United States District Court, D. Arizona
BRIDGET S. BADE, Magistrate Judge.
Wanda Kay Clark (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for disability and disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court affirms the Commissioner's disability determination.
I. Procedural Background
On November 23, 2009, Plaintiff applied for disability and disability insurance benefits under Title II of the Act alleging disability beginning May 14, 2009. 42 U.S.C. § 401-34. (Tr. 128-34, 144.) After the Social Security Administration (SSA) denied Plaintiff's initial application and her request for reconsideration, she requested a hearing before an administrative law judge (ALJ). (Tr. 59-62, 65-69.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 14-21.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 2-7); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).
II. Medical Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's health. The record also includes opinions from State Agency Physicians, who examined Plaintiff or reviewed the records related to her health, but who did not provide treatment, and opinions from lay witnesses.
A. Treatment Record
In May 2009, Plaintiff went to an urgent care clinic reporting that she had injured her back three weeks earlier while lifting boxes at work. (Tr. 220.) Plaintiff complained of pain in her back and right leg. ( Id. ) The physician assistant who treated Plaintiff observed that she was in no apparent distress and that she had muscle spasms in her back, but no skeletal tenderness or deformity. (Tr. 221.) He assessed sciatica, prescribed medication, advised Plaintiff to avoid heavy lifting, and instructed her to return for a follow-up appointment in one week. (Tr. 220-22, 226, 230.)
In June 2009, Plaintiff visited the same urgent care clinic. (Tr. 211.) At that time, she had completed a full week of work and complained that her symptoms were worse. ( Id. ) On June 8, 2009, an MRI of Plaintiff's back showed "[p]ostoperative changes with laminectomy defects at L4-5 and L5-S1, ... some scar formation along the left lateral surface of the thecal sac at L4-L5, [m]inimal bulging of the L1-L2 through L4-L5 discs without focal herniation, ... some foraminal narrowing at L4-L5, [and] severe degeneration of the disc space at L5-S1." (Tr. 208-09.)
On June 16, 2009, Plaintiff sought treatment from Ronney Ferguson, M.D. (Tr. 223.) He reviewed the June 2009 MRI and found that it showed "some slight amount of disc bulging, " but no nerve root effacement or compression. (Tr. 234.) Dr. Ferguson diagnosed "lumbar strain with lumbar spondylosis and without myelopathy." ( Id. ) He released Plaintiff from work for eight weeks and prescribed physical therapy. (Tr. 233-34, 237-39, 240-45, 300, 430-36.)
Between October and November 2009, Plaintiff received treatment from Belinda Uhall, M.D. (Tr. 260-67.) After her initial visit with Plaintiff, Dr. Uhall noted that Plaintiff was in "no distress." (Tr. 264.) She assessed Plaintiff with chronic low back pain, insomnia, anxiety disorder, and cigarette abuse. (Tr. 267.) She advised Plaintiff to stop smoking. During a November 23, 2009 appointment, Dr. Uhall noted that medication had "significantly helped" Plaintiff to sleep and manage her pain during the day. (Tr. 261.) During a November 30, 2009 appointment, Dr. Uhall noted that Plaintiff had a cough, sinus pain, and a headache. (Tr. 260.) She assessed "acute bronchitis" and advised Plaintiff to stop smoking. ( Id. )
On Dr. Uhall's referral, in October 2009, Plaintiff saw Steven Helland, M.D., at the Spine Care Institute for her chronic low back pain. (Tr. 248.) She reported that medication provided mild, temporary relief from her pain, and that physical therapy aggravated her symptoms. (Tr. 248-49.) On examination, Plaintiff had a limited range of motion in her back and positive straight leg raising test. (Tr. 251.) She exhibited full (5/5) muscle strength and did not have any obvious sensory deficits. ( Id. ) Dr. Helland assessed lumbar/sacral degenerative disc disorder, lumbar radiculopathy and neuritis, and lumbar/sacral spondylosis. ( Id. ) Dr. Helland administered a series of injections to Plaintiff's lumbar spine. (Tr. 248-52, 255-58, 304-10.) In late November 2009, Plaintiff reported that she was "somewhat pleased" with the results of the injections. (Tr. 261.) In December 2009, Dr. Helland noted "relatively modest therapeutic improvement." (Tr. 305.)
During 2009 and 2010, Plaintiff also received treatment at the Summit Healthcare Community Clinic (Summit). (Tr. 324-25, 342, 344-48, 362-63, 365-76.) During a July 2010 appointment, Plaintiff complained of pain in her hands, knees, and shins. (Tr. 326-27.) Plaintiff denied swelling or inflammation and examination showed that her joints were not swollen or red. (Tr. 327.) Plaintiff exhibited full mobility in her joints and she refused to participate in range of motion testing, asserting that she was afraid of pain. ( Id. ) Plaintiff had various laboratory tests at Summit, including a blood test showing elevated levels of C reactive protein (a protein produced by the liver). (Tr. 350.) A July 20, 2010 treatment note states that the test results were inconclusive. (Tr. 335.)
