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Rosalind J. G. v. Berryhill

United States District Court, D. Minnesota

March 27, 2019

Rosalind J. G., Plaintiff,
v.
Nancy Berryhill, Acting Commissioner of the Social Security Administration, Defendant.

          Mac Schneider, Schneider (for Plaintiff)

          Bahram Samie, Assistant United States Attorney, and Michael Moss, Special Assistant United States Attorney, (for Defendant).

          ORDER

          Tony N. Leung United States Magistrate Judge

         I. INTRODUCTION

         Plaintiff Rosalind J. G. brings the present case, contesting Defendant Commissioner of Social Security's denial of her applications for disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. § 401 et seq., and supplemental security income (“SSI”) under Title XVI of the same, 42 U.S.C. § 1381 et seq. The parties have consented to a final judgment from the undersigned United States Magistrate Judge in accordance with 28 U.S.C. § 636(c), Fed.R.Civ.P. 73, and D. Minn. LR 72.1(c).

         This matter is before the Court on the parties' cross-motions for summary judgment. (ECF Nos. 13, 15.) Being duly advised of all the files, records, and proceedings herein, IT IS HEREBY ORDERED that Plaintiff's motion for summary judgment (ECF No. 13) is DENIED and the Commissioner's motion for summary judgment (ECF No. 15) is GRANTED.

         II. PROCEDURAL HISTORY

         Plaintiff applied for DIB and SSI asserting that she has been disabled since September 2014 due to “[s]pinal cord compression with distortion and displacement, ” “arthritis of cervical spine c5-c6, ” “2 large broad based disc protrusions, ” “major depression, ” “anxiety, ” “bipolar disorder, ” “concentration, ” “moderate-severe disc space narrowing at ¶ 5-c6, ” “possible schizophrenia, ” and “L4-L5 disc space narrowing and dif[f]use disc signal loss.” (Tr. 12, 65-66, 75-76; see Tr. 87-88, 98-99.) Plaintiff's applications were denied initially and again upon reconsideration. (Tr. 12, 74, 84-86, 97, 108-10.) Plaintiff appealed the reconsideration of her DIB and SSI determinations by requesting a hearing before an administrative law judge (“ALJ”). (Tr. 12, 129-30.)

         The ALJ held a hearing in August 2016. (Tr. 12, 32, 34.) After receiving an unfavorable decision from the ALJ, Plaintiff requested review from the Appeals Council, which denied her request for review. (Tr. 1-3, 10-31, 186.) Plaintiff then filed the instant action, challenging the ALJ's decision. (Compl., ECF No. 1.) The parties have filed cross motions for summary judgment. (ECF Nos. 13, 15.) This matter is now fully briefed and ready for a determination on the papers.

         III. MEDICAL RECORDS

         Plaintiff has a history of chronic neck pain. (Tr. 403.) At an unrelated medical appointment in June 2014, it was noted that “[t]here has been a problem with chronic pain syndrome as well.” (Tr. 396.) At the same time, it was also noted that “[c]urrently, she is really doing quite well indeed.” (Tr. 396.)

         A. Records Related to Chronic Pain

         1. 2014

         In early September 2014, Plaintiff was seen by Pankaj Timsina, MD, for neck pain, among other things. (Tr. 394.) Upon examination, Plaintiff's neck was supple but she had tenderness “on her right neck and across her trapezius.” (Tr. 394.) Dr. Timsina noted that this was “a chronic issue” for Plaintiff and that she had “been taking tramadol”[1] for it. (Tr. 394.) Dr. Timsina ordered x-rays of Plaintiff's cervical spine, prescribed Flexeril[2], and referred Plaintiff “to physical therapy for myofascial release.” (Tr. 394; see Tr. 424-25.)

         Approximately two weeks later, Plaintiff was seen for an unrelated condition by Monika Pokharel, MD, in internal medicine. (Tr. 392.) When “asked if she [wa]s having any neck pain or any weakness in any of the arms or any shortness of breath, ” Plaintiff said “no, ” but also stated that “[s]he has been having, since childhood, the neck pain on and off and she has been used to this pain and does not do anything” for it. (Tr. 392.) Plaintiff had full strength in all of her extremities. (Tr. 392.) Later, when Dr. Pokharel explained that an MRI of her neck showed “advanced arthritis and like[ly] cord impingement at ¶ 5-C6, ” Plaintiff requested something for the pain, including narcotic medications. (Tr. 392; see Tr. 420-22.) Dr. Pokharel referred Plaintiff to neurosurgery and discussed physical therapy “in detail.” (Tr. 392-93.) Plaintiff was also given a limited supply of medication, “30 tablets” to be “use[d] on an as-needed basis.”[3] (Tr. 393.)

