Opinion ID: 2783279
Heading Depth: 2
Heading Rank: 1

Heading: Evidence in ALJ Proceedings

Text: The treatment notes of Dr. Raphael R. Roybal, who treated Jones for his back pain and began seeing him in June 2008, provided a description of Jones’s back condition. Dr. Roybal’s treatment notes from March 2009 state Jones 2 Case: 14-13325 Date Filed: 03/02/2015 Page: 3 of 15 suffered from “isthmic spondylolysis with a retrospondylolisthesis at L4-L5.” 1 R. at 468. On May 4, 2009, Dr. Roybal and Dr. Christopher Senkowski performed anterior-lumbar, interbody-fusion surgery on Jones to correct the problem. Dr. Roybal saw Jones on May 15, 2009, approximately ten days after surgery, and noted Jones was doing very well, his back pain had resolved significantly at that juncture, and Jones was not taking any pain medication. On June 12, 2009, shortly more than one month after surgery, Dr. Roybal found Jones was doing well and had significant reduction in his lower back pain. At that time, Jones was not taking any pain medication. Dr. Roybal recommended Jones begin isometric core strengthening and protective lifting, as long as he did not lift weights over 30 pounds. On July 17, 2009, Dr. Roybal recorded that Jones was not taking any pain or anti-inflammatory medication. Jones reported he still had back pain but he was exercising on his own and walking significantly. Dr. Roybal recommended that Jones take anti-inflammatory medication for his back pain. 1 “Spondylolysis” is a condition where there is a defect in a portion of the spine called the “pars interarticularis,” which is a small segment of bone joining the facet joints in the back of the spine. See http://www.spine-health.com/conditions/spondylolisthesis/spondylolysis-andspondylolisthesis. With the condition of “spondylolisthesis,” the pars interarticularis defect can be on one or both sides of the spine. Id. “Isthmic spondylolisthesis” is when one vertebral body is slipped forward over another. Id. “Retrospondylolisthesis” is the slipping posteriorly of a vertebra, bringing it out of line with adjacent vertebrae. http://www.medilexicon.com/medicaldictionary.php?t=78077. 3 Case: 14-13325 Date Filed: 03/02/2015 Page: 4 of 15 Dr. Roybal saw Jones again on October 16, 2009. Jones again reported having back pain but he still was not taking any pain or anti-inflammatory medication. Dr. Roybal stated that Jones had no deficit in motion with flexion or extension and recommended Jones maximize his core strengthening rehabilitation. Dr. Roybal stated his opinion Jones could begin transitioning to light duty at that time, and he again recommended anti-inflammatory medication. Jones next saw Dr. Roybal on January 15, 2010, and reported Jones was relatively unchanged since his October 2009 visit. Jones still had back pain, which he rated at six out of ten, and he complained of pain in his left leg extending in his anterior and posterior thigh down to his knee. Jones’s physical examination results showed he had appropriate sensation in his bilateral and lower extremities and “5/5 range of motion and muscular strength” in his hips, knees, and ankles. R. at 635. Dr. Roybal prescribed Mobic to manage the “flare up” of Jones’s symptoms; Jones was advised to follow up on an as needed basis. R. at 635. On December 17, 2009, State Agency Medical Consultant Dr. Sherry Crump completed a Physical Residual Functional Capacity (“RFC”) Assessment of Jones based on the record evidence, including Dr. Roybal’s treatment notes. Dr. Crump determined Jones could (1) occasionally lift or carry up to 20 pounds, (2) frequently lift or carry up to 10 pounds, (3) stand, walk, or sit with normal 4 Case: 14-13325 Date Filed: 03/02/2015 Page: 5 of 15 breaks for a total of about 6 hours in an 8-hour day, and (4) push or pull within the stated weight limitations. On August 10, 2010, State Agency Medical Consultant Dr. Stephen Burge completed another RFC Assessment of Jones and reached the same conclusions. Dr. Burge noted, however, Jones had a speech impediment, stuttering and a moderate fluency disorder, that would limit his ability to engage in public speaking, customer service, sales, telephone, and complex verbal interactions. At the June 1, 2011, hearing before the ALJ, Jones was represented by counsel. Jones testified he was a high-school graduate. At the time of the hearing, he was taking meloxicam, a non-narcotic prescription pain medication. He represents the pain medication did not help him at all. After his May 4, 2009 surgery, Jones felt better for a short time, but the pain eventually became increasingly worse. At the time of the hearing, his back pain was worse than it had been before the surgery. Jones stated that his back pain affected his sleep, and he slept for only about four hours without interruption. Additionally, Jones had difficulty showering, especially stepping in and out of the shower. Jones had trouble dressing himself, and his mother, who lived with him, had to put his shoes and socks on him because he could not bend down far enough to do so himself. 5 Case: 14-13325 Date Filed: 03/02/2015 Page: 6 of 15 Jones said he spent most of his days lying on a couch and in bed. He could walk about 50 feet before having to stop because of back pain. Jones drove occasionally, and the longest distance he had driven in the past year was about 12 miles to his doctor’s office. He testified that amount of driving caused him pain. A vocational expert (“VE”) classified Jones’s past work as “medium to very heavy” and unskilled to low-end, semi-skilled. R. at 86. The VE testified that Jones did not have any skills transferrable to a sedentary job. Jones’s counsel asked what positions would be available to someone of Jones’s age, with similar education and past relevant work, who could do light work that did not involve vibrating machinery, too much oral communication, or any bending, squatting, stooping, or climbing. The VE responded that such a person could obtain the positions of ticket taker, office helper, or assembler. Of those positions, the VE explained, ticket taker and office helper would be able to sit or stand at will.