Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_10-cv-00054/USCOURTS-almd-2_10-cv-00054-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF ALABAMA

NORTHERN DIVISION

JESSICA L. GILLILAND, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:10cv54-CSC

) (WO)

MICHAEL J. ASTRUE, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff applied for disability insurance benefits pursuant to Title II of the Social

Security Act, 42 U.S.C. §§ 401 et seq., and for supplemental security income benefits under

Title XVI of the Social Security Act, 42 U.S.C. §§ 1381 et seq., alleging that she was

unable to work because of a disability. Her application was denied at the initial

administrative level. The plaintiff then requested and received a hearing before an

Administrative Law Judge (“ALJ”). Following the hearing, the ALJ concluded that the

plaintiff was not under a “disability” as defined in the Social Security Act. The ALJ,

therefore, denied the plaintiff’s claim for benefits. The Appeals Council rejected a

subsequent request for review. The ALJ’s decision consequently became the final decision

of the Commissioner of Social Security (Commissioner). See Chester v. Bowen, 792 F.2d

1

Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L. No. 1

103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social

Security matters were transferred to the Commissioner of Social Security.

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 1 of 13
129, 131 (11 Cir. 1986). Pursuant to 28 U.S.C. § 636(c), the parties have consented to th

entry of final judgment by the United States Magistrate Judge. The case is now before the

court for review pursuant to 42 U.S.C. §§ 405 (g) and 1383(c)(3). Based on the court's

review of the record in this case and the briefs of the parties, the court concludes that the

decision of the Commissioner should be affirmed.

II. Standard of Review

Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the

person is unable to

engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result

in death or which has lasted or can be expected to last for a continuous period

of not less than 12 months . . . 

To make this determination, the Commissioner employs a five-step, sequential 2

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

(3) Does the person's impairment meet or equal one of the specific

impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?

(4) Is the person unable to perform his or her former occupation?

(5) Is the person unable to perform any other work within the economy?

An affirmative answer to any of the above questions leads either to the next

question, or, on steps three and five, to a finding of disability. A negative

answer to any question, other than step three, leads to a determination of “not

disabled.”

A “physical or mental impairment” is one resulting from anatomical, physiological, or 2

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.

2

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 2 of 13
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11 Cir. 1986). th 3

The standard of review of the Commissioner’s decision is a limited one. This court

must find the Commissioner’s decision conclusive if it is supported by substantial evidence.

42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11 Cir. 1997). “Substantial th

evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence

as a reasonable person would accept as adequate to support a conclusion.” Richardson v.

Perales, 402 U.S. 389, 401 (1971). A reviewing court may not look only to those parts of

the record which supports the decision of the ALJ but instead must view the record in its

entirety and take account of evidence which detracts fromthe evidence relied on by the ALJ. 

Hillsman v. Bowen, 804 F.2d 1179 (11 Cir. 1986). th

[The court must] . . . scrutinize the record in its entirety to determine the

reasonableness of the [Commissioner’s] . . . factual findings . . . No similar

presumption of validity attaches to the [Commissioner’s] . . . legal

conclusions, including determination of the proper standards to be applied in

evaluating claims.

Walker v. Bowen, 826 F.2d 996, 999 (11 Cir. 1987). th

III. The Issues

A. Introduction. The plaintiff was 28 years old at the time of the hearing before the

ALJ and had completed the eighth grade. (R. 37). Following the hearing, the ALJ

concluded that the plaintiff has severe impairments of “Spinal Stenosis/Lumbar

McDaniel v. Bowen, 800 F.2d 1026 (11 Cir. 1986) is a supplemental security income case (SSI). 3 th

The same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately

cited as authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5 Cir. 1981) (Unit A).

th

3

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 3 of 13
Degenerative Disc Disease; Obesity; and Estimated Low Average/Borderline Intellectual

Functioning.” (R. 20). Her prior work experience includes work “as a fast food worker and

information clerk.” (R. 29). Following the hearing, the ALJ concluded that the plaintiff

could return to her past relevant work, and thus, she is not disabled. (Id.).

B. Plaintiff’s Claims. The plaintiff presents a single issue for the court’s review. 

As stated by the plaintiff, the issue is whether the “Commissioner’s decision should be

reversed, because the ALJ failed to properly apply the two-part pain standard.” (Pl’s Br.,

doc. # 12 at 7). 

