I'm a pediatrician and an anesthesiologist, so I put children to sleep for a living. (Laughter) And I'm an academic, so I put audiences to sleep for free. (Laughter) But what I actually mostly do is I manage the pain management service at the Packard Children's Hospital up at Stanford in Palo Alto. And it's from the experience from about 20 or 25 years of doing that that I want to bring to you the message this morning, that pain is a disease.
Pedijatar sam i anesteziolog, dakle, zarađujem za život stavljajući djecu na spavanje. (Smijeh) Ja sam i akademik, dakle publiku uspavljujem besplatno. (Smijeh) No ono čime se najviše bavim je da vodim odjel za upravljanje bolom u Packard dječjoj bolnici kod Stanforda u Palo Altu. Iz iskustva dugog 20 ili 25 godina, koliko se već time bavim, ovog vam jutra želim prenijeti poruku da je bol zapravo bolest.
Now most of the time, you think of pain as a symptom of a disease, and that's true most of the time. It's the symptom of a tumor or an infection or an inflammation or an operation. But about 10 percent of the time, after the patient has recovered from one of those events, pain persists. It persists for months and oftentimes for years, and when that happens, it is its own disease. And before I tell you about how it is that we think that happens and what we can do about it, I want to show you how it feels for my patients. So imagine, if you will, that I'm stroking your arm with this feather, as I'm stroking my arm right now. Now, I want you to imagine that I'm stroking it with this. Please keep your seat. (Laughter) A very different feeling. Now what does it have to do with chronic pain? Imagine, if you will, these two ideas together. Imagine what your life would be like if I were to stroke it with this feather, but your brain was telling you that this is what you are feeling -- and that is the experience of my patients with chronic pain. In fact, imagine something even worse. Imagine I were to stroke your child's arm with this feather, and their brain [was] telling them that they were feeling this hot torch.
Sada većinu vremena mislite o bolu kao simptomu bolesti. To je uglavnom točno. Ona je simptom tumora ili infekcije, ili upale, ili operacije. No oko 10 posto vremena nakon što se pacijent oporavio od nekog od navedenih događaja bol ne popušta. Ustraje mjesecima a vrlo često i godinama. A kad se to dogodi, ono postaje bolest sama za sebe. I prije nego što vam kažem kako mislimo da se to događa i što možemo u vezi toga učiniti želim vam pokazati kako se osjećaju moji pacijenti. Zamislite, ako želite da vam milujem ruku ovim perom kao što to upravo činim Sada želim da zamislite da je milujem ovim. Molim vas ostanite na mjestu. (Smijeh) Prilično drugačiji osjećaj. No kakve to veze ima s kronično boli? Zamislite, ako želite, ove dvije ideje zajedno. Zamislite kakav bi vam život bio da vas milujem ovim perom, ali vaš vam mozak govori da je ovo ono što osjećate -- i upravo je to ono što osjećaju moji pacijenti. Zamislite zapravo štogod još gore. Zamislite da milujem dječju ruku ovim perom. a njihov mozak im govori da osjećaju ovu vruću baklju.
That was the experience of my patient, Chandler, whom you see in the photograph. As you can see, she's a beautiful, young woman. She was 16 years old last year when I met her, and she aspired to be a professional dancer. And during the course of one of her dance rehearsals, she fell on her outstretched arm and sprained her wrist. Now you would probably imagine, as she did, that a wrist sprain is a trivial event in a person's life. Wrap it in an ACE bandage, take some ibuprofen for a week or two, and that's the end of the story. But in Chandler's case, that was the beginning of the story. This is what her arm looked like when she came to my clinic about three months after her sprain. You can see that the arm is discolored, purplish in color. It was cadaverically cold to the touch. The muscles were frozen, paralyzed -- dystonic is how we refer to that. The pain had spread from her wrist to her hands, to her fingertips, from her wrist up to her elbow, almost all the way to her shoulder.
Takvo je bilo iskustvo moje pacijentice, Chandler, koju vidite na fotografiji. I kao što možete vidjeti ona je lijepa, mlada žena. Imala je 16 godina prošle godine kad sam je upoznao, željela je postati profesionalna plesačica. I tijekom jedne od plesnih proba pala je na ispruženu ruku i uganula zglob. Vjerojatno biste pomislili, kao što je i ona, da je uganuće zgloba trivijalan događaj u životu svake osobe. Učvrstite zglob elastičnim zavojem uzimajte ibuprofen tjedan ili dva i to je kraj priče. No u Chandlerinom slučaju bio je to tek početak priče. Ovako je izgledala njena ruka kad je došla u moju kliniku tri mjeseca nakon uganuća. Možete vidjeti da je ruka obezbojena, purpurne boje. Bila je mrtvački hladna na dodir. Mišići su bili smrznuti, paralizirani -- distonija je kako to nazivamo. Bol se proširio sa zgloba na ruku do prstiju, od zgloba do lakta gotovo sve do ramena.
