Opinion
4:20-CV-22-D
08-23-2021
GUY ALAN BRYAN, Plaintiff/Claimant, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
ROBERT B. JURIES, JR., UNITED STATES MAGISTRATE JUDGE
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-17, -19] pursuant to Fed.R.Civ.P. 12(c). Claimant Guy Alan Bryan (“Claimant”) filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of his application for a period of disability and Disability Insurance Benefits (“DIB”). The time for filing responsive briefs has expired, and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be denied, Defendant's Motion for Judgment on the Pleadings be allowed, and the final decision of the Commissioner be upheld.
I. STATEMENT OF THE CASE
Claimant protectively filed an application for a period of disability and DIB on June 28, 2016, alleging disability beginning May 1, 1995. (R. 15, 177-79). His claim was denied initially and upon reconsideration. (R. 15, 55-84). A hearing before the Administrative Law Judge (“ALJ”) was held on January 10, 2019, at which Claimant, represented by counsel, and a vocational expert (“VE”) appeared and testified. (R. 28-54). The Claimant amended his alleged onset date to August 10, 2015. (R. 15, 193). On March 28, 2019, the ALJ issued a decision denying Claimant's request for benefits. (R. 12-27). On December 3, 2019, the Appeals Council denied Claimant's request for review. (R. 1-6). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial'review of a final agency decision regarding disability benefits under the Social Security Act (“Act”), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). “The findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Substantial evidence is “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a “large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is “more than a mere scintilla . . . and somewhat less than a preponderance.” Laws, 368 F.2d at 642. “In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the “substantial evidence” inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in “substantial gainful activity, ” i.e., currently working; and (2) must have a “severe” impairment that (3) meets or exceeds [in severity] the “listings” of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform . . . past work or (5) any other work.
Albright v. Comm 'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). “If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the “special technique” described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the “special technique.” Id. § 404.1520a(e)(3).
In this case, Claimant alleges the following errors: (1) the ALJ failed to properly weigh Dr. Crawford's opinion, (2) the ALJ failed to adequately consider the effects of Claimant's migraines and hypersomnia, and (3) the ALJ improperly rejected Claimant's allegations of pain. Pl.'s Mem.
[DE-18] at 5-16.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant “not disabled” as defined in the Act. At step one, the ALJ found Claimant did not engage in substantial gainful employment for the period from his alleged onset date of August 10, 2015 through his date last insured of December 31, 2018. (R. 18). Next, the ALJ determined Claimant had the following severe impairments: degenerative disc disease, post anterior cervical discectomy and fusion of the cervical spine, and arthritis. Id. The ALJ also found Claimant had nonsevere impairments of headaches and high blood pressure. Id. However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id.
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform medium work with the following limitations:
Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying objects weighing up to 25 pounds. If someone can do medium work, she can also do sedentary and light work. 20 C.F.R. § 404.1567(c).
The claimant can frequently climb ramps and stairs, stoop, kneel, balance, crouch, and crawl. The claimant can frequently reach overhead bilaterally and occasionally climb ladders, ropes, or scaffolds. The claimant must avoid concentrated exposure to hazards, including dangerous moving machinery, uneven terrain, and unprotected heights.
(R. 19-22). In making this assessment, the ALJ found Claimant's statements about his limitations not entirely consistent with the medical and other evidence. (R. 19). At step four, the ALJ concluded Claimant had the RFC to perform the requirements of his past relevant work as a plug and mold finisher as generally performed. (R. 22).
V. DISCUSSION
A. The RFC Assessment
An individual's RFC is the capacity he possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 404.1545(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 404.1545(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5.
1. Dr. Crawford's Opinion
Claimant contends the ALJ erred by failing to evaluate and weigh Dr. Crawford's opinion that Claimant was able to lift, carry, and handle light objects, and if accepted as true, the finding would preclude medium work. Pl.'s Mem. [DE-18] at 5-6.
