Anetumab ravtansine versus vinorelbine in patients with relapsed, mesothelin-positive malignant pleural mesothelioma (ARCS-M): a randomised, open-label phase 2 trial

BACKGROUND

Few treatment options exist for second-line treatment of malignant pleural mesothelioma. We aimed to assess the antibody-drug conjugate anetumab ravtansine versus vinorelbine in patients with unresectable locally advanced or metastatic disease overexpressing mesothelin who had progressed on first-line platinum-pemetrexed chemotherapy with or without bevacizumab.

METHODS

In this phase 2, randomised, open-label study, done at 76 hospitals in 14 countries, we enrolled adults (aged ≥18 years) with unresectable locally advanced or metastatic malignant pleural mesothelioma, an Eastern Cooperative Oncology Group performance status of 0-1, and who had progressed on first-line platinum-pemetrexed chemotherapy with or without bevacizumab. Participants were prospectively screened for mesothelin overexpression (defined as 2+ or 3+ mesothelin membrane staining intensity on at least 30% of viable tumour cells by immunohistochemistry) and were randomly assigned (2:1), using an interactive voice and web response system provided by the sponsor, to receive intravenous anetumab ravtansine (6·5 mg/kg on day 1 of each 21-day cycle) or intravenous vinorelbine (30 mg/m2 once every week) until progression, toxicity, or death. The primary endpoint was progression-free survival according to blinded central radiology review, assessed in the intention-to-treat population, with safety assessed in all participants who received any study treatment. This study is registered with ClinicalTrials.gov, NCT02610140, and is now completed.

FINDINGS

Between Dec 3, 2015, and May 31, 2017, 589 patients were enrolled and 248 mesothelin-overexpressing patients were randomly allocated to the two treatment groups (166 patients were randomly assigned to receive anetumab ravtansine and 82 patients were randomly assigned to receive vinorelbine). 105 (63%) of 166 patients treated with anetumab ravtansine (median follow-up 4·0 months [IQR 1·4-5·5]) versus 43 (52%) of 82 patients treated with vinorelbine (3·9 months [1·4-5·4]) had disease progression or died (median progression-free survival 4·3 months [95% CI 4·1-5·2] vs 4·5 months [4·1-5·8]; hazard ratio 1·22 [0·85-1·74]; log-rank p=0·86). The most common grade 3 or worse adverse events were neutropenia (one [1%] of 163 patients for anetumab ravtansine vs 28 [39%] of 72 patients for vinorelbine), pneumonia (seven [4%] vs five [7%]), neutrophil count decrease (two [1%] vs 12 [17%]), and dyspnoea (nine [6%] vs three [4%]). Serious drug-related treatment-emergent adverse events occurred in 12 (7%) patients treated with anetumab ravtansine and 11 (15%) patients treated with vinorelbine. Ten (6%) treatment-emergent deaths occurred with anetumab ravtansine: pneumonia (three [2%]), dyspnoea (two [1%]), sepsis (two [1%]), atrial fibrillation (one [1%]), physical deterioration (one [1%]), hepatic failure (one [1%]), mesothelioma (one [1%]), and renal failure (one [1%]; one patient had 3 events). One (1%) treatment-emergent death occurred in the vinorelbine group (pneumonia).

INTERPRETATION

Anetumab ravtansine showed a manageable safety profile and was not superior to vinorelbine. Further studies are needed to define active treatments in relapsed mesothelin-expressing malignant pleural mesothelioma.

FUNDING

Bayer Healthcare Pharmaceuticals.

Emergency department presentations in palliative care patients: a retrospective cohort study

OBJECTIVES

To map the patient journey for individuals known to palliative care presenting to the emergency department (ED).

METHODS

A linked dataset from the CUREd database and palliative care services in a region in the North of England was used. The study describes day and time of presentations, events occurring in the ED, mode of leaving the department and length of hospital admissions for presentations occurring within 90 days of a contact with palliative care. Findings were compared with the wider population in the CUREd database.

RESULTS

A significant proportion of individuals known to palliative care (29.4%) presented to the ED. Presentations typically occurred in working hours. Most presented by ambulance (84.4%) and were admitted to hospital (75.1%); these observations persisted across age groups. Most presentations involved investigations (88.5%) and/or treatment (84.1%).

CONCLUSIONS

Palliative patients exhibit significant use of the ED; some have the potential to benefit from attendances, but there is a minority for whom ED is unlikely to have improved their care. Advance care planning and communication between services are important for empowering those who stand to benefit from ED, while ensuring appropriate care is planned for those who prefer to avoid presenting.

