The mystery of chronic pain Elliot Krane

[Music]

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

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

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 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

us please keep UC

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 his 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

sixteen 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 rapid in an ace

bandage takes 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 a 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

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 where

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 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

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 chair 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 the 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

[Applause]

you