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Thread: American Pain Society Centers of Excellence in Pain

  1. #1

    American Pain Society Centers of Excellence in Pain

    A lot of people ask me for recommendations of Pain Centers. In 2007, the American Pain Society selected 6 centers as the best in the United States. The following is their newsletter explaining why they selected them.

    http://enewsletters.org/page_aps_coe_april_07.htm
    Honoring Multidisciplinary Pain Care


    After 30 years of leadership in pain management, the American Pain Society initiated a Clinical Centers of Excellence (CCOE) in Pain Management Awards Program to recognize and reward top-quality clinical care in pain management.

    This was an ambitious effort for APS and took the time and talents of many individuals. APS wishes to thank the CCOE program development committee—co-chairs Russ Portenoy and Deb Gordon, and committee members Christine Miaskowski, Judy Paice, Lori Reisner, Michael Byas-Smith, Robert Jamison, and Steve Weisman—as well the final review committee, co-chairs Judy Paice and Dennis Turk and committee members Michael Byas-Smith, Steven Weisman, Lonnie Zeltzer, and Mark Jensen.

    APS would also like to thank the staff for its administrative oversight and Endo Pharmaceuticals for providing the vision and financial support to create this program.

    APS is extremely proud to recognize its first group of CCOE award recipients. The following 2007 CCOE award recipients exemplify the many multidisciplinary clinical programs throughout the United States.

    NYU Medical Center, Hospital for Joint Diseases, Bellevue Hospital Center, Comprehensive Pain Management Center, New York
    The Rosomoff Comprehensive Pain Center, Miami
    Brigham and Women’s Hospital, Pain Management Center, Department of Anesthesiology, Perioperative and Pain Medicine, Boston
    UCSF Pain Management Center and UCSF PainCARE, Center for Advanced Research and Education, San Francisco
    James A. Haley Veterans Affairs Hospital, Chronic Pain Rehabilitation Program, Tampa
    Cincinnati Children’s Hospital Medical Center, Div. of Pain Management, Cincinnati

    NYU Hospitals Center: NYU Medical Center, Hospital for Joint Diseases (HJD), Bellevue Hospital Center, New York

    The NYU-HJD Comprehensive Pain Management Center may want to consider highlighting the word Comprehensive in its title because this integrated inpatient-outpatient program epitomizes all things comprehensive.

    In terms of patient care, the center’s evidence-based multimodal care targets both physical and psychosocial function by combining analgesics, physical therapy, psychological approaches, and pain interventions. Several times a day, pain physicians, psychologists, and pain nurses follow patients to treat pain and focus on physical and psychosocial function.

    No patients are overlooked. If they don’t speak English, communications sheets come in 40 different languages; if they are deaf or hard of hearing, there’s a sign language interpreter on staff.

    In terms of staffing, pain management consults are available 24/7 from a staff that includes physicians, psychologists, pain management nurses, a palliative care team, physical and occupational therapists, a holistic nurse practitioner, a pastoral caregiver, pharmacists, and clinical social workers. Meanwhile, complex inpatient and outpatient cases are presented at weekly interdisciplinary meetings.

    “Intradisciplinary and multimodal access is integrated into a spectrum of acute and chronic pain management to optimize pain control, clinical outcomes, and patient satisfaction,” says Christopher Gharibo, MD. “This is enhanced by clinicians’ ability to use the vast multidepartmental resources within our institution.”

    The center’s pain management policies and procedures are both “general and specialized.” They include

    a pain management documentation systems that includes pain outcome tracking
    incorporating pain education into nurse and physician orientation and follow-up programs
    instituting hospital-wide “pain awareness weeks,” institution-specific analgesic pocket cards, successful CME programs, and quality-improvement programs
    developing analgesic pathways with other departments for, among others, patients suffering from addictions or post-operative pain.
    Last, the center outreaches to the community to provide comprehensive pain care to the indigent, addicted, and prison populations, as well as to a treatment center with a predominantly Asian patient base. It has also provided clinical and administrative consulting services to a local mental health center.

    Research programs center primarily on the mechanisms, effects, and treatments of pain. For example, clinical investigations include phase 2 and phase 3 analgesic drug trials, neurophysiological testing of patients with neuropathic pain, and assessment of cognitive behavioral techniques in postoperative and cancer pain. Laboratory investigations, meanwhile, focus on sustained hypersensitivity in rats’ DRG cells and developing a single neuron model for preliminary drug screening.

