Opinion ID: 2975099
Heading Depth: 3
Heading Rank: 1

Heading: Fibromyalgia

Text: The Commissioner found Rogers to have severe impairments of “multiple arthralgias and degenerative cervical and lumbosacral disc disease, with mild spondylosis at the L5-S1 level.” While noting that Rogers has been diagnosed with fibromyalgia, the ALJ’s decision reflects some hesitancy in identifying this accepted medical condition as a severe impairment,2 and this hesitancy, in turn, influenced the ALJ’s weighing of the treating physician evidence. On at least one occasion, we have recognized that fibromyalgia3 can be a severe impairment and that, unlike medical conditions that can be confirmed by objective testing, fibromyalgia patients present no objectively alarming signs. See Preston v. Sec’y of Health & Human Servs., 854 F.2d 815, 820 (6th Cir. 1988) (per curiam) (noting that objective tests are of little relevance in determining the existence or severity of fibromyalgia); see also Swain v. Comm’r of Soc. Sec., 297 F. Supp. 2d 986, 990 (N.D. Ohio 2003) (observing that “[f]ibromyalgia is an ‘elusive’ and ‘mysterious’ disease” which causes “severe musculoskeletal pain”). Rather, fibromyalgia patients “manifest normal muscle strength and neurological reactions and have a full range of motion.” Preston, 854 F.2d at 820. The process of diagnosing fibromyalgia includes (1) the testing of a series of focal points for tenderness and (2) the ruling out of other possible conditions through objective medical and clinical trials. Id.; Swain, 297 F. Supp. 2d at 990. The claimant in Preston complained of pain, stiffness, and fatigue. Preston, 854 F.2d at 820. Her treating physician determined that she suffered from fibromyalgia, a determination based upon observation of the characteristic tenderness in certain focal points, recognition of hallmark symptoms, and “systematic” elimination of other diagnoses. Id. The ALJ, however, determined that the claimant did not suffer from the condition based primarily upon objective evidence introduced by the Commissioner demonstrating “fairly normal clinical and test results.” Id. at 819-20. A panel of this court reversed the decision on grounds that it was not based upon substantial evidence, noting that “CT scans, X-rays, and minor abnormalities, noted by these doctors and cited by the Secretary 2 To determine that a claimant has a severe impairment, the ALJ must find that an impairment or combination of impairments significantly limits the claimant’s ability to do basic work activity. 20 C.F.R. § 416.920. An “impairment must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by [claimant’s] statement of symptoms.” 20 C.F.R. § 416.908. Step two has been described as a “de minimus hurdle”; that is, “an impairment can be considered not severe only if it is a slight abnormality that minimally affects work ability regardless of age, education, and experience.” Higgs v. Bowen, 880 F.2d 860, 862 (6th Cir. 1988). 3 Fibromyalgia, also referred to as fibrositis, is a medical condition marked by “chronic diffuse widespread aching and stiffness of muscles and soft tissues.” Stedman’s Medical Dictionary for the Health Professions and Nursing at 541 (5th ed. 2005). We note also that ours is not the only circuit to recognize the medical diagnosis of fibromyalgia as well as the difficulties associated with this diagnosis and the treatment for this condition. See Sarchet v. Chater, 78 F.3d 305, 306 (7th Cir. 1996) (noting that fibromyalgia’s “causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective”); Kelley v. Callahan, 133 F.3d 583, 589 (8th Cir. 1998) (“Fibromyalgia, which is pain in the fibrous connective tissue of muscles, tendons, ligaments, and other white connective tissues, can be disabling.”); Green-Younger v. Barnhart, 335 F.3d 99, 108 (2d Cir. 2003) (noting that “a growing number of courts . . . have recognized that fibromyalgia is a disabling impairment and that there are no objective tests which can conclusively confirm the disease) (internal quotation marks and citations omitted); Welch v. Unum Life Ins. Co. of Am., 382 F.3d 1078, 1087 (10th Cir. 2004) (“‘Because proving the disease is difficult . . . , fibromyalgia presents a conundrum for insurers and courts evaluating disability claims.’”) (quoting Walker v. Am. Home Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir. 1999)). No. 05-4369 Rogers v. Comm’r of Soc. Sec. Page 8 as substantial evidence of no disability . . . are not highly relevant in diagnosing [fibromyalgia] or its severity.” Id. at 820. As in Preston, the ALJ’s decision here impliedly dismissing or minimalizing Rogers’ fibromyalgia and instead accepting the non-treating doctors’ opinions as to her limitations from “arthralgias” was not based upon substantial evidence. As noted, the process for diagnosing fibromyalgia involves testing for tenderness in focal points and ruling out other conditions. Id.; Swain, 297 F. Supp. 2d at 990. The ALJ did not discuss this standard at all in his decision, nor is this standard provided by Preston discussed in the Commissioner’s brief on appeal. The medical evidence submitted by Rogers’ treating physicians, particularly Dr. Stein, is replete with references to observed tender points in the “classic fibromyalgia distribution.” In addition, Drs. Stein and Evans recorded ongoing complaints of intense pain and