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Karanicolas v. Commissioner of Social Security Administration

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

June 12, 2018

MICHAEL KARANICOLAS, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          MEMORANDUM OPINION & ORDER

          Kathleen B. Burke United States Magistrate Judge

         Plaintiff Michael Karanicolas (“Karanicolas”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying his application for Disability Insurance Benefits (“DIB”). 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. 15.

         For the reasons explained below, the Commissioner's decision is AFFIRMED.

         I. Procedural History

         Karanicolas filed his application for DIB in October 2013, alleging a disability onset date of July 26, 2013. Tr. 91, 255. He alleged disability based on the following: neck fusion surgery and neck injury. Tr. 258. After denials by the state agency initially (Tr. 147) and on reconsideration (Tr. 157), Karanicolas requested an administrative hearing (Tr. 166). A hearing was held before Administrative Law Judge (“ALJ”) Peter Beekman on December 2, 2015. Tr. 106-137. In his March 10, 2016, decision (Tr. 91-101), the ALJ determined that there are jobs that exist in significant numbers in the national economy that Karanicolas can perform, i.e. he is not disabled. Tr. 100. Karanicolas requested review of the ALJ's decision by the Appeals Council (Tr. 218) and, on May 23, 2017, the Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-4.

         II. Evidence

         A. Personal and Vocational Evidence

         Karanicolas was born in 1966 and was 47 years old on the date his application was filed. Tr. 255. He completed eleventh grade and previously worked as a warehouse worker lead person, electrician's helper, sales rep delivery driver and carpet cleaner. Tr. 110, 131.

         B. Relevant Medical Evidence

         In February 2013, Karanicolas was involved in a car accident. Tr. 110, 328. He went to the emergency room where he was prescribed medications and given a physician referral. Tr. 328. Shortly thereafter, he began experiencing neck, mid-back, and left shoulder pain. Tr. 328. On February 26, he had an x-ray of his left shoulder, which showed mild degenerative changes involving his left acromioclavicular joint, Tr. 365, and an x-ray of his cervical spine, which showed mild disk space narrowing at the C4-C5 and C6-C7 levels and mild degenerative changes, Tr. 367.

         On May 21, 2013, Karanicolas saw chiropractor John R. Fortuna, D.C., at Parmatown Spinal and Rehabilitation Center. Tr. 328. Karanicolas explained that he had “beg[u]n some therapies” per his physician but that the therapies were “too much” and were causing him increased pain and discomfort. Tr. 328. Fortuna stated that Karanicolas had completed a “neck disability index form” and scored 20/50, which correlates to 40% disability with normal performance of activities of daily living (“ADLs”) and an Oswestry low back pain scale and scored 23/50, which correlates to 46% disability with normal performance of ADLs.[1] Tr. 328. Upon exam, Karanicolas' cervical spine range of motion was 40 degrees of flexion, 34 degrees of extension, and 36 degrees of left and right rotation. Tr. 330. Fortuna diagnosed Karanicolas with cervical, thoracic and lumbar strains and a right shoulder strain and recommended further diagnostics and treatment. Tr. 330.

         On May 24, 2013, Karanicolas had an MRI of his cervical spine, which showed disc bulging at ¶ 3-C4, disc herniation at ¶ 4-C5 and C5-6, and straightening of the normal cervical lordosis. Tr. 363-364.

         On July 1, 2013, Karanicolas saw surgeon Mark Grubb, M.D., complaining of neck and upper extremity pain, right side greater than left, and tingling, numbness and weakness, particularly in his right upper extremity. Tr. 317. Upon exam, he had a diminished range of motion in his neck, particularly to the right; normal range of motion in his shoulder; motor testing was intact in his elbows, wrists, and fingers; distraction was “helpful”; and he had some diminished sensation in his right hand. Tr. 316. Dr. Grubb provided Karanicolas with some treatment options and Karanicolas elected to have surgery. Tr. 316.

         An EMG and nerve conduction velocity study dated July 18 was suggestive of cervical radiculitis best localized at the C5 nerve root most prevalent on the right and right median upper extremity peripheral neuropathy. Tr. 362.

         On July 26, 2013, Dr. Grubb performed fusion surgery on Karanicolas at ¶ 4-5 and C5-6. Tr. 306-307. On September 3, 2013, Karanicolas saw Dr. Grubb and reported that he was much better. Tr. 314. Dr. Grubb had x-rays taken, was satisfied with them, and recommended that Karanicolas begin physical therapy and conditioning and increase his activity. Tr. 314.

