As in the past, most current reports continue to state that osteoarthritis often produces lengthy periods of chronically intractable bouts of pain, joint stiffness and inflammation, as well as multiple functional, social, occupational, cognitive and emotional challenges and restrictions, plus a low life quality, fatigue, sleep disturbances, and feelings of emotional distress, depression or actual clinical depression despite years of study 4202122. Although not a ‘death sentence, its significant overlapping negative aforementioned impacts that are often unrelenting and that may well impact and hasten progression rates towards joint surgery 23, are also increasingly observed to have a negative genetic influence on the risk of acquiring osteoarthritis 2224 and a bi-directional association with myalgic pain 24 and that may preside incrementally in those affected who are socially isolated or perceive this as a ‘hurtful’ state. While some articles discuss or attempt to recount efforts to reduce the magnitude of this problem or help to offset it biochemically or via physical therapy, most fail to pinpoint or offer any definitive set of strategies for reducing osteoarthritis pain that may arise from persistent loneliness and isolation feelings. Nonetheless, many authors agree that more needs to be done in this sphere 25, especially to treat both pain and depression in tandem 26. Alternately, many current authors support the need to more successfully identify if the older adult is at risk for depression, and if so, to try to avert this accordingly.

One important observation is that despite decades where osteoarthritis was deemed an evitable genetic or age associated physical problem, its emotional correlates are now shown of additional value and high salience in explaining findings of disease variations such as declines in vitality, poor life quality, reduced cognitive and physical functioning among diverse older adults with one or more diseased joints and that may enhance the need for surgery 2527. Moreover, in addition to associated ongoing mechanical disturbances, osteoarthritis which may be accompanied by diverse degrees of vascular changes, soft tissue contractures, muscle spasm, crystal deposition, and disease related alterations in sensory inputs to the central nervous system may reduce functional ability as perceived by the sufferer that may impact their ability to interact or participate in social actions and others 28. In addition a pervasive pain experience that reaches catastrophic proportions is often accompanied by bouts of reactive depressive, even if the actual extent of joint pathology itself is not striking and surgery is forthcoming 29 because depression that stems from a progressively emergent state of increased pain sensitivity is considered a disability medically speaking in its own right 30, as is its central nervous system influences including individual behaviors, and increases in pain sensitivity. This emergent state may foster or result in feelings of helplessness, anxiety, poor coping ability, poor self-efficacy, and sleep disturbances that can all prove disabling. In turn, data show this negative series of feedback responses are significantly correlated with future pain and disability, and decreases in physical function 31, while generating a low sense of morale.

Compounding osteoarthritis presence and its highly resistant and unpredictable nature, are misconceptions in this regard about the importance of optimal mental health, mindset, and psychosocial factors in averting osteoarthritis 3233343536, ideas long engendered about its irremediable trajectory by medical organizations and personnel, as well as suboptimal intervention outcomes that have more to do with study design than efficacy failure even where indicated. The experience of constant pain and increasingly difficulties in accomplishing everyday tasks, that engender fatigue, may likewise elicit persistent feelings of sadness, loss of interest and pleasure in daily activities, feelings of hopelessness, and low self-worth and isolation, low life quality, but this is rarely explicitly assessed 37. Moreover, those older individuals already suffering from primary depressive symptoms may experience a declining ability to garner social support, they may be angry and fearful as well as anxious with poor sleep patterns, excessive pain catastrophizing that all foster interference with their daily activities, alongside a greater likelihood of premature death, higher rates of inflammation, increased blood pressure, memory challenges, a decreased desire for physical activities, illness uncertainty, weakness, social withdrawal, and higher rates of bone attrition, and inactivity, factors that could all interact to magnify the extent of osteoarthritis disability, and possible overuse of existing health services 383940. Expected too in the absence of dedicated intervention are high-levels of kinesiophobia, and its negative influence on physical as well as social activities, progressive decreases in mental health, plus a higher prevalence of comorbid conditions relative to age and gender, plus pain 38. They may incur an increasing sense of perceived failure to cope with their difficulties that may compound their recovery trajectory post surgery 5.

As outlined above, it is clear that many older adults with osteoarthritis may feel isolated and depressed for several reasons. Firstly, because they may already be clinically depressed and hence prone to excess disability, as well as more severe disease activity. Second, and in the context of osteoarthritis, a disease frequently associated with obesity and cardiovascular problems including diabetes, related work shows depression can potentially increase the burden of the disease quite significantly in those with one or more of these comorbid conditions. In particular, high body mass indices, often associated independently with depression, can significantly increase the risk for perceiving one s body negatively, and for reducing the ability of the individual with osteoarthritis to carry out activities of daily living that affect wellbeing.

Indeed, among a fairly representative sample of studies that have specifically examined the relationship between depression and osteoarthritis, most provide clear support for improved efforts to identify, study and treat this psychosocial factor, which has a strong bearing on pain, self-efficacy for managing their disease, and higher levels of anxiety and fear-avoidance feelings. Treated suboptimally one can predict immense impacts on wellbeing, mobility and function, plus fewer social contacts, given a strong desire to be more sedentary than not.

However in addition to standard forms of therapy, it appears socially oriented robots may well reduce to some degree excess suffering and health care usage, pain-related fears of movement and poor functional status that stem from feelings of depression and isolation. In this regard, preliminary data show both pets and social robots can provide or offer dynamic communication opportunities and positive interaction patterns for mitigating the distress of an older impaired and isolated adult 62.

