I'm a pediatrician and an anesthesiologist so I put children to sleep for a living
and I'm an academic so I put audiences to sleep for free.
Um but what I actually mostly do is I manage the pain management service at
the packard children's hospital up at stanford in palo alto and it's from the
experience of 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 is 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 often times 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 then 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. 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 were 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
were telling them that they were feeling this hot torch.
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 categorically 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 hard wired 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 up to 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.
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
simply where one nerve communicates 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 wall 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.
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, painkillers 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 a 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 doing a backflip 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 that 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 you
