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Holmes v. Astrue

April 28, 2010


The opinion of the court was delivered by: Yohn, J.


Plaintiff, Joyce E. Holmes, appeals the denial of her claim for Social Security Disability Insurance benefits ("DIB") by the Commissioner of Social Security ("the Commissioner"). She seeks judicial review pursuant to 42 U.S.C. § 405(g) (2006). I referred the matter to a magistrate judge, who submitted a Report and Recommendation ("R&R") recommending that I affirm the Commissioner's decision. Plaintiff filed objections to the R&R. Plaintiff argues in her objections that the Administrative Law Judge's ("ALJ's") determination lacked substantial evidence to support it because it: (1) improperly rejected the results of an MRI report showing pressure on plaintiff's spinal cord; (2) failed to conduct a sufficient analysis of the effects of plaintiff's obesity; (3) provided insufficient support for its conclusion that plaintiff was not fully credible; (4) rejected the opinions of plaintiff's treating physicians without substantial contradictory evidence; and (5) failed to perform an adequate function-by-function analysis of plaintiff's residual functional capacity ("RFC"). I conclude that the ALJ's discussion of plaintiff's obesity and analysis of RFC were once again inadequate. Accordingly, I will remand the matter to the Commissioner for further decisionmaking consistent with this opinion.

I. Factual and Procedural Background*fn1

Plaintiff's DIB claim has a lengthy procedural history-spanning over thirteen years-and has already come once before this court. I addressed plaintiff's case in 2006, on her first appeal to this court. See Holmes v. Barnhart, No. 05-5214, 2006 U.S. Dist. LEXIS 79826 (E.D. Pa. Nov. 1, 2006). Because my previous opinion includes a detailed discussion of plaintiff's procedural history up until 2006, I will provide only a summary here.

Plaintiff is a 57-year-old woman with past work experience as a bank authorization clerk, distribution clerk, and encoding operator. Plaintiff has not engaged in substantial gainful activity since May 13, 1996, when she claims she became disabled due to neck and back problems. She last met the insured status requirements of the Social Security Act on December 31, 2001. As a result, she must show that she became disabled before that date in order to be entitled to DIB.

Plaintiff complains of severe neck pain that radiates to her shoulder and arms. Plaintiff's primary physician, Henry Sadek, D.O., who submitted treatment notes from 1996 to 2003, diagnosed cervical radiculopathy and has noted limitations in cervical range of motion, muscle spasms, and diminished reflexes. He also reported that plaintiff had normal sensation and no muscle atrophy. The notes of Robert Hudrick, D.O., who also treated plaintiff from 1996 to 1997, are not fully consistent with those of Dr. Sadek, as Dr. Hudrick found plaintiff to retain full range of cervical motion. Dr. Hudrick did note that plaintiff suffered from tenderness and spasms. Dr. Hudrick found plaintiff to be neurologically normal, with the exception of mildly diminished power in her right upper extremity. On March 22, 1999, plaintiff was examined by Martin Goldstein, D.O., a consulting neuropsychiatrist. Dr. Goldstein found that plaintiff suffered from uniformly diminished reflexes, but did not make any comments regarding plaintiff's cervical range of motion and found plaintiff to have normal strength and sensation, with no muscle atrophy or spasms. An August 1, 1996, MRI of plaintiff's cervical spine showed multilevel "mild disc bulges with posterior osteophyte formation," causing "mild" impression on the thecal sac and spinal cord at the C4-5 level. (R. 306-07.) A consulting neurologist, Dewey Nelson, M.D., stated that 52% of the normal population have cervical bulges.

Plaintiff also complains of lower back pain. A June 12, 1997, MRI of Holmes's lumbar spine showed "no evidence of disc bulge or herniation" but some "degenerative changes" at the "facet joints at the L5-S1 level, right greater than left."*fn2 (R. 349.) Dr. Sadek has diagnosed plaintiff with lumbar strain. Dr. Nelson has concurred with that diagnosis and, in addition, diagnosed plaintiff with spondylosis of the L5-S1 disc. Dr. Sadek reported some limitations in plaintiff's range of motion, but Dr. Goldstein found only mild limitations, and Dr. Hudrick found none. Dr. Sadek and Dr. Hudrick reported that plaintiff's gait was normal, but Dr. Goldstein noted that plaintiff's gait was wide and "waddling" as a result of her obesity. While Dr. Sadek reported that plaintiff experienced muscle spasm and had somewhat decreased muscle power, Dr. Goldstein reported no problems in these areas. Both Dr. Sadek and Dr. Goldstein agreed that plaintiff had somewhat diminished reflexes. All three examining physicians found that plaintiff experienced no muscle atrophy. Moreover, Dr. Hudrick found tenderness in the lumbar region.

