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Welcome to the December issue of Arizona Pain Monthly magazine. We hope you are able to enjoy the excitement and joy of the holiday season with your families and friends. Each December, we partner with area physicians and community members to host an annual Christmas party for refugees primarily from the country of Burma (Myanmar). If you are interested in helping, we gratefully accept your donations of toys for boys and girls up to age 14 at all three Arizona Pain Specialists locations. Please see the article on page 8 for more information regarding the party. Arizona Pain Specialists fosters an ongoing dedication to local and foreign missions alike. We take this very seriously, and continue to donate time and money to help support these important causes. As we are approaching the new year, many people are thinking of what resolutions they’d like to

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make and the changes they want to see in themselves. As a pain management clinic, we’d like to encourage you to make resolutions toward more pain-free days. There are many small changes you can make that will impact your pain levels and help you have more good days. Most people resolve to exercise to lose weight in the new year, and while losing weight can help with chronic pain, an exercise program may help chronic pain patients immensely. If you suffer from chronic conditions like arthritis or fibromyalgia, a consistent exercise program can help you regain flexibility, range of motion, and can help you have more “good” days with fewer pain flare-ups. The exercise routine should be fairly low-impact and can include walking or water aerobics. Another tool that you can use to help yourself and your doctor is to begin a pain journal. By recording your daily pain level and what activities or outside factors have made your pain worse, you

and your physician will be able to see patterns and may be able to devise a plan or solution to help you with daily pain. By studying the pattern of your pain, you will be able to identify and hopefully avoid the major triggers that cause you severe pain. We hope that this issue is educational and informative. We thank you for your continued loyalty if you are a long-standing patient, and we welcome you to the Arizona Pain Specialists family if you are a new patient. Until next time, remember at Arizona Pain Specialists, we believe you can be pain free. On behalf of the entire staff at Arizona Pain Specialists, we hope that you enjoy a joyful holiday season with your families and friends. Dr. Tory McJunkin & Dr. Paul Lynch Please contact us at Newsletter@ if you have questions or comments.

Arizona Pain Monthly | December 2010

Roasted Cauliflower

Butternut Squash Soup

• 1 large head cauliflower, washed and cut into small florets • 2 tablespoons olive oil • 1 teaspoon oregano • 2 tablespoons balsamic vinegar • 1/3 cup freshly grated Parmesean cheese • Salt and pepper to taste

• 1 butternut squash, peeled, seeded, and cut into 1 inch pieces • 2 tablespoons butter • 1 yellow onion, diced • 6 cups low sodium chicken stock • Nutmeg to taste • Salt and pepper to taste

Preheat oven to 450°F Place cauliflower florets in a large bowl, season with oregano, salt and pepper. Drizzle olive oil on top, and toss to coat. Pour cauliflower into a baking dish, cover with foil and roast 25 minutes. Drizzle balsamic vinegar on top of cauliflower, carefully stir in baking pan. Sprinkle the Parmesean cheese on top, and return to oven, uncovered, until the cheese is melted and cauliflower are fork tender, approximately 10 to 15 minutes. Did you know? Cauliflower comes in purple, green, and orange in addition to the traditional white color!

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Apple Pumpkin Muffins

• 1 1/2 cup whole-wheat flour • 1 cup all purpose flour • 1 tablespoon pumpkin pie spice • 1 1/4 teaspoons baking powder • 2 cups sugar • 1 cup canned 100% pure pumpkin • 1/2 cup vegetable oil Over medium heat, melt the butter in • 2 eggs a large, non-stick stock pot. Add the • 1 cup chopped, peeled and cored onion and cook until soft and transapples lucent. Add the squash and then pour in chicken stock, bring to a sim- Preheat oven to 350°F. mer. Cook until squash is fork tender, approximately 20 minutes. Remove Place muffin liners into 18 muffin the squash pieces (a slotted spoon cups. Sift together the whole-wheat works best), leaving the liquid in flour, all purpose flour, pumpkin the stock pot. Carefully place squash pie spice and baking powder into a pieces in a blender and puree until bowl. In a separate bowl, mix sugar, smooth (this may need to be done in pumpkin, oil and eggs until comsmall batches depending on space). bined. Add sifted dry ingredients Return the blended squash to the and apple pieces, stir to combine. stock pot, mix to re-combine. Add Spoon equal amounts of batter into salt, pepper, and nutmeg to taste. each muffin cup. Bake until muffins are a golden brown color and (Note: You can microwave the squash toothpicks inserted into the center to soften it and make peeling and cut- come out clean, approximately 30 ting much easier. Just pierce the skin a minutes. Place muffins on cooling few times and microwave a minute or rack, and, once cool, frost or decotwo at a time until a little soft to the rate if desired. touch).

