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Underwood v. Social Security Administration

United States District Court, M.D. Tennessee, Nashville Division

January 12, 2017



          William J. Haynes, Jr. Senior Judge

         Plaintiff, Rhonda L. Underwood, filed this action under 42 U.S.C. §§ 405(a) and 1383(c)(3) against the Defendant Carolyn W. Colvin, Acting Commissioner of the Social Security Administration, seeking judicial review of the Commissioner's denial of Plaintiff s applications for disability benefits under Title II and XVI of the Social Security Act. Plaintiff filed her application on April 20, 2010, alleging disability since April 19, 2010 based upon her severe back pain, lumbar spine impairments, hypertensive cardiovascular disease, and hypertension. (Docket Entry No. 12, Administrative Record, at 213-220, 248). Plaintiffs applications were denied initially, and after reconsideration. Id. at 106-08, 110-11. Plaintiff requested a hearing before an Administrative Law Judge ("ALJ") and by decision dated March 5, 2012, ALJ Roberts found Plaintiff had severe impairments, but retained the ability to perform light work. Id. at 84-99. Plaintiff requested review of the AL J's decision by the Appeals Council that ordered a remand for a new hearing. Id. at 100-03.

         After a second hearing, the ALJ found Plaintiff was not disabled and was able to perform light work. Id. at 5-34. Plaintiff requested a review by the Appeals Council that the Appeal Council denied. Id. at 1-5.

         Before the Court is the Plaintiffs motion for judgment on the administrative record (Docket Entry No. 14) contending, in sum, that the AL J erred in evaluating the opinions of Plaintiff s treating physicians and Plaintiffs credibility. The Commissioner responded (Docket Entry No. 17) that the ALJ properly evaluated the evidence and his decision is supported by substantial evidence.

         A. Review of the Record

         Plaintiff, a high school graduate, was 45 years old at the onset of her disability. (Docket Entry No. 12, Administrative Record, at 3 9-40). Plaintiff s past relevant work was as a packer and cashier. M. According to Plaintiffs testimony, after back surgery in 2007, she was unable to work due to severe and sharp pain in her back. Id, at 44, 48. Plaintiff testified that she can sit and stand for 15-20 minutes when her pain bothers her and she must change positions. Id. at 44-45. Plaintiff can lift five pounds. Id. at 46. Plaintiff, who had carpal tunnel surgery in 1997 or 1998, cannot lift over 10 pounds with her right hand and was receiving injections into her right hand and wearing a brace at night to avoid hand pain. Id. at 64. Despite hip surgery in 2008, Plaintiff had left-sided hip pain. Id. at 47-49. Plaintiff has received injections and used a TENS unit without relief. Id. at 49-50. Plaintiff sleeps for a couple of hours and then is awake for two or three hours. Id. at 50. Lack of sleep causes Plaintiff daytime fatigue that has not been alleviated by any treatment. Id. at 50-51.

         At home, Plaintiff tries to sweep or mop, but doing so causes back pain and requires rest. Id. at 44. Plaintiff cannot write for very long due to hand pain, and often drops items if she does not use bothhands. Id. at 69. Plaintiffs medications help her symptoms, but these effects wear off if Plaintiff tries to do housework. Id. at 70. Plaintiff lies down three-fourths of the day to relieve her pain. Id.

         On September 5, 2007, Plaintiff had an L4-L5 laminectomy for low back pain that radiated down her left leg. Id. at 358. On February 25, 2008, Plaintiff began treatment with Pain Management Specialist William H. Leone, M.D., of the Pain Management Group. Id. at 667. Dr. Leone also treated Plaintiff for cervical spondylosis and, on December 9, 2009, administered left C4, C5, and C6 medial branch nerve block. Id. at 596. On February 3, 2010, Dr. Leone performed a left C4, C5, medial branch nerve rhizotomy. Id. at 591. In a follow-up procedure on March 2, 2010, Plaintiff responded that the rhizotomy helped her neck pain and mobility, but her left arm heaviness and left shoulder pain remained. Id, at 587-90. Dr. Leone refilled her medications of Lortab and Neurontin, but added Robaxin. Id. at 590, 615. On March 30, 2010, Plaintiff reported a continued "heavy" feeling in her left arm and a physical examination revealed tenderness and increased tone in the cervical paraspinal muscles. Id. at 583-86. Dr. Leone refilled Plaintiffs medications and ordered an updated MRI of her cervical spine. Id.

