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Nelson v. Commissioner of Social Security

United States District Court, S.D. Ohio, Eastern Division

October 26, 2017

MARGARET JEAN NELSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          Michael H. Watson Judge

          REPORT AND RECOMMENDATION

          KIMBERLY A. JOLSON UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Margaret Jean Nelson, filed this action under 42 U.S.C. § 405(g) seeking review of a decision of the Commissioner of Social Security (the “Commissioner”) denying her application for supplemental security income. For the reasons that follow, it is RECOMMENDED that the Court OVERRULE Plaintiff's Statement of Errors and AFFIRM the Commissioner's decision.

         I. FACTUAL AND MEDICAL BACKGROUND

         Plaintiff filed this case on November 28, 2016 (Doc. 1), and the Commissioner filed the administrative record on February 3, 2017 (Doc. 10). Plaintiff filed a Statement of Specific Errors on March 20, 2017 (Doc. 11), and the Commissioner responded on May 4, 2017 (Doc. 12). Plaintiff replied on May 18, 2017. (Doc. 13).

         A. Personal Background

         Plaintiff was born on September 29, 1968 (Doc. 10-2, Tr. 120, PAGEID #: 157), and alleges a disability onset date of June 5, 2012 (Doc. 10-2, Tr. 105, PAGEID #: 142). She has at least a high school education (Doc. 10-2, Tr. 120, PAGEID #: 157), and work experience as a pottery decorator, cutting vegetables for a produce distributor, and as a retail associate. (Doc. 10-2, Tr. 134-36, PAGEID #: 171-73). Plaintiff's date last insured was June 30, 2016. (Doc. 10-2, Tr. 105, PAGEID #: 142).

         B. Relevant Hearing Testimony

         Administrative Law Judge Timothy Keller (the “ALJ”) held a hearing on June 23, 2015. (Doc. 10-2, Tr. 129, PAGEID #: 166). During the hearing, Plaintiff testified that she suffers pain in her neck, lower back, and legs, which has worsened since 2012. (Id., Tr. 138, PAGEID #: 175). Plaintiff explained that she has had numerous shots, completed physical therapy, visited chiropractors, and had trigger injections to treat her lower back and neck pain, but that nothing seems to work. (Id.). Plaintiff also testified that she has taken pain medication for approximately a year, which “takes the edge off, ” but its efficacy has lessened. (Id., Tr. 139, PAGEID #: 176).

         Plaintiff further testified that she suffers from anxiety and bipolar disorder. (Id., Tr. 144, PAGEID #: 181). She explained that her bipolar disorder causes her to have “good days” and “bad days.” (Id., Tr. 145, PAGEID #: 182). Plaintiff stated that her good days occur when she is feeling manic, but that they only occur “maybe once every six months” to a year, whereas her bad days occur nearly every day and are a result of her depression. (Id.).

         In terms of daily activities, Plaintiff stated that she smoked marijuana up until 2009, and once in 2014 at a party. (Id., Tr. 142, PAGEID #: 179). Plaintiff testified that her bipolar disorder prevented her from keeping up with her housework, spending time with her family, and concentrating on tasks such as reading. (Id., Tr. 145, PAGEID #: 182). She stated that she barely leaves her house. (Id., Tr. 146-47, PAGEID #: 183-84).

         C. Relevant Medical Evidence

         a. Plaintiff's Physical Impairments

         Since at least 2013, Plaintiff has seen a number of physicians for pain management. On May 9, 2013, Dr. Mark Weaver performed a physical examination on Plaintiff and observed no tenderness of Plaintiff's left knee or of any other joints, but noted crepitus of Plaintiff's left knee with “ratchety inconsistency with pain inhibition and giving way in left shoulder muscles and left knee muscles.” (Doc. 10-7, Tr. 527-28, PAGEID #: 569-70). Dr. Weaver also noted that there was no impairment of grasp, manipulation, or grip strength of either hand; and straight leg raising was bilaterally negative. (Id., Tr. 528, PAGEID #: 570). X-rays of Plaintiff's lumbar spine showed mild disc space narrowing at ¶ 1-2 and L5-S1 but no other abnormalities. (Id., Tr. 517, PAGEID #: 559). X-rays of Plaintiff's left knee were read as normal except for being unable to exclude a suprapatellar bursal effusion. (Id., Tr. 516, PAGEID #: 558).

