116 Chapter 7 potentially have great clinical benefit, because fall preventive measures could be taken well on time, which would reduce the risk of fall-related injuries and unnecessary fear of falling. As for intervention, I have suggested to focus future HSP research on patients with maladaptive fear of falling, since this subgroup might benefit most from instrumented gait adaptability training on a treadmill, while safety is provided with a harness. On the other hand, the development of overground gait adaptability training programs for people with HSP as a whole would be essential, as all aspects of adaptability necessary for community ambulation can potentially be integrated, such as coping with terrain demands, postural transitions, quiet standing, and negotiating both expected and unexpected obstacles. In addition, the development of effective home-based intervention programs would allow people to train close to where they need their skills most. It would also create the possibility of ‘lifelong training’, which is probably necessary to make a real difference with regard to attenuating the functional consequences of HSP in the long term. With an eye on the lifespan, lifestyle interventions that promote general physical activity and physical fitness might be equally important, given their proven effectiveness in many (other) conditions. As chronic fatigue is a problem in people with HSP, current multidisciplinary programs that have been proven effective to alleviate fatigue in other neurological conditions, should be tested in people with HSP as well. To optimally tailor any type gait rehabilitation (aimed at stepping pattern, dynamic balance, and/or gait adaptability) to the individual with HSP, it is important to always consider the use of other interventions, such as orthotics, pharmacological and/ or surgical treatment. In many instances, patients may profit from one or more of these medical-technical interventions that are meant to optimize the biomechanical prerequisites for effective gait training, such as plantigrade foot contact with the floor, sufficient foot elevation and knee flexion during swing, adequate ankle and knee stability during stance, and sufficient step width / length. Given the progressiveness of the disease, it is important to regularly evaluate whether the current clinical management plan aligns with the individually experienced problems and needs. Sometimes, it will be important to evaluate the gait problems from a broader perspective by taking a multidisciplinary approach, beyond the involvement of physicians and physical therapists. For example, an occupational therapist may be needed to provide advice on chronic fatigue, or a complicated work-life balance; or a psychologist to help to adopt an active coping style. 53 It should be acknowledged that the highest level of evidence for the effectiveness of specific intervention is hard to obtain for any rare disease, particularly if the disease of interest is characterized by a multitude of genetic causes and phenotypical expressions, such as in HSP. It will be even harder to obtain such evidence for the
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