DETERMINATION OF REVIEW PANEL	
	
CITATION:	Gordian RunOff Ltd v Alabasinis [2025] NSWPICMP 308	
		
CLAIMANT:	Golfo Alabasinis	
		
INSURER:	Gordian RunOff	
		
REVIEW Panel	 	
		
MEMBER:	Gary Victor Patterson	
		
MEDICAL ASSESSOR:	Michael Couch	
		
MEDICAL ASSESSOR:	Mohammed Assem	
		
DATE OF DECISION:	6 May 2025	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); degree of permanent impairment dispute; claimant developed psychological symptoms following the subject accident; claimant had an extensive pre-accident history including significant musculo-skeletal complaints arising from previous work injuries; Medical Assessor (MA) certified 11% whole person impairment (WPI) for various musculo-ligamentous and musculo-skeletal injuries after allowing for pre-existing impairments; Review Panel gave close and detailed consideration to the claimant’s presentation upon examination and all of the medical evidence; Review Panel explains why its findings differ to those of the MA and the claimant’s IMEs; Held – Review Panel finds 7% WPI; no matters of principle; MAC revoked.
	
DETERMINATIONS MADE:  	CERTIFICATE
REVIEW PANEL ASSESSMENT OF DEGREE OF PERMANENT IMPAIRMENT
Certificate issued under s 63 of the Motor Accidents Compensation Act 1999 (the Act)
1.	The Review Panel revokes the Certificate dated 22 November 2023 and issues a new Certificate determining that:
(a)	the following injuries caused by the motor accident give rise to a permanent impairment of 9%,  and is not greater than 10%:
i.	Cervical Spine – possible soft tissue injury
ii.	Right Shoulder – possible aggravation of pre-existing established rotator cuff pathology
iii.	Left Shoulder – possible aggravation of pre-existing establshed rotator cuff pathology
iv.	Left Wrist – soft tissue injury
v.	Left Elbow – soft tissue injury
vi.	Left Knee – contusion/soft tissue injury
vii.	Lumbar Spine – soft tissue injury
viii.	Left hip – soft tissue injury

	

STATEMENT OF REASONS
introduction
1.	Golfo Alabasinis (the claimant) was travelling in a bus on 18 June 2016 on Anzac Parade, Kingsford. The claimant was seated alone immediately behind the driver. There were only a few passengers on the bus. When the bus driver braked suddenly, the claimant was thrown forward from her seat, into the air above the floor. The claimant then fell to the floor and landed on her back. The claimant does not have a clear recollection of what happened after she fell to the floor of the bus.
2.	Following this incident (the accident), the claimant’s husband met her at the next bus stop. The claimant says she had posterior occipital pain, left-sided neck soreness, and extensive bruising from her neck to her left shoulder girdle, left elbow, and an anterior thigh cut. The claimant was taken home and later transported to Prince of Wales Hospital on the same day. The claimant complained of pain in her left wrist, elbow, hip and knee. A cut on her left knee required dressing. The claimant underwent X-rays of her left hip, left wrist and left elbow. No fractures were identified. The claimant was discharged home, after a few hours observation, with a prescription for analgesia and follow up with her local medical officer. The claimant subsequently developed psychological symptoms following the subject accident.
3.	The claimant has an extensive history of musculoskeletal pain from 1990 when she suffered a back injury. The claimant injured both shoulders in 1997 at work. Medical reports indicate that the claimant has suffered from chronic pain syndrome, for the past 15 years, complaining of multiple pain at multiple sites.
4.	Gordian RunOff (the insurer) insured the owner and/or the driver of the at-fault vehicle for liability to pay to the claimant damages under the Motor Accident Compensation Act 1999 (the Act). The insurer admitted liability for the claim.
5.	The issue in dispute is the degree of permanent impairment of the claimant that has resulted from the injuries caused by the motor accident and the extent to which any adjustment should be made for pre-existing impairments.
ASSESSMENT UNDER REVIEW
6.	The present application is a review of a medical assessment pursuant to s 63 of the Act. The medical assessment was conducted by Medical Assessor Farhan Shahzad who certified on 22 November 2023 as follows:
The following injuries caused by the motor accident give rise to a permanent impairment of 11% and IS GREATER THAN 10%:
•	Cervical spine – musculoligamentous injury, musculoskeletal injury
•	Right shoulder – musculoligamentous injury, musculoskeletal injury
•	Left shoulder – musculoligamentous injury, musculoskeletal injury
•	Left knee – musculoligamentous injury, musculoskeletal injury
•	Left wrist – musculoligamentous injury, musculoskeletal injury
•	Right wrist – musculoligamentous injury, musculoskeletal injury
•	Left elbow – musculoligamentous injury, musculoskeletal injury
•	Left leg – musculoligamentous injury, musculoskeletal injury
•	Left hip – musculoligamentous injury, musculoskeletal injury
•	Lumbar spine – musculoligamentous injury, musculoskeletal injury	
Medical Assessor Shahzad assessed 5% whole person impairment for the cervical spine, 3% whole person impairment for the right upper limb and 3% whole person impairment for the left upper limb, due to the motor accident. In making those assessments, he deducted pre-existing whole person impairment, for both upper limbs.
THE REVIEW
7.	The insurer sought a review of Medical Assessor Shahzad’s certificate on the basis that the assessment was incorrect, within the meaning of s 63 of the Act, in a number of material respects. The insurer submitted that the Medical Assessor failed to:
(a)	consider the reports of Dr Obeid and Dr Bodel which were admitted as late documents;
(b)	alternatively, if Medical Assessor Shahzad did consider those reports, he failed to disclose whether and, to what extent, they informed his reasoning and findings;
(c)	provide adequate reasoning as to why the deterioration of the claimant’s range of motion in her neck, some seven years after the subject accident, was causally related to the minor soft tissue injury, rather than the ongoing, long-standing degenerative changes which have been present since as early as 1988, in the insurer’s submission, and
(d)	provide adequate reasoning as to the findings regarding both causation and pre-existing apportionment for the claimant’s left and right shoulders.
The insurer noted that the claimant’s range of motion in both shoulders was vastly different upon examination by Dr Obeid only 4 days prior to Assessor Shahzad’s assessment,
8.	The insurer noted that the claimant was assessed by Medical Assessor Carr on 5 February 2018, when no muscle guarding or asymmetry of neck movement or signs of cervical radiculopathy were found, resulting in an assessment of 0% whole person impairment. The insurer submitted that Medical Assessor Shahzad failed to comment on why he disregarded Medical Assessor Carr’s findings and preferred the opinions of other medical examiners.
9.	The insurer submitted that where the claimant has displayed various ranges of motion, on a background of significant pre-existing and contemporaneous evidence of previous injury to both shoulders, Medical Assessor Shahzad should have provided a proper path of reasoning as to why only a 50% allocation for pre-existing pathology was applied. 
10.	The Review Panel notes that Medical Assessor Shahzad found asymmetry of spinal motion present on clinical examination. He thought that the claimant fits the criteria for DRE Cervical Category II and awarded 5% whole person impairment. However, the data tabulated for cervical movement in all planes are symmetrical. It may be that there is a typographical error in his reasons or the Medical Assessor misinterpreted his own results. 
11.	The insurer’s review application was opposed by the claimant upon grounds that were not made available to the Panel.
12.	President’s delegate Jeremy Lum issued a Determination of an Application for Review of a Medical Assessment on 13 February 2024 which stated the satisfaction of the President’s delegate that there is reasonable cause to suspect that the medical assessment is incorrect in a material respect. The basis of that decision was stated to be Medical Assessor Shahzad’s failure to specify how he arrived at the 50% deduction for pre-existing impairment in the left shoulder.
13.	Accordingly, the application was accepted and was referred to the Review Panel, which is to assess all of the injuries that were referred to Medical Assessor Shahzad, as previously specified. The claimant does not agree that the Review Panel may limit its consideration to the claimant’s neck and both shoulders.
PREVIOUS ASSESSMENT
14.	The claimant previously was assessed by Medical Assessor Gregory Carr, who certified on 
5 February 2018 as follows:
The following injuries caused by the motor accident give rise to a permanent impairment which IS NOT GREATER THAN 10%:
i.	Cervical spine – musculoligamentous injury, musculoskeletal injury
ii.	Right shoulder – Musculoligamentous injury, musculoskeletal injury
iii.	Left shoulder – Musculoligamentous injury, musculoskeletal injury
iv.	Left knee – Musculoligamentous injury, musculoskeletal injury
v.	Left wrist – Musculoligamentous injury, musculoskeletal injury
vi.	Right wrist – Musculoligamentous injury, musculoskeletal injury
vii.	Left elbow – Musculoligamentous injury, musculoskeletal injury
viii.	Left leg – Musculoligamentous injury, musculoskeletal injury
ix.	Left hip – Musculoligamentous injury, musculoskeletal injury
Medical Assessor Carr found 1% whole person impairment (WPI) for the right shoulder and no whole person impairment attributable to any of the other referred injuries. He noted that the claimant had suffered significant pre-existing injuries to her neck and shoulders but there was insufficient documentation in the medical notes to determine a pre-existing whole person impairment percentage. He therefore allocated 0% for pre-existing WPI.
15.	Under the heading Diagnosis and Causation, Medical Assessor Carr recorded as follows:
“Mrs Alabasinis has had a long history of back and bilateral shoulder injuries that forced her to stop work in the 1990’s due to injuries sustained at work. Mrs Alabasinis suffered a heavy fall in a bus, quite suddenly, on Anzac Parade at the Kingsford bus stop….. on 18 June 2016 and had soft tissue injuries to her cervical spine, both shoulders and a particular soreness around the left elbow and left hip region. Fortunately, her left hip pain has settled with trochanteric bursa injection. She no longer suffers any knee symptoms. The bruising in her left elbow quickly settled and she no longer has any pain or restriction of left elbow movement. Unfortunately, she continues to have some right-sided neck pain. The soreness in her wrist almost certainly relates to an underlying degenerative change and not to significant injury in the fall on the bus.”
Medical Assessor Carr did not refer to any injury to the claimant’s lumbar spine as that was not an injury referred for assessment.
16.	It was on the basis of alleged material deterioration in the claimant’s physical symptoms, since Medical Assessor Carr’s assessment and certification, that the claimant was referred for further assessment by Medical Assessor Shahzad. In applying for re-assessment, the claimant relied upon reports by Dr James Bodel, orthopaedic surgeon, dated 1 February 2022 (x3) and a report by Dr Paul Teychenné, consultant neurologist, to which reference will be made.
