102 Chapter 7 Summary The aim of this thesis was to gain more insight into gait impairments in people with hereditary spastic paraplegia (HSP). More specifically, our aim was to explore factors that impact on the severity of gait impairments and other spasticity-related symptoms, either negatively or positively, and how to evaluate gait impairments and fall risk in clinical practice. Furthermore, we investigated whether context-specific training can improve gait adaptability in people with pure forms of HSP. Chapter 1 provides the necessary background by introducing the main clinical characteristics of hereditary spastic paraplegia (HSP). This chapter also elaborates on how HSP-related signs and symptoms result in balance and gait impairments, and it provides insight in current clinical management. Insight in factors that contribute to the level of symptom severity, either negatively or positively, are of great importance for clinical practice. Clinical experience shows that a sufficient level of daily physical activity has a positive impact on the severity of spasticity-related symptoms, whereas psychological stress may impact negatively. Chapter 2 explores this assumption by assessing the impact of the COVID-19-related ‘lockdown’ in the Netherlands through a web-based survey in 58 people with HSP. In total, 74% of the respondents reported reduced levels of physical activity during the lockdown, which was associated with increased levels of muscle stiffness, pain, physical fatigue, and balance and gait impairments. Moreover, 43% of the respondents experienced increased psychological stress, which was associated with increased levels of muscle stiffness, pain and mental fatigue. People with HSP often indicate that balance and gait impairments are among their most disabling symptoms. Insight in interventions to ameliorate balance and gait impairments is, therefore, critical to improve their perspective. Previous studies reported beneficial effects of task-specific gait training interventions in people with HSP, but it remained unclear whether context-specific gait adaptability training may improve gait adaptability in people with HSP. Chapter 3 describes the research protocol of a randomized clinical trial that was conducted to evaluate the efficacy of a five-week gait adaptability training added to usual care, compared to usual care alone, in people with pure HSP. We hypothesized that, compared to usual care alone, five weeks of gait adaptability training would lead to greater improvements in gait adaptability, clinical balance and gait capacity, balance confidence, spatiotemporal gait parameters, and level of daily physical activities. To test this hypothesis, a single-center, two-armed, open-label, randomized controlled trial, with a crossover design for the waiting-list control group, and a fifteen-week follow-up period was conducted. Gait adaptability training was provided on the C-Mill, a treadmill equipped with augmented reality through projections of visual targets onto the
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