ABOUT THE SPEAKER
Elliot Krane - Pediatric anesthesiologist
At the Lucile Packard Children's Hospital at Stanford, Elliot Krane works on the problem of treating pain in children.

Why you should listen

It's an awful problem to contemplate: How do you help a young child in pain? As director of Pain Management Services at Lucile Packard Children's Hospital at Stanford, Elliot Krane works on solving this problem, studying and treating kids who are undergoing surgeries, suffering from complications of diabetes -- and kids suffering "neuropathic pain" resulting from injury to the nervous system itself.

More profile about the speaker
Elliot Krane | Speaker | TED.com
TED2011

Elliot Krane: The mystery of chronic pain

Elliot Krane: O misterio da dor crónica

Filmed:
2,012,954 views

Pensamos na dor como un síntoma, pero hai casos nos que o sistema nervioso desenvolve ciclos de retroalimentación e dor que se converten nunha terrible enfermidade por si mesma. A partir da historia dunha moza cuxa torcedura de pulso se converteu nun pesadelo, Elliot Krane fala sobre o complexo misterio da dor crónica e analiza os feitos que apenas estamos aprendendo acerca do seu funcionamento e tratamento.
- Pediatric anesthesiologist
At the Lucile Packard Children's Hospital at Stanford, Elliot Krane works on the problem of treating pain in children. Full bio

Double-click the English transcript below to play the video.

