Elliot Krane: 解碼慢性疼痛

Elliot Krane: The mystery of chronic pain
Elliot Krane: 解碼慢性疼痛

譯者:法德

We think of pain as a symptom, but there are cases where the nervous system develops feedback loops and pain becomes a terrifying disease in itself. Starting with the story of a girl whose sprained wrist turned into a nightmare, Elliot Krane talks about the complex mystery of chronic pain, and reviews the facts we’re just learning about how it works and how to treat it.

大家都認為疼痛是一種症狀，但有些情況下神經系統自己發展成為一個一個的反饋迴路引起疼痛,所以這疼痛本身就成為一種可怕的疾病.由一個女孩扭傷手腕變成了一場噩夢的故事作開場白.Elliot Krane 揭開複雜的慢性疼痛之謎.並坦承評估對於剛被瞭解的慢性疼痛,現在所能應用的護理和控制方法.

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 a 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.

我是一名小兒麻醉科醫生，所以我靠把孩子們弄睡來賺錢生活。 （眾笑）我也是個專業學者，所以我也會催眠聽眾睡覺–這免費。（眾笑）但實際上我大部份的時間是在 Palo Alto市的斯坦福帕( Stanford)大學附屬兒童醫院( the Packard Children’s Hospital )裡幫助病童控制護理他們的疼痛。我已經擁有大約20年或25年的經驗，所以今天上午我想給你們傳遞一個消息: 疼痛是一種疾病。

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.

大多數的時候，我們都覺得疼痛是疾病所引起的一種症狀。通常這是對的。的確疼痛是腫瘤,感染,發炎或手術後的症狀.但是，大約有百分之十的機會，當病人已經完成痊癒後，疼痛仍然存在。有時疼痛會持續幾個月，甚至於常常疼痛多年。當發生這種情況時，疼痛本身就是一種疾病.在我還沒告訴你們,我們(醫師們)對持續不正常疼痛為何發生的推理,及我們可能治療它的方法之前,我想讓你們瞭解我的病人疼痛的感覺.如果你願意，想像一下，我正用這個羽毛輕撫你的手臂,就像我現在輕輕用羽毛劃過手臂一樣。現在，我要您們想像,我是用噴火槍的火焰來”撫摸”你的手臂.請大家坐好,不要跑掉.（眾笑）一個非常不同的感覺吧。咦,這跟慢性疼痛有什麼關係啊? 如果你願意再想像一下，把這兩個例子擺在一起.想像一下你的生活會是什麼行情?如果我是用羽毛碰觸你,但你的大腦卻一再告訴你-你正在被火紋身-痛不欲生.這就是我的病人對慢性疼痛的經驗.事實上，更可怕的是,如果我是用羽毛碰觸你的孩子的手臂,他們的大腦卻告訴自己，他們正被非常炙熱的火炬煎烤著.

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 out stretched 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.

這就是我的病人，璇得拉,的經驗.這是她的照片。正如你所看到的，她是一個美麗年輕的女孩。去年我見到她時她16歲，她渴望成為一名專業舞蹈演員。然而有一次舞蹈排練過程中,她跌落壓在在她自己伸展的一隻手臂上,並扭傷手腕.你可能會以為，在一個人的日常生活中,手腕扭傷是一個很小的事件.只要用一個ACE繃帶纏繞手腕,再吃一至兩個星期的布洛芬止痛劑,就可以了.但是對璇得拉(Chandler)而言,她的血淚史才剛開始.這是她來到我的診所時手臂的樣子,大概是發生意外扭傷三個月後，你可以看到那手臂已變色，帶點紫色。摸起來有屍體一樣的冰冷感覺.肌肉已經凍結癱瘓–所謂肌肉張力不足異常.疼痛已經從她的手腕擴散到她的手掌,到她的指尖，疼痛也從手腕漫延到胳膊肘，幾乎到達她的肩膀。

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.

但是，最糟糕的是，並非那持續每一天24小時自發性的疼痛,最糟糕的是她有”痛敏感症”. 痛敏感症 是醫學上的術語.所產生的症狀是跟羽毛與火炬的故事一樣.最輕微的觸摸她的手臂-觸摸她的手,甚至於當她穿衣時被衣袖觸到,被衣服磨到–都會造成難以忍受的燒灼痛。

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.