IV. Discussion

A disability claimant bears the initial burden of demonstrating an inability to return

to her past work. Lucas v. Sullivan, 918 F.2d 1567 (11 Cir. 1990). In determining whether th

the claimant has satisfied this burden, the Commissioner is guided by four factors: (1)

objective medical facts or clinical findings, (2) diagnoses of examining physicians, (3)

subjective evidence of pain and disability, e.g., the testimony of the claimant and her family

or friends, and (4) the claimant’s age, education, and work history. Tieniber v. Heckler, 720

F.2d 1251 (11 Cir. 1983). The court must scrutinize the record in its entirety to determine th

the reasonableness of the ALJ’s decision. See Walker, 826 F.2d at 999. The ALJ must

conscientiously probe into, inquire of and explore all relevant facts to elicit both favorable

and unfavorable facts for review. Cowart v. Schweiker, 662 F.2d 731, 735-36 (11 Cir. th

1981). The ALJ must also state, with sufficient specificity, the reasons for his decision

4

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 4 of 13
referencing the plaintiff’s impairments. 

Any such decision by the Commissioner of Social Security which involves a

determination of disability and which is in whole or in part unfavorable to such

individual shall contain a statement of the case, in understandable language,

setting forth a discussion of the evidence, and stating the Commissioner’s

determination and the reason or reasons upon which it is based.

42 U.S.C. § 405(b)(1) (emphases added).

Gilliland contends that the ALJ failed to properly apply the pain standard, and thus

her testimony should be taken as true leading to a finding of disability. As explained below,

the ALJ did not fully credit Gilliland’s testimony. “Subjective pain testimony supported by

objective medical evidence of a condition that can reasonably be expected to produce the

symptoms of which the plaintiff complains is itself sufficient to sustain a finding of

disability.” Hale v. Bowen, 831 F.2d 1007 (11 Cir. 1987). The Eleventh Circuit has th

established a three-part test that applies when a claimant attempts to establish disability

through his own testimony of pain or other subjective symptoms. Landry v. Heckler, 782

F.2d 1551, 1553 (11 Cir. 1986); see also Holt v. Sullivan, 921 F.2d 1221, 1223 (11 Cir. th th

1991). This standard requires evidence of an underlying medical condition and either (1)

objective medical evidence that confirms the severity of the alleged pain arising from that

condition or (2) an objectively determined medical condition of such severity that it can

reasonably be expected to give rise to the alleged pain. Landry, 782 F. 2d at 1553. In this

circuit, the law is clear. The Commissioner must consider a claimant’s subjective testimony

of pain if he finds evidence of an underlying medical condition and the objectively

5

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 5 of 13
determined medical condition is of a severity that can reasonably be expected to give rise to

the alleged pain. Mason v. Bowen, 791 F.2d 1460, 1462 (11 Cir. 1986); Landry, 782 F.2d th

at 1553. Thus, if the Commissioner fails to articulate reasons for refusing to credit a

claimant's subjective pain testimony, the Commissioner has accepted the testimony as true 

as a matter of law. This standard requires that the articulated reasons must be supported by

substantial reasons. If there is no such support then the testimony must be accepted as true. 

Hale, 831 F.2d at 1012.

At the administrative hearing, Gilliland testified that pain in her lower back is the

basis for her disability claim. (R. 44). She testified that the pain is a 

shooting pain in my right leg and my left hip, . . . [M]y back has like a pulling

sensation in it at just about all times. If I move a certain way, it feels like

lightening strikes me and I just about, it takes my breath away, and I can’t, you

know, I have to just sit down or wherever I’m at and just take a break for a

second. 

(Id.)

The ALJ recited Gilliland’s testimony and discussed the medical evidence. The ALJ

acknowledged that Gilliland has “medically determinable impairments that could reasonably

be expected to cause the alleged symptoms; however, the claimant’s statements concerning

the intensity, persistence and limiting effects of these symptoms are not credible to the extent

that they are inconsistent with the above residual functional capacity assessment.” (R. 25-

26). If this were the extent of the ALJ’s credibility analysis, the plaintiff might be entitled

to some relief. However, a review of the ALJ’s analysis demonstrates that the ALJ properly

6

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 6 of 13
considered and discredited Gilliland’s testimony. Rather than give a synopsis of it, the court

will quote it. 