Arizona Pain Monthly | December 2010

Expert Guest Dr. Sherif Nasef Fibromyalgia is a common chronic widespread pain condition. Patients often describe their pain as aching, exhausting, nagging or hurting. Most patients suffer from sleep disturbance, fatigue, cognitive difficulties (fibrofog) and morning stiffness. Multiple comorbidities have been reported with fibromyalgia including tension/migraine headaches, irritable bowel syndrome, temporomandibular disorder, interstitial cystitis, chronic pelvic pain and depression. Fibromyalgia affects 2-4 % of the US population, however, only half of those are diagnosed. It is about seven times more common in women and the typical age of onset is between 20 and 55 years. Fibromyalgia appears to be caused, at least partially, by genetic factors, as several genetic mutations were able to be associated with fibromyalgia. First degree relatives of fibromyalgia patients were more than eight times more likely to develop fibromyalgia than non relatives. Environmental factors have also been seen to play a role in fibromyalgia development. Fibromyalgia patients tend to report more stressful negative lifetime events than healthy controls and, in recent months, fibromyalgia has had a significant impact on the health care system. In one study, the annual health care costs for fibromyalgia patients were three times higher than patients with other diseases. Although the underlying cause of fibromyalgia has not been established, recent data suggests that alteration of pain processing by the central nervous system may contribute to the chronic wide spread pain. Fibromyalgia is the prototype of a unique type of pain referred to as central sensitization syndrome. According to the American College of Rheumatology, fibromyalgia can be diagnosed when a patient with at least three months of widespread pain shows 11 or more of the classic 18 “tender points� during a physical exam. Because many fibromyalgia patients have fewer than eleven tender points, a new Page 4

validated questionnaire has been developed to replace these criteria.

Although there is no commercially available lab tests or imaging studies to confirm the diagnosis of fibromyalgia, several research methods have been used successfully. In research studies, the concentration of chemicals substance P and glutamate were higher in the fluid that surrounds the brain in fibromyalgia patients than in controls. A much less invasive way to test this theory is a special type of MRI called functional MRI, which showed wider areas of the brain activated by non painful stimuli in fibromyalgia patients compared to controls. Treatment of fibromyalgia includes non pharmacologic therapies as well as medications. Moderately intense aerobic exercise has shown to improve pain but gradual exercise progression is advised to avoid exacerbation of symptoms. Intensive patient education also improves pain, sleep, fatigue, and quality of life. There has been some evidence of improvement in pain, fatigue, mood, and physical function with cognitive behavioral therapy. Other modalities include acupuncture, biofeedback, water therapy, and strength training.

gabapentin (Neurontin) was effective in reducing fibromyalgia pain in a small study. Pregablin (Lyrica) is another anti-convulsant that emerged as the first FDA approved medication for fibromyalgia after it showed statistically significant improvement in pain when used by itself for fibromyalgia in a placebo controlled trial. Dizziness and somnolence happened in 38% and 20% of the study patients taking the medication respectively. Duloxetine (Cymbalta) was FDA approved for fibromyalgia several years later to provide another option through a different mechanism of action. Being an anti-depressant, it addressed a common problem seen in fibromylagia patients. Nausea was reported in 29% of the patients taking that medication in the clinical trials. Milnacipran (Savella) which belongs to the same category of medications as Duloxetine was the last FDA approved medication for fibromyalgia after showing significant improvement in a 3-measure composite response in a 3 month trial. In addition to nausea, new onset hypertension was another common adverse event. Monitoring of blood pressure is recommended while taking this medication.

