United States District Court, N.D. Illinois, Eastern Division
KATHLEEN Y. GILMOUR, Claimant,
CAROLYN W. COLVIN, Acting Commissioner of the U.S. Social Security Administration, Defendant.
MEMORANDUM OPINION AND ORDER
MICHAEL T. MASON UNITED STATES MAGISTRATE JUDGE
Kathleen Gilmour (“Claimant”) seeks judicial
review under 42 U.S.C. § 405(g) of a final decision of
Defendant Commissioner of the Social Security Administration
(“SSA”) denying her claim for Social Security
Disability Insurance Benefits (“DIB”) under Title
II of the Social Security Act (“the Act”).
See 42 U.S.C. § 423. The parties have consented
to the jurisdiction of the United States Magistrate Judge
pursuant to 28 U.S.C. § 636(c). For the reasons that
follow, Claimant’s motion for summary judgment  is
granted and the Commissioner’s motion is denied .
filed a Title 2 DIB application on April 7, 2011 alleging an
onset date of April 1, 2003 due to depression, chronic pain,
fatigue, Fibromyalgia (“FMS”), and loss of
cognition. (R. 271-82.) The application was denied initially
on June 8, 2011 and upon reconsideration on October 18, 2011.
(R. 128-29.) After both denials, Claimant filed a hearing
request on December 9, 2011 pursuant to 20 C.F.R. §
404.929 et seq. which was scheduled on January 14,
2013 before an Administrative Law Judge (“ALJ”).
(R. 43-67, 149-50.) Claimant did not offer testimony at that
hearing and another hearing was scheduled on June 5, 2013.
(R. 68-127.) Claimant appeared for her hearing along with her
representative. (R. 43-127.) A Vocational Expert
(“VE”), Medical Expert (“ME”), and
Psychological Expert (“PE”) were also present to
offer her testimony. (Id.) On June 28, 2013, the ALJ
issued a written determination finding Claimant not disabled
and denying her DIB application. (R. 15-36.) Claimant sought
review by the Appeals Council (“AC”), which was
granted. On November 25, 2014, and after a review of the
record, the AC issued a written decision upholding the
ALJ’s findings. (R. 4-6.) The AC adopted the
ALJ’s findings at every step of the sequential
evaluation. (R. 5.)
record contains medical evidence from West Suburban Hospital
Medical Center that date back to May 9, 1995. (R. 1137.) She
complained of pain in her lower back and legs. (Id.)
The attending physician, Dr. Max Harris, opined that Claimant
suffered from FMS. (Id.) Claimant next visited Dr.
Harris on March 13, 1997 due to continuing pain in her
shoulder and right arm. (R. 1143.) A physical examination
returned mostly normal results, as she had normal range of
motion, flexion, and extension in her arm and shoulders.
(Id.) Claimant continued to visit Dr. Harris through
October 6, 2003. (R. 397.) Throughout his treatment of
Claimant, Dr. Harris continued to diagnose Claimant with FMS.
continued to have pain and flare-ups and began acupuncture
therapy with Dr. Jeffrey Oken as early as 2001. (R. 1167.)
Records indicate that Claimant first visited the Marianjoy
Medical Group (“Marianjoy”) on July 26, 2002 due
to radiating pain in her left arm. (R. 353.) Claimant was
treated mainly by Dr. Oken. (Id.) A physical
examination indicated that she had limited abduction in the
left shoulder. (Id.) Her grip strength on the left
side was at 20 pounds and 60 pounds on the right side.
(Id.) She was advised to continue her prescribed
medication regimen, which included Flexeril and Vicodin.
of her left shoulder taken on July 22, 2002 indicated small
joint effusion. (R. 491.) An MRI of her cervical spine on
August 2, 2002 found no significant abnormalities in her
spine. (R. 490.) On September 10, 2002, Claimant reported a
decreased range of motion in her left shoulder. (R. 593.) She
was prescribed an aggressive anti-inflammatory therapy for
the shoulder. (Id.) On April 24, 2003, Claimant
reported feeling “considerably better.” (R. 399.)
August 27, 2002, Claimant visited the Hinsdale Orthopaedic
Associates (“Hinsdale”) at the referral of Dr.
Oken for treatment of her progressive shoulder pain. (R.
370.) She was given an injection in her shoulder and a brace
for Carpal Tunnel Syndrome. (Id.) She was also
prescribed Vicodin to ease her pain. (Id.) She began
physical therapy on September 5, 2002. (R. 372.)
Claimant’s progress during physical therapy fluctuated
as she reported improvements on some days and increased pain
in others. (R. 372-388.) During her later visits in October
2003, Claimant continued to report burning and tightening of
her shoulders and arm pains. (R. 387.) Her supervised
physical therapy ended on October 15, 2003, and she was to
begin a home exercise program. (R. 387-88.)
visited Marianjoy again on February 20, 2003. (R. 351.) She
indicated that her pain worsened in the previous weeks.
(Id.) She was diagnosed with FMS and “frozen
shoulder.” (R. 352.) On March 27, 2003, Claimant
returned to Marianjoy and underwent a medical acupuncture
procedure on her cervical spine. (R. 350.) It was noted that
she tolerated the procedure well and she was advised to
return to continue the procedure. (Id.) On April 30,
2003, Claimant had an EMG performed at Marianjoy. (R. 348.)