17.	As to the circumstances of the accident, Medical Assessor Carr noted that the claimant was sitting alone right behind the bus driver. He records that, when the bus suddenly braked, the claimant was flung forward and hit the back of her head on metal stairs near the driver. The Panel notes that CCTV footage of the incident was made available to Dr Bodel who commented as follows:
“The mechanism of the accident as observed from the CCTV footage could have caused the injuries that she suffered, and the ongoing disability associated with those injuries.”
That CCTV footage was not made available to the Review Panel by either party until it was requested.  

CLAIMANT’S DOCUMENTS
18.	The claimant relied upon the following material which the Review Panel has considered:
(a)	Claimant’s submissions dated 11 May 2022 for further assessment of whole person impairment.
(b)	Reports of Dr James Bodel, orthopaedic surgeon, to the claimant’s lawyers dated 1 February 2022 (x2) and impairment assessment of the same date.
Dr Bodel conducted a virtual examination by video conference due to the COVID-19 restrictions. He was assisted by an interpreter via Zoom. The claimant’s husband accompanied her. Dr Bodel states that he measured ranges of movement using a goniometer across the video screen and that he was satisfied with the ranges of movement so recorded. Dr Bodel gives a brief details of the claimant’s past medical history. Dr Bodel was consulted by the claimant in 1997 and 1998 for a claim arising from gradual onset of pain over her period of employment. The claimant was then complaining of head, neck and back pain, bilateral shoulder girdle pain, left elbow and left wrist pain, left hip and knee pain, all similar to her current clinical presentation.
Dr Bodel states his findings upon examination as follows:
“I observed a good range of hip movement. She has a slight restriction of knee movement on the left. There is no observed restriction of ankle or subtalar movement. There is no restriction of elbow, wrist or hand movement. She is able to make a strong fist on both sides. There is no deformity in the upper limbs. She indicates pain on the right side of the lower part of the back and points to that area with her right hand. She reaches forward in flexion with her hands to the knees and there is backache at this point and also on extension with a reduced range of lateral bending to the left. Straight leg raising is approximately 70° on each side.”
Dr Bodel notes that no diagnostic investigations were available for his review. 
Dr Bodel opined that the claimant suffered soft tissue injuries in the accident and her condition had stabilised. Dr Bodel stated as follows:
“I observed a restricted range of neck flexion, extension and rotation (more on the right) in all directions. She has a restricted range of shoulder movement. She has steadily deteriorated over time and that is the natural history of these injuries…. The injury certainly has caused a material aggravation and acceleration of underlying pre-existing pathology which has been present for nearly 25 years. The pathology was first identified in….. a worker’s compensation matter.”
Dr Bodel thought that the claimant’s treatment should remain conservative. 
In a separate report, Dr Bodel assessed WPI as follows:
“This lady has a DRE Cervicothoracic Category II level of assessable impairment in accordance with the description in Table 73 on Page 3/110 of AMA 4. There is asymmetry of movement and guarding but no clinical sign of radiculopathy. There is a 5% WPI rating.
She has a DRE Lumbosacral Category II level of assessable impairment in accordance with the description in Table 72 on Page 3/110 of AMA 4. Again, there is asymmetry of movement and guarding but no clinical sign of radiculopathy. There is a 5% WPI rating.
She has a rateable restriction of shoulder movement on both shoulders. This is assessed using Figure 38 on Page 43, Figure 41 on Page 44 and Figure 44 on Page 45 of AMA 4. On the right side, she has a 16% Upper Extremity Impairment which converts to a 10% WPI using Table 3 on Page 20 of AMA 4. On the left side, there is a 13% Upper Extremity Impairment which converts to an 8% WPI.
The only other rating is the restricted range of knee movement. The minus 5° of knee extension attracts a 4% WPI using Table 41 on Page 78 of AMA 4.
There is a total of 28% whole person impairment combined in this case. On the basis of the totality of the medical evidence that I have seen, I would indicate that about one-third of the overall level of impairment is due to long-standing, pre-existing pathology which has, from time to time, been symptomatic. The remaining two-thirds is due to the effects of the accident on the bus.
After rounding, there is a total of 19% WPI in this case.
The severity of the fall has led to additional material aggravation of the long-standing pathology in the neck, shoulders, back and the knees. I am satisfied that the levels of WPI that I have given, with the discount that I have made for pre-existing impairment, is appropriate for the injury caused by the accident on the bus.”
(c)	Report of Dr Bodel dated 9 May 2017 (see previously).
(d)	Report of Dr Robert Teychenné dated 12 October 2020 to the claimant’s lawyers.
Dr Teychenné notes that the claimant was first referred to him in October 2018 following the bus accident. Dr Teychenné gives a detailed description of his subsequent involvement. Dr Teychenné states that the claimant had suffered the equivalent of whiplash injury with acute flexion/extension of the neck and that the claimant was at risk of an incomplete cervical cord lesion as a result of the injury described. A Nerve Conduction Study shows a bilateral carpal tunnel syndrome similar to her Nerve Conduction Study in 2018. Dr Teychenné considered that the claimant’s injuries had deteriorated since the previous MAS assessment. In a separate report of the same date, Dr Teychenné assesses 28% WPI for injury to the nervous system.
The Review Panel notes that no other medical expert shares Dr Teychenné’s diagnosis of incomplete cervical chord lesion. In any event, injury to the nervous system is not included in the Review Panel’s referral.
Reports of Dr Paul Teychenné dated 1 October 2019 and 10 June 2020.
These add nothing of significance to Dr Teychenné’s previous report.
(e)	Report dated 18 May 2017 by Dr Andrew Porteous, occupational physician, to the claimant’s lawyers.
Dr Porteous opined that the claimant had musculoligamentous strain and aggravation of underlying degenerative pathology in the cervical spine, in both shoulders, in the thoracic spine, in the lumbar spine and in her elbow, wrists, hips and knees. She likely also developed psychological sequelae. He thought that the effects of the claimant’s musculoskeletal injuries would continue for the medium term at the least. 
In a separate impairment assessment of the same date, Dr Porteous stated as follows:
“She has a DRE Cervicothoracic Category II level of assessable impairment in accordance with the description in Table 73 on Page 3/110 of AMA 4. There is asymmetry of movement and guarding, but no clinical sign of radiculopathy and there is a 5% WPI rating. For the underlying spondylosis changes, there is a 1/10th deduction. The resulting 4.5% is then rounded to 5%.
There is a 7% WPI in the right shoulder and a 5% WPI in the left shoulder. In my opinion, there were substantial pre-existing conditions and restrictions and I would attribute 50% of the pre-existing conditions resulting in 3.5% rounded to 4% WPI in the right shoulder and 2.5% rounded to 3% WPI in the left shoulder.
She has a DRE Thoracolumbar Category I level of assessable impairment in accordance with the description in Table 74 on Page 3/111 of AMA 4. There is no asymmetry of movement or guarding and no clinical sign of radiculopathy and there is a 0% WPI rating.
She has a DRE Lumbosacral Category I level of assessable impairment in accordance with the description in Table 72 on Page 3/110 of AMA 4. There is no asymmetry of movement or guarding and no clinical sign of radiculopathy and there is a 0% WPI rating.
There is no evidence of measurable impairment today in her elbows, wrists, hips, knees or ankles.
The overall level of Whole Person Impairment resulting from this accident is a 12% WPI rating in this case.
Clinical Records
(f)	Discharge referral of Prince of Wales Hospital.
(g)	ED discharge referral of Prince of Wales Hospital dated 16 June 2016.
(h)	Clinical records of Botany Bay Medical Centre as at 7 June 2018.
(i)	Updated clinical records of Botany Bay Medical Centre as at 10 September 2020, 30 September 2020.
(j)	Clinical records of Combines Rheumatology Practice.
(k)	Clinical records of Dr Daniel Wardman.
(l)	Clinical records of Erigoni Aas as at 21 December 2018.
(m)	Clinical records of Dr Ilana Ginges as at 16 August 2018.
(n)	Clinical records of Healthcare Imaging Maroubra.
(o)	Clinical records of Prince of Wales Hospital as at 16 September 2016.
(p)	Clinical records of Dr Teychenné as at 19 December 2023.
DIAGNOSTIC INVESTIGATIONS
19.	As no diagnostic investigations were brought to the examination, the Review Panel is content to restate Medical Assessor Shahad’s summation of the relevant radiological imaging, as the Medical Assessors are satisfied as to its accuracy.
Document No	Description	
A7	Cervical spine CT scan dated 22 February 2018	
A14	MRI arthrogram right shoulder dated 8 August 2017	
A15	MRI arthrogram right shoulder dated 11 March 1998  	
A16	MRI arthrogram left shoulder dated 8 August 2017	
A17	MRI arthrogram lumbar spine dated 24 May 2000	
A23	Scan of both shoulders and cervical spine dated 29 June 2017	
A27	Ultrasound of the forearm dated 14 December 2017	
A30	X-ray and ultrasound left wrist dated 19 February 2018	
A31	X-ray cervical spine and lumbar spine and lumbar spine and ultrasound to both shoulders dated 22 July 2016	
A35	CT cervical spine scan dated 7 November 1997	
A36	CT scan lumbar spine dated 6 March 2017	
A38 	MRI lumbosacral spine dated 5 April 2017	
A39	MRI spinal cord dated 22 January 2019	
X-ray and ultrasound report of the left shoulder dated 7 June 2018	
Whole body scan study with SPECT and CT dated 25 August 2017	
It is not disputed that the diagnostic scans show no evidence of fractures. There are pre-existing bilateral supraspinatus tears. There is evidence of degenerative changes in the cervical spine, both upper limbs and the lumbar spine, commensurate with the claimant’s age.
20.	The insurer relied on the following material which the Review Panel has considered:
•	Insurer’s review application submissions dated 19 December 2023 (previously summarised).
•	Insurer’s further Review Application submissions dated 5 April 2024 objecting to the admission of reports from Dr Teychenné, treating surgeon, who diagnosed a spinal cord compression. The insurer submitted that the clinical records showed the claimant’s ongoing and significant pathology prior to the accident in relation to, in particular, the neck and right shoulder. The insurer noted that Dr Obeid was not able to find the neurological signs found by Dr Teychenné and disagreed with the diagnosis of a partial spinal cord compression syndrome.
