Opinion ID: 619074
Heading Depth: 4
Heading Rank: 2

Heading: Medical Source Statements

Text: Dr. Thompson also completed two medical source statements in which he provided specific opinions concerning the effect of Ms. Franklin’s impairments on her ability to work. In the first statement, dated October 22, 2007, he listed her diagnoses as degenerative disc disease of the cervical spine; degenerative joint disease of the lumbar spine; cervical foraminal stenosis at C4-5 and C6; mixed connective tissue disease; hypertension; hyperlipidemia; fibromyalgia; and fibrocystic mastopathy. He opined that she could sit for one to two hours at a -6- time, and for three to four hours total in an eight-hour day; walk 100 yards at one time; stand for thirty minutes to an hour at one time and for three to four hours total in an eight-hour day; and lift five to ten pounds. Dr. Thompson further opined that she could not complete a normal work week without marked interruptions, due to her pain, weakness and fatigue, and would require more than the typical number of breaks during an eight-hour workday. In his second statement, dated July 28, 2008, Dr. Thompson identified a slightly different list of medical diagnoses: degenerative joint and disc disease; status post cervical disc surgery; cervical and lumbar radiculopathies; chronic pain management; hypertension; and depression. In this statement, his estimates of Ms. Franklin’s physical limitations were similar to those contained in his previous statement, but he now opined that she could only stand for one to two hours total per day “in short segments.” Aplt. App., Vol. II at 345. He again stated that she could not work a normal work week without an unreasonable number of work periods, because of chronic pain and the side-effects of her medications, which made it difficult for her to concentrate. He specified that her medications caused poor concentration, drowsiness, and short-term memory loss. The ALJ gave these opinions some, but not great, consideration in calculating Ms. Franklin’s RFC. He explained: [T]hese findings are not consistent with Dr. Thompson’s treating office and narrative notes which document palliative care for continued medication management. Dr. Thompson’s less than -7- sedentary findings are not supported by the remainder of the medical evidence. Although the claimant had an anterior cervical fusion, the objective MRI studies documented the claimant had mild to moderate stenosis. Post-operatively, the neurosurgeon found the claimant had good results, and even Dr. Thompson noted the claimant had fifty percent reduction in her symptoms. Additionally, these findings appear to have been based upon the claimant’s subjective complaints rather than upon objective diagnostic criteria. Id. at 15. Ms. Franklin asserts that this analysis “was legally insufficient because it did not provide specific and legitimate reasons for rejecting those opinions, and because it did not properly evaluate the opinions under the relevant factors.” Aplt. Opening Br. at 27. While this appears a procedural objection, targeting an alleged failure to follow the procedure required for evaluating treating physician opinions, Ms. Franklin in fact primarily relies on substantive challenges to the ALJ’s reasoning and conclusions. She first objects to the ALJ’s conclusion that Dr. Thompson provided only palliative medication management. She argues that Dr. Thompson also performed various tests and “communicated with neurosurgeon Dr. Cagle.” Id. at 28. Her objections, however, do not suggest that Dr. Thompson himself provided curative treatment that went beyond managing Ms. Franklin’s medications. In assessing a physician’s opinion, the ALJ is entitled to consider the nature of the treatment provided. 20 C.F.R. § 404.1527(d)(2)(ii). We discern no error here. -8- Dr. Cagle did provide surgical treatment that went beyond palliative care, in the form of spinal fusion surgery. But as the ALJ noted, Dr. Cagle’s post-surgical communications about Ms. Franklin’s condition were highly positive. Approximately one month after the surgery, he reported that Ms. Franklin had made good progress, had good relief of her neck and arm pain, that her surgical wound was well-healed, and that her strength and sensation were good. In a letter to Dr. Thompson, he reported that Ms. Franklin had good relief of neck and arm pain and had little residual pain. Ms. Franklin also complains that the ALJ failed to specifically discuss Dr. Thompson’s examination findings of other evidence relating to pain, arthritis, and depression. Aplt. Opening Br. at 28. While the ALJ is not strictly required to discuss every examination finding in assessing a treating physician’s opinion, he should do so if these examination findings are significantly probative and hence relevant to his assessment of the opinion under the appropriate standards will failure to discuss them be significant. See Clifton v. Chater, 79 F.3d 1007, 1010 (10th Cir. 1996). Ms. Franklin attempts to make such a showing of relevance by asserting that the test results, which the ALJ failed specifically to discuss, undercut his statement that Dr. Thompson based his opinions on her subjective complaints rather than on objective diagnostic criteria. But the ALJ’s opinion describes his overall evaluation of the proffered medical records. Although the explanation -9- could have been more robust, the opinion demonstrates a review of all of Dr. Thompson’s opinions and consideration of their weight in light of all the evidence in the record. Ms. Franklin also attacks the ALJ’s finding that the remaining medical evidence did not support Dr. Thompson’s opinions. First, she claims the ALJ incorrectly found that the MRI studies showed the degree of her cervical stenosis was only mild to moderate. She argues that pre-operative findings made prior to her alleged onset date reflected severe or moderate-to-severe neuroforaminal narrowing that was more severe than the ALJ’s “mild-to-moderate” formulation would indicate. She also argues that these pre-operative findings indicated cord compression affecting at least four levels of her cervical spine, rather than the two levels affected by the cervical fusion. We fail to see how these pre-operative findings cast doubt on the ALJ’s rationale. First, with regard to her argument that the ALJ gave insufficient attention to all four levels affected by spinal stenosis, Ms. Franklin does not show that the ALJ’s reasoning was unsupported by substantial evidence. Dr. Cagle, who performed the cervical surgery, opined prior to the surgery that “[a] cervical spine MR scan shows cervical disc disease with spinal stenosis at C5-6 greater than at C4-5. There are milder changes above and below.” Id. at 314 (emphasis added). Based on this understanding, Dr. Cagle offered Ms. Franklin an anterior cervical fusion at C4-5 and C5-6. Id. The ALJ was entitled to rely on Dr. Cagle’s opinion -10- that these were the levels at which spinal stenosis was sufficiently severe to require surgical treatment. They were in fact the levels on which surgery was actually performed. Second, the ALJ’s discussion of the MRI studies must be considered in light of the overall medical record. These studies were performed before the alleged onset date and before Ms. Franklin’s cervical fusion. The cervical fusion occurred less than four months after the alleged onset date, and as the ALJ noted, it provided Ms. Franklin with significant pain relief, at least initially. Even if the most recent pre-onset MRI result showed severe stenosis at some levels and moderate stenosis at others--rather than mild-to-moderate stenosis as the ALJ characterized it--we discern no reversible error in his characterization of the result. The MRI report’s findings, which supported the ALJ decision, contained the following: C3-4: Combination broad-based disc osteophyte complex and small central disc protrusion. Central/left parasagittal disc protrusion. Mild central canal stenosis with an AP diameter of 9 mm. Disc abuts and perhaps minimally contours the anterior aspect of the cervical cord. Mild to moderate right and moderate left foraminal stenosis secondary to facet/uncovertebral degenerative changes. C4-5: Broad-based disc osteophyte complex and small to moderate sized right parasagittal disc protrusion. Moderate central canal stenosis with an AP diameter of 8 mm. Mild compression of the anterior aspect of the cervical cord. Moderate right and moderate left foraminal stenosis secondary to facet/uncovertebral degenerative changes. -11- C5-6: Broad-based disc osteophyte complex. Moderate central canal stenosis with an AP diameter of 8 mm. Mild compression of the anterior aspect of the cervical cord. Severe bilateral foraminal stenosis secondary to facet/uncovertebral degenerative changes. C6-7: Broad-based disc osteophyte complex and small central disc protrusion. Mild