TED2011
Elliot Krane: The mystery of chronic pain
義律•昆: 揭開慢性痛楚嘅奧秘
Filmed:
Readability: 4.4
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我地將痛楚作為一種症狀，但係有啲案例顯示神經系統會發展成為一個個反饋迴路構成痛楚，所以哩種痛楚本身就會成為可怕嘅疾病。我地從一個女仔扭傷手腕後演變成一場噩夢作為開場，義律•昆解開復雜慢性痛楚嘅奧秘。同時評估對於哩種了解未深嘅慢性疼楚可以採取乜嘢護理同埋控制方法。
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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我係一名小兒科醫師亦係麻醉師，
00:17
so I put children to sleep for a living.
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我靠催眠D細路賺錢謀生。
00:19
(Laughter)
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（笑聲）
00:21
And I'm an academic, so I put audiences to sleep for free.
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我仲係一名學者，我可以唔使錢催眠聽眾。
00:24
(Laughter)
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（笑聲）
00:28
But what I actually mostly do
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但事實上我最做得最多嘅
00:30
is I manage the pain management service
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係喺帕洛阿爾托市斯坦福帕卡德兒童醫院
00:32
at the Packard Children's Hospital up at Stanford in Palo Alto.
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進行痛楚管理。
00:35
And it's from the experience
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喺果度嘅
00:37
from about 20 or 25 years of doing that
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有20至25年經驗
00:39
that I want to bring to you the message this morning,
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今日我想話比你地聽，
00:41
that pain is a disease.
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痛楚係一種疾病。
00:43
Now most of the time,
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大多数情况，
00:45
you think of pain as a symptom of a disease,
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你將痛楚睇成疾病嘅一種症狀。
00:47
and that's true most of the time.
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好多時候都係啱嘅。
00:49
It's the symptom of a tumor or an infection
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佢可以係腫瘤或某種感染
00:52
or an inflammation or an operation.
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或者係某種炎症亦或者係手術嘅症狀。
00:54
But about 10 percent of the time,
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但係有大概10%嘅情况，
00:57
after the patient has recovered from one of those events,
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患者從以上所講嘅情況恢復之後，
01:00
pain persists.
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痛楚仍然持續。
01:02
It persists for months
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而且持續好幾個月,
01:04
and oftentimes for years,
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好多時仲係幾年。
01:06
and when that happens,
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哩種情況發生果陣，
01:08
it is its own disease.
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佢就係疾病。
01:10
And before I tell you about how it is that we think that happens
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喺我講比你地聽佢點樣產生之前
01:13
and what we can do about it,
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以及我地可以點做之前，
01:15
I want to show you how it feels for my patients.
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我想同你地講下我D病人嘅感受。
01:18
So imagine, if you will,
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如果可以，請你地想像一吓，
01:20
that I'm stroking your arm with this feather,
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我用哩條羽毛掃你你嘅手臂，
01:22
as I'm stroking my arm right now.
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就好似兒家我就掃緊自己。
01:25
Now, I want you to imagine
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請你地兒家開始想像吓
01:27
that I'm stroking it with this.
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我用佢掃過哩度。
01:29
Please keep your seat.
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大家坐好D啊
01:31
(Laughter)
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（笑聲）
01:33
A very different feeling.
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好唔同嘅感覺。
01:35
Now what does it have to do with chronic pain?
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咁樣同慢性痛楚有咩關係呢？
01:37
Imagine, if you will, these two ideas together.
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想像吓，如果你將哩兩個想法混埋一齊。
01:40
Imagine what your life would be like
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想像你嘅生活會系點
01:42
if I were to stroke it with this feather,
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如果我用羽毛掃過呢度，
01:45
but your brain was telling you
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但係你嘅大腦會話比你聽
01:47
that this is what you are feeling --
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哩個就係你嘅感覺
01:49
and that is the experience of my patients with chronic pain.
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哩個就係我哥個慢性痛楚病人嘅經歷。
01:52
In fact, imagine something even worse.
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事實上，試想像某些更壞嘅事情。
01:54
Imagine I were to stroke your child's arm with this feather,
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想像我用羽毛掃過你細路嘅手臂，
01:57
and their brain [was] telling them
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佢地嘅大腦會話比佢地聽
01:59
that they were feeling this hot torch.
