United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp II United States Magistrate Judge
Crystal Joye Minor (“Plaintiff”) filed a
Complaint against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny disability insurance
benefits (“DIB”). (Doc. 1). The district court
has jurisdiction under 42 U.S.C. §§ 1383(c) and
405(g). The parties consented to the undersigned's
exercise of jurisdiction in accordance with 28 U.S.C. §
636(c) and Civil Rule 73. (Doc. 12). For the reasons stated
below, the undersigned affirms in part, and reverses and
remands in part, the decision of the Commissioner.
filed for DIB in December 2015, alleging a disability onset
date of May 31, 2010. (Tr. 176-77). Her claims were denied
initially and upon reconsideration. (Tr. 81, 99). Plaintiff
then requested a hearing before an administrative law judge
(“ALJ”). (Tr. 119-20). Plaintiff (represented by
counsel), and a vocational expert (“VE”)
testified at a hearing before the ALJ on December 12, 2017.
(Tr. 30-62). On February 14, 2018, the ALJ found Plaintiff
not disabled in a written decision. (Tr. 15-23). The Appeals
Council denied Plaintiff's request for review, making the
hearing decision the final decision of the Commissioner. (Tr.
1-6); see 20 C.F.R. §§ 404.955, 404.981.
Plaintiff timely filed the instant action on September 27,
2018. (Doc. 1).
Background and Testimony
1978, Plaintiff was 31 years old on her alleged onset date,
and 37 on her date last insured. See Tr. 176. She
had past work as a home health aide and nursing assistant.
See Tr. 22, 55-56.
lived alone, and her mother lived in the same trailer park.
(Tr. 36-37). Plaintiff was able to drive and drove to the
hearing. (Tr. 37-38). She was receiving Worker's
Compensation and food stamps at the time of the hearing. (Tr.
injured her back lifting a patient while working for hospice
in 2009. (Tr. 39). She subsequently worked light duty for a
year, but was then let go because she could no longer perform
the job. (Tr. 43). Plaintiff believed she was unable to work
due to her chronic pain, back and leg problems, and
depression; she had difficulty sitting or standing for
lengthy periods. Id. She could not do things she
used to do like bowling. (Tr. 45). After her first surgery,
Plaintiff felt better, but then fell and it set her back.
(Tr. 48-49). She “tried everything” for her pain
including aquatic therapy, physical therapy, acupuncture, and
epidural injections. (Tr. 49). When those were unsuccessful,
she had a trial spinal cord stimulator. Id. It
“seemed to help a little bit”, so she had a
permanent stimulator placed. Id. But then it
“got turned” and she could not charge it, so she
returned to have it “turned” back. (Tr. 50).
received therapy and psychiatric treatment for her depression
and anxiety. (Tr. 44). Counseling “help[ed]
sometimes”. Id. She watched television and was
able to follow storylines, and “[f]or the most
part” remember what happened week to week on a
television show. (Tr. 45-46). Plaintiff's mental state
varied depending on what she was worried about, and her
frustration with her physical condition. (Tr. 52-53). She had
“a little hard time concentrating and focusing on
certain things”. (Tr. 53).
typical day, Plaintiff took medication, watched television or
played games on her phone, showered, and got dressed. (Tr.
46). She stayed home unless she had a doctor's
appointment; sometimes her mom visited and sometimes she took
her mother to appointments. (Tr. 46-47). She ate lunch out
with her mother about once per week. (Tr. 47). She was able
to shower, dress herself, make simple meals, grocery shop
(often with help), put groceries away, and do laundry. (Tr.
47-48). Plaintiff used a scooter at the grocery store, but
not at smaller stores or if she only needed a few items. (Tr.
estimated she could walk for about ten to fifteen minutes
before needing to sit. (Tr. 51). During the hearing, she
noted “[a] little bit” of pain in her hips after
sitting for about 30 minutes. Id. Relevant Medical
Evidence Physical Health Plaintiff injured her
back working as a home health aide in 2009 and was awarded
Worker's Compensation benefits. See Tr. 1813.
