United States District Court, W.D. Missouri, Western Division
NORA J. PALMER, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
NANETTE K. LAUGHREY United States District Judge
Nora J. Palmer appeals the Commissioner of Social
Security's final decision denying her application for
disability and disability insurance benefits under Title II
of the Social Security Act. The decision is affirmed.
was born in 1951. She alleges she became disabled on
11/28/2008, after working for the U.S. Postal Service for
many years. Her date last insured was 12/31/2014. The
Administrative Law Judge held a hearing on 6/10/2015 and
denied her application on 9/22/2015. The Appeals Council
denied her request for review on 1/13/2016.
February 2008, Palmer complained to her primary care
physician, Diane Voss, M.D., of sudden onset of back pain and
said she had gone to urgent care and to the chiropractor.
Palmer declined Dr. Voss' offer of a weight restriction
for work. In April 2008, examination showed normal back and
musculoskeletal findings. In May 2008, Palmer reported some
back pain after walking in a 5K race, but said her back was
better overall. Dr. Voss ordered an MRI of Palmer's back
in November 2008, which showed degenerative disc changes in
the lumbar region and some annular tears, but no central
spinal stenosis or disc protrusions. Palmer declined a pain
clinic referral. An examination later that month showed her
extremities were tender but her back was normal. In December
2008, Palmer was prescribed a TENS unit and physical therapy.
had 12 physical therapy sessions from December 2008 to
January 2009. When the course of therapy ended, she reported
having made good progress, had normal range of motion and
strength, and rated her pain at 0 out of 10. She had another
course of physical therapy consisting often visits that ended
in March 2009. She reported steady improvement and at
discharge, her range of motion and strength were normal.
April 2009, Palmer reported back pain to Dr. Voss, but said
exercises helped. Musculoskeletal findings were normal. Dr.
Voss prescribed pain medication and a muscle relaxer. In July
and October 2009, Palmer told Dr. Voss that she regularly did
yoga and exercises and her back was better.
complained of back pain to Dr. Voss in April 2010. In August
2010, after two months of physical therapy, Palmer reported
that she was doing really well and could manage her back pain
with exercise. Her range of motion and strength were normal.
In October 2010, Palmer told Dr. Voss she had numbness and
decreased grip strength in the right hand and arm, and low
back pain. She also said she could not sit or stand longer
than 15 minutes. Dr. Voss increased Palmer's Vicodin. A
cervical spine x-ray showed lower cervical degenerative
changes with bilateral bony foraminal impingement greater on
January 2011, Palmer reported that she was taking zero to six
doses of Vicodin per day, she was exercising regularly and
doing yoga, and her right arm symptoms had resolved. Hand and
wrist x-rays taken in May 2011 were unremarkable.
went to Dr. Voss' office on May 18, 2011, but after
noting Palmer could not walk, the doctor sent her to the
emergency room to rule out a compression fracture. The
emergency room physician noted "no acute distress"
on physical exam. Tr. 391. Palmer had back tenderness and
spasms, but a straight-leg raise test was negative, and she
had full range of motion in the legs and normal sensation.
She was administered pain medication and discharged with a
diagnosis of back pain of questionable etiology and
prescriptions for pain medication.
her emergency room visit, Palmer followed up twice with an
orthopedic surgeon, Jeffrey T. MacMillan, M.D. On May 9,
2011, she reported debilitating waistline pain that first
began "10 years ago but [began] in earnest about 10 days
ago" and said medication did not help. Tr. 608. She
described the pain as sharp and stabbing, but without
radiation to the legs. She denied numbness. She said she
"typically treated her pain with PT modalities and yoga
which managed it until recently." Id. Except
for generalized lumbar paraspinal tenderness and guarded
motion, her physical exam was normal. Dr. MacMillan ordered
an MRI, which showed minimal lateral lumbar curvature,
degenerative disc disease at ¶ 2-3 and L3-4, and small
to moderate disc bulges at ¶ 4-5 and mild narrowing. At
a follow up visit on May 23, 2011, Palmer told Dr. MacMillan
that her pain medications helped but did not provide adequate
relief. The doctor recommended a trial of facet blocks with
radiofrequency ablation, which Palmer declined.
visit with Dr. Voss in August 2011, Palmer reported that she
had not had a good experience with Dr. MacMillan. She
complained of neck and arm pain. Dr. Voss assessed
degenerative joint disease. At a November 2011 appointment,
Palmer reported to Dr. Voss that she was doing her back and
neck exercises, saw her grandchildren regularly, and visited
a chiropractor for neck pain. Physical exam was normal. Dr.
