Osteoarthritis, a painful common joint disease found among the older population 2526 produces immense progressive functional disability if poorly managed 27. While self-management approaches such as exercise and non-steroidal anti-inflammatory drugs and pain medications may be helpful 27, joint surgery may still be needed to restore function and ameliorating pain. However, in the face of COVID-19 both conservative as well as surgical interventions have been severely jeopardized by social isolation rulings. To avert excess disability in this disease, the importance of exercise and diet has been stressed. The general issues possibly impacted by COVID-19 restrictions and joints that could be affected are shown in Table 1.

COVID-19, an acute highly contagious respiratory disease produced by a novel infective agent was uncovered approximately one year ago. Since that time, efforts to reduce its influence in all spheres of the globe have not proved as successful as anticipated, but commonly involve lock-downs, social distancing, isolation, and mobility limiting public health recommendations. While a vaccine or vaccines are being developed and distributed, public health measures have been seen to be increasing, rather than decreasing.

As outlined above, the Covid-19 pandemic, now one year since its inception and recognition as a pandemic, especially among older populations, remains a highly serious public and individual health threat. In this respect, Wiersinga et al. 27 suggest that as the pandemic proceeds, and in light of its immense impact among older already compromised adults, more, rather than fewer efforts towards basic public health measures are probably indicated. In this regard, the impact of socially restrictive and isolating effects due to COVID-19, are of concern given their potential for negatively impacting the health and wellbeing of older people in particular, including their mental, as well as their physical health as discussed by Sepúlveda-Loyola et al. 20. To this end, although social support is not discussed overtly, the authors recommend the use of communication tools such as apps, online videos, and telehealth to help vulnerable adults to cope with their isolating situation 28.

Similarly, Mesa Vieira et al. 29 have highlighted the fact that while public health measures such as social isolation are desirable for protecting the physical health and wellbeing of vulnerable populations, more than just resolute governmental action is required to overcome these unanticipated pandemic associated negative health impacts of these approaches.

In this regard, De Biase et al. 30 stress the urgent need to protect those who are isolated from becoming deconditioned as a result of movement restrictions, feelings of depression, and the inability to access healthcare resources for pre-existing or new non-COVID-19 illnesses. This is especially problematic at this time for people with osteoarthritis, since delivering rehabilitation in the same way as in pre-pandemic times is clearly not currently possible or practical, nor likely to meet the scale of need in the community.

Palmer et al. 31 similarly stress the importance of the long-term effect of isolation on those individuals with non-communicable diseases, such as osteoarthritis and imply that as well as short-term infection containment measures such social distancing and quarantine restrictions, efforts to combat negative effects of social isolation are indicated to prevent unhealthy lifestyles, such as excess sitting, or sedentarity, that commonly yield a multitude of highly negative potentially irreversible long-term health impacts 18. A recent study shows that among the adults who were already highly active before COVID-19, those above 55 years of age, those with low educational levels, and those used to exercise with friends or in a sport club, and those who were not using online tools to exercise, self-reported that they exercise less during the COVID-19 lock-downs began. Having less time, sitting more, and missing the familiar ways and competitive element of exercising were among the main reasons for the self-reported exercise reduction.

Gustavsson and Beckman 33 found that half of the older participants they surveyed did comply with public health measures and did report staying at home all the time, but at the same time up to half reported decreased mental health in terms of feeling depressed, having sleeping problems, and perceptions that isolation made them feel ‘bad’, an observation supported by Smith et al. 34. Older adults in particular, may reportedly feel especially lonely and at a loss 35. Hence, while elderly people are said to comply more readily than not with public health isolation recommendations and practices to a high degree, they might yet inadvertently and unknowingly jeopardize their prevailing health and disease status that can lead to unwanted and costly long-term negative health effects if precautions against this are not forthcoming 34. Osteoarthritis sufferers may be at especially high risk for a variety of negative events in this regard as this group has been found to often be more socially isolated than desirable due to their disabling situation 36.