00:15
I'm a pediatrician and an anesthesiologist,
0
0
2000
Son pediatra e anestesista,
00:17
so I put children to sleep for a living.
1
2000
2000
polo que gaño a vida durmindo nenos.
00:19
(Laughter)
2
4000
2000
(Risas)
00:21
And I'm an academic, so I put audiences to sleep for free.
3
6000
3000
Tamén son académico,
polo que durmo ao público de balde.
00:24
(Laughter)
4
9000
4000
(Risas)
00:28
But what I actually mostly do
5
13000
2000
Pero en realidade dedícome
00:30
is I manage the pain management service
6
15000
2000
a levar a Unidade de Dor
00:32
at the Packard Children's Hospital up at Stanford in Palo Alto.
7
17000
3000
no Hospital Infantil Packard
en Stanford, Palo Alto.
00:35
And it's from the experience
8
20000
2000
E coa experiencia
00:37
from about 20 or 25 years of doing that
9
22000
2000
de 20 ou 25 anos traballando nisto
00:39
that I want to bring to you the message this morning,
10
24000
2000
tráiovos unha mensaxe esta mañá:
00:41
that pain is a disease.
11
26000
2000
a dor é unha enfermidade.
00:43
Now most of the time,
12
28000
2000
Xeralmente,
00:45
you think of pain as a symptom of a disease,
13
30000
2000
pénsase na dor
coma no síntoma dunha patoloxía
00:47
and that's true most of the time.
14
32000
2000
e isto é certo a maioría das veces.
00:49
It's the symptom of a tumor or an infection
15
34000
3000
É o síntoma dun tumor, dunha infección,
00:52
or an inflammation or an operation.
16
37000
2000
dunha inflamación ou dunha cirurxía.
00:54
But about 10 percent of the time,
17
39000
3000
Pero en arredor do 10% dos casos,
00:57
after the patient has recovered from one of those events,
18
42000
3000
os pacientes seguirán padecendo dor
01:00
pain persists.
19
45000
2000
despois de recuperarse da enfermidade.
01:02
It persists for months
20
47000
2000
Pode persistir meses,
01:04
and oftentimes for years,
21
49000
2000
e, ás veces, anos.
01:06
and when that happens,
22
51000
2000
Cando sucede isto,
01:08
it is its own disease.
23
53000
2000
a dor é unha enfermidade por si mesma.
01:10
And before I tell you about how it is that we think that happens
24
55000
3000
Antes de que vos conte como
cremos que sucede isto,
01:13
and what we can do about it,
25
58000
2000
e qué podemos facer ó respecto,
01:15
I want to show you how it feels for my patients.
26
60000
3000
quixera mostrarvos como senten a dor
os meus pacientes.
01:18
So imagine, if you will,
27
63000
2000
Imaxinade, se podedes,
01:20
that I'm stroking your arm with this feather,
28
65000
2000
que vos acaricio o brazo
con esta pluma,
01:22
as I'm stroking my arm right now.
29
67000
3000
como estou acariciando
o meu neste intre.
01:25
Now, I want you to imagine
30
70000
2000
Agora quero que imaxinedes
01:27
that I'm stroking it with this.
31
72000
2000
que o estou acariciando con isto.
01:29
Please keep your seat.
32
74000
2000
Por favor, ficade nos asentos.
01:31
(Laughter)
33
76000
2000
(Risas)
01:33
A very different feeling.
34
78000
2000
Unha sensación moi diferente.
01:35
Now what does it have to do with chronic pain?
35
80000
2000
Pero, que ten que ver isto
coa dor crónica?
01:37
Imagine, if you will, these two ideas together.
36
82000
3000
Imaxinade, se queredes,
as dúas ideas xuntas.
01:40
Imagine what your life would be like
37
85000
2000
Imaxinade como sería a vosa vida
01:42
if I were to stroke it with this feather,
38
87000
3000
se vos acariciasen con esta pluma,
01:45
but your brain was telling you
39
90000
2000
pero os vosos cerebros vos din
01:47
that this is what you are feeling --
40
92000
2000
que o que están sentindo é isto:
01:49
and that is the experience of my patients with chronic pain.
41
94000
3000
esta é a experiencia dos meus pacientes
con dor crónica.
01:52
In fact, imagine something even worse.
42
97000
2000
De feito, imaxinade algo aínda peor.
01:54
Imagine I were to stroke your child's arm with this feather,
43
99000
3000
Imaxinade que estou acariciando o brazo
dun fillo voso con esta pluma
01:57
and their brain [was] telling them
44
102000
2000
e o seu cerebro dille
01:59
that they were feeling this hot torch.
45
104000
3000
que o que sente é esta chama.
02:02
That was the experience of my patient, Chandler,
46
107000
2000
Esta era a vivencia de Chandler,
unha paciente miña
02:04
whom you see in the photograph.
47
109000
2000
á que vedes na foto.
02:06
As you can see, she's a beautiful, young woman.
48
111000
2000
Como podedes ver, é unha rapaza fermosa.
02:08
She was 16 years old last year when I met her,
49
113000
2000
Tiña 16 anos cando a coñecín o ano pasado,
02:10
and she aspired to be a professional dancer.
50
115000
3000
E quería ser bailarina profesional.
02:13
And during the course of one of her dance rehearsals,
51
118000
2000
Durante un dos seus ensaios de baile,
02:15
she fell on her outstretched arm and sprained her wrist.