Impact of a case-management intervention for reducing emergency attendance on primary care: randomised control trial

BACKGROUND

The impact on primary care workload of case-management interventions to reduce emergency department (ED) attendances is unknown.

AIM

To examine the impact of a telephone-based case-management intervention targeting people with high ED attendance on primary care use.

DESIGN AND SETTING

A single-site data extract from a larger randomised control trial, using the patient-level data from primary care electronic health records (2015-2020), was undertaken.

METHOD

A total of 363 patients at high risk of ED usage were randomised to receive a 6-month case-management intervention (253 patients) or standard care (110 patients). Poisson regression models were used to calculate monthly rates of primary care use over time for the 2 years post-randomisation, comparing both arms. Usage was subclassified into face-to-face, telephone, letter, and community and secondary care referrals, stratified by patient demographics.

RESULTS

No significant difference was found in the mean annual rate of primary care events between the intervention and control arms (P = 0.70). Secondary care referrals saw a 26% reduction in the mean annual referral rate (incident rate ratio [IRR] 0.74, 95% confidence interval [CI] = 0.64 to 0.86, P<0.001) and letters sent increased by 6% in the intervention arm compared with the control arm (IRR 1.06, 95% CI = 1.01 to 1.11, P = 0.01). In the case-managed arm, in patients aged ≥80 years there was a 33% increase in primary care usage (IRR 1.33, 95% CI = 1.28 to 1.40, P<0.001); with a corresponding 10% decrease in patients aged <80 years when compared with controls (IRR 0.90, 95% CI = 0.87 to 0.92, P<0.001).

CONCLUSION

A targeted case-management intervention to reduce ED attendances did not increase overall primary care use. Redistribution of usage is seen among some patient groups, particularly older people, which may have important implications for primary healthcare planning.

245 Changing Demographics of Head Injury During the COVID-19 Pandemic

Introduction

Studies have shown that men are more likely to sustain head injuries (HI) due to a higher likelihood of participation in high-risk behaviours. However, the COVID-19 lockdown caused substantial alterations to the daily routines of the Welsh population. We aimed to describe the demographical changes of HI patients caused by this large-scale restriction of public social activity.

Method

A retrospective review of our neurosurgical referral database was performed between 1/1/19 to 31/12/20 to extract patient demographics and referral outcomes (admission/advice only) of adult head injury patients. Referrals during lockdown in Wales (26/3/20 – 1/6/20 and 31/10/20 and 2/12/20) were compared with non-lockdown periods in 2019 and 2020.

Results

There was no significant difference in HI referral volume in 2019 (n = 1228) vs 2020 (n = 1179) (OR: 0.71; 95% CI: 0.53 – 0.96, p = 0.02). Women were less likely to be admitted in 2019 (OR: 0.60, 95%CI: 0.39 – 0.91, p = 0.02) and 2020 (OR: 0.52, 95%CI: 0.31–0.88, p = 0.01). We observed evidence of interaction by age and sex in lockdown vs non-lockdown (p = 0.02). Most strikingly, there was higher odds of admission in women aged 40–70 years during lockdown (OR: 10.4, 95%CI: 1.13 – 95.8, p = 0.04).

Conclusions

We observed significant demographical shifts in HI during lockdown periods, with striking increases in admission rates of men under 40 years and women aged 40–70. The cause of these substantial changes need clarification and have important public health implications. Given likely reduced road traffic accidents during lockdown, other factors such as alcohol or assault need considering.

Toward next-generation primate neuroscience: A collaboration-based strategic plan for integrative neuroimaging

Open science initiatives are creating opportunities to increase research coordination and impact in nonhuman primate (NHP) imaging. The PRIMatE Data and Resource Exchange community recently developed a collaboration-based strategic plan to advance NHP imaging as an integrative approach for multiscale neuroscience.

Mobile technology and delegated work in specialist community services: the EnComPaSS Integration project

OBJECTIVES

The current UK healthcare workforce crisis is particularly severe in community services. A key limitation with traditional service-delivery models is the reliance on practitioners with levels of training and experience to enable them to operate independently. This paper describes a real-world evaluation of the implementation of digital health technology designed to provide remote, real-time support and task delegation in community palliative care services. It explores the ability of technology to support sustainable community workforce models and reports on key indicators of quality and efficiency.