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佢地感覺到哩把高溫火焰。
02:02
That was the experience of my patient, Chandler,
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哩個就係我個病人Chandler嘅經歷，
02:04
whom you see in the photograph.
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哩張係佢幅相。
02:06
As you can see, she's a beautiful, young woman.
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你地見到佢係一個靚女。
02:08
She was 16 years old last year when I met her,
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我識佢果陣佢先至16歲，
02:10
and she aspired to be a professional dancer.
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佢渴望成為一位職業舞蹈員。
02:13
And during the course of one of her dance rehearsals,
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喺佢一次舞蹈排練嘅過程中，
02:15
she fell on her outstretched arm and sprained her wrist.
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佢跌親壓住咗伸出嘅手臂，跟住扭親埋手腕
02:18
Now you would probably imagine, as she did,
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兒家你地大概可以想象就好似佢感，
02:20
that a wrist sprain is a trivial event
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扭傷手腕喺人生中
02:22
in a person's life.
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只不過係件小事。
02:24
Wrap it in an ACE bandage,
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只需用ACE繃帶包紮吓，
02:26
take some ibuprofen for a week or two,
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只食一到兩個星期嘅布洛芬止痛藥,
02:28
and that's the end of the story.
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就無乜事喇。
02:30
But in Chandler's case, that was the beginning of the story.
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不過喺Chandler嘅病例中，服藥只係故事嘅開始。
02:34
This is what her arm looked like
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哩個係佢手臂嘅樣
02:36
when she came to my clinic about three months after her sprain.
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佢扭傷咗大概3個星期後先來穩我。
02:39
You can see that the arm is discolored,
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你地可以睇到佢嘅手臂，
02:41
purplish in color.
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已經褪色同埋發紫。
02:43
It was cadaverically cold to the touch.
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摸上去好似屍體咁凍。
02:45
The muscles were frozen, paralyzed --
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肌肉僵硬、麻痹、
02:47
dystonic is how we refer to that.
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張力障礙。
02:50
The pain had spread from her wrist to her hands,
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痛楚從腕部擴展到手，
02:53
to her fingertips, from her wrist up to her elbow,
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再到手指，痛楚從手腕擴展到肘部，
02:56
almost all the way to her shoulder.
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甚至幾乎到左肩部。
02:58
But the worst part was,
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最惨嘅係，
03:00
not the spontaneous pain that was there 24 hours a day.
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並唔係自發嘅整日痛楚。
03:03
The worst part was that she had allodynia,
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最慘嘅系佢掂下野就會痛，
03:06
the medical term for the phenomenon that I just illustrated
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醫學上叫觸痛
03:09
with the feather and with the torch.
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同剛才羽毛、高溫火焰一樣。
03:11
The lightest touch of her arm --
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輕輕觸摸佢嘅手臂、
03:13
the touch of a hand,
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手，
03:15
the touch even of a sleeve, of a garment, as she put it on --
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甚至係衣袖
03:18
caused excruciating, burning pain.
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都會引發劇烈的、燒灼般嘅痛苦。
03:22
How can the nervous system get this so wrong?
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神經系統系點解會錯成咁樣？
03:25
How can the nervous system
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點解神經系統
03:27
misinterpret an innocent sensation
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誤解咗一個無辜嘅知覺
03:29
like the touch of a hand
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就好似摸佢隻手
03:31
and turn it into the malevolent sensation
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會變成惡毒嘅知覺
03:34
of the touch of the flame?
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火焰燒灼般嘅觸覺。
03:36
Well you probably imagine that the nervous system in the body
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你大概可以想像機體中嘅神經系統
03:39
is hardwired like your house.
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就好似你屋企裡面嘅導線。
03:41
In your house, wires run in the wall,
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在屋企裡面，導線佈滿牆壁，
03:43
from the light switch to a junction box in the ceiling
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從開關制到天花板嘅連接盒
03:46
and from the junction box to the light bulb.
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從連接盒到燈泡。
03:49
And when you turn the switch on, the light goes on.
