A Glimpse of the Monash-Epworth Longitudinal Head Injury Outcome Study

September 15, 2016

The Longitudinal Head Injury Outcome Study follows up a large cohort of individuals who have sustained moderate to severe Traumatic Brain Injury (TBI). This project aims to provide a comprehensive picture of the changes experienced by people who have sustained a TBI as well as their families over a period of 20 years. Changes are captured in terms of living skills, study, employment, recreation, as well as social and personal relationships. In addition, factors predicting outcomes are identified in each of these domains.

This study comprised 666 individuals from the Monash-Epworth Rehabilitation Research Centre (MERRC) database who had been competitively employed prior to injury, for whom Compensation data Base data were available and who had received loss of earnings payments after injury. In addition, using the CRD the authors were able to begin examining whether specific types of service utilisation were associated with employment status. Each individual’s services were aggregated over the first six months post-injury. This included medical services, such as surgeries, pathology, radiology, and psychiatry, as well as allied health services, which included psychology, social work, and vocational assistance.

The authors have highlighted the presence of a good recovery group as well as groups of individuals who show poorer outcomes despite having similar injury severity. These are associated with greater emotional distress, low economic and family support, low resilience and greater service utilisation. This group also incurs greater costs. They also identified a group of individuals who were potentially affected by reduced self-awareness of injury-related changes, leading to under-reporting of problems and conversely by emotional distress potentially leading to some over-reporting of symptoms. Their findings further highlighted the factors other than injury severity that contribute to longer-term outcomes. These include the personal strengths of the individual, including independence and self-esteem and resilience, as well as economic and family supports, their level of emotional distress and motivation to recover.

The authors have identified some key predictors of early return to work (RTW) as well as more persistent unemployment. Individuals were more likely to return to work in the first 6 months if they had shorter duration of post traumatic amnesia (PTA) and if they were in managerial or professional occupations prior to injury. A combination of background, injury-related, and service utilisation variables predicted more persistent unemployment between 6 months and three years post-injury. Individuals were more likely to experience a protracted RTW if they were older, female, were labourers, machinery workers, or technician prior to injury, had longer duration of PTA, and had a moderate or major limb injury. In addition, greater utilisation of specialist practitioner, psychology services, and analgesic medication within the first 6 months was associated with delayed RTW. Conversely, assessment and rehabilitation for return to driving was associated with earlier RTW, highlighting the importance of driving for RTW. These findings demonstrate the roles of complex physical injuries, pain and mental health factors in delaying return to employment following TBI.

Post-traumatic stress disorder was the most common anxiety disorder and was associated with poor quality of life. PTSD was most commonly diagnosed between 6 and 12 months post-injury. Extended periods of PTA, cognitive dysfunction and hospitalisation following TBI may postpone symptom development rather than reduce the risk, with subsyndromal symptoms frequently preceding the development of full PTSD. This provides a potential time-window for early identification and treatment. Rehabilitation clinicians should be aware that patients might develop clinically significant trauma symptoms despite protracted post-traumatic amnesia. There was high comorbidity between PTSD, anxiety, and depression as well.

The cross-cultural study demonstrated the strong influence of cultural background on outcome following TBI over and above injury severity and other demographic factors. As a group, individuals from culturally and linguistically diverse (CALD) backgrounds reported less independence in daily activities, were more emotionally distressed, showed a heightened awareness of injury-related changes and less problem-focused coping than individuals from English-speaking backgrounds. They tended to believe that more external factors such as Chinese medicine, praying or having family take care of them would help their recovery. They were less likely to believe that their own behaviour could help their recovery. They were more distressed about role changes. However, there were marked differences across geocultural regions, and differences in the demographic characteristics of these subgroups (e.g., age, education) also appear to have been influential.

Changes in sexuality following traumatic brain injury

  • Individuals with TBI tended to score lower than their partners on the measure of sexual functioning
  • Approximately one third of the TBI group scored below the 2nd percentile for orgasm, as well as for sexual arousal, sex drive, and overall sexual function
  • Participants with TBI were more likely to have lower interest in sex compared to their partners, which included both men and
  • The findings suggest that a significant proportion of individuals with TBI have organically based changes in sexual function as a consequence of
  • These impact on their sexuality and that of their

There may also be relationship issues that contribute to a decline in sexual functioning, including cognitive and behavioural changes as well as other stressors.

The authors have highlighted the presence of a good recovery group as well as groups of individuals who show poorer outcomes despite having similar injury severity. These are associated with greater emotional distress, low economic and family support, low resilience and greater service utilisation. This group also incurs greater costs. They also identified a group of individuals who were potentially affected by reduced self-awareness of injury-related changes, leading to under-reporting of problems and conversely by emotional distress potentially leading to some over-reporting of symptoms. Their findings further highlighted the factors other than injury severity that contribute to longer-term outcomes. These include the personal strengths of the individual, including independence and self-esteem and resilience, as well as economic and family supports, their level of emotional distress and motivation to recover. Having identified these key measures and profiles in patients assessed 6 months-10 years post-injury the authors aim to see if these measures are predictive in the early stages after injury. If it is possible to identify these groups early they may be able to develop and tailor appropriate treatments to address issues relevant to each profile with the ultimate aim of improving outcomes.

