United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
Kathleen B. Burke United States Magistrate Judge.
Bobbie Jo Wilson (“Plaintiff” or
“Wilson”) seeks judicial review of the final
decision of Defendant Commissioner of Social Security
(“Defendant” or “Commissioner”)
denying her applications for social security disability
benefits. Doc. 1. This Court has jurisdiction pursuant to 42
U.S.C. § 405(g). This case is before the undersigned
Magistrate Judge pursuant to the consent of the parties. Doc.
13. As explained more fully below, the Court AFFIRMS the
protectively filed an application for Disability Insurance
Benefits (“DIB”) on October 8, 2013, and
protectively filed an application for Supplemental Security
Income (“SSI”) on October 31, 2013. Tr. 19, 115, 116,
273-274, 275-280, 305. Wilson alleged a disability onset date
of July 29, 2013. Tr. 19, 273, 275. She alleged disability
due to neck and back pain and spasm, a brain injury,
post-traumatic stress disorder, memory issues, depression,
anxiety, hand pain and spasms. Tr. 87, 117-118, 151, 163.
Wilson's applications were denied initially (Tr. 151-156)
and upon reconsideration by the state agency (Tr. 163-174).
Thereafter, she requested an administrative hearing. Tr.
177-185. On November 18, 2015, Administrative Law Judge
Joseph G. Hajjar (“ALJ”) conducted an
administrative hearing. Tr. 76-86. During the November 18,
2015, hearing, Wilson's attorney informed the ALJ that
Wilson's physician had ordered a lumbar MRI but it had
not yet been scheduled because she was waiting on insurance
authorization. Tr. 80, 84. The ALJ agreed to reschedule the
hearing to another date so that the MRI results could be part
of the record. Tr. 84-85. That next hearing was held on
January 20, 2016. Tr. 36-75. At the January hearing,
Wilson's attorney informed the ALJ that Wilson had not
had the MRI because her insurance company would not authorize
it until Wilson had received six weeks of physical therapy.
Tr. 39. The ALJ indicated he would proceed with the evidence
that they had. Tr. 39.
February 16, 2016, decision (Tr. 16-35), the ALJ determined
that Wilson had not been under a disability within the
meaning of the Social Security Act from July 29, 2013,
through the date of the decision (Tr. 20, 29). Wilson
requested review of the ALJ's decision by the Appeals
Council. Tr. 15. On March 3, 2017, the Appeals Council denied
Wilson's request for review, making the ALJ's
decision the final decision of the Commissioner. Tr. 1-6.
Personal, vocational and educational evidence
was born in 1981. Tr. 273. At the time of the administrative
hearings, Wilson was living in a house with an individual by
the name of Kevin. Tr. 42, 83, 82. Wilson completed school
through the 10th grade. Tr. 44. She attended
school for part of the 11th grade but did not
finish. Tr. 44. Wilson does not have a GED. Tr. 44.
last worked in March 2013 at the Hampton Inn. Tr. 44. Her
position at the Hampton Inn was full time and she worked
there for 4-5 months. Tr. 44-45. She worked as a night
auditor. Tr. 45. Her duties including checking guests in and
out; setting up the continental breakfast; and anything else
that needed to be done, e.g., folding laundry. Tr. 45. In
2012, Wilson worked full time at a Super 8 Motel for about 6
or 7 months. Tr. 46, 315. Her work at the Super 8 Motel was
similar to the work performed at the Hampton Inn. Tr. 46-47.
Also, in 2012, Wilson worked at LaQuinta Inn for about 3-4
months as a housekeeping supervisor. Tr. 47, 315. Wilson
supervised approximately 5-8 employees. Tr. 47. She did not
have authority to hire employees but she did have authority
to fire employees. Tr. 47. While at LaQuinta Inn, Wilson was
also a Spanish translator. Tr. 47. In 2011, Wilson worked at
Cracker Barrel for about 7-8 months. Tr. 48-49, 315. She also
worked at Cracker Barrel in 2007 for 7 ½ months. Tr.
48, 315. While at Cracker Barrel, Wilson was in training for
management and she worked as a cashier. Tr. 49-50.
