United States District Court, S.D. Iowa, Central Division
REPORT AND RECOMMENDATION
C. Adams Chief U.S. Magistrate Judge
Michelle Spear seeks review of the Social Security
Commissioner's decision denying her application for
disability benefits (DIB) under Title II of the Social
Security Act (the Act), 42 U.S.C. §§ 401-434. This
Court reviews the Commissioner's final decision pursuant
to 42 U.S.C. § 405(g). The case is before the
undersigned for report and recommendation pursuant to 28
U.S.C. § 636(b)(1)(B). The Court considers the matter
fully submitted on the briefs.
PROCEDURAL AND FACTUAL BACKGROUND
2013,  Ms. Spear filed an application for
disability benefits alleging an onset date of August 16,
2013. (Tr. at 175). The Social Security Administration
initially denied Ms. Spear's claim on December 31, 2013,
(id. at 85-98) and again upon reconsideration on
March 6, 2014. (Id. at 99-113). Ms. Spear requested
a hearing (id. at 123-24), which was granted
(id. at 125-133). Administrative Law Judge
(“ALJ”) Eric S. Basse held a video hearing on May
22, 2015. (Id. at 41-84). Ms. Spear appeared with
attorney Shannon Schuehle; vocational expert Carma Mitchell
also attended and testified. On September 25, 2015, the ALJ
issued an unfavorable decision, finding Ms. Spear was not
disabled. (Id. at 17-40). Ms. Spear requested a
review of the ALJ's decision. (Id. at 15-16).
The Appeals Council denied the request for review and the
ALJ's decision became a final decision on August 26,
2016. (Id. at 1-6). Ms. Spear timely filed the
Complaint  in this case on September 20, 2016.
Educational and Vocational Factors
Spear was 42 years old when she filed for benefits. (Tr. at
175). She had past work as a 911 dispatcher for the Warren
County Sheriff's department, an emergency dispatcher for
Mercy Helicopter and Ambulance, and as a public
transportation dispatcher. (Id. at 196). Ms. Spear
also had worked as a medical assistant. (Id. at
75-78). Her highest level of education was an associate of
applied sciences degree which she completed in approximately
2014. (Id. at 45).
Spear's medical issues began after she was involved in a
motor vehicle rollover accident on November 13, 2011. Ms.
Spear was the driver and was not restrained. She was
partially ejected, but able to extricate herself from the
vehicle. (Tr. at 688). Ms. Spear sustained a C7 fracture; rib
fractures; L2 and L5 fractures; left upper extremity, left
hip and pelvic floor injuries; and a scalp laceration with
scalp hematoma, but no other obvious head injuries.
(Id. at 711). A CT and MRI of her head were
negative. Ms. Spear underwent cervical discectomy,
decompression and fixation and fusion procedures, using a
cervical plate and screws and bone graft. (Id. at
discharged to an acute rehabilitation facility and, after a
course of therapy, discharged to her home on November 25,
2011, in stable condition. (Id. at 661-64).
December 6, 2011, Ms. Spear was seen at Mercy Trauma Services
Clinic with complaints of left hip/left lateral thigh muscle
pain as well as some headache and transient dizziness. (Tr.
at 658). An x-ray of her pelvis and left hip showed no acute
osseous abnormality. (Id. at 659).
January 26, 2012, Ms. Spear had a follow-up visit at Iowa
Orthopedics. She noted she continued to have left upper and
lower extremity pain and pelvic floor pain. (Tr. at 470). She
saw Dr. Pothoven in Urology for her pelvic pain, who referred
her for pelvic floor therapy along with the other physical
therapy she was performing post-operatively. She complained
of burning and tenderness in her neck, left hip, and pelvis.
(Id.) At that time Ms. Spear weighed 304 pounds.
(Id. at 471). On physical examination the
physician's assistant noted weak hip muscles and mildly
reduced range of motion. (Id.) Her gait was antalgic
on the left side and she demonstrated tenderness in the
groin. Ms. Spear's bilateral lower extremity strength was
normal, as was her lower extremity neurovascular.
(Id. at 472). The plan was to continue physical
therapy for her neck and left hip and pelvic pain, pool
exercises were encouraged, and Ms. Spear was to follow up in
three to four weeks. (Id.)