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當你開開關制，燈就著。
03:51
And when you turn the switch off, the light goes off.
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當你關閉開關制，燈就熄。
03:54
So people imagine the nervous system is just like that.
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就用咁嘅方式想像神經系統。
03:58
If you hit your thumb with a hammer,
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如果一個錘打傷你嘅手指，
04:00
these wires in your arm -- that, of course, we call nerves --
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你手臂嘅導線，當然，我地稱為神經
04:03
transmit the information into the junction box in the spinal cord
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將信息傳入脊髓裡面嘅連接盒
04:06
where new wires, new nerves,
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脊髓入面嘅新嘅線路、新嘅神經，
04:08
take the information up to the brain
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將信息上傳到大腦
04:10
where you become consciously aware that your thumb is now hurt.
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你意識到你嘅手指受咗傷。
04:14
But the situation, of course, in the human body
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不過在哩種情況下，當然，在人體內
04:16
is far more complicated than that.
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要比哩個複雜好多。
04:19
Instead of it being the case
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並唔係甘純粹
04:21
that that junction box in the spinal cord
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連接盒在脊髓入邊
04:23
is just simple where one nerve connects with the next nerve
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神經之間嘅聯繫非常簡單
04:26
by releasing these little brown packets
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通過釋放哩D棕色包裹
04:28
of chemical information called neurotransmitters
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內涵化學信息，我地叫佢做神經遞質
04:31
in a linear one-on-one fashion,
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線性一一傳導信息，
04:34
in fact, what happens
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事實上，
04:36
is the neurotransmitters spill out in three dimensions --
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神經遞質嘅釋放在三維空間裡進行
04:38
laterally, vertically, up and down in the spinal cord --
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脊髓入面：橫向，縱向，垂直
04:41
and they start interacting
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佢地開始與相連嘅細胞
04:43
with other adjacent cells.
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相互作用
04:46
These cells, called glial cells,
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哩D細胞叫做膠質細胞，
04:48
were once thought to be
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之前被認為係
04:50
unimportant structural elements of the spinal cord
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脊髓中最唔重要嘅結構元素
04:52
that did nothing more than hold all the important things together,
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除咗幫助所有重要嘅好似神經細胞甘嘅物質
04:54
like the nerves.
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聚合在一齊之外，無其他用途。
04:56
But it turns out
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不過其實
04:58
the glial cells have a vital role
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膠質細胞扮演著一個重要角色
05:00
in the modulation, amplification
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在調製，放大
05:02
and, in the case of pain, the distortion
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同埋痛楚、扭曲
05:05
of sensory experiences.
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嘅感覺體驗入邊，
05:08
These glial cells become activated.
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哩D膠質細胞被激活
05:10
Their DNA starts to synthesize new proteins,
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佢地嘅DNA開始合成
05:12
which spill out
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新蛋白跟住釋放出来。
05:14
and interact with adjacent nerves,
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同相連嘅神經相互作用，
05:16
and they start releasing their neurotransmitters,
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佢地開始釋放神經遞質
05:19
and those neurotransmitters spill out
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果D神經遞質釋放出去
05:21
and activate adjacent glial cells, and so on and so forth,
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激活相連嘅膠質細胞，一直持續向前，
05:24
until what we have
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直到找到
05:26
is a positive feedback loop.
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一個確定嘅反饋迴路。
05:28
It's almost as if somebody came into your home
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就好似有人来到你屋企
05:30
and rewired your walls
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重新在牆上拉線，
05:32
so that the next time you turned on the light switch,
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跟住下一次你開燈哥陣，
05:34
the toilet flushed three doors down,
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馬桶開始自動沖洗，
05:36
or your dishwasher went on,
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或者係你嘅洗碗機開咗，
05:38
or your computer monitor turned off.
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或者係你嘅電腦屏幕開咗。
05:40
That's crazy,
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太瘋狂了，
05:42
but that's, in fact, what happens
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但實際上就係咁 ——
05:44
with chronic pain.
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慢性痛楚嘅情况。
05:46
And that's why pain becomes its own disease.
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也就係由痛楚變成疾病嘅原因。
05:49
The nervous system has plasticity.