When assessing a claimant's RFC, the ALJ must consider the opinion evidence. 20 C.F.R. § 404.1545(a)(3). Regardless of the source, the ALJ must evaluate every medical opinion received. Id. § 404.1527(c). In general, the ALJ should give more weight to the opinion of an examining medical source than to the opinion of a non-examining source. Id. § 404.1527(c)(1). Additionally, more weight is generally given to opinions of treating sources, who usually are most able to provide “a detailed, longitudinal picture” of a claimant's alleged disability, than non-treating sources such as consultative examiners. Id. § 404.1527(c)(2). When the opinion of a treating source regarding the nature and severity of a claimant's impairments is “well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence, ” it is given controlling weight. Id. However, “[i]f a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight.” Craig, 76 F.3d at 590.
If the ALJ determines that a treating physician's opinion should not be considered controlling, the ALJ must then analyze and weigh all of the medical opinions in the record, taking into account the following non-exclusive list: (1) whether the physician has examined the applicant, (2) the treatment relationship between the physician and the applicant, (3) the supportability of the physician's opinion, (4) the consistency of the opinion with the record, and (5) whether the physician is a specialist. Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). An ALJ may not reject medical evidence for the wrong reason or no reason. See Wireman v. Barnhart, No. 2:05-CV-46, 2006 WL 2565245, at *8 (W.D. Va. Sept. 5, 2006). “In most cases, the ALJ's failure to consider a physician's opinion (particularly a treating physician) or to discuss the weight given to that opinion will require remand.” Love-Moore v. Colvin, No. 7:12-CV-104-D, 2013 WL 5350870, at *2 (E.D. N.C. Sept. 24, 2013) (citations omitted). However, “[a]n ALJ's determination as to the weight to be assigned to a medical opinion generally will not be disturbed absent some indication that the ALJ has dredged up ‘specious inconsistencies,' or has failed to give a sufficient reason for the weight afforded a particular opinion.” Dunn v. Colvin, 607 Fed.Appx. 264, 267 (4th Cir. 2015) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)).
In the RFC assessment, the ALJ summarized notes from Dr. Crawford's November 12, 2016 consultative exam of Claimant, which stated “he was able to lift, carry, and handle light objects.” (R. 20). This observation was in the section of the report detailing Dr. Crawford's findings on musculoskeletal examination of Claimant, and appears to be what Claimant demonstrated during the examination rather than a limit on the most Claimant could do. (R. 377). This reading is supported by Dr. Crawford's conclusion that Claimant “does not have significant limitations with lifting and/or carrying weight, ” which the ALJ noted when weighing Dr. Crawford's opinion. (R. 21, 379). Dr. Crawford also determined that Claimant had full muscle strength in all groups, normal reflexes, normal range of motion, and the ability to sit, stand and walk normally in an eight-hour workday. (R. 376-79). The ALJ's determination that Claimant could engage in medium work, which requires lifting no more than 50 pounds at a time with frequent lifting or carrying objects weighing up to 25 pounds, 20 C.F.R. § 404.1567(c), is supported by Dr. Crawford's ultimate conclusion that Claimant did not have any significant limitations with lifting or carrying weight. Accordingly, the ALJ's evaluation of Dr. Crawford's opinion does not require remand.
2. Claimant's Headaches/Migraines and Hypersomnia
Claimant contends the ALJ failed to consider the effects of his headaches/migraines and hypersomnia on his ability to function. Pl.'s Mem. [DE-18] at 6-8.
Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) (“[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.”) (citations omitted). “[T]he residual functional capacity ‘assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions' listed in the regulations.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 96-8p). The ALJ must provide “a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).” Id. (quoting S.S.R. 96-8p). “Only after such a function-by-function analysis may an ALJ express RFC ‘in terms of the exertional levels of work.'” Monroe v. Colvin, 826 F.3d 176, 179 (4th Cir. 2016) (quoting Mascio, 780 F.3d at 636); see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ “must build an accurate and logical bridge from the evidence to his conclusion”). However, the Fourth Circuit has rejected “a per se rule requiring remand when the ALJ does not perform an explicit function-by-function analysis.” Mascio, 780 F.3d at 636. Rather, the court explained that “[r]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review.” Id. (citation omitted). Therefore, despite an ALJ's failure to conduct the function-by-function analysis, the court must look to the ALJ's RFC discussion to determine whether it otherwise provides a sufficient basis for meaningful review.
i. Headaches/Migraines
The ALJ noted that Claimant alleged his disability was due to a combination of impairments that included headaches and that Claimant testified his impairments affected his ability to work and caused chronic pain and loss of concentration. (R. 19). At the administrative hearing, Claimant specifically testified that he cannot move his head left or right very far without triggering a migraine; he had just recovered from a three-day migraine; he gets a headache every day and a migraine at least once a week; lifting anything “wrong, ” even a box of tissues, can cause a migraine; and to treat a migraine he lies in a dark, quiet room. (R. 43, 46-48).
The ALJ determined at step two that Claimant's headaches were nonsevere based on the duration and frequency of the headaches for which he sought treatment. (R. 18). In the RFC assessment, the ALJ cited Claimant's complaints of headaches found in the treatment notes on December 15, 2015 and months later on July 1, 2016. (R. 20, 287, 291, 300). These treatment notes do not indicate Claimant received any special treatment for his headaches, but rather he was treated generally for his pain with gabapentin, Celebrex, and naproxen. (R. 287-93, 300-04).
The ALJ also noted that Claimant complained of headaches to Dr. Crawford at the November 12, 2016 consultative examination. (R. 20, 373-74). Plaintiff indicated that his pain intensity associated with headaches was 8/10 on most days, 8/10 on examination that day, and caused difficulty concentrating and functioning, (R. 374); however, the ALJ noted that Dr. Crawford found Claimant was in no acute distress, his cranial nerves were grossly intact, his handeye coordination was good, and his memory and concentration were within normal limits, (R. 20, 376). Dr. Crawford also noted with respect to Claimant's headaches that he had no sensation deficits on the face, normal strength in the bilateral upper and lower extremities, and a fair prognosis, and Dr. Crawford recommended Claimant follow up with his primary care physician or neurology for medical management. (R. 378). Claimant's headaches are mentioned in a January 4, 2017 treatment note, but there was no targeted treatment or plan for treatment of his headaches, and subsequent treatment notes from April 4, 2017 and July 23, 2018 do not mention Claimant's headaches as a current problem. (R. 384, 392). There is no mention in the treatment notes of severe migraines such as the ones described by Claimant at the administrative hearing.
Claimant also points to the fact that on initial review and reconsideration the single decision maker and the state agency reviewer, Dr. Roane, categorized Claimant's migraines as “severe.” (R. 61, 76). Even if the ALJ erred in finding Claimant's headaches were nonsevere, the error was harmless because the ALJ proceeded to consider Claimant's headaches in formulating the RFC. See Winston v. Astrue, No. 4:ll-CV-107-D, 2012 WL 4086448, at *4 (E.D. N.C. Sept. 17, 2012) (“An ALJ's erroneous failure to find an impairment, such as obesity, severe at step two of the sequential analysis is harmless error if other impairments are found to be severe and the omitted impairment is considered at subsequent steps.”). Furthermore, Claimant points to no limitations in Dr. Roane's opinion that are more restrictive than those in the RFC imposed by the ALJ. Although the ALJ could have been more precise in the discussion of Claimant's headaches in the RFC, the court can trace the ALJ's reasoning in finding Claimant's headaches had minimal effect on his ability to work, which was supported by substantial evidence, including the opinion of Dr. Crawford, the normal examination findings, and the minimal treatment Claimant received for his headaches/migraines. See Dunn v. Colvin, 607 Fed.Appx. 264, 276 (4th Cir. June 1, 2015) (“[T]he fact that the ALJ could have offered a more thorough explanation for his decision does not change our conclusion that substantial evidence in the record supports that decision.”).