central canal stenosis with an AP diameter of 9 mm. Mild right and moderate to severe left foraminal stenosis secondary to facet/uncovertebral degenerative changes. Id. at 315 (emphasis added). Thus, although there were a few references to severe stenosis in the MRI report, the vast majority of references support the ALJ’s characterization of mild or moderate stenosis. Moreover, the medical record as a whole contains no objective post-surgical testing revealing continued impact from severe stenosis of the cervical spine. Rather, both the initial subjective reports and post-surgical objective indications suggest a positive surgical outcome with good relief of pain. See id. at 237 (“[Ms. Franklin reports] 50% relief of [symptoms] post op”); 308 (“[Ms. Franklin] has done well with good relief of her neck and arm pain. She has a little residual pain, which is not remarkable”); 309 (“good symptomatic relief of her neck and arm pain . . . strength and sensation are good”); 312 (“anterior screw and plate fixation with intervertebral bone plug positioning at C4, C5, and C6 with good anatomic alignment of the vertebral bodies”). Ms. Franklin complains, however, that the ALJ ignored her continued post-operative pain “with objective findings of sacroiliac tenderness and inflammation, reduced cervical and lumbar mobility, and positive trigger points.” -12- Aplt. Opening Br. at 30. She contends that this lacuna in his analysis made the ALJ’s reasons for rejecting Dr. Thompson’s opinions “not sufficiently legitimate and therefore legally improper.” Id. But the ALJ did provide an adequate discussion of the medical evidence (including the opinions of, and treatment notes from, Dr. Thompson) bearing upon her reduced mobility, fibromyalgia (associated with the positive trigger points), and post-operative pain. See Aplt. App., Vol. II at 15. While Ms. Franklin may not agree with the ALJ’s conclusions, she is incorrect in stating that he “ignored” these conditions or symptoms. Ms. Franklin was examined post-operatively by consulting physician Dr. Dennis Brennan. He described her pain complaints and her medical history. He noted that her range of motion in extension and left and right side bending appeared normal and her straight leg raising tests were negative, though she did complain of pain while undergoing testing. She had some limitation on flexion/extension and rotation in her cervical spine and tenderness on palpation in the cervical musculature and paraspinal musculature throughout her thoraco/upper lumbar area. But there was no evidence of sacroiliac tenderness, trigger point tenderness, or radiculopathy, and she “appear[ed] to ambulate in a steady and safe gait at an appropriate speed without the use of any assistive devices.” Id. at 206. Ms. Franklin complains, however, that the ALJ mischaracterized and failed to discuss Dr. Brennan’s mobility findings. She does not argue that these mobility findings are inconsistent with the ALJ’s RFC. Nor does she explain how -13- they necessarily undermine the ALJ’s conclusion that Dr. Thompson’s less-than-sedentary findings were unsupported by the remainder of the medical evidence. We therefore conclude she has failed to show reversible error on this point relating to the treating physician analysis. Similarly, Ms. Franklin’s protestations that she has had many medical visits over the years for her physical conditions (averaging about ten per year from 2003 to 2008), and that she has taken many medications for these conditions, do not demonstrate reversible legal error in the ALJ’s treating physician analysis. The ALJ was not required to quantify precisely the number of times Dr. Thompson saw Ms. Franklin, and there is no indication he concluded that Dr. Thompson’s consultation with her was a limited one. The ALJ also acknowledged possible limitations on Ms. Franklin’s ability to concentrate, which Dr. Thompson had noted would be a side-effect of her medication, by including in his RFC a limitation that she “is able to sustain concentration necessary for [only] unskilled work.” Id. at 12. This evaluation was supported by substantial evidence. During his examination of Ms. Franklin, Dr. Brennan found her “alert and oriented,” with clear sensorium and one hundred percent intelligible speech. Id. at 205. In sum, we conclude that Ms. Franklin has failed to demonstrate reversible legal error or lack of substantial evidence in the ALJ’s treating physician analysis. -14-