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Spraggins v. Berryhill

United States District Court, N.D. Illinois, Eastern Division

September 20, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.


          Sidney I. Schenkier, United States Magistrate Judge

         Plaintiff Alisa Spraggins seeks reversal and remand of the Commissioner's decision denying her applications for Social Security benefits (doc. # 20: Pl.'s Mot. for Summ. J.). The Commissioner has filed a cross-motion asking the Court to affirm its decision (doc. # 25: Def.'s Mot. for Summ. J.). For the reasons that follow, we grant Ms. Spraggins' motion to remand.


         Ms. Spraggins filed her applications for Social Security benefits in May 2011, alleging she became disabled on September 9, 2010 (R. 180-93). Her date last insured was December 31, 2015 (R. 652). On January 22, 2013, after a hearing, the administrative law judge ("ALJ") denied Ms. Spraggins' applications for benefits in a written decision (R. 16-35), and the Appeals Council denied her subsequent request for review (R. 1). Ms. Spraggins sought review in federal district court, and on May 20, 2015, the district court issued an opinion reversing and remanding the ALJ's decision (R. 813-39). The ALJ held another hearing on April 7, 2016, and on May 6, 2016, the ALJ issued another written opinion denying Ms. Spraggins' applications for benefits (R. 647-89). Ms. Spraggins did not file exceptions with the Appeals Council and the Appeals Council did not assume jurisdiction over the case, making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.984.


         On September 9, 2010, at age 41, Ms. Spraggins was injured while working as a forklift driver when a package fell and crushed the cab of the forklift she was operating, striking her head (R. 414). Ms. Spraggins is 5'3" tall, and her weight during the relevant time period (2010 to 2016) fluctuated from a low of 180 pounds to a high of 261 pounds (R. 703-04, 2114). Ms. Spraggins received non-surgical treatment from orthopedist Theodore Fisher, M.D., for pain in her neck and arms, but physical therapy, medication and steroid injections did not alleviate her pain (R. 366-75). On May 13, 2011, a physical therapist conducted a functional capacity evaluation ("FCE") of Ms. Spraggins and concluded that she could work for three to four hours a day, sit for four to five hours total for 60 minutes at a time, stand for one to two hours total for 15 minutes at a time, walk for a total of three to four hours for occasional, moderate distances, and occasionally (up to 1/3 of the work day) grasp with either hand (R. 463-64). In June 2011, Dr. Fisher completed a report noting Ms. Spraggins continued to complain of neck, back and upper extremity pain, and she had decreased sensation in her left hand and decreased range of motion in her cervical spine (R. 481). He opined that Ms. Spraggins did not require surgery, but that she was at maximum medical improvement with the restrictions outlined in the FCE (R. 477-80).

         Toward the end of 2011, Ms. Spraggins also developed low (lumbar) back pain (R. 574-75, 586-88, 611). In November 2012, a neurologist examined Ms. Spraggins and found limited movement of her neck and decreased reflexes in her upper and lower extremities due to pain (R. 643-45). Ms. Spraggins reported that her pain radiated from her neck down her spine and into her calves at a level of eight to ten out often (Id.). She also complained of numbness in both feet and tingling and weakness in her upper extremities (Id.). At a follow-up appointment in January 2013, Ms. Spraggins reported that physical therapy had made her lumbar and cervical pain worse, and she was getting throbbing headaches (R. 638-39). On examination, she continued to have decreased reflexes in her upper and lower extremities (R. 639-40).

         In February 2013, MRIs of Ms. Spraggins' lumbar and cervical spine showed moderate to severe broad-based disc bulge with flattening of the thecal sac (membrane surrounding the spinal cord) and mild to moderate bilateral neuroforaminal narrowing (of the spinal nerve passages) (R. 1588-89). On March 14, 2013, Sergio Mercado, M.D., completed a cervical spine medical source statement, opining that due to headaches and pain and limited movement in her neck, Ms. Spraggins could only sit or stand for a total of two hours a day, for 15 minutes at a time, and she was likely to be off-task 25 percent or more of the workday (R. 1818-22).

