15 General introduction Outline of the thesis The aim of this thesis is to gain more insight into how balance and gait impairments in people with pure HSP affect their gait capacity. More specifically, we will investigate which factors impact negatively or positively on symptom severity, gait adaptability and fall risk. Furthermore, we will evaluate whether context-specific gait training can improve gait adaptability in people with pure HSP. Based on clinical experience, it is likely that sufficient levels of daily physical activity have a positive impact on the severity of spasticity-related symptoms, whereas psychological stress may impact negatively. In Chapter 2, I investigate this assumption, and report on the results of an online questionnaire that was conducted to evaluate the impact of Covid-19 measures in people with HSP. The Covid-19 measures provided a unique opportunity to evaluate whether changes in levels of physical activity and psychological stress were associated with changes in symptom severity, such as muscle stiffness, pain, or gait impairments. In Chapter 3, I describe the research protocol of a randomized clinical trial with a partial cross-over design that was conducted to evaluate the efficacy of a contextspecific gait adaptability training in ambulatory people with HSP. Chapter 4 presents the results of this randomized clinical trial. I evaluate the efficacy of a five-week gait adaptability training program, added to usual care, to usual care alone on outcome measures related to balance and gait capacity, balance confidence and physical activity. Furthermore, I evaluate potential retention effects of the gait adaptability training after fifteen weeks. In Chapter 5, I take a closer look at increased trunk movements that are observed during gait in people with HSP and investigate whether these trunk movements can (partly) be explained as balance correcting strategies. To this end, I explore whether there is an association between increased trunk movements and reduced balance performance. In Chapter 6, I evaluate whether commonly used clinical tests evaluating balance confidence, balance capacity or gait capacity, and novel biomechanical measures of gait stability differ between people with HSP and healthy controls, and whether these tests may have the potential to differentiate fallers from non-fallers among people with HSP. Finally, in Chapter 7, the main findings of this thesis are summarized and discussed, and implications for clinical practice and future research are provided. 1
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