United States District Court, C.D. Illinois, Springfield Division
EVA M. GRABILL, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE:
Eva M. Grabill appeals from the Defendant Commissioner of
Social Security's final decision on her application for
Social Security Disability Insurance Benefits (DIB) under
Title II of the Social Security Act and Supplemental Security
Income Disability Benefits (SSI) under Title XVI of the
Social Security Act. 42 U.S.C. §§ 416(i), 423,
1381a, and 1382c (collectively Disability Benefits). This
appeal is brought pursuant to 42 U.S.C. §§ 405(g)
and 1383(c). Grabill has filed a Brief in Support of Motion
for Summary Judgment (d/e 12), and Defendant Commissioner has
filed a Motion for Summary Affirmance (d/e 15). The parties
consented, pursuant to 28 U.S.C. § 636(c), to proceed
before this Court. Consent to the Exercise of
Jurisdiction by a United States Magistrate and Reference
Order entered May 4, 2016 (d/e 8). For the
reasons set forth below, this Court recommends that the
decision of the Commissioner be AFFIRMED.
was born on September 15, 1959. She secured her GED in 1993.
Grabill previously worked as a secretarial assistant and a
telemarketer. She last worked on January 15, 2012. Grabill
suffers from degenerative disc disease, facet arthritis,
status post cervical spinal surgery, bilateral chronic venous
insufficiency the lower extremities, chronic obstructive
pulmonary disease (COPD), and obesity. Grabill last met the
requirements for insured status for DIB on December 31, 2013
(Date Last Insured). Certified Transcript of Proceedings
before the Social Security Administration (d/e 10) (R.),
at 14, 36, 37, 170, 193. A claimant will be entitled to DIB
only if she was disabled before her Date Last Insured. 42
U.S.C. §§ 423(a)(1)(A), (c)(1); 20 C.F.R. §
404.131; Briscoe ex rel. Taylor v. Barnhart, 425
F.3d 345, 348 (7th Cir. 2005); Stevenson v.
Chater, 105 F.3d 1151, 1154 (7th Cir.1997).
February 17, 2012, Grabill saw Dr. Taylor Moore, O.D., for
lower back pain. Grabill weighed 193 pounds and had a Body
Mass. Index (BMI) of 36.91. On examination, Grabill had
bilateral SI joint tenderness, and negative straight-leg
testing. The remainder of her examination was normal. Dr.
Moore stated that Grabill could not take NSAID pain relievers
because of a previous nephrectomy. Dr. Moore prescribed
Tramadol. R. 371-72.
March 1, 2012, Grabill saw Dr. Moore again for lower back
pain. Grabill reported that she has had chronic back pain for
five years. She reported that the pain had gradually gotten
worse. According to Grabill, the pain was moderate to severe
and worse when walking long distances. She said the pain
occasionally radiated to her legs bilaterally. Dr.
Moore's examination of Grabill was normal. Dr. Moore
ordered x-rays and prescribed muscle relaxants and NSAIDs. R.
March 2, 2012, x-rays of Grabill showed degenerative disc
disease of the lumbar spine. R. 358. On March 16, 2012,
x-rays of Grabill showed degenerative disc disease of the
cervical spine. R. 359.
March 16, 2012, Grabill saw Dr. Moore. Grabill reported
trouble sleeping due to back pain. At this time, Grabill was
5 feet 1.25 inches tall and weighed 191 pounds, for a BMI of
35.6. She reported that cyclobenzaprine improved her sleep.
Dr. Moore reviewed the x-rays and recommended physical
therapy. R. 365-66. Grabill underwent four weeks of physical
therapy, three sessions per week. R. 393-420.
13, 2012, Grabill saw Dr. Moore. Dr. Moore noted a positive
Hoffmann's sign on the left upper
extremity. Dr. Moore assessed cervical radiculopathy
and neck pain. R. 360.
28, 2012, Grabill completed a Function Report-Adult form. R.
212-19. Grabill stated that she could not stand for long
periods of time and could not lift more than five pounds
without severe pain and losing feeling in her hands. She
stated that when she woke up, she took her medications and
performed exercises learned from physical therapy. She lived
with her family. She reported that she prepared the food for
the family, but later stated that friends helped her with
cooking and cleaning. She said she could not sleep because of
the pain. She took care of herself, but had trouble dressing
and getting in and out of the bath tub. She indicated she had
to sit down from time to time while she cooked. She washed
dishes, but had to sit down while washing them. She did not
do any yardwork because such activities caused pain in her
back and neck. She went shopping once a month for food and
household needs. She sewed, but was unable to sew every day
like she did in the past. She spent time daily with friends
and attended church regularly. She said she could walk one
block before she had to rest for five to ten minutes. R.
August 27, 2012, state agency physician Dr. C.A. Gotway,
M.D., completed a Residual Functional Capacity Assessment of
Grabill. Dr. Gotway opined that Grabill could lift 20 pounds
occasionally and 10 pounds frequently, stand and/or walk six
hours in an eight-hour workday, and sit six hours in an
eight-hour workday; and should avoid concentrated exposure to
extreme heat, cold, humidity, fumes, odors, dusts, gases, and
poor ventilation. Dr. Gotway opined that Grabill had no other
physical limitations on her functional capacity. R. 67-69,
September 17, 2012, Grabill saw Dr. Moore. Dr. Moore noted
that Grabill's neck pain was better, but she had
worsening intermittent paresthesias of the upper extremities. On
examination, Grabill's motor exam was normal and her
pulmonary exam was normal. R. 424.
