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Wilson v. Commissioner of Social Security

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

April 3, 2018

BOBBIE JO WILSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OPINION & ORDER

          Kathleen B. Burke United States Magistrate Judge.

         Plaintiff Bobbie Jo Wilson (“Plaintiff” or “Wilson”)[1] 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 Commissioner's decision.

         I. Procedural History

         Wilson 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.[2] 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.

         In his 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.

         II. Evidence

         A. Personal, vocational and educational evidence

         Wilson 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.

         Wilson 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.

         B. Medical evidence

         1. Treatment history

         On July 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.

         Wilson 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.

         Wilson 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.

         On 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.

         On 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.

         Wilson 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.

         On 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.

         Wilson 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.

         On 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.

         On 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.[3] 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.

         On 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.

         On 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.

         Wilson 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.

         On 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.

         On 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. 623.

         Per Dr. 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.

         On 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.

         Wilson 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.

         Wilson 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.

         Upon 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.[4] Tr. 712.

         On 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.

         On May 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.

         On July 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.

         Wilson 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. 857.

         In 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.

         On 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.

         Wilson 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.

         2.Opinion evidence

         a. Treating providers

         Dr. Buchanan

         On 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.

         Dr. Lager

         On August 8, 2014, Dr. Lager authored a “To Whom It May Concern” letter. Tr. 834. In that letter, Dr. Lager stated:

[Wilson] is currently unable to work secondary to physical and emotional limitations post motor vehicle accident on July 29, 2013.
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 ...

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