Requiring a Longitudinal, SSR 12‑2p-Compliant Evaluation of Fibromyalgia Symptoms in RFC Determinations

Introduction

In Christine Swiecichowski v. Leland Dudek, Acting Commissioner of Social Security, the United States Court of Appeals for the Seventh Circuit vacated a denial of disability insurance benefits because the administrative law judge’s residual functional capacity (RFC) analysis did not clearly reflect the longitudinal, wax-and-wane nature of fibromyalgia as required by Social Security Ruling (SSR) 12‑2p. While acknowledging the ALJ’s detailed review, the court held that fibromyalgia’s unique characteristics necessitate an articulated, holistic evaluation of symptom severity over time, integrated with the two-step symptom-consistency framework of SSR 16‑3p. The court also rejected cursory reliance on “conservative treatment” as an adequate substitute for thorough analysis. Judge Kirsch dissented, emphasizing the highly deferential substantial-evidence standard and cautioning against imposing an unduly onerous articulation requirement.

The case centers on whether the ALJ appropriately evaluated the functional impact of Swiecichowski’s fibromyalgic pain—distinct from the step-two finding that fibromyalgia is a severe, medically determinable impairment. The Seventh Circuit’s decision clarifies how ALJs must apply SSR 12‑2p during RFC assessments and, more broadly, what constitutes a “logical bridge” in fibromyalgia cases.

Summary of the Opinion

The court vacated and remanded. The majority held that, although an ALJ may consider clinical findings (such as normal strength, reflexes, gait, and “no acute distress”) when assessing RFC, fibromyalgia requires a longitudinal analysis that explicitly accounts for waxing and waning symptomatology under SSR 12‑2p. The ALJ’s discussion referenced only a handful of medical visits and lacked clear engagement with a broader series of encounters (about thirty additional visits) that included repeated pain reports. The ALJ also mentioned “conservative treatment” without meaningful explanation, which the court deemed insufficient.

The court found most of the claimant’s appellate arguments (beyond the fibromyalgia evaluation) waived because they had not been presented to the district court. The remand thus focused narrowly on ensuring that the ALJ applies SSR 12‑2p and SSR 16‑3p in a longitudinal, comprehensive manner tailored to fibromyalgia’s clinical profile.

Judge Kirsch dissented, arguing that the ALJ’s explanation—though imperfect—was adequate under the deferential substantial-evidence standard. He cautioned against requiring ALJs to cite a threshold number of records to satisfy “longitudinal” review and emphasized that the ALJ did discuss multiple visits, including objective findings and reports of pain, over time.

Background and Procedural History

Christine Swiecichowski worked for more than three decades in a warehouse before leaving in 2018 due to chronic pain attributed to fibromyalgia, as well as depression and orthopedic and spinal issues. After unremarkable EMG and MRI studies failed to explain her widespread pain and tenderness, clinicians diagnosed fibromyalgia, corroborated by a trigger-point assessment (12 of 18 points positive). Despite medication, injections, and physical therapy, her pain persisted.

Applying for disability benefits, Swiecichowski described significant functional limitations: inability to sit or stand for long periods, need to change positions frequently, limits in lifting and bending, and difficulty completing activities of daily living without breaks or help. The ALJ found fibromyalgia and other severe impairments but concluded that her allegations were “not fully consistent” with the evidence, determined an RFC for light work with additional limitations, and denied benefits at step five based on available jobs in the national economy. The Appeals Council denied review; the district court affirmed. On appeal, most issues were found waived except the contention that the ALJ failed to evaluate fibromyalgia in accordance with SSR 12‑2p.

