Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_05-cv-03689/USCOURTS-cand-3_05-cv-03689-1/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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United States District Court

For the Northern District of California

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UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

TERRY L. GAMBLE,

Plaintiff,

v.

JO ANNE B. BARNHART,

Defendant.

_____________________________/

No. C-05-3689 JCS

ORDER GRANTING IN PART AND DENYING IN

PART PLAINTIFF’S MOTION FOR SUMMARY

JUDGMENT AND/OR REMAND AND

GRANTING IN PART AND DENYING IN PART

DEFENDANT’S CROSS-MOTION FOR

SUMMARY JUDGMENT AND IN OPPOSITION

TO PLAINTIFF’S MOTION FOR SUMMARY

JUDGMENT [Docket Nos. 13, 16]

I. INTRODUCTION

Plaintiff, Terry L. Gamble, filed a complaint on September 13, 2005, seeking review of the

final decision of the Commissioner of Social Security (“Commissioner”) denying his application for

disability benefits under Title II of the Social Security Act. Plaintiff asks the Court to reverse the

Commissioner’s decision and award benefits, or in the alternative, for an order remanding the matter

for further administrative proceedings. 

Plaintiff applied for disability benefits on December 27, 2002, alleging an onset date of

January 2, 2002. The application was denied initially and on reconsideration. Plaintiff made a

timely request for a hearing, which was held on September 15, 2004, before an Administrative Law

Judge (“ALJ”) in Oakland, California. At the hearing, testimony was taken from Plaintiff and the

Plaintiff’s father-in-law, Mr. Michael Henry. Gerald D. Belchick, Ph.D., testified as a vocational

expert. Plaintiff was represented by counsel at the hearing. On December 16, 2004, the ALJ issued

a decision finding Plaintiff was not disabled as defined in the Social Security Act, and denying his

request for benefits. This decision became final when the Appeals Council declined to review the

ALJ’s decision on July 11, 2005. 

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Plaintiff filed a Motion for Summary Judgment on March 15, 2006, and the Commissioner

filed a Cross-Motion for Summary Judgment on April 17, 2006. Plaintiff filed his Reply brief on

May 4, 2006. The parties have consented to the jurisdiction of the undersigned magistrate judge

pursuant to 28 U.S.C. § 636(c). 

II. BACKGROUND

A. Plaintiff’s Background

Plaintiff was 38 years old as of the alleged onset date of his disability, January 2, 2002.

Administrative Record (“AR”) at 44 (date of birth June 2, 1963), 72 (onset of disability January 2,

2002). He completed high school and attended junior college for three years. AR at 88, 397. From

June 1981 until January 2002, Plaintiff worked as a lather in the construction industry. AR at 94-95. 

Plaintiff also spent two days a month working as a firefighter in the U.S. Army Reserves from

February 1988 through February 1994. AR at 94, 96. In addition, he worked as a door-to-door

salesman selling Kirby vacuum cleaners between January 1991 and July 1994. Id. 

B. Plaintiff’s First Injury

On September 4, 2001, while working as a lather, Plaintiff crossed a scaffolding with his

hard hat on and struck his head against a cross bar, jamming his neck. AR at 150. He took one day

off and then returned to work. Id. As a result of the injury, Plaintiff suffered from “fairly severe”

neck stiffness and experienced pain radiating throughout his right arm and shoulder. Id. On

September 14, 2001, Plaintiff sought treatment from Robert C. Dees, D.C., a chiropractor. AR at

257. Dr. Dees diagnosed Plaintiff’s injury as brachial neuritis/radiculitis and a cervical sprain/strain

and recommended chiropractic therapy and shoulder strengthening exercises. AR at 257. On

December 5, 2001, Plaintiff consulted with Desmond Erasmus, M.D., a neurosurgeon, for treatment

of his injury. AR at 150. Because Plaintiff was still experiencing intense pain, Dr. Erasmus

concluded that Plaintiff’s chiropractic treatment had not been successful. AR at 151. He

recommended an MRI to determine whether Plaintiff had a cervical disc herniation and suggested, in

the alternative, that Plaintiff might have cervical radiculitis. Id. 

On December 8, 2001, Charles Fiske, M.D., performed an MRI on Plaintiff’s cervical spine.

AR at 147. In his report, Dr. Fiske concluded that Plaintiff’s C2-3, C3-4, C4-5 and C6-7 discs were

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normal. Id. However, Dr. Fiske found that Plaintiff’s C5-6 disc was narrowed and degenerative and

that there was endplate spurring with annular bulging. Id. Dr. Fiske concluded that Plaintiff

suffered from C5-6 spondylosis with right neural foraminal stenosis, but he found no evidence of

disc herniation. Id.

Still suffering from right neck, arm, and shoulder pain, Plaintiff stopped work completely on

January 2, 2002. AR at 150, 146. On that date, Dr. Erasmus diagnosed Plaintiff with cervical disc

protrusion/spondylosis and cervical radiculitis. AR at 146. Dr. Erasmus advised Plaintiff of the

benefits and risks of surgical intervention, and Plaintiff opted to stay on a nonsurgical treatment

plan. AR at 138. During a subsequent visit to Dr. Erasmus, on March 6, 2002, Plaintiff stated that

he continued to experience pain in his cervical area with radiation into the right upper arm and

shoulder, as well as numbness in his right hand. AR at 139. Plaintiff and Dr. Erasmus discussed the

possibility of minimally invasive cervical surgery, and Dr. Erasmus recommended that Plaintiff

consult with Stanton Schiffer, M.D., a neurosurgeon locally “renowned” for the practice of

minimally invasive surgery on the cervical and lumbar spine. Id. In a March 29, 2002 report, Dr.