         Ms. Spraggins continued to have pain and tenderness in her lower back and neck throughout 2014, She made several visits to a pain clinic that year for various facet joint and epidural steroid injections as well as medial branch blocks; the injections provided some short-term relief, but the pain always returned (see, e.g., R. 1572-79, 1656-58, 1663). Ms. Spraggins was also prescribed multiple medications for her pain, including Tramadol (a narcotic), Elavil (for nerve pain), and gabapentin (for nerve pain) (R. 1972, 1968). MRIs of Ms. Spraggins' cervical, thoracic and lumbar spine in 2014 showed worsening degenerative changes, including disc protrusion in her lumbar and cervical spine and facet joint hypertrophy in the thoracic spine (R. 1560-63, 1752-53). Ms. Spraggins was also diagnosed with scoliosis (R. 1636).

         Cristina Brotea, M.D., was one of Ms. Spraggins' treating physicians (R. 674). On June 3, 2014, Dr. Brotea filled out a physical impairment questionnaire, in which she opined that due to degenerative joint disease and severe cervical and low back pain, Ms. Spraggins could sit, stand or walk for only one hour in an eight-hour workday, needed to lay down every 30 minutes for 45 to 60 minutes, and had marked limitations in her ability to bilaterally reach, handle, and finger (R. 1797-1800). Dr. Brotea noted that Ms. Spraggins' medications made her sleepy and dizzy, and Dr. Brotea wrote that "all days" were bad days for Ms. Spraggins (R. 1800).

         Ms. Spraggins continued to seek pain relief through injections and narcotic medications throughout 2014 (see, e.g., R. 1656-73). On June 19, 2014, Ms. Spraggins was examined by a neurosurgeon, who noted that she had "extreme difficulty moving her arms or legs at all" due to "extreme deconditioning and obesity" (R. 1795). In December 2014, her physician noted that she had increasing weakness, numbness and difficulty walking (see R. 1754-57).

         Despite continuing to receive pain injections and take narcotic and nerve pain medication, Ms. Spraggins' back and neck pain continued in 2015 (see, e.g., R. 1823-25, 1979-2010). Her physicians noted that Ms. Spraggins had reduced reflexes, and her pain was affecting her gait (Id.; see also R. 2104-08). Her cervical and lumbar ranges of motion were limited by pain in all directions, and she had spasms and tenderness in her cervical and lumbar spine and trapezius muscles (between lower thoracic spine and shoulder blades) (see R. 2109).

         In 2014 and 2015, Ms. Spraggins was also diagnosed and periodically treated for dyspnea (shortness of breath) (see, e.g., R. 1670) and obstructive sleep apnea (see, e.g., R. 1943). In September 2015, she was also diagnosed with premature ventricular contractions, or extra abnormal heartbeats (R. 1895).

         On August 20, 2015, Ms. Spraggins began receiving treatment from Sarvottam Bajaj, M.D. (R. 2028). On March 18, 2016, Dr. Bajaj filled out a functional capacity form opining that Ms, Spraggins had back, neck and shoulder pain that reduced by more than 50 percent her ability to sit, stand, walk, lift, carry and reach, but had no effect on her fine manipulation or ability to use a keyboard (R. 2028-29).


         The ALJ held a hearing on April 7, 2016. At that time, Ms. Spraggins' weight was 232 pounds, down from its peak of 286 pounds (R. 703-05). Ms. Spraggins testified that she took several medications for severe pain in her neck, back and shoulder. These made her dizzy and drowsy, and she took daily naps of two to three hours (R. 706-07). She also had chest pain, shortness of breath and sleep apnea that added to her dizziness and fatigue (R. 712, 714).

         Ms. Spraggins shopped for groceries with the assistance of her adult daughter and a motorized cart (R. 715). She sometimes washed dishes and cooked, but she could stand at the stove for only 10 to 15 minutes at a time, and she used a cane to move around her house (R. 716-18). Ms. Spraggins testified that she could not sit for more than about 15 minutes before her lower back began to hurt ...

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