Colby v. SSA

District Court, D. New Hampshire·Decided May 9, 1997·No. CV-96-2 3 8-M·Published

Opinion

Colby v. SSA CV-96-2 3 8-M 05/09/97 UNITED STATES DISTRICT COURT

DISTRICT OF NEW HAMPSHIRE

Eleanor Colby, Plaintiff

v. Civil No. 96-238-M

Shirley Chafer, Commissioner, Social Security Administration, Defendant

O R D E R

Pursuant to section 20 5 (g) of the Social Security Act, 42 U.S.C. § 405(g), Eleanor Colby seeks review of a final decision by the Commissioner of the Social Security Administration denying her claim for benefits. Before the court is plaintiff's motion to reverse the decision of the Commissioner. The Commissioner objects, and moves to affirm that order. For the reasons set forth below, plaintiff's motion is denied.

Administrative Proceedings Plaintiff filed an application for disability insurance benefits on April 28, 1993, alleging an inability to maintain gainful employment since May 10, 1988, due to fibrocytis fibromyalgia, which causes chronic muscle pain and spasms. Her claim was denied initially and again on reconsideration. Subseguently, she reguested a hearing, which was held on February

27, 1995, before Administrative Law Judge Frederick Harap. Plaintiff appeared in person and testified. She was represented by Arthur Kaufman, a lay representative who is also a vocational expert.

In a decision issued on March 31, 1995, the ALJ denied plaintiff's claim at step four of the relevant sequential evaluation process. See 20 C.F.R. § 404.1520(e). The ALJ concluded that plaintiff had "sufficient residual functional capacity for a substantially full range of light work" (T.21), and, therefore, was able to perform her past relevant work as an electronic skills instructor. Moreover, he concluded that even if plaintiff were unable to perform the tasks associated with that occupation, she retained, at a minimum, the residual functional capacity to perform sedentary work. Accordingly, the ALJ held that plaintiff was not disabled within the meaning of the A c t .

Facts

I. Medical Evidence.

Eleanor Colby, is a 47 year-old resident of Danbury, New Hampshire. While employed as an electronics assembler/computer skills instructor in October of 1987, she began to develop back

and neck pain (T.100). She was treated initially by Dr. Carey Rodd in Salisbury, New Hampshire, from December 1987 through October 1992 (T.82). He prescribed physical therapy and medication, and diagnosed her condition as myofascial pain syndrome (T.82, 219-224).

For two weeks in late April of 1988, plaintiff attempted to work on a part-time basis (T.81). Her efforts were unsuccessful and she has not been employed since May 10, 1988. From July of 1988 through August of 1990, she was treated by Dr. Seddon Savage, a pain specialist at Dartmouth Hitchcock Hospital (T.158- 67). In her initial evaluation of plaintiff, dated July 27, 1988, Dr. Savage noted that plaintiff had a full range of motion in her lumbar spine and neck, but experienced discomfort in her back muscles when pulling (T.159). Muscle tenderness was noted in her shoulder with a large trigger point noted in her upper back (Id.). Other tests were within normal ranges, including reflexes, straight leg raising, and motor strength.

Dr. Savage opined that plaintiff demonstrated a "secondary myofascial pain syndrome due to overuse associated with her assembly work" (Id.). She felt plaintiff would be unlikely to return to her past work in the near future. Although Dr. Savage

believed plaintiff could return to a managerial position with no assembly work, she noted that plaintiff's long drive to work might make a successful return difficult (Id.). She recommended injections of pain medications at the trigger points1 in plaintiff's left shoulder (1.161) . In a June 5, 1989 note. Dr. Savage observed that plaintiff was released for work with restrictions in January 1989 and had sought appropriate work, but was unsuccessful (T.162). Plaintiff's fibromyalgia had been asymptomatic for almost two months, but she experienced a flare up after sitting in the cold at her daughter's track meet (Id.). In a letter to plaintiff's compensation attorney. Dr. Savage noted that she had been treating plaintiff for persistent work- related shoulder and left arm pain, which she diagnosed as overuse fibromyocytis due to repetitive muscular contraction (T.163). Muscle relaxants such as flexeril were needed for pain flare-ups, but were not necessary if plaintiff paced her activities and did not overuse the affected muscles (Id.). Dr. Savage noted that plaintiff had been ready to return to work for several months, but had experienced difficulty in finding appropriate employment (T.163-64). Dr. Savage also noted that "the only limitations which have been imposed on her are that her

1 Trigger point - A specific point on the body at which touch or pressure will give rise to pain. P. 806, Stedman's Concise Medical Dictionary (2d Ed. (Williams & Wilkins, 1995).

work not involve repetitive or heavy use of her arms, particularly the left arm, and that her work be done within thirty-five miles of home" (Id.). Dr. Savage cautioned, however, that she could not predict if plaintiff's condition would be permanent or if it would gradually resolve in a few years. She felt it more likely that Ms. Colby would have a "persistent tendency" for further muscle spasms and pain (T.164) .

In a disability report prepared for plaintiff's insurance carrier. Dr. Savage diagnosed plaintiff's condition as "overuse fibrocytis/ myofascial dysfunction." (T.165). Her treatment for this ongoing problem included medication, supervised physical therapy, and trigger point injections (Id.). Dr. Savage felt plaintiff could not return to her past job because the commute to work was too great. However, Dr. Savage stated that other lighter, more suitable work with less driving may be appropriate (T.166) .

On December 12, 1989, Susan A. Emerson, an occupational therapist, performed an upper extremity work capacity evaluation on plaintiff. This evaluation revealed no atrophy, edema, or deformities. Ms. Emerson reported that plaintiff had a full active range of motion in her shoulder, elbow, forearm, wrist and

fingers (T.226). Trigger points for pain were noted in the paracervical muscles, scapula, and trapezium (T.227). Plaintiff's ability to reach was normal (T.228), but her ability to lift was limited to 10 pounds repetitively with a maximum lifting/carrying capacity of 15 pounds (Id.). While her range of motion was normal, her grip strength in both hands was below normal (T.229). Ms. Emerson noted, however, that plaintiff's performance on other strength tests suggested that she "may not have exerted maximal effort during grip testing" (Id.). Ms. Emerson concluded that plaintiff had a light to moderate work capacity, but with limitations on constant forward head movement. Additionally, it was recommended that she be provided with work which permitted some variety in head posturing and did not reguire repetitive reaching at or above shoulder height (Id.). Extensive driving was limited and she was told to do no lifting more than 20 pounds using both hands or 10 pounds with either hand (T.229-30).

Subseguently, a permanent impairment evaluation was done on June 27, 1990 (T.231) by plaintiff's workers' compensation carrier. Its doctor, Kenneth O'Neil, M.D., felt that plaintiff had reached a medical endpoint and noted that she had ongoing

problems with tenosynovitis2 and myofascial3 pain. He concluded that she had minor residual permanent impairment of 3% in her dominant right upper extremities and 2% in her non-dominant left upper extremities, based on continued intermittent trigger points (T.236). Ultimately, however, he concluded that she did not have "any significant permanent impairment" (T.234).

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