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Reynolds v. Commissioner of Social Security

United States District Court, W.D. Virginia, Danville Division

February 6, 2017

KENT REYNOLDS, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          REPORT AND RECOMMENDATION

          Joel C. Hoppe United States Magistrate Judge

         Plaintiff Kent Reynolds 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 (the “Act”), 42 U.S.C. §§ 401-434. The case is before me by referral under 28 U.S.C. § 636(b)(1)(B). ECF No. 13. Having considered the administrative record, the parties' briefs, and the applicable law, I find that the Commissioner's decision is supported by substantial evidence. Therefore, I recommend that the Court DENY Reynolds's motion for summary judgment, ECF No. 14, GRANT the Commissioner's motion for summary judgment, ECF No. 16, and 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); 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 Administrative Law Judge (“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 Universal Camera Corp. v. NLRB, 340 U.S. 474, 487-89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984). 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)). 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 to 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 Heckler v. Campbell, 461 U.S. 458, 460-62 (1983); 20 C.F.R. § 404.1520(a)(4). 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

         Reynolds applied for DIB on June 19, 2012, alleging disability caused by arthritis, cervical stenosis, and sensory loss in the left arm. Administrative Record (“R.”) 58, ECF No. 10. At the time of his alleged onset date of July 13, 2011, Reynolds was forty-six years old. Id. Disability Determination Services (“DDS”), the state agency, denied his claims at the initial, R. 58-66, and reconsideration stages, R. 69-79. On May 1, 2014, Reynolds appeared with counsel at an administrative hearing before ALJ Marc Mates. R. 40-57. Reynolds testified about his past work, medical conditions, and the limiting effect these conditions had on his daily activities. See R. 42-51. A vocational expert (“VE”) also testified at this hearing regarding the nature of Reynolds's past work and his ability to perform other jobs in the national and local economies. See R. 51-56.

         ALJ Mates denied Reynolds's claim in a written decision issued on June 25, 2014. R. 20- 33. ALJ Mates found that Reynolds had severe impairments of degenerative disc disease, left arm difficulty, hypertension, and diabetes mellitus, but that these impairments did not meet or medically equal the severity of a listed impairment. R. 22-23. As to Reynolds's residual functional capacity (“RFC”), the ALJ found that he could perform sedentary work, [1] but must avoid concentrated exposure to heights and more than occasional use of the non-dominant (i.e., left) hand for overhead reaching and gross and fine manipulation. R. 23-32. Relying on the RFC and the testimony of the VE, the ALJ found that Reynolds could not perform his past relevant work, but could perform jobs existing in the national and local economies, including surveillance system monitor and call-out operator. R. 32-33. Therefore, ALJ Mates determined that Reynolds was not disabled. R. 33. The Appeals Council denied Reynolds's request for review, R. 1-3, and this appeal followed.

         III. Facts

         A. Relevant Medical Evidence

         On March 23, 2006, X-rays of Reynolds's cervical spine revealed degenerative disc disease of the mid and lower cervical spine with disc space and bony neural foraminal narrowing at ¶ 4-C5, C5-C6, and C6-C7, and bony neural foraminal narrowing at ¶ 3-C4. R. 337. An MRI from April 4, 2006, also showed a large protrusion at ¶ 4-C5, a prominent bulge at ¶ 5-C6, and a disc osteophyte complex at ¶ 6-C7, all of which impressed the thecal sac. R. 335. The bulge at ¶ 5-C6 also caused significant impression on the spinal cord. Id.

         On July 14, 2011, a day after his alleged onset date, Reynolds visited one of his primary care physicians, John Hoffman, M.D., because his neck had been bothering him at work. R. 264. A physical exam showed a slight decrease in the range of motion in the neck and negative straight leg raise test. Id. Dr. Hoffman ordered imaging of the cervical spine to further assess the situation. Id. Radiology reports and an MRI, compared to Reynolds's 2006 MRI, showed interval progression of the disc disease, increased signal intensity with the cervical cord at ¶ 4, C5, C6, and development of gliosis of the cervical cord. R. 275, 276.

         On August 18, Reynolds saw John Jane, M.D., Ph.D., for a neurological consultation. R. 233-34. Dr. Jane reviewed the imaging, confirmed Reynolds had C4-C5, C5-C6, and C6-C7 disease on the left, and ordered a CT myelogram and electromyography (“EMG”) studies. R. 234. The studies revealed electrophysiological evidence of left chronic C7 radiculopathy with ongoing denervation, but no compelling evidence of polyneuropathy, R. 233, and significant neural foraminal stenosis and herniated nucleus pulposus at ¶ 6-C7, R. 223.

