Ireland v Accident Compensation Corporation

IN THE DISTRICT COURT HELD AT WELLINGTON Decision No. 208 /2001 IN THE MATTER of The Accident Insurance Act 1998 AND IN THE MATTER of an Appeal pursuant to Section 152 of the Act BETWEEN THERESA IRELAND AI 569/00 Appellant AND ACCIDENT COMPENSATION CORPORATION Respondent HEARD at WELLINGTON on the 9th day of May 2001 APPEARANCES: Mr D A Rennie counsel for appellant Mr B A Corkill counsel for respondent RESERVED JUDGMENT OF JUDGE M J BEATTIE [1] The issue in this appeal is whether the respondent was correct to suspend statutory entitlements to the appellant pursuant to section 116 of the Act on the grounds that her current condition, diagnosed as chronic pain syndrome, was a medical condition which was not causally connected with the personal injury for which she had been granted cover. [2] The facts which are relevant to the determination of this issue, as I find them to be, are as follows. 569 00Ireland.doc(gm) [3] In 1995 the appellant, then aged 39 years, was employed as a Home Assistant at a Martinborough Rest Home. [4] On 15 December 1995 she suffered an injury to her right shoulder whilst lifting one of the residents. The circumstances of that injury as related to Mr R Burness, Consultant Orthopaedic Surgeon in January 1996, were as follows: "She lifted a resident and jolted her shoulder in the process and developed significant pain on the top of her shoulder radiating posteriorly to her trapezius and subsequently on to the back of her neck along the midline region. Now her problem is primarily a painful neck. Her shoulder discomfort has settled somewhat now but the distribution is similar to the acute episode. [5] The appellant's GP, Dr Morrison, gave as his initial diagnosis "strain of right shoulder muscles" and this was stated on the claim for cover that was lodged. Her initial treatment was Voltaren and physiotherapy but neither physiotherapy nor subsequent chiropractic treatment proved helpful and a cervical collar, which she had been prescribed, seemed to make her condition worse. [6] In a report dated 19 July 1996 from Mr M K Hunn, Neurosurgeon, to Dr Morrison, Mr Hunn advised that he could detect no neurological deficit although she was tender over the anterior aspect of the right shoulder and seemed to have a painful arc on that side. He noted that x-rays of her cervical spine showed no obvious abnormality. Mr Hunn advised that he could find no evidence to support a cervical radiculopathy as a cause of her symptoms. He considered that she may have rotator cuff tendonitis and suggested she be referred back to an orthopaedic surgeon or rheumatologist for assessment and possible injection of her subacromial bursa. [7] The appellant was referred to the rheumatology unit of Wellington Hospital at its Masterton clinic and an examination was carried out by Dr D Nicholls, Rheumatology Registrar. After that examination Dr Nicholls stated: "I think Mrs Ireland has significant dysfunction of the right shoulder girdle secondary to trauma. There is no structural reason for his but she still experiences significant pain which is almost certainly related to abnormal movement about the right shoulder." [8] Dr Nicholls recommended a course of treatment with an experienced physiotherapist to whom he referred her. 569 00Ireland.doc(gm) 2 [9] The appellant was again seen in the Masterton Clinic, this time by Dr A Harrison, Consultant Rheumatologist. He examined her in July 1997 and reported to her GP. He noted that despite further physiotherapy she was still having significant pain in her neck and shoulder region. He stated he would not be at all surprised if the eventual diagnosis was irritable bowel syndrome as this was very much in keeping with the features of a chronic syndrome which she had accumulated. 10] He gave an injection of steroid to her subacromial bursa, and he also gave her some advice on pain management techniques. [11] In May 1998 the appellant was seen by Mr T W Love, Orthopaedic and Spinal Surgeon, and in a report to Dr Harrison Mr Love stated that there was evidence that part of her aches and pains around her shoulder were due to a subacromial impingement on the right hand side. He noted that she had had a short period of relief as a result of steroid injection. He suggested ultrasound to see whether there was any impingement on her rotator cuff. [12] Ultrasound was duly carried out in May 1998 and Mr Love advised that the results were entirely normal with no signs of inflammation in the subacromial bursa. It was Mr Love's opinion that she did not have a mechanical obstruction and therefore surgery was not an option. [13] Dr Harrison also examined the appellant again in August 1998 and reported to Dr Morrison that in his opinion there seemed to be a regional pain syndrome affecting the right arm which had a reflex sympathetic dystrophy type flavour to it. However, the subsequent ultrasound results discounted the subacromial impingement that Dr Harrison thought may have been the case. [14] Throughout this time the appellant continued to be in receipt of weekly compensation and other entitlements. In May 1999 the respondent sought to review the appellant's situation and referred her to Dr W E D Turner, Specialist in Occupational Medicine. Dr Turner examined the appellant at Masterton on 4 June 1999. [15] For the purposes of his review and report Dr Turner was provided with a number of the previous specialist reports that had been obtained on the appellant, in particular the reports from Mr Hunn, Dr Nicholls, Dr Harrison and Dr Morrison. 