         On April 27, 2010, the MRI revealed posterior disc protrusions at C2-C3, C3 -C4, C4-C5, and C5-C6 causing mild compression of the spinal cord at C4-C5 and C5-C6. Id. at 578. Plaintiff also had a diffuse disc bulge at C6-C7 and bilateral uncovertebral osteophytes causing mild central stenosis and bilateral foraminal narrowing. Id. Dr. Leone also ordered refills of Plaintiffs medications. Id. at 582.

         On May 25, 2010, Plaintiff cited increased neck pain upon turning to the left and Dr. Leone noted that past epidural injections had not helped in the long term. Id. at 574-77. Dr. Leone refilled her medications and recommended IFC treatment. Id. at 577. On June 22, 2010, Plaintiff reported to Dr. Leone that she was attending physical therapy and using her TNS unit, but standing, lifting, bending, and sitting for too long increased her pain. Id. at 571. Dr. Leone refilled her medications, recommended a functional capacity evaluation, and would consider repeating prior procedures as needed. Id. at 573.

         In a June 22, 2010 letter, Malinda Johnson PAC, Dr. Leone's assistant, described Plaintiffs history of treatment at The Paint Management Group for chronic neck and low back pain, Id. at 569, that remained unchanged on My 20, 2010 and August 17, 2010. Id. at 562-68. Plaintiffs medications were refilled. Id., On September 14, 2010, Plaintiff returned to the clinic complaining of increased low back pain radiating to her right lower extremity. Id. at 558. Dr. Leone ordered an updated MRI of Plaintiff s lumbar spine. Id. at 560. On November 9, 2010, Plaintiff reported increased neck pain and her inability to afford physical therapy. Id. at 548. Plaintiff also reported symptoms of low back pain and bilateral lower extremity pain that worsen with walking. Id. Dr. Leone prescribed lumbar epidural steroid injections that Plaintiff received on November 24, 2010, December 8, 2010, and December 19, 2010. Id. at 535-50.

         On February 3, 2011, Dr. Leone refilled Plaintiffs Lortab, prescribed Mobic, and recommended physical therapy. Id. at 532-34. On February 25, 2011, Plaintiff received trigger point injections to her trapezii and supraspinatus areas. Id. at 529. On March 3, 2011, Plaintiff received medication refills. Id. at 525-27. On April 28, 2011, Plaintiff returned to Dr. Leone for additional refills and physical examination that revealed tenderness in the cervical and lumbar paraspinal muscles. Id. at 518-20.

         On October 13, 2011, Plaintiff experienced severe and worsening pain throughout her spine and both legs as well as difficulty falling asleep. Id. at 697. Elizabeth Bruce, PAC, examined Plaintiff on October 13, 2011 and December 8, 2011 and found cervical and lumbar spine tenderness. Id. at 693-98. Bruce prescribed Lortab, Robaxin, and Neurontin, ordered an MRI of Plaintiffs thoracic spine, and recommended additional lumbar epidural injections. Id. at 695. The December 23, 2011 MRI revealed a left paracentral disc protrusion at T7-T8 of Plaintiff s spine. Id. at 699.

         On August 20, 2014, Dr. Leone performed a functional capacity evaluation. Id. at 1085-1103. Based upon the test results, Dr. Leone opined that Plaintiff was unable to perform stooping, kneeling, crouching, lifting or carrying more than ten pounds, pushing or pulling more than ten pounds, reaching with the left arm, or rotating the cervical spine left or right. Id. at 1085. Dr. Leone cited very decreased flexion and extension in Plaintiffs lumbar spine. Id.

         On August 25, 2014, Dr. Leone completed a Disability Impairment Questionnaire summarizing Plaintiff s condition, citing his diagnoses of brachial neuritis, lumbosacral neuritis and spondylosis, cervical spinal stenosis and spondylosis, shoulder joint pain, thoracic spine pain, myalgia and myositis, and facet syndrome. Id. at 1110-14. Plaintiff s primary symptoms were chronic pain in her neck, left shoulder, and lumbar spine that have been present since September 3, 2007. Id. at 1111, 1114. In Dr. Leone's opinion, Plaintiff could sit for up to one hour total and stand/walk for up to one hour total in an eight hour day. Id. at 1112. Dr. Leone recommended that when sitting for 10-15 minutes, Plaintiff should get up and move around every 20 minutes before returning to a seated position. Id. Dr. Leone stated Plaintiff could lift and carry up to ten pounds occasionally and could only work for 1/3 of an eight-hour day where the job would involve reaching in all directions and manipulation. Id. at 1112-13. Plaintiffs pain, fatigue, and other symptoms would limit her attention and ...

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