         On October 3, Reynolds presented to University of Virginia (“UVA”) Hospital East with a primary diagnosis of cervical stenosis. R. 223. His left arm was observed to be noticeably weak, particularly in the triceps and grip strength. Id. Based on his past medical history and his present symptoms, Reynolds was deemed a reasonable operative candidate, and Dr. Jane proceeded with a left C6-C7 foraminotomy and a left C6-C7 posterior diskectomy. R. 224. Dr. Jane subsequently referred Reynolds to physical therapy as part of his recovery. R. 456. Reynolds saw Christine Black, PT, DPT, roughly twice a week from October 13 through November 10. R. 428-51. PT Black discharged Reynolds on November 23, however, having failed to get in touch with him after several attempts. R. 422-25. She noted that Reynolds had denied experiencing improvement in symptoms and complained of increased pain. R. 425. She opined that extended therapy may be necessary to treat his severe symptoms. Id.

         On November 18, Reynolds returned to UVA and saw Thomas Szabo, PA. R. 226. PA Szabo noted that Reynolds had not done as well as expected following the surgery. R. 227. A physical exam revealed loss of fine touch sensation in the thumb, index, and middle fingers of both hands and in the left lateral forearm and triceps. Id. Reynolds had normal strength in both legs; findings of 5/5 for all motor tests in the right arm; 3 grip strength, 4 wrist flexion, 5/5 wrist extension, 5/5 biceps, 4 triceps, and 5/5 deltoid in the left arm; normal tandem gait; no Romberg's sign; and negative Lhermitte's sign and Spurling's test. Id. PA Szabo gave Reynolds a note to be off work until January 2, 2012, ordered a follow-up CT myelogram of the cervical spine, and started him on Neurontin. Id. The myelogram demonstrated that in spite of interval improvement, there still existed persistent moderate neuroforaminal narrowing at ¶ 6-C7 with resolution of the spinal canal stenosis, persistent moderate central canal stenosis at ¶ 4-C5 with mass effect on the spinal cord, and severe left-sided and moderate-to-severe right-sided neuroforaminal narrowing at ¶ 5-C6. R. 243.

         Reynolds continued to see a variety of medical providers in 2012. On January 11, 2012, he visited Dr. Jane, who indicated that although all the muscle groups in Reynolds's left side were weak, Dr. Jane felt it was effort dependent. R. 223. Neurological exam showed that Reynolds had a normal affect, full strength, and intact sensation to light touch and pinprick. Id.

         An EMG showed no active denervation. Id. Dr. Jane added:

I just don't know what further we can do from a surgical point of view. He has had physical therapy and injections without relief. . . . I don't think I am going to be able to come up with a plan that will relieve his pain, the significance of which is not clear to me.

Id.

         On January 13, Reynolds saw Dr. Hoffman, who found decreased range of motion in the neck, decreased grip strength on the left, and light touch sensation a little decreased over the thenor side as opposed to the ulnar. R. 261. Dr. Hoffman assessed cervical radiculopathy and hypertension. Id. Dr. Hoffman referred Reynolds to Neurology Associates of Lynchburg, Inc., where he saw Peter Konieczny, M.D., on February 3. R. 252. Dr. Konieczny performed a physical exam, which showed decreased muscle bulk in the left triceps, biceps, deltoid, and brachioradialis, but no evidence of fasciculations; weakness in the left biceps at 4 MRC, left triceps at 4, left finger and wrist extensors at 4-, and left deltoid at 4/5 MRC; full strength and normal muscle tone in the bilateral lower extremities; and decreased sensation to pin, vibration, and temperature in the left forehand and arm. R. 253. Dr. Konieczny explained that because of Reynolds's left hand weakness, he could not presently grasp or manipulate objects, and that his problems likely stemmed from a chronic history of cervical radiculopathy and the resultant neuropathic damage. Id. He did note, however, that it was unlikely that further cervical surgery would help Reynolds. Id. On March 5, Dr. Konieczny reaffirmed his view that Reynolds was not a surgical candidate, and he increased Reynolds's Neurontin dose. R. 251.