569 00Ireland.doc(gm) [16] Dr Turner's report comprises ten foolscap pages and he obtained an in-depth history of her presenting complaints and injuries as well as carrying out a full physical examination. On page 4 of his report Dr Turner indicates how the appellant herself perceives her situation when he says: "As regards her perceptions/pain beliefs she has no real idea what is wrong with her. She knows in her own mind that her pain signifies or indicates that she has an injury which she rates as 10 out of 10 where O is no injury and 10 is a very large chance that she has an injury . She thinks the injury is in her neck even though she has been told by the surgeon that there is nothing wrong with the discs in her neck Specifically she can recall that she was told that the gaps between the bones were normal and yet somewhat contradictory when she attended the chiropractor she was advised that "C2, C3 and C4 were injured and inflamed". The chiropractor apparently took an X-ray prior to embarking upon treatment. She sees there is a very high risk that her pain will remain persistent as "no one seems to be able to get to the bottom of it". She sees herself as carrying a long terms disability [10 out of 10] and that it is most unlikely that she will have a high chance of working in 6 months. She does not see herself as having any chance of working as a nurse aid with her current level of pain. She can not stop thinking about the pain and how much her pain hurts. At the interview as she sat talking to me she described pain in her neck, right shoulder and the right arm was described as limp and heavy." [17] Under his heading opinion and discussion Dr Turner states as follows: "Opinion and Discussion In my opinion the most appropriate diagnosis taking into account the presentation and development of her condition and response to physical therapy interventions is regional pain syndrome. The regional pain syndrome is a form of the chronic pain syndrome affecting a region, in this case involving the right neck, right shoulder and right arm. The regional pain syndrome as seen with Mrs Ireland is characterised by the following: gradual onset of pain condition following minor trauma pain condition remains activity related perpetuation of pain symptoms despite multiple biomedical interventions evidence of dysaesthesia with pins and needles/burning associated symptoms of stress and migraine headaches and irritable bowel syndrome cervical spine dysfunction presence clinically of tender points in the region affected by the pain evidence of deconditioning but no evidence of damage in the tissues affected by the pain. Regional pain syndrome represents abnormal pain through disordered pain transmission in otherwise completely normal tissue. Indeed my examination failed to show that there was any evidence of injury or structural damage in the tissues where her pain is felt. Most occupational physicians now regard the regional pain syndrome as a form of localised fibromyalgia and indeed this is confirmed with Mrs Ireland in respect of the aforementioned associated symptoms and signs. Clearly her condition is completely resistant to all form of physical therapy which is typical of localised fibromyalgia. During the assessment I could find no evidence that she had a true rotator cuff syndrome, there was end range restriction of most movements very typical of this condition, there was no impingement nor did she have ultrasonic evidence of rotator cuff involvement. I would therefore conclude 569 00Ireland.doc(gm) 4 that she has had the regional pain syndrome present for some considerable time and that this was most likely the presenting diagnosis. The relationship of the regional pain syndrome to trauma of work is controversial. The evidence from the literature suggests anecdotal relationships only emphasising aggravating factors rather than direct causation. There is no evidence of true injury to the tissues rather the tissues themselves exhibit pathophysiological histochemical changes [enzyme depletion, waste product accumulation] secondary to chronic muscle tension. The prevailing view amongst occupational physicians based upon evidence within the literature is that the tender points on which localised or diffuse fibromyalgia is diagnosed are present as a pre- existing state causally based on factors unrelated to the work environment. These factors are at first latent and not spontaneously painful. Their presence arises not from anthropometrics or ergonomics but from personality type, personal risk factors and individual responses to stress. Trauma of the type experienced by Mrs Ireland could certainly theoretically activate these points from their latent state but the traumatic triggering stimulus is incidental and not pathological in itself at least not as far as fibromyalgia is concerned as this condition is characterised by the absence of evidence of tissue injury. In my opinion the episode of trauma described on 15/12/95 is therefore a biologically implausible cause for her regional pain syndrome." 