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我是一名小兒科及麻醉科醫生，所以我靠把孩子們弄睡來賺錢生活。（笑聲）我也是個專業學者，所以會免費催眠聽眾睡覺。（笑聲）但實際上，我大部份的時間是在位於Palo Alto的史丹佛大學附設兒童醫院從事疼痛管理服務。以我從事這個工作大約20年或25年的經驗，今天上午我想向你們傳遞一個訊息：疼痛是一種疾病。
大部份時候我們都覺得疼痛是疾病引起的一種症狀，大部份時候這是對的。這是腫瘤、感染、發炎或手術後的症狀，但大約有百分之十的時候，當病人從上述情形中痊癒後，疼痛仍然存在，有時持續幾個月，甚至常常疼痛多年。當發生這種情況時，疼痛本身就是一種疾病。在我告訴你們，我們認為為何會發生這種情形，以及治療它的方法之前，我想讓你們瞭解我病人疼痛的感覺。如果你願意，想像一下，我正用這個羽毛輕撫你的手臂，就像我現在輕撫自己手臂一樣。現在，我要你想像我用這個（噴火槍火焰）來撫摸你的手臂。請坐好，不要跑掉。（笑聲）一個非常不同的感覺。這跟慢性疼痛有什麼關係？如果你願意，想像一下，把這兩個例子擺在一起，想像一下你的生活會是什麼情形，如果我用羽毛碰觸你，但你的大腦卻告訴你這就是你的感覺（被火紋身）。
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以下為系統擷取之英文原文
I'm a pediatrician and an anesthesiologist, so I put children to sleep for a living. (Laughter) And I'm an academic, so I put audiences to sleep for free. (Laughter) But what I actually mostly do is a manage the pain management service at the Packard Children's Hospital up at Stanford in Palo Alto. And it's from the experience from about 20 or 25 years of doing that that I want to bring to you the message this morning, that pain is a disease.
Now most of the time, you think of pain as a symptom of a disease. And that's true most of the time. It's the symptom of a tumor or an infection or an inflammation or an operation. But about 10 percent of the time, after the patient has recovered from one of those events, pain persists. It persists for months and oftentimes for years. And when that happens, it is its own disease. And before I tell you about how it is that we think that happens and what we can do about it, I want to show you how it feels for my patients. So imagine, if you will, that I'm stroking your arm with this feather, as I'm stroking my arm right now. Now, I want you to imagine that I'm stroking it with this. Please keep your seat. (Laughter) A very different feeling. Now what does it have to do with chronic pain? Imagine, if you will, these two ideas together. Imagine what your life would be like if I were to stroke it with this feather, but your brain was telling you that this is what you are feeling -- and that is the experience of my patients with chronic pain. In fact, imagine something even worse. Imagine I were to stroke your child's arm with this feather, and their brain [was] telling them that they were feeling this hot torch.
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這就是我的病人對慢性疼痛的經驗。事實上，想像更糟的，想像我用羽毛碰觸你孩子的手臂，他們的大腦卻告訴他們，他們正被這個熾熱的火炬煎烤著，這就是我病人Chandler的經驗。這是她的照片，正如你們所見，她是個美麗年輕的女孩，去年我見到她時，她16歲，她渴望成為一名專業舞者。在一次舞蹈排練過程中，她跌倒時伸出手臂支撐，扭傷了手腕。你可能會以為，她也是這麼認為的，手腕扭傷是日常生活中一個很小的事件，只要用ACE繃帶纏繞手腕，再吃一兩個星期的布洛芬止痛藥就沒事了。但對Chandler而言，她的血淚史才剛開始。這是她來我診所時手臂的樣子，大概是發生意外扭傷三個月後。你可以看到那手臂已變色，帶點紫色，摸起來有屍體一樣的冰冷感覺。肌肉已經凍結癱瘓，即所謂的肌肉張力異常，疼痛已從她的手腕擴散到手到指尖，並從手腕蔓延到手肘，幾乎一路延伸到肩膀。
但最糟的部份，並非是一天24小時持續的自發性疼痛，最糟的部份是，她有觸感痛症，這是這種症狀的醫學術語，即我之前所描述的羽毛與火炬的感受。對她手臂最輕微的觸摸，碰觸她的手，甚至是穿衣服時被衣袖、衣服碰到，都會引起難以忍受的灼痛。神經系統怎麼會錯得那麼離譜?