But the worst part was, not the spontaneous pain that was there 24 hours a day. The worst part was that she had allodynia, the medical term for the phenomenon that I just illustrated with the feather and with the torch. The lightest touch of her arm -- the touch of a hand, the touch even of a sleeve, of a garment, as she put it on -- caused excruciating, burning pain.
Ali najgori dio nije bio spontana bol koji je trajala 24 sata na dan. Najgori dio bio je da je imala alodiniju, medicinski termin za fenomen koji sam upravo ilustrirao s perom i s bakljom. Najlakši dodir na njenoj ruci -- dodir ruke, čak dodir rukava, odjeće, koju je nosila -- uzrokovao je iznimno jake, goruće bolove.
How can the nervous system get this so wrong? How can the nervous system misinterpret an innocent sensation like the touch of a hand and turn it into the malevolent sensation of the touch of the flame? Well you probably imagine that the nervous system in the body is hardwired like your house. In your house, wires run in the wall, from the light switch to a junction box in the ceiling and from the junction box to the light bulb. And when you turn the switch on, the light goes on. And when you turn the switch off, the light goes off. So people imagine the nervous system is just like that. If you hit your thumb with a hammer, these wires in your arm -- that, of course, we call nerves -- transmit the information into the junction box in the spinal cord where new wires, new nerves, take the information up to the brain where you become consciously aware that your thumb is now hurt.
Kako može živčani sustav tako pogriješiti? Kako živčani sustav može pogrešno interpretirati nevini osjećaj kao što je to dodir ruke i pretvoriti ga u zlonamjeran osjećaj dodira baklje. Pa vjerojatno zamišljate da je živčani sustav u tijelu umrežen kao što je to vaša kuća. U vašoj kući žice idu u zid, od prekidača do razvodne kutije u stropu i od razvodne kutije do žarulje. I kad pritisnete prekidač, upali se svjetlo. I kad ga opet pritisnete, svjetlo se gasi. Ljudi zamišljaju da je i živčani sustav upravo takav. Ako se udarite čekićem po palcu, te žice u vašoj ruci -- koje, naravno, zovemo živci -- prenose informaciju do razvodne kutije gdje nove žice, novi živci, prenose informaciju do mozga gdje postajete svjesni da je palac ozlijeđen.
But the situation, of course, in the human body is far more complicated than that. Instead of it being the case that that junction box in the spinal cord is just simple where one nerve connects with the next nerve by releasing these little brown packets of chemical information called neurotransmitters in a linear one-on-one fashion, in fact, what happens is the neurotransmitters spill out in three dimensions -- laterally, vertically, up and down in the spinal cord -- and they start interacting with other adjacent cells. These cells, called glial cells, were once thought to be unimportant structural elements of the spinal cord that did nothing more than hold all the important things together, like the nerves. But it turns out the glial cells have a vital role in the modulation, amplification and, in the case of pain, the distortion of sensory experiences. These glial cells become activated. Their DNA starts to synthesize new proteins, which spill out and interact with adjacent nerves, and they start releasing their neurotransmitters, and those neurotransmitters spill out and activate adjacent glial cells, and so on and so forth, until what we have is a positive feedback loop.
No situacija, naravno, u ljudskom tijelu je mnogo kompliciranija od toga. Umjesto toga da je razvodna kutija u leđnoj moždini samo jednostavno mjesto gdje se jedan živac povezuje s drugim oslobađanjem malih smeđih paketa kemijskih informacija zvanih neurotransmiteri na linearan jedan na jedan način, ono što se zapravo događa je da se neurotransmiteri prospu u tri dimenzije -- bočno, okomito, gore i dolje u leđnoj moždini -- i počnu međudjelovati s drugim susjednim stanicama. Te stanice, zvane glijalne stanice, nekoć su se smatrale nevažnim strukturnim elementima leđne moždine koji ne rade ništa drugo nego drže važne stvari zajedno, kao što su živci. No ispada da glijalne stanice imaju vitalnu ulogu u modulaciji, pojačavanju i, u slučaju bola, iskrivljenju osjetilnih iskustava. Te se glijalne stanice aktiviraju. Njihov DNA počinje sintetizirati nove proteine, koji se prospu i reagiraju s susjednim živcima. I oni počinju oslobađati njihove neurotransmitere. I ti neurotransmiteri se prospu i aktiviraju susjedne glijalne stanice, i tako dalje, i dalje, sve dok ne nastane pozitivnu povratnu petlju.