29, 2013, Wilson was taken by EMS to TriHeatlh emergency room
following a motor vehicle accident. Tr. 411-419. She was hit
on the front passenger side of her vehicle while she was
traveling through a green light. Tr. 411. She was wearing a
seatbelt. Tr. 411. A CT scan of Wilson's cervical spine
was unremarkable and chest x-rays were unremarkable. Tr. 413.
The final emergency room diagnoses were neck sprain and chest
wall pain. Tr. 414. Wilson was medicated at the emergency
room and discharged home with IM Toradol, Vicodin, and
Robaxin. Tr. 414.
was seen two days later at the West Chester Hospital
emergency room with complaints of neck, back and abdominal
pain. Tr. 371-389. She also complained of burning at the site
of an abrasion on her neck. Tr. 371. On physical examination,
Wilson was noted to have “an impressive seat belt sign
across her upper chest and lower abdomen[.]” Tr. 373.
Wilson's cervical and lumbosacral area was tender to
palpation. Tr. 373. The balance of Wilson's physical
examination was generally unremarkable. Tr. 373. Her strength
was 5/5 in her upper and lower extremities; her sensation was
intact in her upper and lower extremities; and she had pain
free range of motion in all four extremities. Tr. 373.
Wilson's labs were unremarkable. Tr. 373. Her symptoms
improved significantly with pain medication. Tr. 373. A CT
scan of the abdomen and pelvis showed no acute traumatic
abnormality. Tr. 377-378. A CT of the lumbar spine showed
moderate to severe L5-S1 disc space narrowing, with no
fracture or malalignment identified. Tr. 378. Wilson's
diagnoses at discharge were low back pain, neck pain, motor
vehicle accident, abdominal pain, and numbness and tingling.
Tr. 384. Wilson was prescribed pain medication. Tr. 384.
was seen again on August 4, 2013, at the West Chester
Hospital emergency room (Tr. 390-401) complaining of
continuing chest wall, abdomen, and back pain (Tr. 391).
Wilson was out of pain medication. Tr. 391. On physical
examination, Wilson exhibited no neurological deficits. Tr.
391. She had diffuse lateral back pain with no midline
tenderness. Tr. 391. There was evidence of a seat belt rash
to the left side of Wilson's neck and shoulder and there
was bruising to Wilson's right breast and lower abdomen.
Tr. 393. Wilson had full range of motion in her neck. Tr.
393. Wilson rated her pain an 8/10, indicating her pain was
worse with ambulation and movement. Tr. 391. She denied
numbness or tingling. Tr. 391. Wilson was prescribed Tramadol
(Ultram) and Valium. Tr. 393, 394. She was instructed to take
ibuprofen or Tylenol as well as Ultram for breakthrough pain.
Tr. 393. Wilson was advised to follow up with her primary
care physician and possibly a spine specialist for further
management of her back pain. Tr. 391, 393. Wilson indicated
she did not have a primary care physician but she was working
with her insurance to establish a primary care relationship.
Tr. 393. Wilson's diagnoses at discharge were low back
pain, abdominal wall contusions, and chest wall contusion.
Tr. 394, 396.
August 13, 2013, Wilson started seeing James T. Lutz, M.D.
Tr. 443-446. Her then current symptoms included constant
headaches with associated photophobia, phonophobia, blurry
vision, nausea, and vomiting; constant cervical pain, with
intermittent daily pain, numbness, and tingling radiating
into her arms and down into her hands and fingers; constant
thoracic pain, with intermittent daily pain, numbness, and
tingling wrapping around bilaterally to the sternum and
through the chest; constant low back pain, with intermittent
daily pain, numbness and tingling radiating down both legs
and into her feet and toes; constant chest wall and sternal
pain, radiating into her left shoulder, right breast, and
lower ribs; and constant abdominal pain, described as sharp
and stabbing pain. Tr. 443-444. Wilson also complained of
severe anxiety, fear of going outside, and fear of being in a
car. Tr. 444. Wilson noted a history of anxiety with
significant personal stressors. Tr. 444. She reported seeking
treatment for her mental health issues two years prior but
she had not had symptoms over the prior year and her anxiety
had been well controlled. Tr. 444. Dr. Lutz diagnosed
posttraumatic concussion syndrome, cervical sprain, thoracic
sprain, lumbar sprain, chest wall contusion, abdominal wall
contusion, and anxiety. Tr. 445-446. Dr. Lutz prescribed
Percocet and Baclofen. Tr. 446. Dr. Lutz felt that Wilson
could benefit from physical therapy and he referred her to
Dr. Buchanan, a chiropractor, for evaluation. Tr. 446. Dr.