•	Insurer’s submissions dated 27 May 2022 in response to claimant’s further assessment application. The insurer noted the previous certification by Medical Assessor Carr on 30 January 2018 who found 1% whole person impairment comprising:
(a)	Cervical spine – musculoligamentous/musculoskeletal injury (0%)
(b)	Right shoulder – musculoligamentous/musculoskeletal injury (1%)
(c)	Left shoulder – musculoligamentous/musculoskeletal injury (0%)
(d)	Left knee – musculoligamentous/musculoskeletal injury (0%)
(e)	Left wrist – musculoligamentous/musculoskeletal injury (0%)
(f)	Right wrist – musculoligamentous/musculoskeletal injury (0%)
(g)	Left elbow – musculoligamentous/musculoskeletal injury (0%)
(h)	Left leg – musculoligamentous/musculoskeletal injury (0%)
(i)	Left hip – musculoligamentous/musculoskeletal injury (0%)
The insurer submitted that the claimant had failed to provide evidence of any deterioration and that the material relied upon by the claimant is not new and does not constitute “additional information”.
21.	Report dated 27 May 2021 by Dr Margaret Gibson, occupational physician, to Vardanega Roberts Solicitors.
Dr Gibson opined that, based on the available information, the claimant sustained soft tissue injuries to her left shoulder, wrist, elbow and hip, as well as a laceration to her left knee, in the subject accident. Dr Gibson thought that the soft tissue injuries would have resolved within four to six months after the subject accident. Dr Gibson noted the pre-accident history of bilateral rotator cuff tears, cervical and lumbar spondylosis, all of which is age related with possible work-related aggravation. Dr Gibson thought that the age-related conditions of the shoulders, neck and back are likely to worsen gradually over time. Dr Gibson did not provide a WPI assessment.
22.	Report dated 5 October 2023 by Dr John Obeid, consultant physician and geriatrician, to the insurer’s lawyers.
Dr Obeid outlined the claimant’s history and treatment received since the subject accident. He noted that the claimant had numerous and long-standing musculoskeletal pains related to work injuries. He noted the opinion of Dr Ginges (treating rheumatologist) that the claimant “has long-standing issues and (is) probably developing a level of chronic wide-spread pain after the shock of her accident”. 
At paragraph 3.3 of his report, Dr Obeid refers to the claimant having some mental health and other issues relating to her claim and ongoing medical management. Dr Obeid observes as follows:
“The consultations with her GP were characterised by catastrophising and abnormal pain behaviours.”
At paragraph 3.4 of his report, Dr Obeid refers to the claimant’s being referred to Dr Teychenné (neurologist). Dr Obeid then states as follows:
“Dr Teychenné saw her on numerous occasions in 2018 and 2019 and suggested that the diagnosis was “spinal shock” (see report dated 1/10/2019) due to her “hitting the back of her head….. potentially (causing) an extension/flexion injury to the head and neck.” Dr Teychenné found evidence of long tract signs which he stated indicated a “myelopathy”, but he also described other neurological signs which could not be due to spinal pathology including facial signs (involving the trigeminal nerve), and nerve conduction tests showing bilateral carpal tunnel syndrome. Although he repeatedly appears to be concerned about spinal cord compression, Dr Teychenné did not undertake any further investigations or refer her to a neurosurgeon, suggesting that he probably did not hold firmly to that diagnosis. (Usually, spinal cord symptoms trigger immediate referral and investigations). Furthermore, I was not able to find the neurological signs found by Dr Teychenné.”
At paragraph 3.6 of his report, Dr Obeid summarises the results of investigations performed (see previously).
Dr Obeid noted a history of frequent falls since the accident, occurring both indoors and outdoors, including in her backyard and at the shops, and while walking in the street. Dr Obeid notes that the claimant and her husband disagreed as to when those falls commenced. Dr Obeid records that the claimant attended the Falls Clinic at Prince of Wales Hospital in March 2021, where it was felt that the most likely cause of her falls was wide-spread arthritis (letter of Dr Rodov dated 27/04/2021). 
Dr Obeid notes there is no documented evidence of cognitive decline and that Dr Crawford (psychiatrist) diagnosed the claimant with mild-moderate non-melancholic depression. 
Under the heading Examination Findings, Dr Obeid records as follows:
“General observations: the claimant was observed to be able to:
5.1.1 	get up from a standard kitchen chair without using her hands on the table to push herself up;
5.1.2	reached well above her head to obtain her medications from a high kitchen cupboard using her right arm; and
5.1.3	walked steadily, with good speed and without use of an aid.
Neurological examination:
5.3.1	Gait speed and arm swing were normal, though gait was slightly wide-based. Romberg’s test was negative.
5.3.2	There were no abnormal cranial nerve signs. 
5.3.3	Tone and muscle power in upper and lower limbs was completely normal.
5.3.4	Reflexes in the upper and lower limbs were equal, though brisk.
5.3.5	Plantar responses were flexor.
5.3.6	Sensation to light touch and proprioception were both normal.
Musculoskeletal examination:
5.4.1	Neck range of movement was full in extension and for left and right rotation. Flexion was markedly limited (chin was able to reach 3 cm from chest wall on flexion). Lateral flexion was slightly restricted (approximately 45° on each side). There was tenderness to direct palpation of the cervical vertebrae posteriorly.
5.4.2	Shoulder range of movement was intact in forward flexion (approximately 120°) and abduction (approximately 180°), with mild limitation of internal rotation bilaterally (hands able to reach upper lumbar vertebrae on left and mid-lumbar vertebrae on right). Elbows and wrists had full range of movement.
5.4.3	Lumbar forward flexion was mildly impaired (able to reach down to the knees with hands), but she had minimal extension range.
5.4.4	Straight leg raise was very limited (to about 50° on right and 65° on left). Hip and knee range of motion was full. Trendelenburg’s test was positive on the right. There was tenderness to palpation over both trochanteric bursae.”
Dr Obeid was of the opinion that, as a result of the subject accident, the claimant suffered soft tissue injuries (bruising and lacerations to the left side of body) with a psychological impact causing ongoing distress and fixation on the events surrounding the subject accident. Dr Obeid opined that the following diagnosis/problems are not attributable to the subject accident:
6.2.1	Chronic wide-spread joint pain (neck, shoulders, back, hips and knees). This is caused by osteoarthritis (degenerative) changes, as demonstrated on bone and CT scans. Osteoarthritis is a degenerative (“wear and tear”) process. Whilst it is true that injury or trauma can cause secondary osteoarthritis, this usually occurs many years after the subject injury (whereas, in the case of the claimant, the complaints were either pre-existing or commenced immediately after the accident).
6.2.2	Bilateral rotator cuff tears of the shoulders. These were pre-existing.
6.2.4	Frequent falls. These are likely due to cerebrovascular disease and degenerative osteoarthritis.
Dr Obeid says he was unable to find evidence of cognitive decline or dementia. He notes that the cognitive testing he performed was suggestive of intact cognitive function. He was unable to find any evidence of cervical myelopathy or spinal cord compression, as suggested by Dr Teychenné. Dr Obeid says the neurological signs found by Dr Teychenné appear to be no longer present. 
Dr Obeid is not of the opinion that the claimant has any residual physical impairment (WPI) as a result of the accident.
23.	Report dated 19 March 1998 by Dr James Bodel to GIO Worker’s Compensation.
Dr Bodel records that the claimant commenced full-time work in November 1991 as a cashier in a supermarket. She first developed pain in the right shoulder and later the left shoulder in 1995 associated with the nature and conditions of her employment. The claimant suffered an acute injury in August 1997 when she was hit in the back by a customer’s trolley. The claimant began to develop pain radiating down the right leg. The claimant ceased work in September 1997 certified unfit for work. She developed left leg pain within a few months. 
Under the heading EXAMINATION, Dr Bodel recorded as follows:
“This lady is a little uncomfortable when sitting on a chair and she rises slowly. She is seen to stand erect and she walks without any evidence of a limp. She complains of tenderness in the trapezius muscles at the base of the neck on both sides and has a reduced range of neck flexion, extension and rotation to about 70% of the expected range. There is no crepitus on the rotational movement and no pain on resisted movement. The patient has a restricted range of shoulder abduction and rotation to 100° on both sides and forward flexion to approximately 140°. There is some discomfort in the trapezius muscles on resisted shoulder movement and today, there is some mild evidence of subacromial impingement on the right side. I can detect no lack of elbow, wrist or hand movement. There is some clicking on movement of the interphalangeal joint of the right thumb and there is some slight weakness of resisted thumb movement. There is no wasting of the thenar muscles and no objective sign of median or ulnar nerve pathology in either upper limb. There is no wasting of the forearms. The patient’s reflexes are quite brisk. The patient has no loss of lumbar lordosis or scoliotic tilt but does complain of tenderness on palpation at the lumbosacral junction. She reaches forward in flexion with her hands to the mid-tibia. There is increasing back ache at this point and also pain on extension. Straight leg raising is 80° on both sides and I can detect no objective sign of nerve retention. There is no evidence of reflex abnormality or sensory impairment in either lower limb.”
Under the heading OPINION, Dr Bodel states as follows:
“This patient has had a gradual onset of wide-spread complaints involving both shoulders, the neck, the low back and both legs. She has also had right wrist and thumb pain. She associates these symptoms with the nature and conditions of her work in general and the trouble with her back as a result of an injury on 14 August 1997.
X-rays of the lumbosacral spine showed degenerative change at the L4/L5 and L5/S1 region but no external disc disruption in these areas. The contusion that she suffered at work from 14.8.1997 has now resolved and I see no evidence clinically of ongoing work-related impairment or function in the back. She does however have ongoing disability because of the long-standing degenerative process but this is a constitutional ailment. There is no objective sign of nerve retention in either lower limb and I am at a loss to explain her apparent complaints in the legs. There is certainly no indication for surgery because of these complaints.
The patient’s level of complaint overall is somewhat difficult to understand although she does have genuine pathology in the back and in the region of the right shoulder. There is no indication for a surgical undertaking in the right shoulder. The patient’s long-term prognosis therefore remains guarded.”
