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Fields v. Commissioner of Social Security

United States District Court, M.D. Florida, Jacksonville Division

September 14, 2017

Tammy Lorraine Fields, Plaintiff,
Commissioner of Social Security, Defendant.



         This is a case under 42 U.S.C. § 405(g) to review a final decision of the Commissioner of Social Security denying Tammy Fields's claim for disability insurance benefits.[1] She seeks reversal, Doc. 15; the Commissioner, affirmance, Doc. 16.

         I. Issues

         Fields presents two issues: (1) whether substantial evidence supports the Administrative Law Judge's (“ALJ's”) evaluation of her treatment records and the opinions of treating physician Dr. Luiz Massa; and (2) whether substantial evidence supports the hypothetical he presented to the vocational expert (“VE”). Doc. 15 at 10- 12.

         II. Background

         Fields was born in 1963 and last worked in October 2012. Tr. 155, 190. She has experience as a data-entry specialist. Tr. 190-91. She alleges she became disabled in October 2012 from arthritis; asthma; anxiety; depression; a back injury; tail bone, hip, and neck pain; carpal tunnel syndrome; and bone spurs in her back, neck, and tail bone. Tr. 189. She is insured through 2017.[2] Tr. 182. She proceeded through the administrative process, failing at each level. Tr. 1-7, 8-31, 72-100, 104-09. This case followed. Doc. 1.

         III. Evidence

         This order adopts the summaries of facts in the ALJ's decision, Tr. 16-22, and the parties' briefs, Doc. 15 at 3-8; Doc. 16 at 2-3. Some of the evidence is set forth in more detail here.

         In April 2014, kinesiotherapist[3] Greg Kelly completed a functional capacity evaluation of Fields. Tr. 842-44. He indicated Fields cannot perform even sedentary activity, defined as “Exerting up to 10 lbs. of force occasionally. Frequent and constant negligible.” Tr. 842. He noted that, on a scale of 0 to 10-with 0 being no pain, 1 to 3 indicating mild pain, 4 to 6 indicating moderate pain, 7 to 9 indicating intense pain, and 10 indicating an emergency-Fields reported pre- and post-testing pain levels of 7, her lowest pain level was a 2, and her worst pain was an 8. Tr. 843. Grip-strength testing showed a 27-percent strength deficit in her right hand and a 14-percent deficit in her left. Tr. 843. He opined she should avoid floor-to-knuckle, 12-inch-to-knuckle, and shoulder-to-overhead lifting; bending; squatting; kneeling; crawling; twisting; climbing stairs or ladders; and driving a standard-transmission car. Tr. 844. He opined she could occasionally carry and lift negligible weight from knuckle to shoulder height, occasionally push and pull 1 to 10 force pounds, occasionally stoop, and frequently reach. Tr. 844. He opined she could perform gross and fine hand and foot movement. Tr. 844. He opined she could sit for for 45 minutes at a time, and 3 to 4 hours total; stand for 30 minutes at a time, and 1 to 2 hours total; walk for 15 minutes at a time, and 0 to 1 hour total; and drive an automatic-transmission car for 30 minutes at a time, and 0 to 1 hours total. Tr. 844.

         In a section titled “Summary, ” Kelly stated:

Ms. Fields indicated multiple areas of pain to be the neck, bilateral shoulders arms, hands, low back, bilateral hips, bilateral lower extremities, feet, and reports global fibromyalgia pain symptoms, with present intense pain rating of 7. She presented at time of testing, ambulating with assistance of straight cane, due to reported history of previous falls with lower leg giveaway. She was observed demonstrating guarding and bracing of the back with intermittent changes of position from sitting to standing throughout testing for reported disruption of pain symptoms. The lowest level of pain experienced in the last 30 days is mild pain rating of 5 [sic], with use of medication, and minimizing or avoiding activities of daily living that result in aggravation, or increase of pain symptoms. She claims intense pain level of 8 as the highest level of pain experienced in the last 30 days with increased functional activities of daily living, due to spouses medical conditions, Abbreviations, available at undetermined causes associated with onset of increase pain severity, or changes in weather conditions. Despite moderate to intense pain rating, the client was able to demonstrate a consistency of performance during testing, with no overt findings for inappropriate pain focus on pain assessment questionnaires, observation, and testing, for abnormal pain symptoms. Maximal and 5-position isometric hand grip test revealed bilateral hand grip weakness as compared to normal age group mean handgrip values, with limitations due to reported maximal efforts, with bilateral hand pain. Testing resulted in mostly expected bell shaped curvature of the left hand, and reproducibility of values with bilateral hand grip, suggestive of consistent effort. Functional testing revealed tolerance to negligible levels of effort and repetitions of material and non-material handling activities, suggestive of limitations with ability to safely perform components of even the Sedentary Duty Physical Demand Level. She would also be limited with ability to participate with sustained or frequent basis, due to her poor tolerance for prolonged periods of sitting, standing and walking, from her claims of requiring intermittent supportive positional lying down, totaling 2-3 hrs., to assist with management of progressive elevation of pain symptoms throughout the day. She would also be limited due to reported 3-4 episodic pain flare-up a month resulting in 6-8 days of incapacitating pain severity. The client also indicated minimizing or avoiding driving due to pain and physical limitations. Please refer to functional testing for specific guidelines, capabilities, or limitations.