Lutz also referred Wilson to Dr. Oleski for a psychological
evaluation. Tr. 446.
August 17, 2013, Wilson saw Dr. Buchanan for an evaluation.
Tr. 586-587. Wilson reported suffering from intense neck
pain, mid-back pain, low back pain, headaches, and chest pain
since her accident. Tr. 586. She indicated that her headaches
were severe and she was having memory problems. Tr. 586. She
reported having difficulty walking and balance problems and
she was having intense spasm in her neck and low back. Tr.
586. Wilson was having difficulty with almost all her
activities of daily living due to her symptoms. Tr. 586.
Wilson denied having similar symptoms prior to her accident
on July 29, 2013. Tr. 586. Dr. Buchanan noted some abnormal
objective findings, including a positive Spurling's Test
that referred pain into both shoulder blades and a positive
straight leg raise exam at 40° on the right. Tr. 587. Dr.
Buchanan diagnosed cervical sprain, lumbar sprain, thoracic
sprain, and post-traumatic headaches. Tr. 587. He recommended
that Wilson continue to see Dr. Lutz for medical management
and that she receive therapy through Dr. Buchanan's rehab
department with goals of improving strength and flexibility
and reducing pain. Tr. 587. Dr. Buchanan indicated that, if
Wilson did not progress as expected, she would need MRIs of
her neck and/or low back and possibly a CT scan of her head
due to the intensity of her headaches. Tr. 587.
saw Stephanie Quehl, CMP, in Dr. Lutz's office on
September 10, 2013. Tr. 447-449. Wilson reported some
worsening of her symptoms since her last visit. Tr. 447. She
also reported that she had slipped and fallen in her bathtub
because she was hurrying. Tr. 447. She hit the back her head
- her pupils were different sizes and she was “seeing
stars” but she did not go to the hospital. Tr. 447.
Wilson relayed that she had been having problems with her
memory since the accident, especially with dates. Tr. 447.
She reported that her medication was not making her dizzy.
Tr. 447. Wilson was in therapy with Dr. Buchanan three days
per week and she was seeing Dr. Oeleski. Tr. 447. Wilson was
using a cane. Tr. 447. Wilson was continuing to take Percocet
and Baclofen with some relief of her symptoms and no side
effects. Tr. 447. Wilson was also taking ibuprofen (600 mg),
three to four times per day. Tr. 447. In consultation with
Dr. Lutz, Nurse Quehl recommended MRIs of the cervical,
thoracic and lumbar regions due to the radicular symptoms
that Wilson was continuing to experience. Tr. 449. Also,
Nurse Quehl increased Wilson's Percocet. Tr. 449.
September 14, 2013, MRIs of Wilson's cervical, thoracic
and lumbar regions were performed. Tr. 419-425. The cervical
MRI showed a small right paracentral disc protrusion at the
C5-6 level, abutting the right C6 nerve root, without
evidence of significant central spinal stenosis. Tr. 419-420.
There was no evidence of an acute fracture. Tr. 420. The
lumbar spine MRI showed small broad-based central disc
protrusion at the L5-S1 level with an annular tear, with no
significant central spinal stenosis or nerve root impingement
noted throughout the lumbar spine and no evidence of an acute
fracture. Tr. 422. The thoracic spine MRI showed a small left
paracentral spur formation at the T8-T9 disc level, without
significant central spinal stenosis or nerve root impingement
and no evidence of an acute fracture or subluxation. Tr. 424.
saw Dr. Lutz on October 9, 2013. Tr. 450-452. Wilson
indicated that her symptoms were continuing to worsen. Tr.