ii. Hypersomnia
The ALJ did not discuss Claimant's hypersomnia in the decision. There is a treatment note from March 2, 2015, prior to Claimant's alleged onset date, noting Claimant's complaints of fatigue but the doctor attributed it to, at least partially, over-controlled hypertension with bradycardia. (R. 447-50). There are references to hypersomnia in Claimant's treatment notes from June 8 and August 28, 2015, (R. 313, 326), and Claimant saw a pulmonologist on August 28, 2015, related to hypersomnia, snoring, and apneas, (R. 313). The doctor discussed several possible causes of Claimant's sleepiness, prescribed a trial of Mirapex, ordered testing, and directed Claimant to follow up. (R. 318). There is no record of Claimant following up with the pulmonologist or receiving treatment from his primary care provider for hypersomnia. Claimant did not testify about hypersomnia or sleep disturbances at the administrative hearing and did not list anything related to sleep among the conditions that limit his ability to work, (R. 215). Accordingly, any error in the ALJ's failure to discuss Claimant's hypersomnia was harmless where there is nothing in the record to support a finding that it impacted Claimant's ability to work. See Stewart v. Colvin, No. 5:14-CV-601-FL, 2016 WL 320299, at *8 (E.D. N.C. Jan. 7, 2016) (“[A]n ALJ ‘is not obliged to investigate a claim not presented at the time of the [benefits] application ... and not offered at the hearing as a basis for disability.'” (quoting Meyer v. Colvin, 754 F.3d 251, 257 (4th Cir. 2014))), adopted by 2016 WL 311285 (E.D. N.C. Jan. 26, 2016).
3. Claimant's Subjective Complaints of Pain
Claimant contends the ALJ erred in several respects when assessing his subjective complaints of pain, specifically (1) imposing an improperly high burden of proof, (2) drawing impermissible references from his activities of daily living, (3) relying on insubstantial evidence in discounting his complaints of pain, (4) failing to account for his arthritis, and (5) rejecting his complaints of pain solely on the basis of objective medical evidence. Pl. 's Mem. [DE-18] at 9-16.
When assessing a claimant's RFC, it is within the province of the ALJ to determine whether a claimant's statements are consistent with the medical and other evidence. See Shively v. Heckler, 739 F.2d 987, 989-90 (4th Cir. 1984) (“Because he had the opportunity to observe the demeanor and to determine the credibility of the claimant, the ALJ's observations concerning these questions are to be given great weight.”) (citation omitted). Federal regulation 20 C.F.R. § 404.1529(a) provides the authoritative standard for the evaluation of subjective complaints of pain and symptomology, whereby “the determination of whether a person is disabled by pain or other symptoms is a two-step process.” Craig, 76 F.3d at 593-94. First, the ALJ must objectively determine whether the claimant has medically documented impairments that could cause his or her alleged symptoms. S.S.R. 16-3p, 2017 WL 5180304, at *3 (Oct. 25, 2017); Hines v. Barnhart, 453 F.3d 559, 564 (4th Cir. 2006). If the ALJ makes that determination, he must then evaluate “the intensity and persistence of the claimant's pain[, ] and the extent to which it affects her ability to work, ” Craig, 76 F.3d at 595.
Objective medical evidence may not capture the full extent of a claimant's symptoms, so where the objective medical evidence and subjective complaints are at odds, the ALJ should consider all factors concerning the “intensity, persistence and limiting effects” of the claimant's symptoms. S.S.R. 16-3p, 2017 WL 5180304, at *5; 20 C.F.R. § 416.929(c)(3) (showing a complete list of factors). The ALJ may not discredit a claimant solely because his or her subjective complaints are not supported by objective medical evidence, Craig, 76 F.3d at 595-96, but neither is the ALJ required to accept the claimant's statements at face value; rather, the ALJ must “evaluate whether the statements are consistent with objective medical evidence and the other evidence.” S.S.R. 16-3p, 2017 WL 5180304, at *2; see Taylor v. Astrue, No. 5:10-CV-263-FL, 2011 WL 1599679, at *4-8 (E.D. N.C. Mar. 23, 2011), adopted by 2011 WL 1599667 (E.D. N.C. Apr. 26, 2011).