Analysis

Precedents and Authorities Cited and Their Influence

• SSR 12‑2p (2012): The agency’s fibromyalgia-specific guidance. It requires ALJs to:
  • Determine whether fibromyalgia is a medically determinable impairment (MDI) using accepted diagnostic criteria (including trigger-point assessment).
  • When assessing RFC, consider all relevant evidence and, crucially, evaluate a longitudinal record whenever possible because fibromyalgia symptoms “can wax and wane” and create “good days and bad days.”
  The decision turns on this longitudinal requirement at the RFC stage.
• SSR 16‑3p (2017): Governs evaluation of symptom intensity, persistence, and limiting effects in a two-step framework: (1) whether the impairment could reasonably produce the alleged symptoms; and (2) the consistency of a claimant’s statements with the entire record (objective evidence, treatment, medication, daily activities, etc.). SSR 12‑2p directs ALJs to use this framework for fibromyalgia symptom assessment. The opinion reaffirms this crossover.
• Wilder v. Kijakazi, 22 F.4th 644 (7th Cir. 2022): Social Security Rulings lack the force of law but are binding on ALJs. This underscores that SSR 12‑2p/16‑3p compliance is not optional.
• Sarchet v. Chater, 78 F.3d 305 (7th Cir. 1996): A seminal Seventh Circuit discussion of fibromyalgia, recognizing that symptoms are largely subjective and that normal objective tests (e.g., lack of joint swelling) do not negate fibromyalgia. The majority channels Sarchet to caution against overreliance on normal clinical signs.
• Gerstner v. Berryhill, 879 F.3d 257 (7th Cir. 2018); Vanprooyen v. Berryhill, 864 F.3d 567 (7th Cir. 2017): Severity of fibromyalgia often cannot be measured by objective tests (apart from trigger-point evaluations). These cases reinforce the need to look beyond normal imaging or EMG findings.
• Revels v. Berryhill, 874 F.3d 648 (9th Cir. 2017): Cited for the clinical reality that fibromyalgia patients commonly display normal muscle strength, sensory function, reflexes, and joints. The Seventh Circuit invokes Revels to put “normal” exam findings in proper context in RFC analyses.
• Jeske v. Saul, 955 F.3d 583 (7th Cir. 2020); Gedatus v. Saul, 994 F.3d 893 (7th Cir. 2021): Frame the standard of review (substantial evidence; “logical bridge”) and direct appellate review of ALJ decisions. Jeske also supports waiver principles for issues not raised in the district court.
• Prill v. Kijakazi, 23 F.4th 738 (7th Cir. 2022); Thomas v. Colvin, 745 F.3d 802 (7th Cir. 2014): Address when “conservative treatment” may or may not undercut allegations of disabling pain. The majority notes that a bare reference to conservative care, without explanation, does not suffice.
• Mandrell v. Kijakazi, 25 F.4th 514 (7th Cir. 2022); Kastner v. Astrue, 697 F.3d 642 (7th Cir. 2012): Explain RFC and the five-step sequential process, orienting where the error occurred (between steps three and four).
• Waiver authorities: Puffer v. Allstate, 675 F.3d 709 (7th Cir. 2012); Mendez v. Perla Dental, 646 F.3d 420 (7th Cir. 2011) confirm that undeveloped or reply-only arguments are waived; applied here to limit review to the fibromyalgia-RFC issue.
• Dissent’s authorities: Elder v. Astrue, 529 F.3d 408 (7th Cir. 2008); Lopez v. Barnhart, 336 F.3d 535 (7th Cir. 2003); Deborah M. v. Saul, 994 F.3d 785 (7th Cir. 2021); Martin v. Kijakazi, 88 F.4th 726 (7th Cir. 2023); Beardsley v. Colvin, 758 F.3d 834 (7th Cir. 2014) emphasize the limited scope of review, deference to ALJ factfinding, and “logical bridge” requirements—used to argue the ALJ did enough.
• Groves v. Apfel, 148 F.3d 809 (7th Cir. 1998): Pre-onset evidence can be considered, but the dissent underscores that the ALJ need not cite every pre-onset encounter to satisfy longitudinal review.

