53 Results: gait-adaptability training in people with HSP orthopedic devices was allowed). Participants were excluded if they suffered from concomitant neurological, orthopedic or psychiatric conditions that might affect gait performance, or if they had any HSP-related surgical procedure of the lower extremities in their medical history. Participants provided demographic information including age and sex. Clinical characteristics that were recorded consisted of leg muscle tone assessed with the modified Ashworth Scale (MAS; range 0-5),16 leg muscle strength assessed with the Medical Research Council scale (MRC; range 0-5), 17 vibration sense at the ankles and feet assessed with a semiquantitative tuning fork (Rydel-Seiffer, Neurologicals Poulsbo, Washington) (range 0-8). In addition, we recorded disease duration (years), level of disease severity assessed with the Spastic Paraplegia Rating Scale (SPRS; range 0-52) 18, trunk control assessed with the Trunk Control Measurement Scale (TCMS; range 0-58),19 and self-reported falls during the previous year. Intervention Participants trained their gait adaptability on the C-Mill (Motek Medical, Culemborg, The Netherlands), a treadmill equipped with augmented reality. Visual projections onto the treadmill acted as stepping targets or obstacles to elicit step adjustments. The training sessions were guided by a physical therapist. Sessions lasted 60 minutes and took place twice a week for a period of five weeks, adding up to a total of ten hours of gait-adaptability training. A detailed description of the training has previously been published.14 In short, training sessions started with a tenminute warming-up, followed by five exercises of approximately eight minutes. Each exercise focused on a specific gait-adaptability task: (A) precision stepping, (B) obstacle negotiation, (C) direction of progression, (D), precision acceleration, or (E) walking velocity. Sessions ended with a five-minute game that combined several gait-adaptability tasks and a five-minute cooling-down period. During the training sessions, additional short periods of rest were provided as needed. To ensure sufficient challenge for each participant, progression of task complexity was moderated by the therapist based on the participants capacity. A maximum of two therapists per participant were involved in providing gait-adaptability training sessions. Outcome measures The primary outcome was gait adaptability assessed with the obstacle subtask of the Emory Functional Ambulation Profile (E-FAP).15 Secondary outcomes consisted of the Mini Balance Evaluation Test (MiniBEST),20 Activities-specific Balance Confidence scale (ABC), the Walking Adaptability Ladder Test (WALT),21 and the 10-meter Walk Test (10mWT).22 In addition, three-dimensional gait analysis (Vicon© Motion systems Ltd.) was performed. To this end, retroreflective markers were placed according to the standard Plug-In-Gait upper and lower body marker model. During the gait analysis, participants walked two bouts of three minutes at comfortable speed 4
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