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Allen v. Astrue

March 10, 2008


The opinion of the court was delivered by: Norman A. Mordue, Chief Judge


This action, brought by plaintiff Darlene M. Allen, an unsuccessful claimant for disability benefits, requires the Court to determine whether defendant, Commissioner of Social Security (the "Commissioner"), properly concluded that plaintiff, although severely impaired, was not entitled to such benefits because of her remaining ability to perform light work. The Commissioner argues that there is substantial evidence in support of a conclusion that the plaintiff is not disabled, and claims that this determination was based upon the appropriate legal standards. Plaintiff and the Commissioner have filed opposing motions for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c).

The Court referred this matter to United States Magistrate Judge Gustave J. DiBianco pursuant to 28 U.S.C. § 636(b)(1)(B) and Local Rule 72.3(d). Magistrate Judge DiBianco reported that the Commissioner's decision was supported by substantial evidence, and recommended that the Court uphold the denial of benefits. Plaintiff now objects to Magistrate Judge DiBianco's Report and Recommendation, arguing that the Commissioner's determination of non-disability was improper because it was based upon an inaccurate application of the relevant legal standards and because it was not supported by substantial evidence in the record.

The Court, having considered the Report and Recommendation, the objections thereto, and the entire administrative record, finds that the Commissioner failed to properly evaluate or explain the weight given to the medical opinions of plaintiff's treating sources. Furthermore, the Commissioner did not perform the required analysis when determining the plaintiff's credibility, nor did he support his conclusion of "partial credibility" with substantial evidence. The Court therefore remands this case to the Commissioner for further development of the record and a determination on disability pursuant to the proper legal standards.

I. Background

Plaintiff was born on April 16, 1963, and was 39 years old at the time of the administrative hearing in March of 2003. (T. 261). Plaintiff, a high school graduate, testified that she lived in a mobile home with her husband and school-age son and daughter. (T. 261-263). Plaintiff's prior work history was limited to a brief period when she operated a licensed childcare service from her home.*fn2 Plaintiff claims that she stopped all work activity in October of 1999 due to constant pain, fatigue, and an inability to lift the children in her care. (T. 47).

Plaintiff's medical records indicate that she began to experience chronic pain in her low back after falling off a bicycle in 1988. (T. 105, 110, 129). Plaintiff states that she was diagnosed with fibromyalgia and myofascial pain syndrome in 1989. (T. 68, 133). Despite these diagnoses, plaintiff told consultative examiner Kalyani Ganesh, M.D., that her symptoms were "not that bad" until after the birth of her second child in 1996. (T. 133). Plaintiff's medical chart states that she was diagnosed with chronic lumbosacral dysfunction in October of 1998. (T. 96).

John Finkenstadt, M.D., treated plaintiff for low back pain on a monthly basis between March and December of 2000. (T. 82, 83, 87, 90, 92, 93, 95). According to his treatment notes,

Dr. Finkenstadt diagnosed plaintiff with chronic lumbosacral dysfunction, chronic low back pain, and depression. (Id.). He treated plaintiff with monthly prolotherapy injections, which plaintiff tolerated well, and prescriptions for Flexeril, Paxil, and Zoloft. (Id.). Plaintiff reported that she was under the care of a chiropractor, and Dr. Finkenstadt encouraged her to continue chiropractic treatment. (T. 92, 93).

In his treatment notes from March 17, 2000 and October 10, 2000, Dr. Finkenstadt recognized that plaintiff had a "mild to moderate partial disability." (T. 95, 83). However, during the course of his treatment relationship with plaintiff, Dr. Finkenstadt noted on several occasions that she was unemployed "per her choice," not because of low back pain. (T. 82, 87, 93, 95).

The most recent treatment note from Dr. Finkenstadt, dated December 13, 2000, stated that plaintiff was no longer taking pain medications, and discharged plaintiff in "good condition" with directions to follow up in three months. (T. 82).

On March 7, 2001, plaintiff began treatment with family medicine practitioner Lauri Fairbanks-Doane, D.O. (T. 108-109). Although plaintiff had "no specific concerns or complaints," she requested "a referral to a pain clinic or pain specialist" for chronic pain in her low back and right leg. (T. 108). Dr. Fairbanks-Doane's notes indicate that plaintiff was given a referral to "Dr. Mastin for chronic pain treatment," but there is no further evidence that plaintiff was treated by Dr. Mastin. (Id.).

Dr. Fairbanks-Doane took a detailed history and performed a complete physical examination of plaintiff on April 4, 2001. (T. 105-107). Plaintiff again reported chronic low back pain, which caused her to experience difficulty sleeping. (T. 105). Dr. Fairbanks-Doane diagnosed plaintiff with depression and chronic low back pain with right sciatica. (T. 106). She advised plaintiff to "[c]ontinue counseling every other week," and "[c]ontinue with Dr. Sobhy for pain control and possible steroid injections." (T. 107). Dr. Fairbanks-Doane also prescribed Celexa and Ultram, and referred plaintiff "to Dr. Distefano for consultation regarding back pain and sciatica." (Id.).

