41 Protocol: gait-adaptability training in people with HSP waiting list) is used as an independent between-subjects factors. The retention of gait adaptability training will be tested by merging both groups and using a repeated measures ANOVA with Time as a within-subjects factor (C-Mill group: assessment 1, 2 and 3; waiting list: assessment (2, 3 and 4). Post-hoc tests will be performed in the case of significant main or interaction effects, using paired t-tests. Fall rates will be processed descriptively. Depending on the distribution of the data, the rate of near falls may be analyzed using Wilcoxon signed rank test. In addition, to determine key determinants of C-Mill training efficacy, a stepwise linear regression analysis will be performed with training-induced change in gait adaptability (relative change of the obstacle subtask of the E-FAP) as the dependent variable. Univariate analyses will be performed to select the best factors from the available demographic and clinical characteristics. Discussion Limitations in walking capacity are among the most disabling symptoms in people with hereditary spastic paraplegia (HSP). A handful of studies aimed to improve walking capacity in people with HSP,9, 13, 37 but these studies did not include contextspecific exercises aimed at gait adaptability. Gait adaptability has been successfully trained in several neurological populations using augmented reality on the C-Mill 14, 15 but, so far, this has never been done in people with HSP. Move-HSP is a two-armed, open-label randomized controlled trial that will be the first study to assess the effects of gait adaptability training in people with pure HSP. Participants in the intervention group receive ten hours (one-hour sessions; twice per week) of protocolled C-Mill training, whereas the control group continues with treatment as usual (waiting list). After five weeks on the waiting list, the control group will cross over and follow gait-adaptability training. The primary outcome is gait adaptability assessed with the obstacle subtask of the E-FAP. Secondary outcomes focus on several aspects of balance and gait capacity. Mildly to moderately affected people with pure HSP that fit the a-priori established eligibility criteria will be included. There are no restrictions regarding sex, symptom duration, or use of orthotic/ orthopedic devices in order to represent the clinical heterogeneity characteristic of people with pure HSP. Yet, to provide proof op principle and limit the influence of impaired cognitive capacity, people with complex forms of HSP are excluded. Move-HSP aims to make a step towards evidence-based and individually tailored gait rehabilitation programs for people with HSP. It will reveal whether context-specific training is an effective tool for improving gait adaptability in people with pure HSP. If the C-Mill intervention results in improved walking adaptability, it may be beneficial 3
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