         On July 8, 2013, Plaintiff visited her treating physician, Dr. Paul Mumma with complaints of pain in her thoracic and cervical spine. (Id., Tr. 545, PAGEID #: 587). Throughout the examination, Plaintiff was alert and cooperative. (Id., Tr. 546, PAGEID #: 588). Dr. Mumma opined that Plaintiff's gait and station were normal, and neurological testing was intact. (Id., Tr. 547, PAGEID #: 589). Dr. Mumma further noted that Plaintiff had normal range of motion in all areas of the spine but numerous tender points. (Id.). X-rays of Plaintiff's lumbar spine revealed minimal degenerative changes at ¶ 5-S1 and L3-4, but X-rays of Plaintiff's thoracic spine were unremarkable and demonstrated no significant degenerative changes. (Doc. 10-8, Tr. 698-99, PAGEID #: 741-42). Plaintiff was diagnosed with anxiety, depression, and spinal arthritis. (Id.).

         Plaintiff visited additional physicians, as well as the emergency room, several times from July 2013 to April 2014, with complaints of back pain that radiated into her neck, legs, and arms. (Doc. 10-7, Tr. 579-581, PAGEID #: 621-23; Doc. 10-8, Tr. 702-18, PAGEID #: 745-61). Throughout these visits, Plaintiff consistently demonstrated normal range of motion in her neck (Doc. 10-8, Tr. 703, 705, 716, PAGEID #: 746, 748, 759), and did not demonstrate gross motor or sensory deficits. (Id., Tr. 770, 775, PAGEID #: 813, 818). Multiple physical examinations revealed that Plaintiff was in no acute distress, despite her claims of worsening back pain. (Id., Tr. 770, 775, PAGEID #: 813, 818). X-rays of Plaintiff's cervical spine taken in the emergency room on July 14, 2013, showed mild spondylosis at ¶ 3-C4 and mild facet arthropathy at ¶ 4-C5. (Id., Tr. 706, PAGEID #: 749). An examination with Dr. Yahya Bakdaliah on April 29, 2014, revealed no tenderness to palpation of Plaintiff's neck and lumbar spine. (Doc. 10-7, Tr. 580, PAGEID #: 622). Dr. Bakdaliah also noted that the lordotic curvature of Plaintiff's lumbar spine appeared “well maintained” and that Plaintiff's muscle strength in her lower extremities was “5/5 with good active range of motion.” (Id.). Dr. Bakdaliah diagnosed Plaintiff with cervical and lumbar spondylosis, chronic low back pain, and lumbar degenerative disc disease. (Id.).

         From May 2014 to September 2015, Plaintiff received treatment for her symptoms in the form of cervical blocks to levels C3-C6 (Doc. 10-8, Tr. 733, PAGE ID #: 776), and various joint steroid injections (id., Tr. 719, 843-44, PAGEID #: 801). On August 21, 2014, Plaintiff reported almost 100% relief from her neck pain. (Id., Tr. 748, PAGEID #: 791). On September 4, 2014, Plaintiff reported almost 100% relief from her low back pain. (Doc. 10-7, Tr. 586, PAGEID #: 628). However, almost a year later, on May 5, 2015, Plaintiff was examined by Dr. Courtney Bonner, due to neck pain. (Doc. 10-8, Tr. 807, PAGEID #: 850). Dr. Bonner noted a gait problem and neck stiffness, but X-rays of Plaintiff's spine revealed only mild facet arthritis. (Id., Tr. 807, 812, PAGEID #: 850, 855).

         On June 22, 2015, Tami Mohan, a physician assistant (“PA”) at Genesis Healthcare System Center for Occupational and Outpatient Rehabilitation, completed a physical capacity evaluation (the “PA assessment”) of Plaintiff that was co-signed by Dr. Kocoloski, who performed Plaintiff's spinal injections, and by Plaintiff's physical therapist. (Doc. 10-8, Tr. 804- 06, PAGEID #: 847-49). Ms. Mohan concluded that, in an eight-hour workday, Plaintiff could stand one hour total and five minutes at a time, walk one hour total and fifteen minutes at a time, and sit two hours total and fifteen minutes at a time. (Id., Tr. 805, PAGEID #: 848). The PA assessment further stated that Plaintiff could not use her hands for simple grasping, pushing and pulling, or fine manipulation; and that Plaintiff could rarely lift up to ten pounds. (Id.). Finally, Ms. Mohan opined that Plaintiff could bend, squat, and climb steps on occasion, but was completely unable to crawl or climb ladders. (Id., Tr. 806, PAGEID #: 949). The only remark Ms. Mohan provided regarding her findings was a note that stated Plaintiff had complained of cervical, thoracic, and lumbar pain. (Id.).

         b. Plaintiff's ...


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