Elliot Krane: The mystery of chronic pain

譯者: Inder Peng(彭) 審譯者: Shelley Krishna Tsang

I'm a pediatrician and an anesthesiologist,

我是一名小兒麻醉科醫生，

so I put children to sleep for a living.

所以我靠把孩子們弄睡來賺錢生活。

(Laughter)

（眾笑）

And I'm an academic, so I put audiences to sleep for free.

也是個專業學者,所以會免費催眠聽眾睡覺。

(Laughter)

（眾笑）

But what I actually mostly do

但實際上我大部份的時間是在

is I manage the pain management service

帕羅奧多市史丹佛大學附屬兒童醫院( Packard Children's Hospital )

at the Packard Children's Hospital up at Stanford in Palo Alto.

裡幫助病童控制護理他們的疼痛。

And it's from the experience

我已經擁有

from about 20 or 25 years of doing that

大約20年或25年的經驗，

that I want to bring to you the message this morning,

所以今天上午我想給你們傳遞一個消息:

that pain is a disease.

疼痛是一種疾病。

Now most of the time,

大多數的時候，

you think of pain as a symptom of a disease,

我們都覺得疼痛是疾病所引起的一種症狀。

and that's true most of the time.

通常這是對的。

It's the symptom of a tumor or an infection

的確疼痛是腫瘤,感染,

or an inflammation or an operation.

發炎或手術後的症狀。

But about 10 percent of the time,

但是,大約有百分之十的機會，

after the patient has recovered from one of those events,

當病人已經完成痊癒後，

pain persists.

疼痛仍然存在。

It persists for months

有時持續幾個月，

and oftentimes for years,

甚至於常常疼痛多年。

and when that happens,

當發生這種情況時，

it is its own disease.

疼痛本身就是一種疾病。

And before I tell you about how it is that we think that happens

在我還沒告訴你們,我們對慢性疼痛為何發生的推理,

and what we can do about it,

及我們可能治療它的方法之前,

I want to show you how it feels for my patients.

我想讓你們瞭解我的病人疼痛的感覺。

So imagine, if you will,

如果你願意,想像一下，

that I'm stroking your arm with this feather,

我正用這個羽毛輕撫你的手臂,

as I'm stroking my arm right now.

就像我現在輕撫自己手臂一樣

Now, I want you to imagine

現在,我要您們想像,

that I'm stroking it with this.

我是用噴火槍的火焰來"撫摸"你的手臂。

Please keep your seat.

請大家坐好,不要跑掉.

(Laughter)

（眾笑）

A very different feeling.

一個非常不同的感覺吧。

Now what does it have to do with chronic pain?

咦,這跟慢性疼痛有什麼關係啊?

Imagine, if you will, these two ideas together.

如果你願意再想像一下,把這兩個例子擺在一起。

Imagine what your life would be like

想像一下你的生活會是什麼行情?

if I were to stroke it with this feather,

如果我是用羽毛碰觸你,

but your brain was telling you

但你的大腦卻一再告訴你-

that this is what you are feeling --

你正在被火紋身-(這就是你的感覺)

and that is the experience of my patients with chronic pain.

這就是我的病人對慢性疼痛的經驗。

In fact, imagine something even worse.

事實上,更可怕的是,

Imagine I were to stroke your child's arm with this feather,

如果我是用羽毛碰觸你的孩子的手臂,

and their brain [was] telling them

他們的大腦卻告訴自己。

that they were feeling this hot torch.

他們正被非常炙熱的火炬煎烤著.

That was the experience of my patient, Chandler,

這就是我的病人,璇得拉,的經驗。

whom you see in the photograph.

這是她的照片。

As you can see, she's a beautiful, young woman.

正如你所看到的,她是一個美麗年輕的女孩。

She was 16 years old last year when I met her,

去年我見到她時她16歲，

and she aspired to be a professional dancer.

她渴望成為一名專業舞蹈演員。

And during the course of one of her dance rehearsals,

然而有一次舞蹈排練過程中,

she fell on her outstretched arm and sprained her wrist.

她跌落壓在在她自己伸展的一隻手臂上,並扭傷手腕。

Now you would probably imagine, as she did,

你可能會以為,在一個人的日常生活中,

that a wrist sprain is a trivial event

手腕扭傷是一個

in a person's life.

很小的事件。

Wrap it in an ACE bandage,

只要用一個ACE繃帶纏繞手腕,

take some ibuprofen for a week or two,

再吃一至兩個星期的布洛芬止痛劑,

and that's the end of the story.

就可以了。

But in Chandler's case, that was the beginning of the story.

但是對璇得拉而言,她的血淚史才剛開始.