450. She was continuing therapy with Dr. Buchanan but was no
longer seeing Dr. Oleski because Dr. Oleski's office put
treatment on hold. Tr. 450. Wilson was continuing to take
Percocet and Baclofen with some relief of her symptoms and no
side effects. Tr. 450. Wilson was also taking ibuprofen (600
mg) and extra strength Tylenol as needed. Tr. 450. Dr. Lutz
noted that Wilson entered the examination room with a
stiffened gait and a forward lean using a cane. Tr. 451. On
examination, Dr. Lutz observed some abnormal findings,
including marked tenderness with spasm throughout the entire
paraspinal and lateral cervical regions, worse on the right;
gross sensation revealed a sensation of coldness, tingling
and numbness bilaterally in both arms down into the hands and
fingers; tenderness with spasm over the entire lower lumbar
and upper sacral regions bilaterally; gross sensation
revealed coldness, tingling and numbness bilaterally in both
legs into the feet and toes; bilateral chest wall and lower
rib tenderness to palpation; and generalized tenderness was
present to palpation in the abdomen. Tr. 451. Dr. Lutz
continued Wilson on Percocet and increased her dosage of
Baclofen. Tr. 451-452. Dr. Lutz reviewed the MRI results,
noting that the lumbar spine MRI showed an annular tear and
disc protrusion. Tr. 451-452.
October 10, 2013, Wilson saw Dr. Buchanan for a
re-examination. Tr. 430. Dr. Buchanan noted that Wilson was
still in considerable pain but she was making improvements.
Tr. 430. Wilson was able to walk better than she was able to
three or four weeks prior. Tr. 430. Wilson was not as
dependent upon her cane as she was three or four weeks prior.
Tr. 430. She was able to perform some activities of daily
living more easily as compared to three or four weeks prior.
Tr. 430. Also, Wilson's low back and neck spasms were not
as intense. Tr. 430. Dr. Buchanan recommended that Wilson
continue with therapy two times each week. Tr. 430.
October 21, 2013, Wilson saw Juan Suarez, M.A., pre-doctoral
psychology intern, for a therapy session at Pain Solutions
Network. Tr. 648. The clinical notes were co-signed by
Merritt S. Oleski, M.D., clinical director. Tr. 648. Wilson
discussed her anxiety, indicating that it increased her
chronic pain. Tr. 648. Wilson also discussed feeling
hopeless, nervous and “lost.” Tr. 648. The
therapist discussed with Wilson the idea of trying to
determine what cognitive shifts could be made to make her
thoughts more productive. Tr. 648. At a follow-up
psychotherapy session with Mr. Suarez on November 4, 2013,
Wilson became frustrated. Tr. 649. She felt that therapy was not
helpful and expressed her feeling that her pain was not in
her head. Tr. 649. She did acknowledge that emotional stress
negatively impacted her physical pain. Tr. 649. Wilson opted
not to schedule another appointment with Mr. Suarez. Tr. 649.
November 6, 2013, Wilson saw Jennifer Haigis, a nurse
practitioner in Dr. Lutz's office. Tr. 505-507. Wilson
reported continued worsening of her symptoms since her last
visit. Tr. 505. Due to Wilson's complaints of pain, Nurse
Haigis increased Wilson's Percocet. Tr. 507. Wilson saw
Dr. Lutz on December 4, 2013. Tr. 502-504. Wilson reported
continued worsening pain since her prior visit since she was
no longer walking with a cane and was having worse hip and
leg pain. Tr. 502. Her neck pain on the right was worse but
she had better range of motion in her neck. Tr. 502. Wilson
had stopped treatment with Dr. Oeleski because she did not
feel that it was helping with her anxiety. Tr. 502. Wilson
remained interested in getting insurance so that she could
seek other treatment for her anxiety and insomnia. Tr. 502.
She had started taking Melatonin (3 mg) with limited
response. Tr. 502. She was continuing to take Percocet and
Baclofen with some relief and no side effects. Tr. 502. She
was rarely taking ibuprofen and was no longer taking
over-the-counter Tylenol. Tr. 502.
January 2, 2014, Dr. Buchanan conducted another
re-examination. Tr. 588. Although Wilson was not asymptomatic
and continued to report quite a bit of back and neck pain,
Dr. Buchanan felt that Wilson had made improvements. Tr. 588.
