United States District Court, N.D. Illinois, Eastern Division
ALISA A. SPRAGGINS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER 
I. Schenkier, United States Magistrate Judge
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.
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.
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).
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.
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).
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).
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.
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.
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).
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).
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).
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).
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 ...