The claimant alleges that she experiences back pain that she rates as 8 out of

10, with 10 being the worst pain. She testified that she cannot stand, walk, or

sit for too long and that she has difficulty holding her arms out, reaching,

stooping, bending, and lifting. She also alleges that she has missed more work

than allowed by her employers. The claimant also alleges incontinence as a

result of her back impairment. The claimant also alleges that she has a mental

impairment that causes her to have a poor memory and prevents her frombeing

able to work. She alleges that she has difficulty with subtraction (Exhibit 1E;

Exhibit 2F).

* * *

In terms of the claimant’s alleged back impairment, the claimant’s complaints

are partially credible but not to the extent alleged. The claimant testified that

she has back pain that goes to her left hip and she feels a pulling sensation all

the time. She also testified that when she stands up sometimes she feels a

“lightening” sensation that causes her to have to sit and take a break for a

second. Although she testified that she can sit for thirty to forty-five minutes

a day or stand for thirty minutes at a time, Dr. Metzger recommended that the

claimant walk several mines a day. The claimant testified that she has not

walked that much. The claimant testified that on a daily basis that she can do

the dishes but sits while doing them. She also testified that she can cook, shop

for groceries, make jewelry, carry one or two grocery bags, and drive. She did

state that she was unable to drive for a long distance. However, the claimant

was able to travel recently to Mobile to visit her mother-in-law. In Exhibit 7E,

the claimant has also indicated that she is able to drive enough to drop her

daughter off and pick her up from school twice a day. However, she also

stated that she cannot bathe every day due to pain and that it takes all day to

clean the house due to the need to take breaks. Therefore, the claimant’s

activities of daily living only partly add to her credibility of alleged limitations

(Exhibit 5E; Exhibit 7E).

The claimant has also alleged incontinence and bowel dysfunction resulting

from her back impairment. Although she has indicated this symptom to Dr.

Johnson, he recommended that the claimant see another doctor or have more

invasive treatment for her back impairment. She claimant did see Dr. Metzger

7

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 7 of 13
according to Dr. Johnson, but Dr. Metzger’s treatment notes of the

examination indicate that the claimant did not complain of her bladder or

bowel problems. He recommended, as has Dr. Johnson, that the claimant

consider epidural injections or weight loss treatment. However, Dr. Metzger

also recommended that the claimant avoid taking narcotic pain medications as

well. The claimant declined to see another specialist for the bladder and bowel

dysfunction additional times according to Dr. Johnson’s treatment notes. It is

concluded that there is no limitation on the claimant’s ability to work

suggested due to this complaint. The claimant’s testimony at the hearing

regarding her bladder functioning also fails to show limitations on her ability

to work. She did link her back pain to her incontinence, and the medical

evidence does not indicate such a link. However, she indicated that at her

most recent job that she was able to compensate for her incontinence and she

does not allege the need for frequent breaks or a similar limitation for this

symptom (Exhibit 2E; Exhibi 7F; Exhibit 8F).

The medical evidence does support the existence of the claimant’s back

impairment and her condition is described as an “unusual” level ofstenosis for

her age and “severe congenital spinal stenosis” by Dr. Metzger. He indicates

that her MRI shows mild degenerative changes and only mild to moderate

stenosis but indicates such at each disc space in the lumbar spine. He

specifically states that the claimant should avoid narcotic pain medication and 

that she should walk two miles a day despite her impairment. He states that

the claimant is not a surgical candidate yet, but that she also has refused spinal

injections as a treatment. His opinion is at least somewhat in conflict with the

level of pain and limitations that the claimant reports and does not support the

extent of her allegations. Likewise, Dr. Johnson states that the claimant has

lumbar disc disease but found that she has complete range of motion of her

neck and back in his examinations. Only on his most recent examination did

he find that she had some restriction of motion in her neck. He also found that

her straight leg raises were negative and she has symmetrical reflexes. He also

notes that she has gone for a period of time without taking prescribed pain

medication. He states at her examination on March 15, 2007, that she has not

taken any medication regularly for her back pain that has provided relief. 

