United States District Court, W.D. Virginia, Danville Division
REPORT AND RECOMMENDATION
JOEL C. HOPPE, Magistrate Judge.
Plaintiff Lacy Barksdale asks this Court to review the Commissioner of Social Security's ("Commissioner") final decision denying his application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. Barksdale objects to the Administrative Law Judge's ("ALJ") finding that his back pain was a "non-severe impairment, " the ALJ's determination of his residual functional capacity, and the ALJ's reliance on the Medical-Vocational Guidelines ("the grids") to effectively direct a finding of "not disabled" in his case. He urges the Court to reverse the Commissioner's decision and to award benefits, or to remand his case for further administrative proceedings.
This Court has authority to decide Barksdale's case under 42 U.S.C. § 405(g), and his case is before me by referral under 28 U.S.C. § 636(b)(1)(B) (ECF No. 14). After reviewing the administrative record, the parties' briefs, and the applicable law, I find that substantial evidence supports the Commissioner's final decision that Barksdale was not disabled. Therefore, I recommend that the Court affirm the Commissioner's final decision.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner's final decision that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); see also Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court's role, however, is limited-it may not "reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment" for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether the ALJ applied the correct legal standards and whether substantial evidence supports the ALJ's factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).
"Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). It is "more than a mere scintilla" of evidence, " id., but not necessarily "a large or considerable amount of evidence, " Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); see also Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951). Ultimately, this Court must affirm the ALJ's factual findings if "conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.'" Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal quotation marks omitted)). However, "[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law." Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
A person is "disabled" if he or she is unable 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." 42 U.S.C. § 423(d)(1)(A); 20 C.F.R. § 404.1505(a). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant: (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act's regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work. See 20 C.F.R. § 404.1520(a)(4); see also Heckler v. Campbell, 461 U.S. 458, 460-62 (1983). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Barksdale protectively filed for DIB on May 24, 2011, alleging disability beginning April 30, 2011. (R. 61.) He was 59 years old and had worked for many years in the construction industry. (R. 61, 63.) Barksdale said that he could not work anymore because of "Raynaud's disease in [his] hands and feet, inflammation in [his] lower back, and muscle spasms." (R. 61.) A state agency twice denied his application in 2011. (R. 68-69, 78.)
Barksdale appeared with counsel at an administrative hearing on August 16, 2012. (R. 28.) He testified as to his work history, his current symptoms, and the limiting effects of his conditions. (R. 31-56.) No one else testified at Barksdale's hearing. ( See R. 27.) In a written decision dated September 11, 2012, the ALJ concluded that Barksdale was not entitled to disability benefits. (R. 22, 24-25.)
The ALJ found that Barksdale suffered from severe Raynaud's syndrome but that this impairment did not meet or medically equal any of the impairments listed in the Act's regulations. (R. 19, 21.) He also found that Barksdale's alleged "impairment of lower back inflammation with muscle spasms" (R. 19) did "not even minimally affect [Barksdale's] ability to work, so it [was] a non-severe impairment" (R. 20).
The ALJ next determined that Barksdale had the residual functional capacity ("RFC") to "perform a full range of work at all exertional levels, " but must "avoid all exposure to extreme cold." (R. 22.) At step four, the ALJ found that Barksdale could not return to his past work as a construction foreman because his RFC "limits [him] to avoidance of exposure to extreme cold, " and "evidence indicates that [his] past work presents exposure to weather condition changes." (R. 24 (citing R. 77).)
At step five, the ALJ used grid Rule 204.00 as a "framework" for finding Barksdale "not disabled" based on his age, education, work history, and ability to perform essentially a full range of unskilled work at any exertion level. (R. 25.) Thus, the ALJ denied Barksdale's application because he found that Barksdale was not disabled between April 30, 2011, and September 11, 2012. (R. 25.) The Appeals Council declined to review the ALJ's decision on June 13, 2013 (R. 3-4), and this appeal followed.
On appeal, Barksdale objects to the ALJ's finding that his back pain was a "non-severe impairment" and that it did not affect his RFC, to the scope of the environmental restriction in the ALJ's final RFC determination, and to the ALJ's reliance on the grids to effectively direct a finding of "not disabled" in his case. ( See generally Pl. Br. 13-17, 19-21.)