This is what her arm looked like

這是她來到我的診所時手臂的樣子,

when she came to my clinic about three months after her sprain.

大概是發生意外扭傷三個月後，

You can see that the arm is discolored,

你可以看到那手臂已變色，

purplish in color.

帶點紫色。

It was cadaverically cold to the touch.

摸起來有屍體一樣的冰冷感覺。

The muscles were frozen, paralyzed --

肌肉已經凍結癱瘓--

dystonic is how we refer to that.

所謂肌肉張力不足異常.

The pain had spread from her wrist to her hands,

疼痛已經從她的手腕擴散到她的手掌,

to her fingertips, from her wrist up to her elbow,

到她的指尖,疼痛也從手腕漫延到胳膊肘,

almost all the way to her shoulder.

幾乎到達她的肩膀。

But the worst part was,

但是,最糟糕的是，

not the spontaneous pain that was there 24 hours a day.

並非那持續每一天24小時自發性的疼痛,

The worst part was that she had allodynia,

最糟糕的是她有痛覺過敏症,

the medical term for the phenomenon that I just illustrated

觸感痛是醫學上的術語。所產生的症狀

with the feather and with the torch.

是跟羽毛與火炬的故事一樣。

The lightest touch of her arm --

最輕微的觸摸她的手臂-

the touch of a hand,

觸摸她的手,

the touch even of a sleeve, of a garment, as she put it on --

甚至於當她穿衣時被衣袖觸到,被衣服磨到--

caused excruciating, burning pain.

都會造成難以忍受的燒灼痛。

How can the nervous system get this so wrong?

神經系統為什麼會錯得那麼離譜?

How can the nervous system

為什麼神經系統

misinterpret an innocent sensation

會曲解一個無害的感覺,

like the touch of a hand

比如被手摸到,

and turn it into the malevolent sensation

轉達成被火焰灼傷

of the touch of the flame?

的惡意感覺?

Well you probably imagine that the nervous system in the body

你可能會想像人身體內的神經系統

is hardwired like your house.

就像我們房子內的電線系統.

In your house, wires run in the wall,

房子裡,電線有系統的被嵌在牆壁裡,

from the light switch to a junction box in the ceiling

從電燈開關到天花板的轉接箱,

and from the junction box to the light bulb.

在從轉接箱到燈泡。

And when you turn the switch on, the light goes on.

當你打開開關,燈會亮起。

And when you turn the switch off, the light goes off.

而當你關閉開關,燈就熄滅。

So people imagine the nervous system is just like that.

因此,大家想神經系統就是像這樣子。

If you hit your thumb with a hammer,

如果你的拇指被錘子打著,

these wires in your arm -- that, of course, we call nerves --

你的手臂內的電線--當然,我們稱之為神經

transmit the information into the junction box in the spinal cord

-發送信息去脊髓的轉接箱,

where new wires, new nerves,

在那兒新線,新神經

take the information up to the brain

傳遞信息到大腦，

where you become consciously aware that your thumb is now hurt.

然後你會意識到你的拇指受傷了。

But the situation, of course, in the human body

當然,在人體內的

is far more complicated than that.

情況更為複雜得多。

Instead of it being the case

並不是單純的

that that junction box in the spinal cord

像是在脊髓內的轉接箱,

is just simple where one nerve connects with the next nerve

在那裡一個神經結連絡另一個神經結

by releasing these little brown packets

通過釋放包含化學信息的小棕色包

of chemical information called neurotransmitters

就是神經傳導素來

in a linear one-on-one fashion,

線性一對一傳導訊息。

in fact, what happens

事實上，

is the neurotransmitters spill out in three dimensions --

神經傳導素的釋放是三方向的--

laterally, vertically, up and down in the spinal cord --

在脊髓中:橫向，縱向，上下-

and they start interacting

然後他們開始

with other adjacent cells.

與其他相鄰的細胞相互影響.

These cells, called glial cells,

這些細胞被稱為神經膠質細胞，

were once thought to be

以前被認為是

unimportant structural elements of the spinal cord

不重要的脊髓結構元素,

that did nothing more than hold all the important things together,

除了幫助所有重要的物質(像神經細胞)

like the nerves.

聚集一起外,一無用處。

But it turns out

但事實證明，

the glial cells have a vital role

膠質細胞,扮演至關重要的角色

in the modulation, amplification

不僅調配,放大,

and, in the case of pain, the distortion

對疼痛的感覺,在扭曲的

of sensory experiences.

感官經驗中

These glial cells become activated.