During a March 2011 appointment at Summit, Plaintiff reported a headache related to an upper respiratory infection and diarrhea. (Tr. 324.) Under a section labelled "Past, Family, and Social History, " the treatment provider who completed the treatment note indicated that Plaintiff smoked and wrote "COPD." ( Id. ) However, COPD was not included among Plaintiff's diagnoses. (Tr. 324-25; Tr. 345 (assessing acute bronchitis, not COPD).)
In December 2011, Plaintiff presented to Osaf Ahmed, M.D., "[t]o establish care." (Tr. 416.) Plaintiff reported that, once or twice a week, she experienced diarrhea "all day." ( Id. ) She also reported headaches and pain "all over." ( Id. ) Plaintiff reported a past diagnosis of COPD, but did not complain of any respiratory issues. (Tr. 417.) Dr. Ahmed noted that he did not have significant past medical records related to Plaintiff's health. (Tr. 416-17, 424.) Because his examination of Plaintiff showed evidence of synovitis (Tr. 417), and blood tests showed a rheumatoid factor of 1450 (Tr. 422), Dr. Ahmed referred Plaintiff to the Mayo Clinic for "arthraigia/stiffness" and "elevated RF, R/O RA." (Tr. 411-12.)
B. Medical Opinion Evidence
1. Robert Barker, M.D.
On September 8, 2010, Plaintiff was examined by State Agency Physician Robert Barker, M.D., for her application for disability benefits. (Tr. 291.) Plaintiff complained of back pain from her tailbone to her neck, and some leg pain. ( Id. ) She denied fatigue, weakness, headaches, pulmonary difficulty, bowel, or incontinence issues. (Tr. 292.)
On examination, Plaintiff "sat comfortably, stood up symmetrically", and was able to heel-walk, toe-walk, and squat and rise without assistance. ( Id. ) Her straight leg raising was negative and an examination of her back did not show any muscle spasms. ( Id. ) Plaintiff had full muscle strength, normal reflexes, and intact sensation. ( Id. ) She demonstrated full range of motion in all of her joints except her back. ( Id. ) Dr. Barker observed Plaintiff bend over ninety degrees without evidence of discomfort when she took her shoes on and off. ( Id. ) However, when he asked Plaintiff to "forward flex, " she bent only about twenty degrees before complaining of pain. ( Id. ) Additionally, her lateral movement was "barely perceptible." (Tr. 293.) Dr. Barker found that Waddell's testing was positive in the following five categories: (1) Plaintiff reported superficial and non-anatomic tenderness; (2) Plaintiff reported pain with simulated axial rotation; (3) Plaintiff overreacted to testing; (4) Plaintiff reported regional weakness or sensory changes that deviated from accepted neuroanatomy; and (5) Plaintiff performed normally when distracted. ( Id. ) Dr. Barker found that Plaintiff had a normal examination. ( Id. )
Dr. Barker completed a "Medical Source Statement of Ability to do Work Related Activities (Physical), " on which he opined that Plaintiff could occasionally lift fifty pounds and frequently lift twenty-five pounds. (Tr. 294.) He found Plaintiff unlimited in her abilities to sit, stand, or walk. ( Id. ) He also found that Plaintiff had no postural or environmental limitations. (Tr. 295.)
2. Dr. Ahmed
In December 2011, Dr. Ahmed completed several forms regarding Plaintiff's functional abilities, including headache and fatigue questionnaires and an assessment of her ability to perform work-related activities. (Tr. 407-10.) Dr. Ahmed opined that, in an eight-hour day, Plaintiff could sit for a total of four hours, stand or walk for a total of two hours, frequently lift ten pounds, occasionally lift twenty pounds, and never lift more than twenty pounds. (Tr. 409.)
He found that Plaintiff had eight to ten headaches per month that affected her concentration, attention, memory, and ability to work. (Tr. 407.) He also opined that Plaintiff's fatigue caused "marked" limitations in her abilities to understand and remember short, simple and detailed instructions. (Tr. 408.) He opined that fatigue caused "moderate" limitations in Plaintiff's abilities to carry out short, simple instructions, interact appropriately with the public, co-workers, and supervisors, and to respond to work pressures. ( Id. ) He concluded that Plaintiff's fatigue would cause her to be "off task" for five hours during an eight-hour day. ( Id. ) To support of these opinions, Dr. Ahmed noted "possible rheumatoid arthritis." ( Id. )
C. Lay Witness Statements
In May 2010, Plaintiff's friend, Thomas Thompson, completed a Function Report about Plaintiff's activities for her application for disability benefits. (Tr. 166.) Thompson said that he spent two to three hours a day with Plaintiff. ( Id. ) He reported that Plaintiff provided food and water for her pets, watched television, read, prepared dinner ("most of the time"), performed light cleaning, did laundry (with her husband), watered the yard, drove, and ...