United States District Court, S.D. Mississippi, Eastern Division
Keith Ball United States Magistrate Judge
Ruth West filed for a period of disability, disability
insurance benefits, and supplemental security income on
February 29, 2012. Her application was denied both initially
and upon reconsideration. She requested and was granted a
hearing before an ALJ, which was held on January 22, 2014. On
June 24, 2014, the ALJ issued a decision finding that West is
not disabled. The appeals council denied review. West now
brings this appeal pursuant to § 205(g) of the Social
Security Act, 42 U.S.C. § 405(g). Having considered the
memoranda of the parties and the administrative record, the
Court concludes that the decision of the Commissioner should
Facts and Evidence before the ALJ
was born on November 18, 1956, and was 57 years of age at the
time of the decision of the ALJ. She has a high school
education and completed one year of college. She alleges
disability beginning April 29, 2011, due to back pain,
osteoarthritis, and hypertension.
medical treatment record is sparse. In a letter dated March
20, 2012, Denton Spiers, D.C., stated that he treated West
from October 2006 until January 2007. R. 259-60,  at
262-63. West's presenting complaints were severe neck
pain, lower back pain, and numbness and tingling radiating
into the right arm. R. 259,  at 262. Physical examination
revealed spasms and tenderness of the paraspinal muscles in
the cervical, thoracic and lumbar spine and pain in all
regions. Id. Range of motion was normal in the
cervical spine and moderately restricted in the lumbar spine.
Id. Maneuvers were positive for pinched nerves in
the cervical and lumbar spine. Id. Diagnosis was
degenerative disc disease of the cervical and lumbar spine,
midback pain, and severe muscle spasm. R. 260,  at 263.
Dr. Spiers stated in his letter that West's prognosis in
October of 2006 was poor and that while she was under his
care, she was unable to lift or do any repetitive work for
any amount of time. Id.
January 9, 2007, West underwent a series of x-rays after
being involved in a motor vehicle accident. The x-rays
indicated mild bilateral hip osteoarthritis, degenerative
disc disease at ¶ 5-C6, neuroforaminal stenosis that was
moderate at ¶ 4-C5 and mild at ¶ 5-C6, and
degenerative disc disease of the lumbar spine. R. 227-31, 
Spiers completed a medical source statement on June 11, 2013.
There is no indication that he had treated or evaluated West
since January of 2007. In the statement, he rated as
moderately severe West's limitations in maintaining
attention and concentration for extended periods, performing
activities within a schedule, and maintaining regular
attendance and being punctual. R. 306,  at 309. He rated
as severe her limitations in the ability to complete a normal
workday and workweek without interruptions from medically
based symptoms and to perform at a consistent pace without an
unreasonable number and length of rest periods. Id.
Dr. Spiers opined that West was not capable of performing
light or sedentary work, even if she were allowed a sit/stand
option. R. 307,  at 310.
February 26, 2013, West was seen by Dr. Bridget Tah-Clayton
at the Hattiesburg Clinic. Dr. Tah-Clayton's diagnoses
were hypertension, osteoarthritis, degenerative joint disease
at multiple sites, vitamin D deficiency, and decreased range
of motion in the right shoulder. R. 303,  at 306. On
January 21, 2014, Dr. Tah-Clayton completed a medical source
statement. In the statement, she rated as moderately severe
West's limitations in maintaining attention and
concentration for extended periods. R. 314,  at 317. In
the areas of the ability to perform activities within a
schedule, maintain regular attendance, and be punctual; to
complete a normal workday and workweek without interruptions
from medically based symptoms, and to perform at a consistent
pace without an unreasonable number and length of rest
periods, Dr. Tah-Clayton rated her as severely limited.
Id. Dr. Tah-Clayton opined that West suffers from
cervical and lumbar degenerative joint disease with
radiculopathy, diabetes, and dysphagia. R. 316,  at 319.
She recommended an EGD to evaluate West's numbness and
tingling in the arms, hands, and feet. Id. According
to Dr. Tah-Clayton, West is incapable of performing light or
sedentary work, even with a sit/stand option. R. 315,  at
318. Dr. Tah-Clayton stated that West suffers from headaches
as a result of pinched nerves and that her headaches cause
problems with her concentration. R. 316,  at 319. She
identified West's medications as Benicar HCT and
Claritin. R. 318,  at 321.
Stephen Massey performed a consultative physician examination
of West on June 8, 2012. West's recorded height at the
exam was 5'6”, and her weight was 226 pounds. R.
