United States District Court, E.D. Arkansas, Northern Division
BONNA L. DODGE PLAINTIFF
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT
MEMORANDUM OPINION AND ORDER
Bonna L. Dodge (“Dodge”) commenced this case by
filing a complaint pursuant to 42 U.S.C. 405(g). In the
complaint, she challenged the final decision of the Acting
Commissioner of the Social Security Administration
(“Commissioner”), a decision based upon findings
made by an Administrative Law Judge (“ALJ”).
maintains that the ALJ's findings are not supported by
substantial evidence on the record as a whole and offers two
reasons why. Dodge first maintains that her chronic
back pain/degenerative disc disease is a severe impairment,
and the ALJ erred when she failed to so find at step two of
the sequential evaluation process. Dodge also maintains that
her residual functional capacity was erroneously assessed
because the pain caused by her degenerative disc disease and
fibromyalgia was not properly considered.
two, the ALJ is required to identify the claimant's
impairments and determine whether they are severe. An
impairment is severe if it has “more than a minimal
effect on the claimant's ability to work.” See
Henderson v. Sullivan, 930 F.2d 19, 21 (8th
Cir. 1992) [internal quotations omitted].
steps three and four, the ALJ is required to assess the
claimant's residual functional capacity, which is a
determination of “the most a person can do despite that
person's limitations.” See Brown v.
Barnhart, 390 F.3d 535, 538-39 (8th Cir.
2004). The assessment is made using all of the relevant
evidence in the record, and the assessment must be supported
by some medical evidence. See Wildman v. Astrue, 596
F.3d 959 (8thCir. 2010). As a part of making the
assessment, the ALJ is required to evaluate the
claimant's subjective complaints. See Pearsall v.
Massanari, 274 F.3d 1211 (8th Cir. 2001). The
ALJ makes that evaluation by considering the medical evidence
and evidence of the claimant's “daily activities;
duration, frequency, and intensity of pain; dosage and
effectiveness of medication; precipitating and aggravating
factors; and functional restrictions.” See Id.
at 1218 [citing Polaski v. Heckler, 739 F.2d 1320
(8th Cir. 1984)].
alleges that she became disabled beginning on April 25, 2013.
See Transcript at 144. The ALJ denied Dodge's
application for disability insurance benefits on May 10,
2015. See Transcript at 25. Consequently, the
relevant time period in this case is from April 25, 2013,
through May 10, 2015. Although the evidence prior to April
25, 2013, is outside the relevant period, it will
nevertheless be noted in order to place Dodge's medical
condition in a proper context.
evidence relevant to Dodge's physical impairments
reflects that she sought treatment for, inter alia,
degenerative disc disease, back pain, and fibromyalgia on
several occasions between May 15, 2012, and November 26,
2012. See Transcript at 309-320,
375-376. The progress notes contain no findings as
to the limitations caused by her impairments. CT scans of her
lumbar spine were performed on September 10, 2010, and August
13, 2012, and the results revealed minimal degenerative disc
bulges from L3-4 through L5-S1 with facet arthropathy
appearing moderate at ¶ 4-5. See Transcript at
277, 376. The notes reflect that she was prescribed
medication for her pain.
April 24, 2013, Dodge saw Richard Van Grouw, M.D.,
(“Van Grouw”) for complaints of chest pain.
See Transcript at 298-299. He noted her diagnoses of
fibromyalgia and heart irregularities but observed, inter
alia, that she is “normally able to be active
physically without developing chest discomfort or shortness
of breath.” See Transcript at 299. Upon
physical examination, Van Grouw found Dodge to have a regular
heart rate and rhythm with no “murmurs, rubs, or
gallops.” See Transcript at 299. He assessed
chest pain, atypical for cardiac, and hypertension and
adjusted her medication.
days later, on April 30, 2013, Dodge presented to the White
River Medical Center Emergency Room complaining that she just
did not feel right. See Transcript at 331-345. She
reported that her hands felt “clammy, ”
see Transcript at 331, and she was having dull chest
pains in the middle part of her chest. She reported having
had the symptoms previously but reported that Van Grouw had
told her the symptoms were related to hypertension. Upon
physical examination, Dodge had a regular heart rate and
rhythm and exhibited no murmurs. It is also worth noting that
an examination of her back revealed normal results. Testing
in the form of an EKG and x-rays was performed, and the
results were unremarkable. Borderline hypertension was
diagnosed, and she was discharged with instructions to see
Van Grouw and continue “home antihypertensives.”
See Transcript at 334.
on May 7, 2013, and continuing through June 18, 2013, Dodge
was seen at the Ozark Medical Center on three occasions for
pain associated with fibromyalgia. See Transcript at
306-308 (05/07/2013), 304-305 (05/21/2013), 301-303
(06/18/2013). She reported that she was experiencing a
widespread, sharp, aching pain that occurred constantly and
caused nausea. She reported that her pain was exacerbated by
daily activities, and she was having difficulty standing and
sitting. Dodge was examined each time, and the findings were
unremarkable. She was repeatedly observed to have normal
strength and tone in the lumbar portion of her spine. She was
also observed to have normal posture, gait, coordination, and
reflexes, although some tenderness was noted.
medication was adjusted, and she was referred to a pain
on June 26, 2013, and continuing through October 23, 2013,
Dodge saw Miraj Siddiqui, M.D., (“Siddiqui”) on
four occasions for pain management. See Transcript
at 355-358 (06/26/2013), 347-351 (07/23/2013), 408-409
(09/25/2013), 403-405 (10/23/2013). At the June 26, 2013,
initial consultation, Siddiqui recorded Dodge's history
of present illness to be as follows:
... Refer[r]ing physician has asked my opinion in regards to
[Dodge's] pain condition. She has been experiencing this
pain for last several years. She reports onset of pain
gradual. Stated that the pain has progressively gotten worse,
not being controlled with rest, activity modification and
medication(s). [She] describes the pattern of pain as
constant with intermittent flare ups. She described the
quality of pain as aching, stabbing, sharp, deep, cramping
and pressure. The pain radiates to back side of both thighs.
[Dodge] says, at its worse, her pain is 9/10, at its least it
is 2/10, on an average about 5/10, and right now it is 4/10.
Worsening factor(s) include: standing, walking, getting up
from sitting or lying position, cold weather, pressure
changes and increased activity. Relieving factor(s): stopping
activities that aggravates pain, rest and taking pain
medicine. Other associated symptoms/problems: restrictions on
the activities, difficulty sleeping due to pain and
frustration because of pain.
See Transcript at 355. Upon physical examination, he
observed that her gait and station were antalgic, but she was
able to heel-to-toe, heel walk, and toe walk and had normal
motor strength and tone in her extremities. He additionally
observed the following:
... Palpation of lumbar facet joints at ¶ 3-4, L4-5, and
L5-S1 levels reproduced lower back pain. Hyperextension at
lumbar spine reproduced lower back pain. Stooping 20-30
degree relief pain. Bilateral facets loading maneuver by
lateral flexion/bending reproduced pain. Bilateral lateral
rotation also causes pain. Palpable taut bands/trigger points
in bilateral Latissimus dorsi muscles. Palpable taut