A. Relevant Evidence
1. Medical Evidence
Barksdale sought medical treatment five times between March 2011 and April 2012. On March 18, 2011, Barksdale reported to physician's assistant Debra Cobbeldick that he had experienced back and bilateral hand pain for the past "three to four years." (R. 256.) He explained that he had worked outdoors doing heavy labor for most of his adult life and "that his hands get numb and turn white in the cold." ( Id. ) He also said that his "back muscles tighten up" when he wears his safety harness and that he was "in pain just about every day." ( Id. )
On exam, Cobbeldick observed poor circulation in Barksdale's right hand and noted that his "hands would turn white when cooled." ( Id. ) She also observed "slight tenderness in the lumbar area" with "intact" range of motion. ( Id. ) A lumbar x-ray showed "good disk [ sic ] space and good space for the nerves and no obvious problems in the back." ( Id. ) Cobbeldick assessed low-back strain and recommended that Barksdale treat his pain with heat and Flexeril. ( See id. ) She advised Barksdale that amlodipine, which his family physician had already prescribed, was "the best drug he could take" for Raynaud's disease, but recommended that he add once-daily baby Aspirin. ( Id. ) She also "counseled [Barksdale] on smoking and Raynaud's syndrome that he would do much better if he would quit[;]... he was not open to the idea." ( Id. ) Cobbeldick instructed Barksdale to return as needed if his back pain got worse. ( See id. )
Barksdale visited Volens Family Practice for "back pain" on April 19, 2011. (R. 252.) He specifically denied musculoskeletal stiffness, reduced range of motion, unrelenting pain at rest, numbness, or reduced functional abilities. ( Id. ) He also denied having been diagnosed with inflammatory diseases including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. ( See id. ) Barksdale reported that he took Flexeril (cyclobenaprine Hcl), Naprosyn (naproxen), and amlodipine. ( Id. ) Dr. Paul Buckman, M.D., noted that Barksdale's Raynaud's disease was "chronic, not controlled" (R. 254), although he did not note that Barksdale reported any symptoms related to his Raynaud's at this visit ( see R. 252-54). Dr. Buckman added once-daily diltiazem to Barksdale's amlodipine. ( See R. 252, 254.)
On exam, Dr. Buckman observed "normal" gait and posture without evidence of scoliosis, but with signs of kyphosis and increased lumbar lordosis. ( Id. ) Barksdale experienced spinous process tenderness, paraspinal muscle tenderness, and paraspinal muscle tightness to palpation. (R. 253.) He also experienced pain rotating, bending laterally, and bending forward. ( See id. ) A straight-leg raising test was normal. ( Id. ) Dr. Buckman assessed "acute, moderate" back pain and administered four units of Kenalog 10mg. ( Id. ) He did not recommend further imaging studies, refer Barksdale to an orthopedic specialist or physical therapist, or suggest that Barksdale treat his back pain with anything besides heat and medication. ( See R. 252, 254.)
Dr. Catherine Howard, M.D., reviewed Barksdale's medical records for the state agency on July 22, 2011. ( See R. 64-69.) Dr. Howard found that Barksdale's back pain was a "severe" medically determinable impairment ("MDI"), but she also found that Barksdale's back pain caused no functional limitations. (R. 64-65.) Rather, Dr. Howard opined that Barksdale could work at any exertion level if he "avoid[ed] all exposure" to "extreme cold." (R. 66.)
Barksdale returned to Dr. Buckman's office on July 29, 2011, complaining of fatigue and excessive sleeping. (R. 263.) He did not report any other symptoms at that time, and he was still taking Flexeril, Naprosyn, amlodipine, and diltiazem without reported side effects. ( See R. 263-66.) On exam, Dr. Buckman observed that Barksdale's gait was "normal" and that he did not experience pain to palpation along the neck, thoracic spine, or lumbar spine. (R. 264.) He did not note any abnormalities such as kyphoscoliosis, scoliosis, lumbar lordosis, or paraspinal muscle tightness. ( See R. 264.) Dr. ...