The opinion of the court was delivered by: Craig M. Kellison United States Magistrate Judge
MEMORANDUM OPINION AND ORDER
Plaintiff, who is proceeding with retained counsel, brings this action for judicial review of a final decision of the Commissioner of Social Security under 42 U.S.C. § 405(g). Pursuant to the written consent of all parties, this case is before the undersigned as the presiding judge for all purposes, including entry of final judgment. See 28 U.S.C. § 636(c). Pending before the court are plaintiff's motion for summary judgment (Doc. 25) and defendant's cross-motion for summary judgment (Doc. 27).
Plaintiff applied for social security benefits on February 14, 2006. In the application, plaintiff claims that her disability began on November 1, 2001. In her motion, Plaintiff claims that her disability is caused by a combination of fibromyalgia, chronic neck and back pain, headaches, carpal tunnel syndrome, and depression. Plaintiff's claim was initially denied. Following denial of reconsideration, plaintiff requested an administrative hearing, which was held on December 11, 2007, before Administrative Law Judge ("ALJ") Theodore T.N. Slocum. In a March 21, 2008, decision, the ALJ concluded that plaintiff is not disabled based on the following relevant findings:
1. The claimant met the insured status requirements of the Social Security Act through June 30, 2005.
2. The claimant has not engaged in substantial gainful activity since November 1, 2001, the alleged onset date (20 CFR 404.1520(b), 404.1571 et seq., 416.920(b) and 404.971 et seq.).
3. The claimant has the following severe combination of impairments: fibromyalgia, mild carpal tunnel syndrome, and cervical and lumbar strain (20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity [to] stand and walk six hours in an eight-hour day, sit six hours in an eight-hour day, lift and carry 25 pounds frequently and 40 pounds occasionally; and frequently reaching above the shoulders and frequent fine and gross motor movements (20 CFR 404.1567(c) and 416.967(c).
6. The claimant is capable of performing past relevant work as a courtesy clerk and film scanner (general clerk). This work does not require the performance of work-related activities precluded by the claimant's residual functional capacity (20 CFR 404.1565 and 416.965).
7. The claimant has not been under a disability, as defined in the Social Security Act, from November 1, 2001 through the date of this decision (20 CFR 404.1520(f) and 416.920(f)).
After the Appeals Council declined review on January 27, 2009, this appeal followed.
Additional background review indicates Plaintiff had a prior application, filed on December 9, 2002, which was denied in a hearing decision issued May 13, 2004. In connection with the prior application, ALJ F. Lamont Liggett determined Plaintiff had severe impairments, including "carpal tunnel syndrome, right interosseous nerve impingement, and chronic cervical/lumbosacral strain with mild degenerative changes . . . ." (CAR 29). ALJ Liggett determined Plaintiff had the residual functional capacity ("RFC") to "lift/carry 20 pounds, stand/walk about six out of eight hours, sit about six out of eight hours, occasionally perform postural activities, and no frequent overhead reaching with her upper extremities consistent with a narrow range of light to sedentary work." (CAR 33). Based on that RFC, the ALJ found Plaintiff had the ability to perform her past relevant work.
II. SUMMARY OF THE EVIDENCE
The certified administrative record ("CAR") contains the following evidence, summarized below:
Plaintiff had regular chiropractic treatments from 2000 through 2007.
Medical Records May 3, 2004: Plaintiff seen for follow up on medication. She reported no change, but continued neck pain. She was using trazodone and Vicodin. She reported sleeping almost too deeply with trazodone. On examination, she had full range of motion in her neck. Her muscle tone was okay, but she had "Sl tenderness only at occiput." No mid-line tenderness. She was assessed with chronic cervical pain.
July 21, 2004: Plaintiff was seen for a follow up for pain. She reported decreased energy, that "older people do better than me." She stated her pain seemed worse, her muscles are tight. The trazodone was helping her sleep, but did not help her tight muscles. She stated her pain varied; sometimes it was in her back and other times it was in her shoulders and arms. However, her muscles were always tight. Heat, ice, and stretching did not help. She felt her pain was the main issue, and did not want to take an antidepressant. On examination, she had increased tone in her neck and back muscles. She also had tender trigger points on her trapezius ridge and in her low back. The assessment indicates her symptoms were suggestive of fibromyalgia. The plan was to check an arthritis panel and CPK, and recheck in two months. Medication was continued.
