35 Protocol: gait-adaptability training in people with HSP assessments will consider the date of the BTX injections. BTX injections induce an effect on muscle spasticity approximately two weeks post-injection. The maximum effect is reached around 6-8 weeks, after which it gradually subsides.17, 18 Participants who receive BTX injections in the lower extremities will have the pre-intervention assessment four weeks post-injection, and the post-intervention assessment ten weeks post-injection. In addition, it will be monitored whether the dosage of oral antispasmodic change during the trial. Control group The eighteen participants attributed to the control group are asked to continue with their daily routine and usual care during the five weeks on the waiting list. If therapy is part of the usual care, participants are requested to continue with the same frequency and composition during the waiting period. Intervention: C-Mill training Gait adaptability training takes place on the C-Mill (Motek Medical, Culemborg, The Netherlands). The C-Mill is a treadmill, providing augmented reality via visual cues projected onto the treadmill. The projections are either stepping targets or obstacles that challenge the participants to adjust their steps accordingly. The training sessions take place during five consecutive weeks, twice per week during 60-minute sessions. In total, participants will train gait adaptability on the C-Mill for 10 hours. The C-Mill protocol is based on clinical experience and finalized after a focus group discussion with expert physical therapists. The training sessions are logged to ensure compatibility and a consistent progression. Each session starts with a tenminute warming-up, followed by five training blocks (figure 2, video). Each training block lasts approximately eight minutes. Block A targets precision stepping by practicing accurate foot placement on the projected stepping tiles. Block B targets obstacle negotiation by avoiding the projected obstacles. Block C elicits changes in the direction of progression by using a variety of slalom trajectories. Block D targets precision acceleration and deceleration, as the participants must walk within a projected square that moves forward and backward on the treadmill. Block E challenges walking at different walking speeds. Block F is the endgame, a five-minute track that combines several gait adaptability components in an interactive way. All sessions end with a cooling-down. To further promote the level of variability, each training block consists of small components (i.e. for block A: Stepping Tiles: belt speed will momentarily increase; width between the stepping stones will momentarily decrease). In addition, different walking speeds are used: 100% is the participant’s comfortable walking speed on the treadmill. This will be determined during the first training session. The belt speed will be manually increased until the participant experiences it as comfortable. The therapist will then increase the belt 3
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