Longitudinal Gait Improvement With Multimodal Treatment and Repeated Hybrid Assistive Limb Gait Training in Hereditary Spastic Paraplegia: A Case Report

Hereditary spastic paraplegia (HSP) is a progressive neurodegenerative disorder characterized by lower-limb spasticity and gait impairment.Although spasticity management, including botulinum toxin injections, intrathecal baclofen therapy, and orthopedic surgery, can reduce spasticity and improve limb alignment, translating these improvements into meaningful gains in walking remains challenging.Robot-assisted gait training with wearable exoskeletons, such as the Hybrid Assistive Limb (HAL), may facilitate task-specific gait practice by assisting voluntary movements based on the user's motor intention.We report the case of a 64-year-old man with spastic paraplegia type 4 (SPG4), a subtype of HSP associated with pathogenic variants in the SPAST gene, who underwent stepwise spasticity management combined with repeated HALassisted gait training over long-term follow-up.Botulinum toxin injections were initiated at presentation, followed by intrathecal baclofen therapy during follow-up and tendon lengthening surgery.HAL-assisted gait training was performed repeatedly from Month 29 to Month 49.Over the course of treatment, walking speed and 2-minute walk distance gradually improved, whereas cadence remained relatively stable.These functional gains persisted despite a temporary decline.These sequential interventions may have provided a therapeutic foundation for subsequent gait reconstruction through repeated task-specific gait training using the HAL.Although the individual effects of each intervention cannot be determined from a single case, this clinical course suggests that integrating impairment-oriented interventions with repeated HAL-assisted gait training can optimize functional walking outcomes in patients with HSP.