104 Chapter 7 order to maintain balance during gait, people prefer foot placement strategies and ankle strategies, but people with HSP become limited in recruiting these strategies when disease severity progresses. Hip strategies that require trunk movements may then be recruited to better maintain balance during gait, which is one of several – but not mutually exclusive – explanations for increased trunk movements during gait in people with HSP. Fear-of-falling, falls and fall-related injuries are often the result of the previously mentioned balance and gait impairments in people with HSP. In order to optimally tailor personalized fall prevention intervention, the clinical field needs measures that can distinguish between people who are at risk of falling, and those who are not. Chapter 6 evaluates the potential of different constructs to identify differences between healthy controls and people with HSP. We found that subjective balance confidence, objective balance and gait capacity, and multiple biomechanical measures of gait stability were significantly worse in people with HSP compared to healthy controls. Within the HSP cohort, 14 out of the 32 people were identified as fallers (≥1 fall during a fifteen-week period). We found that subjective balance confidence (ABC-Scale) and clinical balance capacity (Mini-BESTest) are promising parameters in clinical practice to identify fallers in HSP, and outperform biomechanical gait stability measures derived from unperturbed treadmill walking. For future studies, it may be of interest to evaluate these gait stability measures in a free-living environment, as this includes the more challenging circumstances during which falling usually occurs in daily life. General discussion Here, I will discuss the main insights obtained from the work presented in this thesis on gait problems in people with hereditary spastic paraplegia (HSP). I will elaborate on two gait-related themes: assessment and intervention. In addition, I will reflect on methodological considerations and future perspectives for clinical practice and research. Assessment A valid and diligent assessment of gait is required to establish a tailored clinical management plan for the individual with HSP. This is a complex process as, for example, evaluating kinematics obtained from a 3D gait analysis on a level floor will not detect that anxiety while walking outdoors is causing the experienced gait problems. Also, the translational value of clinical research is influenced by proper outcome assessment. Therefore, clinical practice and research require valid, reliable, and responsive measures that can objectify the impact of gait problems in daily life.
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