Brockhouse v. Commissioner of Social Security
Filing
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OPINION entered by Judge Richard Mills on 03/03/2016. SEE WRITTEN OPINION. The Plaintiff's Motion for Summary Reversal (d/e 12 ) is DENIED. The Defendant's Motion for Summary Affirmance (d/e 15 ) is ALLOWED.The Clerk will enter a Judgment affirming the Commissioner's decision and terminating this case. (DM, ilcd)
E-FILED
Friday, 04 March, 2016 05:31:41 PM
Clerk, U.S. District Court, ILCD
IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION
JAYSON K. BROCKHOUSE,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.
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NO. 12-3292
OPINION
RICHARD MILLS, U.S. District Judge:
Plaintiff Jayson K. Brockhouse filed applications for Disability
Insurance Benefits under Title II and Supplemental Security Income
benefits under Title XVI of the Social Security Act. Pursuant to 42 U.S.C.
§ 405(g), the Plaintiff seeks judicial review of an unfavorable decision.
Pending before the Court are the Plaintiff’s Motion for Summary
Reversal and the Defendant’s Motion for Summary Affirmance.
Plaintiff’s Motion is denied.
Commissioner’s Motion is allowed.
I. BACKGROUND
Jayson K. Brockhouse filed his applications on April 1, 2009, alleging
an onset date of July 29, 2008. The Plaintiff was almost 39 years old at the
time of his alleged onset date. Prior to July of 2008, the Plaintiff worked as
a construction worker.
A. Hearing testimony
The Plaintiff testified he has an Associate’s Degree as a distribution
lineman, but needs help reading because he is dyslexic. He testified he has
experienced constant headache pain since being hit on the head at work.
The Plaintiff has never received care from a mental health professional and
denied feeling depressed.
The Plaintiff, who is from Winchester, Illinois, testified that his
activities are limited. He stated that he drove to Peoria two weeks earlier
to attend a state championship basketball game, though he had to go home
prior to one of the games that he wanted to see.
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The Plaintiff testified that lifting a gallon of milk would cause him to
experience a shooting pain down his arm and back. Although he is able to
lift his arms over his head, the Plaintiff stated such a maneuver would cause
him pain.
The vocational expert, Dennis Gustafson, noted that Plaintiff had two
past relevant jobs, both of which were performed at a heavy exertional level.
The ALJ posed a hypothetical to the vocational expert regarding a person
of the Plaintiff’s age, education and work experience who could lift 20
pounds occasionally and 10 pounds frequently, but could not climb ladders,
ropes and scaffolds. The person could occasionally climb ramps and stairs
and could engage in overhead reaching occasionally. He would have to
avoid concentrated exposure to extreme cold, noise and vibration.
The vocational expert testified such a person could not perform either
of the Plaintiff’s past jobs. However, the individual could perform unskilled
light jobs which include 14,210 jobs in Illinois as a housekeeper/cleaner,
44,800 jobs as a cashier (falling under the classification of cashier II), and
18,000 jobs in Illinois as a production worker (hand assembly). An example
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of such a job would be as a mold sheet cleaner. The vocational expert
testified the person could also work in hand packaging. He identified
21,130 jobs in Illinois as a bottling line attendant.
The vocational expert testified this information was consistent with
that contained in government publications, including Dictionary of
Occupational Titles.
B. Medical evidence
On June 4, 2008, the Plaintiff saw his primary care physician,
Marshall Hale, M.D., complaining of neck pain. The Plaintiff was treated
at Heartland Chiropractic from September of 2007 through October of
2008 for neck pain. An examination on October 23, 2008 revealed a
positive foraminal compression test bilaterally and a positive hyperextension
compression test.
On June 15, 2009, the Plaintiff saw Joseph Kozma, M.D., for a
consultative examination. Dr. Kozma observed that Plaintiff had been
healthy until suffering an injury, a blow on his head with a hard hat. Dr.
Kozma described a person with good grip strength and finger dexterity, who
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could use his hands for fine manipulations. Although the Plaintiff stated his
fingers tingled at times, Dr. Kozma did not observe that during the
examination. The Plaintiff was able to walk without difficulty. He reported
difficulty mowing his lawn with a push mower. Although he had some
discomfort turning his head, the Plaintiff did not have permanent joint
abnormalities.
Dr. Kozma found no evidence of a hearing problem.
Moreover, Dr. Kozma found that Plaintiff’s daily activities were affected
“very little” by his injury.
Dr. Kozma’s diagnoses included (1)
posttraumatic condition of the cervical spine; (2) decreased range of motion
of the cervical spine; (3) slight decrease range of motion of both shoulders;
(4) slight memory loss; (5) hearing difficulty that is intermittent; and (6)
hypertension, under treatment, controlled.