為什麼神經系統會曲解一個無害的感覺，例如將手被摸到，轉達成被火焰灼傷的惡意感覺?你可能會想像，人體內的神經系統就像屋內的電線系統。在屋內，電線被嵌在牆壁裡，從電燈開關到天花板裡的接線盒，再從接線盒到燈泡。當你打開開關，燈會亮起；而當你關閉開關，燈就熄滅。因此，大家想像神經系統就像這樣。如果你的拇指被錘子打到，你手臂裡的電線，當然，我們稱之為神經，傳遞訊息到脊髓中的接線盒，在那裡，新電線，即新神經，傳遞訊息到大腦，然後你會意識到你的拇指受傷了。
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That was the experience of my patient, Chandler, whom you see in the photograph. As you can see, she's a beautiful, young woman. She was 16 years old last year when I met her, and she aspired to be a professional dancer. And during the course of one of her dance rehearsals, she fell on her outstretched arm and sprained her wrist. Now you would probably imagine, as she did, that a wrist sprain is a trivial event in a person's life. Wrap it in an ACE bandage, take some ibuprofen for a week or two, and that's the end of the story. But in Chandler's case, that was the beginning of the story. This is what her arm looked like when she came to my clinic about three months after her sprain. You can see that the arm is discolored, purplish in color. It was cadaverically cold to the touch. The muscles were frozen, paralyzed -- dystonic is how we refer to that. The pain had spread from her wrist to her hands, to her fingertips, from her wrist up to her elbow, almost all the way to her shoulder.
But the worst part was, not the spontaneous pain that was there 24 hours a day. The worst part was that she had allodynia, the medical term for the phenomenon that I just illustrated with the feather and with the torch. The lightest touch of her arm -- the touch of a hand, the touch even of a sleeve, of a garment, as she put it on -- caused excruciating, burning pain.
How can the nervous system get this so wrong? How can the nervous system misinterpret an innocent sensation like the touch of a hand and turn it into the malevolent sensation of the touch of the flame. Well you probably imagine that the nervous system in the body is hardwired like your house. In your house, wires run in the wall, from the light switch to a junction box in the ceiling and from the junction box to the light bulb. And when you turn the switch on, the light goes on. And when you turn the switch off, the light goes off. So people imagine the nervous system is just like that. If you hit your thumb with a hammer, these wires in your arm -- that, of course, we call nerves -- transmit the information into the junction box in the spinal cord where new wires, new nerves, take the information up to the brain where you become consciously aware that your thumb is now hurt.
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當然，人體內的情況比這複雜得多，並不單純像是在脊髓內的接線盒中，只是一條神經連絡另一條神經，藉由釋放這些帶有化學訊息的小棕色包，即所謂的神經傳導物質，以一對一的線性方式傳導訊息。事實上，神經傳導物質的釋放是三個方向的，在脊髓中橫向、縱向、上下釋放，然後它們開始與其他相鄰的細胞相互影響。這些細胞被稱為膠質細胞，曾被認為是不重要的脊髓結構元素，除了讓所有重要物質，如神經，聚集在一起之外，並無作用。但事實證明膠質細胞扮演至關重要的角色，可調控及放大對疼痛的感覺，並扭曲感官的體驗。這些膠質細胞變得活化，它們的DNA開始合成新蛋白質，然後釋放出來，與相鄰神經產生互動，使它們開始釋放神經傳導物質，這些神經傳導物質被釋放後，活化鄰近的膠質細胞，然後這種情形一再重演，直到一個正向回饋循環產生。
這幾乎像是有人走進你家，重新佈署你牆中的電線系統，所以當你下次打開電燈開關時，廁所馬桶開始沖水，或洗碗機開始起動，或電腦螢幕關閉，這簡直是瘋了。但事實上，這就是慢性疼痛的情形，這也就是疼痛本身變成疾病的原因。神經系統具有可塑性，它可以改變對刺激的反應，或使其發生變異。
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But the situation, of course, in the human body is far more complicated than that. Instead of it being the case that that junction box in the spinal cord is just simple where one nerve connects with the next nerve by releasing these little brown packets of chemical information called neurotransmitters in a linear one-on-one fashion, in fact, what happens is the neurotransmitters spill out in three dimensions -- laterally, vertically, up and down in the spinal cord -- and they start interacting with other adjacent cells. These cells, called glial cells, were once thought to be unimportant structural elements of the spinal cord that did nothing more than hold all the important things together, like the nerves. But it turns out the glial cells have a vital role in the modulation, amplification and, in the case of pain, the distortion of sensory experiences. These glial cells become activated. Their DNA starts to synthesize new proteins, which spill out and interact with adjacent nerves. And they start releasing their neurotransmitters. And those neurotransmitters spill out and activate adjacent glial cells, and so on and so forth, until what we have is a positive feedback loop.