52
120000
3000
caeu co brazo estendido e torceu o pulso.
02:18
Now you would probably imagine, as she did,
53
123000
2000
Probablemente pensedes, igual ca fixo ela,
02:20
that a wrist sprain is a trivial event
54
125000
2000
que una torcedura de pulso é trivial
02:22
in a person's life.
55
127000
2000
na vida dunha persoa.
02:24
Wrap it in an ACE bandage,
56
129000
2000
Envólvese cunha venda elástica,
02:26
take some ibuprofen for a week or two,
57
131000
2000
Tómase ibuprofeno 1 ou 2 semanas
02:28
and that's the end of the story.
58
133000
2000
e fin da historia.
02:30
But in Chandler's case, that was the beginning of the story.
59
135000
3000
Pero no caso de Chandler,
este foi o inicio da historia.
02:34
This is what her arm looked like
60
139000
2000
Esta era a pinta do seu brazo
02:36
when she came to my clinic about three months after her sprain.
61
141000
3000
cando veu á clínica tres meses
despois da torcedura.
02:39
You can see that the arm is discolored,
62
144000
2000
Fixádevos que o brazo ten a cor alterada,
02:41
purplish in color.
63
146000
2000
como denegrida.
02:43
It was cadaverically cold to the touch.
64
148000
2000
Estaba frío coma o dun cadáver.
02:45
The muscles were frozen, paralyzed --
65
150000
2000
Os músculos estaban xeados, paralizados
02:47
dystonic is how we refer to that.
66
152000
3000
--como nós dicimos, distónicos.
02:50
The pain had spread from her wrist to her hands,
67
155000
3000
A dor estendérase dende o pulso cara á man
02:53
to her fingertips, from her wrist up to her elbow,
68
158000
3000
e as puntas dos dedos, e cara ó cóbado.
02:56
almost all the way to her shoulder.
69
161000
2000
chegando case ó ombreiro.
02:58
But the worst part was,
70
163000
2000
Pero o peor non era
03:00
not the spontaneous pain that was there 24 hours a day.
71
165000
3000
a dor espontánea que sentía
as 24 horas do día.
03:03
The worst part was that she had allodynia,
72
168000
3000
O peor era a alodinia,
03:06
the medical term for the phenomenon that I just illustrated
73
171000
3000
un termo médico usado para o fenómeno
que antes expliquei
03:09
with the feather and with the torch.
74
174000
2000
coa pluma e a chama.
03:11
The lightest touch of her arm --
75
176000
2000
O máis leve contacto no brazo
03:13
the touch of a hand,
76
178000
2000
--o rozamento dunha man,
mesmo o contacto dunha manga,
dunha prenda ao poñela--
03:15
the touch even of a sleeve, of a garment, as she put it on --
77
180000
3000
causáballe unha dor insoportable,
moi ardente.
03:18
caused excruciating, burning pain.
78
183000
4000
03:22
How can the nervous system get this so wrong?
79
187000
3000
Como pode o sistema nervioso
equivocarse dese xeito?
03:25
How can the nervous system
80
190000
2000
Como pode o sistema nervioso
03:27
misinterpret an innocent sensation
81
192000
2000
confundir una sensación inocente
03:29
like the touch of a hand
82
194000
2000
como o tacto dunha man
03:31
and turn it into the malevolent sensation
83
196000
3000
e convertela nunha sensación tan maligna
03:34
of the touch of the flame?
84
199000
2000
como o contacto cunha chama?
03:36
Well you probably imagine that the nervous system in the body
85
201000
3000
Ben, se cadra pensades
que o sistema nervioso
03:39
is hardwired like your house.
86
204000
2000
é como a cablaxe da vosa casa.
03:41
In your house, wires run in the wall,
87
206000
2000
Nela os cables pasan polas paredes
03:43
from the light switch to a junction box in the ceiling
88
208000
3000
dende o interruptor da luz, a unha caixa
de conexións no teito
03:46
and from the junction box to the light bulb.
89
211000
3000
e dende aí ata a lámpada.
03:49
And when you turn the switch on, the light goes on.
90
214000
2000
Cando se calca no interruptor,
acéndese a luz.
03:51
And when you turn the switch off, the light goes off.
91
216000
3000
E cando se pecha, a luz apágase.
03:54
So people imagine the nervous system is just like that.
92
219000
4000
A xente imaxina
que o sistema nervioso funciona así.
03:58
If you hit your thumb with a hammer,
93
223000
2000
Se pegas cun martelo no polgar,
04:00
these wires in your arm -- that, of course, we call nerves --
94
225000
3000
estes cables do brazo --chamados nervios--
04:03
transmit the information into the junction box in the spinal cord
95
228000
3000
transmiten a información á caixa
de conexións na medula espiñal
04:06
where new wires, new nerves,
96
231000
2000
onde novos cables, novos nervios,
04:08
take the information up to the brain
97
233000
2000
levan a información ata o cerebro,
04:10
where you become consciously aware that your thumb is now hurt.
98
235000
4000
que é cando te das conta
de que magoaches o polgar.
04:14
But the situation, of course, in the human body
99
239000
2000
Por suposto, a situación no corpo humano
