Why do stretches?

People with HSP often have a range of stretches to do. Frequently these are agreed with a physiotherapist, but sometimes people choose to do these independently. I remember a discussion with my physiotherapist a few years ago which has stuck with me and hasn't made it into a blog post, until now (with the help of some Google searches to help me remember the details). 

This is a discussion around why we do stretches - what happens to our spastic muscles.

All joint movements have two sets of muscles, the sets are on the opposite sides of each joint. To make the joint move one way you tighten one muscle set and relax the opposite set, and to make the joint move the opposite way you swap the sets of muscles which are tightened and relaxed. 

As a simple example your biceps and triceps control your elbow movement. To fold your elbow you have to tighten your biceps and relax your triceps. To straighten your elbow you must tighten the triceps and relax the biceps. The brain sends the messages to the muscles to do this.

Todays Google search on spasticity brings back an answer from the American Association of Neurological Surgeons, which I have cut, pasted and trimmed: https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spasticity

Spasticity is a condition in which muscles stiffen or tighten, preventing normal fluid movement. The muscles remain contracted and resist being stretched, thus affecting movement. In the elbow example, if your biceps become spastic, then they remain contracted, which means that straightening your elbow becomes more difficult - the triceps have to do the usual work of moving your forearm and the additional work of fighting against the spastic biceps. If both sets of muscles are more spastic then it becomes more difficult to move the elbow in either direction - each muscle has to do its usual work, fight against the spasticity in the opposite muscle, and its own spasticity makes it difficult to move itself.

Spasticity is generally caused by damage or disruption to the area of the brain and/or spinal cord that are responsible for controlling muscle and stretch reflexes. We know that in HSP the nerves in the spine deteriorate and the signals between the muscles and the brain are disrupted.

Muscle cells which are spastic become shorter and stiffer than similar cells not affected by spasticity. (ref: https://onlinelibrary.wiley.com/doi/abs/10.1002/mus.10247). The muscles themselves become physically shorter the more spastic they become. The opposite is also true, muscles that are stretched regularly are longer than those which are not. (This physically shorter/longer muscle point was the key thing I remembered from my physio discussion as the basis of this post)

The purpose of stretching is to help reverse the shortening of the muscle cells. There are plenty of websites offering similar opinions that stretching is beneficial for muscles (although equally there are studies saying that it is difficult to draw firm conclusions on this front). The key point is that if your HSP is such that you are less able or unable to operate the muscles, you can still bend the joint by other means (perhaps with help). By stretching the muscles regularly you can either prevent the muscle from becoming any shorter or reverse some of the shortening that has already occurred. This is one of of the areas where the HSP mantle: 'use it or lose it' comes from. 

Doing a set of stretches will not change the signals which get fed up and down the spine, they will just change how easy it is for the muscle to move in response to the signals which are received from the brain. (Note - I wonder if the nerve signals from the muscles back to the brain may travel more easily, because the 'intended muscle position reached' signal may be stronger. A question for another day!) 

From my perspective, I can still move all of my joints, although I cannot move some joints as far or as easily as I used to. The work that I did with my physio was to look at which muscles were becoming spastic, and to look at stretches to keep those muscles as long as possible. You can see the stretches that I was doing a few years ago here: https://hspjourney.blogspot.com/2018/04/stretching-routine.html. I have added a few more since then, and at some point I'll do an update post with the new ones. 

As we know with HSP the spasticity in our muscles changes slowly as the nerves degrade slowly over time. Similarly, it takes time for the cells in muscles to grow as a result of regular stretching. The most difficult thing is trying to work out if you are getting any benefit from stretches or not. You are mentally trying to balance the speed of your HSP degradation against the slow speed of any gains in muscle length which you are making. So, it might be that you can detect the benefits of your stretches at other times by noticing, for example, that sitting at rest feels more easy than it did before.

If you can move all your joints, and get yourself into a position where you are stretching the muscles, then you may need to keep this up for a number of months to get a noticeable change - and hopefully that is quicker than the speed which your HSP deteriorates. If you cannot move your joints by yourself or you cannot get yourself into a position where you can stretch the muscles then it will be more difficult to explore this issue by yourself.

My approach since I started doing my stretches has been to adapt those stretches to include muscles which I notice are becoming more stiff. My key areas of observation are; how difficult I find exercises at Pilates, how easy I can reach for things, how easy I can put my socks on/cut my toenails, how easy it is to use the stairs, how long it takes me to feel uncomfortable sitting down, and so on. I am still doing all of the stretches which are shown on that stretches page, and I have just added a few more in. I now do one set of stretches each day, which usually lasts between 15 and 20 minutes. Essentially I have become my own physiotherapist!

Obviously, I don't have an identical twin who hasn't been doing those stretches, but my perception is that I get benefits from those stretches. I haven't noticed that I am able to stretch any muscles more as a result, but equally I haven't noticed any muscles becoming shorter either. My conclusion is therefore, that my stretching is more-or-less offsetting the progression of my HSP. My control continues to deteriorate slowly, but I dont think my strength or range of movement is changing much. 

Coronavirus Vaccine Time

In recent weeks there have been various people querying if the various coronavirus vaccines are safe for people with HSP. There is no evidence to say that they are not safe. I advise anyone to discuss any concerns with their GP before having their vaccination. The overwhelming body of evidence shows the available vaccines are safe and effective, with remarkably few side effects other than a mild local reaction (arm soreness at injection site) and mild general symptoms (e.g. slight fever or tiredness) in about 10-20% of cases. These typically only last a day or so. So the risks from catching coronavirus are far greater than any risks from vaccination.

The UK has divided its population up into groups so that they can prioritise the people who have the highest risk of serious illness or mortality. The first group (Group 1) included those living and working in care homes. Much of the evidence was that people with some underlying health conditions put them in this higher risk category. Those with HSP fall into one of two groups.

People who have complex HSP which includes cognitive problems (this might also be called intellectual disability or learning difficulties) are more likely to be considered extremely vulnerable. Depending on exact circumstances these people are likely to be in one of the higher groups (group 4) for Covid-19 vaccination, particularly if those cognitive impairments are advanced or neurological problems are complex. Groups 2 and 3 captured people aged 75 and above. Group 4 also includes people aged 70-75

Those people who have more advanced HSP without cognitive problems will meet the criteria for underlying health conditions (group 6). Group 6 also includes people who care for those who are elderly or disabled, including people with HSP. Group 5 is people aged 65-70, and groups 7 and above capture the population aged below 65.

