63 Results: gait-adaptability training in people with HSP and balance impairments. Because – in the current study – the first assessments took place shortly after a period of generally reduced levels of physical activity, both groups may have increased their levels of activity and exercise in such a way that the added effects of gait-adaptability training were reduced. This study has several strengths and limitations. Despite a delay of four months due to the Covid-19 pandemic, we were able to conduct the trial according to the previously published protocol.14 We were able to recruit the required number of participants and had no participant drop-out during the trial. Moreover, the adherence to the gait-adaptability training was very high. The generalizability of our results to the population of ambulatory people with HSP at large is expected to be high as well, as our participants showed large clinical heterogeneity (i.e., disease severity, disease duration and muscle tone), the use of orthotics was allowed, and the level of independent ambulation varied between the ability to walk 50 meters and completion of a marathon (i.e., 42km). We cannot fully rule out a ceiling effect in the E-FAP obstacle subtask results (limiting room for improvement), however comparison of the current HSP data with unpublished control data obtained by us in healthy controls of similar age (N=15; 49.0± 11.5 years) indicated that only 6 of our 36 HSP participants completed the E-FAP obstacle subtask within a normal range (mean + 2SD of healthy controls). The most important shortcoming of this study was that assessors were not blinded for group allocation. To limit observational bias, a standardized protocol was used for all assessments. In addition, the current protocol implemented a relatively short training period of five weeks. Although this is in line with previous studies9, 12, it remains unknown if people with HSP would benefit from a longer training period, including the use of booster sessions. Furthermore, although we did include the ABC – a self-perceived balance confidence scale – we lack qualitative feedback from our participants on how they perceived the gait-adaptability training. Lastly, we have no details about the content of the usual care (e.g. to what extent aspects of gait adaptability were trained). Hence, it is possible that the contrast between the gait- adaptability training group and the usual care control group was insufficient. With regard to clinical implications, our study provides insufficient evidence to conclude that five weeks of gait-adaptability training, added to usual care, leads to greater improvement of gait-adaptability performance in people with HSP compared to usual care alone. Our study has several implications for future research. Future studies should focus on the evaluation of long-term gait-adaptability training, including booster sessions. They should also make use of a validated outcome measure that is more sensitive than the E-FAP obstacle subtask to the acquisition of complex gait and dynamic balance skills. Lastly, future studies should include qualitative assessments of the intervention by patients to improve its feasibility, content and attractiveness. 4
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