Dr. Buchanan observed that Wilson was noticeably better when
compared to 5 months prior and she was not as dependent on
her cane. Tr. 588. Dr. Buchanan felt that Wilson had
plateaued with therapy and he recommended that she be
released from therapy to a home exercise program. Tr. 588. He
noted that Wilson's prognosis was guarded and she should
contact his office if her symptoms worsened. Tr. 588.
also saw Dr. Lutz and Nurse Quehl on January 2, 2014. Tr.
500-502. It was observed that Wilson's “conditions
directly related to the accident of record have reached a
state of permanency, with residual effects involving
headache, her neck, thoracic and lumbar region, chest wall
pain and abdominal pain.” Tr. 502. Wilson was
instructed to wean off of her medication over the next few
weeks and follow up with various medical providers, including
a neurologist and psychiatrist. Tr. 502. Dr. Lutz would
recheck Wilson as needed. Tr. 502.
January 6, 2014, Wilson saw Jennifer Lager, D.O., at
TriHealth Physician Partners to establish a doctor-patient
relationship. Tr. 569-570. Wilson reported that her range of
motion had improved with therapy but her pain may have
worsened. Tr. 569. Dr. Lager assessed anxiety, lower back
pain, cervicalgia, chronic pain, post-concussion syndrome,
and post-traumatic stress disorder. Tr. 570. Dr. Lager
provided Wilson with medication refills but noted that she
would ultimately need to see pain management. Tr. 570. Dr.
Lager provided both a pain management referral and a referral
to an orthopedic specialist. Tr. 570. Wilson saw Dr. Lager
again at the end of January 2014. Tr. 566-568. Dr. Lager
noted that Wilson was scheduled to see Dr. Knox for pain
management. Tr. 568. Dr. Lager prescribed a low dose of
Cymbalta for her pain and also Ativan for her social anxiety
to take as needed. Tr. 568.
February 4, 2014, upon Dr. Lager's referral, Wilson saw
Dr. Thomas Knox at Integrative Pain Management. Tr. 622-624.
Wilson complained of pain in her neck, upper back, mid back
and lower back. Tr. 622. She also complained of pain
associated with a herniated cervical disc and herniated
thoracic disc, both of which involved some radiation. Tr.
622. She described her pain as constant, aching, sharp,
shooting, stabbing, and hypersensitive to cold. Tr. 622.
Wilson indicated her pain was relieved with pain medication.
Tr. 622. However, she was interested in trying a different
medication because she felt that the Percocet was not lasting
long enough. Tr. 622. On examination, Dr. Knox observed
decreased range of motion in Wilson's neck with forward
flexion, extension and left rotation. Tr. 622. Wilson's
gait was normal. Tr. 622. Dr. Knox noted tenderness in the
low back and bilateral sacroiliac joints and muscle spasms in
the back. Tr. 622-623. Straight leg raise was negative. Tr.
623. Dr. Knox prescribed Oxymorphone, Baclofen, and Percocet.
Tr. 623. He also ordered injections and physical therapy. Tr.
Knox's referral, on February 12, 2014, Wilson saw Derek
McMurry to start therapy. Tr. 620-621. Wilson relayed that
she had tried chiropractic treatment and physical therapy in
the past for her injuries with no benefit. Tr. 620. Mr.
McMurry indicated he would need to review Wilson's prior
physical therapy records and imaging reports and discuss a
plan with Dr. Knox. Tr. 621. Mr. McMurry referred Wilson for
an EMG/NCS for her upper extremity complaints. Tr. 621.
February 20, 2014, Wilson underwent the EMG/NCS testing. Tr.
546-550. Ayse L. Lee-Robinson, M.D., provided her findings
and interpretations regarding the studies. Tr. 546-550. Dr.
Lee-Robinson indicated that the testing revealed
“abnormal EMG findings in a pattern most consistent
with an acute, subacute, right greater than left, most likely
multilevel cervical radiculopathy[.]” Tr. 547. Dr.
Lee-Robinson recommended that the findings be correlated with
cervical spine imagining studies. Tr. 547. Wilson also showed
signs of ulnar neuropathy at the elbow. Tr. 547. Dr.
