Statement of Principles concerning BENIGN PAROXYSMAL POSITIONAL VERTIGO (Reasonable Hypothesis) (No. 56 of 2017) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 18 August 2017 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Nicholas Saunders AO Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Application 5 Definitions 6 Kind of injury, disease or death to which this Statement of Principles relates 7 Basis for determining the factors 8 Factors that must exist 9 Relationship to service 10 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 benign paroxysmal positional vertigo (Reasonable Hypothesis) (No. 56 of 2017). 2 Commencement This instrument commences on 18 September 2017. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 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. 5 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 6 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about benign paroxysmal positional vertigo and death from benign paroxysmal positional vertigo. Meaning of benign paroxysmal positional vertigo (2) For the purposes of this Statement of Principles, benign paroxysmal positional vertigo means recurrent episodes of vertigo lasting less than one minute that are provoked by specific types of head movements, together with the observation of nystagmus during a provoking manoeuver or evidence of response to treatment with repositioning manoeuvers. (3) While benign paroxysmal positional vertigo attracts ICD‑10‑AM code H81.1, in applying this Statement of Principles the meaning of benign paroxysmal positional vertigo is that given in subsection (2). (4) For subsection (3), a reference to an ICD‑10‑AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM), Ninth Edition, effective date of 1 July 2015, copyrighted by the Independent Hospital Pricing Authority, ISBN 978‑1‑76007‑020‑5. Death from benign paroxysmal positional vertigo (5) For the purposes of this Statement of Principles, benign paroxysmal positional vertigo, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's benign paroxysmal positional vertigo. Note: terminal event is defined in the Schedule 1 – Dictionary. 7 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that benign paroxysmal positional vertigo and death from benign paroxysmal positional vertigo 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: relevant service is defined in the Schedule 1 – Dictionary. 8 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 benign paroxysmal positional vertigo or death from benign paroxysmal positional vertigo with the circumstances of a person's relevant service: (1) having trauma involving the head or the head and neck within the 30 days before the clinical onset of benign paroxysmal positional vertigo; Note: Types of trauma include the head being struck by an object, the head striking an object or the head undergoing jolting movements. (2) having surgery to the head or neck, including dental surgery, where that surgery involves transmission of vibration or percussive forces to the inner ear, in the three months before the clinical onset of benign paroxysmal positional vertigo; (3) having cochlear implantation surgery in the three years before the clinical onset of benign paroxysmal positional vertigo; (4) having Meniere's disease on the affected side before the clinical onset of benign paroxysmal positional vertigo; (5) having vestibular neuritis or labyrinthitis on the affected side within the three months before the clinical onset of benign paroxysmal positional vertigo; (6) being infected with herpes simplex virus or varicella zoster virus, where there is evidence of the infection causing a clinical illness involving the vestibular nerve of the affected side, before the clinical onset of benign paroxysmal positional vertigo; (7) undertaking physical activity at a rate of at least six METs, where the activity involves sudden head turning, jolting or vibration of the body, within the seven days before the clinical onset of benign paroxysmal positional vertigo; Note: MET is defined in the Schedule 1 - Dictionary. (8) having active migraine at the time of the clinical onset of benign paroxysmal positional vertigo; Note: active migraine is defined in the Schedule 1 - Dictionary. (9) being in the Trendelenburg position for a surgical procedure within the seven days before the clinical onset of benign paroxysmal positional vertigo; Note: Trendelenburg position is defined in the Schedule 1 - Dictionary. (10) being confined to bed for medical or surgical treatment for periods of at least three days within the 14 days before the clinical onset of benign paroxysmal positional vertigo; (11) having decompression sickness at the time of the clinical onset of benign paroxysmal positional vertigo; (12) having trauma involving the head or the head and neck within the 30 days before the clinical worsening of benign paroxysmal positional vertigo; Note: Types of trauma include the head being struck by an object, the head striking an object or the head undergoing jolting movements. (13) having surgery to the head or neck, including dental surgery, where that surgery involves transmission of vibration or percussive forces to the inner ear, in the three months before the clinical worsening of benign paroxysmal positional vertigo; (14) having cochlear implantation surgery in the three years before the clinical worsening of benign paroxysmal positional vertigo; (15) having Meniere's disease on the affected side before the clinical worsening of benign paroxysmal positional vertigo; (16) having vestibular neuritis or labyrinthitis on the affected side within the three months before the clinical worsening of benign paroxysmal positional vertigo; (17) being infected with herpes simplex virus or varicella zoster virus, where there is evidence of the infection causing a clinical illness involving the vestibular nerve of the affected side, before the clinical worsening of benign paroxysmal positional vertigo; (18) undertaking physical activity at a rate of at least six METs, where the activity involves sudden head turning, jolting or vibration of the body, within the seven days before the clinical worsening of benign paroxysmal positional vertigo; Note: MET is defined in the Schedule 1 - Dictionary. (19) having active migraine at the time of the clinical worsening of benign paroxysmal positional vertigo; Note: active migraine is defined in the Schedule 1 - Dictionary. (20) being in the Trendelenburg position for a surgical procedure within the seven days before the clinical worsening of benign paroxysmal positional vertigo; Note: Trendelenburg position is defined in the Schedule 1 - Dictionary. (21) being confined to bed for medical or surgical treatment for periods of at least three days within the 14 days before the clinical worsening of benign paroxysmal positional vertigo; (22) inability to obtain appropriate clinical management for benign paroxysmal positional vertigo. 9 Relationship to service (1) The existence in a person of any factor referred to in section 8, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 8(12) to 8(22) apply only to material contribution to, or aggravation of, benign paroxysmal positional vertigo where the person's benign paroxysmal positional vertigo was suffered or contracted before or during (but did not arise out of) the person's relevant service. 10 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 8 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 5 1 Definitions In this instrument: active migraine means having at least one migraine headache per year. benign paroxysmal positional vertigo—see subsection 6(2). MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour or resting metabolic rate. MRCA means the Military Rehabilitation and Compensation Act 2004. 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. terminal event means the proximate or ultimate cause of death and includes the following: (a) pneumonia; (b) respiratory failure; (c) cardiac arrest; (d) circulatory failure; or (e) cessation of brain function. Trendelenburg position means a position in which the patient is lying on the back with the feet higher than the head by 15 to 30 degrees. VEA means the Veterans' Entitlements Act 1986.