         On September 6, Karanicolas saw Fortuna and stated that his surgery was “successful and he has noticed a highly marked reduction in the paresthesia and numbness he was previously experiencing in the upper extremities.” Tr. 341. He began physiotherapy and electric muscle stimulation. Tr. 341. On September 9, Karanicolas reported that he was “definitely feeling better” after his surgery with less pain and minimal symptoms radiating into his upper extremities. Tr. 340. Fortuna provided manipulations, physiotherapy and stretches and stated that Karanicolas would transition to an “active rehab program, especially since he is experiencing a lot of weakness in both upper extremities.” Tr. 340. On September 13, Karanicolas reported “ongoing pain” in his mid- and lower-back, but he was slowly improving and the paresthesia in his upper extremities was diminished. Tr. 339. Fortuna noted that Karanicolas had “recently” had an EMG/nerve conduction velocity test of his arms which showed radiculitis at the C5 nerve root. Tr. 339.

         On September 16, 2013, Karanicolas reported to Fortuna that his neck pain was “still significant” and he still had a restricted range of motion in his neck after his fusion surgery. Tr. 338. He was still having a lot of weakness in his upper extremities and pain in his lower back, but his main area of concern was his neck. Tr. 338. On September 23, Karanicolas reported that he had some soreness radiating into both shoulders. Tr. 336. On September 25, he reported neck pain and “a lot of weakness in both upper extremities.” Tr. 335. On September 27, he complained of ongoing post-operative residual soreness and discomfort and Fortuna recommended he continue with treatments. Tr. 334. On September 30, Karanicolas' neck soreness was radiating into his upper extremities. Tr. 333. On October 2, he reported that he was “still very concerned about returning to work this month.” Tr. 332. Fortuna opined that it was doubtful that he will be able to return to his physically demanding job within two weeks, his scheduled return to work date. Tr. 332.

         On October 15, Karanicolas saw Dr. Grubb. Tr. 313. Dr. Grubb's treatment note states that Karanicolas was doing well and that he would like to return to work. Tr. 313. Upon exam, his incision looked good and his strength “remains intact.” Tr. 313. X-rays were taken. Tr. 313. They showed postoperative changes (Tr. 318) and Dr. Grubb remarked that the interbody graft looked good (Tr. 313). Dr. Grubb stated that Karanicolas had “done well” and released him to work beginning the following week. Tr. 313.

         On November 21, 2013, Karanicolas returned to Dr. Grubb complaining of difficulty swallowing and breathing. Tr. 374. He also reported some neck stiffness. Tr. 374. Upon exam, he had intact, normal strength. Tr. 374. Dr. Grubb suggested he see an ear, nose, throat doctor. Tr. 374.

         On June 5, 2014, Karanicolas returned to Dr. Grubb. Tr. 455. He revealed that he was unable to work, his disability had been denied, and he had shortness of breath. Tr. 455. Dr. Grubb stated that Karanicolas had a “number of complaints, ” his symptoms were “infrequent, ” and they occurred “when he goes to work.” Tr. 455. Upon exam, he had good head/neck alignment, good motion, and intact strength. Tr. 455. X-rays were taken and showed additional consolidation in the fusion at ¶ 4-C5 and C5-C6. Tr. 455. Dr. Grubb expressed concern for Karanicolas' overall conditioning and recommended he undergo an evaluation for his cardiorespiratory health and a sleep study. Tr. 455.

         On September 18, 2014, Karanicolas had x-rays of his cervical spine showing postsurgical changes at ¶ 4-5 and C5-6 levels; the height of the vertebral bodies and disc spaces were maintained. Tr. 394.

         At his sixth of twelve visits with physical therapy on October 20, 2014, Karanicolas reported a painful, reduced cervical range of motion. Tr. 398-399. He reported no change in the intensity of his pain since starting physical therapy. Tr. 399. That day his pain was 8/10 and constant. Tr. 397. His neck disability index score was 62% disability. Tr. 398. He had difficulty washing his hair, self-care, and driving due to pain. Tr. 398. The therapist educated Karanicolas on breathing techniques and stretching to promote relaxation. Tr. 399.

         On July 14, 2015, Karanicolas visited his pain management clinic and reported “significant relief of bilateral hand symptoms when he is wearing his wrist splints in bed.” Tr. 457. When he did not wear the splints he had severe pain. Tr. 457. He had not had an EMG done. Tr. 457. He was taking Cymbalta and it was helping; he reported that when he missed a dose he noticed that his pain was significantly worse. Tr. 458. Physical therapy helped when he was at the physical therapist but did not seem to help at home. Tr. 458. Upon exam, he had full motor strength in all extremities, normal reflexes and intact sensation. Tr. 460. It was recommended that he follow up with an EMG for carpal tunnel syndrome, physical therapy was reordered, and an increase in Cymbalta and gabapentin would be considered, noting that Karanicolas had just restarted these medications. Tr. 460.

         The record also shows that Karanicolas complained of shortness of breath, joint pain, and arthritis. See, e.g., Tr. 389, 472.

         C. Medical Opinion Evidence

         1. ...


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