Contradictory information about Zyban from the NIH

May 4, 2016

A classic example of one hand not knowing the other or the perils of partial information.  In Resources you will find 2 papers from NIH.  The first recommends bupropion (Zyban) for use in depression because of lack of weight gain when tested against fluoxetine and sertraline.  The 2nd paper is patient information from Medline Plus and warns against the risks of taking bupropion both for smoking control and for depression! More mind boggling, read for yourself

List of participants First Mental Health Reform Stakeholder Group Meeting 22 February 2016

April 29, 2016

By my count there were:

2 psychiatrists

1 psychologist

1 GP

1 mental health nurse

1 carer rep

1 consumer rep

4 mental health bodies

6 bureaucrats

At the meeting, this diverse range of stakeholders raised a multitude of views and concerns, particularly the lack of mental health consumer and carer input into private health network.

Adjunct Assoc. Prof. Kim Ryan CEO, Australian College of Mental Health Nurses
Professor Malcolm Hopwood President, RANZCP
Professor Lyn Littlefield Executive Director, Australian Psychological Society
Professor Morton Rawlin Vice President, Royal Australian College of General Practitioners
Dr Bill Pring Private Mental Health Alliance (PMHA), AMA Observer
Mr Frank Quinlan CEO, Mental Health Australia
Ms Georgie Harman CEO, Beyondblue
Ms Sue Murray CEO, Suicide Prevention Australia
Ms Marita Cowie CEO, Australian College of Rural & Remote Medicine
Mr David Meldrum Executive Director, Mental Illness Fellowship of Australia
Mr David Butt CEO, National Mental Health Commission
Ms Janet Meagher Consumer representative
National Mental Health Consumer and Carer Forum
Ms Eileen McDonald Carer representative
National Mental Health Consumer and Carer Forum
Mr Stephen Brand Senior Manager, Policy & Advocacy
Australian Association of Social Workers
Professor Tom Calma Advisor
Australian Government Department of Health
Ms Natasha Cole (Chair) First Assistant Secretary, Health Services Division
Australian Government Department of Health
Ms Colleen Krestensen Assistant Secretary, Mental Health Reform Taskforce
Australian Government Department of Health
Dr Anthony Millgate Assistant Secretary, Mental Health Services Branch
Australian Government Department of Health
Ms Emma Gleeson Acting Assistant Secretary,
Mental Health Early Intervention Branch
Australian Government Department of Health



Bullying claim dismissed by the Fair Work Commission (April 2016)

April 22, 2016

The Fair Work Commission has found an anti-bullying applicant couldn’t be at risk of future bullying because she had elected to be “treated as being dismissed” in 2012, and even launched an unfair dismissal claim.

Commissioner Peter Hampton found that despite confusion around the worker’s employment status, it was apparent that both her and her employer had “treated the employment contract as being at an end for some years and the litigation between them has been conducted in that light”.

The Commissioner also rejected the worker’s request to refer the matter to SafeWork NSW.

The worker was employed by a NSW online healthcare business as a marketing director in early 2012. In July that year, she was denied access to work emails while on extended sick leave, which led her to believe she had been sacked.

She subsequently launched several legal proceedings including an unfair dismissal claim, a workers’ comp claim, and complaints to the Australian Human Rights Commission.

The worker also sought anti-bullying orders against the healthcare business’s managing director, telling Commissioner Hampton that she hadn’t been dismissed from the business and was at risk of being bullied in future because she was seeking to return to work there.

She argued she was still an employee of the company because, among other things, she wasn’t paid out any termination entitlements, and the company CEO sent her an email in late July 2012 stating she hadn’t been dismissed.

The employer argued that in launching an unfair dismissal proceeding, the worker clearly believed she had been dismissed, and had abandoned her employment in electing to be treated as being dismissed for the purposes of her unfair dismissal claim.

Commissioner Hampton rejected the worker’s application, finding she was no longer an employee of the company, there were no prospects of her returning, and there was no “foreseeable future risk” of her being bullied by the managing director.

“The employment contract concluded in consequence of the election by the [worker] to be treated as being dismissed and the subsequent events and conduct by the parties,” he said.

“I am also not satisfied that any potential return-to-work arrangements, or other circumstances, exist in this matter where there is a foreseeable future risk of the [worker] being subject to bullying conduct as a worker whilst at work by the managing director of the employer.”