18] Dr Turner identified several so called risk factors which frequently accompany regional pain syndrome and which he considered were the cause of the appellant's ongoing symptoms, those factors being: (i) Psychological factors (ii) Health problems (iii) Catastrophicing and fear avoidance behaviour (iv) Inappropriate pain beliefs (V) Rumination (vi) Smoking [19] Dr Turner concluded by stating as follows: "In conclusion therefore I do not believe that her current incapacity is occupational in origin rather the nexus linking her regional pain syndrome and the incident in December 1995 is a function of non injury related medical factors. In my opinion it is therefore medically and ethically inappropriate for her to consider herself injured particularly when all biomedical injury based treatments which presuppose that pain is a function of an underlying injury have completely failed her. In my view the appropriate thrust of medical care would be to encourage her to make a paradigm shift from an injury to a rehabilitation focus enabling cognitive 569 00Ireland.doc(gm) 5 restructuring wherein she accepts that she does not have an underlying injury and that improved general health fitness and strength and cessation of smoking is the only way she will be able to work harden and therefore return to active employment. Whether she is eventually able to return to the work force will however largely depend upon her willingness to remain active despite her pain, her personal stress vulnerability and her state of muscle conditioning and her motivation to improve her health status." [20] Following the respondent's decision to suspend entitlements Mr Rennie, now representing the appellant, sought a report from her GP, Dr Morrison, and in a letter dated 12 August 1999 Dr Morrison indicated that prior to the shoulder injury which she suffered the appellant was a healthy and busy mother and willing worker and, as he noted, her symptoms began at the time of her injury. His letter to Mr Rennie states as follows: "Quite simply her symptoms began at the time of her injury . I believe that as a direct result of this injury , she has gone on to develop a complication, namely a regional pain syndrome. This condition has a number of other pseudonyms i.e shoulder-hand syndrome, sympathetic dystrophy, Sudeck's atrophy. Unfortunately she developed this complication despite early mobilisation with physical therapy. Retrospectively she may have been better served by early referral to a suitable pain clinic although I don't believe that anything suitable existed within the greater Wellington area in the earlier stages of this problem. The Wellington Pain Clinic has been recently offering an excellent service in the last year or two which was not the case prior to that. I am afraid to say that I was rather slow in making the diagnosis of a regional pain syndrome secondary to her original injury and rather concentrated on referral to what I felt would be appropriate specialists to look for a treatable cause for her problems. My understanding is that with the development of chronic pain syndrome, there are physiological changes which take place within the central nervous system. These have been produced experimentally in animal models. This ultimately produces a relatively irreversible change which modifies the pain pathways and promotes the ongoing sensation of pain despite any lack of ongoing tissue damage in the periphery . These changes are quite apart from the effect of any other factors which may be affecting the perception of pain at the level of the brain. In short, I have absolutely no doubt that this is a direct complication of her initial injury and I believe should be treated as such." [21] Dr Morrison sought a further opinion from Mr Tim Love, Orthopaedic Surgeon, and he referred Dr Turner's report to Mr Love for his comment. In his letter of advice of 16 November 1999 Mr Love stated as follows: "Thank you for your letter regarding this woman. Unfortunately, I feel there is little value in my reassessment of her condition. She clearly does not have an orthopaedic surgically correctable problem. 569 00Ireland.doc(gm) 6 In addition, although I am sure she does have a regional pain syndrome as do the other numerous other surgeons and physicians who have reviewed her, I certainly do not purport to be an expert on this condition. I do understand there is considerable debate as to the role injury plays in the development of regional pain syndrome. Although her in her case the injury that she had may have triggered the regional pain syndrome, in my opinion it would be hard to ascribe the continuing symptoms to this injury. I have read through Dr Turner's report and would find it very hard to contradict any of the statements he has made in this situation. I can understand the patient's distress in ACC stopping her entitlement, but unfortunately there is little I can do to alter this. I certainly am not in a position that I can change the report that I have already sent to ACC on her. I also notice in the communication that she had nerve conduction studies done which showed a mild degree of nerve conduction deficit through the carpal tunnel. With the fact that she has a regional pain syndrome in the right shoulder, in my opinion surgical decompression of her carpal tunnel is totally contraindicated as it is unlikely to help with her symptoms but indeed may precipitate a significant exacerbation of her chronic pain syndrome. In view of the above, I do not believe I can offer her anything useful from further review." [22] In another opinion obtained by Dr Morrison from Chris Williams, Orthopaedic Surgeon at Wairarapa Health, Mr Williams agreed that the appellant exhibited a complex consistent with a chronic pain syndrome. He then stated: "I suspect her initial injury was a stretching of the upper portion of the brachial plexus and this is caused an ongoing diffuse neurogenic type pain. The argument as always, will be whether or not the original injury is still contributing to her current disabilities. This is often a difficult question to answer in this scenario and I am sure that opinions could be provided supporting both view points." [23] The reports from Mr Love, Mr Williams and Dr Morrison were then referred to Dr Turner for his comment and Dr Turner noted as follows: Mr Love agrees with his diagnosis and that it will be hard to ascribe her continuing symptoms to any injury. There is no evidence in the clinical assessment to support a diagnosis of injury to the brachial plexus as opined by Mr Williams. The neurological examination was completely normal In any event, the incident of the original incident is a biologically implausible cause of brachial plexus traction. 