METHODS

The study was a mixed-methods, theory-driven evaluation, incorporating interviews, observations and analysis of routine data. The focus of this paper is the reporting of findings from pre-post implementation comparison and interrupted time series analysis. Data include community hospice service visits, hospital use by hospice patients and patient reported experiences.

RESULTS

The digital health intervention allowed the service to include a more junior workforce (p<0.001, Cramer's V=0.241), requiring fewer joint visits (p<0.001, Cramer's V=0.087). No negative changes in hospitalisation were observed and patient reported experiences improved (p=0.023). Changes in hospital non-emergency bed days were inconclusive. However, emergency department admissions reduced significantly (-76.9 /month at 17 months, p=0.001). The cost per hour for visits reduced from £16.71 to £16.23 and annual savings of £135 153 are estimated for reduced emergency admissions.

CONCLUSIONS

The evaluation demonstrates the value of digital innovation to support programmes of service redesign and begin to address the healthcare workforce crisis, while having a positive economic effect and indicating an improvement to patient experiences.

Multicentre study of 4626 patients assesses the effectiveness, safety and burden of two categories of treatments for central retinal vein occlusion: intravitreal anti-vascular endothelial growth factor injections and intravitreal Ozurdex injections

BACKGROUND/AIMS

To assess the effectiveness, burden and safety of two categories of treatment for central retinal vein occlusion (CRVO): intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) and dexamethasone (Ozurdex).

METHODS

A retrospective analysis of Medisoft electronic medical record (EMR) data from 27 National Health Service sites in the UK identified 4626 treatment-naive patients with a single mode of treatment for macular oedema secondary to CRVO. Statistics describing the overall CRVO patient cohort and individual patient subpopulations stratified by treatment type were generated. Mean age at baseline, gender, ethnicity, social deprivation and visual acuity (VA) follow-up was reported. Absolute and change in VA using ETDRS are used to describe treatment effectiveness, the number of injections and visits used to describe treatment burden and endophthalmitis rates as a marker of treatment safety.

RESULTS

Mean VA was 47.9 and 45.3 EDTRS letters in the anti-VEGF and Ozurdex groups, respectively. This changed to 57.9/53.7 at 12 months, 58.3/46.9 at 18 months and 59.4/51.0 at 36 months. Mean number of injections were 5.6/1.6 at 12 months, 6.0/1.7 at 18 months and 7.0/1.8 at 36 months. Endophthalmitis rates were 0.003% (n=4) for the anti-VEGF group and 0.09% (n=1) for the Ozurdex group.

CONCLUSIONS

VA improvements were greater and more sustained with anti-VEGF treatment. Lower starting acuity resulted in bigger gains in both groups, while higher starting acuity resulted in higher VA at 36 months. Although treatment burden was greater with anti-VEGF, Ozurdex was associated with higher rates of endophthalmitis.

A Personalized Mass Spectrometry-Based Assay to Monitor M-Protein in Patients with Multiple Myeloma (EasyM)

PURPOSE

M-protein is a well-established biomarker used for multiple myeloma monitoring. Current improvements in multiple myeloma treatment created the need to monitor minimal residual disease (MRD) with high sensitivity. Measuring residual levels of M-protein in serum by MS was established as a sensitive assay for disease monitoring. In this study we evaluated the performance of EasyM-a noninvasive, sensitive, MS-based assay for M-protein monitoring.

EXPERIMENTAL DESIGN

Twenty-six patients enrolled in MCRN-001 clinical trial of two high-dose alkylating agents as conditioning followed by lenalidomide maintenance were selected for the study. All selected patients achieved complete responses (CR) during treatment, whereas five experienced progressive disease on study. The M-protein of each patient was first sequenced from the diagnostic serum using our de novo protein sequencing platform. The patient-specific M-protein peptides were then measured by targeted MS assay to monitor the response to treatment.

RESULTS

The M-protein doubling over 6 months measured by EasyM could predict the relapse in 4 of 5 relapsed patients 2 to 11 months earlier than conventional testing. In 21 disease-free patients, the M-protein was still detectable by EasyM despite normal FLC and MRD negativity. Importantly, of 72 MRD negative samples with CR status, 62 were positive by EasyM. The best sensitivity achieved by EasyM, detecting 0.58 mg/L of M-protein, was 1,000- and 200-fold higher compared with serum protein electrophoresis and immunofixation electrophoresis, respectively.