Tr. 842 (errors in original). Other comments are difficult to read but appear to largely track the statements in the summary. See Tr. 843-44. Under a section titled “Musculoskeletal Screen (Comments), ” Kelly stated:

A brief musculoskeletal evaluation was performed with observation of functional mobility during testing for consistency of effort. Testing revealed cervical ROM limitations near end ranges with cervical rotation and lateral bending. She also demonstrate[d] limitations and guarded functional movements of the low back in all planes of movement and inability to perform or complete forward bending, squatting or kneeling due to her reported pain areas of the hips, knees, low back, lower extremity weakness, and loss of balance.

         Tr. 843. He did not perform an endurance test but noted her heart rate during “limited functional testing was suggestive of no overt de-conditioning.” Tr. 843. In June 2014, Dr. Massa signed the evaluation above a line labeled “Physicians Authorization Signature.” Tr. 842.

         In July 2014, Dr. Massa completed a physical medical source statement. Tr. 838-41. He stated he sees Fields about one to two times a month. Tr. 838. He noted her symptoms include pain in her neck, arms, hands, low back, hips, legs, and feet, and she reports “global fibromyalgia.” Tr. 838. He explained a January 2014 x-ray shows “minimal” disc degeneration at ¶ 4/C5; she has a slight osteophyte in her hips; she had tenderness at the trochanteric bursa (fluid sac between the greater trochanter (bony protrusion) of the femur and the skin, see Stedman's Medical Dictionary 222, 1639 (William R. Hensyl et al. eds., 25th ed. 1990)) and at 14 of 18 tenderness points; she reports relief with trochanteric bursa injections; her low-back pain increases with extension; she experiences paraspinal spasms; and she has tenderness at the sacroiliac joint. Tr. 838.

         Dr. Massa opined Fields could walk 5 blocks without rest or severe pain; sit for 20 minutes at a time and about 2 hours total; and stand for 20 minutes at a time and about 2 hours total. Tr. 839. He opined she would need to be able to shift positions at will from standing, sitting or walking and would need to walk around periodically during a workday. Tr. 839. He opined that, due to muscle weakness, chronic fatigue, pain/parethesias, numbness, and adverse medication effects, she would need to take unscheduled breaks about every 20 minutes for about 2 to 5 minutes at a time to stretch. Tr. 839. He opined she must use a cane or other handheld assistive device due to imbalance. Tr. 840. He opined she could never lift 10 pounds and could rarely twist, stoop, crouch, climb stairs, and climb ladders. Tr. 840. He opined she could use her hands for gross and fine manipulation for 100 percent of an 8-hour workday but could only reach in front of her body or overhead between 34 and 66 percent of a workday. Tr. 840. He opined she would be off-task for about 20 percent of a workday but would be capable of low-stress work. Tr. 840. He opined she would have good days and bad days and would likely miss more than four days of work a month from her impairments or treatment. Tr. 840.

         At a 2014 hearing, Fields testified as follows.

         She lives in a house with her husband, her 17-year-old daughter, a cat, and five dogs. Tr. 40. She has a driver's license but usually only drives two to three times a week to go to doctor's appointments, church, the grocery store, and the drug store. Tr. 41. She attended school through the 12th grade but received a GED. Tr. 42. She has never received vocational training or attended college. Tr. 42. She stopped working in October 2012 because she “could no longer do the amount of work that was expected” due to pain in her hands, shoulders, and back and spasms. Tr. 42-43. She worked as a data entry specialist. Tr. 43. She spent most of her workdays sitting. Tr. 44-47. The heaviest item she had to lift was a 45- to 50-pound file box, which she had to move monthly. Tr. 44-45.

