62 Chapter 4 Discussion Move-HSP is the first randomized clinical trial investigating the effects of gaitadaptability training in people with pure HSP. Our results showed that, following gait-adaptability training, participants improved on the obstacle subtask of the Emory Functional Ambulation Profile as well as on various secondary outcome measures of balance and gait. However, our results did not confirm the hypothesis that adding gait-adaptability training to usual care would result in greater improvements on these outcome measures. Previous uncontrolled studies using a pre-post assessment design reported that gait, balance, and/or gait adaptability performance improved following 3.5 to 10 hours of C-Mill training in people with Parkinson’s disease13, stroke 9, and cerebellar degeneration12. In addition, a previous randomized controlled trial in people with chronic stroke reported that the primary outcome walking speed did not show a greater improvement following C-Mill training compared to overground gait adaptability training. Yet, additionally, they reported that the C-Mill training group did show a greater improvement on context-specific walking speed (secondary outcome) directly post intervention, but this effect was not retained after five weeks follow-up. The results of the current study are coherent with the above-mentioned studies, as across both groups, the obstacle subtask of the E-FAP showed a significant improvement of 1.3 seconds directly post intervention, that was retained after 15 weeks follow-up. However, five weeks of gait-adaptability training added to usual care did not lead to a greater improvement of gait adaptability compared to usual care alone. Of note, we did find a greater improvement on the single run of the WALT – a novel test designed to evaluate walking adaptability21 – in the gait-adaptability training group compared to the waiting-list control group. The potential utility of the WALT to evaluate gait adaptability should be investigated in future trials. Surprisingly, during the waiting-list period, participants in the control group improved on the obstacle subtask of the E-FAP as well as on most of the secondary outcomes, including measures of balance, balance confidence, gait speed and gait adaptability. These improvements in the control group may be explained in two ways. First, they may have been influenced by the so-called Hawthorne effect,23 the potential change in behavior that occurs when people become aware of being observed and examined24-27. A second explanation relates to the impact of the Covid-19 pandemic. Unfortunately, we had to postpone the first assessments in all participants until the lockdown related to the Covid-19 restrictions was over. Previous research from our group showed that, during the Covid-19 pandemic, people with HSP were generally less active, 28 a phenomenon that has also been reported in other neurological populations.29-34 In addition, we found that the relative inactivity during the Covid19 lockdown negatively impacted on spasticity-related symptoms, including gait
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