         The following day, Plaintiff had a consultation with Abdul A. Baker, MD, in neurosurgery. (Tr. 390, 353, 457.) Plaintiff presented

with over a 20-year history of neck pain that has progressively worsened, especially with her job as an embroiderer that is a repetitive job with her neck in a flexed posture, that has resulted in multiple episodes of bilateral upper extremity, right worse than left weakness, numbness and tingling, with episodes of dropping objects in the past.

(Tr. 391; accord Tr. 353, 457.) Plaintiff reported “that medicines like Aleve and tramadol, Flexeril help her symptoms, but repetitive activity seems to worsen her symptoms.” (Tr. 391; accord Tr. 353, 457.) Plaintiff had not tried physical therapy or epidural steroid injections. (Tr. 391, 353, 457.)

         Dr. Baker noted that an “MRI of the cervical spine shows spinal cord compression at ¶ 5-C6 with neuroforaminal stenosis at that level, and also neuroforaminal stenosis at ¶ 6-C7 with no evidence of spinal cord compression at that site . . . .” (Tr. 391; accord Tr. 353, 457; see Tr. 420-22; see also Tr. 658-661.) Plaintiff also had “other multilevel degenerative changes, but primarily the cord compression is clearly seen at ¶ 5-C6 with no evidence of intrinsic cord signal change.” (Tr. 391; accord Tr. 353, 457; see Tr. 420-22.) There was “no clear evidence of motor or sensory abnormality on physical examination, and no evidence of myelopathy.” (Tr. 391; accord Tr. 353, 457.) Dr. Baker recommended that Plaintiff undergo physical therapy and an epidural steroid injection. (Tr. 391, 353, 457.)

         The day after she met with Dr. Baker, Plaintiff returned to Dr. Pokharel to discuss the results of her neck MRI. (Tr. 386.) Dr. Pokharel noted that Plaintiff did “not have any weakness in any parts of the body”; “denie[d] any bowl or bladder problems”; and “review of systems [was] negative for all other systems.” (Tr. 386.) Plaintiff asked if Dr. Pokharel can “provide her disability.” (Tr. 386.) Dr. Pokharel discussed with Plaintiff that she would need to bring in certain forms, but offered to provide her with a letter “that as per the request of the patient that she is doing physical therapy and she is the main person of the house to provide food to 2 kids and herself so provide something saying that she would not be able to go to work every day, ” and that “she would be able to work only less hours a day.” (Tr. 386.) Plaintiff responded “that she did not know how that works and she wants money . . . for every hour that she is not working also, and she wants to work some hours, not full hours like 40 hours a week.” (Tr. 386.)

         The same day, Plaintiff began physical therapy. (Tr. 388.) During her initial visit, Plaintiff reported “a history of neck pain over the last 3 to 4 years with progressive worsening.” (Tr. 388.) Plaintiff “note[d] some right upper extremity weakness more recently, but also note[d a] history of right epicondylitis several years ago, which improved following episodes of therapy.” (Tr. 388.) Plaintiff's “neck pain [wa]s worse with stress, sitting . . . [for more than 30 to 60 minutes], standing for prolonged periods, lifting/carrying, and with reaching higher and lower.” (Tr. 388.) Plaintiff described her pain “as tight and note[d] that it feels like her neck is locking up.” (Tr. 388.) Plaintiff's pain was “better with heat and medications.” (Tr. 388.)

         Upon examination, Plaintiff had “decreased cervical range of motion, decreased upper extremity strength and poor posture.” (Tr. 389.) Plaintiff was “noted to guard neck upon assessment . . ., with limited active range of motion with mobility, along with guarded posture.” (Tr. 389.)

