SOP Bulletin No. 142

Decision Support Unit

Intranet site: : http://sharepoint/servingourcustomers/compensation/dsu

10 May 2010

THE FOLLOWING RMA SOPS ARE TO TAKE EFFECT ON 12 MAY, 2010

New SOPs	Joint instability Iliotibial band syndrome
Revocations & Replacements	Cluster headache Alzheimer-type dementia (replaces Alzheimer's disease) Dislocation Reactive arthritis (replaces Reiter's syndrome) Non-Hodgkin's lymphoma Gout
Amendments	Lumbar spondylosis Intervertebral disc prolapse Depressive disorder Anxiety disorder Spondylolisthesis and spondylolysis Neoplasm of the pituitary gland (RH SOP only)

NOTEWORTHY FEATURES

Joint instability

New  – 32 & 33 of '10

• This is a new SOP# that covers instability in a joint, that manifests as recurrent dislocation or subluxation (typically of the shoulder) or recurrent sprain (typically in the ankle).  It is similar to the SOP for internal derangement of the knee, in that it covers recurrent or chronic problems (but not degenerative disease).  Acute and one-off sprains and dislocations are still covered by t — he SOPs for acute sprain and acute strain and for dislocation.  See further comments below re the dislocation SOP.

Iliotibial band syndrome

New  – 34 & 35 of '10

• This is a new SOP# covering a type of overuse injury that results in pain in the outside of the knee and lower thigh.

Cluster headache

Revocation – 20 & 21 of '10 Replaces 66 and 67 of '99

• The word “syndrome” has been dropped from the name of the SOP and the definition has been slightly reworded. These two changes have no operational effect.
• The previous trauma factor has been removed from the BOP SOP.
• The previous alcohol factor (worsening only) has been removed from both the RH and BOP SOPs.
• The drugs factor (worsening only) now covers two specific nitrates only.

Alzheimer-type dementia

Revocation – 22 & 23 of '10 Replaces 17 and 18 of '01

• There are major changes to this SOP.
• There is a shift in emphasis in the SOP name and the definition from the pathological entity (definitively diagnosable only on autopsy) to the clinical condition. 
• There is a new definition in a DSM IV style.  However, this is not a psychiatric disease. Diagnosis will generally require assessment by a neurologist, with neuroimaging (CT scan, MRI) plus other testing (including neuropsychological testing).  This level of investigation is needed to both confirm the presence of dementia and to identify the particular type.
• The old RH and BOP SOP — s had only one causal factor – for head injury.  This has been removed from the BOP SOP.
• The new RH SOP has a range of new onset factors, for:
• Cardiovascular risk factors – smoking, dyslipidaemia, diabetes, obesity, hypertension and hyperhomocysteinaemia;
• Electromagnetic radiation;
• Thyroid abnormalities; and
• Depressive episodes.
• The new BOP SOP has onset factors only for smoking and hyperhomocysteinaemia.

Dislocation

Revocation – 24 & 25 of '10 Replaces 290 and 291 of '95

• The dislocation and joint instability SOPs now work together like the epileptic seizure and epilepsy SOPs.  Which one applies depends on the individual circumstances: 
• A first or one-off episode of dislocation is covered by the dislocation SOP;
• Recurrent dislocation in an unstable (damaged) joint is covered by the joint instability SOP.   A previous diagnosis of dislocation in that joint may then be subsumed by a diagnosis of joint instability;
• A second or subsequent episode of dislocation in a joint may still be covered by the dislocation SOP, but only if there is no underlying joint stability problem (e.g. a second shoulder dislocation, due to trauma, 5 years after a first episode, in an otherwise healthy joint). 
• Each dislocation covered by the dislocation SOP will be a new, separate episode of dislocation, whereas joint instability is an ongoing condition.
• Consequently, there are no worsening factors in th — e dislocation SOP (apart from inability to obtain ACM).
• New causal factors have been added that are joint specific - for the atlantoaxial joint (top of spine) and the temporomandibular joint (jaw).

Reactive arthritis

Revocation – 26 & 27 of '10 Replaces 17 and 18 of '98

• Reactive arthritis develops as an immune reaction, usually to a preceding infection. 
• This new SOP covers a wider range of conditions tha — n the old SOP for Reiter's syndrome that it replaces.  However, the term reactive arthritis can more generally be used to describe a wide spectrum of conditions, a number of which are not covered by this SOP – note the exclusions in the definition.
• The SOP factors now cover a wider range of preceding infections.
• There are also some new non-infection factors, for Hepatitis B vaccine, BCG therapy and intestinal bypass surgery.
• There are no worsening factors in the new SOP, apart from inability to obtain appropriate clinical management.