Lee-Robinson recommended avoidance of compressive forces at
the ulnar nerve while resting and avoidance of repeated
extension and flexion of the elbow. Tr. 547.
continued to see Dr. Lager. Tr. 562, 565. In April 2014, Dr.
Lager switched Wilson from Ativan to Valium because the
Ativan had worn off too quickly. Tr. 562. Also, in April
2014, Dr. Lager provided Wilson with a referral to
psychiatry. Tr. 562. In June 2014, Wilson saw Dr. Lager. Tr.
555-559. Wilson relayed that her pain management doctor told
her she might have ovarian cancer. Tr. 555. Wilson had not
yet made an appointment with psychiatry. Tr. 555. Wilson was
interested in increasing the Valium as well as trying some
other medications. Tr. 555. Wilson liked Cymbalta. Tr. 555.
Reluctantly, Dr. Lager agreed to increase Wilson's Valium
and add phentermine but noted that Wilson needed to see
psychiatry. Tr. 558.
continued treatment with Dr. Knox and Integrative Pain
Management through at least June 2014. Tr. 605-619, 719-720.
Treatment included medication management as well as steroid
injections. Tr. 619, 640-642. Her first injection was
administered on February 24, 2014. Tr. 641. On April 7, 2014,
Dr. Knox observed that Wilson's low back pain was
improving but she was still having persistent neck pain. Tr.
640. Dr. Knox felt that a surgical consult regarding the neck
pain may be warranted. Tr. 640. During a follow-up visit on
April 11, 2014, Dr. Knox observed swelling in Wilson's
foot and three plus pedal edema. Tr. 613. Wilson also had
decreased range of neck motion. Tr. 612. Dr. Knox provided a
referral for a neurosurgeon. Tr. 613. In May 2014, Wilson
continued to have swelling in her foot and three plus pedal
edema. Tr. 608. Dr. Knox continued to prescribe Baclofen,
Oxymorphone, and Percocet. Tr. 608. In June 2014, Wilson
complained that she was having severe spasms affecting the
whole right side of her body. Tr. 719. Mr. McMurry
recommended a referral to a neurologist. Tr. 720.
Dr. Lager's referral, on June 20, 2014, Wilson was seen
at Pledger Ortho Spine for her neck and arm pain. Tr.
708-713. Wilson described the pain as worse in her neck than
in her arms. Tr. 710. Wilson reported arm weakness and arm
numbness. Tr. 710. She reported relief with pain medication.
Tr. 710. She indicated that her pain interfered with personal
grooming, driving, cooking, performing chores, engaging in
leisure activities, and sleeping. Tr. 710. Wilson did not
bring her imaging reports to her office visit so she was
advised to return in three months when she had her imaging
with her. Tr. 712.
March 31, 2015, Wilson was treated at Alliance Community
Hospital's emergency room after she slipped on a stair
and fell forward. Tr. 763-780. She complained of neck, back,
arm, shoulder, and bilateral knee pain. Tr. 763. Wilson also
complained of chronic numbness in her left upper extremity.
Tr. 763. On examination, Wilson's gait was normal and she
had normal strength. Tr. 764. She exhibited lumbar and
thoracic tenderness. Tr. 764. She had full range of motion in
her neck with paraspinal tenderness. Tr. 764. Wilson also had
tenderness in her knees, left hand, right elbow and right
shoulder. Tr. 764. X-rays showed no acute fractures. Tr. 764.
She was treated with pain medication and muscle relaxants and
discharged home in stable condition. Tr. 764.
7, 2015, Wilson saw a new pain management specialist - Marisa
Wynne, D.O., at Comprehensive Pain Management Specialists.
Tr. 804-810. Dr. Wynne noted Wilson's prior pain
management treatment with Dr. Knox. Tr. 807. Dr. Wynne
observed that Wilson had been on a high dose of Oxymorphone
but her toxicology reports were consistently negative for
Oxymorphone. Tr. 807. Dr. Wynne suspected that Wilson was
likely discharged by her prior pain management doctor for
being negative on her Oxymorphone. Tr. 807. Dr. Wynne
indicated that Wilson's diffuse pain/neurological
complaints were not explained by the pathology on her imaging
reports. Tr. 807. Dr. Wynne started Wilson on Gabapentin,
continued Wilson's Duloxetine (Cymbalta), and decreased
her Baclofen. Tr. 808. Dr. Wynne referred Wilson for a
behavioral health evaluation. Tr. 808, 809. Dr. Wynne ordered
a physical therapy evaluation and a TENS unit. Tr. 809.