Erasmus described Plaintiff’s diagnosis as a cervical disc herniation at C5-6 on the right side. AR at

138.

From January 2, 2002 through July 30, 2002, Plaintiff primarily consulted with Dr. Erasmus,

Dr. Dees, and Dr. Schiffer. AR at 138, 214. During this period, Plaintiff reported that his pain

lessened while at rest, but he still experienced constant and severe pain in his neck and arms when

active. AR at 222. He saw Dr. Erasmus every forty-five days, and visited Dr. Dees for chiropractic

treatment three times a week starting on January 2, 2002. AR at 138, 221. On May 3, 2002, Dr.

Dees stated that Plaintiff “should not be allowed to return to his previous capacity at work” because

the nature of his job as a lather would aggravate Plaintiff’s condition. AR at 243. 

Dr. Schiffer performed cervical surgery on Plaintiff on July 30, 2002. AR at 211-12. After

the surgery, Plaintiff underwent physical therapy three times a week. AR 179. On November 26,

2002, a report from his physical therapist to Dr. Schiffer states as follows:

Terry Gamble has continued in physical therapy doing a strengthening

program. He has supplemented this with a regular home program and

has shown excellent strength gains within your weight lifting

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limitations. He is not having any pain and demonstrates good strength

with all muscle groups though he does have mild [right] arm strength

difference.

AR at 168. In a December 2, 2002 report, Dr. Schiffer stated that he had seen Plaintiff that day and

that he “was doing great” other than slight residual hoarseness. AR at 201. On the same day, Dr.

Schiffer referred Plaintiff for a work conditioning program, to occur three times a week for six

weeks. AR at 203. At the hearing before the ALJ, Plaintiff testified that the work conditioning

program “simulated” what he did in his job as a lather, which is a “very heavy lifting physical job.” 

AR at 402. This program began with minor weight lifting and bicycle riding, and progressed to

heavier weight lifting and lifting heavy objects onto different levels of platforms. AR at 403.

Plaintiff used machines to work his arm and shoulder. Id. After each session, Plaintiff went home,

applied ice to stiff muscles and lay down. AR at 404. Between sessions, he was very sore and took

over-the-counter Motrin to reduce swelling. Id.

On January 6, 2003, Plaintiff complained to Dr. Schiffer that he was still experiencing

occasional neck pain and headaches with overexertion, and Dr. Schiffer prescribed physical therapy

with heat and light massage as needed. AR at 199. At this time, Dr. Schiffer projected that Plaintiff

would return to work on January 20, 2003. Id. 

On January 22, 2003, Plaintiff returned to full-time work as a lather. AR at 235-36.

Plaintiff’s job required him to lift 50-pound rolls of wire ten times a day and 100-pound bundles one

to three times a day. AR at 197. Plaintiff still complained of intermittent pain in his right shoulder

and neck which was aggravated in part by his work. AR at 197, 232. Plaintiff also testified that he

suffered from headaches and found his work “very demanding . . . and very painful.” AR at 405-06. 

In a medical source statement dated February 27, 2003, Dr. Schiffer described Plaintiff’s

prognosis as “good,” and stated that Plaintiff could frequently climb, balance, stoop, kneel, and

crouch; that he could crawl occasionally; that his abilities as to handling, fingering, feeling, seeing,

hearing, and speaking were unlimited; and that his ability to reach was limited on both the right and

left sides. AR at 194. Dr. Schiffer also stated that Plaintiff could sit, stand, and/or walk with normal

breaks for about six hours in an eight hour work day. AR at 193. 

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C. Plaintiff’s Second Injury

On August 5, 2003, Plaintiff fell while at work and dislocated his left shoulder. AR at 291. 

As a result of this injury, Plaintiff stopped working; and there is no evidence in the record that

Plaintiff has worked since this injury. A September 2, 2003 MRI scan showed partial thickness

fraying in the supraspinatus tendon with no evidence of a full tear, as well as a “fairly large” cyst in

the spinoglenoid notch. AR at 355. Another MRI taken on November 14, 2003, revealed a “tiny left

paracentral disc protrustion” at C4-5. AR at 372. 

On September 3, 2003, John Turns, M.D., treated Plaintiff for his shoulder injury. Dr. Turns

diagnosed a rotator cuff injury and recommended an orthopaedic evaluation. AR at 359. Plaintiff

was seen by Dr. Dev K. Mishra, an orthopaedic surgeon, on September 12, 2003. AR at 354. 