In a separate impairment assessment of the same day, Dr Bodel states as follows:
“This patient clinically is left with a 15% overall permanent impairment of function in the back. This is due to degenerative change at L4/L5 and L5/S1 and this is a constitutional ailment temporarily aggravated by the injury at work on 14.8.1997. This temporarily aggravation has now settled.
The patient has a 5% overall permanent impairment of function in the neck and this is due to very minor degenerative change in the facet joint on the right hand side at C4/C5. This is also a constitutional ailment and any temporary aggravation caused by work has now settled.
These assessments are in comparison to a most extreme case of neck and back impairment.
The patient has a 10% overall permanent loss of efficient use of the right arm at or above the elbow and a 5% permanent loss of efficient use of the left arm at or above the elbow. These disabilities arise as a result of rotator cuff pathology in both shoulders and clinically this is a work-related disability. This has arisen as a result of the nature and conditions of the patient’s work in general.”
24.	The Review Panel notes that the method of assessment used by Dr Bodel (ie. percentage of a most extreme case of neck and back impairment) was appropriate for worker’s compensation cases. It is not directly comparable to the method of assessment of whole person impairment in motor accident cases. However, it does provide some basis for estimating pre-existing impairment, for the purpose of the present case.
EXAMINATION REPORT
25.	The report of Medical Assessor Michael Couch is as follows:
“PIC REVIEW PANEL – RE-EXAMINATION REPORT
Claimant:	Golfo ALABASINIS
Date of Birth:	 Age:  78 years
Date of Injury:	18 June 2016
Panel Examination:	Assessor Michael Couch
	PIC Rooms
	14 November 2024
Mrs Alabasinis attended promptly accompanied by her husband and the Greek interpreter, Ms Asimina Staikos, NAATI CPN5PS13W.  This assessment was particularly difficult, both because Mrs Alabasinis was a poor historian and the very frequent interruptions by her husband.  (For example, the interview had only just reached a description of the subject accident after 30 minutes).
At the start the Assessor explained to her husband that it was important that he take the history directly from the claimant and not from him.  He responded that she had received a blow on the head and got muddled.  He was told that the Assessor would ask him for specific responses if needed.  
The interpreter, who seemed to be very experienced, sensible and patient found this quite difficult.  At one stage, it Mr Alabasinis suggested that she was interpreting incorrectly.  After approximately 60 minutes, when history taking was still not complete because of these factors, the Assessor found out that the interpreter needed to leave by 4:00 pm at the latest.  This was explained to Mr and Mrs Alabasinis.  The Assessor also told Mr Alabasinis that his presence was discretionary, and allowed at his discretion, and that he would be asked to leave if he interfered further.  After this, he was quieter and at the end of the 1 hour 45 minute session, the Assessor was able to part amicably with Mr and Mrs Alabasinis.  
At the start, Mrs Alabasinis was asked how she wished to use the interpreter.  She said that she preferred to use her throughout and this occurred, although she occasionally spoke spontaneously in English.  The Assessor also explained to Mr and Mrs Alabasinis through the interpreter the role of the Panel re-examination.
Pre-Accident Medical History and Relevant Personal Details
Mrs Alabasinis said that she emigrated from mainland Greece to Australia in 1967 at the age of 21 years.  She was married here.  She has four children, two grandchildren and one great-granddaughter aged 2 months (she smiled spontaneously when mentioning this).
She described initially working in factories, and subsequently she worked at a Franklins supermarket.  She recalled ceasing work there in late 1997 – she said this was on medical advice, “because of health issues at that job”.  When asked more about this, she described work-related injuries/symptoms, apparently mainly in her shoulders.  She said that she had told management to change work practices but they had refused.  She had a workers compensation claim.  She also said that she had six episodes of pneumonia, which she put down to very draughty conditions working in the express lane.  She had not worked since 1997 due to work-related shoulder injuries.
Mrs Alabasinis was asked about her general state of health 10 years earlier (ie, before the subject accident on 18 June 2016).  She replied that, “my health was very good”.  When asked if she had any aches and pains anywhere, she replied that she did not have any health problems then and was not taking any medications.  She did say that she had had a problem with her hearing.  Although Mrs Alabasinis reported “very good health” 10 years before the accident, pre-accident medical records document a history of significant musculoskeletal complaints, including:
•	Bilateral rotator cuff tears (right full-thickness supraspinatus tear noted in 2014).
•	Facet joint arthritis and chronic pain.
•	Obstructive sleep apnoea and subclinical hypothyroidism.
Mrs Alabasinis and her husband live in their own house in Maroubra.  He had previously worked in a factory and later worked for Qantas in maintenance at Sydney airport.  He had retired in 2003.
History of the Motor Accident
Mrs Alabasinis described the accident on 18 June 2016.  She said that she was on a bus travelling from Taylor Square in Paddington back home.  She said that it was a beautiful day, becoming quite talkative about this.  She said there were very few people on the bus – perhaps 10.  She said that she was the single occupant of a pair of seats immediately behind the driver. (The Assessor found it difficult to ascertain from her exactly where this seat was placed.  To assist, he drew a very rough plan of a common seating layout on some Sydney buses, which sometimes have a somewhat elevated seat or seats immediately behind the glass partition separating the driver from the passengers.  As far as could be understood, she was sitting on one of two seats in this position).
She said that the bus stopped very suddenly with no warning and that she was actually thrown up from her seat.  She said that she got a big fright and said, “I said, God save me”.  She said that she then found herself on the floor of the bus next to the driver.  (It was unclear as to exactly where she fell – her husband suggested that she actually was on the entrance steps of the bus). Contemporaneous hospital records describe this as a mechanical fall with no violent ejection or impact injuries.
She was asked if she was able to get up (at this stage, her husband interrupted loudly.  He appeared to be agitated and was questioning the interpreter.  The Assessor had to warn him to keep quiet or he would have to leave).
Through the interpreter she said that “I found myself like that” – it was not clear whether she was lying on her back or in some other position.  She complained that the driver did not do anything in response and that another passenger on the bus tried to lift her but was unable to.  This passenger then got help from a younger woman and they lifted her and put her on a seat.
Mrs Alabasinis said that she kept asking the driver what had happened and that he finally gave her his details. He apparently offered to call an ambulance – she refused and said that her husband would come and pick her up.  (She explained that the incident had happened near the Kingsford Shopping Centre and not far from their home).
She was asked how she got home.  She said that she got off the bus.  She did not have a phone with her and used the phone in a nearby shop to call her husband, who came and picked her up.  He then took her to Prince of Wales Hospital Emergency Department.
History of symptoms and treatment following the motor accident
The discharge referral from Prince of Wales Hospital Emergency Department dated 18 June 2016, from Dr Alexander Whitfield, Registrar, stated, “Golfa Alabasinis presented with a fall on the bus today.  Background: GORD, pneumonia.
Meds: nizatidine.
SHx lives with husband and daughter independent of ADLs.
HPC: seated near front of bus today driver slammed brakes and Golfo fell forward onto her left side.  Also hit back of head.  No loss of consciousness, amnesia, nausea/vomiting headache.  Has pain to left wrist elbow hip and knee but mobilising since.  Has otherwise been well lately.
Examination: Obs normal.  Looks well.  Mobilising well.  Chest clear HSTNM, abdomen SNT, legs SNT.
Neuro: CN normal, PARL.  UL+LL: tone power sensation intact.
Injury: Tender point occiput, no Cspine tenderness, full ROM.  No spinal tenderness.  Chest nontender.  UL: left elbow tender to distal humerus posteriorly.  Left wrist tender over ulnar styloid/hamate area.
Left hip tender to palpation.  Left knee – small bruise over patella but joint nontender with full ROM and able to mobilise.
X-rays of left wrist and elbow, no fractures seen.
Diagnosis: mechanical fall on bus.  No fractures seen.
Plan: return home with regular paracetamol for analgesia (1 g four times per day).  Follow-up with GP on Monday.  Return to ED if pain uncontrolled or any concerns”. 
(At this stage of the interview the Assessor noted that Mrs Alabasinis was rotating her head and neck very fully to the left {approximately 80 degrees} when talking to the interpreter, who was seated on her left).
Mrs Alabasinis said that subsequently she had been treated by her usual GP, Dr Zavras.  The Assessor asked her (noting this was now over eight years since the accident) what injuries she recalled sustaining in the accident.  She replied, “the whole body”.  She was asked about any bruising or abrasions.  She described a “very big cut” on the left knee, although this did not apparently require sutures (the emergency department documentation above, in fact, described a small bruise over the patella and no lacerations).  She said that her whole body was covered in bruises and that “to this day my whole body is painful and I can’t even touch myself – so much pain”.  (At this stage of the interview the Assessor considered that he was unlikely to elicit any more detailed description of injuries sustained more than eight years earlier).  
It is appropriate to here summarise the records of her longstanding GP, Dr Zavras, after the accident:  
Records of Botany Medical Centre (Dr Litsa Zavras) have been seen from September 2012 until June 2018.  On the front sheet: 
“Active past history: facet joint arthritis, chronic pain, pneumonia, community acquired, post-traumatic stress disorder, GORD, obstructive sleep apnoea, subclinical hypothyroidism”. 
Prior to the accident there are attendances on 17 February 2014 and 21 February 2014, with right shoulder pain with a note, “has large R full thickness tear R supraspinatus, very reluctant to undertake any Rx”.  Other attendances up until the date of the accident are unrelated but include for thyroid tests, distress after her mother’s death, and an admission in April 2016 for community acquired pneumonia.  She had also seen Dr Daniel Wardman for longstanding tinnitus and Dr Brian Jarvie, Respiratory and Sleep Physician.
The first entry after the accident was two days later on June 2016 with Dr Zavras, “was passenger in bus driver stopped suddenly.  Passenger was seated but fell forward and found herself on floor.  Two other passengers helped her off floor and helped her back into her seat, no obvious injury.  11:20 am Saturday, 18 June 2016, reported to RTA.  Now presents c/o pain over palmar surface L hand o/e tender no bruising or swelling, 2. Painful L knee o/e no bruising or swelling, 3.  c/o pain L elbow o/e no swelling no bruising mvt and tender on olecranon tip.  Went to POW Hospital on Sat afternoon had Xr L hand elbow knee and hip is now on paracetamol 2 tds.  Reassure and await resolution BP 156/86, still in shock”.
24 June 2016, “review today, c/o generalised pains affecting occiput L wrist, volar aspect low back.  O/e and, reassure.  Very stressed re ‘what to do’ in relation to claim.  Advised to see lawyer”.