On June 4, 2009, an x-ray revealed mild degenerative changes at the
C6-C7 disc space level and no recent or destructive pathology. A June 8,
2009 MRI revealed broad-based disc bulges causing probable clinically
significant lateral recess narrowing and cord signal changes at C5-C6 and
C6-C7.
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On June 16, 2009, the Plaintiff saw Stephen Pineda, M.D., who noted
the incident in which a co-worker struck the Plaintiff on the head and broke
his hard hat. Dr. Pineda reviewed the MRI that showed fairly significant
disc disease that was most notable at C5-6 and C6-7. The MRI showed
osteophyte and disc present in the strictures. Dr. Pineda explained that this
caused narrowing of the spine and would subsequently leave the spinal cord
with limited space. Dr. Pineda also observed some spinal cord compression.
The Plaintiff had a questionable Hoffman sign of the hands. Dr. Pineda was
unable to elicit a triceps reflex. Dr. Pineda advised the Plaintiff to avoid
risks of falls, as well as ladders or climbing or other activities that could put
him at risk. He recommended a course of therapy and exercise.
O
n
November 5, 2009, the Plaintiff saw David T. Volarich, D.O., for an
independent medical examination. Dr. Volarich found mild asymmetry in
bulk in the upper and lower extremities.
Strength in the right upper
extremity was diffusely weak measuring 4.5/5. The left upper extremity was
diffusely weak measuring 3/5. In the lower extremities, the left calf was
weak to dorsiflexion and plantar flexion measuring 4/5. Examination also
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revealed diminished pin prick sensation throughout both the upper and
lower extremities, as well as the torso. The Plaintiff’s gait was noted as
walking with a limp, favoring the left. The Plaintiff was unable to toe walk
due to left leg weakness. He could only stand on the right foot for four
seconds and on the left foot for two seconds before losing balance. The
Plaintiff was able to squat half of normal before stopping because of leg
weakness.
Cervical range of motion was reduced in all directions.
Additionally, the Plaintiff’s extension, left rotation and left lateral flexion
were reduced more than 80%.
On December 16, 2009, the Plaintiff was examined by Vittal V.
Chapa, M.D., S.C., at the request of the agency. Dr. Chapa noted a
decreased range of motion of the cervical spine. He noted that Plaintiff has
a history of headaches which are related to his neck pain.
On January 20, 2010, the Plaintiff saw James T. Doll, D.O., for an
independent medical examination. Dr. Doll noted that Plaintiff worked for
approximately two months after his head injury. The Plaintiff reported
minimal daily activities due to his symptoms.
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He would occasionally
perform household chores and yard work for brief periods of time.
Dr. Doll found that the May 30, 2008 work incident did not cause the
Plaintiff’s multilevel degenerative condition of the cervical spine, chronic
neck pain and, limited motion or other symptoms. That condition was
preexisting is naturally progressive and degenerative over time.
On February 5, 2010, a physical residual functional capacity (RFC)
was performed by James Madison, M.D. Dr. Madison opined that Plaintiff
could occasionally lift 20 pounds, frequently lift 10 pounds, stand and/or
walk 6 hours in an 8 hour workday and sit about 6 hours total. He had
limited the Plaintiff to occasional postural maneuvers but never ladders,
ropes, or scaffolds. Reaching in all directions was limited to occasionally
bilaterally because it could exacerbate neck pain. The RFC indicated that
Plaintiff should avoid concentrated exposure to extreme cold, noise and
vibration.
An October 18, 2010 MRI of the cervical spine revealed a moderate
right central/posterior lateral disc protrusion along with an uncovertebral
osteophyte mildly flattening the ventral right aspect of the spinal cord and
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severe right neural foraminal stenosis at C5–6. At C6–7 there is a moderate
sized central disc protrusion superimposed on a diffuse disc bulge with
uncovertebral hypertrophy causing moderate to severe flattening of the
spinal cord and severe left neural foraminal stenosis.
On October 15, 2010, the Plaintiff was seen by Koteswara Narla,
M.D., for pain management. He complained of neck pain with tingling and
numbness in his hands and knees. The impression was cervical pain and
also burning sensation in hands. Dr. Narla was surprised that Plaintiff had
not been taking pain medications. Although he believed that the Plaintiff’s
loss of sensation was likely nonphysiological, Dr. Narla prescribed
Neurontin. Dr. Narla was reluctant to proceed with any steroid injections.
On January 13, 2011, Dr. Narla administered an epidural steroid
injection at C6–7.
On April 30, 2011, at the request of the administrative law judge
(“ALJ”), Kenneth L. Cloninger, M.D., filled out a form entitled Medical
Source Statement of Ability To Do Work-Related Activities. Dr. Cloninger
found that Plaintiff could occasionally lift up to twenty pounds and
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frequently lift up to ten pounds. He could sit for four hours at a time and
for six hours in an eight-hour day, stand for one hour at a time and for two
hours in an eight-hour day and walk for one hour at a time and for two
hours during an eight-hour day.