Plaintiff reported to Dr. Mishra that he “continue[d] to have very significant neck cramping,

parascapular pain and muscle spasm.” AR at 354. Dr. Mishra noted that this pain was “somewhat

diffuse [in] nature and seem[ed] to be present at rest and accentuated somewhat by movement.” AR

at 354. In an effort to determine the source of this pain, Dr. Mishra “injected the left subacromial

bursa with 10 cc of 1% plain Xylocaine.” AR at 355. This injection did not alleviate Plaintiff’s

pain, leading Dr. Mishra to conclude that Plaintiff’s pain was due an “extra-articular source.” AR at

355. Dr. Mishra recommended that Plaintiff be considered “temporarily totally disabled until he

obtain[ed] an opinion from [Dr. Schiffer].” AR at 355.

In a December 1, 2003 report to Plaintiff’s Worker Compensation adjuster, Dr. Schiffer

reported Plaintiff complained that his “total neck stiffness [had] increased and he note[d] a headache

at the base of the posterior skull.” AR at 291. Dr. Schiffer stated that he had reviewed Plaintiff’s

November 14, 2003 MRI and diagnosed a left C4-5 herniated nucleus pulposus. AR at 291. Dr.

Schiffer recommended that Plaintiff undergo a one level cervical endoscopic discectomy to remove

the herniated disc material. AR at 292. In this report, Dr. Schiffer stated that “surgical intervention

is indicated” because Plaintiff had “not responded to conservative treatments” such as physical

therapy and chiropractic treatment. Id. 

Dr. Schiffer recommended this surgery again on March 22, 2004, when he noted that

Plaintiff was still complaining of neck stiffness and headaches. AR at 287. According to Dr.

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1 There is no official explanation for the denial in the record. However, notes by Dr. Schiffer

indicate the denial may have been based on the conclusion that the proposed surgery addressed medical

problems that did not result from Plaintiff’s second injury and, therefore, were not the responsibility of

his employer. See AR at 384.

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Schiffer, Plaintiff complained that all of his symptoms had become more severe since his last visit,

on December 1, 2003, and that his headaches were more frequent. AR at 287. 

A third letter from Dr. Schiffer to the Worker Compensation adjuster again requested

authorization for surgery, noting that Plaintiff continued to complain of “total neck stiffness that is

constant and severe and a headache at the base of the posterior skull that are very troublesome.” AR

at 284. However, authorization was apparently denied by Plaintiff’s Worker Compensation

adjuster.1 See AR at 284. 

Since his August 2003 injury, Plaintiff has undergone physical therapy and chiropractic

treatment several times a week. AR at 287, 336, 363-67. On July 22, 2004, Dr. Dees wrote that

Plaintiff reported increasing pain which was aggravated by many activities including lifting and

prolonged sitting. AR at 327. 

As a result of his second injury, Plaintiff also suffered from headaches. See AR at 284, 287,

308. In addition to the statements in Dr. Schiffer’s reports, quoted above, on April 30, 2004,

Plaintiff’s physical therapist stated that Plaintiff suffered from “almost daily headaches.” AR at 284,

308. Similarly, Plaintiff’s chiropractor reported that Plaintiff was suffering from headaches. AR at

339, 342.

D. The Hearing

Earl J. Waits, Administrative Law Judge, presided over Plaintiff’s hearing on September 14,

2004. Plaintiff, Plaintiff’s father-in-law, and a Vocational Expert (“VE”), Gerald D. Belchick,

Ph.D., testified at the hearing. Plaintiff described his injuries, surgery, and recovery. AR at 400-

410. He testified that he stopped work on January 2, 2002, because of the pain and numbness in his

right arm, and that before the July 2002 surgery he had to lie down “all the time” because of

headaches, and stiffness and numbness in his right arm. AR at 400-01. Plaintiff described his work

conditioning program, the headaches he experienced after his first injury, and his return to work in

January 2003. AR at 402-05. 

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He also testified about his second injury, elaborating upon the pain resulting from that injury,

such as stiffness, numbness, tingling and severe headaches. AR at 407-10. Plaintiff stated that after

his second injury the headaches made him feel he could not “do anything . . . hear anything” or “see

anything.” AR at 408. Plaintiff testified that at the time of the hearing, the headaches had 

“decreased quite a bit,” but still occurred “at least once a week,” and sometimes forced him to lie

down. Id. Plaintiff’s father-in-law, Michael Henry, also testified that there were “many, many”

times that Plaintiff had severe headaches. AR at 411. Plaintiff’s father-in-law estimated that these

headaches occurred three or four times a week. AR at 412. Mr. Henry stated that he saw his son-inlaw “just about every day.” AR at 411-12.

The VE, Dr. Belchick, testified about Plaintiff’s ability to work. AR at 413-20. The ALJ

asked Dr. Belchick to assume an individual whose ability to lift and carry was limited but who

could easily sit, stand and walk. Id. The VE testified that such an individual could not work as a

lather “at all,” but could work as a door-to-door salesman or as a Cashier II. AR at 415. The VE

estimated that there were numerous job openings as a cashier: 12,000 locally, and almost 200,000

nationally. Id. He stated that finding employment as a door-to-door salesman would be more

difficult, but “there would be some” jobs available. AR at 416. 

