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Osteoarthritis (OA)

by Carlo Raj, MD

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      Rheumatology I 01 Non-Autoimmune Arthritis.pdf
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    00:02 Continue our discussion of Rheumatology. We'll take a look at rheumatic diseases.

    00:07 Under rheumatic disease, our category include non-autoimmune arthritis. Now, the first example that we're going to walk you through is going to be osteoarthritis. But, very importantly, you need to be able to compare this with rheumatoid arthritis.

    00:24 So, how do we approach arthritis in general? With joint pain is going to be a common symptom, except that doesn't tell you much.

    00:31 Apart from the fact that, "Oh, yeah, I have issues in the knee," Most likely, I'm going to go with what most likely.

    00:37 Also, we're going to pay attention to those joints that most likely will lead you into the proper diagnosis.

    00:45 What's the difference between arthritis versus arthralgia? Algia refers to pain, whereas itis refers to well, inflammatory, but even that can be a little tricky, you shall see. But technically speaking, there is a difference in definition between the two.

    01:05 Arthralgia, sensation of pain, but understand that the pain oftentimes is accompanied by the arthritis, perhaps, maybe around the joint or periarticular.

    01:18 Next, we'll be defining what's meant by acute and chronic, especially, for example, we talk about crystalline arthritis, for example, gout.

    01:29 We'll talk about acute and chronic gout or talk about issues even with pseudo gout, what that means.

    01:35 Now, in general, 6 weeks, we'll define or delineate between acute and chronic.

    01:43 Also, we'll take a look at a particular arthritis.

    01:47 Is it's presentation symmetric in nature, or is it asymmetric? That tells us a lot, and also tells us as to well, if it's long standing, maybe went from asymmetric to symmetric, right, or acute to chronic.

    01:59 Or, was it 1 joint to be affected, was it monoarticular, or was it many joints to be affected, polyarticular? Inflammatory versus non inflammatory, and that's a little tricky, huh? Well, let me start off by telling you immediately that one would think that osteoarthritis…what… as the name implies come under inflammatory, but it really doesn't.

    02:20 And the reason for that is we're going to check… together, we're going to check the synovial fluid.

    02:25 Synovial fluid, picture that for me, please? Want you to picture the knee, the most common… that's the joint that I'm going to be using most commonly.

    02:32 And then I'll tell you other joints that might be involved in other types, but picture the knee for me.

    02:38 From anatomy and histology, think about the joint capsule.

    02:41 Think about the synovial lining responsible for secreting or making synovial fluid.

    02:48 Now, we're going to take the synovial fluid and we'll go and check for WBCs.

    02:52 And if you find that WBC count to be quite low, or let's say < 2000, that technically refers to as being non- inflammatory, as we shall see.

    03:00 Even though in osteoarthritis, we… the name implies that it's inflammatory, but it's not, as we shall see.

    03:08 This then forms the basis of what's meant by acute versus chronic.

    03:12 Now, the timeline, approximately 6 weeks.

    03:16 Something also very important.

    03:18 You're going to read or you're going to have a patient comes in and says…or you're going to ask this question of the patient, "So, tell me about this pain when you woke up in the morning, AM, and tell me about, well, how long did it take before you could actually feel better in your joints, for example, the knee?" And if your patient says, "Well, Doc, it took me greater than 1 hour." I repeat, it took the patient greater than 1 hour before the patient started to feel better, then this puts you into what's known as your inflammatory autoimmune type of arthritis.

    03:50 Now, the most common type of arthritis has nothing to do with immune osteoarthritis as we get older.

    03:58 In that patient, the stiffness only lasts for about 30 minutes.

    04:01 Osteoarthritis has nothing to do with immune and it comes under what category? Non-inflammatory. Are you getting a better grasp of how to approach arthritis under rheumatology? If not, not to worry.

    04:15 All this will be repeated as I go through.

    04:20 As I go about osteoarthritis, let's start with the presentation.

    04:25 The common joints to be affected, no doubt, the knee.

    04:28 The patient may have been obese, may have been a female, maybe there's trauma.

    04:35 As we get older, wear and tear, our knee.

    04:39 I need you to really know the histology.

    04:41 If you don't, make sure you go back and review it.

    04:43 What may then happen is the joint space may become narrow.

    04:46 Think about the cartilage.

    04:47 The cartilage covers the articular surface of your knee, doesn't it? The bone and such.

    04:53 But what may then happen there is ulcerations, and I'll talk about this, moving forward. But what I'm saying is, as there's mechanical wear and tear, chronic, over a period of time, the patient is going to start feeling pain.

    05:08 It is non-inflammatory. How do we know? Because the synovial fluid, if you expect it to be inflammatory, you would expect the WBC count to be maybe > 50,000.

    05:18 What's the normal WBC count? 4,500 to 11,000, isn't it? So, if you find the WBC count in your synovial fluid to be < 2000, please know that this is then defined as being non-inflammatory. Is that understood? "But Dr. Raj, I know for a fact that with osteoarthritis that we give the patients…" What kind of management? Well, we give to patients, obviously, Tylenol.

