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.
Ja sam pedijatar i anesteziolog, dakle ja uspavljujem decu da bih zaradio. (Smeh) Ja sam i akademik, dakle ja uspavljujem publiku besplatno (Smeh) Ali ono čime se najviše bavim je rukovođenje službe za upravljanje bolom u dečijoj Packard bolnici na Stenfordu u Palo Altu. Iz iskustva dugog 20 ili 25 godina, koliko se već time bavim ovog jutra želim vam preneti poruku da je bol 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.
Većinom vremena, razmišljate o bolu kao o simptompu oboljenja. I to je tačno većinom vremena. Bol je simptom tumora ili infekcije ili upale ili operacije. Ali oko 10 posto vremena nakon što se pacijent oporavio od ovih događaja, bol ne popušta. Ostaje mesecima, a često i godinama I kad se to dogodi, bol postaje posebna bolest. I pre nego što vam kazem kako mi mislimo da se to događa i šta mi radimo povodom toga, želim da vam pokažem kako to moji pacijenti osećaju. Zamislite sada, ako želite da ja dodirujem vašu ruku ovim perom, kao što diram svoju. Sada, želim da zamislite da vas dodirujem sa ovim. Molim vas ostanite na svojim mestima. (Smeh) Veoma različit osećaj. Kakve to veze ima sa hroničnim bolom? Zamislite, ako želite, ove dve ideje zajedno. Zamislite kakav bi vam život bio ako bih vas ja dodirnuo ovim perom, ali vaš mozak bi vam govorio da je ovo ono što vi osećate i to je iskustvo pacijeta sa hroničnim bolom. Ustvari, zamislite nešto još gore. Zamislite da sam dodirnuo vaše dete ovim perom, i njihov mozak bi im govorio da osete ovaj vreo gorionik.
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.
Ovo je iskustvo moje pacijentkinje Čendler, koju vidite na fotografiji. I kao što vidite ona je prelepa mlada devojka. Imala je 16 godina prošle godine kad sam je upoznao, i želela je da postane profesionalna plesačica. I tokom jedne plesne probe, pala je na ispruženu ruku i uganula zglob. Sad vi verovatno razmišljate, kao što je ona, da je uganuće zgloba beznačajan događaj u životu osobe. Zavijete ga sa elastičnim zavojem, uzimate brufen nedelju ili dve dana, i to je kraj priče. Ali kod Čendler, to je bio početak priče. Ovo je izgled njene ruke kada je došla u moju kliniku posle tri meseca od uganuća. Možete videti da je ruka promenila boju, postala je ljubičasta. Bila je mrtvački hladna na dodir. Mišići su bili smrznuti, paralizovani -- mi to nazivamo diatonija. Bol se širio od njenog zgloba prema njenom dlanu, do njenih prstiju, od zgloba ka njenom laktu, skoro do njenog 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 deo je bio, ne njen spontani bol koji je trajao 24 časa dnevno. Najgori deo je bio to što je ona imala alodiniju, medicinski naziv za fenomen koji sam vam malopre pokazao sa perom i gorionikom. Najnežniji dodir po njenoj ruci -- dodir šake, dodir čak i od rukava, odeće, dok se oblačila -- izazivao bi veoma jake, peckajuće 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 nervni sistem može tako da pogreši? Kako nervni sistem može pogrešno protumačiti nervni nadražaj kao što je dodir ruke i pretvoriti ga u zlonameran osećaj dodira gorionika. Vi sigurno zamišljate da je nervni sistem u telu umrežen kao vaša kuća. U vašoj kući, žice prolaze kroz zidove, od prekidača do razvodne kutije na plafonu i od razvodne kutije do sijalice. I kada uključite prekidač i sijalica se upali. A kada isključite prekidač i sijalica se ugasi. Dakle ljudi zamišljaju nervni sistem tako. Ako udarite palac čekićem, te žice u vašoj ruci -- koje, naravno, zovemo nervne ćelije -- prenose informaciju u razvodnu kutiju u kičmenoj moždini gde nove žice, novi nervi, prenose informaciju do mozga gde vi postajete svesni da vas palac boli.
