United States District Court, W.D. Louisiana, Alexandria Division
REPORT AND RECOMMENDATION
H.L. Perez-Montes, United States Magistrate Judge.
Barnes (“Barnes”) filed an application for
disability insurance benefits (“DIB”) alleging a
disability onset date of January 27, 2014 (Doc. 5-1, p.
117/736) due to degenerative disc and joint disease,
traumatic brain injury, and post-traumatic stress disorder
(Doc. 5-1, p. 137/736). That application was denied by the
Social Security Administration (“SSA”) (Doc. 5-1,
de novo hearing was held before an Administrative
Law Judge (“ALJ”) at which Barnes appeared with
his attorney and a vocational expert (“VE”) (Doc.
5-1, p. 28/736). The ALJ found that, although Barnes suffers
from severe impairments of degenerative disc and joint
disease, traumatic brain injury, and post-traumatic stress
disorder (Doc. 5-1, p. 17/736), he has the residual function
capacity to perform light work except that he cannot do any
overhead lifting, cannot do complex tasks, and can have only
occasional interaction with the public (Doc. 5-1, p. 20/736).
The ALJ further found that work exists in significant numbers
in the nation economy that Barnes can do, such as routing
clerk or mailroom clerk (Doc. 5-1, p. 24/736). The ALJ
concluded that Barnes was not disabled from January 27, 2014
though the date of his decision on July 25, 2016 (Doc. 5-1,
requested a review of the ALJ's findings, but the Appeals
Council declined to review it (Doc. 5-1, p. 4/736), and the
ALJ's decision became the final decision of the
Commissioner of Social Security (“the
filed this appeal for judicial review of the
Commissioner's final decision. Barnes raises the
following grounds for relief on appeal (Doc. 10):
1. The ALJ failed to consider all the evidence, especially
the complete testimony of the VE.
2. The Appeals Council erred in failing to consider the
appeal, which was supported by additional evidence regarding
PTSD and its effect on claimant's ability to work.
Commissioner responded to Barnes's appeal (Doc. 11).
Barnes's appeal is now before the Court for disposition.
was evaluated by Dr. Brad J. Chauvin, an orthopedic surgeon,
in March 2014 for left shoulder pain (Doc. 5-1, p. 240/736).
Barnes complained of constant left shoulder pain that had
increased in the last two months (Doc. 5-1, p. 240/736).
Barnes suffered a parachute injury in 1999 and a car accident
in 2000, which injured his neck, shoulder, and back (Doc.
5-1, p. 377/736). Barnes said his shoulder starts to hurt
when he moves it, then the pain moves down to his hand and
all fingers, without numbness or tingling (Doc. 5-1, p.
240/736). A two-year-old MRI showed a full-thickness
supraspinatus tendon tear, biceps tendinitis, and a partial
subscapular tear (Doc. 5-1, p. 241/736). Dr. Chauvin
diagnosed rotator cuff sprain and strain, shoulder pain,
rotator cuff syndrome of the shoulder, partial tear of the
rotator cuff, compete rupture of the rotator cuff, pain in
the forearm and joint, disorder of the bursae and tendons in
the shoulder region, and non-traumatic rupture of tendons of
the biceps (long head), with left shoulder pain and possible
radiculopathy (Doc. 5-1, p. 241/736).
sought medical care and benefits from a VA Medical Center in
July 2014 (Doc. 5-1, pp. 563, 571/736). Barnes reported
chronic shoulder pain since 2002, he was found to be a high
risk for falling, his PTSD screen was positive, his traumatic
brain injury (“TBI”) screen was positive, and his
depression screen suggested moderate depression (Doc. 5-1,
pp. 570, 572-75/736). Barnes was diagnosed with controlled
hypertension, hyperlipidemia, lower back pain, joint pain,
intermittent tinnitus, traumatic brain injury, and
post-traumatic stress disorder (“PTSD”) (Doc.
5-1, p. 568/736).
