31 Protocol: gait-adaptability training in people with HSP Background Hereditary spastic paraplegia (HSP) is a heterogeneous group of neurodegenerative disorders, caused by retrograde axonal degeneration of the corticospinal tracts, fasciculus gracilis fibers and, to a lesser extent, the spinocerebellar fibers.1-3 Pure forms of HSP are clinically characterized by progressive spasticity, muscle weakness and reduced proprioception in the lower extremities, as well as difficulties in making rapid (alternating) leg movements.4-6 Additional symptoms are present in complex forms of HSP, including mental retardation, epilepsy, ataxia, peripheral neuropathy or optic atrophy.1, 4, 7 For people with pure HSP, gait and balance impairments are among the most disabling symptoms. They especially experience difficulties when forced to adapt their gait to meet environmental demands, hampering the ability to walk safely and independently in the community.4, 8-11. A recent study reported that 57% of pure HSP patients fell at least twice a year, and 73% experience fear of falling.11 Incorporating gait adaptability training in rehabilitation programs for people with pure HSP seems, therefore, logical and potentially beneficial.4, 11, 12 A limited number of task-specific gait interventions has shown to improve walking capacity in people with pure HSP. Twenty-five sessions of robot-assisted exoskeleton and overground walking improved walking velocity and balance capacity.13 In addition, eighteen sessions of robotic Lokomat® training increased walking speed, balance capacity and quality of life.9 Even though these results are promising, the interventions lacked tasks that promote gait adaptability. As a consequence, it remains unknown whether people with pure HSP will benefit from gait adaptability training.4 Furthermore, it is unclear how to tailor gait rehabilitation programs to the individual patient with HSP as it is currently unknown which determinants can predict training efficacy. To fill this gap, Move-HSP is the first randomized controlled trial to provide proof of concept for the efficacy of gait adaptability training in people with pure HSP. The training takes place in a safe environment on the C-Mill, a treadmill providing augmented reality via visual projections onto the treadmill. Participants will train obstacle negotiation, precision stepping, and unexpected accelerations and decelerations. Its feasibility and efficacy have been described in multiple neurological populations, including patients with stroke,14 cerebellar ataxia 15 and multiple sclerosis.16 Currently, the clinical experience with gait adaptability C-Mill training for people with pure HSP is positive, but the scientific evidence is lacking.4 3
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