First, Claimant argues that the ALJ imposed an improperly high burden of proof-whether the alleged symptoms were “entirely consistent with the medical evidence and other evidence.” The ALJ's decision is clear that she applied the two-step process discussed above in considering Claimant's symptoms. (R. 19). As S.S.R. 16-3p explains, “In determining whether an individual is disabled, we consider all of the individual's symptoms, including pain, and the extent to which the symptoms can reasonably be accepted as consistent with the objective medical and other evidence in the individual's record.” 2017 WL 5180304, at *2. The ALJ stated her finding that Claimant's alleged symptoms were not entirely consistent with the objective medical and other evidence in the record. The ALJ went on to discuss all the relevant evidence in evaluating Claimant's subjective complaints of pain and as discussed below, did not ‘“improperly increase[] [the] burden of proof' by effectively requiring her subjective descriptions of her symptoms to be supported by objective medical evidence.” Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 96 (4th Cir. 2020) (quoting Lewis v. Berryhill, 858 F.3d 858, 866 (4th Cir. 2017)).
Second, Claimant argues the ALJ drew impermissible references from his activities of daily living. The ALJ cited Claimant's daily activities listed on his Function Report as evidence that Claimant was not as limited as he claimed to be. (R. 19). Claimant did report preparing simple meals, performing light household chores, driving, using a computer, shopping, watching television, and woodworking, but he explained on the form that he performed these activities either sporadically or for a short amount of time due to pain. Id. An ALJ must consider the extent to which a claimant can perform activities. See Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (finding error when the ALJ stated that the claimant could “maintain her personal hygiene, cook, [and] perform light household chores” but did not consider the claimant's testimony that she has trouble dressing and bathing, she can only prepare simple meals, it takes her longer than normal to do laundry and shop, and she sometimes “spends the entire day on the couch”); Brown v. Comm'r Soc. Sec. Admin., 873 F.3d 251, 263 (4th Cir. 2017). However, there is also evidence in the treatment notes to support that Claimant did continue to perform the most relevant activity, woodworking, with frequency.
On February 24, 2016, Claimant was treated for a woodworking injury. (R. 277). On July 1, 2016, Claimant reported that he worked in his furniture shop in his yard. (R. 287). On April 4, 2017, Claimant complained of tennis elbow. (R. 392). The record stated that “[h]e is a woodworker and is constantly using his left arm, ” “[h]e notes, at times, it has caused increased pain, ” he used a tennis elbow support, and he refused an injection. Id. (emphasis added). At the January 10, 2019 hearing, Claimant testified that he stopped woodworking approximately ten years before and that now he just goes out to his shop and moves things around to look at papers. (R. 38-39). There is substantial evidence in the record to support the ALJ's finding that Claimant continued to do woodworking with frequency despite his impairments and testimony to the contrary. (R. 21). Claimant's woodworking activity is significant because it relates to his past relevant work as a mold and plug builder, which the ALJ found he was capable of performing as it is generally performed. (R. 22, 34-36). Accordingly, the ALJ's reliance on Claimant's activities performed, specifically his woodworking, in discounting his allegations of disability due to pain is not grounds for remand.