One month after the accident on 20 July 2016, she reattended Dr Zavras: 
“Today presents with form from solicitor is proceeding with claim, is now c/o generalised pain affecting most of the body, mostly affecting L palm of hands both shoulders L hip L knee point STO pain affecting both AC joints and c/o pain on occiput.  Is taking Panadol 2 tds daily.  Advised that can refer rheumatologist re generalised pains will consider”.
Two days later, she returned to Dr Zavras:
“Returns from solicitor requesting orthopaedic surgeon to see her for all her joint pain.  I advised her this is not possible and need to see rheumatologist re pains.  Is fixated re fall solicitor requesting that she be sent for orthopaedic assessment. Actions:   Imaging request printed to Spectrum Medical Imaging Maroubra: plain x-ray – cervical spine plain x-ray – lumbosacral spine.  (Had fall 18/6 since then has had pains generalised affecting neck and low back)”.  
On 25 July 2016, Dr Zavras referred Mrs Alabasinis to Dr Ilana Ginges, Specialist Rheumatologist, stating, “… this lady had a fall while travelling as a passenger in bus on 18/6/2016.  She attended POW where she was diagnosed with soft tissue injuries.  No fractures identified.  Golfo has since seen lawyer because she has had persistent widespread body pains particularly occiput, cervical spine R and L shoulder and L elbow L hip and low back.  She has past history of tears both supraspinatus both tendons for which she was advised – nonsurgical treatment by Dr Goldberg.  Golfo is on paracetamol 2 tds.  I have explained the fall may well have precipitated exacerbation of underlying degenerative joint changes. ?hydrotherapy. ?opinion”.  
At her first attendance on 24 August 2016, Dr Ginges obtained a history of worsening pain in the days after the accident, with development of pain in new areas “for example her shoulders and neck.  She has had pain sleeping on the left side and the pain runs down the left leg”.  She noted x-rays of the cervical and lumbar spine showing degenerative change, and ultrasound of the shoulders showing a full thickness tear of the right supraspinatus tendon.  On examination, she found tenderness over the right shoulder with abduction restricted to 90 degrees and limited internalrotation.  She found neck movements restricted to about 75% of normal and normal hip movements with tenderness over the left greater trochanter (GTB).  She added, “there was no other evidence of injury.
“Impression:  Mrs Alabasinis has had a significant fall, possibly flaring the pre-existing rotator cuff tendinopathy.  Clinically she has trochanteric bursitis on the left.  I would also like to exclude a pelvic fracture”.  She recommended a whole body bone scan, ultrasound-guided steroid injection to the right subacromial bursa and left GTB, and agreed that hydrotherapy would be useful.  She also suggested the antidepressant Cymbalta if pain did not improve.  
At review on 20 September 2016, Dr Ginges wrote, “Mrs Alabasinis has had a number of interventions.  Firstly, I was pleased to see that the bone scan did not show any fracture or any sinister changes.  She did have widespread arthritis in the spine, the AC joints, the wrists joints, the hip joints and left trochanteric enthesopathy.  She had an ultrasound-guided injection to the left trochanteric bursa and the right subacromial bursa but these have been unsuccessful.  She now has pain over both lateral hips.  She is still very scared to travel and keeps on thinking about her accident.  She tells me that you have started her on Lexapro last week.  
Her examination is unchanged.  There is still significant tenderness over both lateral greater trochanters with normal leg movements.  Mrs Alabasinis has longstanding arthritic issues and probably developing a level of chronic widespread pain after the shock of her accident”.  She suggested a change of antidepressant medication from Lexapro to Cymbalta which might help more with pain, hydrotherapy, and to see a psychologist.
On 01 November 2016, Dr Ginges reviewed Mrs Alabasinis saying that she had recalled her because of CRP was elevated at 12.2, raising the question of an inflammatory cause of her pain.  She questioned the possibility of polymyalgia rheumatica.  She found it difficult to obtain a useful history.  Repeat ESR was 19 and CRP lower at 5.3. 
One week later on 07 November 2016, Dr Ginges reported that Mrs Alabasinis had no response at all to a trial of prednisolone 15 mg daily (which would be expected to help with polymyalgia rheumatica).  She added, “the problem here is not polymyalgia rheumatica, nor any systemic inflammation.  I do not believe there is anything else I’d be able to add to her treatment as I know from our discussion you have already talked to her about the different aspects of pain management.  It is probably a good time for her now to go to a pain clinic to consider multidisciplinary management of her pain”.
Details of any relevant injuries or conditions sustained since the motor accident
When asked, Mrs Alabasinis said that she had had lots of falls at home including in the garden.  She said that she did not know why.
Current Status
The Assessor asked Mrs Alabasinis if she thought that she was still experiencing problems from the incident, eight years earlier.  She said that she did still have a lot of related problems.  In an attempt to clarify issues, she was asked what symptoms which she related to the accident were now troubling her the most.  It was difficult to get useful answers from her.  She began by talking a lot about falls and problems with bowel and bladder control, causing  a lot of “accidents”.
The Assessor then explained through the interpreter that he was simply trying to find out what symptoms she still had from the accident.  She then replied that her blood pressure had become very high (her husband then interjected that she had an injury to the head and “had some bleeding under the skull”.  He then added more about her bowel and bladder problems, which the interpreter translated for me.  The Assessor then said that he would go through a list of allegedly injured body parts provided by her solicitor,  and that he needed to discuss these rather than any unrelated complaints.  This was done as follows:
1.	Neck
Mrs Alabasinis described headaches and “problems twisting my head”.  (As noted above, she frequently rotated her head and neck very fully to the left to talk to the interpreter).
2.	Shoulders
She said these were both painful. 
3.	Both arms
She responded, “I can’t lift anything – I drop things”.  She described problems in the whole left upper limb including the hand and fingers, and said that she could not lift it upwards much.
4.	Low back
She was asked to point to the location of pain – Mrs Alabasinis could rise easily from a standard office chair without using her arms and pointed to the central lumbosacral area and buttocks.
5.	Right lower limb
When asked, she described pain down “both legs all the way down”.
6.	Left lower limb
She described pain in the whole left leg.  
Present Activities
Mrs Alabasinis said that she does not do any housework and that her husband and daughter do this.  Her husband apparently helps her with the shower.  She was asked if she was receiving an aged care package at home – I understood that an assessment had been performed but no actual help arranged yet.  When asked about cooking, she replied, “I can’t lift anything – I do something very light”.  
Present Treatment
Mrs Alabasinis  provided me with a handwritten list of medications (in English, with dosage in Greek).  These included various vitamins, cod liver oil and other supplements.  The only analgesic appeared to be Paracetamol 665 mg 2 tablets three times per day (the same as Panadol Osteo), Solifenacin (an antimuscarinic agent used to reduce bladder activity) and the antihypertensive Candesartan.  
Physical Examination
Mrs Alabasinis presented as a moderately obese elderly lady.  She had medium length grey hair and wore spectacles.  Her skin was very pale suggesting that she spends little time outside.  She and her husband arrived about 10 minutes prior to her appointment time.
She seemed to understand English reasonably well and spoke English at times, but most history was obtained through the interpreter.  As noted above, considerable time was spent managing the behaviour of her husband.
Height was 150 cm and weight 82 kg, giving a BMI of 35 (in the moderately obese range).  She walked into the examination room somewhat slowly, but general mobility was quite good and she had no difficulty getting in and out of a standard office chair without pushing up with her hands.  She was able to get on and off the examination couch with slight assistance, but when she was asked to roll over from supine to prone, she cried out and it was decided not to persist with this.
She was extremely talkative and discursive, and it was very difficult to keep her to the point or obtain an answer to direct questions.  It was clear throughout the long assessment that Mrs Alabasinis and her husband both wanted to put down all her ailments and complaints to the incident on the bus eight years earlier.
Cervical spine
There was a marked forward protrusion of the head and neck (“poke neck”).  On palpation she reported slight tenderness generally over the cervical spine and trapezius muscles, but there was no spasm or guarding.  Cervical spine flexion was normal and extension was considered to be normal- given her marked “poke neck” posture.  On formal examination she only rotated her head and neck about two-thirds to the left, but earlier she had consistently shown very full rotation to about 80 degrees when talking to the interpreter (this discrepancy was pointed out to her but no useful response was received and she simply said that she was sore).  Rotation during formal examination was about two-thirds of normal to the right, lateral flexion was two-thirds of normal to the right and about one-third of normal to the left. The Medical Assessors concluded that there was no consistent asymmetry of motion or spinal dysmetria.
(As seen below under “Upper extremities”, there were no objective signs of cervical radiculopathy in the upper limbs.  There was no muscle guarding and she was not describing nonverifiable radicular complaints in the upper limbs.  Given the evidence of inconsistency and self-limitation during formal measurement of AROM, the Assessor did not consider that there was genuine dysmetria).  
Lumbar spine
On palpation while Mrs Alabasinis was standing, she reported slight tenderness over the lumbosacral spine only.  Standing with knees straight she could flex forward with fingertips to the knees with a fairly good smooth expansion over the visible lumbosacral segment.  In comparison, she was apparently able to manage minimal lumbar extension, crying out and then exclaiming, “sorry!”.  Lateral flexion was a third of normal bilaterally.  There was no detectible muscle guarding  or spasm.  Because of difficulty obtaining a clear history from her, it was impossible to ascertain whether or not she might be describing any nonverifiable radicular complaints.
(As can be seen below under “Lower extremities”, there were no objective signs of lumbosacral radiculopathy.  The Assessor considered that there probably was genuine painful dysmetria, with effectively no extension compared with quite good flexion.  The reason for this remains to be determined).
Upper extremities
Both upper arms measured equal in circumference at 35 cm.  The right forearm 25 cm and the left 24.5 cm.  Biceps, triceps and brachioradialis reflexes were normal and symmetrical.  Power including grip strength was normal bilaterally and light touch was preserved in both upper limbs.