Legal Reasoning

The majority’s core holding is procedural-substantive: fibromyalgia’s idiosyncrasies demand a longitudinal analysis at the RFC stage that reflects its waxing and waning course, consistent with SSR 12‑2p and implemented through SSR 16‑3p’s symptom framework. The ALJ’s decision did not clearly show that analysis. Three points are central:

• Longitudinal analysis is required and must be apparent. SSR 12‑2p instructs ALJs to “consider a longitudinal record whenever possible” for fibromyalgia because symptoms can vary day-to-day. The ALJ relied heavily on a handful of visits (five dates) to characterize clinical findings as “mixed” and often normal. Yet the record documented roughly thirty other encounters where the claimant reported significant, function-limiting pain. The court did not impose a citation quota but found it “not clear” that the ALJ holistically evaluated the waxing-and-waning symptom evidence across time. That lack of clarity undermines the “logical bridge.”
• Normal clinical findings are not irrelevant but must be contextualized. The court rejected the claimant’s contention that such findings are off-limits in fibromyalgia cases. ALJs may consider exam results to gauge function. But normal strength, reflexes, gait, sensation, and “no acute distress” are common in fibromyalgia and cannot be read to negate disabling pain. The court highlighted a record where “no acute distress” coexisted with multiple trigger points and significant pain—a caution against overreading normalities.
• “Conservative treatment” cannot carry the analysis without explanation. Merely labeling care as conservative (medications, injections, therapy) is not enough. The ALJ must explain why the treatment course undercuts the alleged severity, especially when records may indicate ongoing symptoms despite treatment. The majority cited Prill and Thomas to illustrate how the context of treatment efficacy and available alternatives matters.

The majority also enforced appellate waiver, limiting its review to the SSR 12‑2p/16‑3p issue. This procedural narrowing sharpened the focus on the ALJ’s articulation of longitudinal symptom evaluation rather than broader RFC disputes.

Impact and Implications

The decision crystallizes a practical, enforceable rule in the Seventh Circuit: when fibromyalgia is at issue, an ALJ’s RFC discussion must explicitly reflect a longitudinal analysis of symptom severity and functional impact, consistent with SSR 12‑2p and SSR 16‑3p. Several consequences follow:

• For ALJs:
  • Articulate that you are evaluating a longitudinal record and explain how waxing-and-waning symptoms influence your assessment of intensity, persistence, and functional effects.
  • Discuss the congruence (or lack thereof) between symptom reports, daily activities, treatment history, and objective findings over time—not as isolated snapshots.
  • If invoking “conservative treatment,” explain what more aggressive modalities were available, whether they were medically appropriate, whether treatment provided relief, and how that bears on functional capacity.
  • Clarify the role of normal exam findings given fibromyalgia’s typical presentation. Avoid equating “no acute distress” or normal strength/reflexes with non-disability.
• For claimants and counsel:
  • Develop a thorough longitudinal record that documents good days and bad days, functionality fluctuations, and the frequency/duration of symptom exacerbations.
  • Connect daily activities to symptom variability (e.g., need for breaks, help from others, pacing, postural changes) and demonstrate how activities are performed, not merely whether they are performed.
  • Address treatment context: efficacy, side effects, clinical reasoning for chosen modalities, and any contraindications to more invasive measures.
• Beyond fibromyalgia: Although grounded in SSR 12‑2p, the logic may influence analysis of other waxing-and-waning conditions (e.g., chronic fatigue syndrome, migraine, certain autoimmune disorders) where longitudinal assessment is inherently probative of functional limitations.
• Standard-of-review tension: The dissent flags the risk of ratcheting up articulation demands under the substantial-evidence standard. Expect parties to debate how much explicit longitudinal discussion is “enough” and whether failure to cite additional encounters is harmless where the ALJ’s narrative captures variability.

