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Clark v. Berryhill

United States District Court, E.D. Kentucky, Southern Division, London

May 23, 2018

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.


          Danny C. Reeves, United States District Judge

         This matter is pending for consideration of cross-motions for summary judgment filed by Plaintiff Michael Anthony Clark and Defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration. [Record Nos. 12, 14] Clark contends that the Administrative Law Judge (“ALJ”) assigned to his case failed to properly consider his subjective complaints of pain and other symptoms and that the ALJ's decision is not supported by substantial evidence. The Commissioner contends that the ALJ properly evaluated the evidence of record and that the decision should be affirmed because it is supported by substantial evidence. For the reasons that follow, Clark's motion will be denied. The Commissioner's motion will be granted and the administrative decision will be affirmed.

         I. Procedural History

         Clark filed a Title II application for a period of disability and disability insurance benefits (“DIB”) on December 5, 2014, alleging an onset of disability of January 21, 2014. [Administrative Transcript; hereinafter; “Tr., ” 143] After being denied initially and on reconsideration, Clark requested a hearing. [Tr. 75, 84, 91] He appeared before ALJ Dennis Hansen at an administrative hearing on September 1, 2016. [Tr. 26-45] ALJ Hansen denied benefits in a written decision on November 2, 2016, which the Appeals Council affirmed. [Tr. 7-21, 1-6] Accordingly, the claimant has exhausted his administrative remedies and this matter is ripe for review under 42 U.S.C. § 405(g).

         II. Background

         Clark was 39-years-old at the time of the ALJ's decision. [Tr. 21, 29] He has a high school diploma and has attended some college. [Tr. 29] Clark worked in underground coal mining operations from 2004 through 2012, where he ran heavy equipment and lifted up to one hundred pounds. [Tr. 30-31] He stopped working in 2012 because of back pain. [Tr. 32] According to Clark, his employer told him that he was no longer “keep[ing] up with the other men.” Id. He reported that he had been forced to reside with his parents after the loss of his job. [Tr. 29]

         Clark advised the ALJ that his most significant problems were low back pain and numbness in his left upper extremity. [Tr. 33] He stated that he was unable to hold anything and, that if he moved his neck in certain positions, it caused sharp pains to shoot down his legs. Id. Clark estimated that he could lift ten or fifteen pounds and that he could stand for fifteen to twenty minutes before changing positions. [Tr. 33, 37] Clark claimed that he was unable to drive due to limited neck motion. [Tr. 211] He reported taking several medications to manage his symptoms and had a history abusing pain medications. [Tr. 36] Clark advised that he had to lie down and elevate his feet to relieve his symptoms six or seven times each day. [Tr. 39]

         Clark reported to Appalachian Regional Hospital (“ARH”) Tri City Medical Center on January 10, 2014, where he established care with Joann Martin, APRN, as his primary care provider. [Tr. 384] He told her about his back pain and that he “got hooked on Percocet” and had been going to a Suboxone clinic for a year. Id. Martin referred Clark to physical therapy. [Tr. 385] He continued to follow-up with Martin, advising her in February and March 2014 that he needed a work excuse. [Tr. 392-93] Martin advised Clark in June 2014 that pharmacies had notified her that he had prescriptions for Neurontin filled by two different providers. [Tr. 406] Martin ordered a drug screen and it does not appear that Clark returned to her after that. Id.

         Clark was involved in a motor vehicle accident on or about January 21, 2014, and was transported to ARH in Harlan, Kentucky. [Tr. 276] He reported that his car slid on ice and overturned, and he tested positive for cocaine and benzodiazepines. [Tr. 269] A CT scan of his head was normal, but a CT scan of his neck showed signs of degenerative disc disease at ¶ 5-C6, with mild encroachment of the neural foramen on bilaterally. [Tr. 270] A CT scan of Clark's left leg revealed a contusion and an x-ray of his right shoulder was largely unremarkable. [Tr. 274-75]

         Clark began physical therapy treatment in February 2014. [Tr. 352] He advised his therapist that he had pain in his neck, back, right shoulder, and left Achilles region, which he rated ten-out-of-ten at worst. [Tr. 353] His gross strength was slightly diminished, particularly in the right lower extremity, and his neck range of motion was reduced. [Tr. 354-55] Clark still demonstrated strength and range of motion limitations and complained of ten out of ten pain in April 2014. [Tr. 326] A May 2014 MRI of Clark's cervical spine revealed a moderate-size central disc protrusion herniation at ¶ 5-C6. [Tr. 378] An MRI of the lumbar spine in June 2014 indicated mild diffuse annular bulging at ¶ 2-L3 and L4-L5, but there were no signs of herniated nucleus pulposis or spinal stenosis. [Tr. 376] Finally, an MRI of Clark's shoulder in May 2014 showed mild hypertrophy of the AC joint, but no signs of a rotator cuff tear were identified. [Tr. 380]

         William Rigsby, Ph.D., performed a consultative psychological examination of April 28, 2015. [Tr. 416] Clark advised Rigsby that he had experienced panic attacks and nervousness since 2010. He reported having chronic pain and participating in his sixth substance abuse treatment program. Rigsby noted that Clark related in a cooperative manner but appeared to be “from a deprived background” and was somewhat limited and below average, “but not mentally retarded.” [Tr. 416] He had intact short-term and long-term memory and was able to perform simple math and reasoning. [Tr. 417]

         Rigsby assigned Clark a Global Assessment of Functioning (“GAF”) score of 65, but indicated that he had a moderately impaired ability to understand, retain, and follow simple instructions and to sustain concentration and persistence to complete tasks in normal time. [Tr. 419] Rigsby also indicated that Clark had marked impairment in his ability to maintain social interactions with supervisors, friends, and the public and to adapt and respond to the pressures of normal day-to-day work activity. Id.

         Clark received an independent psychological examination from Robert Spangler, Ed. D., on November 10, 2015. [Tr. 429-35] Spangler observed that Clark had a slow, stiff gait, awkward gross motor movements, and slurred speech. [Tr. 430] He also noted that Clark was “shy, vigilant, anxious, and depressed.” Clark was appropriately persistent on tasks with prompts, but his pace was impacted. He appeared to lose his balance when standing, shifted in his seat frequently, and mumbled constantly. Id.

         Spangler reported that Clark had adequate recall of remote events, but inadequate recall of recent events. [Tr. 432] His judgment and insight were consistent with average intelligence. His stream of thought was unremarkable, his associations were logical, and his thought content was non-psychotic, but was focused entirely on his injuries and pain. [Tr. 432-33] Spangler noted that Clark interacted well during the examination, but he reported that he “stays tired” and “goes into rooms and forgets why he is in there.” [Tr. 433] Spangler administered the Personality Assessment Inventory and concluded that all clinical scales were within normal parameters except anxiety, which included subscale scores confirming Clark's diagnoses of major depressive disorder, ...

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