In terms of some specific impacts that the osteoarthritis sufferer, now forced to be homebound and alone in his/her community may suffer, are many negative health determinants such as excess feelings of helplessness, anxiety, fearfulness, depression, and an inability to cope effectively with their pain and its disabling effects 3536373839. In turn, alone or in combination, the presence of depression, anxiety and a limited ability to cope effectively due to overwhelming demands may strongly impact the motivation and/or desire to participate in exercise, while maintaining a healthy diet, as has been widely recommended. Sleep too may also be impacted in a negative way, as may Vitamin D and sunlight exposure, potentially increasing, rather than decreasing possible infection risk, along with impaired muscle function 40 unless some steps are taken to offset the possible negative implications of prolonged social isolation in this older population 39.

In their study of social isolation, loneliness and physical performance outcomes among older-adults, Philip et al. 41 found isolation and loneliness was indeed related to various aspects of health, including poorer physical performance over time. In addition, according to Janati Idrissi et al. 42 the COVID-19 lock-downs are associated with several stressful factors that can negatively affect peoples' sleep quality and mental health including anxiety, and depressive symptoms. Even more importantly is the observation by Xiao et al. 43 as regards a negative role for social isolation, social distancing and mask wearing by providers and family, as this can not only jeopardize the quality and availability of required supportive communications, resources and personnel, but can indirectly impact immunity potentially adversely, as well as all cause mortality and functional disability, even though designed to protect the individual 1444.

In light of the potential for an extremely negative impact of prolonged social isolation on the health status of the older community dwelling adult with osteoarthritis of one or more joints, as suggested by the data, it appears plausible to propose that some immediate thought be applied to the application of counter strategies known to have beneficial health promoting effects. That is, minimizing the potentially adverse influences of social separation and its possible adverse impact on emotional, as well as physical health, as well as on possible prior coping and self-management strategies, a focus on the provision of social support in its various forms may prove useful.

In this regard, socially supportive approaches that may be especially helpful include making arrangements for vulnerable community dwelling elders who live alone or live with another impaired adult or family member, to receive formal, as well as informal care. As well, strategies to empower vulnerable adults with painful osteoarthritis who want to retain their independence to follow their prescribed health plans, as well as providing them with information and feedback as needed, and if desirable, while encouraging them to join and participate in online support groups are recommended 45.

In particular, on line groups where individuals can share experiences and receive emotional, informational and social support from others with similar health challenges may be especially efficacious in helping community dwelling elders to maintain their overall wellbeing, in the face of depression and excess prolonged isolation. At the same time, regular telephone contacts from family members, as well as health-care workers, plus the provision of opportunities for the affected adults to discuss specific questions and concerns about the disease may prove of high import in mediating health status, health behaviours, and health decision making 46. Especially effective as well may be emotionally supportive empathetic communications, efforts to listen to the affected individual, regular calls, having a supportive hotline open 24 hours a day, plus newsletters, videos, and television programs that promote the value of arthritis self-care, and importance of achieving high levels of wellbeing 28.

In addition, efforts to foster information regarding mindfulness meditation, acceptance therapy, and QiJong approaches have the potential to enable the home bound individual to minimize possible depressive symptoms, pain, inflammation, and anxiety, while heightening immunity 47484950. Education concerning the importance of exercise, weight reduction, avoidance of negative lifestyles and the value of help seeking, or a combination of these approaches are also advocated 51. Ali et al. 52 indicate that the provision of social support, referring to the use of feedback strategies, direct assistance, passive assistance, emotional and informational support are all factors that may be arranged to favorably influence health status in a manner that may be highly advantageous to an individual who is isolated from mainstream resources, both in the short term as well as longer term situations. Moreover, tangible support as required for feeding, washing, and hygiene as indicated or needed, and provided on an individualized basis is recommended as well.

Also favored is the possible advantage of linking the ‘at risk’ older adult who may be isolated from others, to join online support groups or blogs, as may a linkage to a community network of providers who can provide tangible as well as psychological support 43.