July 2014 PTSD screen showed he was a widower with grown
children (Doc. 5-1, pp. 345/736). Barnes served in the Navy
from 1986 through 2007, in the Persian Gulf, OEF, IOF era
(Doc. 5-1, p. 347/736). His title was Engineman, but he
performed bomb patrol duty, served overseas, and received
hazardous duty pay 5 times (Doc. 5-1, p. 345/736). Barnes
suffered a parachute injury in 1999 and a car accident in
2000 with injuries to his neck, shoulder, and back (Doc. 5-1,
p. 377/736). Barnes stated he was involved in several
instances where death or fear for his life were imminent; he
had intrusive experiences such as recurrent thoughts,
nightmares, and physiological reactions to triggers; he did
not want to think, talk about, or go places that remind him
of the trauma; and he had persistent and exaggerated negative
beliefs about the world, persistent negative emotional
states, mood associated symptoms, or marked diminished
interest in significant activities, feelings of detachment
from others, and persistent inability to experience positive
emotions (Doc. 5-1, p. 347/736). Barnes exhibited
irritability, hypervigilance, and sleep disturbances (Doc.
5-1, p. 347/736). Barnes was diagnosed with chronic PTSD (as
evidenced by trauma, war time recollections, and impairment
in life activities for more than one month) (Doc. 5-1, p.
348/736). In September 2014, Barnes was prescribed Trazodone
for insomnia and Prazosin for nightmares (Doc. 5-1, pp.
scan of Barnes's brain in July 2014 was normal (Doc. 5-1,
p. 289/736). Barnes was found to be suffering from bilateral
tinnitus in August 2014 (Doc. 5-1, p. 343/736).
September 2014, Barnes reported frequent left shoulder pain;
cervical pain (C6 herniation) with left arm radiculitis,
intermittent numbness, and weakness of the left hand and
thumb; headaches; insomnia; memory issues; frequent
nightmares; PTSD; hypertension; right foot numbness; left
knee pain; arthritic changes; left elbow pain; and tinnitus
(Doc. 5-1, pp. 516-17/736). Barnes reported that his left
knee would go out on him while standing (Doc. 5-1, p.
510/736). Barnes's left knee pain was believed to be
caused by an ACL injury during parachute jumps, and he was
given a knee brace and a TENS unit (Doc. 5-1, pp. 322,
of Barnes's cervical spine in September 2014 showed
moderate narrowing of the C6-7 disc space, mild anterior
spurring of C5-C7, and narrowing of the left C6 exit foramen
was suggested, but there was no evidence of cervical spine
instability on flexion or extension (Doc. 5-1, p. 232/736).
and nerve conduction studies in September 2014 showed no
clear weakness in the upper extremities, no neurological
symptoms, and normal motor strength, but shoulder pain on
abduction and adduction of his left arm (Doc. 5-1, p.
233-34/736). There was no evidence of neuropathy, carpal
tunnel syndrome, ulnar neuropathy, or blockage at the elbow,
and very mild nonspecific irritability at ¶ 5-6
bilaterally (Doc. 5-1, p. 234/736).
October 2014, Barnes reported increased chronic left knee
pain (Doc. 5-1, p. 317/736). Barnes' knee was not swollen
and there was no edema (Doc. 5-1, p. 489/736), but he had
weakness in his gait and on transferring, and was at a high
risk for falls (Doc. 5-1, p. 499/736). Barnes reported his
knee pain limited comfort, sleep, and activity (Doc. 5-1, p.
494/736). Meloxicam helped reduce the pain (Doc. 5-1, p.
October 2014, Barnes finished cognitive behavioral therapy
for insomnia (Doc. 5-1, pp. 483-84, 487-88, 502, 505, 509,
513-15/736). Barnes's sleep efficiency improved; his
insomnia severity index improved from severe clinical
insomnia to moderate; his Beck Depression Scale II decreased
from 34 (severe) to 23 (moderate); and he fell asleep faster,
awakened less, and woke early less often (Doc. 5-1, pp.
November 2014, Barnes was diagnosed with chronic PTSD and
insomnia at Axis I (Doc. 5-1, p. 475/736). Hyper-alertness
was one of his main problems (Doc. 5-1, p. 475/736). Barnes
had multiple concussions during deployments in the Navy, one
of which resulted in loss of consciousness (Doc. 5-1, p.