         Three days later, Plaintiff met with Shivan Kulasingham, MD, in internal medicine, wanting to discuss the status of the x-rays ordered by Dr. Timsina. (Tr. 383.) Plaintiff was also “not happy” following her appointment with Dr. Pokharel. (Tr. 383.) Dr. Kulasingham noted that Plaintiff was currently undergoing physical therapy. (Tr. 384.) Dr. Kulasingham recommended getting “an opinion from physical medicine rehab to see whether they recommend doing an EMG to see if there is any upper extremity abnormality seen on [the] EMG.” (Tr. 384.) Dr. Kulasingham also refilled Plaintiff's tramadol prescription, had “her sign a pain contract, ” and “filled out FMLA forms so that she can go to physical therapy and her physical medicine appointment.” (Tr. 385.)

         At her physical therapy appointment the same day, Plaintiff reported that she was “feeling better today, ” and that her medications were helping with her pain and also helping her relax. (Tr. 384.) Plaintiff rated her pain at ¶ 6 out of 10. (Tr. 385.) The therapist noted that Plaintiff had “decreased pain and tightness” at the end of the session and demonstrated improved movement. (Tr. 385.) Plaintiff also had “decreased guarding and tightness.” (Tr. 385.) Similar observations were made during Plaintiff's next two sessions. (Tr. 381-82.) During one session, Plaintiff reported that “she feels that it has been more difficult to thread the needle with her right hand and has had to grip harder so she does not drop the thread.” (Tr. 382.)

         In mid-October, Plaintiff had a cervical epidural steroid injection to address her neck pain. (Tr. 377.) Plaintiff's “[c]ervical spine exam [wa]s positive only for some relatively mild paraspinal muscle tenderness on the right side more so than left in the lower cervical region.” (Tr. 377.) In preparation for the injection, “Chronic pain syndrome (10/03/2014)” was listed in Plaintiff's past medical history. (Tr. 379.)

         That same day, after the injection, Plaintiff returned to Dr. Kulasingham. (Tr. 376.)

         Dr. Kulasingham noted:

I have seen her once for back pain. She has several providers here already, including Dr. Timsina and Dr. Pokh[a]rel, and she has seen Dr. Baker in neurosurgery. When I saw her last week I said that if we were going to restrict her work activity or anything I would like at least a reconsult from Physical Medicine, but she returns after just two therapy treatments saying now her low back hurts. She is walking different. She has been using Flexeril at night and using a heating pad. She found that to be helpful, but does not think she can go back to work today. Reviewing her case, I will give her off for 4 days until Friday. I am still awaiting physical med consultation.

(Tr. 376.)

         Approximately one week later, Plaintiff followed up with Dr. Baker. (Tr. 374, 351, 455.) Dr. Baker noted that Plaintiff had some weakness in her left upper extremity. (Tr. 375 (“Bilateral upper extremity strength is 5/5 with the exception of left wrist extensor and bilateral triceps were 4.”), 351 (same), 455 (same).) Dr. Baker ordered an MRI of Plaintiff's lumbar spine, noting afterwards “we can discuss specifics of the treatment of the spinal cord compression, which will probably be 2 level anterior cervical discectomy and fusion at ¶ 5-C6, C6-C7.” (Tr. 375; accord Tr. 351, 455; see also Tr. 658-62.)

         The same day, Plaintiff also saw Dr. Timsina. (Tr. 373.) Plaintiff reported that she “has not been able to work at all” and has “been going to Workers Comp.” (Tr. 373.) Plaintiff was also “wondering about restrictions.” (Tr. 373.) Plaintiff had new complaints of headaches and back pain as well as “some numbness and tingling in both arms and also in her legs.” (Tr. 373.) Plaintiff had “tenderness over the posterior neck muscles.” (Tr. 374.) Plaintiff's mood and affect was “very anxious.” (Tr. 374.)

         Dr. Timsina noted that Plaintiff “has already seen Dr. Baker twice, and he has discussed with her about the plan that will include medications and shots, and if not surgery, which he would not consider right away.” (Tr. 374.) Dr. Timsina prescribe gabapentin[4] and “pulse therapy.” (Tr. 374.) Dr. Timsina theorized that Plaintiff's headaches and back pain were “from tenderness of her neck muscles.” (Tr. 374.) Dr. Timsina provided “written restrictions for not working for 2 weeks until she gets her MRI and more results.” (Tr. 374.)