         Reynolds saw Dr. Hoffman again on March 29, this time complaining of trouble with his lower back and hips. R. 256. A physical exam revealed negative straight leg raise test, and Dr. Hoffman observed that Reynolds ambulated without too much difficulty and had fair range of motion in the lumbar spine, but still used his left arm sparingly. Id. Dr. Hoffman assessed low back pain, hip pain, and cervical stenosis, prescribed Tramadol, and ordered X-rays of the low back and hips. Id. The X-rays of the lumbar spine revealed fairly advanced facet degenerative changes at ¶ 5-S1 with approximately 7-8 mm of anterolisthesis of L5 on S1 and similar findings to a lesser degree at ¶ 4-L5. R. 274. The X-rays of the hips showed nearly normal findings, with only minimal degenerative narrowing bilaterally. Id. On April 5, Reynolds visited Dr. Konieczny, who noted a history of degenerative disc disease and osteoarthritis. R. 250. Dr. Konieczny explained that tripling the Neurontin dosage had provided only minimal-to-moderate pain relief. Id. He also indicated that he discussed further treatment options, including possibly a referral to a pain center, but that Reynolds wished to pursue more conservative options such as physical therapy first, which Dr. Konieczny thought were “perfectly appropriate at this stage.” Id.

         Reynolds began seeing PT Black again for physical therapy on April 12. R. 413. On examination, Reynolds demonstrated limited active range of motion of the lumbar spine, positive midline Slump Test, positive Neurotension Test on the right and left, and positive straight leg raise test on the right and left. R. 414. PT Black recommended physical therapy three times per week for twenty-four total visits, R. 415, which Reynolds attended until mid-July, R. 345. During these visits, PT Black assessed general improvement overall. See, e.g., R. 390 (decreased pain and progression without exacerbation on May 14), 380 (improved hip external rotation, flexion mobility, and range of motion as well as lumbar paraspinals on May 29), 378 (overall improvement in mobility on May 30), 366 (demonstrates improved range of motion and ability to ambulate three times the distance he had been walking without a break on June 13), 360 (improvements on straight leg raise test on June 20), 356 (improvement in subjective reports as well as great improvement in muscle mobility on June 27), 347-48 (note indicating slow progress towards goals on July 16).

         Reynolds saw Dr. Hoffman again on May 11, and Dr. Hoffman observed that Reynolds walked with a little bit of a limp on the left side and seemed to move his left arm okay. R. 255. He also noted that a straight leg raise test was negative. Id. Dr. Hoffman assessed cervical stenosis, low back pain, diabetes, and hypertension. Id. On May 15, Dr. Jane completed a musculoskeletal questionnaire regarding his treatment of Reynolds. R. 277-80. Dr. Jane diagnosed cervical stenosis and identified Reynolds's symptoms as including neck pain and pressure, numbness and weakness in the left arm, and tightness and numbness in the right hand. R. 277. Dr. Jane acknowledged that sensory loss and muscle weakness constituted positive objective signs of Reynolds's pain, R. 278, but further opined that no clinical findings or laboratory and test results provided an explanation for his symptoms, R. 277. Reynolds returned to Dr. Hoffman on July 26 and relayed that physical therapy had not been effective and that his neck and arm continued to hurt. R. 559. Dr. Hoffman noted that on examination, Reynolds walked stiffly, was well muscled, and had positive straight leg raise test near ninety degrees. R. 560.

         On August 13, Reynolds visited the Orthopaedic Center of Central Viginia and treated with Kamal Chantal, PA-C. R. 459-63. PA-C Chantal diagnosed spondylolisthesis, low back pain, lumbar spondylosis without myelopathy, and sciatica. R. 459. On examination, Reynolds walked with a normal, non-antalgic gait; was negative for Patrick's Faber test; experienced back pain with straight leg raise test on the right, but was negative on the left; was moderately restricted in flexion, extension, and lateral bending; and had no pain with hip motion. R. 459-60. PA-C Chantal also ordered an MRI of the lumbar spine, which showed a dominant finding of grade 2 spondylolisthesis of L5 on S1 secondary to bilateral pars defects of L5 with pseudodisc of listhesis severely narrowing the neural foramen and effacing the exiting L5 nerve roots bilaterally. R. 465. The MRI also showed mild-to-moderate foraminal narrowing at ¶ 4-L5, subtle retrolisthesis of L3 and L4, and abutment of the L4 nerve roots. Id. During a follow-up visit on August 29 to obtain the results of his MRI, PA-C Chantal scheduled Reynolds for a bilateral L5-S1 nerve root block (“NRB”), R. 466, which Joyce Huerta, M.D., administered on September 19, R. 474. On October 16, PA-C Chantal and Reynolds discussed further treatment options, including medications, more injections, physical therapy, and surgery. R. 491. Reynolds returned to his orthopedist's office on December 21, claiming that the pain in his lower back, which had been on the left side prior to the NRB, was now greater on the right. R. 495. Jesse Stem, M.D., who had been ...


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