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

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:

Professor Terence Campbell AM Chairperson

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neuropathy No. 75 of 2014 (Federal Register of Legislation No. F2014L01137) made under subsection 196B(3) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004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 (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 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.