         She cannot work because she is in severe pain due to fibromyalgia. Tr. 48. She also has pain in her hips and tail bone from falling. Tr. 48. She has experienced pain “for years” but did not know what was wrong until recently. Tr. 48-49. She takes Lyrica and Percocet, which help but do not eliminate pain. Tr. 49-50. On an average day, her pain is an 8 on a scale of 1 to 10. Tr. 49-50. Stress exacerbates pain, and sleep helps relieve it. Tr. 50. She attends physical therapy, which also helps. Tr. 50- 51. Asthma, anxiety, and depression also prevent her from working. Tr. 51. She has had asthma since she was in a car accident when she was 18, but using a nebulizer and inhaler help. Tr. 52-53. She has had depression “all [her] life, ” but medication helps. Tr. 53. Even with medication, her depression and anxiety prevent her from leaving her house most of the time; if she gets out of her routine, she “get[s] real shaky” and cannot be around crowds. Tr. 53. She experiences some side effects from medication, but they do not bother her. Tr. 54.

         She can sit for 10 to 15 minutes before she needs to stand, and she can stand for only 10 or 15 minutes. Tr. 54-55. She can walk only about 30 feet due to instability arising from her hip, tailbone, and lumbar pain. Tr. 55-56. She has used a cane since she applied for disability benefits, but not one prescribed it to her; she uses it because she feels unstable. Tr. 55. She cannot lift more than 5 or 10 pounds. Tr. 56. She gets along well with others. Tr. 56. It takes her “a little while to comprehend things, ” and she has trouble following longer conversations. Tr. 56. She has always had that difficulty. Tr. 56. She can “sometimes” follow the storyline of a 30-minute television show. Tr. 56-57. Her memory is “getting worse, ” but she remembers to take medication daily. Tr. 57.

         In a typical day, her feet hurt as soon as she wakes up. Tr. 57. She makes a pot of coffee, sits down, and reads daily scriptures. Tr. 57. She goes outside to feed her dogs but must hold onto things to keep from falling. Tr. 57. She comes back inside, watches television, and makes food for herself. Tr. 57. She then takes a nap because her body “shuts down.” Tr. 57. She usually cooks easy meals, and her daughter helps with cooking. Tr. 58. She does not cut things like potatoes or onions because she is afraid she will cut herself. Tr. 58. Her husband and daughter help with cleaning and laundry. Tr. 58. She goes grocery shopping by holding onto the shopping cart, and it is “a lot on” her. Tr. 58. She has no hobbies. Tr. 58. Her family comes from Lakeland, Florida, to visit her. Tr. 59. She has few friends but will occasionally go to neighbors' houses “around the corner.” Tr. 59. She does not use a computer and uses her phone only to call her husband and text her children. Tr. 59. She attends church weekly but is not involved with church activities. Tr. 59. She and her husband occasionally go out for dinner. Tr. 59. She performs physical therapy exercises on her bed but does nothing else to exercise. Tr. 60. She will sometimes play with and talk to her dogs outside. Tr. 60.

         Her pain began when she fell in 2010 or 2011. Tr. 61. She has fallen “maybe four” times. Tr. 61. Dr. Massa said using the cane was “fine.” Tr. 61-62. She has to lie down or recline many times throughout the day. Tr. 63. Her body typically “shuts down” at around 2:00 p.m., at which point she must lie in bed. Tr. 63.

         The ALJ asked a VE to consider a hypothetical person with Fields's work history who could lift, carry, push, and pull 20 pounds occasionally and 10 pounds frequently; could sit for up to 6 hours, stand for up to 6 hours, and walk for up to 6 hours; could occasionally use hand and food controls; could occasionally reach overhead; could frequently handle, finger, and feel; could occasionally climb ramps and stairs; could not climb ladders or scaffolds; could frequently balance, stoop, and crouch; could occasionally kneel; could never crawl; should not work around unprotected heights or moving mechanical parts; should avoid concentrated exposure to humidity, wetness, dust, fumes, and gases; should avoid temperature extremes; could perform simple tasks with simple work-related decision-making; should have no more than occasional interaction with supervisors, coworkers, and the public; and whose time off-task would be accommodated by normal breaks. Tr. 66. The VE responded that person could not perform Fields's past work but could perform jobs such as bench assembler, electronics worker, and inspector. Tr. 66-67.

         The ALJ asked the VE to consider a hypothetical person with the same limitations but who would need a sit/stand option allowing her to change positions at least every 30 minutes for a brief (3- to 4-minute) period of time. Tr. 67-68. The VE responded all three of the jobs would be available but reduced by about 75 percent. Tr. 68. The VE testified that, as reduced, there are 720 bench assembler jobs in Florida and 21, 000 in the United States; 450 electronics worker jobs in Florida ...

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