477/736). Barnes suffered from headaches, poor concentration,
forgetfulness, difficulty sleeping, anxiety, and irritability
(Doc. 5-1, p. 477/736).
of Barnes's lumbar spine in November 2014 showed
degenerative changes in the lower lumbar spine and anterior
wedging of the L1 (Doc. 5-1, p. 258/736). A nerve root block
in December 2014 at ¶ 5 right made Barnes's pain
tolerable at 3/10, with tolerable intermittent discomfort
radiating into the right lower extremity (Doc. 5-1, pp. 254,
256/736). Barnes was prescribed Mobic (Doc. 5-1, p. 254/736).
Barnes's neurological and lumbosacral exams were normal,
his gait was normal, there were no paraspinal muscle spasms,
and the motor strength in his upper extremities was normal
(Doc. 5-1, p. 255/736). Barnes was prescribed Lisinopril for
his hypertension, which was stable (Doc. 5-1, p. 468-49/736).
It was noted that pain in his left elbow restricted extension
sometimes, and that he had previously been offered surgery
(Doc. 5-1, p. 468/736). Barnes reported that pain affected
his physical activities, sleep, and walking (Doc. 5-1, p.
had several MRIs in January 2015: Barnes's lumbosacral
spine showed anterior wedging of L1 and mild spondylosis at
¶ 1 (Doc. 5-1, p. 287/736); his right and left elbows
were normal (Doc. 5-1, pp. 284, 286/736); his right shoulder
showed post-operative changes (Doc. 5-1, pp. 285-86/736); his
left shoulder was normal (Doc. 5-1, p. 288/736); and his
right knee was normal (Doc. 5-1, pp. 283-84/736). Barnes
injured his left knee when he was a paratrooper (Doc. 5-1, p.
283/736), and he complained of left knee pain that was sharp
on rotation and instability (Doc. 5-1, pp. 365-66/736). A
February 2015 MRI showed chondromalacia patellae (Doc. 5-1,
pp. 283-84, 414/736).
evaluation in March 2015 indicated Barnes suffers from
obstructive sleep apnea, and a CPAP machine was recommended
(Doc. 5-1, pp. 308-9/736).
March 2015, Barnes had a neurological exam with Dr. Michael
L. Drerup, a neurological surgeon, for his complaints of
chronic cervical pain, radiating left shoulder pain, and left
upper extremity numbness, tingling, and weakness (Doc. 5-1,
p. 248/736). Dr. Drerup noted disc protrusion with osteophyte
formation at ¶ 6-7 left, foraminal stenosis, and mild
C5-6 irritability with no radiculopathy. (Doc. 5-1, p.
252/736). Dr. Drerup diagnosed a cervical herniated nucleus
pulposis and cervical spondylosis without myelopathy (Doc.
5-1, p. 232/736), which caused: (1) chronic mechanical low
back pain secondary to supraspinatus/infraspinatus
ligamentous syndrome L3-4 (nearly resolved with a block at
¶ 3-4); (2) L5 radiculopathy secondary to foraminal
stenosis L4-6 and L5-S1 (improved with a block at ¶ 5
right); and (3) chronic intrascapular pain with cervical
radiculopathy left, secondary to lateral disc protrusion with
osteophyte formation C6-7 left, somewhat improved with blocks
at ¶ 7 left (Doc. 5-1, p. 252/736). Dr. Drerup
recommended repeat nerve root blocks (Doc. 5-1, p. 252/736).
April 2015, Barnes complained that, despite taking his pain
medication, he had constant, chronic pain:
“shooting” pain in his neck; dull pain in his
back; “ripping, pulling, tearing” pain in his
shoulder; popping and cracking in his elbow; and
“ripping” pain in his knee (Doc. 5-1, p.
400/736). Physical activity caused the pain, which limited
his activities (Doc. 5-1, p. 400-01/736). Barnes had a
cervical nerve root block of the left C6 and C7 for treatment
of radiculopathy (Doc. 5-1, p. 247/736).
2015, Barnes underwent a sleep study and was diagnosed with
sleep apnea by Dr. Gerald Foret (Doc. 5-1, pp. 314,
403-04/736). Barnes was ...