Third, Claimant contends the medical record upon which the ALJ relied to assess Claimant's pain, such as a lack of cyanosis, clubbing, and edema, is insubstantial evidence. The Fourth Circuit has found error where an ALJ points to normal results that are not symptoms of the impairment at issue to discount complaints as inconsistent with the objective evidence. See Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83, 96 (4th Cir. 2020) (finding error where the ALJ relied on an absence of symptoms not associated with fibromyalgia to discredit the claimant's subjective complaints about the severity of her fibromyalgia symptoms). However, “objective medical evidence is a useful indicator to help make reasonable conclusions about the intensity and persistence of symptoms....” S.S.R. 16-3p, 2017WL5180304, at*5. “Examples such as reduced joint motion, muscle spasm, sensory deficit, and motor disruption illustrate findings that may result from, or be associated with, the symptom of pain.” Id. The ALJ, in discussing Claimant's ongoing complaints of pain in light of his treatment records, noted many normal examination findings that are relevant to assessing pain, including Claimant's normal range of motion, intact strength, and lack of focal motor or sensory deficits. (R. 20, 279, 376-78).
While Claimant takes issue with the fact that the “opinion” regarding the lack of motor or sensory deficits was from a physician's assistant, who is not an acceptable medical source, Pl.'s Mem. [DE-18] at 14, a lack of motor or sensory deficits is an examination finding not an opinion. Claimant further suggests that the examination was “probably quite cursory” and doubts its thoroughness and reliability, but this is pure speculation, and the Claimant points to no records where motor or sensory deficits were noted that would contradict the PA's examination finding. The ALJ relied on both treatment notes and the consultative examination of Dr. Crawford, none of which reflect significant examination findings indicative of the severe and disabling pain Claimant described. (R. 20). Dr. Crawford, who determined Claimant could sit, stand, and walk normally in an eight-hour workday with no significant limitations with lifting or carrying weight, noted the following examination findings that are not supportive of Claimant's complaints of severe and debilitating pain: with respect to Claimant's headaches, he had no cranial nerve abnormalities and no sensation deficits on the face, and normal strength in the bilateral upper and lower extremities; with respect to his carpal tunnel secondary to arthritis, he exhibited good grasp strength, pincer strength, and was able to do all physical manipulations without any noticeable weakness on physical examination; with respect to his osteoarthritis, he demonstrated good internal and external rotation of his shoulder, good strength in bilateral upper and lower extremities, no palpable step off on the back, good sensation bilaterally, normal ambulation, and the ability to squat unassisted. (R. 378). Accordingly, the medical evidence relied upon by the ALJ in discounting Claimant's complaints of pain was not insubstantial.
Fourth, Claimant argues the ALJ failed to account for his arthritis in evaluating his complaints of pain. Claimant complained of pain in his back, arms, shoulders, and neck. Claimant suggests the ALJ did not properly consider his arthritis in evaluating his pain, but he does not explain how the source of his pain, i.e., whether from arthritis or degenerative disc disease, would change the ALJ's decision. The ALJ did not parse the sources of Claimant's pain, but it is apparent from the decision that the ALJ found Claimant's arthritis to be a severe impairment and considered Claimant's arthritis along with degenerative disc disease, post spinal surgery, and headaches in assessing Claimant's complaints of pain and formulating the RFC. (R. 18, 20). Accordingly, Claimant has not demonstrated any reversable error in the ALJ's consideration of his arthritis in evaluating his complaints of pain.
Finally, Claimant contends the ALJ rejected his complaints of pain solely on the basis of objective medical evidence. As discussed above, in assessing Claimant's complaints of pain, the ALJ considered not only the lack of objective medical findings suggestive of pain but also that Claimant continued to do woodworking and the opinion evidence from Dr. Crawford and Dr. Roane. (R. 20-21); S.S.R. 16-3p, 2017 WL 5180304, at *6 (listing medical sources and daily activities among the evidence properly considered in assessing the limiting effects of symptoms). Thus, the ALJ did not rely solely on a lack of objective evidence of pain, and the ALJ's decision to discount Claimant's subjective complaints of pain was based on a correct application of the law and supported by substantial evidence.
Although not mentioned by the ALJ, it is noteworthy that Claimant also testified at the hearing that his own doctor does not think he has any problems. (R. 48).
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-17] be DENIED, Defendant's Motion for Judgment on the Pleadings [DE-19] be ALLOWED, and the final decision of the Commissioner be UPHELD.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until September 7, 2021 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D. N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).