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.
Ali situacija, naravno, u ljudskom telu je mnogo komplikovanija. Umesto toga da je razvodna kutija u kičmenoj moždini samo običan spoj gde se jedan nerv povezuje sa sledećim otpuštajući ove male braon pakete hemijske informacije nazvane neurotransmiteri na linearan način, jedan-na-jedan, ono što se zapravo događa jeste da se neurotransmiteri prosipaju u tri dimenzije -- doslovno, vertikalno, dole i gore u kičmenoj moždini -- i počinju da reaguju sa drugim susednim ćelijama Za te ćelije, nazvane glijalne ćelije, se mislilo da su nevažni strukturni elementi kičmene moždine koji nisu radili ništa više od držanja važnih ćelija zajedno, kao na primer nervnih ćelija. Ali se ispostavilo da glijalne ćelije imaju vitalnu ulogu u modulaciji, pojačavanju i u slučaju bola, distorziji osećajnog iskustva. Ove glijalne ćelije su postale aktivne. Njihova DNK je počela da sintetiše nove proteine, koju su se prosipali i reagovali sa susednim nervima. I onda oni počnu oslobađati svoje neuro transmitere. I ti neurotransmiteri se prosipaju i aktiviraju susedne glijalne ćelije i tako dalje, dok ne dobijemo 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 kao kada bi vam neko došao u kuću i zapetljao žice u vašim zidovima, tako da kada sledeći put upalite svetlo, vaš vodokotlić pusti vodu tri sobe dalje, ili vaša mašina za pranje sudova se upali, ili se vaš monitor od kompjutera ugasi. To je ludo, ali to je ustvari, ono što se događa sa hroničnim bolom. I tako bol postaje zasebno oboljenje. Nervini sistem je plastičan. Menja se i oblikuje kao odgovor na nadražaj.
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, šta da učinimo povodom toga? Šta da radimo u slučajevima kao što je Čendler? Lečimo obolele na prlično sirov način u ovom trenutku. Lečimo ih lekovima protiv simptoma -- lekovima protiv bola -- koji nisu baš delotvorni za ovu vrstu bola. Uzimamo nerve koji su bučni i aktivni a koji bi trebalo da su tihi, i uspavljujemo ih sa lokalnom anestezijom. I najvažnije što radimo, je da koristimo rigorozne i često neugodne, procese fizičke terapije i radne terapije da bi naučili nerve u nervnom sistemu da reaguju normalno na aktivnosti i osećajna iskustva koja su svakodnevica. I sve to podržavamo sa intezivnim psihoterapijskim programom da bi prevazišli malodušnost, očaj i depresiju koji uvek prate jak, hronični 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 uspešno, kao što možete videti iz snimka o Čendler, koja je, dva meseca nakon što sam je prvi put sreo, počela da radi kolut unazad. Juče sam ručao s njom, ona studira ples ovde u Long Biču. I ide joj apsolutno fantastično.
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
Ali budućnost je ustvari još svetlija. Budućnost obećava da će biti napravljeni novi lekovi koji neće uklanjati samo simptome koji jednostavno maskiraju problem, kao što imamo sada, nego koji će ustvari uklanjati oboljenja koji će zapravo ići pravo do korena problema i napasti te glijalne ćelije, ili štetne proteine koje proizvodi glijalna ćelija, koji se prospu i uzrokuju paralizu centralnog nervnog sistema, ili plastičnost, koja je sposobna da menja ili pojačava osećajno iskustvo koje nazivamo bol. Ja 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 u budućnosti, biti ostvarene proročanske reči Džordža Karlina, koji je rekao, "Moja filozofija: Bez bola, nema bola."
Thank you very much.
Mnogo vam hvala.
(Applause)
(Aplauz)