Spear started physical therapy for her continued pelvic pain
at Mercy West Physical Therapy on March 29, 2012. (Tr. at
449). The treatment plan included twice-a-week visits for
eight weeks, to include “range of motion exercises,
manual therapy, therapeutic exercise, a personalized home
exercise program, patient education, body mechanics, posture,
strengthening, self-care and home management, behavioral
modification, biofeedback, neuromuscular re-education and
dynamic activities.” (Id. at 451). She
continued with physical therapy for her hip throughout the
spring and summer of 2012 (with some absences (id.
at 473-84)), experiencing cycles of pain and relief.
(Id. at 372-442). She also walked in the swimming
10, 2012, Ms. Spear was seen at Mercy West Physical Therapy
for lymphedema treatment of her head and cognitive
assessment. (Tr. at 341). Ms. Spear had experienced head
edema since the accident, most noticeable in the morning, as
well as numbness at the left temple. (Id.) She
complained of headaches on the left side. Cognitively, Ms.
Spear had memory recall problems, word finding issues, and
could not remember passwords. (Id.) On examination
the occupational therapist noted Ms. Spear had increased
girth of her head and neck due to fluid retention, pitting
edema/fibrotic tissue at the right mastoid process and
occiput, dysesthesia in the left parietal area of the skill,
and accepted Ms. Spear's report of memory recall and word
finding issues. (Id. at 342). The treatment plan was
for lymph node massage, myofascial release, Kinesio taping,
guided therapeutic exercise, training in a home program and
further cognitive retraining and assessments twice a week for
10 to 12 weeks. (Id.) Ms. Spear followed through
with the therapy prescribed through July and August 2012.
(Id. at 345-53).
August 1, 2012, Ms. Spears was seen at Iowa Orthopaedic
Center for a re-check of her persistent hip pain, which had
been diagnosed as left hip trochanteric bursitis. (Tr. at
316). She received a cortisone injection in her hip in May
2012, and apparently another one before August. (Id.
at 318). Physician's assistant Dudley Phipps discussed
use of a foam roller in conjunction with continuing physical
therapy, but was hesitant to administer another injection as
she already had received two injections since May.
August 1, 2012, Ms. Spears began to see Dr. Donald Gilbert, a
psychologist, as she was having trouble driving, getting out
of the house, flashbacks to the accident, and daily panic and
anxiety attacks. (Tr. at 321). In a September 17, 2012,
Psychiatric Assessment Form, Dr. Gilbert noted he had only
met with Ms. Spears two times so far and could not yet
determine what services might benefit Ms. Spear.
(Id. at 322, 326).
Spear saw nurse practitioner Michelle Hunerdosse at Mercy
Indianola Family Medicine & Urgent Care on August 14,
2012, following up from her injuries in the car accident.
(Tr. at 527). Ms. Spear reported she was still in pain,
particularly her left hip. Ms. Hunerdosse took a history from
Ms. Spear, including all the treatment she was undergoing.
Ms. Spear weighed 301 pounds on this occasion. On physical
examination, Ms. Hunerdosse observed an edematous area on the
left scalp. (Id. at 528). Ms. Spear was to follow up
in eight weeks. (Id.)
August 15, 2012, Ms. Spear called Mercy Neurosurgery
complaining of neck pain and continued numbness and tingling
affecting the index and middle fingers of her right hand.
(Tr. at 518). A certified nursing assistant and
physician's assistant saw her on August 23, 2012, at
which time x-rays of the cervical spine were taken.
(Id. at 511-12, 519). The x-ray showed the anterior
fixation plate and interbody fusion material remained intact
and in place with no significant change in the position and
alignment of the bony elements. No new bony lytic or
destructive changes were seen and the prevertebral soft
tissues were unremarkable. (Id. at 519). On physical
exam, Ms. Spear did not have any difficulty ambulating back
to the exam room. No limp was detected. Her surgical incision
was well healed. She weighed 295 pounds. The examiner noted
5/5 strength in bilateral upper extremities. (Id. at
511). Ms. Spear did have decreased sensation to light touch
and pinprick over the webspace between her right index and
middle fingers, and decreased sensation over the ulnar border
of her thumb. (Id.) There was no evidence of thenar
or hyperthenar wasting. She did have hyperesthesia with light
touch over her upper thoracic spine. Her strength in her
lower extremities was 5/5 and symmetric. Sensation was intact
to light tough bilaterally in her lower extremities, her
reflexes at biceps and triceps were 2 and symmetric
bilaterally, as were reflexes at patella and Achilles.