04:16
is far more complicated than that.
100
241000
3000
é moito máis complexa.
04:19
Instead of it being the case
101
244000
2000
Poderíase pensar
04:21
that that junction box in the spinal cord
102
246000
2000
que a caixa de conexións na medula espiñal
04:23
is just simple where one nerve connects with the next nerve
103
248000
3000
é só onde un nervio conecta
co seguinte
04:26
by releasing these little brown packets
104
251000
2000
liberando paquetiños marróns
04:28
of chemical information called neurotransmitters
105
253000
3000
de información química que chamamos
neurotransmisores
04:31
in a linear one-on-one fashion,
106
256000
3000
de forma linear un a un;
04:34
in fact, what happens
107
259000
2000
pero en realidade o que sucede
04:36
is the neurotransmitters spill out in three dimensions --
108
261000
2000
é que se esparexen en tres dimensións
04:38
laterally, vertically, up and down in the spinal cord --
109
263000
3000
--lateralmente, verticalmente,
arriba e abaixo na medula espiñal--
04:41
and they start interacting
110
266000
2000
e comezan a interactuar
04:43
with other adjacent cells.
111
268000
3000
con outras células adxacentes.
04:46
These cells, called glial cells,
112
271000
2000
Estas células, chamadas gliais,
04:48
were once thought to be
113
273000
2000
antes pensábase que eran
elementos estruturais pouco importantes
da medula espiñal
04:50
unimportant structural elements of the spinal cord
114
275000
2000
04:52
that did nothing more than hold all the important things together,
115
277000
2000
que non tiñan máis función
ca a de unir os elementos importantes,
04:54
like the nerves.
116
279000
2000
como os nervios.
04:56
But it turns out
117
281000
2000
Pero a verdade é que
04:58
the glial cells have a vital role
118
283000
2000
a glía xoga un papel vital
05:00
in the modulation, amplification
119
285000
2000
na modulación, amplificación
05:02
and, in the case of pain, the distortion
120
287000
3000
e, no caso da dor, na distorsión
05:05
of sensory experiences.
121
290000
3000
das experiencias sensoriais.
05:08
These glial cells become activated.
122
293000
2000
Estas células gliais actívanse.
05:10
Their DNA starts to synthesize new proteins,
123
295000
2000
O seu ADN sintetiza novas proteínas
05:12
which spill out
124
297000
2000
que se liberan
e interactúan cos nervios adxacentes,
05:14
and interact with adjacent nerves,
125
299000
2000
05:16
and they start releasing their neurotransmitters,
126
301000
3000
e comezan a liberar
os seus neurotransmisores.
05:19
and those neurotransmitters spill out
127
304000
2000
E estes esparéxense,
05:21
and activate adjacent glial cells, and so on and so forth,
128
306000
3000
activan células gliais adxacentes,
e así sucesivamente,
05:24
until what we have
129
309000
2000
ata que se produza
05:26
is a positive feedback loop.
130
311000
2000
unha retroalimentación positiva.
05:28
It's almost as if somebody came into your home
131
313000
2000
É case como se alguén fora á vosa casa
05:30
and rewired your walls
132
315000
2000
e cambiara a cablaxe das paredes,
05:32
so that the next time you turned on the light switch,
133
317000
2000
de modo que a seguinte vez
que acendedes a luz
05:34
the toilet flushed three doors down,
134
319000
2000
funcionara a cadea do WC
tres portas máis alá,
05:36
or your dishwasher went on,
135
321000
2000
ou o lavalouza acendera só
05:38
or your computer monitor turned off.
136
323000
2000
ou se apagara o monitor
do ordenador.
05:40
That's crazy,
137
325000
2000
É unha loucura,
05:42
but that's, in fact, what happens
138
327000
2000
pero de feito, iso é o que sucede
05:44
with chronic pain.
139
329000
2000
coa dor crónica.
05:46
And that's why pain becomes its own disease.
140
331000
3000
E por iso a dor convértese
nunha enfermidade por si mesma.
05:49
The nervous system has plasticity.
141
334000
2000
O sistema nervioso ten plasticidade.
05:51
It changes, and it morphs
142
336000
2000
Cambia e transfórmase
05:53
in response to stimuli.
143
338000
2000
en resposta ós estímulos.
05:55
Well, what do we do about that?
144
340000
2000
E que facemos ó respecto?
05:57
What can we do in a case like Chandler's?
145
342000
3000
Que podemos facer nun caso
como o de Chandler?
06:00
We treat these patients in a rather crude fashion
146
345000
2000
Hoxe en día tratamos eses pacientes
06:02
at this point in time.
147
347000
2000
de forma bastante rudimentaria.
06:04
We treat them with symptom-modifying drugs --
148
349000
3000
Tratámolos con fármacos modificadores
dos síntomas
06:07
painkillers --
149
352000
2000
--analxésicos--
06:09
which are, frankly, not very effective
150
354000
2000
que verdadeiramente non son
moi eficaces
06:11
for this kind of pain.
151
356000
2000
para este tipo de dor.
06:13
We take nerves that are noisy and active