Those people who have mild HSP probably have a similar risk profile to people of the same age, but could still be classified under group 6 as they have a neurological condition, which is on the list of underlying health conditions.

In terms of timelines, those in Group 4 were invited to have their vaccination late January - early February. Those in group 6 are being invited at the moment (early March), and the advice in the last day or two has been that anyone with an underlying health condition who has not been invited to have their first vaccine, and this can be done on-line or by calling 119.

22 Charities have written an open letter to encourage people to get the vaccine, and further details and a copy of that letter can be seen here:

https://www.gov.uk/government/news/health-charities-back-vaccines-drive-for-those-at-risk

For me, I was notified that I was eligible to have the vaccine by my doctor, and I had my first jab yesterday evening. I had the Astra-Zeneca one. In terms of side effects, my arm feels a little sore, but otherwise there are no side effects for me.

If there is anyone reading this in the UK with HSP and has not been invited to have their vaccination yet, then I encourage you to go and get your vaccination.

For any readers outside the UK, I suggest that you investigate opportunities for vaccinations in your countries, especially if your HSP is more advanced.

  

2020 Survey Results

Rare disease day is here again, and I am very pleased to publish the results of my 2020 survey.

This post is an abbreviated version of the full results. If you wish to read the full version of the results please follow this link: https://drive.google.com/file/d/1Ect9mdluhSY3xGo8MZLezp22hk435l5r. 

In the post below table numbers are not sequential. There are other tables of data in the full version of the results, and this approach avoids confusion between people referring to results from this post against the full results just by table number.

Thanks are due to all who helped with this. Most importantly, thank you to all the respondents in many countries who took time to respond to this survey, without these excellent answers this analysis would not be possible. Thank you to the various HSP groups around the world and on Facebook who have let members know about this survey. Thank you also to individuals who assisted with translating the survey questions and those who gave comments on earlier versions of these findings.

Introduction

This paper presents the results of my eighth survey, launched in October 2020. This survey repeats the multi-language setup introduced in 2019, with the survey in different languages allowing people to read and answer directly in their own language. 

Respondents

There were 317 respondents who completed the survey, predominantly from the UK, Brasil and USA. Table 1 shows the distribution of respondents’ locations;

Table 1 - Location of respondents

Location	Respondents	Percentage
UK	69	22%
Brasil	67	21%
USA	51	16%
France	39	12%
Netherlands	21	7%
Canada	17	5%
Australia	16	5%
Other Europe	32	10%
Rest of world	5	2%

 The number of responses to this survey is lower than in 2019, but higher than earlier ones, reflecting the wider reach with the survey available in multiple languages. The ‘Other Europe’ category includes higher numbers of answers from Italy, Belgium, Spain, and Denmark. With this survey the analysis also separates out results from countries with higher numbers of respondents to identify country-to-country differences, with 88% of respondents coming from seven countries. The main change from previous analyses is that USA and Canada have previously been grouped together.

 A brief analysis shows that 170 people who completed this survey had also completed at least one of my previous surveys, representing about 54% of respondents, the proportion is increased from 2019. There are ten people who have completed six or more of my eight surveys.

HSP Analysis

The first questions in the questionnaire asked if people had HSP. 313 respondents answered this question, selecting from the following options:

Table 2 – HSP Diagnosis

HSP Diagnosis	Respondents	Percentage
I have HSP - genetic test	170	54%
I have HSP - other diagnosis	103	33%
I do not know if I have HSP	8	3%
I am answering on behalf of someone else with HSP	32	10%

 Around 54% have had a genetic test. The proportion having a genetic test is lowest in Brasil (38%), and highest in Netherlands (76%) and Australia (69%), with all other areas being within 5% of the average.

There were 201 respondents (55%) who knew which type of HSP they had, with the most common answer being type 4 – SPG4, indicating a mutation in the Spast gene. HSP types with at least three people reporting a diagnosis are shown, with the gene which is mutated in that type of HSP:

Table 4 – Type of HSP

HSP Type	Gene	Respondents
SPG 3/3a	ATL1	9
SPG 4	Spast	89
SPG 5/5a	CYP7B1	7
SPG 7	Paraplegin	30
SPG 8	WASHC5	4
SPG 11	Spatacsin	10
SPG 30	KIF1A	3
Other types	-	22

These results are similar to those in previous years, where SPG 4 and SPG 7 are the most common types of HSP reported. SPG4 is the most common type of HSP across the world. There are some variations in country between the more common types of HSP:

Of the respondents to this survey, SPG4 is more common in UK, France and Netherlands than in other countries, and SPG7 is more common in USA, Canada and Australia than in other countries. Brasil shows the greatest number of different types of HSP.

Wellbeing

In order to assess the wellbeing of people with HSP, respondents completed the Warwick-Edinburgh Mental Well-being scale (WEMWBS). The scale is scored by summing the response to each item answered on a 1 to 5 Likert scale. The minimum scale score is 14 and the maximum is 70. The total score is higher for those with a better wellbeing. The average score across England and Scotland populations is 51-52 with most scoring between 41 and 59.

There were 308 respondents who answered this question, with the average wellbeing score of 42.9, which is lower than the average scores of 47.4 in 2019 and 45.9 in 2017 and 2018. The scores ranged between 14 and 70. The average is lower than UK population norms, however it is still within the “average” definition and is also similar to those with a self-perceived health status of “poor”. 

Wellbeing scores throughout this post that could be significantly different from the average have been shaded yellow or light green, and those that are likely to be significantly different from the average are shaded orange and green. Wellbeing scores have not been evaluated for small groups of respondents (less than 10). Wellbeing scores for groups of less than 20 people are shown in brackets and these cannot be reliably assessed in respect of the significance due to group size.

It is relevant to note that this years’ average score is approximately five points lower than last years’ average score, potentially indicating that wellbeing between 2019 and 2020 has dropped significantly. One potential explanation for lower wellbeing this year is the effect of Coronavirus on people around the world, with people having answered these questions October to December 2020. This year is the fourth year the wellbeing questions have been asked, and there are 83 people who have answered these in at least three surveys.