Even though only three medications are FDA approved for fibromyalgia at this time, we are much The earliest clinical trial for more advanced in our understandmedications to treat fibromyalgia ing and treatment of the disease in 1986 looked into amitriptyline than we were ten years ago. New (Elavil), which is a widely used medications are constantly being tricyclic antidepressant. Amitriptested as treatments for fibrotyline was the recommended first myalgia. Patients and physicians line treatment at that time. The continue to be hopeful that the results of multiple trials on that future might bring a cure for such a medication and similar medications disabling and widespread disease. were mixed in terms of achieving significant improvement of fibroSherif Nasef, myalgia symptoms. Trials on opioid M.D. practices analgesics - including IV Morphine rheumatol- failed to show significant improveogy at Valley ment with the exception of TramaArthritis Care dol (Ultram), which is an opioid with locations medication that increases serotonin in Peoria, Phoeand norepinephrine levels in the nix, and Sun brain. Tramadol has been used for City West. Apthe treatment of fibromyalgia when pointments can there was no FDA approved medibe made by calling 623-815-2690. cations for it. The anticonvulsant Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

Q: Why is my Pain Physician an Anesthesiologist? This is a great question, and is one that I am even asked by other physicians! Many people believe anesthesiologist just “put people to sleep” for surgery, but being an anesthesiologist has a much broader spectrum of responsibilities. Anesthesiology is a unique specialty in medicine that involves caring for patients of all ages in the preoperative, intra-operative and postoperative periods (or said another way: before, during and after surgery). This includes examining and assessing patients before their surgeries to make sure that all of their medical conditions (everything from diabetes to high blood pressure to chronic pain) are in the best state possible for surgery. Then we care for patients during their surgeries and ensure that they are free of pain and safe by managing all of their medical conditions and as well treating anything that arises during surgery (which in and of itself is quite a broad list!). Once surgery is done, the Anesthesiologist’s job is not over, as we then manage our patients throughout their recovery in the Post Anesthesia Care Unit (or PACU for short). A vital part of this postoperative care is of course treating any pain that the patient may have after surgery. When possible, we even work to prevent pain from occurring in the first place by performing nerve blocks, epidurals, spinal blocks, pain catheters and/or other procedures before or during the operation. In addition to the operating room, if you have ever had a baby, you most likely came into contact with an anesthesiologist as well because we play a big role in treating the pain of labor through our placement and management of epidural catheters and nerve blocks. You will also come across Anesthesiologists in Intensive Care Units (ICU’s) as Critical Care specialists taking care of the most seriously ill patients (of course this also includes making sure that their pain is well controlled). So as you can see, treating pain is an essential and large part of what every anesthesiologist does every day! As leaders in the treatment of pain in perioperative medicine, it was only natural that anesthesiologists were

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among the first Pain Medicine specialists in the outpatient area as well. All of this knowledge and expertise in the treatment of pain surrounding surgery was further developed and applied to the treatment of those with chronic pain conditions. In fact the American Board of Anesthesiology was the first to offer subspecialty Board Certification in Pain Medicine (in 1993). Lately there has been a trend of other types of physicians (such as physiatrists or rehab physicians) seeking training in Pain Medicine as well, though the vast majority of Board Certified Pain Medicine doctors are still anesthesiologists. In order to be eligible for Board Certification in Pain Medicine, a Physician must first complete four years of medical school, complete four years of an anesthesiology residency and then an additional year of specialized training in Pain Medicine (called a Pain Fellowship). Once done with residency and fellowship, Pain Medicine specialists must complete an extensive set of examinations (including several written and oral exams) to become Board Certified in Anesthesiology and as well in Pain Medicine. I know that these terms can become confusing, but it is essential to seek the care of Pain Medicine Doctor who has completed an accredited Fellowship in Pain Medicine and is Board Eligible or Board Certified in Pain Medicine. The good news is that here at Arizona Pain Specialists, all of our Pain Doctors are Board Certified anesthesiologists who have completed accredited Fellowships in Pain Medicine at the top programs in the country (Harvard, MD Anderson, Cleveland Clinic, and Texas Tech), so you are in great hands… -William Thompson, M.D. Q: My prescriptions are starting to cost more and more. Is it safe to buy my medications online? Since you can buy practically anything online, and often for cheaper than in a brick-and-mortar store, it may seem like prescriptions would be a great item to purchase online. Additionally, many of us receive emails daily announcing that you can buy cheap prescriptions from their online pharmacy. With all of that adver-