    05:43 Maybe give the patient NSAIDs, right? So you give them non-inflammatory. I get it.

    05:48 But, by definition, you can't call it as such in medicine.

    05:52 The degenerative.

    05:53 What's degenerating? Oh, the cartilage.

    05:56 Where is the cartilage located? In between the joints. Can you think of the knee, please? I want you to think of the femur and understand that it should be covered by cartilage, protecting the articular surface, but that cartilage may undergo ulcerations.

    06:11 In addition, over a period of time, with stress occurring on your knee that the bone may then react, and when it reacts, it becomes thicker.

    06:20 We call this sclerosis.

    06:22 So, there might be subchondral cysts or subchondral…what's known as sclerosis.

    06:29 And then this made them give rise to what's known as osteophytes.

    06:32 Remember those? Yeah, those are to come.

    06:35 So osteoarthritis going to be a collection of these type of issues that we'll take a look at.

    06:39 I want you to, once again, use as an example, the knee.

    06:42 Once you understand the knee, I will tell you other common joints that also will be affected, undergoing the same type of process, wear and tear.

    06:50 Know thy patient well.

    06:53 So what are the common joints that are to be affected? Well, the small joints. That's a big, big, big, big deal.

    06:59 Small joints. What do you mean small joints? Oh, maybe the fingers.

    07:03 Those are really tiny, huh? I want you to put out your hand for me.

    07:06 Can you reach out? There you are.

    07:08 Now, what I'm reaching out for is going to be the DIP.

    07:13 Picture that for me.

    07:14 Distal interphalangeal joint. Huh.

    07:16 So if in osteoarthritis DIP is affected, technically, do you remember what the name of that is? If you've never seen it before, then you have no idea, but it's called Heberden nodes.

    07:26 Heberden, DIP. Picture that.

    07:29 What's a little bit proximal to it? How about we call that PIP? Ha ha. That's brilliant.

    07:34 Proximal interphalangeal joint.

    07:36 Those are called Bouchard's nodes, okay? So those are 2 joints. Quite specific.

    07:42 Usually going to be asymmetrical.

    07:45 What else might be affected? Can you…thumb up? Give me a thumbs up because you're doing well. You're getting this down.

    07:51 No. Seriously speaking, that is your first digit.

    07:55 Can you picture the carpometacarpal? CMC stand for carpal.

    07:58 What are your carpal bones? Think, for example, the trapezium.

    08:01 Can you picture the trapezium for me? Now, that, plus your metacarpal is your joint.

    08:08 Interesting enough, the thumb joint, carpometacarpal phalangeal joint be affected by osteoarthritis.

    08:14 So what I'm trying to give to you is the foundation of comparing osteoarthritis with rheumatoid arthritis that we'll discuss, moving forward.

    08:22 Small joints: DIP, PIP, carpal metacarpal.

    08:26 You're focusing upon the thumb, the knees, as I told you. Obviously, over a period of time, let's say the patient is 45, 50, 55, whatnot.

    08:35 As I stand here, I know I'm developing osteoarthritis.

    08:38 I'm putting a lot of strain on my knees.

    08:41 Hips, and maybe the spine.

    08:45 At this point, give yourself a good example.

    08:47 I told you the knee can be affected, but obviously, there are other joints as well.


    About the Lecture

    The lecture Osteoarthritis (OA) by Carlo Raj, MD is from the course Introduction and Non-Autoimmune Arthritis. It contains the following chapters:

    • Rheumatic Diseases
    • Introduction to Osteoarthritis

    Included Quiz Questions

    1. Proximal interphalangeal joints
    2. Carpometacarpal joints of hands
    3. Distal interphalangeal joints
    4. Knee joint
    5. Shoulder joint
    1. The WBC count of the synovial fluid is more than 50,000
    2. It is a degenerative condition of the joint
    3. It usually involves weight bearing joints
    4. The reparative mechanism involves the formation of osteophytes
    5. The pathogenesis involves decreased hydration of the articular surface
    1. Osteoarthritis
    2. Septic arthritis
    3. Gout
    4. Rheumatoid arthritis
    5. Ankylosing spondylitis
    1. To avoid exercise
    2. Weight reduction
    3. NSAID’s
    4. Chondroitin sulphate
    5. Chondroplasty
    1. Morning stiffness lasting more than 1–2 hours
    2. Polyarticular pain
    3. Symmetric pain
    4. Persistent pain
    5. Warmth

    Author of lecture Osteoarthritis (OA)

     Carlo Raj, MD

    Carlo Raj, MD


    Customer reviews

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    Very well explained!
    By Thar M. on 11. July 2020 for Osteoarthritis (OA)

    Very clear , short and great explanation. I really recommend this teacher and his lectures.

     
    Introduction to Osteoarthritis
    By Olufemi A. on 17. October 2018 for Osteoarthritis (OA)

    It is an area I have always skipped to study well and as such, I am very ignorant of the subject. I really like Dr Raj's approach to getting it to sink.