stiffness throughout Rogers’ body, as well as fatigue. Finally, Dr. Stein’s notes for his course of treatment evidence a process of diagnoses elimination, as he sought to determine whether Rogers’ symptoms resulted from fibromyalgia and/or rheumatoid arthritis. Again, this was neither acknowledged nor discussed by the ALJ. Other factors tend to support affording the opinions of Rogers’ treating physicians’ significant weight. Dr. Evans began treating Rogers in 1993, and Dr. Stein first began treating her in 1997. Combined, these physicians have been treating Rogers for more than twenty years. Further, the more than 500 pages of medical evidence in this case reflect continuous and frequent treatment by both physicians. Their documentation consistently demonstrates treatment for the same symptoms; namely, pain and stiffness, symptoms that according to these same documents have progressively increased in severity. Drs. Evans and Stein reached similar diagnoses, prescribed similar medications, and suggested similar limitations with respect to Rogers’ ability to perform basic functions. Moreover, the medical opinions reflected in both physicians’ medical records and reports are credible in light of medically acceptable practices. Although fibromyalgia is not susceptible of objective verification through traditional means, Dr. Stein’s records in particular reflect that he continually tested for and Rogers increasingly exhibited the medically-accepted and recognized signs of fibromyalgia. Specifically, he noted on numerous occasions that she complained of tenderness in the appropriate focal points. Finally, unlike the non-treating physicians upon whose testimony and reports the ALJ placed great emphasis, Dr. Stein is a rheumatologist, and thus a specialist in the particular types of conditions Rogers claims to suffer from. Despite this evidence, the ALJ disagreed with the opinions of Drs. Evans and Stein and, more critically, failed to provide an analysis of the factors to be considered in determining the weight accorded the opinions of Rogers’ treating physicians. Instead, the ALJ focused on the testimony of Dr. Leeb and the limitations opined by Dr. Rath. Neither Dr. Leeb nor Dr. Rath are treating physicians, a fact of special significance given the unique nature of fibromyalgia. Nor did either of them perform a physical examination of Rogers. Indeed, the agency expert who did perform a physical exam, Dr. Naomi Waldbaum, noted that Rogers exhibits significant pain behavior and would be unable to maintain full-time employment. Although Dr. Rath’s specialization is not indicated in the record, Dr. Leeb’s specialization is orthopedic surgery. At hearing, Dr. Leeb shared that he had never had occasion to treat a patient diagnosed with fibromyalgia. Furthermore, it appears as though a significant amount of time has passed, at least some six years, between Dr. Rath’s review of Rogers’ medical history in 1998 and No. 05-4369 Rogers v. Comm’r of Soc. Sec. Page 9 the ALJ’s decision. Dr. Rath therefore offered medical opinions without the benefit of observing later symptoms or reviewing subsequent treatment notes of Drs. Evans or Stein.4 Most importantly, it is clear that the opinions offered by Drs. Leeb and Rath were concerned solely with objective medical evidence. Dr. Leeb testified that “objectively” he found no evidence that Rogers had a severe physical impairment. He also testified that if Rogers’ subjective complaints were considered, she would likely be limited to essentially sedentary work. But based on “pure objective findings,” Dr. Leeb opined that Rogers has very few limitations. The physical limitations assessed by Dr. Rath were very similar to those ultimately found by the ALJ in determining Rogers’ RFC. Although Dr. Rath acknowledged that Rogers has fibromyalgia, the limitations he suggested were based upon the lack of objective findings. Thus, the foundation for the opinions offered by Drs. Leeb and Rath was the lack of objective findings. However, in light of the unique evidentiary difficulties associated with the diagnosis and treatment of fibromyalgia, opinions that focus solely upon objective evidence are not particularly relevant. See Preston, 854 F.2d at 820. As for the “good reasons” given by the ALJ for rejecting Dr. Stein’s opinions, the required explanation is even more deficient. The ALJ noted only that “[o]nce again, in assessing the evidence in light of Section 404.1527 of the Social Security Administration Regulations No. 4, the record does not support the limitations of the severity suggested by Dr. Stein.” This explanation simply does not satisfy the notice requirement discussed in Social Security Ruling 96-7p and reaffirmed by this Court in Wilson. This required explanation, or the lack thereof in this particular case, is directed to explaining not just why these opinions do not warrant controlling weight, but should also explain what weight was given the treating opinions. No such evaluation was conducted by the ALJ here or, if it was, it is not articulated in the written decision. Because the ALJ failed to provide sufficient justification for the weight given to the opinions of Rogers’ treating physicians, his decision in this regard did not meet the requirements of 20 C.F.R. § 416.927, and therefore cannot serve as substantial evidence. See Wilson, 378 F.3d at 544.