August 23, 2004: Plaintiff reported her pain continued in her neck and back. There were tender trigger points noted on her trapezius ridge. The arthritis panel was negative. She was assessed with fibromyalgia, and instructed to continue her medication.
October 25, 2004: Plaintiff was seen for a follow up on her back and neck pain. She reported the cold weather made her symptoms worse. Tender trigger points on her back and neck were noted, with increased tone. She was again assessed with fibromyalgia and was to continue with her intermittent Vicodin. She was also started on Mobic.
January 10, 2005: Plaintiff was seen for a follow up. She reported occasional numbness on her upper lip and that the Mobic did not help her pain, bothered her stomach, and lead to nausea. Increased tone in her neck and back muscles with trigger points were observed. Her range of motion was okay, as was a sensory exam of her face. She was assessed with neuropathy and fibromyalgia.
April 5, 2005: Plaintiff was seen for a medication refill. She reported her pain varies, and she has good and bad days. She was using 200 mg of trazodone at night to sleep. She reported tight muscles, and being active caused more pain. Tenderness on the trapezius ridge and cervical muscles was observed. Her muscle tone was noted as okay. She was assessed with fibromyalgia. Her prescriptions were renewed, and she was asked to consider Cymbalta.
July 8, 2005: Plaintiff reported no change in her pain, her neck was burning, and her sleep was fair. She reported waking up early even with the trazodone. She had tenderness in paracervical muscles, and increased tone in her neck and back muscles. She was assessed with chronic neck pain and fibromyalgia. Her medication was changed to Avinza, and her Vicodin was continued. She was advised to increase her aerobic exercise and her trazodone.
August 11, 2005: She was seen for follow up on medication. She reported tolerating the Avinza, which seemed to help. She was not having much break through pain and no change in the location of her pain. Increased tone and tenderness in her neck and upper back were noted. It was also noted that her chronic pain was under better control with the Avinza, which was continued.
September 7, 2005: Follow up visit for medication. Plaintiff reported the pain program was effective, but she continued to have pain and tight muscles. She stated the Vicodin was not much help, but that she was generally doing okay. Increased tone in neck and back muscles with tenderness at the occiput and paracervical muscles were noted. She was assessed with chronic neck and back pain, and was continued on Avinza.
October 5, 2005: Plaintiff reported a severe headache two weeks prior, which lasted for two days with vomiting. She reported coping okay otherwise. Tender upper back, trapezius ridge, and paracervical muscles were noted. She was assessed with chronic neck and back pain. Avinza was renewed, but Vicodin would not be renewed for another month per her pain contract.
November 4, 2005: Follow up visit. She reported increased pain with headache, so she took extra Avinza which did not help. She reported she was back to her "usual" pain at the time of the visit. She had full range of motion in her neck, but increased headache with full flexion. She was tender at occiput times two. She was assessed with chronic back and neck pain with headaches. She was counseled not to overdo her narcotic pain medication, and to supplement her medication with Tylenol or ibuprofen if needed.
December 9, 2005: Plaintiff reported her pain was still a problem, and worse in the cold weather. A hot pulsating shower helped. Increased tone in trapezius ridge with trigger points was noted, as well as neck with increased tone and vague tenderness. She was assessed with fibrositis, fibromyalgia, and chronic pain. Her medication was renewed, and she was encouraged to try to increase aerobic exercise.
January 17, 2006: Plaintiff reported feeling worse, with good and bad days. Slight kyphotic posture was noted, as well as tenderness on trapezius ridge and paracervical muscles. Her range of motion was okay. She was assessed with chronic upper back pain, fibromyalgia.
February 6, 2006: Plaintiff reported left hand tingling, which can also occur in the right. Her pain continued about the same in her neck and back. No Thenar muscle wasting was noted, she had a negative Tinel's sign at wrists, and negative Spurling's maneuver. Increased tone in neck and trapezius ridge with trigger points was also noted. She was assessed with fibromyalgia and neck pain. Her medication was renewed, and it was noted that the increase in trazodone has not helped a great deal.
February 9, 2006: Plaintiff seen for back pain again. She reported her hand was not bad, but wanted something done for her back pain. "Not much fun in life." It was noted that her x-rays and CT were negative, the nerve conduction study suggested carpal tunnel on the left, but there was no cervical pathology. She was assessed with chronic neck, back pain. It was also noted that Plaintiff did not tolerate NSAIDS. She was to try a brace on her left wrist, and Lexapro was added to her medications.