Although plaintiff reported using a cane since sometime in 1996, Dr. Sadek opined in April 1997 and September 1998 that plaintiff had no need for one, only finding that a cane was necessary in May 2003.

In addition to her orthopedic impairments, plaintiff is obese, with a height of five feet and six inches and a weight varying between 206 and 230 pounds over the course of her claimed period of disability.

Aside from the MRIs and physical examinations performed by plaintiff's examining physicians, no imaging or other diagnostic tests, such as electromyograms or nerve conduction studies, have been performed. Moreover, between plaintiff's alleged onset date and her date last insured, she has primarily treated her pain with acupuncture, heat massage, and pain medications or anti-inflammatories such as Relafen, Motrin, and Daypro.

Plaintiff filed her first application for DIB on December 9, 1996, alleging that she experienced neck and back pain starting on May 13, 1996. An ALJ held a hearing on November 11, 1998, and issued an unfavorable decision on August 19, 1999. On July 11, 2000, while her appeal of the first application was pending before the Appeals Council, plaintiff filed a second DIB application, alleging the same impairments. The Social Security Administration issued a favorable decision on that application on February 16, 2001, with a finding of disability beginning on August 20, 1999, the day after the ALJ's unfavorable decision on Holmes's first DIB application.

On August 26, 2002, the Appeals Council vacated the unfavorable determination from August 19, 1999, reopened the favorable decision from February 16, 2001, consolidated both applications, and referred the matter to the ALJ for another hearing. That hearing resulted in another unfavorable decision on July 11, 2003.

The Appeals Council vacated that decision and remanded to another ALJ, who also issued an unfavorable decision on August 5, 2004. The Appeals Council denied plaintiff's request for review on August 3, 2005. Plaintiff appealed to this court. On November 1, 2006, I remanded the matter to the Commissioner for further decisionmaking. See Holmes, 2006 U.S. Dist. LEXIS 79826. I concluded that the ALJ had provided an inadequate basis for her rejection of the opinions of plaintiff's treating physicians, Dr. Sadek and Dr. Goldstein. I also concluded that a medical expert, Stanley Askin, M.D., gave improper testimony by focusing on whether plaintiff would benefit from working rather than on whether her medical condition could reasonably produce her allegedly disabling pain. See Leslie v. Barnhart, 304 F. Supp. 2d 623, 629 (M.D. Pa. 2003). It was unclear to what extent this testimony influenced the ALJ's decision. I further concluded that the ALJ did not properly address Holmes's obesity in her RFC determination at step four, as required by the Social Security Administration's Policy Interpretation Ruling, S.S.R. No. 02-01p (2002) ("S.S.R. 02-01p"). Finally, I concluded that the ALJ erred in failing to discuss the results of an MRI of Holmes's lumbar spine conducted around September 9, 2003.

On remand, the ALJ conducted another hearing with a new medical expert, Donald I. Goldman. Dr. Goldman, a board-certified orthopedic surgeon, testified that there was little objective medical evidence of a serious orthopedic impairment, that obesity was not a contributing factor in producing plaintiff's pain, and that plaintiff's symptoms were likely caused by some other impairment such as fibromyalgia or diabetic neuropathy. (R. 686-709.) Dr. Goldman concluded that plaintiff was not disabled from an orthopedic standpoint and that the opinions of her examining physicians were not medically supported. (Id.)

Subsequent to that hearing, the ALJ issued another unfavorable decision on August 27, 2007. The ALJ found that plaintiff's obesity, cervical spine impairment, and lumbar spine impairment were "severe," but that plaintiff retained the RFC to perform sedentary work. The ALJ specifically credited Dr. Goldman's testimony to the extent that it conflicted with the opinions of Dr. Sadek and Dr. Goldstein.

The Appeals Council denied review and plaintiff appealed again to this court. I referred the matter to a magistrate judge, who recommended that I affirm the decision of the Commissioner. Plaintiff has objected to the magistrate judge's recommendation.

II. Legal Standard

A. Standard of ...

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