Commissioner Hampton noted that the worker had also sought for the FWC to refer the alleged ongoing risk of bullying faced by other workers at the business to SafeWork for investigation.

“[There] is no basis to deal with this under this application,” he said.

In June last year, Commissioner Hampton found the FWC only had jurisdiction to formally refer bullying incidents to the relevant work health and safety regulator if the applicant was at risk of future bullying (see related article).

KM [2016] FWC 2088 (18 April 2016)

Statistics from Work Safe Australia about Work and Mental Disorders

March 3, 2016



This is a brief overview of this interesting paper.  You can find the full document here.

Work-related mental disorders, each year on average:

  • 7820 Australians are compensated
  • 6% of workers’ compensation claims
  • $480 million total claims payments
  • $23 600: typical compensation payment per claim
  • 14.8 weeks: typical time off work
  • 90% of mental disorder claims are attributed to mental stress
  • 39% of mental disorder claims are caused by harassment, bullying or exposure to violence
  • 0.5 mental disorder claims awarded per 1 million hours worked
  • 0.8 mental disorder claims awarded per 1000 workers
  • Female workers 2.3 times the number of claims per million hours worked compared with male workers
  • 65% of mental disorder claims awarded to workers aged 40 and over
  • Compensated for a work-related mental condition:
    • 1 in 5 compensated defence force members, fire fighters or police officers
    • 1 in 5 compensated teachers
    • 1 in 10 compensated health and welfare support workers
  • 64% of mental disorder claims arise from 4 out of 19 industry divisions:
    • Public administration and safety (21%)
    • Education and training (14%)
    • Health care and social assistance (21%)
    • Transport, postal and warehousing (8%)
  • 46% of mental disorder claims from the transport, postal and warehousing industry are associated with a vehicle accident
  • 17% mental disorder claims awarded to female workers were made by school teachers or health and welfare support workers
  • Female defence force members, fire fighters, and police: 16 times higher than average claim rate
  • Mental disorder claims involving a form of harassment or bullying:
    • 1 in 3 females
    • 1 in 5 males

NSW workers compensation guidelines for the evaluation of permanent impairment (4th edition) released

December 3, 2015

The NSW workers compensation guidelines for the evaluation of permanent impairment (4th edition) 1 April 2016 has just been released.  It has been re-written to conform with the Safe Work Australia template. However there is no agreement by states using the GEPIC to use the PIRS and considering the disdain with which the PIRS and AMA6 are held together with the cost of training any such change is unlikely. The changes to the PIRS are as follows:

Psychiatric and Psychological disorders

Paragraph 11.4 from the 3rd edition, on the development of the PIRS has been removed to align to the Safe Work Australia national template guideline. The numbering therefore changes from 11.4 onwards (in comparison to the 3rd edition).

Clause Change

  1. 3


Removed 3rd and 4th sentences that referenced s67 pain and suffering.

Removing the reference to s67 in this clause does not affect an exempt worker’s entitlement to claim for pain and suffering compensation. The reference to s67 in this clause was a case management tool which is now considered inappropriate in a medical guideline.

  1. 9


Removed the Alzheimer’s disease example. Replaced with a bi-polar disorder example.


Pre-existing impairment Minor change to second half of the paragraph for improved clarity, and to align with the wording in 1.28 in the Guidelines: Rephrased to:

The injured worker’s current level of WPI% is then assessed, and the pre-existing WPI% is subtracted from their current level, to obtain the percentage of permanent impairment directly attributable to the work-related injury. If the percentage of pre-existing impairment cannot be assessed, the deduction is 1/10th of the assessed WPI.

WorkSafe Victoria, problems, doctors and political shenanigans

April 10, 2015

Doctor’s attitudes towards WorkCover in Victoria

AMA Victoria did a survey of doctors attitudes towards issues regarding workers compensation in Victoria in December 2014 and January 2015. As expected comments were made that these patients generally demand more time, attention and effort than other patients but this is not reflected in the remuneration rates for medical practitioners.  There were concerns about the way the scheme was operated in particular its adversarial nature, the complex processes that resulted in delays getting approval for appropriate treatment and mitigated against an early return to work. There were also a range of ethical issues. Just over half of the survey respondents considered reducing their participation in the scheme and almost 20% considered withdrawing fully.

Victorian branch of the AMA prepared a submission to a WorkSafe Victoria independent review of reimbursement rates for medical services

This submission noted the results of the survey and commented on particular matters including:

Inadequate reimbursement

  • some activities not reimbursed at all
  • doctors feeling like you’re being treated as the enemy
  • a recommendation at the AMA list of services and fees was more reasonable than using the medical benefits schedule.

 A Breakup of WorkSafe Expenditure

 in 2013/2014 the largest cost to the scheme was compensation paid to workers for loss of earnings amounting to $624 million or 42% of total scheme costs. By contrast the medical practitioner component treatment and rehabilitation costs was estimated at $102 million, just over 30% of all treatment and rehabilitation costs and less than 7% of total scheme costs.

