13 General introduction make people more cautious and make them cease certain activities, even when they are still physically capable of doing them. This can result in physical inactivity and deconditioning, along with a decline in muscle strength and balance capacity, which further increases fall risk.42 To prevent or break this vicious cycle, insight is needed into parameters that can identify people with HSP who are at increased risk of falling in order to tailor fall prevention interventions. Currently, this is a relatively unexplored topic in people with HSP. Clinical management of balance and gait problems in HSP. During consultations with their physician and allied health professionals, people with HSP prioritize the rehabilitation of their balance and gait problems.43 As there are currently no therapies available to prevent, delay or reverse the progressive impairments due to HSP, the clinical management of balance and gait problems in people with HSP must be symptomatic. Possible interventions consist of four domains: (1) exercise therapy (e.g. aimed at maintaining muscle length and functional skills), (2) pharmacological interventions (e.g. to reduce troublesome spasticity), (3) walking aids and orthotic devices, including orthopedic footwear (e.g. to support foot clearance and compensate for foot deformities), and (4) surgical interventions (e.g. to reduce disabling spasticity or contractures). In addition, self-management programs (e.g. directed at fatigue management or attaining adequate levels of physical activity) can be indicated. Some people may require psychosocial support to deal with, for instance, emotional of societal consequences.43,44 A few studies have evaluated the efficacy of gait training interventions.45 The interventions were mainly task-specific, and consisted of functional gait training in combination with intramuscular botulinum toxin46, robotic gait training (e.g., Lokomat® or exoskeleton)47,48, or hydrotherapy49. Following these interventions, promising improvements were reported regarding balance capacity, gait capacity, pain relief, and quality of life.46-49 Although these results are promising, most of the studies used an uncontrolled design comparing pre vs post-training assessments, and included a small number of participants. None of the aforementioned gait training interventions included context-specific tasks that targeted gait adaptability required for walking in the community. Therefore, part of this thesis focuses on the effect of a gait adaptability training in ambulatory people with pure HSP. Gait adaptability training was provided on the C-Mill, a treadmill equipped with augmented reality that provides contextspecific gait adaptability training exercises (for a detailed description of the C-Mill - see Box 2). 1
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