神經系統為什麼會錯得那麼離譜?為什麼神經系統會曲解一個無害的感覺,比如被手摸到,轉達成被火焰灼傷的惡意感覺?你可能會想像人身體內的神經系統就像我們房子內的電線系統.房子裡,電線有系統的被嵌在牆壁裡,從電燈開關到天花板的轉接箱,在從轉接箱到燈泡。當你打開開關，燈會亮起。而當你關閉開關，燈就熄滅。因此，大家想神經系統就是像這樣子.如果你的拇指被錘子打著,你的手臂內的電線–當然，我們稱之為神經-發送信息去脊髓的轉接箱,在那兒新線，新神經傳遞信息到大腦，然後你會意識到你的拇指受傷了。

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.

當然，在人體內的情況更為複雜得多。並不是單純的像是在脊髓內的轉接箱,在那裡一個神經結連絡另一個神經結是通過釋放包含化學信息的小包(神經傳導素)來線性一對一傳導訊息.事實上，神經傳導素的釋放是三方向的–在脊髓中橫向，縱向，上下-然後他們開始與其他相鄰的細胞相互影響.這些細胞被稱為神經膠質細胞，以前被認為是不重要的脊髓結構元素,除了幫助所有重要的物質(像神經細胞)聚集一起外,一無用處.但事實證明，膠質細胞，不僅調配,放大,對疼痛的感覺,在扭曲的感官經驗中扮演至關重要的角色.這些膠質細胞就活化起來。他們的DNA開始合成新的蛋白質，然後釋放出來與相鄰神經互動,然後神經細胞被活化,釋出神經傳導素.這些神經傳導素被釋放,活化鄰近的神經膠質細胞.然後相同故事一再重演.直到一個正向回饋循環系統產生.

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.

這幾乎好像有人走進你的家裡,重新佈署牆中的電線系統.所以當下次你開燈時,廁所馬桶自動乒乒乓乓大聲沖洗.或者洗碗機會自動起動,或電腦顯視窗自動關閉.這簡直是瘋了,但事實就是這樣.這就是慢性疼痛的行情.這就是為什麼疼痛本身變成了疾病的原因.神經系統具有對環境改變的可塑適應性.它會改變 或者說變種來反應不同的刺激.

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 — pain-killers — 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.

那麼，我們該怎麼辦呢？有什麼我們可以幫助璇得拉的呢?目前我們對這些病人的治療方法,還停留在一個相當不成熟,粗糙的階段.我們隨他們症狀改變調整藥物–止痛藥-坦率地說，對這種痛苦,藥物不是很有效.對於原本是安靜但現在嘈雜過動的神經,我們使用局部麻醉劑使它們睡覺.但最重要的方法是,我們採用很嚴格的，而且通常非常不舒服的物理治療及職業治療的過程來再教育神經系統裡的神經反應正常,尤其是那些日常生活的一切正常活動與感官經驗. 我們利用密集心理治療課程來支持所有這一切因嚴重慢性疼痛所伴隨引起的 沮喪,絕望和憂鬱症。

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.

璇得拉的例子是成功了，你可以看到這個視頻中的璇得拉,距離她第一次踏入我們的診療室後兩個月的現在,她已經可以表演後翻轉。昨天我和她一起吃午飯，因為她在Long Beach的一間大學學習舞蹈專業,她現在康復非常好,在校表現很棒.

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 that in the future, the prophetic words of George Carlin will be realized, who said, “My philosophy: No pain, no pain.”

Thank you very much.

(Applause)

實際上未來的藍圖將更美好.曙光已出現,新的有效藥品已經快要問世.未來新發展的藥品不再是只是症狀控制的藥物，不再是如我們現在所用的藥物,只是掩蓋了疼痛症狀而已.新的藥品將是為疾病本身作必要的修改(對症下藥)，新的藥品會確切的尋覓到疼痛根本的問題,攻擊神經膠質細胞,或那些神經膠質細胞所產生的有害的蛋白質,這些蛋白質釋出後會導致這個中心神經系統罷工或變異.這麼就可以對抗扭曲和放大的感官經驗，也就是我們所指的疼痛。所以我希望在不久的將來，喬治卡林的聞名真言可成真:“我的哲學是：沒有痛苦，沒有痛苦。“

謝謝!

http://www.ted.com/talks/elliot_krane_the_mystery_of_chronic_pain.html