TED2011
Elliot Krane: The mystery of chronic pain
Elliot Krane: Misterij kroničnog bola
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Mislimo o bolu kao simptomu, no postoje slučajevi kad živčani sustav razvije povratne petlje i bol postaje zastrašujuća bolest sama po sebi. Počevši od priče o djevojci čiji se iščašeni zglob pretvorio u noćnu moru, Elliot Krane govori o kompleksu misterija kroničnog bola i analizira činjenice o kojima tek učimo, o tome kako nastaje i kako ga liječiti.
Elliot Krane - Pediatric anesthesiologist
At the Lucile Packard Children's Hospital at Stanford, Elliot Krane works on the problem of treating pain in children. Full bio
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,
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Pedijatar sam i anesteziolog,
00:17
so I put children to sleep for a living.
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dakle, zarađujem za život stavljajući djecu na spavanje.
00:19
(Laughter)
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(Smijeh)
00:21
And I'm an academic, so I put audiences to sleep for free.
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Ja sam i akademik, dakle publiku uspavljujem besplatno.
00:24
(Laughter)
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(Smijeh)
00:28
But what I actually mostly do
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No ono čime se najviše bavim
00:30
is I manage the pain management service
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je da vodim odjel za upravljanje bolom
00:32
at the Packard Children's Hospital up at Stanford in Palo Alto.
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u Packard dječjoj bolnici kod Stanforda u Palo Altu.
00:35
And it's from the experience
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Iz iskustva
00:37
from about 20 or 25 years of doing that
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dugog 20 ili 25 godina, koliko se već time bavim,
00:39
that I want to bring to you the message this morning,
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ovog vam jutra želim prenijeti poruku
00:41
that pain is a disease.
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da je bol zapravo bolest.
00:43
Now most of the time,
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Sada većinu vremena
00:45
you think of pain as a symptom of a disease,
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mislite o bolu kao simptomu bolesti.
00:47
and that's true most of the time.
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To je uglavnom točno.
00:49
It's the symptom of a tumor or an infection
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Ona je simptom tumora ili infekcije,
00:52
or an inflammation or an operation.
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ili upale, ili operacije.
00:54
But about 10 percent of the time,
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No oko 10 posto vremena
00:57
after the patient has recovered from one of those events,
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nakon što se pacijent oporavio od nekog od navedenih događaja
01:00
pain persists.
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bol ne popušta.
01:02
It persists for months
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Ustraje mjesecima
01:04
and oftentimes for years,
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a vrlo često i godinama.
01:06
and when that happens,
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A kad se to dogodi,
01:08
it is its own disease.
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ono postaje bolest sama za sebe.
01:10
And before I tell you about how it is that we think that happens
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I prije nego što vam kažem kako mislimo da se to događa
01:13
and what we can do about it,
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i što možemo u vezi toga učiniti
01:15
I want to show you how it feels for my patients.
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želim vam pokazati kako se osjećaju moji pacijenti.
01:18
So imagine, if you will,
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Zamislite, ako želite
01:20
that I'm stroking your arm with this feather,
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da vam milujem ruku ovim perom
01:22
as I'm stroking my arm right now.
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kao što to upravo činim
01:25
Now, I want you to imagine
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Sada želim da zamislite
01:27
that I'm stroking it with this.
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da je milujem ovim.
01:29
Please keep your seat.
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Molim vas ostanite na mjestu.
01:31
(Laughter)
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(Smijeh)
01:33
A very different feeling.
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Prilično drugačiji osjećaj.
01:35
Now what does it have to do with chronic pain?
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No kakve to veze ima s kronično boli?
01:37
Imagine, if you will, these two ideas together.
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Zamislite, ako želite, ove dvije ideje zajedno.
01:40
Imagine what your life would be like
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Zamislite kakav bi vam život bio
01:42
if I were to stroke it with this feather,
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da vas milujem ovim perom,
01:45
but your brain was telling you
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ali vaš vam mozak govori
01:47
that this is what you are feeling --
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da je ovo ono što osjećate --
01:49
and that is the experience of my patients with chronic pain.
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i upravo je to ono što osjećaju moji pacijenti.
01:52
In fact, imagine something even worse.
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Zamislite zapravo štogod još gore.
01:54
Imagine I were to stroke your child's arm with this feather,
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Zamislite da milujem dječju ruku ovim perom.
01:57
and their brain [was] telling them
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a njihov mozak im govori
01:59
that they were feeling this hot torch.