Pain specialist Saad Sobhy, M.D., first treated plaintiff on April 9, 2001. Plaintiff told Dr. Sobhy that her problems started in 1988 after she fell. (T. 129). Over time, plaintiff began to experience "right sided mid and low back pain that gradually progressed to involve the right lower limb, [and] became associated with neck stiffness and numbness involving both hands." (Id.). Plaintiff's pain worsened in 1996 and, as of April 9, 2001, plaintiff reported that her symptoms were constant, "exacerbated by sitting, standing, walking, and lifting and nothing improves them." (Id.). Dr. Sobhy diagnosed plaintiff with myofascial pain syndrome and mechanical low back pain syndrome. (T. 131). Electrophysiological studies performed by Dr. Sobhy showed no evidence of neuropathy, radiculopathy, plexopathy, or myopathy. (T. 121, 123).

On February 6, 2002, Dr. Sobhy noted that plaintiff "showed reduction in the range of motion of the cervical spine with tenderness at end of ranges." (T. 119). However, Dr. Sobhy's notes also stated that plaintiff's lumbar spine range of motion "showed significant improvement following the epidural injections which helped her significantly." (Id.). He prescribed Celexa, Amitriptyline, and Depakote for treatment of plaintiff's pain, but indicated that she could not tolerate the anti-convulsant medications Lamotrignine or Zonegran because of GI upset. (Id.).

Dr. Sobhy completed a "Physical Medical Source Statement," which the Administration received on April 4, 2002. (T. 174). According to his statement, Dr. Sobhy diagnosed plaintiff with myofascial pain syndrome and mechanical low back pain syndrome, and he reported that plaintiff's symptoms included neck and low back pain, tiredness, and fatigue. (T. 230). He evaluated plaintiff's prognosis as "poor," and indicated that treatment with oral medications caused plaintiff to experience tiredness, fatigue, and sexual dysfunction. (Id.). Dr. Sobhy also affirmed that plaintiff's experience of pain and other symptoms was frequently severe enough to interfere with her attention and concentration. (T. 231).

Kalyani Ganesh, M.D., performed a consultative orthopedic examination of plaintiff on April 19, 2002. (T. 133-135). Plaintiff reported lower back pain extending from her right ribs and hip down her right leg, which increased with being in one position for too long. (T. 133). Plaintiff also stated that she suffered from constant fatigue, depression, and sadness. (Id.). Plaintiff informed Dr. Ganesh that she was currently receiving nerve blocks at a pain management clinic, which helped to alleviate her symptoms. (T. 133). According to plaintiff, prolotherapy was not successful in relieving her pain, but medications helped some. (Id.).

Based on her examination of plaintiff, Dr. Ganesh diagnosed plaintiff with fibromyalgia.

(T. 135). Dr. Ganesh indicated that plaintiff's prognosis was stable, and that there were "[n]o physical limitations to sitting, standing, walking, bending, and climbing." (Id.). However, Dr. Ganesh believed that plaintiff had "minimal to mild limitations to lifting, carrying, pushing, and pulling." (Id.).

Plaintiff was evaluated at the Onondaga Pastoral Counseling Center in August of 1997 after she was referred for treatment by her daughter's school counselor. (T. 179). The initial assessment indicated that plaintiff suffered from symptoms of low self-esteem, low energy, poor appetite, poor concentration, and feelings of hopelessness. (Id.). The evaluating physician diagnosed plaintiff with dysthymic disorder and noted that her Global Assessment of Functioning ("GAF") level was 53. (T. 182). Pursuant to this evaluation, plaintiff began weekly psychotherapy sessions with a clinical social worker. (T. 183)

In 2000, plaintiff began treatment with Jennifer L. Wainman-Sauda, a marriage and family therapist. (T. 132). Ms. Wainman-Sauda diagnosed plaintiff with post-traumatic stress disorder, generalized anxiety disorder, major depression, and borderline personality disorder. (Id.). She began treating plaintiff with weekly psychotherapy sessions, and, with the approval of Dr. Sobhy, advised that plaintiff discontinue all psychotropic medications. (T. 211). The administrative record contains three statements from Ms. Wainman-Sauda which indicate the debilitating nature of plaintiff's psychological impairments along with the therapist's opinion regarding plaintiff's inability to work. (T. 132, 141-146, 236-238).

Kristen Barry, Ph.D., performed a psychological examination of plaintiff on April 19, 2002. (T. 136-140). Dr. Barry concluded that plaintiff was able to follow and understand simple directions and instructions, and was able to maintain attention and concentration. (T. 139). However, Dr. Barry believed that plaintiff would have difficulty handling stressors, and that plaintiff's high level of pain impaired her ability to function. (Id.). The psychologist ...

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