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MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Winter | 2014

Decompressing Pain

Susie Young doesn’t know what it feels like to be stabbed. But if she could describe the feeling, she thinks she would come very close. It’s a pain she endured for years — a sharp, piercing pain that started in the back of her neck and traveled to her eye — “like someone was stabbing me with a knife,” she says.

The pain started as tension headaches shortly after her mother died of leukemia in August of 2008. Young thinks the stress of taking care of her sick mother may have triggered the headaches. The tension headaches became more frequent and eventually migrated to her neck. Then the migraines began. Eventually, they increased to four to six migraines a week.

For five years, Young lived with continual neck pain and recurring migraines. “I probably spent over a $1,000 on specialty pillows, but nothing would work,” she says. She tried over-the-counter drugs, a chiropractor, acupuncture, anti-depressants, steroids. You name it, she tried it. But nothing gave her long-term relief. “I didn’t want to go to sleep at night,” she says. “The pain in my neck hurt so bad that I would just toss and turn all night long. By morning, the pain was unbearable.”

Some days were worse than others. But Young continued with life the best she could. If there was one thing that gave Young solace through it all, it was scuba diving. A hobby she and her husband took up more than 10 years ago, Young often counted the days until her next trip. When Young was diving, she could almost forget about her neck pain. It was calm and peaceful and the compression of the water provided a soothing relief from the piercing discomfort in the back of her neck.

“The first time I dove in the ocean, I was hooked and had a new love,” she says. “There is no feeling like floating in water around colorful coral and fish.”

But when Young would emerge from the water, the pain always returned. She knew there had to be help for her somewhere so she never gave up hope. Her family practitioner’s office eventually referred her to The Nebraska Medical Center’s Pain Clinic, where she met with Angie Rakes, MD, pain and headache specialist and director of the Pain Clinic.

“Many people suffer for years with chronic pain because they haven’t received the right treatment or they’ve been led to believe it is not treatable,” says Dr. Rakes. “The field of pain management has advanced greatly in the last 10 years. We have so many new medications and treatment options that no one should have to suffer from disabling chronic pain anymore.”

“We have so many new medications and treatment options that no one should have to suffer from disabling chronic pain anymore.”
Angie Rakes, MD

The Pain Clinic is one of the most comprehensive clinics in the country with a group of highly skilled doctors who bring a wealth of knowledge and experience to treating pain. The pain team uses a comprehensive approach to pain management that attacks pain from many fronts and uses some of the most cutting edge medical and surgical techniques and therapies.

“Treating pain often involves a multimodality approach,” says Dr. Rakes. “We may use medications, epidurals, steroid injections, ablation or spinal cord stimulators to treat the problem. Physical therapy, massage therapy and acupuncture may also be recommended. If it has become chronic, depression, anxiety and sleep deprivation may be issues that need to be treated too.”

The Pain Clinic Team at The Nebraska Medical Center. From left to right: Kim Haynes-Henson, MD;
Madhuri Are, MD; Angie Rakes, MD; Thomas Brooks, MD

In addition to Dr. Rakes, the Pain Clinic team includes pain specialists Thomas Brooks, MD; Madhuri Are, MD; and Kim Haynes-Henson, MD, each of whom is board certified in pain medicine. These doctors are dedicated to treating all types of pain, acute or chronic, cancer pain and pain associated with many types of conditions such as headaches, back pain, fibromyalgia, arthritis, post-strokes or cancer pain.

People with chronic pain often find themselves trapped in a vicious cycle. Pain causes increased stress, which causes muscles to tighten, which produces more pain, leading to more stress, causing more tension, and the cycle continues.

“Chronic pain can become physically disabling, leading to depression, loss of sleep, missed work days and decreased physical functioning,” says Dr. Rakes. “It can change your whole life. These people are so miserable that they will stop going out and some lose their social lives completely and just stay home and lay in bed. We get patients who come from all over the Midwest. We’re often their last resort.”