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da osjećaju ovu vruću baklju.
02:02
That was the experience of my patient, Chandler,
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Takvo je bilo iskustvo moje pacijentice, Chandler,
02:04
whom you see in the photograph.
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koju vidite na fotografiji.
02:06
As you can see, she's a beautiful, young woman.
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I kao što možete vidjeti ona je lijepa, mlada žena.
02:08
She was 16 years old last year when I met her,
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Imala je 16 godina prošle godine kad sam je upoznao,
02:10
and she aspired to be a professional dancer.
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željela je postati profesionalna plesačica.
02:13
And during the course of one of her dance rehearsals,
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I tijekom jedne od plesnih proba
02:15
she fell on her outstretched arm and sprained her wrist.
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pala je na ispruženu ruku i uganula zglob.
02:18
Now you would probably imagine, as she did,
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Vjerojatno biste pomislili, kao što je i ona,
02:20
that a wrist sprain is a trivial event
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da je uganuće zgloba trivijalan događaj
02:22
in a person's life.
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u životu svake osobe.
02:24
Wrap it in an ACE bandage,
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Učvrstite zglob elastičnim zavojem
02:26
take some ibuprofen for a week or two,
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uzimajte ibuprofen tjedan ili dva
02:28
and that's the end of the story.
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i to je kraj priče.
02:30
But in Chandler's case, that was the beginning of the story.
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No u Chandlerinom slučaju bio je to tek početak priče.
02:34
This is what her arm looked like
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Ovako je izgledala njena ruka
02:36
when she came to my clinic about three months after her sprain.
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kad je došla u moju kliniku tri mjeseca nakon uganuća.
02:39
You can see that the arm is discolored,
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Možete vidjeti da je ruka obezbojena,
02:41
purplish in color.
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purpurne boje.
02:43
It was cadaverically cold to the touch.
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Bila je mrtvački hladna na dodir.
02:45
The muscles were frozen, paralyzed --
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Mišići su bili smrznuti, paralizirani --
02:47
dystonic is how we refer to that.
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distonija je kako to nazivamo.
02:50
The pain had spread from her wrist to her hands,
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Bol se proširio sa zgloba na ruku
02:53
to her fingertips, from her wrist up to her elbow,
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do prstiju, od zgloba do lakta
02:56
almost all the way to her shoulder.
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gotovo sve do ramena.
02:58
But the worst part was,
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Ali najgori dio nije bio
03:00
not the spontaneous pain that was there 24 hours a day.
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spontana bol koji je trajala 24 sata na dan.
03:03
The worst part was that she had allodynia,
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Najgori dio bio je da je imala alodiniju,
03:06
the medical term for the phenomenon that I just illustrated
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medicinski termin za fenomen koji sam upravo ilustrirao
03:09
with the feather and with the torch.
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s perom i s bakljom.
03:11
The lightest touch of her arm --
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Najlakši dodir na njenoj ruci --
03:13
the touch of a hand,
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dodir ruke,
03:15
the touch even of a sleeve, of a garment, as she put it on --
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čak dodir rukava, odjeće, koju je nosila --
03:18
caused excruciating, burning pain.
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uzrokovao je iznimno jake, goruće bolove.
03:22
How can the nervous system get this so wrong?
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Kako može živčani sustav tako pogriješiti?
03:25
How can the nervous system
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Kako živčani sustav može
03:27
misinterpret an innocent sensation
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pogrešno interpretirati nevini osjećaj
03:29
like the touch of a hand
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kao što je to dodir ruke
03:31
and turn it into the malevolent sensation
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i pretvoriti ga u zlonamjeran osjećaj
03:34
of the touch of the flame?
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dodira baklje.
03:36
Well you probably imagine that the nervous system in the body
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Pa vjerojatno zamišljate da je živčani sustav u tijelu
03:39
is hardwired like your house.
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umrežen kao što je to vaša kuća.
03:41
In your house, wires run in the wall,
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U vašoj kući žice idu u zid,
03:43
from the light switch to a junction box in the ceiling
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od prekidača do razvodne kutije u stropu
03:46
and from the junction box to the light bulb.
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i od razvodne kutije do žarulje.
03:49
And when you turn the switch on, the light goes on.
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I kad pritisnete prekidač, upali se svjetlo.
03:51
And when you turn the switch off, the light goes off.
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I kad ga opet pritisnete, svjetlo se gasi.
