United States District Court, D. New Hampshire
JOSEPH A. DiCLERICO, Jr., District Judge.
Theresa Trumbull seeks judicial review, pursuant to 42 U.S.C. § 405(g), of the decision of the Acting Commissioner of the Social Security Administration, denying her application for disability insurance benefits. In support of reversing the decision, Trumbull contends that the Administrative Law Judge ("ALJ") erred in evaluating the medical opinion evidence, failed to consider the record evidence, and erred in making the residual functional capacity and credibility assessments. The Acting Commissioner moves to affirm.
Standard of Review
In reviewing the final decision of the Acting Commissioner in a social security case, the court "is limited to determining whether the ALJ deployed the proper legal standards and found facts upon the proper quantum of evidence." Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999); accord Seavey v. Barnhart, 276 F.3d 1, 9 (1st Cir. 2001). The court defers to the ALJ's factual findings as long as they are supported by substantial evidence. § 405(g). "Substantial evidence is more than a scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Astralis Condo. Ass'n v. Sec'y Dep't of Housing & Urban Dev., 620 F.3d 62, 66 (1st Cir. 2010). Substantial evidence, however, "does not approach the preponderance-of-the-evidence standard normally found in civil cases." Truczinskas v. Dir., Office of Workers' Compensation Programs, 699 F.3d 672, 677 (1st Cir. 2012).
In February of 2012, Trumbull filed an application for social security benefits, claiming a disability that began in April of 2010. Trumbull alleged that she was disabled by fibromyalgia, multiple sclerosis, chronic lower back pain, depression, and anxiety. She has a high school education and previously worked as a construction site cleaner and a bartender. Trumbull was forty-nine years old at the time of her application.
A. Medical Records Evidence
The medical evidence begins with records of an incident in the early morning of February 3, 2010, when a passerby found Trumbull outside and unable to walk. She was transported by ambulance to a hospital emergency room where she said she had consumed alcohol and taken anti-anxiety medication and then went outside to look at the stars. She fell asleep outside and had difficulty walking when she awoke. Trumbull had knee pain due to abrasions, bruising, and frostbite. She was diagnosed with alcohol abuse, polysubstance abuse, and methadone withdrawal.
Trumbull saw Dr. Russell Brummett at Concord Orthopedics in March of 2010 for back pain following a car accident in February. On examination, Trumbull walked normally but slowly, had a diminished cervical range of motion, normal arm and leg strength, and tenderness along her lumbar spine. Dr. Brummett diagnosed cervical, thoracic, and lumbosacral sprain or strain caused by the accident without neurological deficits. He recommended physical therapy.
In May of 2010, Trumbull reported to Dr. Brummett that she had tried physical therapy but stopped because the physical therapist was not comfortable continuing due to Trumbull's low back pain. Trumbull had a normal gait, full cervical range of motion, and was neurovascularly intact in her arms and legs. She said that her pain was in her low back, and she had diminished lumbosacral range of motion although she had no discernible tenderness in the lumbosacral spine area. Dr. Brummett made the same diagnosis as previously and advised Trumbull to continue home exercises. At a follow up appointment in August, Dr. Brummett diagnosed lumbar degenerative disc disease and facet arthritis. He scheduled cortisone injections but advised Trumbull that the relief from injections was only temporary and that she would have to make lifestyle changes to include exercise, strengthening, and conditioning for improvement.
In October of 2010, her primary care practice referred Trumbull to Pain Care Centers, where she saw a physician's assistant, Christopher Clough, for a consultation about her low back pain and neck pain. Trumbull complained of a plethora of ills, including back pain, fevers, chills, sweats, amenorrhea, stiffness, arthritis, paresthesias, tremors, vertigo, and anxiety. P.A. Clough performed an examination, noting that Trumbull was in no acute distress and had normal gait and station. He found that Trumbull had normal range of motion with no joint enlargement or tenderness. Her neurologic examination was unremarkable. P.A. Clough assessed Trumbull with sacroiliac backache, chronic low back pain, and depression. He prescribed Flexeril and recommended sacroiliac injections.
Examinations in November, December, and January of 2011 yielded similar results, but P.A. Clough added the pain medication, Vicodin, and tried trigger point injections in January. In February of 2011, Trumbull reported improvement, and her examination results were similar to previous examinations. In March, Trumbull reported back spasms, but her examination results were similar to previous results. P.A. Clough changed Trumbull's pain medication prescription to Norco.
In May of 2011, Trumbull raised new symptoms at her appointment with P.A. Clough reporting a sudden onset of multiple joint pain. P.A. Clough's examination showed that Trumbull was in no acute distress, had normal gait and station, had some mild or minimal spinal tenderness, and had the same test results as prior examinations. A month later, Trumbull again complained of multiple joint pains, but P.A. Clough's examination had the same results as the prior examinations. P.A. Clough prescribed Oxycodone and Norco, pain medications.
Trumbull saw her primary care physician, Peter Cook, M.D., in July of 2011. Dr. Cook noted Trumbull's history of right back pain following the accident in February of 2010, along with anxiety and depression. On examination, Dr. Cook found that Trumbull was alert; in no acute distress; had normal motor function, gait, and station; was oriented in all spheres, and had appropriate affect and mood. He assessed Trumbull with fatigue, depression, and ...