Table 6 – Wellbeing Over Time

Area	2017	2018	2019	2020
All respondents	45.9 (+3)	45.9 (+3)	47.4 (+4.9)	42.9
Those answering in at least 3 years	47.4 (+4.5)	46.1 (+3.2)	48.6 (+5.7)	43.4 (+0.5)

This table shows that those who have answered this question regularly have a lower wellbeing in 2020 compared with previous years, which is more likely to indicate a genuine reduction in wellbeing in 2020.

 The wellbeing for each country has been calculated to identify if there is potential for differences in wellbeing across the world.

 Table 7 – Regional Wellbeing

Area	Wellbeing
UK	42.4
Brasil	40.8
USA	44.9
France	43.5
Netherlands	43.4
Canada	(41.4)
Australia	(45.5)

This shows that people in Brasil and Canada have a slightly lower wellbeing and those in USA and Australia have a slightly higher wellbeing. These results are different from 2019, however all scores are within 3 points of the average suggesting that any regional differences are not significant.

When comparing with the 2019 results, results in all areas are lower except for Australia which is similar. Anecdotally, Australia appears to have been less affected by Coronavirus than the other areas where respondents are. This may suggest that coronavirus is one of the factors leading to a lower wellbeing, however it is acknowledged that this questionnaire does not contain information to support this idea directly.

Those who have SPG4 have an average wellbeing of 44.8, slightly above the overall HSP average. Those with SPG7 have a lower wellbeing score of 37.9, 5 points below the average and consistent with results from 2019. There are insufficient people with SPG11 in this survey to assess if having SPG11 is a factor in peoples wellbeing.

Mobility Analysis

Just over half of respondents use walking sticks/poles/crutches/ canes, two fifths use wheelchairs/mobility scoters and just over a quarter use walking frames/rollators. FES is the mobility aid used by the least number of people, with a take-up of less than 5%. Broadly these results are similar to those from previous years. Table 7 shows these results, including the percentage of respondents. These add to more than 100% as some people use more than one type of mobility aid.

Table 8 – Use of mobility aids

Mobility Aids Used - Summary:	Respondents	Percentage
Using sticks/poles/crutches/canes	161	51%
Using Wheelchair/Mobility Scooter	128	40%
Using Walking Frame/Rollator	88	28%
Using Orthotics/AFO/Insoles	92	29%
Using FES	11	3%

The results also allow the distribution of respondents within a scale of mobility to be understood. I have devised an “HSP mobility score” which then allows me to cross-reference mobility against the other questions in the questionnaire. The definition of the HSP mobility score is;

0. No mobility effects
1. Can walk without aids but some effects
2. Orthotics/AFO/FES and/or Sticks/Poles/Crutches/Canes some of the time
3. Sticks/Poles/Crutches/Canes and Frame/Chair some of the time
4. Sticks/Poles/Crutches/Canes most of the time
5. Sticks/Poles/Crutches/Canes all of the time
6. Rollator/Walking frame most of the time
7. Rollator/Walking frame all of the time
8. Wheelchair/Mobility scooter most of the time
9. Wheelchair/Mobility scooter all of the time

The results are simplified into five broader groups;

Table 9 – Overview of mobility aids used

Mobility Aids Used - Overview:	Respondents	Percentage	Mobility Score	Wellbeing
Those without aids	54	17%	0-1	43.7
Those who use mobility aids some of the time	59	19%	2-3	42.4
Those who use sticks most/all of the time	101	32%	4-5	42.8
Those who use frames most/all of the time	44	14%	6-7	44.0
Those who use chairs most/all of the time	58	18%	8-9	42.2

The wellbeing scores do not vary significantly across types of walking aid being used. The distribution of wellbeing scores is shown for all respondents in the following figure, split by mobility score.

 

Needs

Questions were asked to identify the needs of people with HSP, based on a list of needs derived from observing people’s stories and concerns over time, and the experiences of people with HSP from different areas. The list of needs was split into five topics. In the questionnaire, respondents were asked to select their top five needs in each category.

To rank the different needs into an overall list, the total number of votes for each need has been weighted by the rank, so the total score is:

(Top Rank * 5) + (2^nd Rank * 4) + (3^rd Rank * 3) + (4^th Rank * 2) + (5^th Rank).

The results were also reviewed, and any duplicate answers given by people were deleted, such that for any one individual a choice is counted once in the overall score. Some people chose to choose five different needs, whereas others chose fewer than five needs or skipped some topics. Between 300 and 312 respondents gave answers for each topic.

For each topic, a table reports the number of people choosing the need as their most important need (1^st rank), the total number of people choosing the need in any rank including first rank (total votes), the weighted score (score), and the weighted score expressed as a percentage of the highest scoring need (percent). The background of the percent column has been shaded to show the relative importance of each, with the more important needs being shaded darker green. Needs which feature in the top five in any country group are shown in bold, and these are country specific needs are presented in country specific needs analysis sheets in a separate post (https://hspjourney.blogspot.com/2021/02/2020-survey-results-country-specific.html). Similar scoring needs are grouped using light shading.

Living with HSP   

This topic included 20 needs.

Table 12 – Living with HSP needs

Living with HSP Needs	1st Rank	Total Votes	Score	Percent
Stretches and exercises that help	129	211	907	100%
Information on appropriate physical activities to take part in	34	135	500	55%
Information on tailoring physical activities to suit HSP	22	109	367	40%
Information on how best to walk	19	104	324	36%
Information on living with HSP & other long-term conditions	30	92	305	34%
Understanding if changes/new symptoms are to do with HSP	15	86	246	27%
Information on staying healthy with reduced mobility	12	86	242	27%
Information on how to select mobility aids	7	88	242	27%
Information on getting up from falls	8	70	199	22%
Information on how participation levels may change over time	9	67	185	20%
Information on types of modifications around the home	6	60	143	16%
Understanding when to review/change treatments	5	54	138	15%
Information on how dietary choices can influence HSP	3	57	136	15%
Information on how to use mobility aids	3	42	96	11%
Information on when to change mobility aids	4	34	92	10%
Information on when you might need home modifications	1	41	95	10%
Information on best practice using the toilet	1	37	79	9%
Information on dietary supplements and their effects on HSP	1	32	67	7%
Information on driving with HSP	1	29	61	7%
Information on reviewing/changing modifications around the home	1	17	47	5%

Stretches and exercises that help is the clear top need in this topic, with 41% of respondents identifying it as their top need. The second need is information on appropriate physical activities to take part in. The remaining needs are in fairly distinct groups, with percentages in the ranges: 34-40%, 27%, 15-22%, and lower scoring ones.