(Id.) The physician's assistant suspected Ms.
Spear's neck pain to be myofascial in nature as her
x-rays showed positive signs of fusion. (Id. at
512). Ms. Spear was directed to continue to work with
physical therapy for both her chronic trochanteric bursitis
and now upper thoracic back pain. She had no activity
restrictions surrounding her cervical fusion and was to
return to clinic as needed. (Id.)
September 12, 2012, the physical therapist returned Ms. Spear
to her physician as “patient is unable to progress due
to perception of pain.” (Tr. at 370). Ms. Spear was
scheduled for consultation with a pain specialist to discuss
other options of care. (Id.)
September 20, 2012, Ms. Spear saw Dr. Clinton Harris at Mercy
Center for Pain Medicine. (Tr. at 504). She described the
pain to Dr. Harris as extending over the left outside of her
left thigh with pain into the left buttock and into the
inside of the left leg, up into the groin region. An MRI of
her hip demonstrated evidence of bursitis. Ms. Spear reported
having been treated with trochanter bursa injections twice,
the first giving better results than the second.
(Id.) The pain occasionally kept her up at night and
was present throughout the day, worse with sitting.
(Id.) Ms. Spear weighed 300 pounds at this visit. On
physical examination, Dr. Harris noted negative straight leg
raise bilaterally, normal gait and station and posture, and
mild tenderness in the lumbosacral spine and pelvic regions
with pain over the left greater trochanter and left ischial
tuberosity with palpation. (Id. at 505). Dr. Harris
administered an injection of Depo-Medrol in the left ischial
tuberosity bursa. (Id. at 506). He directed Ms.
Spear to continue with therapy. (Id.)
Spear returned to physical therapy on September 26, 2012,
reporting her left hip was significantly better. (Tr. at
366). Treatment modalities were undertaken, the therapist
noting tenderness at the greater trochanter but significantly
reduced, improved levator ani mobility, tenderness at
obturator internus and along the med ischial tuberosity and
pubic rami, and significantly decreased tenderness and
tightness in piriformis and gemellus along the sacral border.
(Id.) The same day Ms. Spear also had manual
lymphedema drainage techniques during occupational therapy
for her head pain. (Id. at 364). She had met her
short term goals with a decrease in fullness of the left
parietal lobe of her head and reduced dysesthesia on the left
aspect of her head. Ms. Spear was to continue to work on long
term goals of participating in home program without active
outpatient therapy and working on getting to sleep and
improving her word finding ability. (Id. at 363).
October 10, 2012, Ms. Spear reported more pain to the
physical therapist as she had been driving more because her
husband had shoulder surgery. (Tr. at 361). Ms. Spear felt
better mentally, although sleep was variable, and she was
walking more. (Id.)
Spear returned to Mercy Center for Pain Medicine on October
18, 2012, for follow-up on her hip pain. (Tr. at 499). She
reported she was at least 40% better and the pain over the
side of her left hip was improved. She continued to have pain
into her left buttock, although the intensity had improved,
and some pain into her head. (Id.) Her physical
examination findings remained the same and Dr. Harris noted
he would hold off repeating injections at that time.
(Id. at 500).
November 12, 2012, Ms. Spear was discharged from physical
therapy care for her complaints of left arm pain as she had
seen good resolution of the pain with treatment. (Tr. at
Spear underwent a neuropsychological evaluation at On With
Life on December 7, 2012, at the recommendation of Dr.
Gilbert. (Tr. at 329). Dr. Gilbert referred Ms. Spear to On
With Life because she was experiencing some cognitive
difficulties following the accident. (Id.). Dr.
David Demarest, a clinical neuropsychologist, reviewed Ms.
Spear's medical records from her hospitalization after
the accident and conducted an extensive interview with Ms.
Spear. (Id. at 329-30). She described her pain
problems with her hip and pelvis and headaches, which were
getting worse. (Id. at 330-31). Ms. Spear had
recently returned to work full-time dispatching for a public
transportation company. (Id. at 330). She reported
she had been in occupational therapy for lymph massage and
myofascial release procedures and in physical therapy for her
hip and pelvis pain. (Id.) She was taking three pain
medications at the time of this visit. With respect to the
cognitive difficulties, she reported that her husband said
her personality had changed and she had some short-term
memory difficulty, such as forgetting to flush the toilet or
to shut the top of the washer. A friend had noted that Ms.
