The opinion of the court was delivered by: Elaine E. Bucklo United States District Judge
Plaintiff Shacarlia Robinson ("Robinson") brought this action against the Commissioner ("the Commissioner") of the Social Security Administration seeking review of the Commissioner's denial of her application for supplemental security income ("SSI") under the Social Security Act ("SSA"), 42 U.S.C. §§ 405(g) and 1383(c)(3). The parties have filed cross motions for summary judgment. For the reasons discussed below, I reverse the ALJ's decision and remand the case to the Social Security Administration for further proceedings. Accordingly, I deny the Commissioner's motion for summary judgment. I also deny Robinson's motion for summary judgment insofar as it seeks a reversal of the ALJ's decision for an award of benefits. However, to the extent that Robinson's motion requests in the alternative that the case be remanded for further proceedings, it is granted.
Shacarlia Robinson began complaining of severe headaches and severe neck and back pain in 2002. In June 2002, she underwent an MRI, which revealed a syrinx in her cervical spine (R. at 365) and she was diagnosed with syringomyelia.*fn1 Since that time, Robinson has continued to complain of headaches and of pain in her neck and back.
On November 9, 2005, she filed an application for supplemental security income. The claim was initially denied on April 10, 2006, and was denied upon reconsideration on July 20, 2006. Robinson filed a request for a hearing before an Administrative Law Judge ("ALJ"), which was held on August 9, 2007. (R. at 18.) A supplemental hearing was held on November 28, 2007. What follows is a summary of the testimony of the witnesses who appeared at the hearings.
Robinson testified that she was 5'11" tall, and that she weighed 310 pounds. (R. at 56.) She reported having gained fifty pounds over the past several years. (R. at 36.) Robinson explained that she lived with her three children -- a sixteen year-old son, a thirteen year-old daughter, and a twelve year-old son.
(R. at 26.)*fn2 She further stated that she received food stamps and a medical card. (R. at 28.) Robinson received schooling through the seventh or eighth grade (R. at 29, 513) during which time she received special education services (R. at 41-42).
Robinson testified that she slept most of the day, and that household chores were performed by her children and other family members. (R. at 23.) She stated that was unable to dress herself, and that for the past four or five years, her daughter had assisted her in putting on her clothes. Robinson reported that she was able to walk approximately the distance of a block between breaks (R. at 27) but that she was unable to travel alone (R. at 25). The farthest she had traveled, she stated, was to her doctor's office.
With respect to her symptoms, Robinson testified that she had experienced persistent and severe pain in her back, lower back, neck, and head. (R. at 26.) She also reported having difficulty getting up from a seated position. (R. at 27.) In addition, Robinson stated that she experienced bowel and bladder problems on a daily basis, and explained that the problem was a source of embarrassment for her. (R. at 27, 29.) She said that her headaches had gotten worse during the past two years. On a scale of one to ten (with ten representing the worst pain), she ranked her daily pain between seven or eight. (R. at 29.) Because of the pain, she testified that she was able to sleep only for periods of thirty minutes at a time. (R. at 36.) Robinson also reported difficulty in holding objects, and difficulty in picking up small objects. (R. at 34.)
In addition, Robinson stated that for the past two years, she had been treated for depression and had experienced difficulty concentrating. (R. at 34-35.) She reported taking several different medications for pain, as well as medications for asthma and high blood pressure. (R. at 33, 56-58.) These medications, she testified, made her jittery and drowsy. (R. at 33.)
As for her employment, Robinson testified that her most recent job was in 2006 with the Church of Joy, where she provided childcare services for two to three hours per day. (R. at 37, 40-42, 46-47.) She further reported that, with her children's assistance, she had also occasionally earned money by providing childcare services from her home. (R. at 48, 62.)
B. Dr. Rudolph's Examination
During Robinson's testimony at the hearing, she appeared to have difficulty understanding and answering certain of the ALJ's questions -- particularly questions concerning her prior work history. (R. at 48-49.) As a result, the ALJ ordered that she undergo a psychological examination. (R. at 50.) On September 7, 2007, Robinson was evaluated by Dr. Gregory C. Rudolph ("Dr. Rudolph"). Dr. Rudolph administered the Wechsler Adult Intelligence Scale (WAIS) - III, Revised. (R. at 515.)*fn3 He found that Robinson had a full score IQ of 46, a verbal IQ of 51, and a performance IQ of 50. (R. at 515.) Dr. Rudolph further observed that these scores placed Robinson in "the lower portion of the mild mentally handicapped range to the moderate mentally handicapped range." (R. at 515) (emphasis in original).
In his report accompanying the test results, Dr. Rudolph noted that while Robinson exhibited no memory problems and possessed good knowledge of general information, she experienced difficulty performing rudimentary mathematical computations (for example, she counted her fingers to calculate that 5 4 equaled 9, and she was unable to solve equations such as "10 - 6" and "4 x 6"). (R. at 512, 514.) Dr. Rudolph further explained that Robinson was able to exercise her judgment, but that she had poor reasoning skills (for example, when asked in what way a tree and a bush were alike, she answered that both were brown; she was unable to indicate any ways in which a tree and bush were different). (R. at 512, 515.)