Several people commented that it was difficult to choose a top five out of these needs. Others made comments identifying other needs, with many saying about enjoying what you can do, having a positive mindset and living one day at a time. Similarly, needs around acceptance and motivation were identified, and the need to mentally prepare for the future. Also, knowing if changes in health are to do with HSP or something else, and identifying when a change in care/caring is needed. Additionally, information on discounts or grants for modifications around the home or mobility aids, and having an HSP FAQ which could be given to employers.

Diagnosis and Inheritance   

This topic included 11 needs:

Table 13 – Diagnosis and Inheritance needs

Diagnosis and Inheritance Needs	1st Rank	Total Votes	Score	Percent
Explanation of HSP on diagnosis	126	234	924	100%
Signposting about potential future needs	36	207	652	71%
Signposting about HSP information	21	144	433	47%
Reduced clinical diagnosis time	27	121	393	43%
Having genetic tests available for more types of HSP	29	120	360	39%
Understanding what a genetic diagnosis means	17	128	343	37%
Information on the likelihood of others in family having HSP	15	114	325	35%
Information on the likelihood of next generation having HSP	12	113	314	34%
Signposting about HSP communities	7	115	292	32%
Fewer clinical misdiagnoses	14	87	267	29%
Greater certainty on genetic diagnosis results	9	79	210	23%

‘Getting an explanation of HSP on diagnosis’ is the clear top need in this topic, with 40% of respondents identifying it as their top need. The second need is signposting where to find information about potential future needs. The remaining nine needs are grouped closely together, indicating broad spread of opinion.

Several people made comments, with strong themes around misdiagnosis, around medical professionals needing better knowledge about HSP, and around not wanting to repeat information to multiple doctors. Other themes included; basic information about HSP (variation in symptoms, inheritance, etc.), being told some positive aspects rather than entirely negative perspectives, advice on needing strength of character, receiving information so people don’t feel so alone, and coverage of genetic tests on insurance policies.

Wellbeing  

This topic included 12 needs.

Table 14 – Wellbeing Needs

Wellbeing Needs	1st Rank	Total Votes	Score	Percent
Information on improving mental health/wellbeing	136	229	957	100%
Information on finding/accessing relevant healthcare professionals	45	188	614	64%
Information on obtaining benefits	22	165	512	54%
Information on communicating with healthcare professionals	30	143	473	49%
Understanding your rights	12	138	366	38%
Information on asking for adjustments at work	18	108	354	37%
Information on finding HSP patient communities	12	110	300	31%
Information on maintaining a good sleep routine	12	99	258	27%
Links with other organisations - larger community	5	56	129	13%
Links with other organisations - shared activities	3	48	109	11%
Understanding discrimination	3	45	96	10%
Information on changing job/career	2	36	73	8%

Information on improving mental health and wellbeing is the clear top need in this topic, with 43% of respondents selecting it as their top need. The next three needs score similarly, covering benefits and finding and communicating with healthcare professionals.

Comments made in this topic were around being able to be heard and understood, and about integrating HSP in with other roles that people have in life. Communication was also mentioned in the context of being able to share details of symptoms with others. Several mentioned having a positive mindset, an active mind, and a higher quality of life. A few seek further information about work, including redundancies, and others seek more information on accessibility and understanding benefits.

Treatments   

This topic included 19 needs:

Table 15 – Treatment needs

Treatment Needs	1st Rank	Total Votes	Score	Percent
Treatment options for spasticity	146	219	953	100%
Treatment options for pain	32	141	510	54%
Treatment options for bladder issues	26	131	443	46%
Treatment options for fatigue	21	142	445	47%
Better information on existing treatments	24	139	418	44%
Understanding how effective treatments are	5	81	193	20%
Setting up a patient registry for participation in trials	7	73	177	19%
Treatment options for other ‘pure’ HSP symptoms	7	63	176	18%
Treatment options for ‘complex’ HSP symptoms	9	58	167	18%
Development of new treatments	8	66	162	17%
CBD oils/cannabis based treatments	2	62	141	15%
Increased patient involvement in clinical trials	4	55	131	14%
Functional electrical stimulation	6	40	124	13%
Clarity on who is/isn’t helped by a treatment	1	53	123	13%
Genetic treatments	6	29	80	8%
Understanding potential side-effects of treatments	1	34	70	7%
Understanding consequences of taking multiple treatments	2	26	64	7%
Surgery options	0	29	49	5%
Re-purposing existing medications for HSP	0	15	26	3%

Treatment options for spasticity is the clear top need in this topic, with 46% of respondents identifying it as their top need. The next four needs score similarly, and are treatment options for the other common symptoms: pain, bladder and fatigue, and having better information on existing treatments. The next block of  needs scores in the range 13-20%, indicating a broad spread of opinion.

Respondents identified other pure or complex HSP symptoms that they felt treatment needs for. Symptoms identified by more respondents were: Eyesight, memory, balance, cognitive issues and bowel problems. Other symptoms mentioned included: incontinence, breathing, swallowing, sexual function, stiffness, depression, stress, anxiety, neuropathy, and upper body involvement. Some identified needs around stretching, exercise, walking, strength, changes with changing emotion, and counselling. Several said all of these treatment needs were important.  

Some comments were made around other treatment options. Physical treatments mentioned included swimming, massage, yoga, exercise and stretching. Other treatments included art and music therapy, meditation and counselling. Suggestions were also made around, herbs, vitamins, cannabis, botox and diet/weight control.