However in the meantime in early March 2015 the Labour government fired the Chief Executive Officer and chairperson of WorkSafe Victoria. The ostensible reason was because of the failure to identify health risks associated with the Fiskville Fire Brigade training depot. It is believed there was a strong political reason because those in charge were trying to move to a more cooperative framework and had met a good deal of opposition. Who knows what will happen with this review of reimbursement rates!

Richard III and work capacity

March 26, 2015

A leaked email from WorkCover, describing the last Plantagenet king as a “lazy bastard” and “just pretending to be dead” has been strenuously defended by WorkCover.

The company that carried out the Work Capability Assessment test on the deceased king, whose remains were found in a car park in 2012, controversially found him capable of working in an office, or performing light manual labour such as driving a forklift truck.

A spokesperson for WorkCover said:

“Being a withered pile of smelly old bones that have been rotting under a car park for several centuries, is not in itself a reason to sit around all day not working. We have recommended that the King be dug up immediately and placed on a back-to-work scheme, and have his benefits sanctioned for being a blood-sucking, lazy old bastard.

The Bishop of Leicester, who led the king’s re-internment ceremony has criticised the ruling, saying:

“This is absolutely disgusting. The man’s been dead since 1485, and is in no state to pack people’s shopping bags or sweep up popcorn at the Odeon. He wouldn’t even make a good security guard for a sleepy village shop. Anyway, we’ve just buried him, and we’re not digging him up again. The poor old corpse won’t know if he’s coming or going. Leave him alone,”

New research from ISCRR (how’s that again?)

February 4, 2015

I have written about the ISCRR before. I think it is a stupid name as it is almost impossible to remember, it stands for the Institute for Safety, Compensation and Recovery Research. Why, oh why, did they not twist this into RRISC or something similar?

Anyway it produces a monthly newsletter which has some interesting research finding. In the latest newsletter there are two items of research that I thought were interesting.

The first article is regarding Gender Differences with Mental Disorder Claims.

WorkSafe Victoria (Australia) workers’ compensation data (254,704 claims with affliction onset 2004–2011) were analysed. Claim rates were calculated by combining compensation data with state-wide employment data.


Mental disorder claim rates were 1.9 times higher among women; physical injury claim rates were 1.4 times higher among men. Adjusting for occupational group reversed the gender difference in musculoskeletal and tendon injury claim rates, i.e., these were more common in women than men after adjusting for occupational exposure.


Men had higher rates of physical injury claims than women, but this was mostly attributable to occupational factors. Women had higher rates of mental disorder claims than men; this was not fully explained by industry or occupation. Am. J. Ind. Med. © 2015 Wiley Periodicals, Inc.

The second article was one of those articles that seem to be a total waste of time and provided a blinding glimpse of the obvious. I have summarised it for you.

Journal of Occupational Rehabilitation December 2014, Volume 24, Issue 4, pp 766-776

Mental Health Claims Management and Return to Work: Qualitative Insights from Melbourne, Australia

Mental health conditions (MHC) are an increasing reason for claiming injury compensation in Australia; however little is known about how these claims are managed by different gatekeepers to injury entitlements. This study, drawing on the views of four stakeholders—general practitioners (GPs), injured persons, employers and compensation agents, aims to describe current management of MHC claims and to identify the current barriers to return to work (RTW) for injured persons with a MHC claim and/or mental illness.

Methods Ninety-three in-depth interviews were undertaken with GPs, compensation agents, employers and injured persons. Data were collected in Melbourne, Australia.

Results MHC claims were complex to manage because of initial assessment and diagnostic difficulties related to the invisibility of the injury, conflicting medical opinions and the stigma associated with making a MHC claim. Mental illness also developed as a secondary issue in the recovery process. These factors made MHC difficult to manage and impeded timely RTW.

Conclusions It is necessary to undertake further research (e.g. guideline development) to improve current practice in order to enable those with MHC claims to make a timely RTW. Further education and training interventions (e.g. on diagnosis and management of MHC) are also needed to enable GPs, employers and compensation agents to better assess and manage MHC claims.

Don’t you hate it when researchers’ conclusion is that more research is needed!

Role of Impairment Assessment in Injury Compensation Schemes in Australia and New Zealand, a presentation at the 1st ISCRR Conference in 2011

December 3, 2014

I came across this paper recently and thought it might be of interest to you. It is a little out of date but the general information remains applicable.  The last 2 tables are especially interesting with an overview of thresholds and an overview of methods.

Role of Impairment Assessment in Australian & NZ Injury Compensation Schemes
Andrew Fronsko and David Swift
ISCRR 1st Australian Compensation Health Research Forum
October 2011