Plaintiff’s attorney then questioned the VE. AR at 416-20. Plaintiff’s attorney expanded

upon the ALJ’s hypothetical by adding the limitations of limited to occasional use of one arm and

“difficulty with sustained forward flexion.” AR at 416. The VE testified that if forward flexion was

limited to one to two hours a day, that “pretty well” eliminated every possible job. AR at 417. The

VE also stated that decreased use of one arm could “at times” affect Plaintiff’s ability to work as a

cashier. AR at 419. Additionally, Plaintiff’s attorney added the limitations of “sustained”

headaches and the need to lie down one to two hours a day to the hypothetical individual. AR at

419-20. The VE asserted such headaches could possibly affect that individual’s ability to work, and

that the need to lie down eliminated “all work.” AR at 420. 

E. The ALJ’s Five-Step Analysis and Findings of Fact

Disability insurance benefits are available under the Social Security Act when an eligible

claimant is unable “to engage in any substantial gainful activity by reason of any medically

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determinable physical or mental impairment . . . which has lasted or can be expected to last for a

continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A); see also 42 U.S.C.

§ 423(a)(1). A claimant is found disabled if his physical or mental impairments are of such severity

that he is not only unable to do his previous work but also “cannot, considering his age, education

and work experience, engage in any other kind of substantial gainful work which exists in the

national economy.” 42 U.S.C. § 423(d)(2)(A). The claimant bears the burden of proof in

establishing a disability. Gomez v. Chater, 74 F.3d 967, 980 (9th Cir.), cert. denied, 519 U.S. 881

(1996). 

The Commissioner has established a sequential five-part evaluation process to determine

whether a claimant is disabled under the Social Security Act. 20 C.F.R. § 404.1520(a). At Step

One, the Commissioner considers whether the claimant is engaged in “substantial gainful activity.”

20 C.F.R. § 404.1520(a)(4)(I). If he is, the Commissioner finds that the claimant is not disabled, and

the evaluation stops. If the claimant is not engaged in substantial gainful activity, the Commissioner

proceeds to Step Two and considers whether the claimant has “a severe medically determinable

physical or mental impairment,” or a combination of such impairments, which meets the duration

requirement in 20 C.F.R. § 404.1509. An impairment is severe if it “significantly limits [the

claimant’s] physical or mental ability to do basic work activities.” 20 C.F.R. § 1520(c). If the

claimant does not have a severe impairment, disability benefits are denied at this step. If it is

determined that the impairments are severe, the Commissioner will next perform Step Three of the

analysis, comparing the medical severity of the claimant’s impairments to a compiled listing of

impairments that the Commissioner has ratified as disabling. 20 C.F.R. § 494.1520(a)(4)(iii). If one

or a combination of the claimant’s impairments meet or equal a listed impairment, the claimant is

found to be disabled. Otherwise, the Commissioner proceeds to Step Four and considers whether

the claimant, in light of his impairments and residual functional capacity (“RFC”) can still perform

work he has performed in the past. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant can still perform

previous work, he is found not to be disabled. If the claimant cannot perform past relevant work, the

Commissioner performs the fifth and final step of the analysis. 20 C.F.R. § 404.1520(a)(4)(v). At

Step Five, the burden shifts to the Commissioner to show that the claimant, in light of his

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2 It is unclear what evidence the ALJ relied on in concluding that Plaintiff returned to work on

January 21, 2003. The record is inconsistent on this point, sometimes referring to Plaintiff’s return-towork date as January 23, 2003, see, e.g., AR at 105, 127, and sometimes referring to it as January 22,

2003, see AR at 235. In other places, Plaintiff’s doctors projected he would return to work on January

20, 2003. See, e.g., AR at 236. 

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impairments, age, education, and work experience, can adjust to other work in the national economy.

See Distasio v. Shalala, 47 F.3d 348, 349 (9th Cir. 1995). A claimant who is found able to make the

adjustment to other work is not considered disabled, and will not receive disability benefits. 20

C.F.R. § 404.1520(f). 

At Step One, the ALJ in this case found that Plaintiff had engaged in substantial gainful

activity from January 21, 2003 until August 6, 2003.2

 AR at 35. The ALJ found that Plaintiff had

not engaged in any substantial gainful activity between January 2, 2002, through January 20, 2003,

or from August 6, 2003, to the date of the ALJ’s decision, December 16, 2004. AR at 35, 41. 

At Step Two, he found that Plaintiff suffered from cervical spondylosis and C5-6 disc

protrusion, status-post C5-6 anterior cervical discectomy and recurrent disc protrusion at C4-5, and

left shoulder dislocation and a left rotator cuff injury. AR at 39. The ALJ concluded that Plaintiff’s

combination of impairments was “severe.” AR at 39. 

At Step Three, the ALJ found that Plaintiff’s impairments did not meet or equal any listed

impairment which is considered conclusively disabling. AR at 39.

At Step Four, the ALJ considered Plaintiff’s RFC. The ALJ found that within 12 months of

Plaintiff’s first injury, Plaintiff regained at least the ability to perform light work with no more than

minimal overhead reaching bilaterally and occasional crawling. AR at 40. Plaintiff would also need

to be able to alternate sitting and standing during the day to relieve pain and discomfort. AR at 40. 

The ALJ found that the Plaintiff had regained the same RFC within 12 months of his second injury. 

AR at 40.