tising paired with the fact that many people are having a hard time affording their prescriptions, it seems like there can be no harm in purchasing your prescription medications online. However, it is important to be extremely careful, as there are some online pharmacies that can be very dangerous. Some illegal online pharmacies may dispense medications that may have incorrect or dangerous ingredients, may be too strong or too weak, may have expired, and may not have been FDA approved. There have been cases of unmarked higher dosages causing fatalities, as people are unintentionally taking two or more times their regular prescribed dose of medication. Even with the warnings against ordering your prescriptions from online pharmacies, there are legitimately safe online pharmacies and they can be extremely convenient and can save you money. Safe pharmacies often have recognizable names and are from the United States. There may be safe and legitimate pharmacies in other countries, but they often do not have to comply with the same FDA and safety standards that pharmacies in the United States must adhere to. There is an online verification website where you can check the legitimacy of an online pharmacy. Hosted by the National Association of Boards of Pharmacy, this website will allow you to find out if the online pharmacy you wish to order from is in the national database, alerting you to the potential danger of a pharmacy that is not verified. According to the verification website, they have reviewed close to 7,000 online pharmacy websites – and only 280 or about 4% were verified as practicing safe dispensing practices and adhering to pharmacy laws and standards of care. With statistics like that, it is extremely important to make sure that the pharmacy you are ordering your medications from is safe. The National Association of Board of Pharmacy website for verifying online pharmacies is: Copy and paste the URL of the online pharmacy into the text box at the bottom of the webpage. -Paul Lynch, M.D.

Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

Arizona Pain Foundation Update

Each year, Dr. Lynch and Dr. McJunkin team up with other physicians and community members to host a Christmas party for refugee families primarily from the country of Burma (Myanmar). These families have fled their homeland due to military oppression and fear for their lives. Now in Arizona, Burmese families are working hard to make a living and a home for themselves and their families. This year marks the 3rd annual party that the Arizona Pain Foundation has hosted. Aided by donations from you, the foundation will be able to once again host a gathering that will include gifts for the children, a hot meal for the families, and supplies they so desperately need. As the situation in Burma (Myanmar) has grown even more dire, we have seen an increase in party participants, from approximately 50 the first year to nearly 400 last year! Because times are difficult, we expect that we will see an increase again this year, and it is for this reason that we are asking for your help.

For those that would like to donate, there will be donation boxes set up in the lobbies of all three Arizona Pain Specialists locations. Donations should include toys for boys and girls up to age 14 and toiletry items. We thank you for your donations!

The Arizona Pain Foundation is a nonprofit organization founded by Drs. McJunkin and Lynch. The Foundation’s mission is to bring compassion, healing and resources to those in need. Drs. Lynch and McJunkin have dedicated themselves to both local and foreign missions, and began the Foundation with their first paycheck in 2007. They continue to donate 5% of all profits to finance medical mission work, charitable causes and pain research.

Photos taken at the 2nd Annual Burmese Christmas Party, 12/13/2009.

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Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

Welcome, Dr. Thompson! Dr. William Thompson, the newest member of the Arizona Pain Specialists team, comes to us from the highly acclaimed Harvard Medical School where he recently completed his fellowship in pain management.

Dr. Thompson is a skilled physician who is compassionate and has been dedicated to becoming a physician his entire life. “I’ve pretty much been ready to be a doctor since I was born,” Dr. Thompson says. “My father is a physician, my mother is a nurse. I considered law briefly, but knew I could make much more of a difference in the world by practicing medicine.”

every day with a multitude of patients, which allowed him to see patients with a variety of medical histories, conditions and different sources of pain. One patient, however, stands out starkly in his mind and had a profound effect on him as a physician. “One patient in particular had a very aggressive form of cancer, had been in the hospital for weeks, and we managed to get her out of the hospital to spend time with her newborn – she had recently had a baby. She was so

Dr. Thompson is an avid traveler and says that he is excited to be in Arizona for the perfect weather and to be able to travel to winter climates, rather than living in them. He is especially excited, however, to be at Arizona Pain Specialists, and working with chronic pain patients in an office setting. “I am honored to be part of such of a dynamic group of physicians and specialists and think it’s really beneficial to have multi-disciplinary care under one roof and under one group. I think that the personalities, talents and skills that we all contribute as a group is an excellent thing that we can offer patients.”