CONCLUSIONS

EasyM was demonstrated to be a noninvasive, sensitive assay with superior performance compared with other assays, making it ideal for multiple myeloma monitoring and relapse prediction.

Charting physiotherapy students' attitudes toward people with chronic pain as they progress through their undergraduate programme: An observational study

BACKGROUND

Healthcare professionals' attitudes toward people with chronic pain influence their clinical practice.

OBJECTIVES

To investigate physiotherapy students' attitudes and beliefs toward people with chronic pain over the course of their Scottish undergraduate program.

METHODS

In this observational study, physiotherapy students from one university were recruited in the first year and followed up to their final year (year 1 n = 62/75, year 2 n = 68/72, year 3 n = 59/69, year 4 n = 74/74) for 4 years. The Health-Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS with scores ranging from 15 to 105) was completed annually.

RESULTS

A one-way ANOVA found that attitudes and beliefs improved significantly (p < .01) from the first to final year (9.2 ± 11.5 (mean±SD)). Participants showed a reduction in scores (signifying improved attitudes) annually with smaller reductions initially followed by a larger reduction in the final 2 years.

CONCLUSIONS

This is the first study to chart changes in the same cohort of physiotherapy students' attitudes and beliefs toward people with chronic pain over time. Future work should explore which aspects of degree courses, if any, impact upon attitudes and beliefs toward people with chronic pain so that courses can be enhanced accordingly.

Biotic threats for 23 major non-native tree species in Europe

For non-native tree species with an origin outside of Europe a detailed compilation of enemy species including the severity of their attack is lacking up to now. We collected information on native and non-native species attacking non-native trees, i.e. type, extent and time of first observation of damage for 23 important non-native trees in 27 European countries. Our database includes about 2300 synthesised attack records (synthesised per biotic threat, tree and country) from over 800 species. Insects (49%) and fungi (45%) are the main observed biotic threats, but also arachnids, bacteria including phytoplasmas, mammals, nematodes, plants and viruses have been recorded. This information will be valuable to identify patterns and drivers of attacks, and trees with a lower current health risk to be considered for planting. In addition, our database will provide a baseline to which future impacts on non-native tree species could be compared with and thus will allow to analyse temporal trends of impacts.

Measurement(s)	area of attack of enemy species on non-native tree • intensity of attack of enemy species on non-native tree
Technology Type(s)	species identification • visual observation method
Factor Type(s)	plant health • country • species
Sample Characteristic - Organism	tree
Sample Characteristic - Environment	forested area
Sample Characteristic - Location	Europe

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.14345921

Evolving Treatment Patterns and Outcomes of Neovascular Age-Related Macular Degeneration Over a Decade

PURPOSE

Management of neovascular age-related macular degeneration (nAMD) has evolved over the last decade with several treatment regimens and medications. This study describes the treatment patterns and visual outcomes over 10 years in a large cohort of patients.

DESIGN

Retrospective analysis of electronic health records from 27 National Health Service secondary care healthcare providers in the UK.

PARTICIPANTS

Treatment-naïve patients receiving at least 3 intravitreal anti-vascular endothelial growth factor (VEGF) injections for nAMD in their first 6 months of follow-up were included. Patients with missing data for age or gender and those aged less than 55 years were excluded.

METHODS

Eyes with at least 3 years of follow-up were grouped by years of treatment initiation, and 3-year outcomes were compared between the groups. Data were generated during routine clinical care between September 2008 and December 2018.

MAIN OUTCOME MEASURES

Visual acuity (VA), number of injections, and number of visits.

RESULTS

A total of 15 810 eyes of 13 705 patients receiving 195 104 injections were included. Visual acuity improved from baseline during the first year, but decreased thereafter, resulting in loss of visual gains. This trend remained consistent throughout the past decade. Although an increasing proportion of eyes remained in the driving standard, this was driven by better presenting VA over the decade. The number of injections decreased substantially between the first and subsequent years, from a mean of 6.25 in year 1 to 3 in year 2 and 2.5 in year 3, without improvement over the decade. In a multivariable regression analysis, final VA improved by 0.24 letters for each year since 2008, and younger age and baseline VA were significantly associated with VA at 3 years.

CONCLUSIONS

Our findings show that despite improvement in functional VA over the years, primarily driven by improving baseline VA, patients continue to lose vision after the first year of treatment, with only marginal change over the past decade. The data suggest these results may be related to suboptimal treatment patterns, which have not improved over the years. Rethinking treatment strategies may be warranted, possibly on a national level or through the introduction of longer-acting therapies.