Information about HSP  

This topic included 9 needs:

Table 16 – Information about HSP needs

Information about HSP Needs	1st Rank	Total Votes	Score	Percent
Predicting how HSP will progress in individuals	76	228	838	100%
Understanding the burden of HSP symptoms	68	194	713	85%
Understanding what the affected genes do	71	170	595	71%
Understanding the day-to-day variation in HSP symptoms	16	194	515	61%
Predicting if other HSP symptoms will start over time	13	154	446	53%
Understanding the prevalence of HSP symptoms	26	130	428	51%
Setting up a patient registry for understanding HSP	21	123	326	39%
Understanding which are the more common types of HSP	5	103	234	28%
Understanding regional differences in prevalence of types of HSP	1	32	67	8%

Predicting how HSP will progress in individuals is the top need in this topic, with ‘understanding the burden of symptoms’ and ‘understanding what the affected genes do’ forming a top three group of needs, with similar numbers of people scoring these as their top need.

Comments on this topic were generally around specific pieces of information, including about passing HSP on to children and looking at childhood development milestones and understanding potential for genetic treatments. Several wanted to know information sources for all HSP information.

Mention was made about getting healthcare professionals to share information between themselves more, about getting more involvement from pharmaceutical companies, and more media coverage.

Topic Ranking

Respondents were asked to identify which of the five topics they considered to be the most important and which they considered to be second most important. 305 respondents answered these questions. Overall, 40% of people selected Living with HSP to be the most important category.

To rank the order of all topics, the number of votes for each of the most important topics has been doubled and added to the number of votes from second most important topics to give an overall score:

Table 17 – Needs Topic Ranking

Needs Topic	1st Rank	2nd Rank	Score
Living with HSP	122	79	323
Treatments	97	73	267
Wellbeing	35	70	140
Diagnosis and inheritance	35	47	117
Information about HSP	17	36	70

Living with HSP was the highest scoring topic in each country except Brasil, where Treatments was the highest scoring topic.

Respondents also identify which topics they considered to be the most important for different groups of people, and the number of votes are shown, with the topics scoring the highest and second highest votes shaded dark and light green respectively. Between 187 and 298 respondents answered these questions. Several people noted it was difficult to select these topics.

Table 18 – Needs Topic Ranking for Groups of People

Needs Topic	Starting HSP Journey	Advanced HSP	Young with HSP	Older with HSP	With ‘pure’ HSP	With ‘complex’ HSP	Carers	Friends and family
Living with HSP	50	81	116	92	82	68	75	70
Treatments	32	118	95	72	103	130	31	18
Wellbeing	7	86	25	118	44	39	45	41
Diagnosis and inheritance	56	9	24	4	12	8	8	14
Information about HSP	42	4	17	1	12	9	53	63

Needs Summary

The needs data can be used by HSP support groups, medical professionals and others with an interest in supporting those with HSP to identify how well the identified needs are met. Although wellbeing needs are addressed, The WEMWBS wellbeing scores have not been examined in this analysis because the questions were around identifying what the important needs are, rather than exploring how well they have been met.

There are several patterns in the topic ranking data:

• Diagnosis and inheritance is considered most important for those starting their HSP journey, and scores in the bottom two in every other group of people.
• Information about HSP is considered to be second most important for those who care for people with HSP and for friends and family of people with HSP. It is in the bottom two of every other category except those starting their HSP journey.
• Wellbeing is considered most important for older people with HSP and second most important for those with advanced HSP.
• Living with HSP is considered the most important or second most important category in all groups except those with advanced HSP, where this topic scores a close third.
• Treatments is considered most important for those with advanced HSP, pure HSP and complex HSP, and second most important for young people with HSP, and third most important for older people with HSP.

Looking at overall patterns:

• Pure and complex HSP have similar distributions of scores, indicating that type of HSP does not change people’s needs.
• Wellbeing is seen to become more important as either age or HSP progress.
• Meeting needs around Living with HSP has the potential to benefit the greatest number of people, and is particularly seen as important for young people with HSP and those providing support to those with HSP.
• Treatment needs are seen as important in all groups of people with HSP.

Coronavirus

Given the worldwide nature of the Coronavirus pandemic, the opportunity was taken to explore how peoples access to healthcare has been affected.

Number of Appointments

Respondents were asked to report if their number of appointments had changed as a result of Coronavirus Covid-19. The question did not seek to identify any particular types of healthcare appointments. 306 respondents answered the question.

Table 23 – Number of Appointments under Covid-19

Appointments	All	Well-being	UK	Brasil	USA	France	Netherlands	Canada	Australia
More	5%	(42.1)	1%	12%	4%	0%	5%	6%	6%
Similar	36%	45.4	28%	20%	46%	54%	10%	38%	69%
Fewer	59%	41.1	71%	68%	50%	46%	85%	56%	25%

The group with a similar number of appointments had a higher wellbeing than the group with fewer appointments. There were no differences between use of mobility aids and changes in the number of appointments. The countries where the greatest proportion of people had fewer appointments were The Netherlands and the UK. The countries with the greatest proportion of people with similar numbers of appointments were Australia and France.

Comments about availability provided a little more context. Those answering fewer appointments had the greatest range, with some reporting that all appointments have been cancelled, and others reporting that their appointments had been delayed or postponed. Some respondents had elected to not to go to appointments because they were isolating and not wishing to increase their potential exposure to coronavirus.

Some commented that the number of appointments had remained the same, but the method had changed, for example now done by phone. A few people noted impacts from their physio or PT appointments being cancelled. Others noted that nothing had changed, and they were able to go to all of their appointments.

Availability of Digital Appointments

One of the main changes with Covid-19 lockdowns is the advice to maintain social distance between people, and a consequential proportion of people working at home. There has been a sharp uptake in the use of digital communications and digital meetings. Respondents were asked if they had digital healthcare appointments before Covid-19 and since Covid-19. 302 respondents answered these questions.

Before Covid-19 digital healthcare appointments were not available to 60% of respondents, with the UK (not available for 76%) and Canada (not available for 75%) having the least access. As shown in the following chart 16% of respondents had access to digital appointments. Of these, most had a few appointments.

The Netherlands had the greatest access with 42% having had appointments, followed by Canada (25%) and USA (22%). The remaining 25% of respondents either could not access digital appointments or did not want to access them. All differences in wellbeing are within 3 points of the average, so pre-covid digital access is not a factor in wellbeing.