When it came to deciding what type of medicine he would specialize in, Dr. Thompson knew early on that he wanted to be a pain management physician, as he was most interested in helping his patients as much as possible. “It was the best avenue in anesthesiology to make a profound difference in the lives of my patients,” Dr. Thompson explains. “Pain is an often misunderstood and undertreated condition, and I wanted to be an expert in bringing relief to those who couldn’t get it elsewhere.” At Harvard Medical School, Dr. Thompson worked closely with some of the best physicians in the country, and was able to learn the most advanced methods in treating pain. By receiving education and training through a premier pain fellowship such as Harvard, Dr. Thompson will be able to bring this expertise to his patients at Arizona Pain Specialists, and says “Having the opportunity to train at Harvard and work with some absolutely fantastic teaching physicians, I think that I bring a little bit of their concept to pain medicine that I can integrate into the group to help each individual patient.” He continues, “The advantage of Arizona Pain Specialists is that we have excellent physicians from a number of different training programs, and as pain is a developing process, it’s very important to see what is going on in other parts of the country.” At Harvard, Dr. Thompson worked Page 11

only made it possible for her to go home to her newborn, but also made her eligible for a clinical drug study that her pain had made her ineligible for. Through that study and with our pain control, she had an outstanding response to treatment. The last I heard, she was still on almost no pain medication, and she was still at home, enjoying time with her baby and living a relatively pain free life. It was one of the most profound differences I’ve ever seen. It was a phenomenal experience; I will never, ever forget her.”

debilitated by pain from her cancer that she was unable to leave the hospital. This patient was in so much pain that she spent every day at the hospital curled in the fetal position, living a miserable and painful life. She was unable to really do anything, even unable to carry on a conversation. This case was particularly difficult because she had gotten pregnant while having cancer, and had given birth to her child recently. She had a devastating form of cancer and was unable to function – she was delirious with pain, and was unable to interact and be with her newborn.” Dr. Thompson continues, “We did an interventional procedure that not

Dr. Thompson understands the impact pain has on the lives of his patients, and has their best interests in mind. He makes it his specific goal to help them regain their lives and functionality, and, like in the case of the cancer patient from Harvard, tries above all to help his patients get back to their families. Dr. Thompson wants his patients to always hold on to the hope that things can, and will, get better. “There is hope, even though it will often seem like there isn’t, particularly in the throes of pain,” he explains. “With some time, a positive difference can be made in everyone’s life. You may not be 100% pain free after one visit, but with time, your life can change substantially. It’s important to seek out a board certified, fellowship trained pain physician who is dedicated to multi-disciplinary care, because that is the best way to make a difference in your life when you have pain.” Arizona Pain Monthly | December 2010

Backaches are a pretty common life occurrence. Things like sitting or standing improperly or just over-using the muscles can cause episodes of pain. Back pain can also come from physical injuries due to falling or bending the wrong way. Some sources of pain are unavoidable, while others we bring upon ourselves. If you have nagging back pain, and can’t figure out what caused it, you may want to consider your attire and accessories. Many women, myself included, love wearing high-heeled shoes. Not only are they stylish but they can also complete an outfit. Women everywhere are wearing high heels. Super models and businesswomen alike are constantly photographed wearing heels. It’s an image that we have learned since childhood. They can be cute but they can also damage your back and cause pain. High heels alter the balanced position of a person’s body. When a woman wears high heels, a new dynamic equilibrium occurs. Heels force your body weight to be thrown forward, and the muscles in your back must work overtime to counteract this. Essentially, wearing high heels for any length of time increases the normal forward curve of the back and causes the pelvis to tip forward. This causes abnormal mechanics of the pelvis and spine to maintain the center of gravity. Women who wear heels on a daily basis can suffer not only from back pain but also from bunions, misshapen muscles, curvature of the spine, painful knee and hip issues and osteoarthritis.  That sounds cute doesn’t it?  Let’s not forget fallen arches and unsightly calluses.