152
358000
2000
Collemos nervios
que son ruidosos e activos
06:15
that should be quiet,
153
360000
2000
que deberían estar en silencio,
06:17
and we put them to sleep with local anesthetics.
154
362000
2000
e adormecémolos con analxésicos locais.
06:19
And most importantly, what we do
155
364000
3000
E o máis importante que facemos
06:22
is we use a rigorous, and often uncomfortable, process
156
367000
4000
é usar un rigoroso, e a miúdo
incómodo proceso
06:26
of physical therapy and occupational therapy
157
371000
3000
de terapia física e terapia ocupacional
06:29
to retrain the nerves in the nervous system
158
374000
3000
co fin de reeducar os nervios
no sistema nervioso
06:32
to respond normally
159
377000
3000
para que teñan unha resposta normal
06:35
to the activities and sensory experiences
160
380000
3000
ás actividades e experiencias sensoriais
06:38
that are part of everyday life.
161
383000
2000
que forman parte da vida cotiá.
06:40
And we support all of that
162
385000
2000
E apoiamos todo isto
06:42
with an intensive psychotherapy program
163
387000
3000
cun programa de psicoterapia intensiva
06:45
to address the despondency, despair and depression
164
390000
3000
para enfrontar o desánimo, a desesperación
e a depresión
06:48
that always accompanies
165
393000
2000
que acompañan sempre
06:50
severe, chronic pain.
166
395000
2000
á dor crónica severa.
06:52
It's successful,
167
397000
2000
É exitoso,
06:54
as you can see from this video of Chandler,
168
399000
2000
como se pode ver neste vídeo de Chandler
06:56
who, two months after we first met her,
169
401000
2000
quen, dous meses despois de coñecela,
06:58
is now doings a back flip.
170
403000
2000
está facendo unha viravolta para atrás.
07:00
And I had lunch with her yesterday
171
405000
2000
Onte comín con ela,
07:02
because she's a college student studying dance at Long Beach here,
172
407000
3000
porque é unha estudante universitaria
de danza en Long Beach,
07:05
and she's doing absolutely fantastic.
173
410000
2000
todo lle está indo moi ben.
07:07
But the future is actually even brighter.
174
412000
4000
Pero o futuro é incluso máis brillante.
07:11
The future holds the promise
175
416000
3000
O futuro promete
07:14
that new drugs will be developed
176
419000
2000
que os novos medicamentos
que se desenvolverán
07:16
that are not symptom-modifying drugs
177
421000
3000
non serán fármacos
modificadores da sintomatoloxía
07:19
that simply mask the problem,
178
424000
2000
que simplemente agachan o problema,
07:21
as we have now,
179
426000
2000
como facemos agora,
07:23
but that will be disease-modifying drugs
180
428000
3000
senón que serán fármacos
modificadores da enfermidade
07:26
that will actually go right to the root of the problem
181
431000
2000
que realmente actuarán na raíz do problema
07:28
and attack those glial cells,
182
433000
2000
e atacarán ás células gliais
07:30
or those pernicious proteins
183
435000
2000
ou a esas proteínas prexudiciais
07:32
that the glial cells elaborate,
184
437000
3000
que as células gliais elaboran,
07:35
that spill over and cause this central nervous system wind-up,
185
440000
3000
esparexéndose e provocando
no sistema nervioso a sensibilización
07:38
or plasticity,
186
443000
2000
ou plasticidade,
07:40
that so is capable
187
445000
2000
que é capaz
07:42
of distorting and amplifying
188
447000
2000
de distorsionar e amplificar
07:44
the sensory experience that we call pain.
189
449000
2000
a experiencia sensorial coñecida como dor.
07:46
So I have hope
190
451000
2000
Así, esperamos
07:48
that in the future,
191
453000
2000
que no futuro
07:50
the prophetic words of George Carlin will be realized,
192
455000
3000
se cumpran as palabras proféticas de
George Carlin
07:53
who said, "My philosophy:
193
458000
2000
que dicía: "A miña filosofía:
07:55
No pain, no pain."
194
460000
3000
non hai dor, non hai dor"
(Risas)
07:59
Thank you very much.
195
464000
2000
Moitas grazas.
08:01
(Applause)
196
466000
6000
(Aplausos)
Translated by Noelia Samartin
Reviewed by Servizo de Normalización Lingüística

▲Back to top

ABOUT THE SPEAKER
Elliot Krane - Pediatric anesthesiologist
At the Lucile Packard Children's Hospital at Stanford, Elliot Krane works on the problem of treating pain in children.

Why you should listen

It's an awful problem to contemplate: How do you help a young child in pain? As director of Pain Management Services at Lucile Packard Children's Hospital at Stanford, Elliot Krane works on solving this problem, studying and treating kids who are undergoing surgeries, suffering from complications of diabetes -- and kids suffering "neuropathic pain" resulting from injury to the nervous system itself.

More profile about the speaker
Elliot Krane | Speaker | TED.com
THE ORIGINAL VIDEO ON TED.COM