Wilson was interested in a surgical referral but Dr. Wynne
suggested that Wilson proceed with seeing a neurologist first
because she did not see anything surgical on Wilson's
current imaging. Tr. 809. Wilson saw Dr. Wynne again in June
and September 2015. Tr. 798-802, 812-817. Dr. Wynne's
June 12, 2015, notes reflect that the behavioral health
evaluation had been completed in June and that the evaluation
indicated that Wilson met the criteria for diagnoses of major
depression disorder, mild and social anxiety disorder with
panic attacks, rule out personality disorder. Tr. 801. The
plan was for Wilson to continue with on-going counseling. Tr.
801. On September 17, 2015, Wilson was contradictory with
respect to opioids. Tr. 816. Dr. Wynne indicated that the
plan had been to avoid chronic opioid therapy and Wilson had
been in agreement with that plan but she was also requesting
opioids. Tr. 816. Dr. Wynne released Wilson from her care,
noting that it seemed like Wilson was having difficulty
having any physician prescribe her opioids. Tr. 815-816. By
releasing Wilson from her care, Dr. Wynne indicated that
Wilson would no longer be considered in a pain management
contract and she could receive treatment that her evaluating
physicians deemed appropriate. Tr. 815-816.
28, 2015, Wilson was seen by Andrew Stalker, M.D., at the
NeuroCare Center for headaches and memory loss. Tr. 844-847.
Dr. Stalker's examination generally revealed normal
findings. Tr. 846. Dr. Stalker did observe give away weakness
and a gait and station that he described as “slow, mild
antalgia.” Tr. 846. Dr. Stalker ordered diagnostic
testing, including a brain MRI, EEG, and EMG/NCT of her
bilateral lower extremities. Tr. 846-847. The diagnostic
testing was normal. Tr. 841-843. During a September 29, 2015,
visit, Dr. Stalker observed that Wilson continued to report
symptoms without any objectively abnormal findings shown on
the EMG, EEG or MRI. Tr. 839. There were no signs of
radiculopathy or peripheral neuropathy. Tr. 839. Wilson
indicated that she planned to consult with the spine and pain
institute. Tr. 839.
injured her right knee while she was on vacation in 2015. Tr.
860. Wilson had gone into the ocean to save a small child who
was in distress and she got caught up in the undertow and her
leg went out behind her and she experienced a popping
sensation and immediate onset of pain. Tr. 860. Wilson
obtained x-rays at a medical center while on vacation. Tr.
860. That medical center diagnosed a strain but recommended
that Wilson follow up with an MRI because they thought Wilson
could have a possible ACL or MCL tear. Tr. 860. On August 10,
2015, she was seen at Mercy Health Center for follow up and
requested an order for an MRI. Tr. 860. Wilson described
moderate to severe pain in her right knee. Tr. 860. She had
her knee braced and was using crutches. Tr. 860. On August
19, 2015, Wilson was seen again at Mercy Health Center. Tr.
859. She complained of worsening depression and requested a
referral to orthopedics for her knee. Tr. 859. Wilson also
requested pain medication. Tr. 859. Since Wilson was under
the care of pain management, no pain medication was
prescribed. Tr. 859. An orthopedic referral was provided. Tr.
859. An MRI was obtained on September 1, 2015. Tr. 857-858.
The MRI showed an MCL sprain and small joint effusion. Tr.
October 2015, Wilson saw Kathleen Hathaway, a nurse
practitioner at Mercy Health Center for follow up. Tr.
