Statement of Principles concerning peripheral neuropathy (Reasonable Hypothesis) (No. 72 of 2023)
1Statement of Principles concerning peripheral neuropathy (Reasonable Hypothesis) (No. 72 of 2023)
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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
Definitions
1 Name
This is the Statement of Principles concerning peripheral neuropathy (Reasonable Hypothesis) (No. 72 of 2023).
2 Commencement
This instrument commences on 25 July 2023.
3 Authority
This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.
4 Repeal
The Statement of Principles concerning peripheral neuropathy No. 74 of 2014 (Federal Register of Legislation No. F2014L01135) made under subsection 196B(2) of the VEA is repealed.
5 Application
This instrument applies to a claim to which section 120A of the VEA or section 338 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
(c) excludes:
(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
The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that peripheral neuropathy and death from peripheral neuropathy can be related to relevant service rendered by veterans, members of Peacekeeping Forces, 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 as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting peripheral neuropathy or death from peripheral neuropathy 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 200 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 200 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(2) 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
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
(c) undergoing chronic dialysis.
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;
(c) being sprayed with;
(d) handling or sawing timber treated with;
(e) being in an environment shrouded in dust from timber treated with; or
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);
(c) vitamin B6 (pyridoxine);
(d) vitamin B12 (cobalamin);
(e) vitamin E; or
(f) niacin.
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) operational service under the VEA;
(b) peacekeeping service under the VEA;
(c) hazardous service under the VEA;
(d) British nuclear test defence service under the VEA;
(e) warlike service under the MRCA; or
(f) non-warlike service under the MRCA.
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-V-TR is also defined in the Schedule 1 – Dictionary.
specified list of agents means:
(a) a polychlorinated biphenyl;
(b) brevetoxin;
(c) ciguatera toxin;
(d) cobalt;
(e) colloidal silver;
(f) diethylene glycol;
(g) dimethylamine borane;
(h) ethylene glycol;
(i) fruit of the Buckthorn shrub (Karwinskia humboldtiana);