Osteoarthritis , COVID-19 Social Isolation-Impacts , and Counter Solutions

Background to the Issue: Many older adults, including those already suffering from chronically painful disabling osteoarthritis of one or more joints remain more susceptible than healthy age and gender matched adults to the COVID-19 corona virus. Aims: This report sought to examine what has been published in 2020 on this health condition from the perspective of the variable of widely imposed social isolation strategies designed to mitigate the spread of this highly infectious disease, and to especially keep older community dwelling adults ‘safe’ from infection. Methods: Reviewed were all articles published in 2020 in PUBMED from January 1-December 24, 2020 on osteoarthritis and COVID-19 isolation impacts, plus relevant past osteoarthritis and isolation literature among older adults. The focus was on ascertaining how social isolation and distancing strategies might impact current community-dwelling adults diagnosed with osteoarthritis and whether more should be done specifically to mitigate any potentially preventable ‘socially’ induced negative health impact among this group, in spite of the laudable goals of this public health strategy. Results: Older adults with osteoarthritis living in the community who are asked to self-isolate, may incur more osteoarthritis pain and disability than would otherwise be encountered if actions taken to counter this possibility are not forthcoming. Advocated over and above basic care approaches are several psychosocial strategies including the role of mobilizing various forms of social support. Conclusion: Data indicate a need for concerted thoughtful and immediate attention to offset isolation, fear, and anxiety and depression effects as part of a carefully devised integrated plan of management to reduce excess osteoarthritis disability, as well as excess COVID-19 risk among otherwise free living older adults already compromised by osteoarthritis. DOI: 10.14302/issn.2474-7785.jarh-20-3682 Corresponding author: Marks Ray, Department of Health and Behavior Studies, Teachers College, Columbia University, Box 114, 525W, 120 Street, New York, NY 10027, United States, Telephone: +1-212-6783445 Fax: +1-212-6788259, Email: rm226@columbia.edu


Background
A growing body of data is revealing that elderly adults, especially those suffering from obesity, frailty or one or more chronic health conditions, such as osteoarthritis, are not only highly susceptible to the novel Corona virus known as COVID-19, but are commonly hospitalized at high rates due to the acquisition of acute respiratory symptoms produced in response to becoming infected by this virus [1][2][3].
Conversely, the ensuing pandemic and its accompanying publically recommended preventive approaches, for example, the widespread application of societal shutdowns, including the practice of advocating for self-isolation, social isolation, social distancing, and quarantine periods of varying length may yet arguably provoke, rather than diminish the risk of acquiring COVID-19 in the face of the presence of one or more prevailing comorbid health challenges known to be COVID-19 risk factors, as well as risk factors for acquiring severe disease. In particular, it seems those older adults already suffering from osteoarthritis, a widespread disabler of the neuromuscular system that prevails among elderly populations in all parts of the world would in all likelihood also be more challenged, rather than less challenged at this pandemic point in time [4] for many reasons, and again, at higher risk for disability, as well as COVID-19 disease risk. For example, prevailing isolation associated challenges that may extend to a reduced ability to self-manage the disease without adequate access to personnel, as well as closures of sites of assistance, may interact with the multitude of physiological processes underlying the disease and its oftentimes associated accompaniment of unrelenting pain to worsen this situation and to thereby provoke or intensify prevailing depression and anxiety, with dire health implications, including adverse inflammatory and immune system implications At the same time, health providers, normally able to consult directly or indirectly with this group may be overwhelmed in their own right, or restricted to offering online versus in person interventions [8], but even so, are less able to help those with one or more chronic health challenges or risks as effectively as when they can be consulted as desired in an office or face-based based environment. Those adults with osteoarthritis with visual and/or hearing impairments, hand osteoarthritis sufferers, or those with multiple joint lesions may be especially challenged in their efforts to receive needed care and information in a timely way either in the context of primary prevention or secondary and tertiary prevention efforts without extra help and assistance. As a result, the prevailing restrictions on mobility may extend to the impedance of exercise participation, while raising the challenges in maintaining a healthy weight, an immense disabling problem among many osteoarthritis cases. As well, challenges in obtaining, using, and accessing required medications, obtaining and preparing healthy foods, using masks effectively, as well as technology, and even hand washing challenges, may be raised in the face of an in mind the potential negative impact of prolonged social isolation, will it be more helpful than not to many chronic osteoarthritis sufferers, especially those who are elderly, and highly vulnerable to the virus and its more severe forms [13] to be assessed carefully for possible social support needs in its various forma to compensate for their unexpected restrictive and possibly highly stressful situation?
In this regard, in accord with Kim and Su [14] who advocate applying a biopsychosocial model approach to address issues such as those highlighted above that do not appear to have been anticipated, considered, or duly acted on in urgent public health efforts to flatten the COVID-19 pandemic situation, as well as recommendations proposed by Karasavvidis et al. [15], we would like to offer an additional few thoughts that may help older adults living in the community to maintain sufficient wellbeing and the ability to recover if they are found to be positive for the Corona virus.