November 6, 2012, Grabill underwent an anterior cervical
discectomy and fusion with allograft. On November 16, 2012,
Grabill saw Dr. Moore. Grabill reported some neck pain and
severe muscle spasms after the surgery. Grabill reported that
the paresthesias improved after the surgery. Grabill had an
apneic episode under anesthesia. Grabill also reported
chronic fatigue. Dr. Moore ordered a sleep study. R. 421. The
sleep study showed COPD and sleep apnea. R. 433.
December 1, 2012, Grabill completed another Function
Report-Adult form. R. 243-53. She lived with her family. She
said others helped her with housework and cooking. She
reported that she took more time to care for herself and
dress herself. She said she helped prepare some meals, but
could not prepare all meals by herself. She stated that she
did “light household work” but the work took
“all day” because she had to rest often. She
shopped for food once a month. She said she could not draw or
sew anymore because her hands “would lock up.”
She reported that she spent time with others daily and went
to church weekly. She opined that she could lift no more than
five pounds, walk a block before she needed to rest for ten
minutes. R. 243-48.
December 21, 2012, Grabill underwent a pulmonary function
test. Grabill had an FEV1 of 1.44 liters, 60% of predicted;
FVC of 2.06 liters, 72% of predicted. Bronchodilator therapy
showed significant improvement. Grabill's FEV1 improved
to 1.58 liters and her FVC improved to 2.43 liters. The test
showed moderate obstruction with significant change
post-bronchodilator therapy. R. 460.
January 3, 2013, x-rays showed stable, satisfactory alignment
and appearance of Grabill's surgical fusion of C4-5 and
C5-6. R. 461. Grabill underwent another course of physical
therapy. R. 439-56.
January 22, 2013, state agency physician Dr. Richard Smith,
M.D., completed a Physical Residual Functional Capacity
Assessment of Grabill. Dr. Smith agreed with Dr. Gotway's
opinions in his August 2012 assessment. R. 92-93, 101-02.
March 12, 2013, Grabill saw Dr. Moore. Grabill complained of
continuing neck pain and, in addition, lower extremity pain.
Grabill reported that she had begun having headaches. She
reported that the therapy helped her. On examination, Grabill
had increased swelling and redness in her lower extremities,
but she could ambulate without assistive devices and she
could fully bear her weight on both legs. Grabill's motor
and pulmonary examinations were normal. Dr. Moore continued
Grabill's medications and recommended continuing to
perform the exercises from physical therapy. R. 435.
April 12, 2013, Grabill saw Dr. Moore. Grabill reported left
ankle pain and cramps in her lower extremities at night.
Grabill had been wearing compression stockings. The stockings
improved the swelling in her legs. At this visit, Grabill
weight 232 pounds 4 ounces and had a BMI of 43.29.
Grabill's pulmonary examination was normal. R. 499-500.
An ex-ray of the ankle showed soft tissue swelling, but was
otherwise negative. R. 466. Dr. Moore told Grabill to
continue wearing compression stockings. R. 499.
30, 2013, Grabill saw Dr. Moore for headaches. Grabill
reported that she had been having headaches since the neck
surgery. Grabill reported, “The headaches were
debilitating, and pretty much every morning.” R. 496.
Dr. Moore prescribed nortriptyline and strongly advised
Grabill to increase her activity, decrease caffeine intake
and avoid MSG. Dr. Moore also told Grabill to stop taking
ibuprofen due to stomach upset. R. 496.
August 26, 2013, Grabill saw Dr. Anne Degreve, D.O.,
complaining of numbness and tingling in her arms bilaterally
when she leaned on her elbows. She did not have any loss of
grip strength and the numbness did not awaken her at night.
She had intact sensation to light touch and pinprick. Her
pulmonary examination was normal. Dr. Degreve recommended
consultation with an orthopedic surgeon. R. 492.
October 17, 2013, physiatrist Dr. Maria Espejo, M.D.,
examined Grabill and performed a nerve conduction/EMG study
on her upper extremities. On examination, Grabill could
ambulate within normal limits, she had normal muscle bulk and
tone in her upper extremities, normal sensory and reflex
tests in the upper extremities, and negative Hoffmann's,
Spurling's, and Phalen's tests
bilaterally. The nerve conduction/EMG study showed
results were normal. R. 464-65.
November 22, 2013, Grabill saw Dr. Degreve for chronic back
pain. Grabill reported that the pain started at her neck
surgery incision and radiated down her back. Grabill reported
that the pain made her eyes water. She said that she had
tried muscle relaxers, amitriptyline, flexeril, NSAIDs, and
Tylenol, and nothing helped. Grabill reported that the pain
limited her daily activity. Grabill had no weakness no
decreased range of motion, and no decreased sensation.
Grabill also could ambulate. R. 490. On examination, Dr.
Degreve found full range of motion in all extremities, intact
sensation, and negative straight leg testing. Dr. Degreve
noted, “Pain out of proportion of exam. Multiple tender
points bilat.” R. 491. Dr. Degreve changed
Grabill's medication to Lyrica and prescribed additional
physical therapy. R. 490.
February 3, 2014, Grabill saw Dr. Degreve for back pain.
Grabill was having problems getting her insurance to approve
the prescription for Lyrica. Dr. Degreve prescribed
gabapentin, and told Grabill to increase her activities of
daily living as she was able. R. 487. On examination, Grabill
had a normal gait and did not use assistive devices to
ambulate. Grabill's sensory exam and motor examination
March 19, 2014, Grabill saw Dr. Degreve complaining of low
back pain when walking, and also swelling feet. The back pain
was worse after walking and first thing in the morning.
Grabill reported that her strength was fine. On examination,
Dr. Degreve ordered x-rays of Grabill's lumbar spine. R.
483. The x-rays showed minimal ...