Voss assessed stable low back pain.
February 2012 visit, Dr. Voss noted mild back tightness and
tenderness, but that Palmer's musculoskeletal findings
were essentially normal and stable, and assessed lumbar
spinal stenosis. In May 2012, Palmer complained of difficulty
sleeping, and back spasm with radiation. Dr. Voss'
findings on exam were similar to her February 2012 findings,
and she recommended that Palmer continue her medications, and
to stretch and stay active. At an August 2012 visit, Palmer
reported that her back pain had flared up after being with
her grandchildren and doing a lot of driving and sitting. She
said she was taking six hydrocodone tablets a day without
relief and asked to resume OxyContin, which Dr. Voss
prescribed. In December 2012, Palmer saw a nurse
practitioner, Tammy Osborn. Palmer reported that her
radiating low back pain had improved since her last
appointment, that she exercised regularly and was active, and
that she took hydrocodone daily and OxyContin as needed.
Osborn noted paraspinal back spasm on physical exam, but that
Palmer's musculoskeletal findings were essentially normal
or stable and compatible with known history. She also noted
long-term use of high-risk pain medication. Osborn's
assessment included stable spinal stenosis and she
recommended stretching, yoga, and staying active.
next saw Dr. Voss in February 2013, with back spasm and
antalgic gait. Dr. Voss noted normal or stable
musculoskeletal findings and intact sensation, and prescribed
physical therapy. From February through May 2013, Palmer made
steady progress in physical therapy. She had decreased pain,
which she could manage with pain medication, heat, and
stretching. By the time of discharge from physical therapy,
she no longer had muscle spasms and her range of motion had
improved. At an April 2013 visit with Dr. Voss, Palmer said
her pain level had improved and she tried to stay active. She
described her pain as only moderately limiting but said she
had to be careful with her grandchildren. Dr. Voss noted that
Palmer's back pain was stable and encouraged her to
continue stretching and yoga as tolerated. At a July 2013
visit, Dr. Voss noted Palmer had had a flare up of back pain
but was better, and renewed Palmer's pain medications. At
an October 4, 2013 visit, Dr. Voss noted back spasm, but that
Palmer's back was better and stable, and renewed
Palmer's pain medications. Palmer also complained of
bilateral hand pain, but declined referrals to a pain clinic
or for a surgery consult. Palmer saw Dr. Pampolina on October
21, 2013, in follow-up for an epigastric issue, and on exam,
the doctor noted normal musculoskeletal findings, i.e., full
range of motion without tenderness or swelling. On October
24, 2013, Palmer saw the nurse practitioner, Osborn, about
pain and a rash on her chest. Osborn diagnosed shingles. She
noted Palmer had an antalgic gait and a left-side limp.
December 2013, Palmer had a mental consultative examination
with Jane W. Ruedi, Ph.D. Palmer told Dr. Ruedi that she
retired from the postal service due to a back injury. She
said physical therapy helped her control her symptoms and
that she exercised and performed stretches. She also said she
drove, managed her brother's Social Security Supplemental
Security Income payments, did laundry, walked, went to the
gym, attended weekly Bible study, had her grandchildren and
friends over to visit, read, visited another woman once a
week, took craft classes with a friend, and played cards once
saw Dr. Voss for a physical in January 2014. She reported
that chronic back pain was a factor "at times" and
that she tried to remain active. Tr. 560. Her pain level had
improved since her last appointment and was moderately
limiting, but medications helped and she did not want to
pursue pain clinic treatment or surgery. She said she had to
be careful with her grandchildren, but had hobbies, engaged
socially, went to the gym two to three times weekly, and
performed her activities of daily living without difficulty.
Examination revealed mild back tenderness and tightness and
antalgic movement, and essentially normal and stable
musculoskeletal findings. Dr. Voss assessed controlled lumbar
spinal stenosis and recommended a book regarding back pain.
had physical therapy in March and April 2014 and was
discharged with improved range of motion. The physical
therapist noted deficits in all planes of motion. She also
noted that she had instructed Palmer about modifying
activities at home to aid in decreasing her pain level, but
did not believe Palmer had followed the instructions.
images taken in April 2014 showed mild degenerative changes.