Mass Spectrometry Provides a Highly Sensitive Noninvasive Means of Sequencing and Tracking M-Protein in the Blood of Multiple Myeloma Patients

The amino acid sequence of the M-protein for multiple myeloma is unique compared to the polyclonal antibodies in patients' blood. This uniqueness is exploited to develop an ultrasensitive M-protein detection method utilizing mass spectrometry (MS). The method involves the de novo amino acid sequencing of the full-length M-protein, and a targeted MS/MS assay to detect and quantify the unique M-protein sequence in serum samples. Healthy control serum spiked with NISTmAb and serial samples from an MM patient were used to demonstrate the ability of the platform to sequence and monitor a target M-protein. The de novo NISTmAb protein sequence obtained matched the published sequence, confirming the ability of the platform to accurately sequence a target M-protein in serum. NISTmAb was quantified down to 0.0002 g/dL in serum, a level hundreds of times more sensitive than conventional blood-based tests such as SPEP and IFE. The M-protein in the patient sample could be quantified throughout complete remission, demonstrating the utility of the assay to track M-protein considerably beyond the sensitivities of current blood-based tests. Notably, the assay detected a 2-fold rise in M-protein levels 10 months before any changes were detected by conventional IFE. The MS-based assay is highly sensitive, noninvasive, and requires only a small amount of serum, less than 100 μL. Sequencing data is deposited into PRIDE with identifier PXD022784, and quantification data can be found in Panorama Public with identifier PXD022980.

A Systematic Review and Meta-Analysis of the Effects of Biopsychosocial Pain Education upon Health Care Professional Pain Attitudes, Knowledge, Behavior and Patient Outcomes

Pain is a significant health burden globally and its management frequently fails to comply with evidence based, biopsychosocial guidelines. This may be partly attributable to inadequate biopsychosocial focussed pain education for students and clinicians. We aimed to undertake a systematic review, using Cochrane methodology, of randomized controlled trials with meta-analysis to quantify the effects of biopsychosocial education strategies in changing student/qualified health care professionals (HCPs) pain related attitudes, knowledge, clinical behaviour or patient outcomes. A systematic search of the literature was undertaken using CINAHL, AMED, PEDro, Cochrane Central Library, MEDLINE, ScienceDirect, Rehabdata, SportDiscus, EMBASE, ASSIA, Dentistry and Oral Science, Psycinfo, Education Research Complete and OpenGrey from 1977 to November 2020. Pooled effect sizes were quantified in random effects meta-analyses for attitudes, knowledge, and clinical behaviors. From a sample of 1812 records, 6 were narratively analysed and 15 were included in the meta-analyses. These studies represented 3022 patients and 3163 HCPs and students. Education improved attitudes by 11.3% (95% confidence interval: 2.2-20.4%, P = .02), and knowledge by 18.8% (12.4-25.3%, P = .01). The effects of education on clinical behavior favoured a clinically relevant improvement (OR = 2.4, 0.9-5.9, P = .06). Narrative analysis of the effect of biopsychosocial education for student HCPs/HCPs upon patient outcomes was inconclusive. These findings demonstrate that biopsychosocial focussed pain education strategies can improve student/qualified HCPs' pain related knowledge and attitudes and increase the likelihood that they will behave more in keeping with evidence-based practice. This should result in improved patient outcomes, however, evidence to support or refute this is lacking. PROSPERO systematic review record number, CRD42018082251. Perspective: We outline the effectiveness of biopsychosocial pain education for health care professionals and students in improving pain knowledge, attitudes, and evidence-based behaviors. These improvements should enhance clinical outcomes in patients with pain but further evidence is needed to confirm this.

Functional Neuroimaging During Asleep DBS Surgery: A Proof of Concept Study

Object: A real-time functional magnetic resonance imaging (fMRI) feedback during ventral intermediate nucleus (VIM) deep brain stimulation (DBS) under general anesthesia (or “asleep” DBS) does not exist. We hypothesized that it was feasible to acquire a reliable and responsive fMRI during asleep VIM DBS surgery.

Methods: We prospectively enrolled 10 consecutive patients who underwent asleep DBS for the treatment of medication-refractory essential tremor. Under general anesthesia, we acquired resting-state functional MRI immediately before and after the cannula insertion. Reliability was determined by a temporal signal-to-noise-ratio >100. Responsiveness was determined based on the fMRI signal change upon insertion of the cannula to the VIM.