Spear had become more assertive and would say things she
would not have before the accident. (Id. at 331).
She had been referred to a mental health professional because
she was ruminating on her pain problems (among other personal
issues). (Id.) Dr. Demarest conducted some tests
over a four-hour period, noting Ms. Spear worked to the best
of her abilities on all tests. (Id. at 332). Her
test performances fell in the average range. What manifested
during the testing were some mild attentional issues, which
Dr. Demarest found consistent with her pain problems.
(Id. at 335). He recommended she continue to work
with Dr. Gilbert. (Id.)
January 4, 2013, Ms. Spear was discharged from occupational
therapy treatment for the lymphedema symptoms in her head and
neck as she did not return for follow-up with the therapist
after her visit on September 26, 2012, and canceled an
October 23, 2012, appointment. (Id. at 357).
Spear saw Ms. Hunerdosse at Mercy Indianola Family Medicine
on April 25, 2013. (Tr. at 524). She complained her right arm
had been retracting and she was having aching pain.
Specifically, Ms. Spear reported experiencing increasing
episodes of involuntary movements of her right upper
extremity. Her right wrist would flex and shoulder extend.
Ms. Spear said her triceps was becoming sore. Her right index
finger and middle finger had been numb since the accident.
She had taken Nortriptyline and Cymbalta in the past, but did
not feel these medications helped. (Id.) She did not
have neck pain any longer and no longer did physical therapy.
(Id.) Ms. Hunerdosse conducted a physical
examination, finding no paraspinal tenderness in the cervical
spine. She was unable to elicit triceps reflexes.
(Id.) She assessed nerve irritation in connection
with the ACDF site and recommended Ms. Spear follow up with
her neurosurgeon and restart Nortriptyline. (Id.).
Cervical spine x-ray taken the same date showed the cervical
segments were anatomically aligned with no fracture or
dislocation and no evidence of instrumentation. (Id.
at 529). There was interval incorporation of the bone graft
as compared to an x-ray taken August 23, 2012. (Id.)
Spear followed up with Mercy Neurosurgery on May 6, 2013. She
reported her right hand was “cramping up, ”
making it difficult to type or write when this occurred. (Tr.
at 515). The physician's assistant who saw Ms. Spear
noted they could consider EMG/NCS for further evaluation.
August 30, 2013, Ms. Spear returned to Mercy Indianola Family
Medicine for refills on prescriptions. (Tr. at 521). She
reported to Ms. Hunerdosse that she tried to return to work
at Red Rock, but had a return of pain and was unable to keep
the job. (Id.) She complained of right arm pain
“contracture” and her left posterior leg/groin
pain was much worse. (Id.) She was using more
Hydrocodone and using Butalbital for her increased headaches,
but still was feeling poorly. (Id.) Her scalp was
painful and numb so she was doing lymphatic massage. Ms.
Spear reported anxiety, which affected her ability to ride in
a car or drive. (Id.) She also was still taking
Nortriptyline. (Id.) Ms. Spear weighed 309 pounds at
this visit. On physical examination, all was normal. Her gait
and station were within normal limits and her spine had
normal alignment and range of motion. (Id. at 522).
Her cranial nerves II to XII were intact. (Id.) Ms.
Hunerdosse planned to refer Ms. Spear to Physical Medicine
and Rehabilitation for consultation. Ms. Spear was going to
return to the swimming pool as that made her pain manageable.
Hunerdosse saw Ms. Spear again on November 7, 2013. (Tr. at
532). Ms. Spear said she was in the process of filing for
Social Security disability and needed to have an exam within
thirty days of the determination. She reported she was
feeling better since leaving her job and was using less pain
medication, although her pain was not better. (Id.)
According to Ms. Spear's husband, her pain was not well
controlled at home, she was irritable, and likely was not
taking pain medications as needed. (Id.) Ms. Spear
was experiencing intermittent “contracture”
symptoms in her right hand and arm, like a spasm or cramp,
had headaches three to four times a week, and was awake a lot
at night and up and down. (Id.) She weighed 309
pounds at this visit. (Id. at 533). After discussing
Ms. Spear's pain issues, Ms. Hunerdosse suggested trying
Cymbalta, refilled the prescription of Butalbital for
headaches, and Ms. Spear was to continue with other
medications, and recheck with the clinic in six weeks.