However, social support is only deemed ‘useful’ if the recipient perceives this to be beneficial, for example, leaving a care package at the door that the recipient can’t open may prove counterproductive, as may failure to address emotional concerns or sensitive topics, using on line communications. Hence, caution is advised in looking for ‘generic’ solutions to counter possible isolation effects, because the form of social support provided has to be personally valued to yield possible positive health effects. Indeed, in terms of technology, research shows many older adults may not benefit uniformly from access to online groups or information because they are not familiar with this process, and even if they are, may not value the absence of physical contact provided by remote services 53. Availability of technology and its associated ongoing costs are also important to consider, as the necessary funds to do this may not be accessible to all potential participants. Technology may also be challenging to employ uniformly if for example the individual’s hands are severely disabled, sitting is very painful, and/ or vision impairments prevail. Safety and security issues should also be addressed here, given that the Internet commonly requires secure confidential information to access sites and materials, and hence assurance of privacy as well practicality, and user-friendly operations, rather than simple access, warrant careful consideration 28.

Possible socially supportive protective factors providers can foster in efforts to improve anxiety control, stress, pain control, adherence to self-protection/management strategies, sleep hygiene, immunity, and depression among isolated older adults with osteoarthritis 32445155

In addition to these possible aforementioned tangible and intangible forms of assistance, to help older community dwelling adults with osteoarthritis and possible comorbid illnesses to maintain a viable immune system, often impaired by having to stay indoors, providers can further assist their vulnerable clients in this regard by encouraging them to carry out one or more of the strategies highlighted in Box 3, especially if these can be implemented regularly.

Meditation-related practices 44

Guided imagery

Acceptance therapy

Participation in online support group^s

Use of Social Networking Sites 56

Adoption of a positive demeanor//benefit finding approaches 45

Regular mild-moderate exercises and outdoor activities as prescribed by a professional 4657

Sound nutritional practices 115558

Use of appropriate joint sparing techniques

Use of appropriate assistive devices

Use of varied relaxation/stress reduction and optimal sleep routines

Seek counseling help as/if required 44

Possible strategies community dwelling adults with osteoarthritis may benefit from during extended isolation periods

As outlined by Zhang et al. 59, even if this realm of public health is not a current priority it appears essential to consider the aforementioned ideas, without excessive delay, in order to prevent any decline in the overall health status of the individual osteoarthritis case during any isolation period and that can hasten COVID-19 vulnerability. In particular, the possible importance of exercise and psychological support to buffer stress, along with the provision of foods that enhance immunity appear of high import 223260.

Alternately, even if this currently imposed social isolation policy is only temporary, its overall negative health ramifications should not be underestimated. In this regard, Manderson et al. 1 have strongly emphasized the pressing need to attend to and acknowledge both the short, as well as the long-term effects of COVID-19, and to do this especially in the context of offering continued care opportunities to adults living with lifelong medical conditions, including osteoarthritis, who may be asked to self-isolate.

Cisternas et al. 12 too provide further support for the need to have a greater appreciation of the downstream crisis created by delayed surgical correction for severe osteoarthritis that in their view requires aggressive consideration of nonsurgical, non-opiate supported interventions to reduce the morbidity associated with these delays due to current restricted access rulings. In the meantime, as argued bySaltzman et al. 35, one way of reducing harmful isolation effects may be to increase one or more forms of social support, as required. Ostensibly, this would not only be important for reducing negative health effects of social isolation in general, but also osteoarthritis specific symptoms and behaviors that may be harmful both to the disease, as well as to immune functioning and well-being, such as poor dietary behaviors. Moreover, assessing and intervening to address any unmet socially oriented need during the current pandemic lock-downs, may also promote, rather than deter, the possibility of positive health outcomes for older community dwelling adults in the future even if COVID-19 rulings no longer apply 57616263646566676869707172. See Table 2.