Working Hypothesis
Based on the literature and the past work of the author, we hypothesize that a focus on going beyond general recommendations for osteoarthritis selfmanagement during the COVID-19 pandemic lock-down restriction periods will prove more helpful than not for Modes of social support that may be applied independently or collectively to promote wellbeing among isolated elders with osteoarthritis living in the community addition, the sudden introduction of a myriad of unanticipated socially impactful pandemic oriented isolation rules, along with the associated withdrawal or closure of usual assistance or resource mechanisms is likely to seriously impact general health, plus dietary and other essential self-care behaviors along with the ability to fight infection [17]. By contrast, the presence of supportive others, either formally, or informally, or both, as well as the availability of desirable supportive strategies and resources to counter any life threatening unexpected loss of these due to social and mobility restrictions can potentially help to mitigate the tendency for older adults in isolated circumstances to adopt a more sedentary lifestyle than in former times, as well as to suffer unremitting stress [17]. Moreover, the current worldwide albeit artificially-induced withdrawal of socially supportive resources and contacts, especially mobility resources and personnel, coupled with possible exposure to poor ventilation and limited sunlight, in efforts to stem the COVID-19 pandemic, may also be expected to foster a lower sense of overall wellbeing, and thereby a possible higher infection risk if immunity is severely compromised [18][19][20][21][22], especially among those who are obese [23]. Given the many current socially oriented restrictions, along with the absence of numerous normally available life-affirming resources, we sought evidence to support the idea that to maintain, and hopefully to optimize the wellbeing of older osteoarthritis afflicted adults residing in the community under lock-down rulings, more programs to overcome any gap in services plus efforts to secure their emotional wellbeing are likely to reduce or limit any inevitable health related deterioration as proposed by Ammar et al. [24]. This would be especially important for those scheduled for surgery [12] where delays could lead to muscle wasting and comorbidity exacerbation, as well as an increase in osteoarthritis severity, and a decrease in life quality.

Methods and Procedures
To garner information on the topic of COVID-19 as this pertains to osteoarthritis disability, we strove to examine the PUBMED data bases for the year 2020 as well as past observations that discussed osteoarthritis pathology, and the link between health status and social support strategies and approaches. All possible articles related to either -osteoarthritis and COVID-19 or osteoarthritis and social support, lock-down measures and older adults, as well as COVID-19 and social isolation were examined. With no actual current research on this theme, some related reports are presented in descriptive narrative format. To be included, all forms of reports were deemed valid, but published in the English language.

Results
A very dedicated search showed that very few articles on PUBMED currently discuss osteoarthritis and COVID-19 in any detailed consistent manner. In addition, the health impacts of social distancing and isolation, while attaining some interest, do not specifically speak to the elderly community dwelling adult with osteoarthritis disability. Support for social support and its favorable health affirming role have been discussed for some time, for example in the context of support groups. The relevant data in this regard are described below.

Osteoarthritis
Osteoarthritis, a painful common joint disease found among the older population [25,26] 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 and Social Isolation
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. [ 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 userfriendly operations, rather than simple access, warrant careful consideration [28].
for premature mortality in the event their support system is attenuated or withdrawn, even for a short period.
Although very few papers were found concerning osteoarthritis and COVID-19 in general, and very few discussed potential negative impacts of self-isolating imperatives on this condition, past efforts in the realm of osteoarthritis care, as well as current data in other spheres, imply that more concerted efforts to counter any potentially excess burden attributable to COVID-19 lock-downs among osteoarthritis sufferers who live alone and are elderly is strongly indicated.
Indeed, while isolation is strongly advocated currently for protecting many vulnerable older adults living in the community, this sudden move towards self-isolation and social distancing, while designed to reduce rates of transmission, and the risk of severe illness, has the potential to produce unwanted long and short term impacts on the individual, and ultimately on the health care system unless efforts are undertaken to counter this [54].
In particular, to counter the possible negative impacts of social isolation, and its widespread negative potential for impairing health status among older isolated adults, it appears an array of consciously supplied supportive and empowering strategies, especially those with some past research underpinnings would be more helpful than not [35].
To carefully assist in this process, the formal health care provider may want to survey their clients carefully to uncover if they have unmet needs.
Thereafter, they may want to consider the value of a variety of accessible medical, social services, allied health services strategies and others less tangible, such as help with decision-making that may prove highly efficacious for their clients, while helping to mobilize and deliver these [see Box 2].
• Empathetic communications that reinforce favorable beliefs/expectations, discuss negative emotions • Culturally tailored and understandable educational and informational resources • Accessible meal/medication resources/delivery as indicated • Access to immunity enhancing foods [55,58] • Resources to help allay fears and distress/promote sleep health • Resources and personnel to monitor and optimize air quality • Information on safety issues and use of vitamin D/ other supplements  • A host of direct health-enhancing benefits, such as problem solving, emotional regulation.
• A decline in the negative effects of self-isolation on health due to excess stress.