The Plaintiff could reach overhead
occasionally, and reach in other directions frequently. He could perform
handling, fingering and feeling occasionally and pushing/pulling frequently.
Dr. Cloninger prohibited the climbing of ladders and scaffolds but found
that other postural activities, including climbing stairs and ramps, could be
performed occasionally. Dr. Cloninger also prohibited any working at
unprotected heights. The Plaintiff was limited to only occasional exposure
to moving mechanical parts, operating a motor vehicle, extreme cold and
heat. Dr. Cloninger identified mild to cognitive dysfunction. He found that
Plaintiff had positive bilateral Hoffman’s signs, decreased Babinski and
positive Lhermitts sign. Dr. Cloninger noted the MRI showed spinal cord
compression.
C. ALJ’s decision
On August 22, 2011, ALJ Gerard J. Rickert issued a decision, finding
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that Plaintiff has not been under disability since July 29, 2008.
The ALJ found that Plaintiff has not engaged in substantial gainful
activity since his alleged onset date of July 28, 2008. At step two, the ALJ
identified a closed head injury and recurrent headaches as severe
impairments.
At step three, the ALJ determined that Plaintiff’s
impairments, whether considered individually or in combination, did not
meet or equal the requirements of any listed impairment. The ALJ observed
that Plaintiff’s closed head injury did not meet Listing 11.18, finding that
it had not resulted in cerebral trauma. Moreover, no listing existed that
specifically addressed headaches.
The ALJ also found that Plaintiff retained the RFC to perform a
limited range of light work that precluded him from climbing ladders, ropes
or scaffolds. He could only occasionally climb ramps and stairs and could
engage in overhead reaching on an occasional basis and he must avoid
concentrated exposure to cold, noise and vibrations. The ALJ cited what he
found to be inconsistencies which led to an adverse credibility finding. At
step four, the ALJ found that Plaintiff could not perform any of his past
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jobs.
At step five, the ALJ relied on vocational expert testimony, in
conjunction with the medical-vocational guidelines, to find that Plaintiff was
not disabled because he could perform a significant number of light jobs as
a housekeeper, cashier II, production worker, mold sheet cleaner, and hand
packager and bottle line attendant.
II. DISCUSSION
A. Standard of review
“The findings of the Commissioner of Social Security as to any fact,
if supported by substantial evidence, shall be conclusive.” 42 U.S.C. §
405(g). Pursuant to section 205(g) of the Social Security Act, the ALJ’s
decision must be upheld if it is supported by substantial evidence. See
Moore v. Colvin, 743 F.3d 1118, 1120 (7th Cir. 2014). “Substantial
evidence” includes “such relevant evidence as a reasonable mind accepts as
adequate to support a conclusion.” Id. (citations omitted). The ALJ’s
decision must include a “logical bridge from the evidence to the conclusions
sufficient to allow . . . a reviewing court[] to assess the validity of the
agency’s ultimate findings and afford [the Plaintiff] meaningful judicial
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review.” Id. This Court may not substitute its judgment for that of the ALJ
“by reconsidering facts, reweighing evidence, resolving conflicts in evidence
or deciding questions of credibility.” Williams v. Apfel, 179 F.3d 1066,
1071-72 (7th Cir. 1999) (citation omitted).
B. Plaintiff’s limitations due to headaches
The Plaintiff first alleges that the ALJ violated Social Security Ruling
(“SSR”) 96-8p by not considering the effect of the Plaintiff’s headaches on
his ability to work, despite finding them to be a severe impairment. The
decision concluded that Plaintiff could perform light work as noted above.
An RFC assessment determines the most work that a person can
perform regularly despite any limitations. See 20 C.F.R. § 404.1545(a)(1);
SSR 96-8p. An RFC assessment must be “based on all of the relevant
evidence in the case record,” including medical source statements. See SSR
96-8p. SSR 96-8p instructs ALJ’s to consider a claimant’s work-related
abilities on a function-by-function basis, despite any limitations. See Pepper
v. Colvin, 712 F.3d 351, 362 (7th Cir. 2013). The RFC determination
should logically connect the evidence to the ALJ’s conclusion. See Jones v.
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Astrue, 623 F.3d1155, 1160 (7th Cir. 2010). The ALJ “must also explain
how any material inconsistencies or ambiguities in the evidence in the case
record were considered and resolved.” SSR 96-8p.
