25 Covid-19 and symptom severity in people with HSP Discussion The partial lock-down in the Netherlands due to the COVID-19 pandemic resulted in a reduction of physical activity in the majority of participants with HSP, which proved to be associated with increased muscle stiffness, pain, physical fatigue and gait impairments. This result is coherent with findings in other chronic (neurodegenerative) conditions4 and underscores the potential impact of physical activity on symptom severity in people with HSP. Future studies may investigate whether the present findings can be extended to other conditions resulting in spastic paraparesis (e.g. multiple sclerosis and primary lateral sclerosis). Future studies may also evaluate the effect of interventions targeting daily physical activity in this population, preferably including objective outcomes, which were lacking in the present study. Another limitation is the lack of comparison between current and previous clinical status, which was not possible due to the lockdown restrictions. An additional limitation is the risk of selection bias, which may have resulted in an overestimation of changes in physical activity, psychological stress, and/or symptom severity. The question remains whether people with HSP are able to return to ‘baseline’ levels of functioning after release of the lockdown and expected increase in physical activity. 2
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