263,  at 266. West relayed to Dr. Massey a history of neck
pain, low back pain, and intermittent numbness in her legs at
night. R. 262,  at 265. Dr. Massey observed that she
experienced minor difficulty in getting on and off the
examination table. R. 263,  at 266. Physical examination
revealed a full range of motion in her upper extremities and
in her lower extremities except for her left hip, where she
experienced pain with flexion and rotation. R. 264,  at
267. There was no back tenderness or spasm. Id.
Range of motion in the lumbar spine was 45 degrees with
flexion, 10 degrees with extension, and 20 degrees with
rotation. Id. Her gait was slightly antalgic, but
she used no assistive device. Id. She was able to
squat halfway, at which point she stopped with complaints of
knee and leg pain. Id. West was unable to walk
heel-to-toe because of unsteadiness. Id. Straight
leg raising was negative. Id. Deep tendon reflexes
were 2/4 in the arms and legs, and strength was 5/5.
Id. Hand grip was 4/5 bilaterally. Id. Fine
and gross manipulation were within normal limits.
Id. Dr. Massey's diagnoses were chronic low back
pain, chronic neck pain, polyarthralgia, hypertension,
obesity, diabetes, and dyspnea on exertion. R. 264-65,  at
267-68. As to her exertional abilities, Dr. Massey opined
that Plaintiff could lift only light objects, would need to
avoid climbing, kneeling, and squatting, and would need
periodic position changes when sitting. R. 265,  at 268.
He stated that she should avoid repetitive and prolonged
manipulation of small objects, squeezing, and grasping.
Id. Dr. Massey also warned that West was at risk for
injury due to knee instability. Id.
Alvin Brent conducted a consultative review of West's
medical records on July 20, 2012. Dr. Brent identified
West's diagnoses as hypertension and degenerative joint
disease. R. 274,  at 277. He opined that West was capable
of lifting ten pounds frequently and 20 pounds occasionally,
that she could stand and walk six hours in an eight-hour
workday, that she could occasionally climb, that she could
frequently balance, stoop, kneel, crouch, and crawl, and that
she had no manipulative limitations. R. 276-78,  at
279-81. X-rays of the lumbar spine performed in connection
with the examination revealed mild multilevel degenerative
changes. R. 268,  at 271.
hearing, West testified and gave the following account of her
living circumstances, work history, medical problems, and
symptoms. She lives alone in an RV. R. 41,  at 44.
West's only source of income is the help she receives
from her children. R. 42,  at 45. West also depends on her
children and grandchildren to perform housekeeping and
laundry tasks. R. 55,  at 58. She owns a truck and drives
it approximately once per week. R. 41,  at 44.
previously worked in a photo processing lab but had to quit
because of back pain. R. 43,  at 47. At Kohler Company,
she worked as a machine operator, but she left that job
because of problems with her hands. R. 44,  at 47. West
tried to work as a janitor but had to quit because she
developed overuse syndrome from operating a buffer. R. 45,
 at 48. West also worked as a childcare worker at the
University of Southern Mississippi and as an activities
director for the Boy Scouts. R. 46,  at 49. According to
West, the main problems that prevent her from working are
pain in her lower back, hips, neck, and arms; arthritis in
her hands; and carpal tunnel syndrome. R. 47,  at 50. She
takes Aleve for her pain but no other pain medication because
of side effects, difficulty swallowing pills, and the
inability to afford payment for drugs. R. 50-51,  at
described significant difficulties with her morning routine.
To help with getting out of bed, she sleeps on a board with a
mattress that is tilted sideways so that she can slide out.
R. 51,  at 54. Once her feet are on the floor, she has to
place her feet apart to keep from falling and has to hold
onto the wall to get to the bathroom. R. 52,  at 55. She
has difficulties getting up from the toilet. Id.
West is unable to lift her arms and for that reason has been
unable to brush her teeth for the past year. Id.
When she finishes in the bathroom, she usually goes back to
the bed and rests. Id. Before taking a shower, West
checks her blood pressure to make sure it is not too high for
her to get up. R. 53,  at 56. Once in the shower, she is
unable to wash certain parts of her body, such as her legs,
because she cannot bend down. R. 52,  at 55. She wears
bath gloves for scrubbing because she is unable to hold a
washcloth. Id. Taking a shower usually causes her
blood pressure to go up, so she rests again before getting
dressed. R. 53,  at 56. She has to lie down in order to
put her clothes on and does not wear undergarments because
she is unable to put them on. R. 53, 54,  at 56, 57. Once
she is dressed, she eats cold cereal for breakfast. R. 54,
 at 57. She is unable ...