03:54
So people imagine the nervous system is just like that.
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Ljudi zamišljaju da je i živčani sustav upravo takav.
03:58
If you hit your thumb with a hammer,
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Ako se udarite čekićem po palcu,
04:00
these wires in your arm -- that, of course, we call nerves --
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te žice u vašoj ruci -- koje, naravno, zovemo živci --
04:03
transmit the information into the junction box in the spinal cord
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prenose informaciju do razvodne kutije
04:06
where new wires, new nerves,
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gdje nove žice, novi živci,
04:08
take the information up to the brain
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prenose informaciju do mozga
04:10
where you become consciously aware that your thumb is now hurt.
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gdje postajete svjesni da je palac ozlijeđen.
04:14
But the situation, of course, in the human body
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No situacija, naravno, u ljudskom tijelu
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is far more complicated than that.
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je mnogo kompliciranija od toga.
04:19
Instead of it being the case
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Umjesto toga
04:21
that that junction box in the spinal cord
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da je razvodna kutija u leđnoj moždini
04:23
is just simple where one nerve connects with the next nerve
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samo jednostavno mjesto gdje se jedan živac povezuje s drugim
04:26
by releasing these little brown packets
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oslobađanjem malih smeđih paketa
04:28
of chemical information called neurotransmitters
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kemijskih informacija zvanih neurotransmiteri
04:31
in a linear one-on-one fashion,
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na linearan jedan na jedan način,
04:34
in fact, what happens
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ono što se zapravo događa
04:36
is the neurotransmitters spill out in three dimensions --
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je da se neurotransmiteri prospu u tri dimenzije --
04:38
laterally, vertically, up and down in the spinal cord --
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bočno, okomito, gore i dolje u leđnoj moždini --
04:41
and they start interacting
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i počnu međudjelovati
04:43
with other adjacent cells.
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s drugim susjednim stanicama.
04:46
These cells, called glial cells,
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Te stanice, zvane glijalne stanice,
04:48
were once thought to be
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nekoć su se smatrale
04:50
unimportant structural elements of the spinal cord
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nevažnim strukturnim elementima leđne moždine
04:52
that did nothing more than hold all the important things together,
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koji ne rade ništa drugo nego drže važne stvari zajedno,
04:54
like the nerves.
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kao što su živci.
04:56
But it turns out
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No ispada
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the glial cells have a vital role
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da glijalne stanice imaju vitalnu ulogu
05:00
in the modulation, amplification
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u modulaciji, pojačavanju
05:02
and, in the case of pain, the distortion
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i, u slučaju bola, iskrivljenju
05:05
of sensory experiences.
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osjetilnih iskustava.
05:08
These glial cells become activated.
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Te se glijalne stanice aktiviraju.
05:10
Their DNA starts to synthesize new proteins,
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Njihov DNA počinje sintetizirati nove proteine,
05:12
which spill out
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koji se prospu
05:14
and interact with adjacent nerves,
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i reagiraju s susjednim živcima.
05:16
and they start releasing their neurotransmitters,
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I oni počinju oslobađati njihove neurotransmitere.
05:19
and those neurotransmitters spill out
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I ti neurotransmiteri se prospu
05:21
and activate adjacent glial cells, and so on and so forth,
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i aktiviraju susjedne glijalne stanice, i tako dalje, i dalje,
05:24
until what we have
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sve dok ne nastane
05:26
is a positive feedback loop.
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pozitivnu povratnu petlju.
05:28
It's almost as if somebody came into your home
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To je otprilike kao kad bi netko ušao u vašu kuću
05:30
and rewired your walls
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i ponovno postavio žice u zidovima
05:32
so that the next time you turned on the light switch,
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i to tako da se kad sljedeći put upalite svjetlo
05:34
the toilet flushed three doors down,
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ispere toalet tri vrata niže
05:36
or your dishwasher went on,
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ili da se upali stroj za pranje suđa,
05:38
or your computer monitor turned off.
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ili ugasi kompjuterski monitor.
05:40
That's crazy,
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To je suludo,
05:42
but that's, in fact, what happens
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ali to je upravo ono što se događa
05:44
with chronic pain.
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s kroničnom boli.
05:46
And that's why pain becomes its own disease.
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I zbog toga bol postaje bolest sama po sebi.
05:49
The nervous system has plasticity.
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Živčani sustav je plastičan.
05:51
It changes, and it morphs
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Mijenja se i oblikuje se
05:53
in response to stimuli.