However, after that point, Dr. Johnson states that the claimant is getting good

relief with the Lortab as he adjusts her medication. Dr. Johnson’s treatment

notes also never indicate any abnormalities or other findings related to the

claimant’s back impairment. He does not indicate tenderness in the spinal area

and he only indicates subjective pain complaints by the claimant. While those

complaints are fairly frequent, claimant’s reports of pain in Dr. Johnson’s

8

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 8 of 13
treatment notes correspond mainly to the times that her prescription for Lortab

has run out which occurs several times (Exhibit 14F; Exhibit 8F; Exhibit 7F).

The claimant testified that she takes Lortab five days a week in a seven day

week and that she takes three a day on the days that she needs them. She also

testified that she took 800 mg Motrin and Tylenol Arthritis and had some

relief, but not as much relief as she experiences with the Lortab. For a number

of months, however, the claimant was not able to take Lortab and she was only

taking Motrin and Tylenol alone. She testified that she was unable to afford

Lortab, but there is no indication of attempting to get low cost or free

medication and she does testify that she had some relief without the Lortab.4

She also testified that Lortab gives her headaches, but only when wearing off.

The claimant testified that she experiences drowsiness as a side effect of

Lortab, but no side effects at all from the Motrin or Tylenol. She testified that

she would rate her pain as an eight out of ten, on a scale with ten being the

worst pain. However, the over the counter pain medication, to some extent,

and Lortab, to a greater extent, both have decreased her level of pain according

to her testimony.

In terms of the claimant’s limitations from obesity, the impact of the

claimant’s obesity is considered also in the assessment of limitations of the

claimant’s ability to work. However, the claimant has not alleged limitations

in her ability to work arising from her obesity other than those also attributed

to his (sic) back impairment. While the claimant’s obesity is considered

alongside her back impairment in the reduction of the claimant’s ability to

work to the light exertional level and the postural limitations of climbing,

stooping, kneeling, crouching and crawling, additional limitations in the

claimant’s ability to work are not alleged to be caused by this impairment. The

claimant testified that she is 5'8" and weighs 290. Dr. Metzger indicates that

weight loss would be of tremendous benefit to the claimant, but indicates no

limitation due to her weight other than the enhancement of the back

impairment. The claimant was diagnosed as obese or overweight by Dr.

Butler, Dr. Johnson, and Dr. Metzger. Each doctor also indicated that a weight

loss program would help the claimant relieve her back pain and Dr. Johnson

also discussed gastric bypass surgerywith the claimant during an examination. 

However, no additional limitations in the claimant’s residual functional

The court notes that Gilliland testified that she has insurance through her husband, (R. 43), and 4

while she may have had difficulty one time getting Lortab, Dr. Johnson has continued to prescribe the drug

for her beginning in 2006, and continuing until the administrative hearing.

9

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 9 of 13
capacity are supported by the medical evidence due to her obesity alone. As

for the limitations of the claimant’s back impairment, the impact of the

claimant’s obesity has been considered by the undersigned with regard to the

effect of obesity on the claimant’s other impairments and the medical evidence

and the limitations caused by the impairments in combination have been

considered. However, the claimant does not allege further difficulties arising

from her obesity nor does the medical evidence support further limitations on

the claimant’s ability to work than provided in the residual functional capacity

(Exhibit 6F; Exhibit 8F; Exhibit 4F; Exhibit 7F).

Therefore, the claimant’s allegations arising from her back impairment and

obesity are partly credible to support the limitation to light work with

limitations in climbing, stooping, kneeling, crouching, crawling, pushing,

pulling and concentrated exposure to machinery, or heights. However, the

claimant’s complaints ofsymptoms of her back impairment are not credible to

support further limitations in her residual functional capacity. 

(R. 25-28) (footnote added).

Where an ALJ decides not to credit a claimant’s testimony, the ALJ must articulate

specific and adequate reasons for doing so, or the record must be obvious as to the credibility

finding. Foote v. Chater, 67 F.3d 1553, 1561-62 (11 Cir. 1995); Jones v. Dept. of Health th

& Human Servs., 941 F.2d 1529, 1532 (11 Cir. 1991) (articulated reasons must be based on th

substantial evidence). If proof of disability is based on subjective evidence and a credibility

determination is, therefore, critical to the decision, “‘the ALJ must either explicitly discredit

such testimony or the implication must be so clear as to amount to a specific credibility

finding.’” Foote, 67 F.3d at 1562, quoting Tieniber, 720 F.2d at 1255 (although no explicit

finding as to credibility is required, the implication must be obvious to the reviewing court). 