The wrists were not tender to palpation.  AROM of both wrists was carefully measured with repetition with a goniometer as follows: 
Wrist Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	45	45	
Extension	50	50	
Ulnar deviation	30	30	
Radial deviation	20	20	
Both elbows were normal in appearance.  Mrs Alabasinis reported slight tenderness over the left antecubital fossa but not elsewhere.  AROM was measured with repetition with a goniometer as follows: 
Elbow Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	130	130	
Extension	0	-10 (fixed flexion deformity)	
Pronation	90	90	
Supination	80	80	
In the shoulders she reported slight tenderness to palpation over both glenohumeral joints.  There was no obvious wasting of the periscapular muscles on either side.  AROM was again measured with repetition with a goniometer as tabulated:
Shoulder Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	100	90	
Extension	40	30	
Abduction	90	80	
Adduction	20	40	
External rotation	50°	50°	
Internal rotation	20°	40°	
Consistent with restricted internal rotation Mrs Alabasinis was unable to reach either thumb up behind her back above L1 level.  She cried out spontaneously at the limits of right shoulder abduction.
With Mrs Alabasinis’ consent the Assessor gave very gentle, passive assistance during flexion and abduction – these were still not possible beyond 110 degrees on either side with apparent pain.  No crepitus on movement was detectible in either shoulder.
When asked to show where the pain was, she simply said, “my shoulders” putting each hand over the opposing shoulder cowl.  (The Assessor noted that Mrs Alabasinis did not appear to try to compensate for restricted glenohumeral movement by manoeuvres such as leaning her body to one side or hitching up the scapula.  The impression was of generally painful stiff shoulders bilaterally.  The Assessor was uncertain how reliable the measured AROM was).
Lower extremities
Measured 10 cm proximal to the patella the right thigh measured 57 cm in circumference, the left 56 cm.  The right calf measured 41 cm and the left 40.5 cm.  Both lower limbs were neurologically normal, with intact and symmetrical knee jerks and ankle jerks and normal plantar responses (flexor).  Power and light touch was preserved bilaterally.  (As noted above, Mrs Alabasinis moved quite briskly getting in and out of a chair and could stand up without using any hand assistance).  Straight leg raising tested in the supine position was 50 degrees bilaterally – she did complain of some pain but it was impossible to determine exactly where.  Seated straight leg raising was 70 degrees bilaterally and apparently pain-free.
Both knees were normal in appearance.  The right knee measured 43 cm in circumference, left 43.5 cm.  On gentle palpation she described slight very vague tenderness over both knees.  Extension was full bilaterally and flexion to 100 degrees on the right and 90 degrees on the left.  Ligaments were all clinically intact and there was no crepitus on movement.  
AROM of the hips was carefully measured with repetition with a goniometer as tabulated: 
Hip Movements	Active ROM Measured
RIGHT	Active ROM Measured
LEFT	
Flexion	90	90	
Extension	0	0	
Abduction	30	30	
Adduction	20	20	
Internal rotation	30°	30°	
External rotation	30°	30°	
A few other functional activities were observed: Mrs Alabasinis was just able to stand with weight on her forefeet with heels off the floor and then on her heels with forefeet off the floor.  Using her left hand on a chair back for light support she was able to squat a third of the way down to the floor before stopping and recovering.
Both flexion of 90 degrees and external rotation of 30 degrees give “mild” impairment from Table 40 of AMA 4, ie 2% WPI or 5% LEI.  Flexion of 100 degrees on the right and 90 degrees on the left in the knees gives 4% WPI or 10% LEI from Table 41.  The LEIs would be combined to give 15% for each lower limb which would convert to 6% WPI on each side.  
Assessor’s Conclusions Following this Re-examination
1.	This was one of the most difficult examinations this Assessor had performed in a motor accident manner – as described above.  Mrs Alabasinis and her husband clearly attribute all her ailments and symptoms to the fall off a bus seat some eight years earlier.
2.	Mrs Alabasinis’ description to Assessor Shahzad in October 2023, that she “was abruptly thrown forward from a seat and she was in the air above the floor looking down on the floor” is probably not accurate.  However, it does seem clear that she fell from the seat onto the metal floor of the bus and needed to be helped back to her seat by two other passengers.
3.	She was ambulant immediately afterwards and able to get off the bus, go into a shop and call her husband to come and collect her.  It is probable that the quite clear report from the emergency department registrar at Prince of Wales Hospital, followed by the early contemporaneous notes of her longstanding GP, Dr Zavras, are the best guide as to actual injuries sustained.  Early involvement of a solicitor and discussion of this with Dr Zavras is noted.
Review of Bus CCTV Footage
Useful footage over a period of more than 20 minutes was seen from three cameras. Cam Forward and Rear Deck do not show anything relevant. The most useful footage is from Driver Cam, with some extra from Front Door and Rear Door.  
Driver Cam
This camera points backwards and includes a view of the driver and seats behind. The driver appears to be a middle-aged Asian man, wearing dark glasses. At approximately 25 seconds, a grey-haired older lady, identifiable as Mrs Alabasinis, gets on the bus, taps on with her card and sits down in the double red seat immediately behind the glass partition behind the driver.  (This seat and its counterpart on the opposite side of the bus are on a raised plinth, approximately 150 mm above the main floor of the bus).  She moves quite normally and at a normal pace and is carrying bags, including a red bag. Throughout she is noted to sit near the left side of the seat (i.e. close to the edge and away from the window). 
7.05:  Reaches forward into her bag, apparently for a mobile phone, then appears to be dialling on phone.
7.35:  Puts phone to left ear with her right hand.
8.00:  Still using phone, bus moving.
8.06:  Bus stops. Mrs Alabasinis still has phone to her left ear. A younger woman with fair hair gets onto the bus. 
8.15:  Bus moves off again – Mrs Alabasinis is still using phone.
8.45:  Phone in right hand in front of her – possibly hanging up from call or dialling again.
9.00:  Dialling again and puts mobile phone back to left ear using right hand.
9.03: Footage from Driver Cam, Front Door and Rear Door all appear to show the bus stopping at or close to an intersection.
Driver Cam shows Mrs Alabasinis still sitting on the edge of her seat, holding a mobile phone to her left ear with her right hand. As the bus stops/slows, she suddenly pitches forward and extends her right arm to the side. As she falls, she twists and lands on the red floor area between the front door and the driver on her back.  It would appear that she probably first strikes the floor with her left buttock/left side of her back, and then rolls fully onto her back.  It is not clear whether she struck the back of her head on the floor or not, but she briefly puts her right hand to the right side of her head. She looks shocked/surprised. 
9.12:  Driver reaches down with his left hand to Mrs Alabasinis, and a young Asian passenger with a red top moves forward from a few seats behind and helps her up – pulling her up by both hands.
9.38:  Mrs Alabasinis sits back in the same seat.  She points her finger at the driver, who is still standing, and appears to talk quite animatedly with the driver.  The young man who helped her up comes forward from his seat and talks to driver, before returning to his seat.
10.20:  Driver returns to his seat.  Mrs Alabasinis is only half in her seat and still apparently talking. The driver moves off.  Mrs Alabasinis remains on the edge of her seat with her left leg dangling clear of the floor.
11.00:  Bus stops again.  Mrs Alabasinis appears to be reaching forward and talking to the driver. 
11.20:  Bus moves off again. 
11.45:  Bus stops.  The young man who helped Mrs Alabasinis gets off the bus, and several more passengers get on. The bus remains stationary with the front door open and the driver has a  long discussion with Mrs Alabasinis, including apparently looking at his phone/other device and showing it to Mrs Alabasinis. 
18.00:  Bus moves off again. 
20.30:  Mrs Alabasinis appears to be preparing to get off her seat. 
21.00:  Mrs Alabasinis gets off the bus normally and then reaches back through the open front door to tap off.
Impressions From This Footage
1.	The footage confirms that Mrs Alabasinis was sitting in one of the two seats (usually reserved for less mobile passengers) behind the driver and that she fell forwards off it when the bus stopped, landing on her back in the area between the driver and the front door.
2.	The bus did not appear to brake particularly violently – footage from the forward-facing Cam Front  did not appear to show anything unusual to cause sudden braking.  Mrs Alabasinis was noted to sit on the edge of her seat throughout and immediately prior to the incident was holding a mobile phone to her left ear with her right hand, and did not seem to be holding on at all – this may have made her more prone to fall when the bus braked. 
3.	Mrs Alabasinis’ account given to the Assessor (eight years after the accident) had some inaccuracies – she said that she did not have a mobile phone with her, but she was clearly seen to have this and to be using it on the bus. Mrs Alabasinis also complained that the driver did not do anything in response – he did appear to initially reach and try to help her, but a young male passenger came forward and was able to lift her to her feet, holding both her hands. Mrs Alabasinis was noted to cooperate well with this. The driver later stopped and had a long conversation with her.
4.	Mrs Alabasinis moved normally and at a good pace when getting onto the bus. 
5.	Mrs Alabasinis was obviously upset and appeared to be somewhat agitated/angry and remonstrating with the driver after the incident. She appeared to be moving quite normally when getting off the bus some 11 minutes later. It appeared that she had forgotten to tap off while on the bus, and she then reached back through the driver’s door to do so from the pavement. 
6.	This fall had the potential for causing significant injury, but from her movements and activities in the 11 minutes after the fall and the way she alighted from the bus, there was no immediate visible evidence of injury.  
Panel Review of all Injuries referred to Medical Assessor Shahzad
Note:  The same list of injuries was referred to Assessor Carr in early 2018, except for the lumbar spine. Each referred injury will be reviewed in terms of contemporaneous documentation, current impairment assessment, pre-existing Permanent Impairment (if applicable) and finally any impairment attributable to the subject accident. 
1.	Cervical Spine
The discharge referral from Dr Whitfield, a Registrar at Prince of Wales Hospital Emergency Department, did not mention any complaint of neck pain. On examination he found a tender point over her occiput (consistent with probably striking the back of her head on the bus floor) but “no Cx spine tenderness, full ROM.  No spinal tenderness.”  No imaging of the cervical spine was performed.  Apparently there were x-rays of the left wrist and elbow (no fractures seen). 
Mrs Alabasinis attended her usual GP, Dr Zavras, two days after the accident. He reported: 
“(1)	now presents c/o pain over palmar surface L hand, o/e tender, no bruising or swelling.
(2) 	painful L knee, o/e no bruising or swelling. 
(3)	C/o pain L elbow, o/e no swelling, no bruising, mvt and tender on olecranon tip.”  
Six days after the accident, she was reviewed by Dr Zavras: 
“C/o generalised pains affecting occiput, L wrist, volar aspect low back…”
One month after the accident, on 20 July 2016, Dr Zavras stated that Mrs Alabasinis presented with a form from the solicitor, was proceeding with a claim, and was complaining of generalised pain affecting most of the body.  The cervical spine was not specifically mentioned. 