Since Covid-19 digital healthcare appointments have been used by 47% of respondents, with most having had a few appointments. The proportion of people not having access to these has decreased to 28%, and the proportion not being able to or not wanting to access these remains the same. Since Covid-19, those who do not have access to digital appointments have a wellbeing score of 40.4, 2.6 points below average, which is approaching the threshold to indicate a relevant factor in wellbeing. Those who use digital appointments have a wellbeing score of 44.0. The UK, France and Brasil have the greatest proportion where digital appointments are not available (53%, 57% and 79% respectively). The Netherlands, USA, Canada and Australia have the highest proportion of digital appointments (available for 80%, 67%, 63% and 63% respectively).

The change in availability is similar in the USA, Australia, the Netherlands, Canada, and the UK, each having the proportion of people having digital appointments increasing by between 38% and 44%. The smallest increase in digital appointments is in Brasil (13% more) and France (27% more).

Opinions of Digital Appointments

Respondents were also asked if they thought digital appointments were better than face-to-face appointments. 299 respondents answered, with 58% saying that face-to-face appointments were better than digital appointments, 17% saying that these were similar and 2% saying that digital are better than face-to-face. The remaining 21% said the question was not relevant for them.

The proportions of answers are broadly similar across use of mobility aids and countries. The small number of people identifying digital to be better than face-to-face were in the UK, Brasil and the USA. Those saying digital and face-to-face are similar are more often in Australia (38%) and the Netherlands (30%). Of those saying face-to-face are better than digital, the highest proportions are in Canada (75%), the Netherlands (70%) and France (69%), and the lowest proportions are in the UK (43%) and Australia (50%).

Respondents identified their key benefit for digital appointments. 199 respondents answered this question, selecting from a multiple choice question:

Table 24 – Benefits for digital appointments

Benefit	Respondents	Percentage
Reduced effort travelling	52	26%
Less time taken	40	20%
Less reliance on others to help	16	8%
Reduced costs	9	5%
Feels more personal	2	1%
Other	22	11%
There are no benefits	58	29%

The main benefits for digital appointments are around travel, with reduced effort and less time being the key factors, selected by almost half of respondents. The highest proportions identifying the key benefit as reduced effort travelling generally were those with the highest reliance on mobility aids. The highest proportion identifying the key benefit as less time taken were those who do not use mobility aids or those who use them some of the time.

Of the respondents saying other, reasons included that it was easier to see specialists from other locations more easily, that appointments were covid-safe, and people are able to send their questions in advance. Several commented that digital appointments with neurologists or other specialists were better than digital appointments with their doctors. Some prefer digital appointments because they are self-conscious about their changing mobility.

Respondents also identified their key disadvantage for digital appointments. 290 respondents answered this question, selecting from a multiple choice question:

Table 25 – Disadvantages for digital appointments

Disadvantage	Respondents	Percentage
Less chance to show symptoms	152	52%
Feels less personal	46	16%
Issues with technology	28	10%
Feels less important	15	5%
Miss the opportunity to travel	2	1%
Other	16	6%
There is no disadvantage	31	11%

 Over half of respondents identify that they have less chance to show their symptoms with digital appointments, and the proportion is very similar across the use of mobility aids. This is the key disadvantage identified with digital appointments.

Of those who said other, reasons include appointments feeling very short or feeling rushed, not being taken as seriously as a face-to-face appointment. Some noted the lack of eye-to-eye contact means it feels like less information being conveyed, and others miss out on interacting with others who have HSP at clinics.

Digital Appointments in the Future

Respondents were asked if they would like to use digital healthcare in the future. 308 respondents answered, with approximately equal numbers saying Yes, No and Not sure. Differences in wellbeing scores for these answers were smaller than 3 points, indicating this is not a factor affected by wellbeing.

Comments to this question were generally re-expressing the advantages or disadvantages depending on the opinion. Notable comments include observing that face-to-face appointments are more memorable than digital appointments, and that with digital appointments it is more easy to hide things like personalities and mental health issues. Many people have mixed views about this, and there are many who have not had digital appointments who would be willing to try. Despite the disadvantages discussed, several expressed the view that it is better to have digital appointments rather than no appointments at all.

Respondents were also asked about using digital exercise classes or activities, for example Pilates or training. 308 respondents gave answers.

Table 26 – Digital Exercise

Disadvantage	Respondents	Percentage	Wellbeing
I already use these	56	18%	47.4
I would like to use these	93	30%	40.8
I am not sure	78	25%	42.3
I do not want to do this	81	26%	42.3

Approximately 1 in 5 already use digital exercise classes, and their wellbeing is higher, 4.5 points greater than average. Almost 1 in 3 would like to use these, and they have a slightly lower wellbeing. The remaining people, approximately half, are either not sure or do not want to do this, and their wellbeing is similar to the average wellbeing. The results are shown in the following figure.

The greatest uptake in digital classes is in France where 33% of people use them, and the smallest uptake is Brasil with 9%. Brasil has the greatest proportion of people wanting to use digital classes, with 48% wanting to do this. There is little variation in proportions across the use of mobility aids.

Comments on digital exercise vary depending on the view. Several commented that they did not know this type of class existed, and the would be willing to give it a try. Most of the comments made were negative, with many lacking interest or motivations to take part in these classes, and others say they cannot do these types of classes because of things like fear, lack of space, lack of technology, they feel it is not personal enough or they perceive HSP to be too complex to do this type of class. The positives identified include it being cheaper, more convenient, getting enjoyment from them, and feeling the benefits of being able to exercise. Like digital healthcare appointments, several said it is better to have some digital exercise rather than none at all.

Life with HSP

Do you Consider Yourself to be Disabled?

There are 314 respondents who answered this question, as shown in the following grid.

Table 27 – Identify as Disabled?

Consider Self Disabled?	Yes	No	Wellbeing Yes	Wellbeing No
All	256 (82%)	58	42.2	45.1
Mobility 0-1	27 (50%)	27	40.9	46.2
Mobility 2-3	43 (74%)	15	40.1	(47.9)
Mobility 4-5	88 (87%)	13	42.8	(42.6)
Mobility 6-7	42 (98%)	1	43.4	-
Mobility 8-9	56 (97%)	2	42.8	-

Four fifths of respondents consider themselves to be disabled and one fifth do not. Although the proportion of people who identify as disabled increases with reduced mobility, there are both people who do not use mobility aids who consider themselves disabled and those who use a wheelchair all or most of the time who do not consider themselves to be disabled. This indicates that mobility is not the only factor in individuals deciding if they are disabled or not.