The ALJ has discretion to discredit a plaintiff’s subjective complaints as long as he provides

“explicit and adequate reasons for his decision.” Holt, 921 F.2d at 1223. Relying on the

10

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 10 of 13
treatment records, objective evidence, and Gilliland’s own testimony, the ALJ concluded 

that her allegations regarding the extent of her back pain were not credible to the extent

alleged and discounted that testimony. After a careful review of the ALJ’s careful and

thoughtful analysis, the court concludes that the ALJ properly discounted the plaintiff’s

testimony and substantial evidence supports the ALJ’s credibility determination. It is

undisputed that the plaintiff suffers from pain. However, the ALJ concluded that while

Gilliland’s underlying condition is capable of giving rise to some pain and other limitations,

her impairments are not so severe as to give rise to the disabling intractable pain as she

alleged. 

The medical records support the ALJ’s conclusion that while Gilliland’s back

impairment could reasonably be expected to produce pain, Gilliland was not entirely credible

in her description of her symptoms or her pain. For example, Gilliland testified that while

her back pain renders her disabled, she is able to do chores around the house, and go grocery

shopping. (R. 49-50). She also testified that she is able to cook, shower, and bathe as well

as go out. (R. 49). She can drive and walk, although she does not walk as recommended by

Dr. Metzger. (R. 44, 46). 

Furthermore, the medical records do not corroborate her testimony of debilitating

pain. In January 2007, Gilliland presented to the South Central Medical Center complaining

of back pain. (R. 218). However, her examination was normal with “[n]o swelling, redness,

or tenderness” noted. (R. 219). She had normal strength and tone as well as full range of

11

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 11 of 13
motion in her back. (Id.) Although Gilliland was referred to physical therapy, there is no

indication in the record that she attended physical therapy. 

Gilliland presented to the Red Level Clinic in March 2007 complaining of back pain. 

(R. 236). At that time, no deformities were noted, her straight leg raises were negative, and

her reflexes were symmetrical. (Id.) On March 22, 2007, Gilliland reported that she only

took the Lortab at night because it relieved her pain and allowed her to sleep. (R. 234). She

took Tylenol and Ibuprofen during the day for relief. (Id.) She declined epidural injections

or surgery, “preferr[ing] to continue with what she has.” (Id.) Dr. Johnson recommended

that she lose weight and do back exercises regularly. (Id.) There is no indication in the

record that Gilliland attempted to follow the prescribed exercise treatment. Although

Gilliland continued to present to Dr. Johnson complaining of back pain, she declined

referrals to orthopedic doctors or other specialists. (R. 232, 225, 228). 

More importantly, Dr. Johnson noted that Gilliland had full range of motion in her

back with negative straight leg raises and symmetrical reflexes when he saw her on January

7, 2008, February 7, 2008, March 7, 2008, July 11, 2008, and November 7, 2008. (R. 222-24

& 277-76). 

During an consultative psychological evaluation on June 10, 2007, Gilliland reported

that she felt good on most days. (R. 251). Dr. Warren Brantley, PhD., opined that Gilliland

“should be able to re-enter the work force.” (R. 253).

After a careful review of the record, the court concludes that the ALJ’s reasons for

12

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 12 of 13
discrediting the plaintiff’s testimony were both clearly articulated and supported by

substantial evidence. To the extent that the plaintiff is arguing that the ALJ should have

accepted her testimony regarding her pain, as the court explained, the ALJ had good cause

to discount her testimony. This court must accept the factual findings of the Commissioner

if they are supported by substantial evidence and based upon the proper legal standards.

Bridges v. Bowen, 815 F.2d 622 (11 Cir. 1987). th

V. Conclusion

The court has carefully and independently reviewed the record and concludes that

substantial evidence supports the ALJ’s conclusion that plaintiff is not disabled. Thus, the

court concludes that the decision of the Commissioner is supported by substantial evidence

and is due to be affirmed.

A separate order will be entered.

Done this 30 day of June 2011. th

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

13

Case 2:10-cv-00054-CSC Document 15 Filed 06/30/11 Page 13 of 13