According to Dr. Rudolph, Robinson was able to take care of herself and her personal needs, but she was unable to go shopping by herself and did not know how to make change when making purchases. (R. at 514.) In addition, Dr. Rudolph concluded that Robinson suffered from Post Traumatic Stress Disorder ("PTSD") and Generalized Anxiety Disorder. (R. at 512.) Overall, he reported that Robinson had put forth good effort during the test. He concluded that the "evaluation appears to be considered valid and appears to be commensurate with [Robinson's] educational level and her level of adaptive functioning." (R. at 515) (emphasis in original).
After Dr. Rudolph's evaluation, a supplemental hearing was held in November 2007. (R. at 52.) At the hearing, the ALJ heard testimony from three experts: Dr. Ellen Rosenfeld, Ph.D. ("Dr. Rosenfeld"), a clinical psychologist; Dr. Ashok Jilhewar, M.D. ("Dr. Jilhewar"), an internist; and Frank M. Mendrick ("Mendrick"), a vocational expert.
During her testimony, Dr. Rosenfeld disputed the accuracy of the test results reported by Dr. Rudolph. (R. at 63.) According to Dr. Rosenfeld, Robinson's IQ scores were inconsistent with other evidence in the record. (R. at 64-65.) In particular, Dr. Rosenfeld pointed to the fact that Robinson was able to care for herself; that she had raised her own children and had performed daycare services for other children; that she had previously worked as a cashier; and that she could write and was able independently to fill out the "daily living form" submitted as part of her SSI application. (R. at 65.) Dr. Rosenfeld stated that none of these tasks could have been performed by a person with an IQ in the range found by Dr. Rudolph. (R. at 65.)
Furthermore, Dr. Rosenfeld observed that no cognitive impairment had been noted during any of Robinson's medical evaluations prior to her consultation with Dr. Rudolph in September 2007. (R. at 63, 80.) This suggested, she stated, that whatever Robinson's current level of cognitive functioning might be, it was unlikely that it could be traced very far back in her medical history. (R. at 65, 69-70.) Nevertheless, Dr. Rosenfeld acknowledged that Dr. Rudolph was a seasoned evaluator. (R. at 74.) Based on her review of the record, Dr. Rosenfeld recommended that, due to Robinson's difficulties in concentration and "mood regulation," Robinson be limited to jobs that involve operations of a simple and routine nature. (R. at 72.)
The ALJ next heard testimony from Dr. Jilhewar. Dr. Jilhewar reviewed Robinson's medical records and opined that her complaints of neck and back pain could not be explained by objective findings.
(R. at 83.) He stated that Robinson's complaints had begun when she visited a hospital emergency room in April 2002, apparently after a physical confrontation with the police. (R. at 24-25.) As characterized by Dr. Jilhewar, an MRI taken approximately one month later showed "only minimal disc bulge at C4-5." He opined that this could not account for Robinson's pain. (R. at 84.) Dr. Jilhewar also described "an incidental finding of syrinx . . . from C4 level to C7 level," but he added that the consulting neurologist had not documented any degenerative changes in Robinson's spinal cord or in her motor or sensory systems. (R. at 84.)
Dr. Jilhewar next noted that Robinson had a neurological consultation with Dr. M. Elena Gragasin ("Dr. Gragasin") in October 2003. He stated that Dr. Gragasin had observed Robinson's gait to be normal and that Robinson had a full range of movement in her neck. (R. at 84, referring to Tr. 414.) Dr. Jilhewar also observed that Dr. Gragasin had stated in her notes that Robinson's syrinx had not grown since the previous MRI and that Dr. Gragasin had opined that the syrinx was "most likely an incidental finding."
(R. at 84 citing 414.) Dr. Gragasin had ordered an MRI exam of Robinson's lumbar spine because of Robinson's complaints of pain. The test showed a minor disc bulge with a facet,*fn4 as well as joint degenerative changes at L5-S1. However, Dr. Jilhewar stated, Dr. Gregasin saw no effect on Robinson's spinal canal. (R. at 85.)
On December 17, 2003, Robinson had a neurological consultation with Dr. Herbert H. Engelhard ("Dr. Engelhard") due to the syrinx.
(R. at 86, referring to R. at 420.) As Dr. Jilhewar explained, Dr. Engelhard stated that if Robinson's neurological condition were to deteriorate, she might be treated surgically. (R. at 86, referring to R. at 420.) Dr. Jilhewar also noted that Robinson's regular doctor followed her complaints of neck and back pain. He observed, however, that none of Robinson's neurologists or neurosurgeons found her to be suffering from any motor weakness. (R. at 88.)
On November 30, 2004, Robinson was admitted to the Emergency Room ("ER") at John H. Stroger, Jr. Hospital in Chicago, Illinois.
(R. at 87, referencing R. at 451-52.) At that time, the ER staff reported that Robinson's gait was normal. (R. at 87.) However, she was assessed with chronic neck and back pain, and was referred for another neurological consultation. (R. at 87.)*fn5 She underwent another MRI on April 5, 2005. According to Dr. Jilhewar's review, the results were the same as those shown in Robinson's previous MRI (R. at 87.)
Lastly, Dr. Jilhewar testified that there was a conflict between the assessments of Robinson reached by two doctors in the same office. (R. at 88.) The first exam, performed by Dr. Michael K. Raymond ("Dr. Raymond"), took place in March 2004. (R. at 88.) Dr. Raymond noted that Robinson's motor strength was "3/5." (R. at 88.) He also explained that Robinson's ...