         During her physical therapy appointment a couple of days later, Plaintiff reported having more headaches and numbness in her left arm following the injection. (Tr. 372.) Plaintiff's back also “went out.” (Tr. 372.) Plaintiff also reported that “the [g]abapentin has helped a lot . . . [and she] is no longer symptomatic, notes decreased pain, headaches, stiffness, and denies any numbness.” (Tr. 372.) Plaintiff “note[d] ¶ 40% improvement overall with neck pain.” (Tr. 372.)

         Plaintiff continued to report headaches during her next three sessions, but also noted improvement during the latter two sessions. (Tr. 368, 370-71, 517-18.) Plaintiff's neck pain was noted to be improving during each session. (Tr. 368, 370-71, 517-18.) Plaintiff did have some lower back pain. (Tr. 368, 370, 517.) Plaintiff reported that she was “taking it easy at home beyond the essential tasks that she needs to complete to avoid aggravation.” (Tr. 371; accord Tr. 370, 368, 517.) Plaintiff reported being able to wash dishes, cook, and do laundry “without aggravation of pain, ” but “[a]void[ed] heavy lifting including laundry and groceries.” (Tr. 369; accord Tr. 517.) The therapist “[c]ontinue[d] to note tension along [Plaintiff's] right cervical musculature.” (Tr. 371; accord Tr. 369-70, 517-18.)

         At the beginning of November, Plaintiff had a consultation with Bangalore Vijayalakshmi, MD, in physical medicine. (Tr. 362, 344, 486.) Plaintiff reported that her neck “symptoms have gotten progressively worse” over the last five years. (Tr. 363; accord Tr. 345, 487.) Plaintiff's work as an embroiderer “involves repetitive position of her neck in flexion, ” and, as a result of this repetitive action, she has had “progressively worsening neck pain, along with bilateral upper limb symptoms of pain, paresthesias, weakness, and tingling numbness.” (Tr. 363; accord Tr. 345, 487; see Tr. 348, 366, 490.) Plaintiff “report[ed] constant aching discomfort in her posterior neck, which she rate[d] ¶ 6 to 7 out of 10.” (Tr. 363; accord Tr. 345, 487.) Plaintiff's symptoms were “[a]ggravated by standing, sitting too long, lifting, [and] repetitively looking down . . . .” (Tr. 363; accord Tr. 345, 487.) They improved with “rest, medication, [and] massage.” (Tr. 363; accord Tr. 345, 487.) Among other medical conditions, Dr. Vijayalakshmi noted a history of “[c]hronic neck pain.” (Tr. 365; accord Tr. 347, 488.) Dr. Vijayalakshmi also noted that Plaintiff was pursuing a workers' compensation claim. (Tr. 344-45, 349-50, 362-63, 367, 486-87, 491-92.)

         During the physical examination, Dr. Vijayalakshmi observed that Plaintiff had “functional strength in [her] bilateral upper limbs, with the exception of subtle collapsing weakness in [the] bilateral deltoids, 4 to 5-/5.” (Tr. 366; accord Tr. 348, 490.) Plaintiff's gait was normal. (Tr. 348, 366, 490.) Plaintiff's posture was “forward head positioning” with “[r]ounded, protracted shoulder girdles.” (Tr. 366; accord Tr. 348, 490.) Plaintiff was “tender to palpation in [her] bilateral upper trapezius, splenius cervicis, [and] splenius capitis”; in her “bilateral SI joints, iliolumbar ligaments, [and] lumbar paraspinal muscles”; and “over [her] cervical paraspinal muscles.” (Tr. 366; accord Tr. 348, 490.) Range of motion of Plaintiff's cervical spine “cause[d] discomfort in forward bending, backward bending, [and] side-to-side bending.” (Tr. 366; accord Tr. 348, 490.) Range of motion in her thoracolumbar spine similarly “cause[d] discomfort in forward bending, [and] backward bending.” (Tr. 366; accord Tr. 348, 490.) Dr. Vijayalakshmi also noted that Plaintiff had “[m]usculotendinous imbalances - tight, overactive, restricted in upper trapezius, sternocleidomastoid, levator scapulae, scalenes, [and] pectoral girdles, ” as well as “[p]seudoparetic, inhibited, and deconditioned in deep cervical flexors and rhomboids.” (Tr. 366; accord Tr. 348, 490.)

