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Douglass v. Astrue

June 29, 2010


The opinion of the court was delivered by: Young B. Kim United States Magistrate Judge

Magistrate Judge Young B. Kim


Before the court is the motion of plaintiff Janice Susan Douglass ("Douglass") for summary judgment. Douglass seeks review of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for a period of disability and Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. § 423(d)(2), and Supplemental Security Income ("SSI") under Title XVI of the Act, 42 U.S.C. § 1382c(a)(3)(A). Douglass asks the court to reverse the Commissioner's decision and award benefits, or in the alternative, remand the decision for further proceedings. For the following reasons, the motion is granted to the extent that the cause is remanded for further proceedings consistent with this opinion.

Procedural History

Douglass applied for DIB and SSI on July 22, 2005, alleging that she became disabled on October 29, 2003, due to a back disorder, carpel tunnel syndrome, severe depression, and anxiety. (Administrative Record ("A.R.") 51, 66-68, 631-33.) Her applications were denied initially on November 25, 2005, and again on reconsideration on May 25, 2006. (Id. at 11, 49-53, 625-28.) Thereafter, Douglass filed a timely request for a hearing on July 3, 2006. (Id. at 47.)

An administrative law judge ("ALJ") held a hearing on July 22, 2008. (A.R. 634-93.) Douglass appeared and testified at the hearing. (Id. at 636-84.) Dennis Gustafson ("Gustafson"), a vocational expert, and Kevin Spencer ("Spencer"), a witness for Douglass, also appeared and testified at the hearing. (Id. at 684-92.) On August 25, 2008, the ALJ issued a decision finding Douglass not disabled. (Id. at 11-23.) In reaching his decision, the ALJ relied on medical evidence showing that Douglass had no abnormal findings, but ignored medical evidence that supported her disability claim.

Douglass then filed a request for review of the ALJ's decision and, on November 26, 2008, the Appeals Council denied her request, making the ALJ's decision the final decision of the Commissioner. (A.R. 4-6.) Pursuant to 42 U.S.C. § 405(g), Douglass initiated this civil action for judicial review on February 19, 2009, of the Commissioner's final decision.*fn1


Douglass was born on March 29, 1959, and was 49-years old at the time of the administrative hearing. (A.R. 638.) She finished eighth grade, but never went to high school or obtained a general equivalency diploma. (Id. at 642.) Douglass was most recently employed as a lead scale worker at Illinois Laundry. (Id. at 21, 86, 113, 415.) Her main duties entailed pushing, pulling, and maneuvering large carts of laundry material weighing between 150 to 500 pounds onto large floor scales, and cataloging the contents of the carts. (Id. 218, 674-75.) She stopped working at the end of October 2003, because she was suffering from back, hip, leg, and neck pain, bilateral carpal tunnel syndrome, depression, and anxiety. (Id. at 21, 113, 644.)

A. Physical Impairments

1. Neck and Back Pain

The record establishes that Douglass initially sought treatment for neck, hip, leg, abdomen, and lower back pain on October 29, 2003. (A.R. 185.) A November 3, 2003, xray of Douglass's pelvis and left hip showed degenerative disease of the spine and the radiologist incidentally noted that there were "severe degenerative changes at the L5-S1 level." (Id. at 122.) The reviewing doctor noted that Douglass's pain emanated from the L5-S1 level and referred her to physical therapy. (Id.)

Two months later, Douglass was treated by Dr. William Olivero, a neurosurgeon.*fn2 (A.R. 213.) Her physical examination showed her range of motion and reflexes were normal, but there was tenderness in her left groin. (Id.) The results of a magnetic resonance imaging ("MRI") scan of Douglass's pelvis, on January 22, 2004, showed no abnormalities. (Id. at 118.) However, an MRI of Douglass's lumbar spine performed three weeks later showed central canal stenosis at L2-L3 and marked narrowing of the left neural foramen at L3-L4. (Id. at 116.)

In May 2004, Douglass had an initial pain management consultation with Dr. Maria Pilar-Estilo, a pain specialist. (A.R. 376-77.) Treatment notes indicate Douglass reported she had continuous left flank and left lower abdominal pain, which started nine months earlier with no specific triggering event. (Id. at 376.) Douglass told Dr. Pilar-Estilo that her sleep was interrupted due to pain and that she took Tylenol #4 four to five times a day to relieve her pain. (Id.) Douglass also underwent two MRIs that month. The first, taken of Douglass's thoracic spine, showed an incidental finding of a moderate to large sized C5-C6 disc protrusion with possible cord impingement, signifying a herniated disc and a smaller disc protrusion at the C6-C7 level. (Id. at 373-74.) The second, of Douglass's cervical spine, showed a central to right posterolateral C5-C6 herniated disc, and partial left C5-C6 postarthritic neuroforaminal stenosis secondary to osteoarthrosis. (Id. at 368.)

