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Henry v. Astrue

June 10, 2009

DANA M. HENRY, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, DEFENDANT.



The opinion of the court was delivered by: Jeanne E. Scott, U.S. District Judge

OPINION

Plaintiff Dana M. Henry appeals from a final Decision of the Social Security Administration (SSA) denying her application for Disability Insurance Benefits (DIB) under Chapter II of the Social Security Act, 42 U.S.C. § 423. Henry brings this appeal pursuant to 42 U.S.C. § 405(g). The parties have filed cross-motions for summary judgment or affirmance pursuant to Local Rule 8.1(D). Plaintiff's Motion for Summary Judgment and Memorandum of Law in Support Thereof (d/e 11); Motion for Summary Affirmance (d/e 13). Henry asks this Court to find her disabled.

BACKGROUND

Henry applied for Disability Insurance Benefits (DIB) on October 9, 2003. She alleges that she suffers from chronic back, hip, and leg pain and depression. The SSA denied her claims initially and on reconsideration. Henry requested a hearing, which was held November 21, 2006. On December 8, 2006, an Administrative Law Judge (ALJ) issued a Decision denying Henry's application. Henry filed a request for Appeals Council review, and the Appeals Council remanded the case back to the ALJ. On September 14, 2007, the ALJ held a second hearing, and on October 16, 2007, he again issued a Decision denying Henry's application. The Appeals Council denied Henry's second request for review, and Henry now seeks judicial review.

I. MEDICAL HISTORY

Henry alleges that she became disabled on July 6, 2001. At the time, she was working as a machine operator, which required her to stand 8 to 10 hours a day, with regular lifting of 25 to 35 pounds. For at least several months before, Henry had been experiencing back, hip, and leg pain and depressive symptoms. In a June 28, 2001, visit with Dr. Geoffrey Bland, Henry stated that she previously had undergone physical therapy, epidural injections, and medical pain management, all without sufficient improvement. She told Dr. Bland that she intended to quit her job because she believed it was exacerbating her symptoms. Dr. Bland found that her spine had a fairly full range of motion, but she was tender along the left SI joint and into the left iliac wing area. He also found that she had increased pain on the left side during straight leg raises. Dr. Bland prescribed pain medication and an exercise program.

Dr. Bland also noted that Henry had "finally agreed" to see a psychiatrist. Adm. Rec. (d/e 8) (R.) 376. His records state that Henry believed her depression was secondary to her pain. He observed that while her thought content and memory seemed intact, she became tearful intermittently and had a definite flattened affect.

On March 22, 2002, Henry returned to Dr. Bland's office and reported worsening symptoms of depression. Dr. Bland noted a definite change in personality over the last couple years, "with more flattened affect, increased signs of depression." R. 374. Henry was tearful at this appointment and said she felt "like she would like to die when she's in pain all the time." R. 374. She informed Dr. Bland that she was scheduled for a disk fusion in her lumbar spine soon. Dr. Bland prescribed Wellbutrin.

In a follow-up visit on April 11, 2002, he noted marked improvement on the Wellbutrin.

On April 18, 2002, Henry underwent surgery for an L5-S1 anterior interbody fusion. Dr. Timothy VanFleet performed the surgery. His notes state that the surgery was uneventful and she was discharged on April 21, 2002, in good condition. At a follow-up visit six months later, on September 20, 2002, Dr. VanFleet found that Henry could stand and ambulate "without any difficulty whatsoever." R. 391. Additionally, X-rays demonstrated that the implant remained in good position. Henry complained of continued back pain, however, primarily when she was "up and moving around." R. 391. Dr. VanFleet saw pain management as her only option and referred her to Dr. Koteswara Narla for evaluation.

Henry saw Dr. Narla on October 4, 2002. Henry told Dr. Narla that before her surgery, she rated her back pain as 9 or 10 out of 10, but since the surgery it had been only 5 out of 10. She explained that the pain was continuous, grinding, aching, and sharp. Her pain lessened with cold packs and when she laid down or sat with elevated legs. Henry said that standing, walking, sitting, and driving all increased her pain. Dr. Narla found that Henry had "a tendency to magnify things during the conversation," but noted that MRI scans on August 3, 1999, showed a mild diffuse disc bulge at L4-5 and a mild right paracentral disc bulge at L5-S1. R. 426. He added, however, that he saw "clearcut evidence of symptom magnification in this lady for some unknown reason, which I do not understand." R. 425.

On November 6, 2002, Dr. Narla saw Henry again and noted possible neuropathic pain. He advised lowering her dosage of Neurontin, a medication used to treat nerve pain, and noted, "I do not think there is any necessity of interventional procedures such as epidural injection at this stage as she is able to function quite well." R. 423.

On November 19, 2003, Dr. Vittal Chapa performed a consultative examination for the SSA. At this examination, Henry demonstrated tenderness on palpation of the sacroiliac joints, or those at the base of the spine. Dr. Chapa found no evidence of nerve root compression and noted that Henry had no difficulty with ambulation. He concluded that she could perform fine and gross manipulation with both hands.