這些膠質細胞就活化起來。

Their DNA starts to synthesize new proteins,

他們的DNA開始合成新的蛋白質，

which spill out

然後釋放出來

and interact with adjacent nerves,

與相鄰神經互動

and they start releasing their neurotransmitters,

然後神經細胞被活化,釋出神經傳導素,

and those neurotransmitters spill out

這些神經傳導素被釋放

and activate adjacent glial cells, and so on and so forth,

活化鄰近的神經膠質細胞.然後相同故事一再重演.

until what we have

直到一個

is a positive feedback loop.

正向回饋循環系統產生。

It's almost as if somebody came into your home

這幾乎好像有人走進你的家,

and rewired your walls

重新佈署你的牆中的電線系統.

so that the next time you turned on the light switch,

所以當下次你開燈時

the toilet flushed three doors down,

廁所馬桶自動乒乒乓乓沖洗.

or your dishwasher went on,

或者洗碗機自動起動,

or your computer monitor turned off.

或電腦顯視窗自動關閉.

That's crazy,

這簡直是瘋了,

but that's, in fact, what happens

但事實就是這樣.這就是

with chronic pain.

慢性疼痛的行情.

And that's why pain becomes its own disease.

這也就是為什麼疼痛本身變成了疾病的原因。

The nervous system has plasticity.

神經系統具有(對環境改變的)可塑適應性。

It changes, and it morphs

它會改變或者說變種

in response to stimuli.

來反應不同的刺激.

Well, what do we do about that?

那麼,我們該怎麼辦呢？

What can we do in a case like Chandler's?

有什麼我們可以幫助璇得拉的呢?

We treat these patients in a rather crude fashion

目前我們對這些病人的治療方法,還停留在

at this point in time.

一個相當粗糙的階段.

We treat them with symptom-modifying drugs --

我們隨他們症狀改變調整藥物

painkillers --

--止痛藥--

which are, frankly, not very effective

坦率地說,對這種痛苦

for this kind of pain.

藥物不是很有效。

We take nerves that are noisy and active

對於原本是安靜但現在

that should be quiet,

嘈雜過動的神經,

and we put them to sleep with local anesthetics.

我們使用局部麻醉劑使它們睡覺.

And most importantly, what we do

但最重要的方法是,我們

is we use a rigorous, and often uncomfortable, process

採用很嚴格的，而且通常非常不舒服的

of physical therapy and occupational therapy

物理治療及職業治療的過程來

to retrain the nerves in the nervous system

再教育神經系統裡的神經,

to respond normally

反應正常。

to the activities and sensory experiences

尤其是那些日常生活的一切

that are part of everyday life.

正常活動與感官經驗。

And we support all of that

我們利用

with an intensive psychotherapy program

密集心理治療課程

to address the despondency, despair and depression

來支持所有這一切因

that always accompanies

嚴重慢性疼痛所伴隨引起的

severe, chronic pain.

沮喪,絕望和憂鬱症。

It's successful,

璇得拉的例子是成功了，

as you can see from this video of Chandler,

你可以看到這個視頻中的璇得拉,

who, two months after we first met her,

距離她第一次踏入我們的診療室後兩個月的現在,

is now doings a back flip.

她已經可以表演後翻轉。

And I had lunch with her yesterday

昨天我和她一起吃午飯，

because she's a college student studying dance at Long Beach here,

因為她在Long Beach的一間大學學習舞蹈專業,

and she's doing absolutely fantastic.

現在康復非常好,在校表現很棒.

But the future is actually even brighter.

實際上未來的藍圖將更美好。

The future holds the promise

曙光已出現,

that new drugs will be developed

新的有效藥品已經快要問世.

that are not symptom-modifying drugs

未來的藥品不再是只是症狀控制的藥物，

that simply mask the problem,

如我們所知現在的藥物

as we have now,

只會掩蓋了疼痛症狀而已。

but that will be disease-modifying drugs

新的藥品將為疾病本身作必要的修改(對症下藥)，

that will actually go right to the root of the problem

會確切的尋覓到疼痛根本的問題,

and attack those glial cells,

攻擊神經膠質細胞,

or those pernicious proteins

或那些神經膠質細胞

that the glial cells elaborate,

所產生的有害的蛋白質,

that spill over and cause this central nervous system wind-up,

這些蛋白質釋出後會,導致這個中心神經系統罷工

or plasticity,

或變異。

that so is capable

這麼就可以對抗

of distorting and amplifying

扭曲和放大的感官經驗，

the sensory experience that we call pain.

也就是我們所指的疼痛。

So I have hope

所以我希望

that in the future,

在不久的將來，

the prophetic words of George Carlin will be realized,

喬治卡林的聞名真言可被實現:

who said, "My philosophy:

“我的哲學：

No pain, no pain."

沒有痛苦，沒有痛苦。“

Thank you very much.

謝謝大家。

(Applause)

（鼓掌）