         Among other things, Dr. Vijayalakshmi diagnosed Plaintiff with “Cervical cord compression with neural foraminal stenosis at ¶ 5-C6 and cervical radiculopathy”; “Myofascial pain and dysfunction syndrome”; “SI joint dysfunction”; “Cervicothoracic musculoligamentous sprain/strain”; and “Lumbosacral musculoligamentous sprain/strain.” (Tr. 367.) Dr. Vijayalakshmi recommended that Plaintiff remain “off work until she sees neurosurgery.” (Tr. 368; accord Tr. 350, 492.)

         A couple of days later, Plaintiff reported during physical therapy that she felt her headaches and range of motion in her neck were better overall, but she continued to experience neck stiffness. (Tr. 361, 515.) Plaintiff “denie[d] any numbness or tingling.” (Tr. 361; accord Tr. 515.) Plaintiff continued to have “tension along [her] right cervical musculature, but [it was] decreased from previous sessions.” (Tr. 361; accord Tr. 515.)

         Plaintiff followed up with Dr. Timsina around the middle of November to discuss the results of a lumbar MRI. (Tr. 360; see Tr. 412-16, 529-32, 512-13.) The lumbar MRI showed “mild disk bulging, ” for which Dr. Timsina did not feel surgery was necessary. (Tr. 360; accord Tr. 512, see Tr. 412-16, 529-32.) Dr. Timsina encouraged Plaintiff to continue seeing Dr. Baker with regards to the “significant arthritis with disk disease” in her neck. (Tr. 360; accord Tr. 512-13.)

         Towards the end of November, Plaintiff met with Crystal Knutson, PA-C, in neurosurgery primarily to discuss questions regarding surgery on her neck. (Tr. 453, 484.) Plaintiff “continue[d] to experience severe neck pain, [and] right greater than left upper extremity pain associated with numbness and tingling in both arms, primarily into the 4th and 5th digits.” (Tr. 453; accord Tr. 484.) Plaintiff reported that physical therapy, traction, and an epidural steroid injection did not help. (Tr. 453, 484.) Plaintiff rated her neck pain at ¶ 7 out of 10. (Tr. 453, 484.)

         Upon examination, Plaintiff's “[b]ilateral upper extremity strength [wa]s 5/5 with the exception of the left wrist extensor and bilateral triceps 4.” (Tr. 453-54; accord Tr. 484.) Knutson listed Plaintiff's diagnoses as “C5-C6 and C6-C7 cervical spondylosis with cord compression and upper extremity radiculopathy, refractory to conservative measures, ” and “[l]umbar degenerative disk disease.” (Tr. 454; accord Tr. 485.) With regards to Plaintiff's lumbar spine, Plaintiff “ha[d] no neurologic deficit and [her] pain [wa]s not consistent with L4-L5 degenerative disk disease.” (Tr. 454; accord Tr. 485.) Knutson noted that Plaintiff wanted to proceed with cervical spine surgery with Dr. Baker. (Tr. 454, 485; see Tr. 450, 481.)

         2. 2015

         In mid-January 2015, Plaintiff underwent an anterior cervical discectomy and fusion surgery with Dr. Baker to address C5-C6 and C6-C7 cervical spondylosis with cord compression and radiculopathy. (Tr. 446, 477; see Tr. 442-44, 473-75.) Following the surgery, Plaintiff's arm pain improved. (Tr. 438, 469.) The pain in Plaintiff's neck “changed in character and [she] described it as surgical pain.” (Tr. 438; accord Tr. 469.) Plaintiff had full strength, and was discharged the following day. (Tr. 436, 438, 469, 467.)

         Plaintiff followed up with Knutson approximately one month after her surgery. (Tr. 463.) Plaintiff reported “significant improvement in her neck pain and headaches” as well as “in her arm symptoms.” (Tr. 463.) Plaintiff “no longer ha[d] arm pain, numbness, or tingling, ” and “[h]er arms fe[lt] lighter and stronger.” (Tr. 463.) Knutson noted that Plaintiff's incision had “healed well” and she was “able to stand and walk with normal posture and stride.” (Tr. 463.) Plaintiff had full strength and her “[s]ensation [wa]s grossly intact.” (Tr. 463.) Knutson described Plaintiff as having “complete resolution of neck pain, headaches, and upper extremity symptoms.” (Tr. 463.)