    The gathered knowledge is published in peer reviewed publications and is featured at CME conferences and media outlets such as the Internet, radio, and television. Faculty also share their knowledge with colleagues at local and regional meetings, as well as at APS, AAPM, and ASA meetings.


    The Rosomoff Comprehensive Pain Center (RCPC), Miami, FL

    Since RCPC’s founding in 1974 by Dr. Hubert Rosomoff—a founder and former president of APS, past-president of AAPM, founder of the Southern Pain Society (SPS), and longtime champion of pain medicine—the center has developed a reputation of excellence nationally and internationally. Consider these developments:

    RCPC’s innovative approach serves as a model for other national and international programs. The RCPC has helped establish a pain center in Cali, Colombia; Lima, Peru; and Cairo, Egypt, and has been consultant to Pain Centers both nationally and abroad. The center regularly receives visitors, medical students, fellows, and residents to learn its techniques. Data are reviewed and outcome results published regularly.
    The center serves as a consultant on pain management for government agencies at the federal, state, and local levels.
    RCPC rehabilitation nurse Renee Rosomoff was recognized by UCLA Pain Library as one of six nurses worldwide for her contributions to pain medicine. She served as president of the Association of Rehabilitation Nurses and SPS and as an APS Board Director. She received the APS and the Association of Rehabilitation Nurses Distinguished Service Awards and the SPS President’s Award for Excellence in Pain Management.
    RCPC educates professionals and the general public about pain diagnosis, treatment, costs, access, risk, and safety issues through community centers, public events, and through national and international media outlets including radio, television, and the Internet. Collectively, the faculty has presented at more than 2,500 local, national, and international meetings.
    RCPC staff has written more than 750 combined scientific and lay publications. RCPC has been featured in numerous periodicals and magazines, including People, Prevention, Life, Tennis, U.S. News & World Report, Medical World News, Good Housekeeping, TIME, and the AARP Bulletin.
    The RCPC employs a full-time integrated team—including physicians, psychologists, physical therapists, occupational therapists, massage therapists, biofeedback technicians, ergonomic engineers, rehabilitation aides, case managers, an acupuncturist, vocational counselors, and nursing assistants—that interacts on a daily basis to provide treatment throughout patients’ stays, which average 4 weeks. The staff is multilingual, multicultural, and receives ongoing education and training in cultural sensitivity.

    Staff members address patients’ physical, functional, behavioral, socioeconomic, and medical issues concurrently. For example, patients are tapered from narcotics and other dependency-inducing drugs, and are provided alternative treatments and other medications, as needed. The medical director and clinical staff hold twice-daily multidisciplinary rounds to review and adjust care. Patients are team-conferenced on a weekly, if not more frequent, basis. Patients treated range in age from 14–103. They are barely functional mentally and physically, have up to 42 surgical procedures, and are taking up to 1000 mg of methadone per day.

    Evaluations and treatments at the RCPC are individualized to patients’ needs and conditions. The multidisciplinary evaluation process spans up to 3 days of assessments and screening by pain medicine physicians, nurses, physical therapy, occupational therapists, massage therapists, psychologists, and a vocational counselor.


    Pain Management Center, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA

    Staff from BWH Pain Management Center say that patients who enter their facility get fully immersed in multidisciplinary pain assessment and treatment—not a surprising description from a staff that includes massage therapists and physical therapists. In fact, the center’s staff comprises experts from diverse backgrounds ranging from anesthesiology, neurology, orthopedics, internal medicine, pharmacy, psychiatry, psychology, and nursing to physical therapy, dentistry, acupuncture, and massage therapy. Together, they stress a unified approach to evaluation and management of pain problems.

    As such, the center serves as a model of interventional and noninterventional treatment approaches. These include psychotherapy; medication management; biofeedback; physical and occupational therapy; neural blockade procedures; radiofrequency lesioning and chemical neuroablation; and implantation of spinal cord stimulators, intrathecal pumps, and epidural portacaths.