March 15, 2006: Plaintiff was seen for routine follow up. She stopped taking the Lexapro, because it made her too crazy. She also reported the trazodone was making her too sleepy. She wanted carpal tunnel fixed. She was wearing the splint, but was having some ongoing pain. She appeared subdued and sleepy. On examination, she had increased tone in her neck and back with trigger point on the trapezius ridge. Her finger to nose, Romberg, and tandem gait were all okay. She was assessed with chronic neck and back pain, chronic myalgia, and carpal tunnel syndrom. She was advised to check on availability of an orthopedist who would take Medi-Cal. If she was able to find one, she would get a referral. Otherwise, she was instructed to continue wearing the splint.
April 19, 2006: Plaintiff reported her pain was continuing, but she was coping with Avinza. Her psychomotor activity was observed to be slow. Increased tone in upper back and left lower back, and tenderness at occiput times two were noted. She was assessed with chronic back and neck pain. She was provided a sample of Cymbalta to try.
May 19, 2006: Plaintiff reported she had not tried the Cymbalta yet, and she had no change in her pain symptoms. Increased tone in neck and back with tenderness at occiput was noted. She was assessed with fibromyalgia and chronic pain.
June 16, 2006: Plaintiff reported the Cymbalta made her feel weird. Some of her days were better, some worse, but she had woken up stiff that day. Increased tone in neck and back with tender trigger points on trapezius ridge and low back were noted. She was assessed with chronic pain and fibromyalgia. Cymbalta was discontinued, and she was to try Neurontin.
September 18, 2006: Plaintiff was seen for a follow up on her medication. She reported the Neurontin made her sick. She had been off Avinza for twenty days because her Medi-Cal status was on hold. She reported her back is stiffer, and she is not sleeping as well. It was noted that her motivation is poor, but she denied depression. She stated sometimes her right hand goes to sleep. Increased tone in neck and upper back muscles were noted. She had negative Tinel's sign at right wrist. She was assessed with fibromyalgia and chronic back pain. Her Avinza was renewed, she was going to taper off trazodone, and was going to consider Effexor or Wellbutrin.
October 18, 2006: Plaintiff was seen for a follow up. She reported she does not want to use an anti-depressant. The colder weather had not been good for her back. She had increased pain in her back with the cold. She appeared more alert, less sedated, and her mood and affect were improved. She had tenderness at the mid cervical spine. She was assessed with chronic neck pain. Her Avinza was renewed, and she was advised to use ibuprofen for break through pain. Decided to hold off on anti-depressant.
December 18, 2006: Plaintiff reported a little worse with the colder weather, had decreased energy, and was gaining weight, but denied depression. Her affect was flat. She had increased tone in her neck and back muscles with trigger points on trapezius ridge. Assessed with fibromyalgia, chronic fatigue, weight gain. Decision to hold off on anti-depressant, but advised to consider it at next visit.
January 18, 2007: Failed appointment.
January 22, 2007: Plaintiff reported some numbness in both arms. It switches, sometimes on the left, sometimes on the right. She also reported some numbness on the right side of her face, tightness in muscles of her back, and the cold weather was bothering her. She went a few days without Avinza and noted increased pain. She reported the use of Avinza allowed her to function better. She was observed as alert with minimal distress. Had marked increase in tone in back and neck muscles. Her range of motion was at 80%. She had a positive Spurling's Maneuver on the left shoulder. Her deep tendon reflex in her arms was okay, she had negative Tinel's sign in wrists, negative Phalen's test, and no thenar atrophy. She was assessed with chronic back and neck pain with development of parathesia to her arms and face. The plan was to check her c-spine x-ray, and maybe an MRI of her neck. She was advised to stay with ibuprofen and Avinza.
February 20, 2007: Plaintiff reported she did not have x-rays taken, and the cold seemed to make her neck pain worse. Increased tone in neck and upper back with tenderness and spasm on trapezius ridge was noted. Her drug test was positive only for opiates. She was assessed with chronic neck pain. Her Avinza was refilled, and she was to get a c-spine x-ray.
Cervical x-ray was completed on February 20, 2007. The findings were: "AP, lateral, swimmer's, odontoid and oblique views were obtained. Alignment is normal. The disc spaces are preserved. The neural foramina are patent. No fracture or prevertebral soft tissue swelling is ...