         Approximately one month later, in the middle of March, Plaintiff saw Dr. Timsina for continued complaints of neck pain. (Tr. 503.) Plaintiff's pain was “worse on a cold, gloomy day.” (Tr. 503.) Plaintiff was “taking tramadol, oxycodone [5], and also hydrocodone[6].” (Tr. 503.) Plaintiff took oxycodone when her pain was more severe and hydrocodone when her pain was mild. (Tr. 503.) Plaintiff reported having “a hard time getting up from the chair when she wakes up in the morning and this makes her pain worse.” (Tr. 503.) Plaintiff's headaches were gone along with the pressure on the side of her neck. (Tr. 503.) There was “[n]o numbness or tingling.” (Tr. 503.)

         Dr. Timsina noted that Plaintiff was “in mild distress.” (Tr. 503.) Dr. Timsina felt that Plaintiff's pain was “coming from muscle spasm and muscle tension.” (Tr. 503.) Dr. Timsina had “an extensive talk with [Plaintiff] regarding cutting back on her medications.” (Tr. 503.) Dr. Timsina directed Plaintiff to follow up with neurosurgery regarding her continued pain, and also to inquire whether she could begin physical therapy, including myofascial release. (Tr. 503-04.)

         Plaintiff saw Dr. Timsina again approximately three weeks later for a medication check. (Tr. 501.) Plaintiff was “trying to cut back on her pills, without much relief in her symptoms.” (Tr. 501.) Plaintiff had “days where neck pain will definitely make her feel hurt.” (Tr. 501.) Plaintiff had “more muscle tenderness in her neck” and spasms on occasion. (Tr. 501.) Plaintiff was again “in mild distress.” (Tr. 501.) Upon examination, Dr. Timsina noted “some tenderness over her neck muscles” and “some tightening.” (Tr. 501.)

         Dr. Timsina did “not know why [Plaintiff] is still having a lot of pain, ” and noted that Plaintiff had an upcoming appointment with neurosurgery. (Tr. 501.) Dr. Timsina “told [Plaintiff] clearly that pain management has to be done by [the] pain clinic and not by me because of the chronicness [sic] of her pain.” (Tr. 501.) Dr. Timsina added Flexeril in the interim. (Tr. 501.)

         Plaintiff followed up with Knutson a few days later. (Tr. 461.) Plaintiff's arm symptoms remained resolved, but Plaintiff was having trouble with “neck stiffness and [wa]s struggling to get off narcotics.” (Tr. 461.) Overall, Plaintiff “fe[lt] happy with her surgery.” (Tr. 461.) Plaintiff rated her neck pain at ¶ 7 out of 10. (Tr. 461.) Plaintiff continued to be “able to stand and walk with normal posture and stride” and had full strength. (Tr. 461.) Plaintiff's range of motion in her neck was “limited, but painless.” (Tr. 461.) Knutson noted that Plaintiff was “doing well” following surgery, but also included a diagnosis of “[c]hronic pain.” (Tr. 461.) Knutson recommended that Plaintiff engage in “[p]hysical therapy for gentle neck stretches and strengthening.” (Tr. 461.)

         In mid-April, Plaintiff consulted with the Center for Pain Medicine in Fargo, North Dakota, for her neck pain based on a referral from Dr. Timsina. (Tr. 558.) Plaintiff reported that “[m]ornings are always difficult” and she is having trouble sleeping. (Tr. 558.) Plaintiff's pain “varied throughout the day.” (Tr. 558.) Plaintiff's pain was aggravated by raising and using her arms as well as lifting. (Tr. 558.) Plaintiff's pain improved with “medication, getting outside, walking around the block, sunshine, [and] warm weather.” (Tr. 558.) It was noted that Plaintiff had “recently stopped taking oxycodone, ” and transitioned to hydrocodone. (Tr. 558.) Plaintiff was also taking tramadol and Flexeril. (Tr. 558.)

         Upon examination, Plaintiff had “[a]bnormal - muscle tightness in shoulders/neck” and [t]enderness with palpation of Sacroiliac joints.” (Tr. 560.) Plaintiff had full strength in her upper extremities and equal range of motion in each. (Tr. 560.)