    The center receives national and international referrals, including from other tertiary care center pain programs. Among its offerings

    patient-centered care for a wide variety of acute and chronic medical pain conditions
    state-of-the-art approaches to procedural and implantable techniques
    biobehavioral therapies and complementary medicine methods such as biofeedback, hypnosis, acupuncture, massage, and mind/body techniques
    evidence-based patient selection criteria for treatment protocols
    weekly team meetings and case conferences
    rigorous surveys and electronic diary data collection to determine efficacy of therapy
    interpreter services and indigent care
    domestic violence counselors.
    According to BWH Pain Management Center officials, the center is a model of innovation and excellence. The center, for example, uses longitudinal medical records, note scanning, and electronic diary technology, and implements a developed system of assessment of risk/benefit potential to tailor treatment to patient profiles. On the legislative front, BWH Pain Management Center staff was invited by its state governor to participate on a special commission on drug abuse. Staff representatives, meanwhile, are developing Massachusetts legislative policies favorable to pain management.

    The BWH Pain Management Center staff is committed to advancing scientific knowledge. Staff members contribute an average 15 publications a year, sit on editorial boards of four pain journals, and frequently grant interviews to local and national press, among other things.

    The BWH Pain Management Center offers a superb educational program in pain medicine, and maintains a highly competitive fellowship accredited by the American Council on Graduate Medical Education. Each year, eight fellows graduate from the program, which is a key teaching site for approximately 35 residents per year and has hosted trainees from other national and international educational programs. Upon completion of the program, many of the graduates of the BWH Pain Medicine fellowship continue as leaders in their field, both in academics and private practice settings.

    The center actively collaborates with other Boston-area healthcare systems, such as the Dana Farber Cancer Institute to provide state-of-the art pain and palliative care services, Partners HealthCare to improve access to pain services for all of its patients, and the BWH Spine Center whose aim is to bring evidence-based practice to a cost-conscious outcome-based model of care for patients with spinal and musculoskeletal disease.


    UCSF Pain Management Center (PMC) and PainCARE, San Francisco, CA

    Meet Pamela Pierce Palmer, MD PhD, director of PainCARE, UCSF's Center for Advanced Research and Education and Professor, UCSF Department of Anesthesia and Perioperative Care. An internationally respected physician and a leader in peripheral inflammation mechanisms and opioid receptor signaling research, Palmer became director of UCSF’s Pain Management Center (PMC), working with healthcare leaders worldwide to advocate for improvements in research, patient care, and pain education for healthcare practitioners. Five years later, with the help of a challenge grant from The Mayday Fund and other key supporters, she and her staff launched PainCARE to intensify these efforts.

    “The PainCARE-PMC collaboration is transforming the conventional treatment center by integrating state-of-the-art PMC clinical care with research, training for healthcare professionals and patients, and active community, media, and government outreach to foster true collaboration between patients, policymakers, and....healthcare providers."

    PMC faculty develop patient care policies and education programs for UCSF and teach “everywhere,” from community hospital grand rounds to major international conferences. David Lee, MD, has been the medical director of the PMC since 2005, and also heads the ACGME-accredited UCSF Pain Management Fellowship program and is a key part of the collaboration’s success.

    In 2003, Dr. Palmer and her staff began a significant expansion of UCSF’s continuing education offerings. At the request of the associate dean and associate chief medical officer at UCSF Mount Zion, they created the Challenges of Managing Pain Symposia, a live lecture series that has helped physicians across the San Francisco Bay Area to comply with California’s law requiring 12 CME credits in pain management and end-of-life care. Now also teleconferenced to multiple sites in California, this series will soon reach even further through streaming video. In 2005, Dr. Palmer and PainCARE staff also launched the only intensive web-based pain management education program of its kind in the country, the UCSF Postgraduate Certificate in Pain Management-Online. This program is part of an international pain education program developed with the Universities of Sydney and Edinburgh.

    PMC and PainCARE faculty, often with UCSF staff, educate patients and their families on disease processes, treatment options, and coping strategies. PMC staff also tap various UCSF facilities and resources, such as its Integrative Medicine center, to provide patients access to complementary therapies—acupuncture, biofeedback, massage therapy, and stress management—and services such as nutrition counseling, social work, and occupational therapy.