She was treated for L4-L5 and L5-S1 disc bulges, lumbar
post-laminectomy syndrome, sacroiliitis, L4-L5 lumbar disc
displacement, and L5-S1 radiculitis. See Id. Records
from chiropractor David Leone, D.C., at the Spine and Pain
Institute in 2011 reveal Plaintiff reported a lumbar pain
level ranging from five to eight out of ten, muscle cramps
and weakness, as well as psychological symptoms. See
Tr. 1039-40, 1045-52, 1057-1155. She underwent both
chiropractic manipulation and acupuncture. See Id.
Dr. Leone's physical findings included: moderate
generalized tenderness in the lumbar area, moderately
restricted movement in all directions, pain in all
directions; he also observed decreased sensation in the
dorsal aspect of the left foot and lateral aspect of the
calf, as well as a positive straight leg raise on the left at
30 degrees. See id.
and early 2012, Plaintiff saw Karen Hodakievic, CRNP, and
Bina Behta, M.D., at the Spine and Pain Institute.
See Tr. 979-1014, 1019-22, 1026-30, 1035-1038,
1041-1044, 1053-56. They noted examination findings of
reduced mobility and range of motion, slow and antalgic gait,
moderate generalized tenderness in the lumbar area, right
lumbar stenosis, movement moderately restricted in all
directions, decreased left lateral calf sensation as compared
to the right, bilateral hyporeflexic reflexes, and negative
straight leg raising tests. See Id. Ms. Hodakievic
and Dr. Behta refilled Plaintiff's pain medications.
See Id. In May 2012, Plaintiff reported her
medications “take the edge off the pain and allow her
to maintain her [activities of daily living]” and that
her spine symptoms were improving. (Tr. 979).
April 2011 EMG/nerve conduction study was “suggestive
of a left S1 chronic active radiculopathy.” (Tr. 1112).
In August and September 2011, Plaintiff also underwent lumbar
epidural steroid injections. See Tr. 1015-18;
January 2013 lumbar spine MRI showed multilevel degenerative
changes, most prominent at ¶ 5-S1 and L4-L5 showing
moderate canal narrowing at ¶ 3-L4. (Tr. 1205).
2014 MRI of Plaintiff's lumbar spine showed postsurgical
changes at ¶ 5-S1, effacement of the left lateral recess
and mass effect on the left ventral aspect of the thecal sac
thought largely to be due to post-operative granulation
tissue, as well as underlying residual or recurrent disc
bulging suspected. (Tr. 380). It also revealed degenerative
changes most pronounced at ¶ 5-S1 and L4-L5. (Tr.
July 2014 visit with Ms. Hodakievic, Plaintiff reported her
lumbar spine pain was moderate, constant, and stable. (Tr.
1400). It radiated to her left leg (causing numbness, spasms,
and tingling), and was aggravated by walking and standing.
Id. Her medications took the edge off her pain, and
allowed her to perform her activities of daily living.
Id. On examination, Ms. Hodakievic observed
Plaintiff had an antalgic gait, and normal paraspinous and
lower extremity muscle tone with no spasm. (Tr. 1403). She
had tenderness to palpation in her bilateral gluteal,
paraspinous, and lumbar regions. Id. She had limited
lumbar range of motion with pain, and her left knee, ankle,
and foot strength was limited. (Tr. 1403-04). Straight leg
raising caused “back pain only” bilaterally. (Tr.
1403). Plaintiff had some reduced reflexes in her patella and
Achilles, and decreased sensation at right S1 and left L5 and
S1. (Tr. 1404). Dr. Mehta and Ms. Hodakievic noted similar
findings through 2014 and 2015. See Tr. 1407-77,
December 2014, Krishna Satyan, M.D., wrote a letter stating
Plaintiff's symptoms and MRI findings were related to her
original work injury. (Tr. 373). She noted symptoms of
moderate to severe low back and left leg pain, with numbness
and tingling in the left foot. Id.
January 2015 CT scan of Plaintiff's lumbar spine showed
multilevel lumbar degenerative disc disease and probable
central canal stenosis at multiple levels. (Tr. 365). It also
revealed probable right neural foraminal narrowing at ¶
4-L5 and possible right neural foraminal narrowing at ¶
February 2015, Plaintiff underwent a hemilaminotomy for
recurrent disc displacement and a left-sided hemilaminotomy
for microdiscectomy. (Tr. 344-45). In March 2015, Plaintiff
started physical therapy. (Tr. 279). She reported waking due
to pain, difficulty washing, dressing, and putting on shoes;
she was unable to do laundry, cooking, or cleaning.