After a review of the EMG, Dr. Oken opined that Claimant had
radicular pain syndrome, “not manifesting on EMG, but
causing her significant pain, ” and suggested that she
continue physical therapy. (R. 349.)
first visited the Chiropractic Healing Center
(“CHC”) on July 7, 2005 to seek treatment for her
spine. (R. 852.) The treating physician noted that she had
decreased cervical spine rotation and suggested that she
return for chiropractic therapy. (Id.) Claimant
received near weekly therapy sessions at CHC through May 5,
2011. (R. 1021.) Treatment notes from CHC indicate that
Claimant’s progress fluctuated and there were certain
days where her pain was much more severe than other days. (R.
872, 885, 900, 965.) She would also present with new issues
on occasion, such as new pain in her neck and thighs. (R.
913, 946.) Generally, the treating practitioner considered
her prognosis to be “good.” (R. 873, 913, 1008.)
records show that Claimant was treated by Dr. Yolanda Co
since 2003 for FMS and depression. (R. 459.) The treatment
notes indicate that she provided Claimant with routine
checkups and examinations and regularly prescribed Vicodin.
April 25, 2009, Claimant has seen Dr. Keri Topouzian, who
specializes in thyroid disorders. (R. 547.) During her April
25, 2009 visit, Dr. Topouzian noted that Claimant complained
of FMS, chronic fatigue, and “brain fog.”
(Id.) Dr. Topouzian noted that Claimant suffered
from a hormone imbalance and suggested additional diagnostic
tests. (R. 566.) Claimant continued to visit Dr. Topouzian
through April 8, 2011. (R. 620-21.) Much like the findings at
CHC, Claimant’s progress fluctuated greatly. On May 20,
2009, she was diagnosed not only with FMS but with Lyme
Disease. (R. 564.) Claimant continued to visit Dr. Topouzian
for help in treating her FMS, fatigue, and Hashimoto’s
disease, a form of thyroiditis. (R. 554, 550, 552.) Claimant
continued to see Dr. Topouzian for her various conditions
including bloating, leg pain, and sinus infections. (R. 535,
648.) On January 21, 2010, Claimant reported feeling
depressed and suffering from crying spells lasting five days.
(R. 529.) Dr. Topouzian diagnosed her with seasonal affective
disorder and depression. (Id.)
March 3, 2010, Dr. Gail Rosseau of the Northshore University
Medical Group (“Northshore”) conducted a
neurological evaluation due to Claimant’s complaints of
head pain. (R. 691.) He reviewed an MRI of Claimant’s
brain and found that she had a frontal tumor that she
believed was meningioma, a non-cancerous tumor.
(Id.) An April 23, 2011 neurological evaluation
yielded no change in Claimant’s chronic mild headaches.
(R. 689.) Dr. Rosseau noted that Claimant had good power in
all extremities, a normal gait, and normal balance.
11, 2012, Claimant returned to Marianjoy and underwent a
physical evaluation. (R. 1044.) After the evaluation,
Claimant was found to have mobility dysfunction secondary to
FMS, depression, chronic pain syndrome, and myofascial pain
syndrome. (R. 1048.) On June 25, 2012, she entered into a
comprehensive pain program at Marianjoy, which included
treatment in the form of physical therapy, psychology,
biofeedback and education. (R. 1093-94.) Her progress
throughout the program fluctuated, as did her symptoms. On
June 29, 2012, she reported feeling increased morning pain
and was almost unable to return to therapy. (R. 1062.) On
July 16, 2012, she reported feeling much better but that her
pain level is at an eight out of ten. (R. 1077.) On July 25,
2012, Claimant stated that she had increased pain in her
upper back region and increased neck tightness. (R. 1088.)
She was given trigger point injections to treat her
myofascial pain syndrome. (R. 1090.) On August 1, 2012, she
was discharged from pain management therapy. (R. 1100.) She
was prescribed pain medication and advised to do aqua-therapy
two times a week for eight weeks. (Id.)
January 4, 2013, Melanie Weller, a clinical counselor, wrote
a statement regarding her treatment of Claimant’s
mental impairments. (R. 1122-1123.) Ms. Weller indicated that
she had been treating Claimant since March 24, 2011 for her
depression and anxiety, both of which she opined were related
to her FMS. (R. 1122.) She further indicated that Claimant
was able to detox off of her pain medication. (Id.)
However, Ms. Weller opined that Claimant’s pain could
still be chronic at times and less so at other times.
(Id.) She further stated that “her
intermittent sleep/pain problems leave her unable to function
well during mornings and sometimes whole days.”
(Id.) Ms. Weller stated that Claimant’s
depression was in part due to her inability to return to a
normal life because of her pain. (Id.) As a result,
Ms. Weller noted that she “d[oes] not see how
[Claimant] can hold a job with any regularity.”
was present at both the January 14, 2013 and June 5, 2013
hearing, but only offered testimony on June 5, 2013. (R.
95-127.) She testified that from the relevant disability
period between 2003 through 2005, she did not work. (R.
95-96.) Claimant further testified that she had been treated
for depressive episodes in the 1980’s and sought
treatment from 35 to 50 doctors while working. (R. 96.) She
returned to school during the spring of 2004 and saw both Dr.
Harris, her rheumatologist, and Dr. Cullany, a treating
physician. (R. 100, 103.) Claimant explained that she visited
Dr. Harris once to twice a year, and he would refer her to
Dr. Cullany, who treated her for her FMS. (Id.) Dr.
Cullany prescribed Lexapro for her depression but she
testified that she felt “terrible” while taking
it. (R. 101.) Claimant further testified that Dr. Cullany