868-869. Wilson indicated she had been dismissed from pain
management and was advised to seek an opinion because pain
management was not certain how to proceed. Tr. 869. Nurse
Hathaway noted that she would follow up with pain management
to verify Wilson's statements. Tr. 869. Wilson reported
she was supposed to wear a knee brace for support due to the
MCL “tear” but she was unable to get the brace on
due to a lack of strength. Tr. 869. Wilson was using a cane
with a limp observed on the right but she had complete
mobility and a steady gait. Tr. 869. Nurse Hathaway noted
concerns related to Munchausen syndrome and noted that Wilson
significantly exaggerated her diagnoses. Tr. 868. During a
follow-up visit, Nurse Hathaway noted that records showed
inconsistencies between what Wilson had told her office and
what was appearing in her records. Tr. 867.
October 19, 2015, Wilson saw Patrick McIntyre, M.D., of the
Spine & Pain Institute for a cervical facet injection.
Tr. 878-882. Wilson also saw Dr. McIntyre on November 3, 2015
(Tr. 872-877) and November 17, 2015 (Tr. 884-890). She
continued to complain of pain and she was having difficulty
walking because of her pain. Tr. 872, 884. During her
November 3 visit, she was using a cane. Tr. 872. During her
November 17 visit, Wilson complained of jaw, back, neck and
arm pain. Tr. 884. Wilson reported that her neck pain was
much improved following the cervical facet injection and she
reported benefiting from epidural injections for her neck and
arm pain a year prior and was interested in receiving another
injection. Tr. 884. On examination, Wilson's gait was
normal. Tr. 887. On cervical spine range of motion testing,
Wilson exhibited pain and she was moderately restricted on
flexion, extension and lateral bending. Tr. 887. Her cervical
sensation was intact and her upper extremity strength was
normal bilaterally. Tr. 887. She had a positive
Spurling's cervical examination on the right and left.
Tr. 887. Dr. McIntyre scheduled a cervical epidural
injection; recommended that Wilson continue with a physical
therapy/exercise regimen; provided medications, including
tramadol and tizanidine; and advised Wilson to see a dentist
for her TMJ complaints. Tr. 888. Dr. McIntyre felt that
Wilson was stable and did not feel that a referral for a
psychological consultation was needed at that time. Tr. 888.
continued treatment at the Spine & Pain Clinic in
December 2015 (Tr. 931-935) and January 2016 (Tr. 923-929).
On December 28, 2015, Wilson received a cervical epidural
steroid injection at the C6-7 level. Tr. 931-935. On January
8, 2016, Wilson reported about 60% relief from the cervical
injection but indicated that over the prior two days her pain
had worsened. Tr. 923. She reported receiving no benefit from
lumbar injections she received in November 2015. Tr. 923. A
lumbar MRI had been requested but was denied because she had
not recently received physical therapy. Tr. 923. On
examination, Wilson exhibited active painful range of motion
in the cervical and lumbar areas and in her right shoulder.
Tr. 926. Wilson's gait was normal. Tr. 926. Her cervical
sensation was intact. Tr. 926. Wilson had normal strength in
her upper extremities with the exception of her right
shoulder. Tr. 927. With the exception of decreased strength
in her right ankle/foot, Wilson had normal strength in her
lower extremities. Tr. 927. Since Wilson reported relief from
her cervical injection, a repeat injection was scheduled. Tr.
927. Wilson was urged to get started on physical therapy so
the request for a lumbar MRI could be resubmitted. Tr. 927.
Wilson's prescriptions for tramadol and tizanidine were
refilled. Tr. 927.
November 25, 2013, Dr. Buchanan completed a statement in
which he indicated that Wilson should be able to perform fine
and gross manipulation. Tr. 428. Dr. Buchanan described
Wilson's gait as slow and antalgic, favoring the right.
Tr. 428. He indicated that Wilson used an ambulatory aid. Tr.
428. Dr. Buchanan indicated that Wilson was progressing with
treatment and she should be able to use her extremities for
functional tasks. Tr. 428.
August 8, 2014, Dr. Lager authored a “To Whom It May
Concern” letter. Tr. 834. In that letter, Dr. Lager
[Wilson] is currently unable to work secondary to physical
and emotional limitations post motor vehicle accident on July
There have been no changes in her disability status. She
continues to experience physical pain and increased anxiety.
She has been referred to Dr. Thomas Knox for pain management
and physical rehabilitation. Per [Wilson], Dr. Knox has
referred her to Dr. Jennifer Smail with Pledger Orthopedic