569 00Ireland.doc(gm) 7 Dr Morrison's opinion cannot be supported with reference to evidence in the literature on the regional pain syndrome. The prevailing view amongst occupational physicians working first hand in the onsite management of these sorts of cases is that minor trauma of the type experienced by Mrs Ireland does not actually chronically injure tissues, it causes activation of pre- existing otherwise latent tender points. The triggering stimulus is incidental, not an injurious action in itself, it is therefore a symptom provoking one as a regional pain syndrome or regional fibromyalgia. It is characterised by the absence of evidence of tissue injury. Once activated the process is self-sustaining and progressive resulting in a state of heightened pain sensitivity. The presence of these trigger points and indeed the sensitisation process in the absence of any underlying injury arises in the main from personality type, personal risk factors and individual responses to stress. [24] In his decision dated 7 November 2000 the Reviewer considered the medical evidence and noted that the agreed diagnosis now was of a regional pain syndrome. The Reviewer found that the balance of medical opinion did not support a connection between the appellant's current symptoms and her initial injury and accordingly he upheld the respondent's primary decision. [25] For the purposes of appeal to this Court, no further medical evidence has been sought to be introduced but the Court received extensive written and oral submissions from both counsel in relation to the evidence which I have reviewed above. [26] Mr Rennie, counsel for the appellant, submitted as follows: Dr Turner's report and opinion must be treated with caution as it makes no reference to the earlier reports of Mr Burness, Mr Love or Dr Kanji. Dr Turner bases his opinion on the fact of there not having been an injury - this is contrary to the medical evidence of several of the specialists who saw the appellant shortly after her claim was lodged. 569 00Ireland.doc(gm) Dr Morrison, the appellant's GP, has given an opinion which is based on a lengthy doctor patient relationship and must be taken seriously. The decision of this Court in Walker (152/00) is on point and is authority for the proposition that cover can continue for CPS where there has been an underlying physical injury. Similarly the decision of this Court in Lukken (15/00). The fibromyalgia Consensus Report issued following a meeting held in Vancouver in 1993 found that studies determined that it was more than 51% likely that trauma does play a causative role in some fibromyalgia syndrome patients. [27] Mr Corkill, counsel for the respondent, submitted as follows: The issue is causation. Dr Turner says there is no causal link, Mr Love says there is, Dr Morrison does not know and Dr Kanji does not address that point. Chronic pain syndrome is not usually trauma related. The decision of His Honour Judge Hubble in Millsteed and Cunningham (20/00) is relevant and on point. The onus is on the appellant and where there is a conflict of expert evidence, it must be shown that one of the conclusions is illogical and if not then, an onus cannot be established or discharged. See Calver v Westwood Vetinerary Group [2001] Lloyds' Law Reports 20. The report of Dr Turner is comprehensive and the contrary opinions do not have a sufficient basis of reasoning to undermine Dr Turner's opinion. On the preponderante of evidence, causation cannot be established. DECISION [28] This appeal again raises the issue of whether the appellant's condition as it currently presents, or as it presented at the time the respondent made its primary decision on 26 July 1999, was causally connected with the personal injury for which 569 00Ireland.doc(gm) 9 the appellant was granted cover in December 1995. In other words, is the regional pain syndrome which the appellant presented in July 1999 attributable to and arising from the right shoulder strain which she suffered whilst lifting a patient. [29] There can be no doubt that the appellant did suffer a shoulder strain on 15 December 1995 and this was initially diagnosed by her GP, Dr Morrison, and confirmed by Mr Burness, Orthopaedic Surgeon, in January 1996 and then subsequently by Mr Hunn in July 1996. Whilst the appellant did suffer a strain injury it is clear from the neurological investigation conducted by Mr Hunn that the appellant suffered no neurological deficit in the incident, nor did she suffer any injury to her cervical spine, nor could Mr Hunn find any cervical radiculopathy. [30] Even in 1996 when she was seen respectively by those two specialists the appellant's principal complaint was pain radiating from her neck, shoulder region but the cause of it was baffling the experts. [31] The