TED2011
Elliot Krane: The mystery of chronic pain
Eliot Krejn: Misterija hroničnog bola.
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Mi mislimo o bolu kao o simptomu, ali postoje slučajevi kad nervni sistem razvije povratne petlje i bol postaje zastrašujuća bolest sama po sebi. Počevši od priče o devojci čiji se iščašeni zglob pretvorio u noćnu moru, Eliot Krejn govori o komplikovanoj misteriji hroničnog bola i analizira činjenice o kojima tek učimo, o tome kako nastaje i kako ga lečiti.
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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Ja sam pedijatar i anesteziolog,
00:17
so I put children to sleep for a living.
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dakle ja uspavljujem decu da bih zaradio.
00:19
(Laughter)
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(Smeh)
00:21
And I'm an academic, so I put audiences to sleep for free.
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Ja sam i akademik, dakle ja uspavljujem publiku besplatno
00:24
(Laughter)
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(Smeh)
00:28
But what I actually mostly do
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Ali ono čime se najviše bavim
00:30
is I manage the pain management service
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je rukovođenje službe za upravljanje bolom
00:32
at the Packard Children's Hospital up at Stanford in Palo Alto.
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u dečijoj Packard bolnici na Stenfordu u Palo Altu.
00:35
And it's from the experience
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Iz iskustva dugog
00:37
from about 20 or 25 years of doing that
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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 jutra želim vam preneti poruku
00:41
that pain is a disease.
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da je bol bolest.
00:43
Now most of the time,
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Većinom vremena,
00:45
you think of pain as a symptom of a disease,
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razmišljate o bolu kao o simptompu oboljenja.
00:47
and that's true most of the time.
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I to je tačno većinom vremena.
00:49
It's the symptom of a tumor or an infection
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Bol 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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Ali 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 ovih događaja,
01:00
pain persists.
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bol ne popušta.
01:02
It persists for months
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Ostaje mesecima,
01:04
and oftentimes for years,
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a često i godinama
01:06
and when that happens,
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I kad se to dogodi,
01:08
it is its own disease.
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bol postaje posebna bolest.
01:10
And before I tell you about how it is that we think that happens
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I pre nego što vam kazem kako mi mislimo da se to događa
01:13
and what we can do about it,
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i šta mi radimo povodom toga,
01:15
I want to show you how it feels for my patients.
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želim da vam pokažem kako to moji pacijenti osećaju.
01:18
So imagine, if you will,
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Zamislite sada, ako želite
01:20
that I'm stroking your arm with this feather,
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da ja dodirujem vašu ruku ovim perom,
01:22
as I'm stroking my arm right now.
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kao što diram svoju.
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 vas dodirujem sa ovim.
01:29
Please keep your seat.
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Molim vas ostanite na svojim mestima.
01:31
(Laughter)
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(Smeh)
01:33
A very different feeling.
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Veoma različit osećaj.
01:35
Now what does it have to do with chronic pain?
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Kakve to veze ima sa hroničnim bolom?
01:37
Imagine, if you will, these two ideas together.
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Zamislite, ako želite, ove dve 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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ako bih vas ja dodirnuo ovim perom,
01:45
but your brain was telling you
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ali vaš mozak bi vam govorio
01:47
that this is what you are feeling --
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da je ovo ono što vi osećate
01:49
and that is the experience of my patients with chronic pain.
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i to je iskustvo pacijeta sa hroničnim bolom.
01:52
In fact, imagine something even worse.
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Ustvari, zamislite nešto još gore.
01:54
Imagine I were to stroke your child's arm with this feather,
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Zamislite da sam dodirnuo vaše dete ovim perom,
01:57
and their brain [was] telling them
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i njihov mozak bi im govorio
01:59
that they were feeling this hot torch.
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da osete ovaj vreo gorionik.
02:02
That was the experience of my patient, Chandler,
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Ovo je iskustvo moje pacijentkinje Čendler,
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 vidite ona je prelepa mlada devojka.
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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i želela je da postane profesionalna plesačica.
02:13
And during the course of one of her dance rehearsals,
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I tokom jedne plesne probe,
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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Sad vi verovatno razmišljate, kao što je ona,
02:20
that a wrist sprain is a trivial event
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da je uganuće zgloba beznačajan događaj
02:22
in a person's life.
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u životu osobe.
02:24
Wrap it in an ACE bandage,
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Zavijete ga sa elastičnim zavojem,
02:26
take some ibuprofen for a week or two,
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uzimate brufen nedelju ili dve dana,
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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Ali kod Čendler, to je bio početak priče.
02:34
This is what her arm looked like
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Ovo je izgled njene ruke kada
02:36
when she came to my clinic about three months after her sprain.
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je došla u moju kliniku posle tri meseca od uganuća.
02:39
You can see that the arm is discolored,
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Možete videti da je ruka promenila boju,
02:41
purplish in color.
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postala je ljubičasta.