    Likewise, PMC patients are referred to healthcare consultants both inside and outside of UCSF, including UCSF's internationally respected migraine specialists, neurologists, orthopaedic surgeons, and internal medicine practitioners. PMC and PainCARE serve about 10,230 patients a year, of which 7,294 are treated for chronic noncancer pain. Each patient’s case is reviewed by a multidisciplinary staff to ensure that the best combination of therapies is provided. “Each patient is reviewed by our team…and patients are encouraged to attend free programs on pain and coping presented by treatment staff,” according to PMC officials. “PMC’s anesthesiologists, neurologist, psychologist, nurses and physical therapist have extensive experience with multiple pain conditions, from back pain to cancer, musculoskeletal, neuropathic, and post-surgical pain.”


    James A. Haley Veterans Affairs Hospital, Chronic Pain Rehabilitation Program (CPRP), Tampa, FL

    Outcomes-driven and interdisciplinary: This approach to pain treatment allows the CPRP to maintain “a proactive, responsive, and constantly evolving program.” It’s so proactive, in fact, that CPRP officials believe they were the first pain program to routinely implement clinical pathways to guide treatment and to measure pain treatment satisfaction as a primary outcome.

    To treat returning Iraq and Afghanistan soldiers, the CPRP recently implemented three innovative programs to provide comprehensive symptomatic and prophylactic treatment to those injured in combat or during deployment. Meanwhile, the CPRP developed a pain outcomes instrument requested by more than 800 clinicians and researchers in 36 countries and initiated a preliminary validation of actigraphy as an objective pain outcomes measure.

    “Consistent with the military actions in Iraq and Afghanistan, our latest research efforts focus on the assessment and treatment of pain in returning military personnel who experienced combat-related polytrauma or other deployment-related injuries,” says Clinical Director Michael E. Clark, PhD. He adds that current research funding of CPRP principal investigators is in excess of $1.4 million.

    Since its opening in 1988, CPRP has treated more than 32,000 active duty, veteran, and veteran family members for pain. Each year it serves about 3,900 patients, mostly on an outpatient basis.

    This evidence-based program has for 17 years systematically collected outcomes data to monitor its success and guide its program development. “We utilize an active rehabilitation strategy with a strong cognitive-behavioral focus to treat pain, and our success in this area is reflected in our multitude of national awards… and continuous CARF accreditation,” Clark says.
    Within the Veterans Administration (VA) community, the CPRP’s reputation for excellence has led to its position as a national VA pain treatment referral center and as the premier VA pain resource center. It serves as a model of clinical care, program development and implementation, cost offsets, and resource needs for other VA and non-VA healthcare systems in the United States and abroad. The CPRP also provides intensive training to VA pain providers and multidisciplinary treatment teams, and shares its materials on policy, program, treatment, and validated outcomes with other facilities worldwide.

    CPRP’s core team comprises physicians (neurologists, physiatrists, an anesthesiologist, Pain Fellows, and medical residents), pain psychologists, ARNPs, RNs, LPNs, a registered dietician, rehabilitation therapists (physical therapists, occupational therapist, kinesiotherapist, vocational therapist, and recreational therapist), and a social worker. Extended team members include a chiropractor, acupuncturist, and pharmacist. Moreover, key members of the CPRP also

    participate in VA and non-VA national pain advisory groups, committees, and task forces that focus on enhancing pain care
    conduct local, regional, and national education seminars
    consult with health systems and facilities
    provide training to interdisciplinary pain management teams.

    Division of Pain Management, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

    Kenneth R. Goldschneider, MD FAAP, director of the Division of Pain Management, knows why his pain management program, which last year made about 11,000 visits to children suffering from acute pain, gets consistent high marks in patient satisfaction. “We simply have the most wonderful team of inspired, compassionate pain practitioners, who are creative as well as focused on the kids and their families,” he commented.
    Another reason is that they put safety first . The division collaborates with its hospital safety committee to track the in-hospital use of Naloxone, a medication used to counter the effects of opioid overdose, and its relation to sedation and respiratory depression. As a result, Goldschneider says, the division has improved its physician ordering, pharmacy practice, and nursing policy and practice. “Our policy and treatment paths are based on literature reviews and expert consensus,” he says. “Our staff includes NIH-funded investigators who conduct clinical trials in evidence-based treatment of pediatric chronic pain.”