next medical discipline to examine the appellant was a rheumatologist and while he made a tentative diagnosis of a significant dysfunction of the right shoulder girdle he could find no structural reason for this but he again noted that the appellant continued to experience significant pain and which was related to movement about her right shoulder. [32] By July 1997 the appellant's condition had been diagnosed as a chronic pain syndrome, that first being identified by Dr Harrison in his report to the appellant's GP on 28 July 1997. At that time Dr Harrison also hazarded a guess as to diagnosis or cause when he stated that he would not be surprised if the diagnosis was irritable bowel syndrome. [33] Further investigations which involved ultrasound identified no rotator cuff pathology and all was normal in her biceps tendon as were the muscles and tendons of her rotator cuff. [34] It was as a result of the ultrasound that Mr Love, an orthopaedic Surgeon, indicated that there was nothing in the appellant's presentation which was amenable to surgery. I take his advice to indicate that there was nothing physically out of order with her shoulder or neck and therefore there was just no reason or purpose for surgery. Again however, Mr Love talks of a syndrome, this time shoulder - hand syndrome or similar. 569 00Ireland.doc(gm) 10 [35] It is with that background of medical evidence and opinion that the appellant's case was reviewed and considered by Dr Turner. Dr Turner has presented a substantial report on the appellant and he has given his reasons for his diagnosis of regional pain syndrome, noting as he did the various factors that the appellant displayed. His reasoning is set out above under the heading opinion and discussion. [36] It is significant to note that Dr Turner could find no evidence that the appellant had a true rotator cuff syndrome as there was no impingement nor did she have any ultrasonic evidence of rotator cuff involvement. [37] Furthermore, for the reasons that he gave, Dr Turner was of the opinion that the episode of trauma described on 15 December 1995 was a biologically implausible cause for the appellant's regional pain syndrome. Having said that, Dr Turner went on to indicate the various causes or risk factors which he considered were present in the appellant's makeup and which were causative of her condition. [38] It is also to be noted that Dr Turner is of the view that the appellant is not currently suffering from an injury although she is suffering from pain. His exhaustive examination of her and having regard to the tests that previous specialists had carried out indicated to him that hers was a true pain syndrome quite unconnected with the presence of any physical injury. [39] For this reason therefore I find that her present condition per se does not qualify for entitlement under the Act unless it is a downstream consequence of the physical injury which she suffered. 40] Undoubtedly there is a temporal connection, in that appellant experienced pain as a result of the physical strain she underwent on 15 December 1995 whilst attempting to lift the patient and the appellant has continued to experience pain ever since. However the reason for the continuation of pain I find is not related to the cause of the initial shoulder strain which was indeed physical pain caused from a physical straining of the shoulder ligaments or tendons. The medical evidence is that that strain would have resolved in a comparatively short time. However for this appellant, pain has continued without there being any biological reason for it and it continued for another five years before the respondent determined that entitlements must cease. 569 00Ireland.doc(gm) 11 [41] I accept that from the appellant's perspective she would attribute all her problems over those five years as stemming from and being caused by the shoulder strain that she suffered. However, on the medical evidence and reasoning that has been presented in this case, I find that there cannot be a connection established between her present condition and the pain she would have endured at the time of, and for a short period after, the lifting incident. [42] I acknowledge that Dr Turner is a person who has made a study over a number of years of regional pain syndromes, chronic pain syndromes and fibromyalgia and whilst there may still be some controversy over cause, nevertheless there appears to be general agreement that it is characterised by the absence of any evidence of tissue injury and is not connected to any physical injury and is in effect allied to the nervous system and stressors outside physical injury are in the main the reason for its continuation. [43] Both counsel have referred to previous decisions of this Court on this issue and in particular the decisions of Walker and Millsteed and Cunningham. In my judgment those cases are to be distinguished from the present case, in that in the present case the appellant suffered what could only be described as a trauma type injury that occurred in the instant she attempted to lift a heavy patient and was therefore characterised as personal injury by accident. Whereas almost all other chronic pain/regional pain/fibromyalgia decisions with which this Court has been concerned, and certainly in the cases of Walker and Millsteed and Cunningham, were cases of gradual process injury where repetitive use of or strain to particular tendons or muscles had given rise to the pain syndrome and the medical evidence was directed to the effects of gradual