Dr. Rakes, an assistant professor with the Department of Anesthesiology at the University of Nebraska Medical Center (UNMC), has been with the clinic since 2000. Dr. Rakes completed medical school at Creighton University School of Medicine, a three-year residency in anesthesiology and a fellowship in pain medicine at the University of Nebraska Medical Center (UNMC). She became board certified in headache medicine in 2008.

Susie Young

When Young decided to see Dr. Rakes, she was at the end of her rope. Her neck pain had become unbearable and was extremely sensitive to any sort of stimulation. The migraines were so frequent that between the two and very little rest, she had no energy. “I felt like I was living in a constant fog,” she recalls. She was popping six ibuprofens daily and getting steroid blocks every few months.

“Dr. Rakes did a physical exam and looked at my MRI and she knew immediately,” says Young. “She said I have occipital neuralgia and chronic migraines. She also said that I was rebounding from too much ibuprofen.”

Dr. Rakes took Young off of all over-the-counter medications and experimented with several migraine medications. When none of those produced results, she started her on botulinum toxin therapy (Botox). Botox is becoming a more common and effective treatment for migraines because of its high efficacy and low side effects, says Dr. Rakes. Injections are required every three to four months. Within several weeks of her first injection, Young’s neck pain disappeared for the first time in years. Her migraines went from four to five a week to just one.

“Being pain-free is unbelievable. I didn’t think I would ever get to this point.”
Susie Young

“Being pain-free is unbelievable,” says Young. “I didn’t think I would ever get to this point.”

Young says she is like a different person and is living life with new vigor. “I have all kinds of energy now,” she says. “I can walk, swim laps and sleep now. I am enjoying life again.”

She has a new appreciation for diving too and is more passionate about it than ever. “I can enjoy it more now that the stress of my migraines and neck pain is gone,” she says.

She and her husband recently completed a great white shark diving expedition and have more trips planned in the future. The two are also volunteers with the Yutan Emergency Response Dive Team and clean shark tanks at the Henry Doorly Zoo a couple times a month.

Dr. Rakes says that most headaches and migraines can be treated and managed fairly effectively with the right treatment regimen. Like Young, many people don’t seek medical advice soon enough and tend to overmedicate. Individuals who take over-the-counter medications regularly may experience rebound headaches and, in rare cases, may develop toxicities in the liver and kidneys, says Dr. Rakes. There are also abortive medications that can be taken that can eliminate a migraine if taken at the first sign of its onset.

Treating a patient early is an important factor in providing the most effective pain relief for most any type of pain, notes Dr. Rakes. “The longer you wait to seek treatment, the more difficult it becomes to treat pain. After months or years of chronic pain, the body generates a map to pain that is difficult to break. The pain receptors change and what might have been a problem that could have been treated very easily early on, now becomes much more complicated.”

By the time patients reach the Pain Clinic, many have exhausted numerous therapies with little or no relief. Unfortunately, many of these patients eventually end up on opioids — a narcotic that is effective at providing short-term pain relief, but has not been shown to relieve pain on a long-term basis or to help patients become functional again. It also can be dangerous when abused.

Spinal Cord Stimulator

“The problem with opioids is that they merely mask the pain but do not treat the source of the problem,” says Dr. Brooks. “We see many patients who have been taking them on a long-term basis and have become dependent on them. Opioids have become a serious problem in this country. We are seeing a growing problem with overuse and overdosing of this drug, sometimes resulting in death.”

Dr. Brooks specializes in several surgical procedures that can help relieve pain when medications and other therapies have failed. Dr. Brooks is a graduate of Creighton University School of Medicine and completed his residency in pediatric anesthesiology and pain medicine at St. Louis University Medical Center. He practiced for nine years in Salina, Kan., followed by another nine years in Springfield, Mo., where he also served as director of the pain center. He is leading an initiative to reestablish a pain fellowship program at UNMC.

“We want doctors to think of us before they begin prescribing opioids,” says Dr. Brooks. “We have a variety of procedures that can reduce a person’s pain greatly and eliminate the need for pain medications like opioids. Our goal is to get people’s pain reduced to the point that they can increase their function again, return to the things they love and start enjoying life again.”