It's almost as if somebody came into your home and rewired your walls, so that the next time you turned on the light switch, the toilet flushed three doors down, or your dishwasher went on, or your computer monitor turned off. That's crazy, but that's, in fact, what happens with chronic pain. And that's why pain becomes its own disease. The nervous system has plasticity. It changes, and it morphs in response to stimuli.
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那麼，我們該怎麼辦呢？我們要如何處理像Chandler的情況?我們目前對這些病人的治療方法，還停留在一個相當粗糙的階段。我們隨他們症狀改變而調整藥物，止痛藥，坦白說，藥物對這種痛苦並不是很有效。對於應該安靜，但現在卻吵雜而過動的神經，我們使用局部麻醉劑使它們睡覺。但最重要的是，我們採用很嚴格的，而且通常非常不舒服的物理治療及職能治療過程，再訓練神經系統裡的神經，對日常生活的活動與感官經驗正常反應。我們在整個過程中加入密集心理治療課程，以解決總是伴隨嚴重慢性疼痛而來的沮喪、絕望和憂鬱。
這方法成功了，如你們在影片中看到的Chandler，第一次見到她的兩個月後，她已經可以表演後翻。昨天我跟她一起吃午餐，她是Long Beach一間大學的舞蹈系學生，她現在康復非常好。
但事實上未來的前景將更美好，未來充滿希望，新藥正開發中，不再是如我們現在所使用的隨症狀調整，僅能掩飾症狀的藥物，而是為疾病本身量身訂做的藥物，會確實針對疼痛根源，攻擊膠質細胞，或那些膠質細胞產生的有害蛋白質，它們釋出後會導致中樞神經系統罷工或產生變異，因此能扭曲及放大所謂疼痛的感官體驗。所以我希望在不久的將來，George Carlin的預言可以成真。他說，「我的哲學：沒有痛苦，沒有痛苦。」
謝謝。
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Well, what do we do about that? What can we do in a case like Chandler's? We treat these patients in a rather crude fashion at this point in time. We treat them with symptom-modifying drugs -- pain-killers -- which are, frankly, not very effective for this kind of pain. We take nerves that are noisy and active that should be quiet, and we put them to sleep with local anesthetics. And most importantly, what we do is we use a rigorous, and often uncomfortable, process of physical therapy and occupational therapy to retrain the nerves in the nervous system to respond normally to the activities and sensory experiences that are part of everyday life. And we support all of that with an intensive psychotherapy program to address the despondency, despair and depression that always accompanies severe, chronic pain.
It's successful, as you can see from this video of Chandler, who, two months after we first met her, is now doings a back flip. And I had lunch with her yesterday, because she's a college student studying dance at Long Beach here. And she's doing absolutely fantastic.
But the future is actually even brighter. The future holds the promise that new drugs will be developed that are not symptom-modifying drugs that simply mask the problem, as we have now, but that will be disease-modifying drugs that will actually go right to the root of the problem and attack those glial cells, or those pernicious proteins that the glial cells elaborate, that spill over and cause this central nervous system wind-up, or plasticity, that so is capable of distorting and amplifying the sensory experience that we call pain. So I have hope
that in the future, the prophetic words of George Carlin will be realized, who said, "My philosophy: No pain, no pain."
Thank you very much.