         Plaintiff was diagnosed with facet joint arthropathy and sacroiliac joint pain. (Tr. 561.) A number of treatments were recommended, including injections, “dry needling, ” heat, massage, and physical therapy. (Tr. 561.) Opiate medications were not recommended. (Tr. 561.) Plaintiff “became upset after hearing . . . [the] recommendations, and . . . [the] decline to prescribe opiate medication for her.” (Tr. 561.)

         During an appointment near the end of April for right leg pain, the treatment provider included a “[h]istory of chronic pain” in Plaintiff's past medical history. (Tr. 497.)

         Approximately one month later, Plaintiff was seen for a refill of her hydrocodone prescription. (Tr. 611.) Among other conditions, Plaintiff's past medical history included “[c]hronic pain syndrome.” (Tr. 611.) Plaintiff was assessed as having “[c]hronic neck pain” and given a one-week refill of hydrocodone until she could be seen by Dr. Timsina. (Tr. 611.)

         Plaintiff was able to see Dr. Timsina a few days later, who noted that she continued to experience neck pain following her surgery and described it as “a history of chronic neck pain status post cervical spinal fusion.” (Tr. 609.) Dr. Timsina noted that “[t]here has been a plan about her being sent to [a] pain clinic. She went to on[e] pain clinic in Fargo, but was not very happy with the plan. She has another pain clinic assessment lined up for next week.” (Tr. 609.) Dr. Timsina noted that Plaintiff had enough pain pills until she was able to been seen at the pain clinic. (Tr. 609.)

         At the end of May, Plaintiff saw David J. Hanson, MD, at a pain clinic in Fargo, North Dakota for neck, hip, and low-back pain. (Tr. 715.) Plaintiff rated her current pain at ¶ 7 out of 10. (Tr. 712.) Upon examination, Dr. Hanson noted:

Range of motion of the arms at the shoulders is decreased with flexion bilaterally. Range of motion of the head is severely limited with flexion and extension of the neck and moderately limited with rotation in both directions. There is apprehension with straight leg raise at about 40[ degrees] bilaterally. There is apprehension with Faber test on the left and hip pain with Faber test on the right. The infraorbital nerves are both tender to palpation, the right subclavicular area is tender. The anterior pelvis is nontender. The occiput is nontender. Trapezius muscles of both tender to palpation, the serratus anterior muscles and the paraspinous muscles in the lumbar region are tender to palpation bilaterally. Both SI . . . joints are mildly tender and both greater trochanters are tender to palpation. The knees are nontender.

(Tr. 708, 712.)

         Dr. Hanson diagnosed Plaintiff with cervical and lumbar radiculopathy, low back pain, cervicalgia, myofascial pain syndrome, and bursitis. (Tr. 710.) Dr. Hanson recommended trigger point and steroid injections. (Tr. 710-11.)

         Plaintiff saw Dr. Hanson again approximately one week later for treatment of her “myofascial pain syndrome that is causing pain in the back of the neck and the upper back bilaterally.” (Tr. 707.) Plaintiff again rated her pain at ¶ 7 out of 10. (Tr. 707.) Plaintiff wanted to proceed with trigger point injections and also “need[ed] medications.” (Tr. 707.) Dr. Hanson noted that there were “trigger points present in the trapezius, rhomboids and posterior neck muscles bilaterally.” (Tr. 706.) Dr. Hanson prescribed a 30-day supply of hydrocodone-acetaminophen[7] and administered trigger point injections. (Tr. 705.)

         Around the middle of June, Plaintiff was seen in orthopedics for a labral tear in her right hip. (Tr. 605.) Plaintiff's past medical history listed “[c]hronic pain syndrome” as of “10/3/2014.” (Tr. 606.) During the appointment, Plaintiff “also mentioned pain in her wrists, hands, and ankles, ” which made her treatment provider wonder about possible rheumatoid arthritis and noted that Plaintiff was scheduled to be seen in rheumatology. (Tr. 605.)

         Plaintiff had another three visits with Dr. Hanson during June and into the first part of July. (Tr. 695, 699, 703.) Plaintiff twice received trigger point injections and once received a lumbar epidural steroid injection. (Tr. 695, 697, 701.) Plaintiff reported that the trigger point injections were beneficial and helped relieve her pain. (Tr. 699, 703.) During visits where trigger point injections were administered, Dr. Hanson noted that “trigger points [were] present in the posterior neck muscles, trapezius, and rhomboids bilaterally, ...


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