Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-4_05-cv-04056/USCOURTS-arwd-4_05-cv-04056-0/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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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

TEXARKANA DIVISION

JESS A. MAY PLAINTIFF

VS. CIVIL NO. 05-4056

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Jess May (“plaintiff”), brings this action pursuant to § 205(g) of the Social Security Act (“the

Act”), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of the

Social Security Administration denying his applications for disability insurance benefits (“DIB”),and

supplemental security income (“SSI”), under Titles II and XVI of the Act.

Background:

The applications for DIB and SSI now before this court were filed on May 28, 2003, alleging

an onset date of March 22, 2001, due to right hip, leg, and lower back pain. (Tr. 13, 31, 64, 74, 231).

An administrative hearing was held on November 2, 2004. (Tr. 237-268). Plaintiff was present and

represented by counsel. 

The Administrative Law Judge (“ALJ”), entered a written opinion on February 16, 2005,

finding that, although severe, plaintiff’s impairments did not meet or equal the criteria of any of the

impairments listed in Appendix 1, Subpart P, Regulations No. 4. (Tr. 23). At this time, plaintiff was

thirty-seven years old and possessed the equivalent of a high school education. (Tr. 64, 80). The

record reveals that he has past relevant work (“PRW”), as a construction worker and cook’s helper.

(Tr. 75). 

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After discrediting plaintiff’s subjective allegations, the ALJ concluded that he maintained

the residual functional capacity (“RFC”), to perform a wide range of sedentary work, limited only

by his ability to lift and/or carry no more than ten pounds, stand and/or walk for two hours total

during an eight-hour workday, and occasionally climb, balance, stoop, kneel, crouch, and crawl. (Tr.

24). With the assistance of a vocational expert, the ALJ then found that plaintiff could still perform

work existing in significant numbers in the national economy, to include positions as a hand

assembler and driller. (Tr. 24). 

On July 12, 2005, the Appeals Council declined to review this decision. (Tr. 5-7).

Subsequently, plaintiff filed this action. (Doc. # 1). This case is before the undersigned by consent

of the parties. The plaintiff and Commissioner have filed appeal briefs, and the case is now ready

for decision. (Doc. # 7, 8). 

Applicable Law:

This Court’s role is to determine whether the Commissioner’s findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir.

2002). Substantial evidence is less than a preponderance but it is enough that a reasonable mind

would find it adequate to support the Commissioner’s decision. The ALJ’s decision must be

affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d

964, 966 (8th Cir. 2003). As long as there is substantial evidence in the record that supports the

Commissioner’s decision, the Court may not reverse it simply because substantial evidence exists

in the record that would have supported a contrary outcome, or because the Court would have

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decided the case differently. Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other words,

if after reviewing the record it is possible to draw two inconsistent positions from the evidence and

one of those positions represents the findings of the ALJ, the decision of the ALJ must be affirmed.

Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).

It is well-established that a claimant for Social Security disability benefits has the burden of

proving his disability by establishing a physical or mental disability that has lasted at least one year

and that prevents him from engaging in any substantial gainful activity. Pearsall v. Massanari, 274

F.3d 1211, 1217 (8th Cir. 2001); see 42 U.S.C. § § 423(d)(1)(A), 1382c(a)(3)(A). The Act defines

“physical or mental impairment” as “an impairment that results from anatomical, physiological, or

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A plaintiff must show that his

disability, not simply his impairment, has lasted for at least twelve consecutive months. Titus v.

Sullivan, 4 F.3d 590, 594 (8th Cir. 1993).

The Commissioner’s regulations require her to apply a five-step sequential evaluation process

to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful

activity since filing his claim; (2) whether the claimant has a severe physical and/or mental

impairment or combination of impairments; (3) whether the impairment(s) meet or equal an

impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past

relevant work; and, (5) whether the claimant is able to perform other work in the national economy

given his age, education, and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003). Only if the final

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stage is reached does the fact finder consider the plaintiff’s age, education, and work experience in

light of his or her residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42

(8th Cir. 1982); 20 C .F.R. § § 404.1520, 416.920 (2003).

Discussion:

Of particular concern to the undersigned is the ALJ’s RFC assessment. RFC is the most a

person can do despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). A disability claimant has

the burden of establishing his or her RFC. See Masterson v. Barnhart, 363 F.3d 731, 737 (8th

Cir.2004). “The ALJ determines a claimant’s RFC based on all relevant evidence in the record,

including medical records, observations of treating physicians and others, and the claimant’s own

descriptions of his or her limitations.” Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004);

Guilliams v. Barnhart, 393 F.3d 798, 801 (8th Cir. 2005). Limitations resulting from symptoms such

as pain are also factored into the assessment. 20 C.F.R. § 404.1545(a)(3). The United States Court

of Appeals for the Eighth Circuit has held that a “claimant’s residual functional capacity is a medical

question.” Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001). Therefore, an ALJ’s determination

concerning a claimant’s RFC must be supported by medical evidence that addresses the claimant’s

ability to function in the workplace.” Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). 