It's almost as if somebody came into your home and rewired your walls so that the next time you turned on the light switch, the toilet flushed three doors down, or your dishwasher went on, or your computer monitor turned off. That's crazy, but that's, in fact, what happens with chronic pain. And that's why pain becomes its own disease. The nervous system has plasticity. It changes, and it morphs in response to stimuli.
To je otprilike kao kad bi netko ušao u vašu kuću i ponovno postavio žice u zidovima i to tako da se kad sljedeći put upalite svjetlo ispere toalet tri vrata niže ili da se upali stroj za pranje suđa, ili ugasi kompjuterski monitor. To je suludo, ali to je upravo ono što se događa s kroničnom boli. I zbog toga bol postaje bolest sama po sebi. Živčani sustav je plastičan. Mijenja se i oblikuje se kao odgovor na podražaj.
Well, what do we do about that? What can we do in a case like Chandler's? We treat these patients in a rather crude fashion at this point in time. We treat them with symptom-modifying drugs -- painkillers -- which are, frankly, not very effective for this kind of pain. We take nerves that are noisy and active that should be quiet, and we put them to sleep with local anesthetics. And most importantly, what we do is we use a rigorous, and often uncomfortable, process of physical therapy and occupational therapy to retrain the nerves in the nervous system to respond normally to the activities and sensory experiences that are part of everyday life. And we support all of that with an intensive psychotherapy program to address the despondency, despair and depression that always accompanies severe, chronic pain.
Dobro, što ćemo učiniti u vezi toga? Što možemo učiniti u slučaju kao što je Chandlerin? Liječimo te bolesnike na prilično sirov način u ovom trenutku. Liječimo ih lijekovima koji uklanjaju simptome -- lijekovima protiv bolova -- koji, iskreno, nisu veoma učinkoviti za ovu vrstu boli. Uzimamo živce koji su bučni i aktivni, a trebali bi biti mirni, i uspavljujemo ih lokalnom anestezijom. I najvažnije što radimo je da koristimo krut, i često neugodan, proces fizikalne i radne terapije da bismo naučilii živce u živčanom sustavu da odgovaraju normalno na aktivnosti i osjetilna iskustva koja su dio svakodnevice. I sve to podržavamo intenzivnim programom psihoterapije zbog malodušnosti, očaja i depresije koji uvijek prate jaku, kroničnu bol.
It's successful, as you can see from this video of Chandler, who, two months after we first met her, is now doings a back flip. And I had lunch with her yesterday because she's a college student studying dance at Long Beach here, and she's doing absolutely fantastic.
To je uspješno, kao što možete vidjeti na ovom Chandlerinom videu koja dva mjeseca nakon našeg prvog susreta, sada izvodi kolut unazad. Ručao sam s njom jučer zato jer studira ples ovdje na Long Beachu. I izvrsno se osjeća.
But the future is actually even brighter. The future holds the promise that new drugs will be developed that are not symptom-modifying drugs that simply mask the problem, as we have now, but that will be disease-modifying drugs that will actually go right to the root of the problem and attack those glial cells, or those pernicious proteins that the glial cells elaborate, that spill over and cause this central nervous system wind-up, or plasticity, that so is capable of distorting and amplifying the sensory experience that we call pain. So I have hope
Budućnost je zapravo još svjetlija. Budućnost nam pruža nadu da će biti otkriveni novi lijekovi koje neće uklanjati samo simptome koji jednostavno maskiraju problem. kao što imamo sada, nego da će postojati lijekovi koji uklanjaju bolest koji će zapravo ići do korijena problema i napasti te glijalne stanice ili štetne proteine koje stvaraju glijalne stanice, koje se prospu i uzrokuju paralizu središnjeg živčanog sustava, ili plastičnost, koja može iskriviti i pojačati osjetilno iskustvo koje nazivamo bol. Pa se nadam
that in the future, the prophetic words of George Carlin will be realized, who said, "My philosophy: No pain, no pain."
da će ubuduće proročanske riječi Georga Carlina biti ostvarene. koji je rekao: "Moja filozofija? Bez boli, bez boli.
Thank you very much.
Mnogo vam hvala.
(Applause)
(Pljesak)