On November 20, 2003, Linda Lanier, a licensed clinical psychologist, performed a consultative examination for the SSA. Henry told Lanier that her worst depression occurred five years before, when she was trying to work in spite of significant pain. Henry stated that she was currently experiencing mild symptoms of depression, including trouble sleeping and a feeling of hopelessness. She was no longer on medication, but took some briefly five years earlier. Lanier diagnosed Henry with dysthymic disorder and a GAF of 55. Lanier also observed that Henry appeared to be in pain throughout their interview.

On December 15, 2003, Kirk Boyenga, Ph.D., and Thomas W. Low, Ph.D., reviewed Henry's medical records for the SSA. They found that she was moderately limited in her abilities to carry out detailed instructions, to maintain attention and concentration for extended periods, to complete a normal workday and workweek without interruptions from psychologically based symptoms, to perform at a consistent pace, to interact appropriately with the general public, and to respond appropriately to changes in the work setting. They also found mild limitations in her restriction of activities of daily living and difficulty maintaining concentration, persistence, and pace. They concluded that Henry suffered from dysthymia, a chronic mood disorder.

On July 6, 2004, Dr. Barry Free conducted a physical residual capacity assessment of Henry for the SSA. He found that she could occasionally lift or carry 20 pounds, frequently lift or carry 10 pounds, stand or walk with normal breaks for a total of 6 hours in an 8-hour day, sit with normal breaks for a total of 6 hours in an 8-hour day, and push or pull without limitation. He also found that she could occasionally climb, balance, kneel, and crouch. He suggested she suffered no manipulative, visual, communicative, or environmental limitations.

On January 7, 2005, Henry visited Dr. Narla again. She asked for Dr. Narla's opinion regarding her permanent work restrictions. Dr. Narla noted:

I made it very clear, since she has not worked for the last 3-1/2 years, I am not certain what restrictions can be given as she has no official work. . . . I have explained to her that unfortunately since she does not have any job to do there is no place for trying to define the restrictions for her. If she does wish to have them, she probably would need a functional capacity evaluation.

R. 473.

Henry visited Dr. Heidi Prather, a doctor of osteopathy, on July 14, 2005. Henry told Dr. Prather that her pain management doctor in Springfield was unwilling to write any restrictions for her work, so she wanted a second opinion. Dr. Prather diagnosed S1 radicular pain and sacroiliac pain, and she advised Henry to arrange for a functional capacity evaluation so that she could review the results and determine whether Henry should have any work restrictions.

On February 7, 2007, Dr. Chapa performed another consultative examination of Henry for the SSA. He noted that Henry continued to complain of pain in her lower back, radiating into both hips and the left lower extremity. At this meeting, Henry was able to ambulate and bear weight without assistance, and Dr. Chapa noted that she had no difficulty getting on or off the exam table. He diagnosed her with chronic back pain but found her range of motion normal.

That same day, Henry also saw a licensed clinical psychologist, Dolores Trello, who performed a mental status examination for the SSA. Henry told Trello that she felt depressed because her pain controlled her life and she could not do the things she used to do. Trello diagnosed Henry with adjustment disorder with depressed mood and depressed mood associated with chronic pain. She assessed Henry a GAF score of 50 and found serious impairment in vocational and interpersonal functioning due to depression associated with chronic pain. Trello also noted that Henry's understanding, memory, sustained concentration and persistence, social interaction, and adaptation were adequate.

More than a week later, on February 16, 2007, Ronald Havens, Ph.D., performed a psychiatric review of Henry's records for the SSA and also concluded that Henry suffered from adjustment disorder with depressed mood and depressed mood associated with chronic pain. Additionally, he concluded that Henry had mild limitations in her daily living activities and in maintaining social functioning. He found moderate limitations in her ability to maintain concentration, persistence, and pace. In a task-by-task breakdown, however, Dr. Havens found that Henry was not significantly limited in any tasks, but he rated her ability to maintain attention and concentration for extended periods as moderately limited. He found no episodes of decompensation. He summarized his findings as follows:

Claimant is experiencing depressed mood associated w physical issues, she is fully oriented, free of thought disorder, free of cognitive deficits, claimant is capable of understanding, remembering and carrying out detailed instructions with some moderate limitations in concentration as noted by CE. Claimant has the social skills and the emotional temperament required to interact appropriately with others. Claimant can adjust to routine changes in the work environment.

R. 551.

II. FIRST ADMINISTRATIVE HEARING

Two administrative hearings occurred in Henry's case. The first took place on November 21, 2006, via video conference. At this hearing, Henry and Bonnie Gladden, a vocational expert, both testified. Henry was 42 at the time of this hearing and lived with her husband and 18-year-old daughter. Henry drove herself to the hearing. She testified that she was a high school graduate and formerly worked as a machinist in a factory and before that as a census surveyor. She testified that she stopped working as a machinist because she could not tolerate the pain anymore. She received a worker's compensation settlement.

At the time of this first hearing, Henry was taking Elavil, Neurontin, Loricet, and a Fentanyl patch for pain. The medications made her a little tired, but she could think of no other side effects. At this point, Dr. Narla was the only doctor she was seeing regularly.

Henry testified that at this time, she also was performing physical therapy at home. The ALJ asked her to explain the physical therapy she was performing at home, and Henry described several exercises. Then, they had the following exchange:

A: I do about five or six different things a day.

Q: Do you have any equipment that you use in the process?

A: I have a ...


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