In the present case, the evidence reveals that plaintiff has been treated for chronic back and

right hip pain since March 22, 2001, when he injured his back while carrying a one hundred-pound

box. (Tr. 15). In August 2001, plaintiff reported the occasional loss of control in his back and leg,

resulting in multiple falls. (Tr. 120). At that time, an examination revealed paralumbar muscular

spasms, point tenderness with increased pain to lateral bending and extension, a positive straight-leg

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raise test, tenderness to palpation in the hip and groin, and decreased strength in hislower extremity.

(Tr. 123). Further, an x-ray of plaintiff’s pelvis revealed vascular calcifications. (Tr. 126). 

In October 2001, Dr. Mohammad Hussain diagnosed plaintiff with possible osteoarthropathy

of the apophyseal joints, spinal degenerative joint disease, lumbar radiculopathy, and possible

sacroilitis and thoracic spinal stenosis. (Tr. 132). His examination revealed weakness in the

extremities, right side greater than left; mildly decreased strength in the distal muscles of the right

lower extremity; tenderness in the lumbar spine; and, decreased perception in the lateral third of the

left leg. (Tr. 132). 

In July 2002, plaintiff sought emergency treatment after his back “locked up.” (Tr. 136). He

was diagnosed with lumbar strain with spasm and radicular symptoms, after an examination revealed

paraspinous tenderness and spasm. (Tr. 136-137). The doctor prescribed Lortab, Vioxx, Medrol,

Skelaxin, and ice therapy. (Tr. 136).

In August 2002, plaintiff was treated for back pain and leg pain on three separate occasions.

(Tr. 142, 145, 148). In mid-August, plaintiff was noted to have numbness around the abdominal

wall, as well as mild numbness on the right side. (Tr. 145). On August 23, 2002, records indicate

that an x-ray of plaintiff’s lumbar spine revealed some degenerative changes. (Tr. 149). Plaintiff

was prescribed pain medication and muscle relaxers, such as Robaxin, Anaprox, Vicodin, Norflex,

Toradol, and Ultram. (Tr. 142, 145, 148). 

In May 2003, x-rays of plaintiff’s right hip revealed a possible old stress injury to the

femoral neck. (Tr. 180). Further, radiographs of his lumbar spine showed mild spondylosis at the

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A common congenital midline defect of fusion of the vertebral arch without protrusion 1

of the spinal cord or meninges. Robert J. Joynt, CLINICAL NEUROLOGY, p. 34 (1992). The

lesion is also covered by skin. Id. L5 and S1 are the most common vertebrae involved. Id. 

The majority of individuals with this malformation are asymptomatic, although there is an

increased incidence of tethered cord syndrome and lumbar spondylosis. Id.

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thoracolumbar junction and spina bifida occulta at the S1 level. Stephanie Hickerson, a nurse 1

practitioner practicing with Dr. R. Mayo at the Christus St. Michael Family Clinic, prescribed

Hydrocodone and Flexeril. (Tr. 181). Plaintiff was noted to have paravertebral spasms, spinous

process tenderness, and a positive straight-leg raise test. (Tr. 181).

In June 2003, Ms. Hickerson noted that plaintiff had a poor range of motion in his right hip,

pain in his right hip with straight-leg raise testing, decreased strength in his right leg, and reduced

spinal mobility. (Tr. 177). She prescribed Flexeril, Hydrocodone, Mobic, and Ultracet. (Tr. 178).

Records dated from August 2003, until November 2003, indicate that Ms. Hickerson

consistently prescribed Hydrocodone, Flexeril, and Mobic. (Tr. 191-192, 194-195, 199). On several

occasions, she also prescribed Ultracet to help alleviate plaintiff’s pain. (Tr. 195, 199). 

In February 2004, plaintiff was treated by Mary Stanley, another nurse practitioner at Dr.

Mayo’s clinic. (Tr. 214-216). Ms. Stanley diagnosed plaintiff with hypertension, right hip pain, and

back pain. For this, she prescribed Flexeril, Capozide, Mobic, and Hydrocodone. Because plaintiff

also reported problems with anxiety, Ms. Stanley prescribed Zoloft. (Tr. 214-216). Records indicate

that plaintiff consistently obtained refills of these medications between February 2004, and October

2004. (Tr. 217, 220-223).