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, paralizovani --
02:47
dystonic is how we refer to that.
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mi to nazivamo diatonija.
02:50
The pain had spread from her wrist to her hands,
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Bol se širio od njenog zgloba prema njenom dlanu,
02:53
to her fingertips, from her wrist up to her elbow,
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do njenih prstiju, od zgloba ka njenom laktu,
02:56
almost all the way to her shoulder.
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skoro do njenog ramena.
02:58
But the worst part was,
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Ali najgori deo je bio,
03:00
not the spontaneous pain that was there 24 hours a day.
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ne njen spontani bol koji je trajao 24 časa dnevno.
03:03
The worst part was that she had allodynia,
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Najgori deo je bio to što je ona imala alodiniju,
03:06
the medical term for the phenomenon that I just illustrated
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medicinski naziv za fenomen koji sam vam malopre pokazao
03:09
with the feather and with the torch.
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sa perom i gorionikom.
03:11
The lightest touch of her arm --
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Najnežniji dodir po njenoj ruci --
03:13
the touch of a hand,
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dodir šake,
03:15
the touch even of a sleeve, of a garment, as she put it on --
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dodir čak i od rukava, odeće, dok se oblačila --
03:18
caused excruciating, burning pain.
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izazivao bi veoma jake, peckajuće bolove.
03:22
How can the nervous system get this so wrong?
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Kako nervni sistem može tako da pogreši?
03:25
How can the nervous system
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Kako nervni sistem može
03:27
misinterpret an innocent sensation
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pogrešno protumačiti nervni nadražaj
03:29
like the touch of a hand
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kao što je dodir ruke
03:31
and turn it into the malevolent sensation
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i pretvoriti ga u zlonameran osećaj
03:34
of the touch of the flame?
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dodira gorionika.
03:36
Well you probably imagine that the nervous system in the body
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Vi sigurno zamišljate da je nervni sistem u telu
03:39
is hardwired like your house.
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umrežen kao vaša kuća.
03:41
In your house, wires run in the wall,
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U vašoj kući, žice prolaze kroz zidove,
03:43
from the light switch to a junction box in the ceiling
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od prekidača do razvodne kutije na plafonu
03:46
and from the junction box to the light bulb.
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i od razvodne kutije do sijalice.
03:49
And when you turn the switch on, the light goes on.
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I kada uključite prekidač i sijalica se upali.
03:51
And when you turn the switch off, the light goes off.
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A kada isključite prekidač i sijalica se ugasi.
03:54
So people imagine the nervous system is just like that.
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Dakle ljudi zamišljaju nervni sistem tako.
03:58
If you hit your thumb with a hammer,
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Ako udarite palac čekićem,
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 nervne ćelije --
04:03
transmit the information into the junction box in the spinal cord
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prenose informaciju u razvodnu kutiju u kičmenoj moždini
04:06
where new wires, new nerves,
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gde nove žice, novi nervi,
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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gde vi postajete svesni da vas palac boli.
04:14
But the situation, of course, in the human body
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Ali situacija, naravno, u ljudskom telu
04:16
is far more complicated than that.
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je mnogo komplikovanija.
04:19
Instead of it being the case
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Umesto toga
04:21
that that junction box in the spinal cord
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da je razvodna kutija u kičmenoj moždini
04:23
is just simple where one nerve connects with the next nerve
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samo običan spoj gde se jedan nerv povezuje sa sledećim
04:26
by releasing these little brown packets
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otpuštajući ove male braon pakete
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of chemical information called neurotransmitters
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hemijske informacije nazvane neurotransmiteri
04:31
in a linear one-on-one fashion,
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na linearan način, jedan-na-jedan,
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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jeste da se neurotransmiteri prosipaju u tri dimenzije --
04:38
laterally, vertically, up and down in the spinal cord --
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doslovno, vertikalno, dole i gore u kičmenoj moždini --
04:41
and they start interacting
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i počinju da reaguju
04:43
with other adjacent cells.
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sa drugim susednim ćelijama
04:46
These cells, called glial cells,
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Za te ćelije, nazvane glijalne ćelije,
04:48
were once thought to be
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se mislilo da su nevažni
04:50
unimportant structural elements of the spinal cord
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strukturni elementi kičmene moždine koji
04:52
that did nothing more than hold all the important things together,
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nisu radili ništa više od držanja važnih ćelija zajedno,
04:54
like the nerves.
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kao na primer nervnih ćelija.
04:56
But it turns out
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Ali se ispostavilo
04:58
the glial cells have a vital role
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da glijalne ćelije 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, distorziji
05:05
of sensory experiences.
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osećajnog iskustva.
05:08
These glial cells become activated.
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Ove glijalne ćelije su postale aktivne.
05:10
Their DNA starts to synthesize new proteins,
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Njihova DNK je počela da sintetiše nove proteine,
05:12
which spill out
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koju su se prosipali
05:14
and interact with adjacent nerves,
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i reagovali sa susednim nervima.