Cervical spine symptoms are first mentioned in Dr Zavras’ referral letter of 25 July 2016 to Dr Ilana Ginges, Rheumatologist. On 24 August 2016, Dr Ginges described pain after the accident in various new areas including her shoulders and neck, and on examination found neck movements restricted to about 75% of normal. 
In summary, the first mention of cervical spine symptoms is a month after the accident, by which time she had returned to her longstanding GP, Dr Zavras, having consulted a lawyer and now complaining of pain in multiple bodily areas.  This is a considerable contrast to localised symptoms in her left wrist, elbow, hip and knee, reported at Prince of Wales Hospital and similar specific reports to her GP two days later. 
Current Impairment
As detailed in the examination report, there was no convincing evidence of dysmetria (Mrs Alabasinis was noted to rotate her head and neck very fully spontaneously, but showed some apparent restriction during more formal examination).  There was no muscle guarding or spasm.  She was not reporting non-verifiable radicular complaints in the upper limbs and there were no signs of radiculopathy. The cervical spine is therefore assigned to DRE Cervicothoracic Category I, giving 0% impairment. Therefore, even if the Medical Panel was persuaded that Mrs Alabasinis had sustained some sort of soft tissue injury to the cervical spine in the accident, there is no related assessable impairment. The Panel assesses 0% WPI for the cervical spine.
2.	Right shoulder
The right shoulder was not mentioned at Prince of Wales Hospital or two days later by Dr Zavras.  The first mention of “both shoulders” was one month after the accident on 20 July 2016, when she returned to Dr Zavras with a form from her solicitor. Dr Zavras again mentioned both shoulders on 25 July 2016, when he referred Mrs Alabasinis to Dr Ginges, Rheumatologist.  
Two months after the accident, on 24 August 2016, Dr Ginges found tenderness over the right shoulder with abduction restricted to 90% and limited internal rotation. She concluded:
“Impression:  Mrs Alabasinis has had a significant fall, possibly flaring the pre-existing rotator cuff tendinopathy. Clinically she has trochanteric bursitis on the left. I would also like to exclude a pelvic fracture.” 
She recommended an ultrasound-guided steroid injection to the right subacromial bursa. At review in September 2016, three months after the accident, Dr Ginges wrote:
“…firstly I was pleased to see the bone scan did not show any fracture or any sinister changes. She did have widespread arthritis in the spine, the AC joints, the wrist joints, the hip joints and left trochanteric enthesopathy. She had an ultrasound-guided injection to the left trochanteric bursa and the right subacromial bursa, but these have been unsuccessful. She now has pain over both lateral hips. She is still very scared to travel and keeps on thinking about her accident. She tells me you have started her on Lexapro last week.
Her examination is unchanged. There is still significant tenderness over both lateral greater trochanters with normal leg movements.  Mrs Alabasinis has longstanding arthritic issues and probably developed a level of chronic, widespread pain after the shock of her accident.”
She suggested a change of antidepressant medication from Lexapro to Cymbalta, which might help more with pain, hydrotherapy and referred to a psychologist. 
Later in 2016, Dr Ginges instituted a 7 day trial of prednisolone because of a temporarily elevated CRP, which had raised the possibility of polymyalgia rheumatica.  In her letter on 7 September 2016, she wrote:
“The problem here is not polymyalgia rheumatica, nor any system inflammation. I do not believe there is anything else I would be able to add to her treatment, as I know from our discussion you have already talked to her about the different aspects of pain management. It is probably a good time for her now to go a pain clinic to consider multidisciplinary management of her pain.” 
The Panel considers that Mrs Alabasinis may have aggravated pre-existing established rotator cuff pathology in the right shoulder in the fall, but this is not certain.
Current Impairment Assessment
At the Panel re-examination there was quite marked restriction of AROM in both shoulders. There was also slight tenderness to palpation over both glenohumeral joints.  Referring the tabulated range of movement in the right shoulder to figures 38, 41 and 44 of AMA4, this gives a total of 15% UEI.
However, the Panel notes that in his Certificate of 5 February 2018 (approximately 18 months after the accident), Assessor Carr only found very minor limitation of flexion in the right shoulder (170 degrees compared with a full 180 on the left) and minor restriction of internal rotation (70 degrees, compared with 80 on the left), giving 2% UEI or 1% WPI.  This was in fact the only impairment which Assessor Carr rated and considered applied for this accident. 
The Panel also notes that Mrs Alabasinis attended her usual GP, Dr Zavras, in February 2014 with right shoulder pain with the comment:
“Has large R full thickness tear R supraspinatus, very reluctant to undertake any Rx.”
Later, after the accident, in July 2016 when referred Mrs Alabasinis to the rheumatologist, Dr Zavras added:
“She has past history of tears both supraspinatus, both tendons for which she was advised – non-surgical treatment by Dr Goldberg…”
The two medical Assessors in this Panel consider that Dr Carr’s measured AROM of both shoulders in 2018 was, if anything, surprisingly good for a 70-year-old patient with a known full thickness rotator cuff tear. Given the lack of early contemporaneous documentation of injury to either shoulder, and the fact that eight years have now elapsed since the accident, the Panel considered that Assessor Carr’s examination, 18 months after the accident, might in fact offer the most reliable objective assessment of any impairment in the right shoulder attributable to the accident. 
The Panel also notes that there was previous well-documented rotator cuff disease with bilateral  supraspinatus tears. The natural history of such conditions is gradual deterioration. In addition, the Panel particularly notes that, during the 3 hour assessment performed by Dr Obeid at the Claimant’s home in 2023,  he was able to observe various functional activities including:
“reached well above the head to obtain her medications from a high kitchen cupboard using her right arm.”  
 The Panel considered that, even if Mrs Alabasinis did sustain a temporary aggravation of her  rotator cuff disease in the subject fall, that this in itself would not have led to progressive deterioration since Assessor Carr’s examination in 2018.  
After careful consideration, the Panel considered that it was preferable to make a fresh assessment of current impairment.  Given Mrs Alabasinis’ somewhat problematic presentation at the two-hour re-examination, evidence of inconsistency and self-limitation during some active movements (for example, moving her head and neck very well spontaneously, but less during formal examination), and the apparent marked inconsistency between AROM demonstrated in both shoulders at this re-examination compared with previous examinations – particularly that of Dr Obeid in 2023., the Panel considered that range of movement was not a valid method of impairment assessment (see MAG Paragraph 6.50.4 and 6.50.5).  
In this situation, the Guidelines make it permissible to use assessment by analogy.  A well-established method, which has been used on various occasions by de novo Assessors and also Review Panels, is by analogy with joint crepitation (such crepitation does not have to have been actually observed at the examination in question).  The Panel considered that the best analogy in this case is with mild crepitation of the acromioclavicular joint.  Referring to Tables 18 and 19 of AMA4, this gives 2.5% UEI (Upper Extremity Impairment),   or 1.5% WPI , which is rounded up using the usual convention to   2% WPI.   
3.	Left Shoulder
Causation
The early documentation (or lack of it) is similar here to that with the right shoulder. There is no mention of the left shoulder at Prince of Wales Hospital or when she first consulted Dr Zavras two days later.  The first mention of “both shoulders” was one month after the accident with Dr Zavras on 20 July 2016.  Dr Zavras mentioned the same in a referral letter to Dr Ginges a few days later – as above mentioning a previous history of supraspinatus tears in both shoulders, with non-surgical treatment previously recommended by Dr Goldberg (a very experienced shoulder surgeon).  As with the right shoulder, the Panel considers that Mrs Alabasinis may have aggravated pre-existing established rotator cuff pathology in the left shoulder in the fall, but this is not certain.
Impairment Assessment
At the Review Panel re-examination there was marked restriction of AROM in the left shoulder (marginally worse than the right).  If these movements are applied to relevant Tables 38, 41 and 44 of AMA4, there is 17% LEI.
However, as noted above, 18 months after the accident, Medical Assessor Carr found a completely full AROM of the left shoulder, with no assessable impairment. The Medical Panel considers, that with a history of well-established rotator cuff pathology documented prior to the accident, any deterioration between 2018 and 2024 was more likely due to the natural history of the condition than any effect of the fall on the bus.  As with the right shoulder, the Medical Panel considered that Medical Assessor Carr’s examination, 18 months after the accident, might in fact offer the most reliable objective assessment of any impairment in the right shoulder attributable to the accident. 
The Panel also notes that there was previous well-documented rotator cuff disease with bilateral  supraspinatus tears. The natural history of such conditions is gradual deterioration. In addition, the Panel particularly notes that, during the 3 hour assessment performed by Dr Obeid at the Claimant’s home in 2023,  he was able to observe various functional activities including:
“reached well above the head to obtain her medications from a high kitchen cupboard using her right arm.”  
 The Panel considered that, even if Mrs Alabasinis did sustain a temporary aggravation of her  rotator cuff disease in the subject fall, that this in itself would not have led to progressive deterioration since Assessor Carr’s examination in 2018.  
After careful consideration,  the Panel considered that it was preferable to make a fresh assessment of current impairment.  Given Mrs Alabasinis’ somewhat problematic presentation at the two-hour re-examination, evidence of inconsistency and self-limitation during some active movements (for example, moving her head and neck very well spontaneously, but less during formal examination), and the apparent marked inconsistency between AROM demonstrated in both shoulders at this re-examination compared with previous examinations – particularly that of Dr Obeid in 2023., the Panel considered that range of movement was not a valid method of impairment assessment (see MAG Paragraph 6.50.4 and 6.50.5).  
In this situation, the Guidelines make it permissible to use assessment by analogy.  A well-established method, which has been used on various occasions by de novo Assessors and also Review Panels, is by analogy with joint crepitation (such crepitation does not have to have been actually observed at the examination in question).  The Panel considered that the best analogy in this case is with mild crepitation of the acromioclavicular joint.  Referring to Tables 18 and 19 of AMA4, this gives 2.5% UEI (Upper Extremity Impairment), which is rounded up using the usual convention to 3% UEI.   