(Id. at 534).
Disability Determination Services Bureau referred Ms. Spear
to Raymond Tibe, Psy.D, for mental status interview. Ms.
Spear was tested on December 5, 2013, and Dr. Tibe's
report prepared on December 9, 2013. (Tr. at 537). At the
conclusion of his interview, Dr. Tibe concluded that Ms.
Spear had an Axis I diagnosis of adjustment disorder with
mixed mood, and a GAF of 55 to 60. (Id. at 539). Dr.
Tibe could see that with respect to work activities, her
“physical discomfort, difficulties with anxiety and
catastrophizing could make attention, concentration and pace
difficult at times.” (Id.) Her judgment,
ability to relate to people, and ability to process incoming
information were all intact. (Id.)
David Smith, M.D, made an initial disability determination
based on record review on December 31, 2013. (Tr. at 85-97).
The examiner noted a consultative examination was required
because the evidence at that time was insufficient to support
a decision on the claim. (Id. at 89). The examiner
found Ms. Spear's statements about her functional
limitations related to her mental medically determinable
impairments were mostly credible, but partially eroded by the
fact she did not have ongoing psychological/psychiatric
treatment. (Id. at 92). As for the credibility of
her allegations concerning her physical impairments, the
examiner suggested that because all her treatment was
provided by midlevel providers, physicians' assistants
and practicing nurses, Ms. Spear's symptoms were not
treatable or severe. (Id.) The examiner rated her
exertional limitations as occasionally lifting/carrying 20
pounds; frequently lifting/carrying ten pounds; standing or
walking about six hours in an eight-hour workday; sitting
about six hours in an eight-hour workday; unlimited
pushing/pulling; occasional ability to climb ramps/stairs;
never climbing ladders/ropes/scaffolds; and occasionally
balancing, stooping, kneeling, crouching and crawling.
(Id. at 92-93). In reaching this RFC, the examiner
explained the medical evidence of record did not identify
ongoing limitations attributable to the medically
determinable impairments which were non-severe. (Id.
at 93). Ms. Spear was morbidly obese and had chronic
myofascial pain syndrome. She admitted to improvement when
participating in aquatic exercise programs. (Id.)
The examiner was critical of her care as being provided by
“unacceptable medical providers” and lacking in
depth evaluations of her complaints in the files.
(Id.) Russell Lark, Ph.D, assessed Ms. Spear's
mental residual functional capacity, noting there was no
evidence of ongoing mental health treatment in spite of Ms.
Spear's reports to providers that she was struggling with
depression. (Id. at 95). He concluded that
“[h]er attention, concentration, and pace may vary with
her . . . pain/pain medications, ” but she “is
able to complete at least 3-4 step tasks on a sustained
Spear returned to Mercy Indianola Family Medicine on January
24, 2014. (Tr. at 541). Her chief complaint was pain in her
hips and pelvis, headaches, right upper arm cramping, nerve
pain down to her second and third fingers, and intermittent
right-side rib aches. She wanted a referral to Physical
Medicine and Rehabilitation. (Id.) Ms. Spear weighed
308 pounds at this visit. On physical examination, Ms.
Spear's gait and station were within normal limits.
(Id. at 542). A referral was made to the
rehabilitation physician. (Id. at 543).
were taken on February 28, 2014, and March 10, 2014 (Tr. at
591-92). The first was a single view of the pelvis that
showed chronic-appearing heterotopic ossification or
periosteal reaction adjacent to the proximal femoral
diaphysis, similar to a previous x-ray taken May 1, 2012.
(Id. at 592). The radiologist recommended a
dedicated view of the entire left femur. He saw no acute
fracture involving the hips, but did see very mild
degenerative spurring. (Id.) The left femur x-ray
showed good position and alignment of the bony elements with
no evidence of fracture or dislocation. Density was seen
abutting the lateral and posterior aspect of the midshaft of
the femur, most in keeping the heterotopic ossification and
likely related to old trauma. (Id. at 591).