In June 2004, Douglass saw Dr. Pilar-Estilo for left hip pain and mild pain in her neck radiating to the lateral aspect of her right arm. (A.R. 363-65.) Douglass's examination that day showed no abnormalities, but she continued to seek treatment with Dr. Pilar-Estilo for severe neck, hip, and back pain on many occasions in 2004 and 2005. (Id. at 255, 257, 259, 261, 263, 271, 303, 308, 310, 348, 359, 361.) During this period, Douglass had a series of lumbar epidural steroid injections (id. at 257-58, 259-60, 261-62, 359, 361, 362, 364), and was prescribed various medications, including Ultracet, Naproxen, and Darvocet for pain, and Effexor for depression (id. at 261-62, 303-04, 310, 359, 361, 362, 363, 364). Douglass also engaged in a physical therapy program for her back pain. (Id. at 265-70, 273-79, 283-85, 289-91, 296-97, 301, 315-19, 321-23, 325-26, 328-31, 333-36, 342-45, 347, 351-58). The physical therapy included soft tissue mobilization, ultrasound therapy, electrical stimulation, traction, hot and cold packs, and therapeutic exercises. (Id.) Dr. Pilar-Estilo's diagnoses included acute posterior neck pain, chronic lower back pain, mid to lower thoracic spine degenerative joint disease, a moderately enlarged C5-C6 disc protrusion, lumbar central canal stenosis at L2-L3, and depression. (Id. at 255, 257, 259, 261, 263, 271, 303, 308, 359, 361, 363.)

From June 2006 through April 2007, Douglass sought treatment for severe back pain from Dr. Jyoti Karla, a pain specialist. (A.R. 463-68.) Dr. Karla prescribed intervertebral differential dynamics ("IDD"), ultrasound, and transcutaneous electrical nerve stimulation ("TENS") therapies for Douglass's back pain. (Id. at 458.) Dr. Karla also prescribed physical therapy, Vicoden, pain patches, and other medications for Douglass's back pain during this period. (Id. at 457, 463-68.)

Douglass had another MRI of her lumbar spine in November 2006. (A.R. 243-44.) The results showed mild to moderate lumbar spondylosis without significant central canal stenosis, and narrowing of the L3-L4 and L4-L5 neuroforamen. (Id. at 244.) The MRI also revealed post-operative changes of the L5-S1 intervertebral disc with anterior epidural scarring that encircles both S1 nerve roots. (Id.) There was no recurrent or residual disc protrusion. (Id.) On that same day, Douglass had an x-ray of her lumbar spine, which showed mild to moderate lumbar spondylosis with moderate to severe L5-S1 disc degeneration. (Id. at 245.) The following month, Douglass sought emergency medical treatment for pain on the left side of her neck and shoulder that had persisted for three to four days. (A.R. 237-39.) Her treating physician diagnosed the problem as torticollis (twisted neck) and prescribed medication for her treatment. (Id. at 237.)

In March 2007, Douglass underwent another MRI and x-ray of her cervical spine. (A.R. 233-35.) The MRI revealed an overall stable appearance of a posterior disc bulge at the C5-C6 level with narrowing of the spinal canal to 7.4 millimeters and flattening of the spinal cord. (Id. at 233.) A partial left neuroforaminal narrowing at the C5-C6 level was noted. (Id.) The x-ray showed a curvature, reversal lordosis, and degenerative changes as well as longstanding calcification adjacent to the anterior inferior aspect anterior arch of C1. (Id. at 135.)

2. Wrist and Hand Pain

Douglass first sought treatment for her wrist pain on October 29, 2003. (A.R. 185.) An electromyography ("EMG") and nerve conduction study of Douglass's hands performed in November 2003, showed "mildly abnormal" findings that were "most likely consistent with a mild distal right median nerve neuropathy at the wrist level, probably consistent with a mild right carpal tunnel syndrome." (Id. at 178.) The next month, Dr. Keith Rezin, an orthopedic surgeon, diagnosed Douglass with right carpal tunnel syndrome by history. (Id. at 438.) Dr. Rezin opined that Douglass could be on light-duty work restrictions, and ordered physical therapy. (Id.)

Douglass had an independent medical examination, in August 2004, with Dr. John Fernandez, an orthopedic specialist. (A.R. 216-28.) Douglass reported that she began having discomfort in her hands and wrists in April 2003. (Id. at 216.) Douglass complained of numbness and tingling affecting the thumb, index, and middle fingers, and her symptoms became worse with any significant activity, including forceful gripping or grasping. (Id. at 217.) She rated the severity of her symptoms as a seven out of ten. (Id.) An examination of her hands showed paresthesias affecting the median nerve distribution on the hands with the right being greater than the left, and irritability over the median nerve at the wrist on percussion and compression with positive Tinel and Phalen's tests. (Id. at 219.) There was also tenderness along the carpal canal palmarly, but without significant instability or mechanical symptoms such as crepitus, locking, or triggering. (Id.) Dr. Fernandez diagnosed bilateral carpal tunnel syndrome, with the right wrist being worse than the left wrist. (Id.) He restricted Douglass to light work entailing lifting twenty pounds occasionally, ten pounds frequently, and negligible force constantly. (Id. at 223.) She was also limited to repetitive pushing, pulling, twisting, gripping, and pinching occasionally, which meant she could perform these tasks once every ten minutes and for a total of one to three hours. (Id.)