4.	Right Wrist   
Causation 
The right wrist is not mentioned at Prince of Wales Hospital or two days later by her GP, Dr Zavras. When she returned one month later in late July, and Dr Zavras referred her in turn to Dr Ginges, Rheumatologist, Dr Zavras described generalised pain, but in his referral letter to Dr Ginges, he did not specifically mention the right wrist. In August 2016, Dr Ginges did not specifically mention symptoms or abnormal physical signs in either wrist, although she did later state that bone scan showed arthritis in many joints, including both wrists.
The Panel also notes that from viewing the CCTV footage, Mrs Alabasinis initially fell forward, then as she fell rotated to the right, landing more on her left side, before rolling right over onto her back. This mechanism makes injury to the left upper limb more likely and is consistent with the report at POWH of complaints of pain in the left wrist, elbow, hip and knee with tenderness over the left elbow and left wrist on examination, and also tenderness over the left hip and a bruise on the left knee.
The Panel considers that there is no evidence that Mrs Alabasinis injured the right wrist (as opposed to the left) in the accident.  Impairment assessment therefore is not required. 
5.	Left Wrist
Causation
Of the 10 injuries referred to Assessor Shahzad, injury to the left wrist was documented at POWH Emergency Department.  The wrist was x-rayed and showing no fracture.  Two days later, Dr Zavras said that she was reporting pain over the palmar aspect of the left hand. On examination he found tenderness but no bruising or swelling. The Panel accepts causation for an injury to the left wrist in this accident.   
Impairment Assessment
At the Panel re-examination there was slight and symmetrical restriction of AROM in both wrists.  Applying the tabulated AROM to Figures 26 and 28 of AMA4, there is 5% UEI in each wrist for slight restriction of both flexion and extension.  Noting the long history of arthritis and the observation by Dr Ginges Rheumatologist, that the bone scan showed arthritic changes in both wrists, the Panel considered that pursuant to Paragraph 6.51 of the MAG, the uninjured right wrist should be used as a baseline for assessment of the left wrist, giving no net assessable impairment.  The Panel therefore assesses  0% WPI for the left wrist.  
6.	Left Elbow
Causation
Injury to the left elbow was also documented at POWH, with tenderness found on examination over the distal humerus. X-rays showed no fracture.  Two days later, Dr Zavras found no swelling or bruising, but tenderness over the tip of the olecranon.  When she was later referred to Dr Ginges, Rheumatologist, she documented widespread musculoskeletal pain but did not specifically refer to the left elbow. The Panel accepts causation of a soft tissue injury to the left elbow.
Impairment Assessment 
At the Panel re-examination there was minor symmetrical restriction of flexion in both elbows and 10 degrees lack of extension in the left elbow. Applying these measurements to Figure 32 of AMA4, there is 1% UEI on the right and 2% on the left. In this instance the Panel considers it preferable to apply the advice in Paragraph 6.51 of the MAG and use the slightly restricted flexion of the right elbow as a baseline. There is thus net 1% UEI for the left elbow because of lack of extension. 
Combined Assessment of Left Upper Limb 
3% UEI for the left shoulder is combined with 1% for the left elbow to give 4% UEI.  This converts using Table 3 from Page 20 of AMA4 to 2% WPI.  (Note that UEI’s for different joints of the same limb are combined before converting to WPI).
7.	Left Hip
Causation
Pain in the left hip was documented at POWH, with tenderness to palpation over the left hip. She was noted to be ambulating normally and the CCTV footage showed her getting off the bus with an apparently normal gait.
Two days later, Dr Zavras did not specifically record ongoing pain in the left hip, but he did mention it when she returned, complaining of widespread symptoms one month later.  He also mentioned the left hip in his referral in July 2016 to Dr Ginges, Rheumatologist. 
In August 2016, two months after the accident, Dr Ginges documented normal hip movements, with tenderness over the left greater trochanter (GTB) and arranged ultrasound-guided steroid injection to the left GTB.  Unfortunately, one month later in September 2016, she said that this injection had not been successful. By then, Mrs Alabasinis was complaining of pain over both lateral hips.  She also noted that bone scan showed widespread arthritis, including in the hip joints and left trochanteric enthesopathy. 
The Panel accepts causation of an injury to the left hip. Particularly noting from the CCTV footage that she twisted as she fell forward from her seat, landing more on her left side, a direct injury to the left lateral hip producing greater trochanteric bursitis/enthesopathy seems probable,  and is supported by the contemporaneous documentation. 
Impairment Assessment 
At the Panel re-examination there was minor symmetrical restriction of hip flexion and external rotation.  Applying these figures to Table 40 of AMA4, there is 5% LEI (2% WPI) for each hip.  The Panel notes that greater trochanteric bursitis, although painful, does not specifically restrict AROM of the hip (which does occur with osteoarthritis, however). The Panel considers that the slight restriction of AROM measured is probably due to underlying degenerative osteoarthritis in both hips (previously demonstrated on bone scan).  It considers that Paragraph 6.72 of the MAG applies and that the right hip should be used as a baseline for the left, giving nil net assessable impairment for the left hip.  The Panel also notes that Table 64 of AMA4 only allows 7% LEI (3% WPI) for chronic trochanteric bursitis if there is an abnormal gait.  Gait was normal and symmetrical at this assessment and this section does not apply. The Panel assesses  0% WPI for the left hip.
8.	Left Knee
Causation
Pain in the left knee was noted at POWH.  Examination showed:
“Left knee – small bruise over patella but joint non-tender with full ROM and able to mobilise.”  
She also reported pain to her GP, Dr Zavras two days later, when on examination he found no bruising or swelling. She was apparently continuing to complain of left knee pain one month later. 
However, Dr Ginges, Rheumatologist, two months after the accident, did not specifically comment on the knee.  The Panel accepts causation for a direct injury to the anterior left knee, in the form of contusion/soft tissue injury. 
Impairment Assessment
At the Panel re-examination, both knees were normal in appearance. Mrs Alabasinis reported very slight and vague tenderness over both knees bilaterally on gentle palpation. Extension was full bilaterally.  Flexion was 100 degrees on the right and 90 degrees on the left.  .  Flexion of 90 degrees on the left gives 5% LEI or 2% WPI from Table 40 of AMA4.  Flexion of 100 degrees on the right also gives 5% LEI or 2% WPI 
The Panel notes that in his certificate of 22 November 2023, Assessor Shahzad recorded a normal range of movement in both left and right hips and knees and assessed no related impairment. Nearly six years earlier, Assessor Carr found considerably better AROM in both knees (120 degrees on the right and 140 degrees on the left). At his three-hour home assessment in October 2023, Dr Obeid, Consultant Physician and Geriatrician, described full range of motion in hips and knees. 
The Panel considered that, assessing Mrs Alabasinis eight years after the accident, that it was unlikely that the slight observed restriction of flexion of the left knee at the Panel re-examination was related to the direct blow sustained in the fall.  This was supported by earlier observations of considerably better AROM (since the accident). The Panel considered that restricted flexion in both knees was probably caused by degenerative osteoarthritis, and that the right knee should be used as a baseline for the left, pursuant to MAG para 6.72. Thus, there is no assessable net WPI for the left knee by AROM. There were no other abnormalities on examination that would lead to another method of impairment assessment-in particular no patella-femoral crepitus, The Panel therefore assesses 0% WPI for the left knee.
9.	Left Leg – Musculoligamentous Injury, Musculoskeletal Injury 
It is not clear to the Panel if this refers to any separate documented injury. Referred injuries to the left hip and knee have been discussed above. 
10.	Lumbar Spine
No injury to the lumbar spine was documented at POWH  or two days later by Dr Zavras.  However, 6 days after the accident on 24 June 2016, he wrote: “review today c/o generalised pains affecting occiput L wrist, volar aspect low back….”
When Mrs Alabasinis attended Dr Zavras one month later, complaining of widespread pains, he did not specifically mention the lumbar spine/low back, although he did mention it a few days later in his referral letter to Dr Ginges, Rheumatologist.
Two months after the accident in August 2016, Dr Ginges noted that x-rays of both cervical and lumbar spines showed degenerative change. She found abnormalities on examination in both shoulders, a slight restriction of neck movement, tenderness over the left greater trochanter and added:    “There is no other evidence of injury.”
At later review in September 2016, when Mrs Alabasinis had not responded to injections of the left GTB and shoulder, Dr Ginges commented the bone scan had showed:  “Widespread arthritis in the spine….”,  but again did not mention low back pain. The Panel does not accept causation for an injury to the lumbar spine in this accident.  
Given the relatively early single mention of the back by her GP, Dr Zavras, and the mechanism of the fall, the Panel does accept some form of soft tissue injury to the lumbar spine in the accident.  
Impairment Assessment
As with some of the other ten injuries referred, given all the circumstances, especially the eight years which have elapsed since the accident, and the known pre-existing pathology, it was not clear to the Panel whether or not the current painful dysmetria with lack of lumbar extension found at examination was substantially related to the fall on the bus. In particular, at examination in March 1998, Dr James Bodel, Orthopaedic Surgeon, in an assessment for GIO Workers’ Compensation assessed “15% overall Permanent Impairment of function in the back. This is due to degenerative change at L4/L5 and L5/S1 and this is a constitutional ailment temporarily aggravated by the injury at work on 14.8.1997”.  The Panel notes that he also found pain on lumbar extension.  The Panel notes that this assessment was under the old “Table of Maims” and cannot be converted to WPI.  
Medical Panel considered that it was quite probable that there would have been similar findings on physical examination at a detailed assessment immediately prior to the accident on the bus, the Medical Panel also considered that Dr Bodel’s report 16 years prior to the date of injury would not be adequate objective evidence of a pre-existing symptomatic impairment.  Accordingly, after long and careful deliberation, the Medical Panel assessed 5% WPI for the lumbar spine in relation to the subject accident. 
Final Impairment Assessment
2% WPI for the right upper limb, 2% WPI for the left upper limb (shoulder and elbow), and 5% WPI for the lumbar spine are combined to give a total 9% WPI. 
FINDINGS
26.	The Review Panel conducts a new assessment of all the matters with which the medical assessment is concerned. The Review Panel is not required to choose between competing medical opinions and is required to form its own opinion. The medical assessment of permanent impairment is made at the time of the examination. In that respect, the previous assessments are outdated, and do not reflect current symptomatology.
CONCLUSION
27.	For the above reasons, the Review Panel concludes that the Certificate issued by Medical Assessor Shahzad dated 22 November 2023 should be revoked. The new Certificate appears at the commencement of these reasons.