The ALJ stated that he did not find Plaintiff’s “theory of disability” persuasive. AR at 39.

He thought it improbable that Plaintiff would transform “literally overnight” from being unable to

do even sedentary work to being able to perform the medium-exertion job of lather on a full-time

basis. Id. The ALJ concluded that the record pointed to a period of gradual improvement following

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 The ALJ is referring here, apparently, to the second injury. As the ALJ notes in his background

section, Plaintiff’s first injury resulted in “chronic neck pain, radiating to the right shoulder and down

the right arm; right arm numbness; and tingling in the fingers of the right hand.” AR at 37 (emphasis

added). 

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the July 2002 surgery. Id. At some point after this surgery, but within 12 months of the alleged

onset date, the ALJ determined that Plaintiff had improved sufficiently to return to a limited range of

light work activities. Id. He cited the evidence of substantial medical improvement set forth in Dr.

Schiffer’s progress notes and the physical therapy records as reasons to reject Plaintiff’s theory. Id.

The ALJ noted that he had “no reason” to reject Dr. Schiffer’s February 27, 2003 medical source

statement, which indicated that Plaintiff had regained the ability to perform light work activities, as

well as Dr. Schiffer’s description of Plaintiff’s prognosis for recovery as “good.” AR at 40. Further,

the ALJ believed that the existence of the [Worker Compensation] litigation had “much to do with

the prolongation of [Plaintiff’s] symptoms.” AR at 40.

The ALJ did not find the Plaintiff’s allegations regarding his limitations “credible,” and

found that these claims were not supported by the evidence of record. AR at 40. He did not credit

Plaintiff’s testimony regarding Plaintiff’s headaches because he claimed there were “no notations of

headaches in the treating records, except in the chiropractic notes.” AR at 39. The ALJ did not

expressly reject the testimony of Plaintiff’s father-in-law, but implicitly discredited it, stating that

Plaintiff’s father-in-law “confirmed that the claimant reports chronic headaches and complains that

he cannot raise his right arm above his head, although the injury was to his left arm.”3

 AR at 39

(emphasis added).

At Step Five, the ALJ, citing to the testimony of the VE, found that Plaintiff would be able to

do his past job as a door-to-door salesman, an unskilled light job. Id. The ALJ noted, however, that

the VE had testified there were few such jobs available in the national economy. Id. The ALJ

concluded, nonetheless, that Plaintiff could perform other work that was available based on the VE’s

testimony that a hypothetical person with Plaintiff’s vocational profile and RFC could do work as a

Cashier II and that many such jobs existed in the national and local economy. Id. 

Based on this testimony, the ALJ found that the Plaintiff was not disabled for the purposes of

Title II of the Social Security Act. AR at 41. 

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4 These are the terms used by the ALJ in his decision to refer to the period between the January

2, 2002 alleged onset date and Plaintiff’s return to work in January 2003 (the Closed Period of

Disability) and the period following Plaintiff’s second injury, on August 6, 2003 (the Open-Ended

Period of Disability).

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D. The Motions

The dispute in this case involves the ALJ’s determinations of Plaintiff’s RFC at Step Four

and his ultimate conclusion at Step Five that there is work available in the national economy that

Plaintiff can perform. Plaintiff cites a series of alleged errors on the part of the ALJ. 

First, he asserts that the ALJ mistakenly failed to consider Plaintiff’s necessary medical

treatment, in particular, Plaintiff’s demanding physical therapy schedule in the fall of 2002, when

determining the RFC, even though the ALJ is required by statute to take treatment into account

when analyzing RFC. See Social Security Ruling (“SSR”) 96-98p. 

Second, Plaintiff argues that the ALJ’s reliance on the February 2003 assessment by Dr.

Schiffer in support of his RFC was erroneous because that opinion bore no relationship to Plaintiff’s

RFC prior to returning to work, in January 2003 (“the Closed Period of Disability”), or subsequent

to the additional injury sustained by Plaintiff in August 2003 (“the Open-Ended Period of

Disability”).4

Third, Plaintiff asserts that the ALJ improperly failed to credit Plaintiff’s testimony regarding

his pain, including his testimony about his headaches. In this regard, Plaintiff argues that the

suggestion that the Worker Compensation litigation explained Plaintiff’s complaints is not sufficient

to satisfy the ALJ’s burden. Plaintiff also challenges as incorrect the ALJ’s assertion that there are

“no notations of complaints of headaches in the treating records, except in the chiropractic notes,”

citing to several references to headaches in Dr. Schiffer’s treating notes.

Fourth, Plaintiff argues that the ALJ improperly rejected the lay testimony of Plaintiff’s

father-in-law regarding Plaintiff’s pain and headaches.

Fifth, Plaintiff argues that the ALJ erred in concluding at Step Five that Plaintiff could

perform his past work as a door-to-door salesman given that the ALJ concluded Plaintiff could

perform only light work. Plaintiff points to evidence in the record that the vacuum cleaners he

formerly sold weighed 24 pounds, which exceeds the upper weight limit for light work. 