Id. On examination, the physical therapist observed
some lower extremity reduced muscle strength, poor body
mechanics, and a moderate postural shift to the left (Tr.
280); he recommended six weeks of physical therapy (Tr. 282).
He noted Plaintiff's examination was “consistent
with [left] postlateral derangement of the lumbar spine and
recent surgery of the [low back].” Id.
Plaintiff continued physical therapy through July 2014.
See Tr. 284-95. In July, she had made
“excellent progress” toward several of her
therapeutic goals, but no change in her goal regarding pain.
See Tr. 284-85.
September 2015, Plaintiff saw John Butler, M.D., complaining
of mild to moderate back pain radiating to the left leg and
foot; she described “jolts” in her left foot.
(Tr. 495). On examination, Dr. Butler found Plaintiff had an
antalgic gait, a normal straight leg raise, some reduced
strength in her left lower extremity, and pain with knee
flexion and extension. (Tr. 496). He assessed improved
radiculitis and renewed medications. (Tr. 497).
April 2016, after her date last insured, Plaintiff saw
Ms. Hodakievic. (Tr. 953). She reported improvement with
prednisone, but continued lumbar and leg pain. Id.
On examination, she had decreased range of motion, pain, and
spasm in her lumbar spine; she also had an abnormal gait and
an abnormal straight leg raise test. (Tr. 955).
also underwent additional physical therapy in 2016. (Tr.
1548-1608). The July 2016 discharge summary notes Plaintiff
was able to cook for about fifteen minutes with pain in her
lower back and hips, had difficulty vacuuming, was able to
grocery shop with a scooter, and able to carry some
groceries. (Tr. 1548). On examination, Plaintiff had some
reduced muscle strength in her lower extremities (improved
since May), and some reduced range of motion in her
lumbosacral spine (also improved since May). (Tr. 1549).
Plaintiff was noted to have made “some” to
“good” progress on her therapy goals, but was
discharged from therapy due to a plateau in progress. (Tr.
1550-51); see also Tr. 1549 (“Client appears
to have reached a plateau at this time until her L knee
condition is resolved.”).
September 2016, Plaintiff saw Todd Hochman, M.D., after being
discharged from Dr. Mehta's practice. (Tr. 1725). She
reported back pain associated with numbness and tingling in
the hips and lower extremities, worse on the left, and knee
pain. Id. On examination, Plaintiff was in moderate
discomfort, had some flattening of the normal lumbar
lordosis, midline discomfort, paraspinal muscle spasm and
pain, and pain with straight leg raising. (Tr. 1726). She had
some weakness in the left ankle and a diminished patellar
reflex on the left. Id. Dr. Hochman prescribed
Topamax and referred Plaintiff to pain management. (Tr.
follow up appointment with Dr. Hochman in April 2017,
Plaintiff was “at her wits end” and
“extremely frustrated.” (Tr. 1719). She reported
her medications helped with the pain, but she wanted to
pursue something to get off medication. Id. Dr.
Hochman noted Plaintiff's pain management physician
recommended a spinal cord stimulator trial. Id. On
examination, Plaintiff was in moderate discomfort; she had
spasm and trigger points, discomfort with a straight leg
raise (greater on the left), and weakness. Id. Dr.
Hochman opined, for purposes of Worker's Compensation,
that Plaintiff had not yet reached maximum medical
improvement and should be authorized for the stimulator
trial. (Tr. 1720). Plaintiff had similar physical findings,
including an antalgic gait, in June. (Tr. 1717).
had a trial spinal cord stimulator implanted in her back in
June 2017, and subsequently a permanent stimulator implanted
in August. See Tr. 1785, 1800, 1813. In September
2017, Dr. Hochman noted Plaintiff had moderate discomfort,
some tenderness in the lumbar region, weakness, and pain with
straight leg raising on the left. Id.
February 2016, State agency physician Esberdado Villanueva,
M.D., reviewed Plaintiff's records, and opined Plaintiff
could perform the lifting requirements of light work (20
pounds occasionally and 10 pounds frequently), stand or walk
for four hours in an eight-hour workday, and sit for about
six hours in an eight-hour workday. (Tr. 75). He ...