February 28, 2014, Ms. Spear saw Dr. Ai Huong Phu at Mercy
Physical Medicine and Rehabilitation to be evaluated for her
hip pain. (Tr. at 783). She also had right sided arm pain and
described the pulling sensation she would get in her arm with
numbness in the index and middle finger. She described her
left hip/groin/buttock pain as constant and worse with
prolonged sitting. (Id. at 784). She did not have
problems walking. Ms. Spear described the treatments she had
tried. Dr. Phu took a complete history and conducted a
physical examination. As relevant to her complaints, Dr. Phu
observed Ms. Spear's gait and stance were normal, she was
able to walk on toes and heels with good balance.
(Id. at 785). Dr. Phu observed decreased cervical
flexion, limited forward flexion of bilateral shoulders, no
tenderness over the right arm nor spasticity. (Id.)
lumbar was normal with full flexion, extension, sidebending,
rotation and no pain. (Id.) She had a negative
straight leg raise on the left, positive Faber on the left,
tenderness over the left greater trochanter and over the left
SI and buttock and ischial tuberosity and pubic ramus.
(Id.) Dr. Phu reviewed prior x-rays. Dr. Phu
concluded Ms. Spear had neuropathic pain from her head
laceration, left-sided greater trochanter bursitis, possibly
a left SI joint irritation, and left gluteal myofascial pain.
Dr. Phu recommended x-rays of the left SI joint and that Ms.
Spear start a transdermal cream for her neuropathic pain on
her head and left hip region. Dr. Phu thought Ms. Spear might
need another greater trochanter injection and perhaps an
ultrasound for possible fluid drainage. She recommended
Baclofen for Ms. Spear's right upper extremity spasms and
would see her in four weeks. (Id. at 787).
Hunter, D.O., undertook a second record review on March 5,
2014. (Tr. at 100-13). Dr. Hunter reviewed the same medical
records and other sources (statements by Ms. Spear, her
husband, and a friend). Again, the examiner determined Ms.
Spear's credibility was eroded because the medical
evidence was treatment provided by “midlevel providers,
physician assistants and practicing nurses suggesting her
symptoms are not treatable or not severe.”
(Id. at 108). The mental health examiner, Scott
Shafer, Ph.D, reached the same conclusions as before.
(Id. at 110- 11).
Spear followed up with Dr. Phu on March 28, 2014. (Tr. at
788). She reported the Baclofen seemed to help, but she could
only tolerate the evening dose, which assisted her in
sleeping two to three hours at a time. She reported still
having the left internal pelvic pain, which worsened when she
sat. At this visit she rated the pain at 4/10 and said it was
constant. Lying down improved the pain. The films were not
present for review, but the report indicated there was
heterotopic ossification on the lateral aspect of the
proximal femur. Ms. Spear also reported she continued to have
intermittent spasms in her right arm. (Id.) Dr. Phu
conducted another physical exam with findings similar to the
previous month. (Id. at 790). Dr. Phu continued the
Baclofen prescription and would look for a provider who could
do a pudendal block from which she thought Ms. Spear would
benefit. Dr. Phu recommended Ms. Spear start pool therapy
independently at least once a week. (Id. at 791).
April 11, 2014, Ms. Spear saw Dr. Harris, the pain
specialist, to assess her left pelvic pain. (Tr. at 588). Ms.
Spear weighed 300 pounds at this visit. She described her
pain as continuous and worsening as the day progressed.
(Id. at 588). She needed to constantly change
positions from lying down to standing up and sitting on the
toilet to relieve the pain. On physical examination, Ms.
Spear was alert and in no acute distress; as relevant here,
her motor strength was normal in the upper and lower
extremities; and there was tenderness over the ischial
tuberosity on the left. (Id. at 589). Dr. Harris
diagnosed pudendal neuralgia and thought it would be
reasonable to try a left pudendal nerve block. (Id.)
He started Ms. Spear on Lyrica and Venlafaxine and suggested
she talk to a psychologist regarding biofeedback.
saw Ms. Spear on April 22, 2014, for a follow-up visit. Ms.
Spear reported discussing the pudendal nerve block with Dr.
Harris and felt she was interested, but wanted another
opinion. (Tr. at 794). Her pain level on this occasion was
3/10, sharp and aching in nature, and constant.
(Id.) Dr. Harris had given her a prescription for
Cymbalta, but she had not started it yet. (Id.) She
reported her pain worsened throughout the day, and when she
changed positions from sitting to standing. (Id.) It
mildly improved when she sat on the toilet and with lying
down. (Id.) She had been taking the Baclofen in the
morning and at night to help with the right arm, but the
spasms were still ...