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The Commissioner argues that the ALJ determined the appropriate RFC by basing his

finding on the record as a whole. The Commissioner further contends that the ALJ properly

evaluated the Plaintiff’s credibility by providing clear and specific reasons for rejecting the

Plaintiff’s claims and Plaintiff’s father-in-law’s testimony. Finally, the Commissioner argues that

the ALJ properly found that Plaintiff could return to work, even if Plaintiff cannot work as a doorto-door salesman. 

III. ANALYSIS

A. Legal Standard 

When asked to review the Commissioner’s decision, the Court takes as conclusive any

findings of the Commissioner that are free from legal error and supported by “substantial evidence.”

42 U.S.C. § 405(g). Substantial evidence is “such evidence as a reasonable mind might accept as

adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial

evidence means “more than a mere scintilla,” id., but “less than a preponderance.” Desrosiers v.

Sec’y of Health and Human Servs., 846 F.2d 573, 576 (9th Cir. 1985). Even if the Commissioner’s

findings are supported by substantial evidence, they should be set aside if proper legal standards

were not applied when weighing the evidence and in reaching a decision. Benitez v. Califano, 573

F.2d 653, 655 (9th Cir. 1978). In reviewing the record, the Court must consider both the evidence

that supports and detracts from the Commissioner’s conclusion. Smolen v. Chater, 80 F.3d 1273,

1279 (9th Cir. 1996) (citing Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985)). 

B. The ALJ’s Consideration of Plaintiff’s Treatment

Plaintiff contends that the ALJ did not correctly follow its own rules requiring the ALJ to

take into account limitations imposed by treatment, including the demands of physical therapy, in

determining Plaintiff’s RFC. See Social Security Ruling (“SSR”) 96-98p. The Court disagrees.

SSR 96-8p states that, “[t]he RFC assessment must be based on all of the relevant evidence

in the case record, such as . . . [t]he effects of treatment, including limitations or restrictions imposed

by the mechanics of treatment.” Throughout his opinion, the ALJ explicitly refers to Plaintiff’s

various treatments, including physical therapy, visits to the doctor and chiropractic treatment. See

AR at 38-40. The ALJ directly questioned Plaintiff on the impact of his treatment and analyzed

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evidence of Plaintiff’s success in treatment when determining Plaintiff’s RFC. AR at 39. For

example, the ALJ directly cited to Plaintiff’s physical therapy records and Dr. Schiffer’s progress

notes when establishing Plaintiff’s RFC. AR at 39. The ALJ does not need to recite “magic words”

for his finding to be legitimate. Magellanes v. Bowen, 881 F.2d 747, 755 (9th Cir. 1989). The Court

can draw reasonable inferences from the ALJ’s opinion. Id. Here, the record shows that the ALJ

adequately considered Plaintiff’s treatment when determining Plaintiff’s RFC, as required by the

Commissioner’s regulations. 

C. The ALJ’s Reliance on Dr. Schiffer’s February 2003 Medical Source Statement

Plaintiff asserts that the ALJ erred in relying on Dr. Schiffer’s February 2003 assessment of

his ability to work because that opinion had little evidentiary of value for determining Plaintiff’s

RFC prior to his return to work, during the Closed Period of Disability, or subsequent to Plaintiff’s

second injury. The Court concludes that the ALJ’s reliance on Dr. Schiffer’s opinion was

reasonable as to the Closed Period of Disability but that the ALJ erred in relying on that opinion as

to the Open-Ended Period of Disability.

With respect to the Closed Period of Disability, the ALJ reasoned that Plaintiff experienced a

“period of gradual improvement” following his surgery in July 2002 such that he attained a limited

ability to perform light work sometime before January 2, 2003, that is, 12 months from the alleged

onset date of January 2, 2002. This conclusion is based on the fact that Plaintiff returned to a

medium exertion job just a few weeks later. The ALJ also cited to “Dr. Schiffer’s progress notes and

physical therapy records,” as well as the February 2003 assessment. As described above, the

progress notes and physical therapy records show that Plaintiff was recovering well during the fall of

2002 – well enough, in fact, to undergo a demanding work conditioning program in December 2002. 

While the discomfort experienced by Plaintiff as a result of this program indicates he was not yet

ready for the medium work he was preparing to return to, the ALJ could rationally conclude that

these records showed an ability to perform light work sometime before Plaintiff returned to work. 

The ALJ’s reliance, in part, on Dr. Schiffer’s February 2003 opinion also is not unreasonable, given

that Dr. Schiffer had last seen Plaintiff during the Closed Period of Disability, on January 6, 2003. 

See AR at 194. In addition, the ALJ adjusted the RFC to reflect more limited abilities than Dr.

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Schiffer had indicated in his February assessment, thus adequately taking into consideration the fact

that Dr. Schiffer completed that form after Plaintiff had returned to work. 

On the other hand, the ALJ erred in relying on Dr. Schiffer’s opinion with respect to

Plaintiff’s RFC for the Open-Ended Period of Disability, which the Court concludes is not supported

by substantial evidence. The ALJ concluded that Plaintiff’s RFC after his second injury was the

same as it was before that injury. The ALJ did not offer any additional reasoning beyond that

already offered in support of the RFC for the Closed Period of Disability. The ALJ did not explain

why this assessment continued to be applicable for the later period, given that Dr. Schiffer had

diagnosed Plaintiff with a new condition following the second injury and noted in numerous reports

that Plaintiff’s condition had worsened in a number of respects, including increased neck stiffness,

severe headaches, and “severe tenderness of the posterior left shoulder.” See AR at 291, 287 and

284. During this period, in fact, Dr. Schiffer was recommending additional surgery, based on his

review of an MRI done in November 2003 that Dr. Schiffer concluded reflected a “left C4-5

herniated nucleus pulposis with granulation tissue on the right at C5-6.” AR at 291. 