Palmer subsequently told Dr. Voss that she found it difficult
to be comfortable in view of the back pain, and that it was
painful to sit, stand, and lift. She said physical therapy
did not provide lasting benefit, and a TENS unit, which she
used 30 minutes a day, did not help. She had tried a Lidoderm
patch with mild improvement. Dr. Voss noted that Palmer's
x-rays did not explain her pain. An MRI of the lumbar spine
taken April 30, 2014 showed mild degenerative disc bulges at
different levels, with slight worsening at ¶ 3-L4; a
small right L4-L5 disc protrusion that remained stable; no
significant foraminal or central canal stenosis; and no
definitive nerve root compression.
saw a pain specialist, Howard Aks, M.D., in June 2014 for low
back pain that radiated to her legs. She reported having had
previous treatment including physical therapy, chiropractic,
nonsteroidal anti-inflammatory drugs and other pain
medications, and bedrest, but said that all treatment other
than bedrest was ineffective. Examination showed her spine
was non-tender and stable. She had normal range of motion
except for pain with lumbar extension. She had positive
bilateral straight-leg raises, but stable joints and normal
muscle strength, tone, and leg range of motion. Right leg
strength had decreased dorsiflexion compared to the left, and
ankle reflexes were 0 on the right and 1 on the left. Her
neck was normal and symmetrical; posterior cervical muscles
were nontender; and the cervical spine was stable with normal
range of motion. Her arms were normal and she had stable
joint stability and normal range of motion. Dr. Aks assessed
lumbar radiculitis and recommended a lumbar epidural steroid
injection, but Palmer wanted to think about it and later
visit in August 2014, Dr. Voss noted that Palmer had declined
the epidural steroid injection, and that Palmer said
stretches helped. Dr. Voss prescribed pain medications, and
recommended a back brace, Lidoderm patches, and a back pain
book. In November 2014, the doctor noted Palmer had not
followed up on the recommendations.
Palmer saw Dr. Voss in February 2015, she reported that she
had gotten the back brace and Lidoderm patch, and they were
helpful. She also reported that she was able to cut down on
her medications. Examination showed back spasm and
tenderness, but Dr. Voss noted that Palmer's
musculoskeletal findings were essentially normal or stable.
At a March 2015 appointment with Dr. Pampolina for a rash,
Palmer said she had gone on a cruise at the end of February.
Examination showed she had full range of motion, no extremity
clubbing or swelling, full motor strength in her arms and
legs, and intact sensation.
saw the nurse practitioner, Osborn, in May 2015, reporting
arm numbness, tingling, and weakness, and that she was unable
to open and hold things well. Palmer reported partial relief
with massage and past improvement with wrist braces.
Examination showed back spasm and tenderness, but essentially
normal and stable musculoskeletal findings, and normal deep
tendon reflexes. Palmer had paresthesia in her arms when
raised above her head for less than a minute, but sensation
was otherwise intact. Osborn assessed carpal tunnel syndrome
and recommended that Palmer restart her wrist braces. Osborn
also ordered a cervical spine x-ray and an EMG. The test
results showed mild bilateral carpal tunnel syndrome.
saw Dr. Voss in June 2015, reporting numbness and tingling in
her hands. She said she had been to pain management for her
back, but she was not interested in pursuing it again. She
denied neuro-muscular symptoms, but complained of
life-limiting pain. She told Dr. Voss that her co-pay for
OxyContin had increased, so she only took it half of the
time. Examination showed mild back tenderness and tightness,
and antalgic movement, and pain medications were prescribed.
Voss filled out a medical source statement in February 2009.
Tr. 604-05. Palmer's diagnoses included degenerative
joint disease, disc disease, and annular tear. Dr. Voss
stated that Palmer's symptoms, "back pain with
radiculopathy, " resulted from a "sickness"
that first appeared on November 7, 2008 and were not work
related. Tr. 604. The doctor described Palmer's treatment
plan as physical therapy, continued visits with her primary
care physician, and medication. Where asked on the form to
list medications that had been prescribed, the doctor listed