    Another reason is innovation. The division’s Procedural Management Program (a sedation service) undergoes regular reassessments by families, physicians, and the nursing staff with the goal of improving its current care models. Among other things, the program aims to lower the distress suffered by children with cancer, hematologic diseases and other chronic illnesses by

    focusing on schedule design that maximizes clinic flow and reduces NPO time
    training the oncology clinic nurses in recovery room skills and limiting the number of anesthetists and proceduralists to enhance continuity of care and improve communication and standardize treatment
    serving children undergoing radiation therapy and patients with Epidermolysis Bullosa undergoing whirlpool debridements
    An interdisciplinary approach to care is also seen in its Chronic Pain Clinic, where core staff comprises pain APNs, pain physicians, psychologists, and physical therapists. Patients and families at the clinic receive an initial assessment by the entire team as well as follow-up care which remains integrated via weekly team meetings. The clinic collaborates closely with the orthopedics, GI, Neurology, and PM&R departments, and is integrated with Hemangioma and Vascular Malformation and Epidermoloysis Bullosa clinics, both which are themselves interdisciplinary.

    The division’s accomplishments have captured the attention of others, from other divisions within their own hospital, to other institutions and media outlets. For example, Children's Healthcare of Atlanta, which has recently begun their own pain program, visited the division to observe its structure, philosophy, and operations. Meanwhile, the hospital’s director of palliative care has been working with programs nationwide to glean the best ideas for providing palliative care. Division APNs design many of the the nursing pain education efforts at the Cincinnati Children’s Hospital. Division members also consult on or design hospital policies on pain assessment, treatment, and side-effect management.

    Meanwhile, several Division members have been featured in segments and articles on pediatric pain in USA Today, The Washington Post, ABCNews.com, and local newspapers, radio, and television shows. Members also are editing an upcoming book on practical pediatric pain management, which provides practical recommendations to help primary care physicians better treat and advocate for their young patients.


    These programs represent the many clinical programs throughout the United States that overcome difficult challenges to provide exemplary multidisciplinary pain care to their patients.

    APS also recognizes the following programs as 2007 CCOE Honorable Mentions:

    Beth Israel Medical Center, Department of Pain Medicine and Palliative Care (DPMPC), New York
    UW Health, UW Health Pain Care Services, Madison
    Johns Hopkins Medicine, Adolf Meyer Chronic Pain Treatment Program, Baltimore
    University of California, Davis, Division of Pain Medicine, Sacramento
    University of California, San Diego, Center for Pain Medicine
    The University of Texas M.D. Anderson Cancer Center Pain Medicine, Houston
    Dartmouth-Hitchcock Medical Center, Richard Barrett Pain Management Center, Lebanon, NH
    Oregon Health & Science University, Pediatric Pain Management Center, Portland



    CCOE Gala, Smithsonian Museum of Natural History

    APS believes that a special award deserves a special celebration. To mark this milestone and honor the 2007 award recipients, APS will host a gala at its Annual Scientific Meeting in May. On Thursday, May 3, a gala celebration will take place at the Smithsonian National Museum of Natural History.

    During the evening recipients and hundreds of guests will enjoy a cocktail reception and dinner and countless wonders of the Smithsonian, such as the Hope Diamond. Guests will be served cocktails and hors d’oeuvres in the Gems and Minerals Halls, whose walls are lined with some of the finest jewels in the world. A harpist will play soothing background music, as time for dinner approaches. Guests will then be escorted by a strolling string trio to the Rotunda for dinner.

    The evening’s presentation will include remarks from the APS leadership, an award presentation, and acknowledgement of industry partners who have supported this magnificent program. The evening will commence at 7 pm and conclude at 10:30 pm.

    Please show your support and commitment to multidisciplinary pain care by attending this prestigious event. Tickets can be purchased online for $100 per person. The funds collected are for cost recovery. This is not a fundraising event. Transportation to and from the museum will be provided.


    APS would also like to acknowledge the following companies for their generous support of this program: Endo Pharmaceuticals, Pfizer, Inc., Abbott Laboratories, Cephalon, Inc., King Pharmaceuticals, and Merck & Co., Inc.

  2. #2
    Thanks for posting this!