Because Dr. Schiffer was Plaintiff’s treating physician, as acknowledged by the ALJ, see AR

at 38, the ALJ could only reject his opinion if he made “findings setting forth specific, legitimate

reasons for doing so that are based on substantial evidence in the record.” Murray v. Heckler, 722

F.2d 499, 502 (9th Cir. 1983). Yet, as noted above, the ALJ provides no explanation for his implicit

rejection of Dr. Schiffer’s later opinions, expressed concurrent with the Open-Ended Period of

Disability, in favor the February 2003 assessment by Dr. Schiffer made prior to Plaintiff’s second

injury. The Court concludes that the ALJ erred in relying on Dr. Schiffer’s earlier opinions without

providing any explanation for his rejection of later opinions that appear to modify the earlier

assessment. As a result, the RFC for the Open-Ended Period of Disability is not supported by

substantial evidence.

D. Rejection of Plaintiff’s Pain Testimony

In developing a claimant’s RFC, the ALJ must consider limitations imposed by all of the

claimant’s impairments. SSR 96-8p. The ALJ must also consider “the impact of any related

symptoms, including pain,” when establishing the RFC. 20 C.F.R. § 404.1545; see also 20 C.F.R.

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 The ALJ appears to have been unaware of the numerous reports following Plaintiff’s second

injury regarding headaches, incorrectly stating that there were“no notations of headaches in the treating

records, except in the chiropractic notes.” AR at 39.

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§ 404.1529(c)(4) (addressing how pain is assessed in determining ability to work). If a plaintiff

produces medical evidence of underlying impairments consistent with his complaints and there is no

affirmative evidence that he is malingering, the ALJ’s reasons for rejecting the testimony must be

clear and convincing. Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1996) (citation omitted). Social

Security Regulations state that “the finding on credibility of an individual’s statements cannot be

based on an intangible or intuitive notion about an individual’s credibility,” but must be grounded

in the evidence and articulated in the ALJ’s decision. SSR 96-7p; see also Varney v. Secretary of

Health and Human Services, 846 F.2d 581, 584 (9th Cir. 1988), rev’d on other grounds upon reh’g,

859 F.2d 1396 (9th Cir. 1988).

Here, Plaintiff has medical evidence that he suffered from pain and headaches as a result of

his two injuries to his neck and back and the ALJ has pointed to no affirmative evidence of

malingering. Therefore, his pain testimony must be credited unless the ALJ has articulated clear and

convincing reasons for rejecting that testimony. As to the Closed Period of Disability, the Court

concludes the ALJ met this standard by citing to evidence that Plaintiff’s doctor and physical

therapist believed that Plaintiff was doing very well in the fall of 2002, that Plaintiff was able to

undergo a demanding work conditioning program in December of that year, and that he returned to

his medium-exertion work in January 2003.

In contrast, the ALJ has not provided clear and convincing reasons for rejecting Plaintiff’s

pain testimony for the Open-Ended Period of Disability. As to that period, the only reason offered

by the ALJ for rejecting Plaintiff’s testimony was the pending Worker Compensation claim. Yet

everyone who treated Plaintiff noted that Plaintiff was experiencing increased pain and headaches

following his second injury.5

 These reports were supported by MRI’s showing a condition that

Plaintiff’s treating physician believed was causing the pain and which required surgery. While

authorization for that surgery was denied, there is no evidence in the record that the denial was for

medical reasons. Rather, the limited evidence in the record indicates that the denial was for nonCase 3:05-cv-03689-JCS Document 18 Filed 09/15/06 Page 15 of 18
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medical reasons. Further, Plaintiff was receiving physical therapy and treatment from his

chiropractor on a frequent and regular basis throughout this period. In light of this evidence, the fact

that Plaintiff was seeking authorization for surgery recommended by his treating physician does not

constitute a clear and convincing reason for rejecting Plaintiff’s testimony. 

E. Rejection of Lay Testimony

Plaintiff asserts that the ALJ erred in rejecting the lay testimony of his father-in-law

regarding his pain. The Court agrees.

In the Ninth Circuit, it is established that an ALJ “need not discuss all evidence presented,”

but rather must explain only why “significant probative evidence has been rejected.” Vincent v.

Heckler, 739 F.2d 1393. In Vincent, the court affirmed the decision of the ALJ, even though he did

not discuss in his decision lay testimony about the claimant’s impairments, because the court found

that the ALJ’s findings were supported by medical evidence that contradicted the lay testimony. Id. 

In a subsequent decision, the Ninth Circuit explained that in Vincent, the ALJ was not required to

provide reasons for disregarding the lay testimony because the lay witness purported to make a

medical diagnosis – something lay witnesses are not competent to testify about – and, therefore, the

evidence was not “probative.” Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir. 1996). 