05:16
and they start releasing their neurotransmitters,
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I onda oni počnu oslobađati svoje neuro transmitere.
05:19
and those neurotransmitters spill out
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I ti neurotransmiteri se prosipaju
05:21
and activate adjacent glial cells, and so on and so forth,
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i aktiviraju susedne glijalne ćelije i tako dalje,
05:24
until what we have
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dok ne dobijemo
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 kao kada bi vam neko došao u kuću
05:30
and rewired your walls
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i zapetljao žice u vašim zidovima,
05:32
so that the next time you turned on the light switch,
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tako da kada sledeći put upalite svetlo,
05:34
the toilet flushed three doors down,
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vaš vodokotlić pusti vodu tri sobe dalje,
05:36
or your dishwasher went on,
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ili vaša mašina za pranje sudova se upali,
05:38
or your computer monitor turned off.
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ili se vaš monitor od kompjutera ugasi.
05:40
That's crazy,
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To je ludo,
05:42
but that's, in fact, what happens
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ali to je ustvari, ono što se događa
05:44
with chronic pain.
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sa hroničnim bolom.
05:46
And that's why pain becomes its own disease.
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I tako bol postaje zasebno oboljenje.
05:49
The nervous system has plasticity.
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Nervini sistem je plastičan.
05:51
It changes, and it morphs
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Menja se i oblikuje
05:53
in response to stimuli.
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kao odgovor na nadražaj.
05:55
Well, what do we do about that?
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Dobro, šta da učinimo povodom toga?
05:57
What can we do in a case like Chandler's?
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Šta da radimo u slučajevima kao što je Čendler?
06:00
We treat these patients in a rather crude fashion
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Lečimo obolele na prlično 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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Lečimo ih lekovima protiv simptoma --
06:07
painkillers --
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lekovima protiv bola --
06:09
which are, frankly, not very effective
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koji nisu baš delotvorni
06:11
for this kind of pain.
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za ovu vrstu bola.
06:13
We take nerves that are noisy and active
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Uzimamo nerve koji su bučni i aktivni
06:15
that should be quiet,
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a koji bi trebalo da su tihi,
06:17
and we put them to sleep with local anesthetics.
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i uspavljujemo ih sa 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 rigorozne i često neugodne, procese
06:26
of physical therapy and occupational therapy
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fizičke terapije i radne terapije
06:29
to retrain the nerves in the nervous system
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da bi naučili nerve u nervnom sistemu
06:32
to respond normally
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da reaguju normalno
06:35
to the activities and sensory experiences
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na aktivnosti i osećajna iskustva
06:38
that are part of everyday life.
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koja su svakodnevica.
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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sa intezivnim psihoterapijskim programom
06:45
to address the despondency, despair and depression
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da bi prevazišli malodušnost, očaj i depresiju
06:48
that always accompanies
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koji uvek prate
06:50
severe, chronic pain.
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jak, hronični bol.
06:52
It's successful,
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To je uspešno,
06:54
as you can see from this video of Chandler,
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kao što možete videti iz snimka o Čendler,
06:56
who, two months after we first met her,
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koja je, dva meseca nakon što sam je prvi put sreo,
06:58
is now doings a back flip.
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počela da radi kolut unazad.
07:00
And I had lunch with her yesterday
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Juče sam ručao s njom,
07:02
because she's a college student studying dance at Long Beach here,
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ona studira ples ovde u Long Biču.
07:05
and she's doing absolutely fantastic.
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I ide joj apsolutno fantastično.
07:07
But the future is actually even brighter.
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Ali budućnost je ustvari još svetlija.
07:11
The future holds the promise
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Budućnost obećava
07:14
that new drugs will be developed
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da će biti napravljeni novi lekovi
07:16
that are not symptom-modifying drugs
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koji 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, nego
07:23
but that will be disease-modifying drugs
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koji će ustvari uklanjati oboljenja
07:26
that will actually go right to the root of the problem
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koji će zapravo ići pravo do korena problema
07:28
and attack those glial cells,
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i napasti te glijalne ćelije,
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 proizvodi glijalna ćelija,
07:35
that spill over and cause this central nervous system wind-up,
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koji se prospu i uzrokuju paralizu centralnog nervnog sistema,
07:38
or plasticity,
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ili plastičnost,
07:40
that so is capable
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koja je sposobna
07:42
of distorting and amplifying
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da menja ili pojačava
07:44
the sensory experience that we call pain.
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osećajno iskustvo koje nazivamo bol.
07:46
So I have hope
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Ja se nadam
07:48
that in the future,
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da će u budućnosti, biti
07:50
the prophetic words of George Carlin will be realized,
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ostvarene proročanske reči Džordža Karlina,
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 bola, nema bola."
07:59
Thank you very much.
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Mnogo vam hvala.
08:01
(Applause)
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(Aplauz)
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