Complex Concepts Simplified

• Medically Determinable Impairment (MDI): A health condition confirmed by medical evidence (e.g., a recognized diagnosis, such as fibromyalgia via trigger-point testing). Step two of the disability analysis asks whether the claimant has a severe MDI.
• Residual Functional Capacity (RFC): The most a person can do on a sustained basis despite limitations. It is assessed between steps three and four and feeds into steps four and five to determine work capability.
• SSR 12‑2p: The SSA’s fibromyalgia guidance. It covers how to establish fibromyalgia as an MDI and, crucially here, instructs ALJs to consider a longitudinal record in RFC evaluation because symptoms “wax and wane.”
• SSR 16‑3p: The symptom evaluation policy. Step one asks if the impairment could cause the alleged symptoms; step two assesses the intensity/persistence and how consistent the claimant’s statements are with the entire record (medical evidence, treatment, activities, etc.).
• Trigger-Point Test: A clinical examination pressing on 18 standardized body points; 11 or more positive points traditionally support a fibromyalgia diagnosis. It’s one of the few objective tools tied to fibromyalgia.
• Longitudinal Record: Evidence tracked over time showing patterns, fluctuations, and functional effects—not just isolated snapshots. For fibromyalgia, this includes “good days and bad days.”
• “No Acute Distress” and Normal Exams: Common in fibromyalgia and, without context, not strong evidence against disabling pain or functional restriction.
• Conservative Treatment: Non-surgical, lower-risk modalities (e.g., medication, injections, therapy). Its presence may or may not undercut allegations, depending on efficacy, side effects, clinical judgment, and available alternatives.
• Substantial Evidence: A deferential standard; means only “such relevant evidence as a reasonable mind might accept as adequate.” Even so, the ALJ must build a “logical bridge” from evidence to conclusions.

The Dissent’s Perspective

Judge Kirsch emphasized that substantial evidence review is “extremely limited.” He read the ALJ’s opinion as adequately grappling with both objective findings and subjective complaints across time, noting that pre-onset evidence need not be exhaustively cited and cautioning against implying a numeric threshold for longitudinal analysis. He highlighted that the ALJ credited state-agency opinions and even imposed more restrictive RFC limits than those consultants, indicating careful weighing. In his view, the ALJ built a sufficient logical bridge, and the majority’s approach risks elevating form over deference.

Practice Pointers

• For ALJs:
  • State expressly that you are conducting a longitudinal analysis under SSR 12‑2p and explain the waxing-and-waning pattern’s effect on RFC.
  • Integrate SSR 16‑3p factors with fibromyalgia context; explain how daily activities are performed and whether they translate to sustained work.
  • When relying on normal clinical findings, explain their limited probative weight in fibromyalgia and counterbalance with symptom reports over time and functional observations.
  • If citing “conservative treatment,” describe why it undermines the claimed limitations in this case (consider efficacy, contraindications, and alternatives).
• For Claimants/Counsel:
  • Document variability: frequency, duration, and severity of flare-ups; functional consequences (e.g., unscheduled breaks, postural shifts, absences).
  • Present treatment narratives: what has been tried, side effects, reasons for not pursuing invasive options, and provider assessments of response.
  • Corroborate with longitudinal third-party statements and therapy/rehab notes that capture function over time.

Conclusion

The Seventh Circuit’s decision in Swiecichowski v. Dudek establishes a clear, enforceable expectation: in fibromyalgia cases, an ALJ’s RFC determination must reflect a longitudinal, SSR 12‑2p-compliant evaluation of symptoms and functional impact, acknowledging waxing-and-waning patterns and integrating SSR 16‑3p’s symptom-consistency analysis. Normal clinical signs and “no acute distress” may be considered but cannot be overread to negate fibromyalgia’s disabling potential. A bare reference to “conservative treatment” will not substitute for a reasoned, contextual explanation. While the dissent highlights the deference owed under substantial evidence, the majority insists on an articulated logical bridge that meaningfully engages fibromyalgia’s unique clinical profile. The ruling should sharpen how ALJs write fibromyalgia decisions and how advocates build records—shifting the focus from snapshots to sustained patterns that reveal true work-related limitations.