103 Summary and general discussion treadmill belt. Participants trained for five weeks, twice per week, while each session lasted 60 minutes, adding up to a total of ten hours of gait adaptability training. All training sessions were personalized and took place under supervision of a trained physical therapist. The primary outcome was gait adaptability as measured with the obstacle subtask of the Emory Functional Ambulation Profile (E-FAP). Furthermore, the assessment included a complementary set of secondary outcome parameters: gait speed (10-Meter Walk Test), balance capacity (mini-BESTest), balance confidence (ABC-scale), physical activity for 24 hours (Activ8 monitors), fall rates, walking adaptability (Walking Adaptability Ladder Test / WALT), and spatiotemporal gait parameters obtained through 3-D motion analysis (gait speed, step length, step time and step width). Chapter 4 presents the results of the randomized clinical trial, in which 36 people with pure HSP participated. Despite delays due to Covid-19-related lockdown measures, we were able to conduct the protocol as described in chapter 3. At baseline, both groups did not differ in demographic or clinical characteristics such as age, disease duration or disease severity. All participants adhered to their allocated group and there was no participant drop-out during the study period. Furthermore, adherence to the intervention was high, since 99.7% of the planned training sessions were completed. After adjusting for baseline differences, we found that the gait adaptability training group did not improve more on the obstacle subtask of the E-FAP compared to the waiting-list control group. Similar results were found for most of the secondary outcome parameters. After merging the pre-training, posttraining, and follow-up assessments for both groups, we found that participants had improved on the obstacle subtask of the E-FAP directly post-training, which effect was retained at the fifteen-week follow-up. Similar results were found for the 10meter walk test, the mini-BESTest, the ABC-scale, the WALT, and the spatiotemporal gait parameters: walking velocity and average stride length. We concluded that there was insufficient evidence for adding five weeks of context-specific gait adaptability training to usual care to improve gait adaptability in people with HSP. When evaluating gait impairments in people with HSP, previous studies have reported increased trunk movements during gait, which was evident even in the early stages of the disease. Yet, it remains ambiguous how these exaggerated trunk movements should be interpreted. It is often assumed that people with HSP generate increased trunk movements as a compensatory mechanism to improve their foot clearance and step length. Chapter 5 reports that increased trunk movement may (additionally) reflect balance correcting strategies. After reviewing gait analysis videos of 86 people with HSP and classifying their observed trunk movements into three categories (‘normal’, ‘moderately increased’, ‘markedly increased’), a significant association was found between increased trunk movements and reduced balance capacity as assessed with the Berg Balance Scale or the Mini-BESTest. Generally, in 7
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