Non-Hodgkin's lymphoma

Revocation – 28 & 29 of '10 Replaces 37 and 38 of '03

• The — r — e have been substantial changes to this SOP.
• The disease definition has been reworded but covers the same group of diseases.  Waldenstrom's macroglobulinaemia is now explicitly excluded.
• In the RH SOP t — he old factor concerning immunosuppressive therapy for autoimmune disease has been split. There is now a factor covering a different list of autoimmune diseases and a separate factor for specific immunosuppressive drugs.
• In the BOP SOP there is a factor with a shorter list of autoimmune diseases for NHL generally, plus some further specific autoimmune disease and immunosuppressive drug factors that apply to certain types of NHL only.
• The RH-only herbicides factor now covers an extra herbicide, allows for more ways of being exposed, but has a larger dose requirement and a new maximum latency.
• There are new causal factors for:
• RH SOP only:
• B — enzene; e — thylene oxide; chemicals contaminated by dioxin (TCDD);
• RH and BOP:
• Obesity; h — epatitis C
• A host of specific infections that each apply to specifi — ed sub-types of NHL only e.g. Plasmodium falciparum for Burkitt's lymphoma only.

Gout	Revocation – 30 & 31 of '10 Replaces 11 and 12 of '00 As amended by 43 & 44 of '03

• There have been substantial changes to this SOP.
• The disease definition is very similar, but no longer refers to cellulitis being a clinical manifestation.
• The old factors have been retained but with some modifications:
• There are additional drugs covered by the drugs factor;
• The obesity factor now also covers being overweight (BMI ≥ 25);
• The alcohol factor dose requirement has been lowered and the duration shortened.
• There are new causal and worsening factors for:
• RH SOP only:
• Hypertension, dyslipidaemia and type 2 diabetes mellitus;
• RH and BOP:
• Short term alcohol consumption (with 48 hours before);
• Medium and short term dietary intakes (red meat or offal, seafood, drinks containing fructose);
• Being postmenopausal;
• Organ or bone marrow transplant;
• Chronic renal failure;
• Fasting.
• Some of these new dietary factors stipulate levels of consumption that could be met by a normal diet.  As such, meeting the quantitative requirements of such a factor (step 1 in applying a SOP factor) may be eas — y, but establishing a relationship to service (step 2) may be difficult – because there may be nothing out of the ordinary about that level of consumption.

Lumbar spondylosis

Amendment – 36 & 37 of '10 Amends 37 and 38 of '05 As amended by 78 & 79 of '08

• The amendment is to the aircraft flying factor, which previous said:

“flying a motorised aircraft...”

• The RH factor has been changed to:

“flying in a powered aircraft as operational aircrew...”

• In t — he BOP SOP there are now two factor — s:

“flying a powered aircraft...”

and

“flying in a helicopter as operational aircrew...”

• The change from “m — otorised” to “powered” clarif — ies that jet aircraft are included.
• There are no accompanying definitions for “flying”, “flying in” or “operational aircrew”.  The DSU interpretation is that:
• “flying” covers pilots and copilots;
• “flying in...as operational aircrew” covers pilots, copilots, navigators and loadmasters and anyone else operating that aircraft.  Passengers are not covered.

Intervertebral disc prolapse

Amendment – 38 & 39 of '10 Amends 39 and 40 of '07 As amended by 80 & 81 of '08

• The factors for cumulative hours of aircraft flying have been changed as for lumbar spondylosis.
• This SOP has an addition — al factor (cervical spine only) for flying high performance aircraft.  The definition of “high performance aircraft” has been changed from:

“an aircraft capable of routinely sustaining a positive G force of four or more”

to:

“an aircraft capable of generating an acceleration force (G force) of four G, or more during routine, normal operations”

• This new definition does not cover aircraft that do not routinely generate such G force but that may be subjected to such force during extreme manoeuvres or when generated by an external source (e.g. aircraft carrier launch or arrest systems).

Depressive disorder

Amendment – 40 & 41 of '10 Amends 27 and 28 of '08

Anxiety disorder

Amendment – 42 & 43 of '10 Amends 101 and 102 of '07

• These amendments add an onset factor to both RH and BOP SOPs for “severe childhood abuse”.

Spondylolisthesis and spondylolysis

Amendment – 44 & 45 of '10 Amends 05 and 06 of '06

• The existing SOP ha — d the following factor:

“for degenerative lumbar spondylolisthesis only, having lumbar spondylosis affecting the vertebral facet joints, at the level of the involved vertebra, before the clinical onset of spondylolisthesis or spondylolysis”

• This wa — s in the standard format, where the name of the SOP wa — s used in the last phrase.  However, the inclusion of  “or spondylolysis” in that phrase had caused confusion in a particular case.  By definition, i — n degenerative spondylolisthesis there is no “pars defect” (spondylolysis).  S — lippage of one vertebrae on another is due to degeneration of the facet joints.  T — he words “or spondylolysis” ha — ve now been deleted from the factor.

Neoplasm of the pituitary gland

Amendment – 46 of '10 Amends 42 of '04

• The S — pecialist Medical Review Council (SMRC) is the body that reviews the contents of SOPs, on appeal.  The SMRC has directed the RMA to amend the RH SOP.  The amendment deletes the only causal factor (for undergoing bilateral adrenalectomy) and removes the “within the 10 years before” requirement from the corresponding worsening factor. 
• The date of effect for this change wa — s the date the SMRC decision was gazetted, which was 10 March 2010.
• The RMA is now undertaking a focussed review of the bilateral adrenalectomy factors in the BOP SOP. 

#  Any claims held up by the non-SOP investigations into joint instability and iliotibial band syndrome can now be processed.