Results: It was feasible to acquire reliable fMRI during asleep DBS surgery. The fMRI signal was responsive to the brain cannula insertion, revealing a reduction in the tremor network's functional connectivity, which did not reach statistical significance in the group analysis.

Conclusions: It is feasible to acquire a reliable and responsive fMRI signal during asleep DBS. The acquisition steps and the preprocessing pipeline developed in these experiments will be useful for future investigations to develop fMRI-based feedback for asleep DBS surgery.

Adherence to Neuromuscular Electrical Stimulation Interventions for Muscle Impairment in Hip and Knee Osteoarthritis: A Systematic Review

BACKGROUND

Neuromuscular electrical stimulation (NMES) provides a promising approach to counteract muscle impairment in hip and knee osteoarthritis, and to expedite recovery from joint replacement surgery. Nonetheless, application into clinical orthopaedic practice remains limited, partly due to concerns regarding patient tolerance.

OBJECTIVES

This systematic review aimed to quantify levels of adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis and identify strategies to increase compliance.

DATA SOURCES

Randomised controlled trials (RCTs) were identified in a web-based literature review, completed in December 2020. The databases sourced included the Cochrane Library, CINAHL Complete, Medline Complete and PubMed.

ELIGIBILITY CRITERIA

Studies were included if they were: (i) conducted in cohorts of adults with hip or knee osteoarthritis; (ii) a protocol of electrical muscle stimulation prescribed to treat muscle impairment; and (iii) reported intervention adherence or attrition rate. Data were extracted on adherence rate, reasons for non-adherence and potential strategies to increase adherence. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

The search yielded 120 articles, of which 15 studies were considered eligible and included in the analysis (n = 922). All NMES treatment was applied to the quadriceps, with 1 study targeting the quadriceps and calves. The mean PEDRO score of the included studies was 6.80 out of a possible 10 (range 6-8). Mean adherence did not differ between groups receiving treatment with NMES (85% ± 12%) and control groups receiving voluntary exercise or education (84% ± 9%) (P = .97). Reasons for non-adherence or attrition included a dislike of the device, dizziness, pain and discomfort. Strategies to increase adherence included NMES education, a familiarisation period, supervision, setting thresholds based upon patient tolerance, monitoring pain levels during stimulation and using built-in adherence trackers.

CONCLUSIONS

This systematic review indicates that adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis in clinical trials does not differ to control groups receiving education or voluntary exercise, and hence should not be a barrier to application in clinical practice.

Strength and endurance deficits in adults with moderate-to-severe hip osteoarthritis, compared to healthy, older adults

PURPOSE

This study compares lower limb muscle strength and endurance in adults with hip osteoarthritis, to an age-matched control group.

METHODS

Thirteen adults with moderate-to-severe hip osteoarthritis (as graded by the Oxford Hip Score) and fifteen older adults participated. Maximal voluntary isometric contraction of the knee extensors, knee flexors and hip abductors and isotonic endurance of the knee extensors were measured using a dynamometer. Function was assessed using the 30-second chair stand test, the 40 m fast-paced walk test and a stair negotiation test. Data were compared between groups using t-tests.

RESULTS

Participants with hip osteoarthritis demonstrated weakness in the affected limb when compared to the control limb during knee flexion (34%, p = 0.004) and hip abduction (46%, p = 0.001). Weakness was also observed in the contralateral knee flexors (31%, p = 0.01). When compared to the control limb, the knee extensors of the hip osteoarthritis group were exhausted prematurely in the affected (70%, p = 0.001) and contralateral limb (62%, p = 0.005). The hip osteoarthritis group took twice as long to stair climb (p = 0.002), walked 40% slower, (p < 0.001), and had a 35% lower sit-stand performance (p < 0.001).

CONCLUSIONS

Moderate-to-severe hip osteoarthritis may be characterised by bilateral deficits in lower-limb maximal strength, markedly lower knee extensor endurance and impaired functional performance.Implications for rehabilitationIn addition to bilateral deficits in maximal strength of the hip and knee muscles, moderate-to-severe hip osteoarthritis may be characterised by markedly lower muscular endurance of the knee extensors and impaired functional performance.The endurance capacity of the knee extensors can play an important role in daily function, and thus it is important to consider endurance training principles when prescribing exercise for this patient group.Research studies evaluating exercise programmes underpinned by endurance training principles are required to understand the benefits to patients with hip osteoarthritis, and to inform specific exercise prescription in clinical practice.