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kao odgovor na podražaj.
05:55
Well, what do we do about that?
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Dobro, što ćemo učiniti u vezi toga?
05:57
What can we do in a case like Chandler's?
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Što možemo učiniti u slučaju kao što je Chandlerin?
06:00
We treat these patients in a rather crude fashion
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Liječimo te bolesnike na prilično sirov način
06:02
at this point in time.
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u ovom trenutku.
06:04
We treat them with symptom-modifying drugs --
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Liječimo ih lijekovima koji uklanjaju simptome --
06:07
painkillers --
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lijekovima protiv bolova --
06:09
which are, frankly, not very effective
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koji, iskreno, nisu veoma učinkoviti
06:11
for this kind of pain.
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za ovu vrstu boli.
06:13
We take nerves that are noisy and active
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Uzimamo živce koji su bučni i aktivni,
06:15
that should be quiet,
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a trebali bi biti mirni,
06:17
and we put them to sleep with local anesthetics.
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i uspavljujemo ih lokalnom anestezijom.
06:19
And most importantly, what we do
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I najvažnije što radimo
06:22
is we use a rigorous, and often uncomfortable, process
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je da koristimo krut, i često neugodan, proces
06:26
of physical therapy and occupational therapy
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fizikalne i radne terapije
06:29
to retrain the nerves in the nervous system
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da bismo naučilii živce u živčanom sustavu
06:32
to respond normally
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da odgovaraju normalno
06:35
to the activities and sensory experiences
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na aktivnosti i osjetilna iskustva
06:38
that are part of everyday life.
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koja su dio svakodnevice.
06:40
And we support all of that
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I sve to podržavamo
06:42
with an intensive psychotherapy program
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intenzivnim programom psihoterapije
06:45
to address the despondency, despair and depression
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zbog malodušnosti, očaja i depresije
06:48
that always accompanies
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koji uvijek prate
06:50
severe, chronic pain.
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jaku, kroničnu bol.
06:52
It's successful,
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To je uspješno,
06:54
as you can see from this video of Chandler,
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kao što možete vidjeti na ovom Chandlerinom videu
06:56
who, two months after we first met her,
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koja dva mjeseca nakon našeg prvog susreta,
06:58
is now doings a back flip.
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sada izvodi kolut unazad.
07:00
And I had lunch with her yesterday
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Ručao sam s njom jučer
07:02
because she's a college student studying dance at Long Beach here,
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zato jer studira ples ovdje na Long Beachu.
07:05
and she's doing absolutely fantastic.
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I izvrsno se osjeća.
07:07
But the future is actually even brighter.
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Budućnost je zapravo još svjetlija.
07:11
The future holds the promise
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Budućnost nam pruža nadu
07:14
that new drugs will be developed
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da će biti otkriveni novi lijekovi
07:16
that are not symptom-modifying drugs
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koje neće uklanjati samo simptome
07:19
that simply mask the problem,
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koji jednostavno maskiraju problem.
07:21
as we have now,
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kao što imamo sada,
07:23
but that will be disease-modifying drugs
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nego da će postojati lijekovi koji uklanjaju bolest
07:26
that will actually go right to the root of the problem
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koji će zapravo ići do korijena problema
07:28
and attack those glial cells,
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i napasti te glijalne stanice
07:30
or those pernicious proteins
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ili štetne proteine
07:32
that the glial cells elaborate,
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koje stvaraju glijalne stanice,
07:35
that spill over and cause this central nervous system wind-up,
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koje se prospu i uzrokuju paralizu središnjeg živčanog sustava,
07:38
or plasticity,
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ili plastičnost,
07:40
that so is capable
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koja može
07:42
of distorting and amplifying
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iskriviti i pojačati
07:44
the sensory experience that we call pain.
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osjetilno iskustvo koje nazivamo bol.
07:46
So I have hope
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Pa se nadam
07:48
that in the future,
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da će ubuduće
07:50
the prophetic words of George Carlin will be realized,
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proročanske riječi Georga Carlina biti ostvarene.
07:53
who said, "My philosophy:
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koji je rekao: "Moja filozofija?
07:55
No pain, no pain."
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Bez boli, bez boli.
07:59
Thank you very much.
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Mnogo vam hvala.
08:01
(Applause)
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(Pljesak)
ABOUT THE SPEAKER
Elliot Krane - Pediatric anesthesiologistAt 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.
Elliot Krane | Speaker | TED.com