In contrast, lay witnesses are competent to testify about how a claimant’s symptoms affect

his ability to work. Id. For example, in Nguyen, the court held that the ALJ erred when he failed to

consider testimony by both the claimant and his wife that the claimant had a serious coughing

problem. Id. Consequently, the ALJ did not include in his hypothetical to the vocational expert a

limitation reflecting this symptom. Id. The court held that the ALJ could only reject the testimony

of the lay witness (the claimant’s wife) if he gave reasons that were “germane” to that witness. Id.

(citing Dodrill v. Shalala, 12 F.3d 915, 919 (9th Cir. 1993)). The court further held that because the

ALJ did not include the coughing limitation in the hypothetical to the vocational expert, the

conclusion that there was work available in the national economy that the claimant could perform

was not supported by substantial evidence. Id.

Here, as in Nguyen, Plaintiff offered probative lay testimony regarding the impact of

Plaintiff’s symptoms on his ability to work. In particular, he offered the testimony of his father-inCase 3:05-cv-03689-JCS Document 18 Filed 09/15/06 Page 16 of 18
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law, who sees Plaintiff on a daily basis, that Plaintiff has difficulty raising his right arm over his

head and that he frequently needs to lie down because of his headaches. The ALJ did not give any

reason for rejecting this testimony, although he noted elsewhere in the decision – incorrectly – that

there were no notations of headaches in the medical records other than those of the chiropractor. 

The ALJ did imply that he might not have believed the father-in-law’s testimony because that

testimony referred to Plaintiff’s right arm whereas Plaintiff’s second injury was to his left arm. See

AR 39 (stating that Plaintiff’s father-in-law “confirmed that the claimant reports chronic headaches

and complains that he cannot raise his right arm above his head, although the injury was to his left

arm”). To the extent this was the ALJ’s reason for rejecting this testimony, it is not supported by

substantial evidence, given that Plaintiff also had a long history of problems with his right arm

resulting from his first injury. Morever, even if this reason were adequate to reject the testimony

regarding Plaintiff’s ability to raise his right arm, it is not germane to the testimony concerning

Plaintiff’s headaches and his need to lie down. Therefore, the ALJ failed to meet the standard

articulated in Nguyen.

F. Determination at Step Five Regarding Available Work

Plaintiff asserts that the Commissioner’s conclusion at Step Five, that there was work

available that he could perform in the national economy, is not supported by substantial evidence

because: 1) the finding that Plaintiff could perform his past work as a door-to-door salesman is not

consistent with the evidence he presented showing the weight of the vacuum cleaners he used to sell

exceeds the weight limitation for light work; and 2) the ALJ failed to adequately consider Plaintiff’s

pain in his RFC, for the reasons stated above, and therefore, did not include all of Plaintiff’s

limitations in his hypotheticals to the VE. 

The Court rejects Plaintiff’s first argument because the ALJ’s conclusion at Step Five was

not based on Plaintiff’s ability to work as a door-to-door salesman. Rather, the ALJ expressly cited

the VE’s evidence that there were few such jobs in the national economy, stating that despite this

evidence, the Commissioner’s burden was met by evidence that Plaintiff could perform “other

work.” AR at 40. The ALJ went on to cite evidence that Plaintiff could work as a Cashier II and

that there were 12,000 such jobs in the local economy. AR at 40.

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With respect to Plaintiff’s RFC, the Court concludes, for the reasons stated above, that the

ALJ did not err as to the Closed Period of Disability and therefore, his determination at Step Five

was supported by substantial evidence. On the other hand, also for the reasons stated above, the

ALJ’s erred with respect to Plaintiff’s RFC for the Open-Ended Period of Disability by ignoring the

reports of Plaintiff’s treating physician without providing adequate explanation, discrediting

Plaintiff’s pain testimony, and failing to address lay testimony regarding Plaintiff’s pain. As a

result, the ALJ’s finding at Step Five is not supported by substantial evidence for this period.

IV. CONCLUSION

Based on its review of the pleadings and administrative record, a court may affirm, modify,

or reverse the decision of the Commissioner, with or without remanding the case for a rehearing. 42

U.S.C. § 405(g). Absent rare circumstances, the proper course is to remand to the Commissioner for

additional investigation or explanation. Benecke v. Barnhart, 379 F.3d 587, 595 (9th Cir. 2004). 

Accordingly, the Court affirms the decision of the ALJ as to the Closed Period of Disability,

reverses the decision of the ALJ as to the Open-Ended Period of Disability, and remands to the

Commissioner for further proceedings. 

On remand, the ALJ is instructed to reevaluate Plaintiff’s RFC for the Open-Ended Period of

Disability. In doing so, he should address the pain testimony of Plaintiff, the lay testimony of

Plaintiff’s father-in-law, and the opinions of Dr. Schiffer as they relate to Plaintiff’s limitations after

his second injury. Should he determine that Plaintiff’s RFC must be revised to include additional

limitations, he shall proceed to Step Five to reevaluate whether, in light of the revised RFC, Plaintiff

can perform any jobs that are available in significant number in the national economy. 

IT IS SO ORDERED.

Dated: September 15, 2006

___________________________ JOSEPH C. SPERO

United States Magistrate Judge

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