United States District Court, S.D. Ohio, Eastern Division
Michael H. Watson Judge
REPORT AND RECOMMENDATION
KIMBERLY A. JOLSON UNITED STATES MAGISTRATE JUDGE.
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.
FACTUAL AND MEDICAL BACKGROUND
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).
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
Relevant Hearing Testimony
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).
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.).
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).
Relevant Medical Evidence
Plaintiff's Physical Impairments
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).
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.).
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.
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).
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