Those who consider themselves to be disabled have a lower wellbeing score than those who do not. Once mobility aids are taken into account there is a clearer distinction on wellbeing, with those identifying as disabled who do not use mobility aids or who use them some of the time have a lower wellbeing. Once mobility aids are used all or most of the time the wellbeing is similar to the overall average, irrespective of if people consider themselves to be disabled.

Did you get a description of HSP when you were diagnosed?

There are 304 respondents who answered this question, as shown in the following grid. Wellbeing scores are also calculated.

Table 29 – Description of HSP on diagnosis?

HSP Description on diagnosis?	Yes	No	Wellbeing Yes	Wellbeing No
All	180 (59%)	124	44.0	41.5

This shows that over half of respondents got a description on diagnosis, and those who did have a slightly better wellbeing. It is noted that the wellbeing questions are focussed on recent times, and time since diagnosis was not asked. The proportion getting the description is similar across mobility aid usage and country. The only country where fewer people got a description than didn’t on diagnosis was Canada, where 44% received a description.

How well do you understand HSP?

There are 253 respondents who answered this question, as shown in the following grid.

Table 30 – How well do you understand HSP?

How well do you understand HSP?	Respondents	Wellbeing
Very Well	58 (23%)	48.4
Well	129 (51%)	43.2
Somewhat	63 (25%)	39.7
Not at all	3 (1%)	-

This shows that half of respondents consider that they understand HSP well. Approximately a quarter consider they know HSP very well, and another quarter consider they know HSP somewhat. Those that know HSP better have a higher wellbeing (5.5 points above average), and those that know HSP somewhat have a lower wellbeing (3.2 points below average).

The proportion that know HSP well is relatively constant across the use of mobility aids, although there is a slight upward trend suggesting that peoples knowledge of HSP increases with the length of time they are affected by HSP. Across the countries, between 52% and 71% of people know HSP well, except in Brasil, where 61% know HSP somewhat. Those in Brasil are the majority (75%) of those who know HSP somewhat.

How well do you feel medical professionals understand what it is like to live with your HSP?

There are 235 respondents who answered this question, as shown in the following grid.

Table 31 – How well do you feel medical professionals understand your HSP?

How well do medical professionals understand your HSP?	Respondents	Wellbeing
Very Well	29 (12%)	48.6
Well	65 (28%)	43.0
Somewhat	75 (32%)	43.6
Not at all	66 (28%)	37.1

This shows that one in eight respondents consider that medical professionals understand their HSP very well, and those respondents have the highest wellbeing, 5.7 points above average. Respondents for the other answers are split approximately equally, and those who thing that medical professionals do not understand their HSP at all have the lowest wellbeing, 5.8 points below average.

There is a lower proportion (less than 10%) of those that think medical professionals know their HSP very well for those who use frames or wheelchairs all or most of the time. Those who do not use mobility aids generally (41%) feel medical professionals know their HSP somewhat.

Across the countries, most in the Netherlands think medical professionals know their HSP well. In Brasil and France most think medical professionals know their HSP somewhat. In the UK, USA and Australia most think medical professionals do not know their HSP at all.

Have you ever delayed or avoided seeking medical advice because you felt embarrassed about your HSP?

There are 313 respondents who answered this question, as shown in the following grid. Wellbeing scores are also calculated.

Table 32 – Delayed/avoided seeking advice due to embarrassment?

Delay/avoid seeking advice?	Yes	No	Wellbeing Yes	Wellbeing No
All	48 (15%)	265	35.6	44.2

This shows that about one in seven people with HSP have delayed or avoided seeking medical advice because they have felt embarrassed about their HSP. These people have a lower wellbeing, 7.3 points below average, indicating that being embarrassed about their HSP is an important factor in wellbeing.

There is only a small variation in this proportion across use of mobility aids, indicating that it is not mobility aids themselves that make people embarrassed about their HSP.

Have you ever felt that a medical professional did not believe the extent or severity of your symptoms?

There are 315 respondents who answered this question, as shown in the following grid. Wellbeing scores are also calculated.

Table 33 – Extent or severity of symptoms not believed?

Extent/severity not believed?	Yes	No	Wellbeing Yes	Wellbeing No
All	173 (55%)	142	41.0	45.3

This shows that more than half of people with HSP feel that the extents or severity of their symptoms have not been belied by medical professionals. Those who feel this have a lower wellbeing than those who have had the extent/severity of their symptoms believed.

There is little variation in this proportion across use of mobility aids. Doubts on extent or severity occur for 56% - 61% of respondents, except for those using walking sticks all or most of the time, where the extent or severity of their symptoms is believed the most (doubts for 46%). 74% of those from Brasil feel that the extent or severity of their symptoms has not been believed.

Have you ever felt that you did not receive adequate or appropriate treatment because a medical professional did not take you seriously?

There are 313 respondents who answered this question, as shown in the following grid. Wellbeing scores are also calculated.

Table 34 – Inadequate treatment as not being taken seriously?

Inadequate treatment?	Yes	No	Wellbeing Yes	Wellbeing No
All	174 (56%)	139	40.5	46.0

This shows that more than half of people with HSP feel that they have not received adequate or appropriate treatment because they have not been taken seriously. Those who feel this have a lower wellbeing than those who have been taken seriously. There is little variation in this proportion across use of mobility aids. Perceptions of inadequate treatment occur for 49% - 64% of respondents, depending on mobility aid use, but there are no strong patterns. 74% of those from Brasil feel that they have received inadequate treatment and not been taken seriously.

 

What would a cure for HSP look like? 

There are 312 respondents who answered this question, as shown in the following grid.

Table 35 – What would a cure for HSP look like?

What would a cure for HSP look like?	Respondents
Something which stops the progression of my symptoms	91 (29%)
Something which reverses the symptoms I have	140 (45%)
Something which prevents the next generation from getting HSP	72 (23%)
Other	9 (3%)

This shows that the majority of people would consider that a cure for HSP would reverse the symptoms that they have. There was little variation in wellbeing between these answers. Comments around what a cure would look like generally rephrased one of the three options often with specific details added, or bought two of the options together.

Several went for one-word answers, my favourite of which was that a cure for HSP would be wonderous. One person expressed that a cure when they first started showing symptoms of HSP would have been reversal, but now their HSP is more advanced they would see a cure as just stopping progression. Another, referring to their adult child with complex HSP, observed that a cure to reverse damage would allow them to meet the adult their child they should have been.