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神經系統有可塑性，
05:51
It changes, and it morphs
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佢會改變，會變換
05:53
in response to stimuli.
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作為刺激嘅回應。
05:55
Well, what do we do about that?
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好，咁我地打算點做呢？
05:57
What can we do in a case like Chandler's?
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Chandler嘅病例我地可以點做？
06:00
We treat these patients in a rather crude fashion
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目前我地對於哩D患者嘅治療方法
06:02
at this point in time.
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仲停留在非常粗糙嘅階段。
06:04
We treat them with symptom-modifying drugs --
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我地用可以改變症狀嘅藥物來治療佢地
06:07
painkillers --
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止痛药
06:09
which are, frankly, not very effective
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講真，對於哩類痛楚來講
06:11
for this kind of pain.
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唔係特別有效。
06:13
We take nerves that are noisy and active
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對於本來安靜但係現在
06:15
that should be quiet,
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亢奮過度嘅神經，
06:17
and we put them to sleep with local anesthetics.
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我地用局部麻醉方式令到佢地休眠。
06:19
And most importantly, what we do
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最重要嘅係，我地所做嘅
06:22
is we use a rigorous, and often uncomfortable, process
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係用一個嚴格嘅進程，通常並唔咁係舒服嘅
06:26
of physical therapy and occupational therapy
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物理治療同職業療法
06:29
to retrain the nerves in the nervous system
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喺神經系統入面重新訓練神經
06:32
to respond normally
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使到能正常應答
06:35
to the activities and sensory experiences
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尤其係果D日常生活嘅所有
06:38
that are part of everyday life.
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正常活動同感覺體驗。
06:40
And we support all of that
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我地全力支持
06:42
with an intensive psychotherapy program
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用密集嘅心裡療法計劃
06:45
to address the despondency, despair and depression
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打擊嚴重慢性痛楚所引起嘅
06:48
that always accompanies
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失望、绝望、
06:50
severe, chronic pain.
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憂慮症狀。
06:52
It's successful,
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Chandler嘅病例係成功嘅，
06:54
as you can see from this video of Chandler,
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你地睇到嘅視頻来自Chandler，
06:56
who, two months after we first met her,
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兩個月後嘅现在，
06:58
is now doings a back flip.
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正在進行後翻身跳轉。
07:00
And I had lunch with her yesterday
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我我昨天同佢一齊吃午餐，
07:02
because she's a college student studying dance at Long Beach here,
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因為佢喺在長灘市嘅大學學習舞蹈。
07:05
and she's doing absolutely fantastic.
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佢表演得太好了。
07:07
But the future is actually even brighter.
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未來會更加精彩。
07:11
The future holds the promise
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未來將承諾
07:14
that new drugs will be developed
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新藥將會發展
07:16
that are not symptom-modifying drugs
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成唔係症狀控制嘅藥物
07:19
that simply mask the problem,
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我地現在哩D藥物，
07:21
as we have now,
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太輕易地掩飾痛楚。
07:23
but that will be disease-modifying drugs
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但係改變症狀嘅藥物
07:26
that will actually go right to the root of the problem
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將會真正瞄準問題嘅本源
07:28
and attack those glial cells,
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攻擊果D會擴張神經膠質細胞
07:30
or those pernicious proteins
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產生有害蛋白
07:32
that the glial cells elaborate,
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有害嘅蛋白，
07:35
that spill over and cause this central nervous system wind-up,
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佢地嘅釋放會終結可塑嘅
07:38
or plasticity,
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樞神經系統，
07:40
that so is capable
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咁樣就可以扭曲同放大
07:42
of distorting and amplifying
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感覺體驗嘅能力
07:44
the sensory experience that we call pain.
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我地稱之為痛楚。
07:46
So I have hope
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所以我希望
07:48
that in the future,
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在未来，
07:50
the prophetic words of George Carlin will be realized,
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George Carlin嘅预言可以被咁樣理解，
07:53
who said, "My philosophy:
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佢話：我嘅哲學：
07:55
No pain, no pain."
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“唔痛，唔痛”
07:59
Thank you very much.
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多谢大家
08:01
(Applause)
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（鼓掌）
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