110 Chapter 7 risk-taking by subgroups of people with HSP. The assessments should include measures of gait capacity, gait performance, and gait perception, next to the regular clinical examination of muscle tone, muscle strength, joint range of motion, and proprioception of the lower extremities. Following the baseline assessment, falls should be prospectively recorded at fixed time intervals across at least one year. A fall diary should include questions about the situation (activities) and environmental factors (indoor vs. outdoor, ambiance, footwear) surrounding the fall. This will provide insight into how and why falls occur; for instance, does a fall occur due to poor obstacle negotiation in the case of impaired proprioception or due to a sudden, spontaneous change in behavior in the case of urinary urgency. Preferably, such a study would be multicentered to enroll a sufficient number of participants and be able to obtain representative results. Intervention Multiple (combined) interventions can be administered to improve functional gait and mobility in people with HSP. As mentioned in the introduction, well-known interventions are pharmacological treatment (e.g., intramuscular botulinum toxin injections), orthotics, ankle-foot surgery (e.g., Achilles tendon lengthening), and training interventions. Within the context of this thesis, I will elaborate specifically on training interventions to improve gait adaptability and I will provide some considerations on the potential of (additional) lifestyle interventions. Gait adaptability interventions Chapter 4 reported that C-Mill training improved gait adaptability in people with HSP, but the observed improvements were similar to those found in a control group that received usual care. Several factors can be considered to advance future gait adaptability training in people with HSP. As a basis, our study showed that a treadmill-based intervention on the C-Mill (or likely similar devices such as the Gait Real-time Analysis Interactive Lab (GRAIL), Motek Medical BV. The Netherlands, or Computer Assisted Rehabilitation Environment (CAREN), Motek Medical BV, The Netherlands) could be a viable option to train gait adaptability in people with HSP. From a clinical perspective, however, our study did not show added value of the C-Mill over usual care in the entire group of participants with HSP. Given this unexpected neutral finding, the first factor to consider is a more targeted patient cohort. One example is gait adaptability training for people who experience debilitating fear of falling. To this end, specifically people with HSP in whom fear of falling is the main reason to avoid walking activities, despite their being physically capable of conducting such activities, should be targeted. This condition can be referred to as maladaptive fear of falling. 30 This maladaptive fear of falling hinders the efficacy of conventional gait training, but with e.g., C-Mill training people can practice their gait while a safe training
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