process as a cause fibromyalgia etc. [44] In the Walker case the principal evidence on regional pain syndrome was given by Dr John Alchin, Specialist Occupational Physician, although there had been previous reports on that appellant from Dr Turner. The opinion of Dr Alchin in that case is similar to the opinion expressed by Dr Turner in this case and as it is of general application and importance I set it out here. "Aetiology. RPS is due to altered pain physiology, including sensitization of the pain transmission neurones in the spinal cord. There is no detectable associated tissue injury or pathology. That is, it is not correct to say that she had an "injury". Such chronic pain syndromes are abnormal pain and tenderness of normal tissue; it is pathological pain. As stated, this is due to altered physiological processes in the central nervous system, in particular the spinal cord. You ask for the cause of this. I make the following comments, which are essentially those that have been made in the previous reports by Drs Turner and Kirk, and in particular in Dr Turner's 569 00Ireland.doc(gm) 12 initial reports (except the fourth), which still portray accurately the current understanding: 1) The cause or causes of RPS is/are not fully understood. 2 ) From what is known, there is no simple and single cause, but it is a complex process with many interacting factors. 3) Therefore it is simplistic and wrong to attribute it to one factor, such as an accident or work process. That is because most people with such a triggering event do not develop RPS, but recover quickly and normally. The question is, why do a few people develop RPS? She had an initial right medial epicondylitis: why did that change into RPS, when most do not? Clearly other factors are involved to explain this. 4) This is confirmed by the current (imperfect) understanding of the aetiology of RPS. This is that, although physical factors do play a role, and could be considered "the trigger" of the RPS, they are not the main factor. Although the causes are not fully understood, it appears that personal factors (e.g. beliefs, and emotional, psychological, behavioural) and societal factors (beliefs in society, compensation systems, medicolegal processes and disputes) are more responsible than are the initial physical factors which may trigger the process. It is these other non-injury or non-occupational factors (i.e. the "psychosocial" factors) that determine why a few people develop severe pain, when most people would recover in a predictable fashion. 5) Contrary to popular belief, it has never been shown and widely accepted medically that it is work factors which are the cause of RPS". [45] As I have previously noted, in the Walker case the Court was dealing with a gradual process injury, in particular the development of right medial epicondylitis due to the particular work that Mrs Walker did as a machinist, and it was the decision of this Court that there was sufficient evidence of a progression from the injury of epicondylitis arising from her work to the regional pain syndrome that she presented. [46] In the present case, I find that the link is far more tenuous, if indeed there is a link, and I identify the evidence of Dr Turner and also the reasoning enunciated by Dr Alchin which is of general application and which in effect mirrors that which has been stated by Dr Turner in his evidence in this case. [47] At the end of the day, I find that at most it can only be said that the shoulder strain triggered or precipitated a condition which was itself unconnected with the injury of the shoulder strain and was therefore not a continuation of that injury but had as its cause personal, psychological and other factors, being factors unrelated to 569 00Ireland.doc(gm) 13 injury, that have perpetuated the pain in a way that the experts have described, that is, by altered physiological processes in the central nervous system. [48] The appellant does not still suffer from any aspect of the personal injury for which she was granted cover and this again is a distinguishing feature of this case from the factual situation that presented in the Walker case. In those circumstances, I find that on the line that must be drawn as to whether there is or is not a causal connection, the facts of this case as I have found them to be, do not fall on the side of the line which would allow continuation of entitlement. [49] I have not overlooked the earnest submissions of the appellant's GP, Dr Morrison, and whilst he indicated in his advice that he had an understanding of the makeup of a regional pain syndrome, his advice that he has no doubt that the appellant's condition is a direct complication of her initial injury cannot be borne out by an analysis of what in fact constitutes a regional pain syndrome and how it arises and what it feeds on. I therefore consider that Dr Morrison has done what many well meaning generalists do and transferred a temporal connection into a causal connection without in effect giving the reasoning why the two should be regarded as one. [50] As was submitted by Mr Corkill, the onus is on the appellant to establish her claim on the balance of probabilities. On the facts as I have found them and applied them to the legal principles which I have enunciated at the beginning of this decision, I find that the necessary causal connection cannot be made out. Accordingly, this appeal must be dismissed. DATED at WELLINGTON this 30 day of July 2001 M J Beattie District Court Judge 569 00Ireland.doc(gm) 14