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Barnes v. U.S. Commissioner, Social Security Administration

United States District Court, W.D. Louisiana, Alexandria Division

January 10, 2018

GREGORY BARNES
v.
U.S. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION

          TRIMBLE, JUDGE.

          REPORT AND RECOMMENDATION

          Joseph H.L. Perez-Montes, United States Magistrate Judge.

         I. Background

         A. Procedural Background

         Gregory 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, p. 63/736).

         A 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, p. 24/736).

         Barnes 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 Commissioner”).

         Barnes 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.

         The Commissioner responded to Barnes's appeal (Doc. 11). Barnes's appeal is now before the Court for disposition.

         B. Medical Records

         Barnes 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).

         Barnes 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).

         Barnes's 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. 406-09/736).

         A CT 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).

         In 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, 332/736).

         X-rays 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).

         Electromyography 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).

         In 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. 494/736).

         Also in 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. 483-84/736).

         In November 2014, Barnes was diagnosed with chronic PTSD and insomnia at Axis I[1] (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).

         X-rays 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. 472/736).

         Barnes 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).

         A sleep evaluation in March 2015 indicated Barnes suffers from obstructive sleep apnea, and a CPAP machine was recommended (Doc. 5-1, pp. 308-9/736).

         In 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).

         In 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).

         In June 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 ...


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