The Plaintiff contends the ALJ’s decision failed to identify any
limitations caused by the Plaintiff’s headaches. Moreover, it does not
discuss the severity, frequency, duration or intensity of the headaches or
how the headaches affect the Plaintiff. The Plaintiff further asserts that the
ALJ does not explain how the exposure to cold, noise and vibration affects
the Plaintiff’s headaches, even though the decision restricts the Plaintiff
from such exposure.
As the Commissioner alleges, there is no record evidence that any of
the doctors who evaluated the Plaintiff found any limitations due to
headaches.
Although Dr. Kozma observed that Plaintiff had frequent
headaches, he did not note any limitations as a result. Dr. Volarich did not
find that Plaintiff was disabled due to headaches. Dr. Chapa also noted a
history of headaches but did not list any limitations. Although the Plaintiff
reported frequent headaches to Dr. Doll, Dr. Doll did not identify
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headaches among his diagnoses. Dr. Cloninger’s evaluation included a
detailed discussion of the Plaintiff’s medical issues but also did not mention
headaches.
The Court concludes that Plaintiff has not demonstrated that he has
limitations due to headaches. The ALJ did not commit error by failing to
articulate limitations that no doctor found. Accordingly, the ALJ’s decision
on this issue is supported by substantial evidence.
C. ALJ’s RFC assessment
The Plaintiff also asserts the ALJ’s RFC assessment was conclusory and
fails to contain rationale or reference to the supporting evidence and is thus
not supported by substantial evidence. He claims the ALJ did not account
for Dr. Volarich’s restrictions or Dr. Doll’s report.
In stating that “the record does not demonstrate clearly that he has
the significantly limited range of motion, muscle spasms, muscle atrophy,
motor
weakness,
sensation
loss,
difficulty
ambulating,
or
reflex
abnormalities which are associated with intense and disabling pain,” see R.
at 23, the Plaintiff contends the ALJ is ignoring objective medical findings
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which include weakness in upper and lower extremities, decreased pin prick
sensation in the extremities, decreased range of motion in the cervical spine,
positive Hoffman’s sign, decreased grip strength and a positive MRI showing
increased T2 signal changes and positive cord compression in the cervical
spine.
The Plaintiff contends that the decision ignores these medical findings,
in addition to those of Dr. Cloninger, and generally cites the alleged lack of
objective medical findings and resulting limitations. The ALJ does not
specify precisely what this evidence is or explain why most of Dr.
Cloninger’s objective conclusions are rejected.
As the Commissioner alleges, however, there is significant agreement
as to certain restrictions. The ALJ found that Plaintiff could lift up to 20
pounds occasionally and ten pounds frequently, which is consistent with Dr.
Cloninger’s opinion.
Light work is also defined as sitting for two hours in an eight-hour
work day and standing/walking for the other six working hours. See 20
C.F.R. § 404.1567(b). Dr. Cloninger found that Plaintiff was capable of
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standing/walking for a total of four hours in an eight-hour day instead of six,
as found by the ALJ. Dr. Cloninger found that Plaintiff could sit for six
hours in an eight-hour day.
As the Commissioner alleges, the ALJ’s
assessment as to sitting and standing/walking is only slightly different from
that of Dr. Cloninger and it is supported by the opinion of Dr. Kozma, who
stated that Plaintiff was able to walk without difficulty.
Based on the foregoing, there is evidence supporting the ALJ’s
assessment as the Plaintiff’s ability to lift, sit, stand/walk. To that extent,
therefore, the Court finds the ALJ’s RFC assessment is supported by
substantial evidence.
There is other evidence in the record which supports the ALJ’s
findings.
Although Dr. Doll found a positive Hoffman’s sign in the
Plaintiff’s hands which could indicate problems with the spinal cord and the
loss of grip strength, Dr. Kozma found that Plaintiff had good finger
dexterity and grip strength. Dr. Pineda recommended only that Plaintiff
avoid falls, a limitation with which Dr. Doll agreed. The ALJ accounted for
this limitation by prohibiting the Plaintiff from climbing ladders, ropes and
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scaffolds and noting he could only occasionally climb ramps and stairs.
Although Dr. Volarich recommended that Plaintiff should change
positions frequently to maximize comfort and rest when he needed, this
recommendation is not included in the ALJ’s RFC finding. Even if this
restriction were imposed, however, the Court has no basis to find that any
of the six unskilled, light jobs identified by the vocational expert would be
eliminated.
For all of these reasons, the Court finds that the ALJ’s determination
is supported by substantial evidence.
Ergo, the Plaintiff’s Motion for Summary Reversal [d/e 12] is
DENIED.
The Defendant’s Motion for Summary Affirmance [d/e 15] is
ALLOWED.
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The Clerk will enter a Judgment affirming the Commissioner’s
decision and terminating this case.
ENTER: March 3, 2016
FOR THE COURT:
s/Richard Mills
Richard Mills
United States District Judge
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