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As you wear heels through the day, your body weight is pressed down on your toes rather than the entire foot. Heels also make your legs, feet, and hips work in opposition to the way they were designed to work. This uneven pressure on your feet adds stress to your bones, muscles and tendons. Add the average 10,000 steps a day that most people take to that, and it may start to make sense why your feet and back are hurting. To help your feet, limit the time you wear your heels. If you feel you can’t go to work without them, there are things you can do to help your feet. Take a pair of slippers or flat shoes with you to work and while you are sitting at your desk, you can slip them off and put on the more comfortable footwear to give your feet a break. You can also wear sneakers to and from work and change into your heels when you arrive at work. If you need to wear heels during the day, make sure to stretch your legs throughout the day. Choose a lower and wider heel when shopping for shoes. Though a wider heel won’t lessen foot pain or the effects of wearing heels, they will give you a wider base support. This will help with significantly decreasing the chances of suffering from a twisted ankle. A lower heel will also put less strain on your whole body and can be just as nice looking as the higher versions. Get the best shoe fit possible, and take note that it is best to shop in the late afternoon, since your feet expand during the day. If you buy your shoes when your feet are at their largest size, you will guarantee a much more comfortable fit. Additionally, wearing a tight shoe adds even more stress to your muscles and bones. Avoid shoes

that come to a point at the toe. When you wear these shoes, your toes are pushed into an unnatural position that can damage joints in the toes over time. Another unhealthy fashion statement is the use of heavy purses, backpacks and handbags. Women and men alike tend to carry too many items in one bag or briefcase, and are often not aware of the potential health risks associated with toting an excessive amount of “stuff.” Improper balance can be caused by carrying a bag that weighs more than 10 percent of one’s body weight. When a bag is perched on a single shoulder, it will interfere with the natural movement of the body. This is due to the fact that body will subconsciously hike the other shoulder higher to counteract the weight. The combination of the extra weight and the hiking of the shoulder will cause the spine to curve. Many men and some women carry their credit cards, ATM cards and personal identification in the back pocket of their pants. This might be a convenient way to carry your items, but carrying your wallet in the back pocket of your pants can cause discomfort. It is suggested that men and women both remove their wallets or other items before sitting for long periods of time. Sitting on your wallet can cause a mechanical imbalance in the pelvis and low back, which can result in joint and muscle pain. In today’s society, it is important for you to look your best, but it is more important to choose clothes and accessories that are comfortable and don’t cause pain. By following these simple suggestions, it is possible to look and feel your best. Tiffany Moat, D.C.

Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

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Arizona Pain Monthly | December 2010

Dr. Tristan Pico has recently joined the Arizona Pain Specialists family, but already fits in very well. He has been seeing patients at the Chandler location, and patients have had great things to say about him! See what you have in common with Dr. Pico!

Meet Dr. Pico, Chandler of fice

Favorite activities: Coaching soccer, Cub Scout Leader, and mountain biking. Favorite TV shows: Scrubs and The Office. Favorite sports team: Alabama Crimson Tide. Favorite food: In-N-Out Double-Double. Favorite movie: High Noon. Favorite location in the world: Anywhere in the Rocky Mountains. Favorite location in Arizona: Lake Powell. Favorite bands: Beatles, Cardigans, and Switchfoot. Favorite book: The Great Gatsby. Famous person you would like to meet, dead or alive, and why? Ghengis Kahn, that guy was unstoppable. Unknown talent: I can play the vuvuzela. What celebrity do people say you look like: Christopher Reeves. As a child, what did you want to be when you grew up? I wanted to be a lawyer, like my dad. Where are you from originally: Glendora, California.  

Employee of the Month at APS Colton works in the Surgery Center of the Scottsdale Arizona Pain Specialists location, and has been with Arizona Pain Specialists for about two months. Colton originally started at Arizona Pain Specialists because a family friend let him know of the job opening, but he has found that he enjoys his job, especially the patients and his coworkers. Colton is a Patient Care Technician, which means that he assists patients after their procedure. He helps the nurses and other Surgery Center staff with paperwork and postprocedure tasks, and then helps each patient to their car, taking care that they are able to get to their vehicle comfortably and safely. Colton wants patients to know that we understand that the busy clinic setting can be overwhelming, but that we care about each patient as an individual and we are here to help you on your way to a pain-free lifestyle!

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Arizona Pain Monthly | December 2010

Arizona Pain Monthly December  

Arizona Pain Monthly December

Arizona Pain Monthly December  

Arizona Pain Monthly December