling treated timber, or being in an environment shrouded in dust from treated timber. Documentary proofs include work records, photographs, material safety data sheets, timber treatment records and witness statements.
Address the requirement that the factor be related to relevant service. Section 10(1) requires that the factor be related to the person’s relevant service. Evidence must therefore connect the factor to service: for example, show that exposure occurred during deployment, training or duties qualifying as relevant service, or that a medical event occurred in service. For subsections 9(32)-9(62) used as aggravation factors, ensure the neuropathy pre‑existed before or during service and that the factor materially contributed to or aggravated it (s 10(2)).
Cross‑check other Statements of Principles. If the factor refers to another disease covered by a separate Statement, obtain and comply with that other Statement’s documentation requirements because s 11 makes that other Statement applicable.
Use expert opinions to bridge gaps. Where primary records are incomplete, admissible expert medical opinion that links the clinical presentation, test results and exposure history to the recognized factors may be decisive. Experts should address the specific language of the Statement, including timing windows and the balance of probabilities standard.
Prepare for contest of onset date. Disputes about the date of clinical onset are common and can alter whether a factor’s timing window is satisfied. Assemble contemporaneous clinical notes, GP records, early specialist correspondence and any electrodiagnostic test dates to anchor onset.
Keep conversions and calculations transparent. Where the instrument requires conversion of alcohol consumption using the Australian standard of 10 grams per standard drink, provide the arithmetic and the sources (for example quantity and frequency records) used to reach aggregate quantities such as the 300 kilogram threshold.
Anticipate cross‑evidentiary challenges. Because many components require biochemical, occupational or specialist evidence, anticipate requests for further information and plan to procure test results, workplace records, and prescribing data proactively.

Advisers should structure claims prospectively around the precise text of the Statement and its defined lists and thresholds. The emphasis must be on objective, contemporaneous evidence that matches the Statement’s criteria and timing windows so that the decision maker can lawfully find a connection on the balance of probabilities.

Statement of Principles concerning peripheral neuropathy (Balance of Probabilities) (No. 73 of 2023)

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