  3. #3

    Smile

    Around here i cant find a pain mgmt center that accepts the Medical card from the state. Only the rich or well insured are fortunate to get pain relief here i suppose, lol. Thanks for the post.
    “If everybody's thinking alike, somebody isn't thinking.” Gen. Patton

  4. #4
    Thanks for posting this, and good on James A. Haley VA for making the list.

  5. #5

    2009 List

    http://www.ampainsoc.org/awards/ccoe/index.htm
    APS is pleased to announce the following 2009 CCOE Award Recipients:

    •Pain Management Center, M.D. Anderson Cancer Center, Houston, TX
    •Department of Pain Medicine and Palliative Care, Beth Israel Medical Center New York, NY
    •University of Virginia Division of Pain Medicine/University of Virginia Health System, Charlottesville, VA
    •Center for Pain Management, Rehabilitation Institute of Chicago
    •University of California, Los Angeles Pediatric Pain Program, Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA
    To read about the 2009 CCOE programs, click here.

    2009 Honorable Mentions:
    •University of California, Davis Division of Pain Medicine
    •University of California, San Diego, Center for Pain Medicine
    •Minnesota Head and Neck Pain Clinic, University of Minnesota
    •University of Pittsburgh, Interprofessional Program on Pain Research, Education and Health Care
    Special Commendation
    APS is also pleased to confer a special commendation to the following program for their innovative work in pain management for wounded military personnel:

    •Acute & Chronic Pain Management, Walter Reed National Military
    Every day I wake up is a good one

  6. #6
    Thanks, Cheese. I am sticking this. Wise.

    Quote Originally Posted by cheesecake View Post
    http://www.ampainsoc.org/awards/ccoe/index.htm
    APS is pleased to announce the following 2009 CCOE Award Recipients:

    •Pain Management Center, M.D. Anderson Cancer Center, Houston, TX
    •Department of Pain Medicine and Palliative Care, Beth Israel Medical Center New York, NY
    •University of Virginia Division of Pain Medicine/University of Virginia Health System, Charlottesville, VA
    •Center for Pain Management, Rehabilitation Institute of Chicago
    •University of California, Los Angeles Pediatric Pain Program, Mattel Children's Hospital, David Geffen School of Medicine, Los Angeles, CA
    To read about the 2009 CCOE programs, click here.

    2009 Honorable Mentions:
    •University of California, Davis Division of Pain Medicine
    •University of California, San Diego, Center for Pain Medicine
    •Minnesota Head and Neck Pain Clinic, University of Minnesota
    •University of Pittsburgh, Interprofessional Program on Pain Research, Education and Health Care
    Special Commendation
    APS is also pleased to confer a special commendation to the following program for their innovative work in pain management for wounded military personnel:

    •Acute & Chronic Pain Management, Walter Reed National Military

  7. #7
    I wish a good pain center was closer to where I am in Albany, NY. NYC is 3 hrs away and a bit far to travel. Since my injury I've had terrible neurogenic pain...the meds I take for it, effexor and gabapeptin, don't seem to make a big difference. The pain level varies day to day...one day it could be mild and the next it could be severe, like today. I'd really like to get this pain under control because when it's bad it's hard to focus on much else or enjoy the good times.

  8. #8
    I have chronic thoracic and lumbar pain, more thoracic then lumbar.most of my problems are in my my thoracic area.I have annular disruption in t 6-7 t 7-8 t 8-9 t 9-10. radial tear in t 6-7 . t 7-8 7 8-9 t 9-10 diffuse spread. t 10-11 nuclear contaiment. multilevel discogenic syndrome. spinal stenosis of thoracic and lumbar.t 6-7 herniation. disk degeneration at t 6-7 t 11-12 l 4-5. moist disks.cervical,lumbar and thoracic degenerative disk disease.lumbar,thorasic and cervical facet arthropathy.discogenic disease/myofascial syndrome.arthritis. t 6-7 t 7-8 t 8-9 t 9-10 diffuse opacification. t 10-11 central opacification of the nucleus and disk space.loss of disc signal L 4-5 L 5-s1. loss of disc height L-4-5. bulging disc L 4-5 L 5- S1...... and sooo much more....I have no idea how any of this happened.....I live in pittsburgh, please email me at foreverlost32@yahoo.com...please help, i am in so much pain

  9. #9
    Senior Member craig's Avatar
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    Thanks for making the list Wise young.

  10. #10
    Has anyone had success with these centers?

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