This approach, while not yet well developed, may support the disabled or impaired older adult s desire to remain independent, while having a positive effect on features of the osteoarthritis disease process, such as pain. That is, given that an increased prevalence of at least moderately severe depression is observed among a reasonable percentage of older adults and that a fair number have declining mental health, repeated robotic interactions may heighten their ability to be more active physically, as well as socially, rather than perpetuating the avoidance thereof.

To this end, such efforts do not negate a role for efforts to impact depression directly, including some form of cognitive behavioral therapy, emotional and social support, plus a combination of adequate nutrition, exercise, stress control strategies, weight management, and sleep assistance, plus efforts to minimize inflammation and negative beliefs. However, loneliness and social isolation are increasingly prevalent public health concerns among community-dwelling older adults that may be exacerbated by osteoarthritis and may be greatly benefited by exposure to robotic methods of reducing levels of loneliness and social isolation. Minimizing the extent of any comorbid condition, plus reducing the risk for cardiovascular disease, insofar as these problems can heighten the risk of depression, plus educating osteoarthritis sufferers about treatment options can potentially help affected individual s to control their pain, and thereby to heighten or optimize their mental function. Finally, reducing the stigma of depression due to negative media, ageism, or social network influences, a social carefully construed robot application may be especially helpful as well. In addition, as opposed to using antidepressants to treat depression, and narcotics to treat pain, the importance of minimizing depression safely without side effects cannot be underestimated in the context of both weight control, as well as pain control and the probability socially constructed tailored automated robots can help is quite high.

However, caution is advised because some research offers only weak support for social robots to universally mitigate loneliness. Clearly, as with other forms of therapy, some participants may feel uncomfortable with this form of intervention, or have limited dexterity and strength as well as vision and hearing attributes. However, as with other osteoarthritis interventions, greater attentiveness to the desirability of the therapy and comfort with this as well as adaptations can certainly be addressed. To date, one study showed most participants (68.7%) did not think an automated companion robot would make them feel less lonely and felt somewhat-to-very uncomfortable (69.3%) with the idea of being allowed to believe that an artificial companion is human. In adjusted models, even though one additional year of age was also associated with lower likelihood of perceived benefit of reducing loneliness, those with high confidence using computers experienced greater comfort and heightened social robot acceptance 6364.

However, Lei et al. 65 cautions to not be too optimistic given that participants' acceptance of technology in the face of loneliness may not increase the intention to use the robots in cases where there were signs of related emotional anxiety, hesitant attitudes, the perceptions of an unreal social presence, and usability difficulties. The study has however provided health workers with valuable insights into why they should avoid introducing robots to their clients without due thought and in light of the prevailing needs and health regimens of older isolated/depressed adults.

In sum, because both comorbid as well as reactive depression can influence pain perception as well as the severity of comorbid conditions, and functional disability quite markedly, even if social robots can reduce loneliness, strategies to treat or minimize depression remain highly indicated in efforts to foster optimal health status and overall health outcomes and osteoarthritis associated life quality . While social oriented companion robotics may impact the extent of any excess health care utilization by the affected adult or serve as a proxy in poor service areas, osteoarthritis treatments may require input from the target person in conjunction with the provider to benefit from this. In addition Lee et al. 66 conclude well-designed robotic interventions, as complements to existing aging and clinical interventions, have the potential to improve health behaviors among socially isolated older adults and this should be explored further.

However, it is fair to say, more favorable outcomes of socially automated social support has considerable potential. Indeed, Tobis et al. 67 found older adults not only assessed the robot in question more positively with respect to its roles as a companion and assistant than their providers, they also had higher scores on their need to increase their knowledge about the robot. Regarding the robot's functions, the greatest differences between groups were observed for the social aspects on a survey, including experiencing a decreasing sense of loneliness when accompanying the user in everyday activities. Mean scores of the Animacy, Likeability, and Perceived Intelligence scales were significantly higher for older participants than for caregivers, suggesting providers have their own preferences and should step back when helping their clients.

It also appears therapies that foster feelings of efficacy and confidence and engage the mental and social capacities of the arthritis sufferer such as social robots are expected to be more positively impacted than not 68. Educational programs to foster an individual's self-management capacity, and that could be delivered remotely, may similarly heighten the individual older adult osteoarthritis options, especially for those who are isolated with limited social support and feel distressed 12.

To this end, regular screening and follow up assessments using the robotic unit and an appropriate set of measurement instruments are indicated. In addition, from what we know about the nature of culture and perceptions of homogeneity on health delivery and communication outcomes the development of socially interactive robots and their non-verbal communication attributes should be given more consideration 69. Other benefits should be explored even if loneliness is not impacted significantly after using a socially constructed robotic device 7071, for example their inputs appeared to foster adherence. The main mechanism of effect within group settings however, does appear to be the stimulation of social interaction with other humans 72

Among the many products now available, Broadbent et al. 14 describes an automated social robot device termed ElliQ, which is a consumer robot with a friendly appearance that uses voice, sounds, light, and buttons through a touch screen to facilitate conversation. It also provides opportunities for engagement in music, video calls, and assessments, plus stress relief approaches, games, and health reminders. According to 15 US government agencies ElliQ is not only highly engaging for older people but may be able to improve their life quality and reduce their sense of loneliness. In addition, the development of a weekly report that patients can share with their clinicians to allow better integration into routine care is described but more work is strongly indicated for current findings to be deemed generalizable 73. Nakai et al. 74 specifically highlight the potential of robotics to complement traditional therapies in alleviating pain and enhancing emotional well-being.