A procedure that has become a mainstay of chronic pain management is the implantation of a spinal cord stimulator, a device reserved for the most severe and chronic pain patients. Allison Pagitt is one of those patients. For years, Pagitt had suffered from chronic pain in her knee. Knee replacement surgery only made her pain worse. “It was getting to the point where I could barely move,” recalls Pagitt. “I tried a lot of different things to relieve my pain, but nothing worked.

After seeing Dr. Brooks, Pagitt agreed to undergo surgery to have a spinal cord stimulator device permanently implanted. Within a week after surgery, Pagitt said she was like a different person. “I just can’t believe the relief the device has given me from pain.”

The spinal cord stimulator delivers low-voltage electrical stimulation to the spinal cord or targeted nerves to block sensations of pain from reaching the brain. Unlike high doses of pain-relieving drugs, spinal cord stimulation does not cause sedation, nausea, vomiting, sleep disturbance or dizziness and does not affect cognitive function.

Susie Young

Radiofrequency ablation is another procedure performed by Dr. Brooks that uses an electrical current to heat and destroy nerve tissues to interrupt pain signals to the brain. It is most commonly used for patients with chronic low neck and back pain and arthritic joint pain. “It can provide relief for several months to a couple of years,” he says.

For patients with painful compression fractures, Dr. Brooks performs a procedure called kyphoplasty that can restore bone height in the vertebra and reverse deformity of the spine.

Providing pain relief to patients through minimally invasive and invasive procedures is an area of specialization provided by Dr. Are. An associate professor in the Department of Anesthesiology at UNMC, Dr. Are joined the staff in 2008.

She attended medical school at St. George’s University School of Medicine in the West Indies, completed an internship at Medical College of Pennsylvania and Hahnemann University in Philadelphia, Penn., and a residency at Baylor College of Medicine in Houston, Texas. She completed a fellowship in pain management at MD Anderson Cancer Center. She is board certified in physical medicine and rehabilitation and in pain medicine. She practiced pain medicine for six years at MD Anderson before coming to The Nebraska Medical Center. Dr. Are says she was attracted to The Nebraska Medical Center because of the depth of its pain program.

“I have all kinds of energy now. I can walk, swim laps and sleep. I am enjoying life again.”
Susie Young

“There’s not a single pain patient that one of us doesn’t have the expertise to treat and manage,” says Dr. Are. “We offer everything from minimally invasive to more invasive procedures. You could call us a one-stop shop for pain. When patients come here, they will have access to every aspect of pain management available and they will receive it in a timely and compassionate manner.”

Dr. Are specializes in several procedures that can provide longer-lasting pain control to cancer patients as well as noncancer patients such as intrathecal pain pumps and kyphoplasty. An intrathecal pump injects chemicals directly into the spinal canal from a surgically implanted pump. She also performs nerve blocks, an injection of local anesthesia that is injected near a peripheral nerve to help diagnose and treat painful areas of the extremities; trigger point injections, a diluted and long-lasting dose of anesthesia that is injected to relieve muscle pain or spasms; or radiofrequency ablation that burns and destroys the nerves.

“These procedures will prevent them from having to take high doses of narcotics or opioids,” says Dr. Are. “In some cases, it may allow a cancer patient to continue treatment who otherwise may have given up due to pain or side effects. Or it may provide a higher quality of life to a cancer patient during his or her last weeks or months of life.”

Pain is a very subjective thing, but it is very real,” says Dr. Rakes. “It is also multifaceted and can affect every aspect of a person’s life. We understand that. Eliminating a person’s pain can change so many other parts of that person’s life.”

Young can vouch for that. “The problem with pain is that you can’t see it,” she says. “And that makes it difficult for others to understand. Life is so much more enjoyable when you are not in constant pain.”

A migraine sufferer herself, Dr. Rakes has a personal understanding of the challenges these patients and others who suffer pain experience. “If I can help someone whose life has been changed due to debilitating pain — that’s huge,” she says. “That’s what it’s all about.”

Previous article in the Winter | 2014 issue of One Thousand And One:
A Tribute to Glenn A. Fosdick