In December 2004, Dr. Jason Franklin, an osteopathic doctor, evaluated Douglass for bilateral hand pain and numbness. (A.R. 415.) She stated that a year and a half earlier, she noticed problems with neck and shoulder pain, and pain in her hands and arms as well numbness and tingling in her hands. (Id.) Douglass experienced pain that was aching, burning, or squeezing, in her neck, radiating into her arms. (Id.) Her pain was worse when she used her hands and she used anti-inflammatory and pain medications as well as splints. (Id.) Dr. Franklin diagnosed bilateral carpal tunnel syndrome and ordered an EMG of the left wrist. (Id.) That same month, Douglass underwent right carpal tunnel syndrome release and right trigger thumb release surgery. (Id. at 409-10.) Two months later, in February 2005, Douglass underwent left carpal tunnel release and left trigger finger release surgery. (Id. at 396-97.)

In March 2005, Douglass told Dr. Rezin she was unable to return to work. (A.R. 391.) Dr. Rezin examined Douglass and found she did not have any trigger thumb problems, but had little crepitants in the interphalangeal joint of both thumbs. (Id.) Her grip strength was fair and her range of motion was good. (Id.) Dr. Rezin recommended that Douglass continue physical therapy for another week and a half, after which, he would release her to light duty work. (Id.) Douglass saw Dr. Rezin for a follow-up appointment regarding her bilateral carpal tunnel surgeries in April 2005. (Id. at 385, 387.) Dr. Rezin noted that she was no longer having numbness and tingling in her hands, and had recently returned to work. (Id. at 385.) Dr. Rezin indicated Douglass was capable of doing light duty work through May 1, 2005, that she would reach maximal medical improvement by May 2, 2005, that she would return to full duty work with no restrictions, and that she would be released from his care and seen on an as needed basis. (Id.)

B. Mental Impairments

In November 2004, Douglass initially sought treatment for depression with Dr. Yung Chung, a psychiatrist. (A.R. 153-58.) One month later, Douglass reported to Dr. Chung that she felt "overwhelmed and depressed." (Id. at 124.) Dr. Chung diagnosed Douglass as having a depressive disorder not otherwise specified, prescribed Remeron, and noted she was taking Methadone for pain. (Id. at 124-25.) Douglass continued to be treated by Dr. Chung in 2005 and 2006, and also attended group therapy during this period. (Id. at 127-28, 139-52.)

Douglass next sought psychiatric treatment at North Central Behavioral Health Systems, Inc. ("NCBHS") in October 2006. (A.R. 498-533.) Dr. Sheth Atul, a psychiatrist, diagnosed Douglass with depression, post-traumatic stress disorder ("PTSD") and mood disorder not otherwise specified. (Id. at 499, 501, 505-06, 508.) At that time, Douglass reported having difficulty dealing with physical, financial, and family issues. (Id. at 506, 508.) Dr. Atul recommended that Douglass attend individual therapy sessions. (Id. at 506.) She was taking Buspar for anxiety, Remeron, and Cymbalta for depression. (Id. at 507, 508.)

Douglass continued her treatment with NCBHS through August 2007, at which time her case was closed due to noncompliance. (A.R. 479-542, 594.) During that period, she had continuous individual therapy, group therapy, medication monitoring, and psychiatric services. (Id.) Progress notes indicate Douglass had good and bad days, and had bouts of depression and sadness at times over certain events in her life, including her daughter's tragic death in 2007. (Id. at 486.) Her treatment objectives included working on managing her depression, PTSD, anxiety, mood problems, and seeing the doctor for her medications. (Id. at 479, 485.) She reported being in severe pain, running out of her pain medications, and losing her medical card. (Id. at 535, 486.)

In March 2008, Douglass once again sought treatment from NCBHS. (A.R. 577-95.) At that time, she described a number of problems, including a depressed mood, crying spells, social withdrawal, loss of energy, changes in sleep patterns, anxiety exacerbated by ongoing physical pain, and unresolved grief over the loss of her daughter. (Id. at 577-78.) Progress notes indicate Douglass had stopped participating in NCBHS treatment in 2007 because of transportation problems. (Id. at 578.)

In May 2008, Douglass reported she was depressed and believed her depression had worsened due to untreated physical pain and continuing difficulties over the loss of her daughter. (A.R. 605.) Treatment notes indicate she had stopped seeking treatment for her back pain because she did not have any health insurance, and her severe pain seemed to underlie all of her current problems. (Id.) ...

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