On March 16, 2004, Ms. Stanley completed an RFC assessment of plaintiff for Dr. Mayo.

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(Tr. 228-230). This assessment was signed by both Dr. Mayo and Ms. Stanley. The assessment

revealed that plaintiff was capable of lifting a maximum of ten pounds frequently and occasionally,

could stand/walk less than two hours during an eight-hour workday, could sit less than two hours

during an eight-hour workday, would require a break every thirty minutes to walk around for thirty

minutes, would need to be able to sit/stand at will, and would need to lie down two to three times

per day. Dr. Mayo and Ms. Stanley indicated that plaintiff’s MRIsupported this assessment, noting

a stress injury to plaintiff’s femoral neck. Further, they stated that plaintiff should never twist, stoop,

crouch, or climb ladders, and should only occasionally climb stairs, as these activities could cause

further damage to plaintiff’s femoral head. They also advised that he avoid concentrated exposure

to wetness. (Tr. 230). 

 In spite of this evidence, the ALJ concluded that plaintiff could perform a wide range of

sedentary work, limited only by his ability to lift and/or carry no more than ten pounds, stand and/or

walk for two hours total during an eight-hour workday, and occasionally climb, balance, stoop,

kneel, crouch, and crawl. (Tr. 24). He did not, however, consider Dr. Mayo’s and Ms. Stanley’s

notation that plaintiff should never twist, stoop, crouch, or climb ladders, as this may cause further

damage to plaintiff’s hip. (Tr. 230). We note that a treating physician’s opinion is generally entitled

to substantial weight. Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 730 (8th Cir. 2003).

Accordingly, we believe remand is necessary to allow the ALJ to reevaluate plaintiff’s RFC. 

Also of significance is the fact that the ALJ failed to properly consider plaintiff’s medications

and the possible side effects of those medications. (Tr. 136, 137, 142, 145, 148, 178, 181, 195, 199,

214-216). In his opinion, the ALJ incorrectly stated that plaintiff had a history of conservative

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treatment for his alleged impairments, consisting of nothing more than prescriptions for “modest

dosages of medication.” (Tr. 20-21). However, as indicated above, among other medications, the

record reveals that plaintiff was prescribed Hydrocodone, Flexeril, and Zoloft. (Tr. 143, 155, 176-

177, 181, 191-192, 194-195, 199, 214, 215-216, 217-223). We note that Hydrocodone is a

semisynthetic narcotic analgesic that affects the central nervous system. PHYSICIAN’S DESK

REFERENCE, pp. 531 (60th ed. 2006). It is used to treat moderate to moderately severe pain. Id.

Frequently reported side effects include lightheadedness, dizziness, sedation, nausea, and vomiting.

Id. at 532. Zoloft is a selective serotonin reuptake inhibitor used to inhibit the central nervous

system’s neural uptake of Serotonin, thereby treating depression and anxiety symptoms. Id. at 2583-

2584. Common side effects associated with Zoloft include dizziness and fatigue. Id. Flexeril is a

muscle relaxer used to relieve skeletal muscle spasm without interfering with muscle function. Id.

at 1832. Its side effects include, drowsiness, dry mouth, fatigue, and headache. Id. However, when

used in conjunction with other medications affecting the central nervous system, such as narcotic

pain medications and antidepressants, testing has shown that Flexeril may impair the mental and/or

physical abilities needed for the performance of hazardous tasks, such as operating machinery or

driving a vehicle. Id. at 1833. However, the ALJ failed to consider both the fact that these

medications were prescribed, and the possible side effects of each medication. He also failed to

consider the side effects possible when these medications are used simultaneously. As such, the ALJ

is reminded of his duty to consider all of the evidence relating to plaintiff’s subjective complaints,

including evidence that relates to the dosage, effectiveness, and side effects of his medications. See

Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984). Therefore, on remand, he is directed to

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determine what effect these medications may have had on plaintiff’s ability to perform work-related

activities. Id.

The ALJ also erred in discounting plaintiff’s allegations of disabling pain because he had

been treated medically, not surgically, for his impairments. (Tr. 20-21). “No medical report suggests

that [plaintiff] has not been pursuing a valid course of treatment.” Tate v. Apfel, 167 F.3d 1191,

1197 (8th Cir. 1999). No doctor has recommended surgery for his condition. (Tr. 120-230).

Accordingly, on remand, the ALJ should reconsider plaintiff’s subjective complaints in light of the

fact that surgical intervention has not been a recommended mode of treatment, according to the

record. 

Conclusion:

Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore, the denial of benefits to the plaintiff, should be reversed and this matter should be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

405(g). 

DATED this 21st day of September 2006.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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