Reversal of symptoms had the greatest proportion of respondents across all types of mobility aid, and across all countries, with two exceptions. An equal number of people selected stopping progression and reversal of symptoms in: those who use mobility aids some of the time, and those in the Netherlands.

Access to Healthcare

These questions explore how often people have appointments with various specialists and identifies how common surgery options are used to treat HSP.

Are you under the treatment of a specialist or neurologist for your HSP?

There are 315 respondents who answered this question, as shown in the following grid. Wellbeing scores are also calculated.

Table 36 – Under the treatment of a specialist?

Under treatment of a specialist?	Yes	No	Wellbeing Yes	Wellbeing No
All	256 (81%)	59	43.4	40.9

This shows that four out of five people with HSP are under the treatment of a specialist or neurologist for their HSP. Those who are under treatment have a slightly higher wellbeing than those who are not.

How frequently do you see a genetics team?

There are 307 respondents who answered this question, as shown in the following grid.

Table 37 – How frequently do you see a genetics team?

How frequently do you see a genetics team?	Respondents	Wellbeing
All	307	-
Never	150 (49%)	42.1
Once or twice	114 (37%)	43.6
A few times	23 (7%)	41.1
Every year or two	15 (5%)	(45.3)
Several times a year	5 (2%)	-
Monthly	0	-
More than monthly	0	-

This shows that around half of people with HSP have never seen a genetics team. Of those that have, most have seen the team once or twice, or a few times. A small number see their genetics team regularly.

Looking at use of mobility aids, there is a higher proportion of people who do not use mobility aids who have not seen a genetics team, otherwise the distribution is relatively even. Looking at countries, those in the USA have seen their genetics teams the least and those in France have seen their team the most.

How frequently do you see a neurologist?

There are 313 respondents who answered this question, as shown in the following grid.

Table 38 – How frequently do you see a neurologist?

How frequently do you see a neurologist?	Respondents	Wellbeing
All	313	-
Never	28 (9%)	45.2
Once or twice	55 (18%)	40.0
A few times	82 (26%)	43.0
Every year or two	87 (28%)	42.3
Several times a year	56 (18%)	44.8
Monthly	3 (1%)	-
More than monthly	2 (1%)	-

This shows that just over half of people with HSP have either seen a neurologist a few times or see them every year or two. There is a small number of people who see their neurologist monthly or more regularly.

Looking at use of mobility aids, there is a higher proportion of people who use mobility aids all or most of the time who have not seen a neurologist, otherwise the distribution is relatively even. Looking at countries, those in the USA see their neurologist most frequently, and are seen the least in the Netherlands.

How frequently do you see a physiotherapist?

There are 309 respondents who answered this question, as shown in the following grid.

Table 39 – How frequently do you see a physiotherapist?

How frequently do you see a physiotherapist?	Respondents	Wellbeing
All	309	-
Never	94 (30%)	42.7
Once or twice	24 (8%)	40.1
A few times	74 (24%)	39.8
Every year or two	15 (5%)	(43.3)
Several times a year	34 (11%)	47.6
Monthly	8 (3%)	-
More than monthly	60 (19%)	46.1

This shows that less than a third of people with HSP have never seen a physiotherapist. Those that have seen one tend to have seen them a few times or are seeing them more than monthly.

The distribution of results is fairly constant over the range of use of mobility aids, although those using mobility aids some of the time see neurologists more. Looking at countries, in the Netherlands and Australia physiotherapists are seen most often, and in the USA and France physiotherapists are seen the least.

How frequently do you see rehabilitation specialist?

There are 303 respondents who answered this question, as shown in the following grid.

Table 40 – How frequently do you see a rehabilitation specialist?

How frequently do you see a rehabilitation specialist?	Respondents	Wellbeing
All	303	-
Never	176 (58%)	41.8
Once or twice	38 (13%)	45.1
A few times	30 (10%)	42.8
Every year or two	21 (7%)	44.3
Several times a year	17 (6%)	(50.5)
Monthly	5 (2%)	-
More than monthly	16 (5%)	41.8

This shows that most (58%) of people with HSP have never seen a rehabilitation specialist. Those that have seen one tend to have seen them once or twice, or a few times.

The distribution of results is fairly constant over the range of use of mobility aids, although those using wheelchairs all or most of the time see more often. Looking at countries, these specialists are more commonly seen in the Netherlands and least often in the UK.

How frequently do you see specialists for other symptoms?

There are 301 respondents who answered this question, as shown in the following grid.

Table 41 – How frequently do you see specialists for other symptoms?

How frequently do you see specialists for other symptoms?	Respondents	Wellbeing
All	301	-
Never	111 (37%)	40.2
Once or twice	49 (16%)	44.3
A few times	70 (23%)	44.8
Every year or two	21 (7%)	44.3
Several times a year	37 (12%)	43.9
Monthly	3 (1%)	-
More than monthly	10 (3%)	(47.8)

This shows that around a third of people with HSP have never seen a specialist for other symptoms. Those that have seen one tend to have seen them a few times.  The proportion of people who have never seen another specialist is higher in those that do not use mobility aids (50%).

Specialists mentioned include; bladder/urologist, orthopaedics, orthotist, eyesight, bowels, nutrition, psychologist, occupational therapist, paediatrics, and gynaecologist.

Looking at countries: In the USA and Canada around 75% have seen another specialist. In the UK, Brasil, and Australia, those who have seen specialists (55% to 70%) tend to have seen them a few times. The distribution is similar in most countries, although the proportion seeing the specialist several times a year or more regularly is highest in the USA (27%) and Australia (20%).

Have you had Surgery for HSP?

Approximately 300 respondents answered this question, as shown in the following grid.

Table 42 – Have you had surgery?

Have you had surgery?	Yes	No
Tendon release	30 (10%)	271
Baclofen Pump	22 (7%)	278
Muscle release	11 (4%)	283
Selective dorsal rhizotomy (SDR)	3 (1%)	291
Other	13 (5%)	248

This shows that tendon release surgery is the most common surgery for those with HSP, followed by implanting a baclofen pump. Other surgeries mentioned included several which may not be related to HSP. Those mentioned include cataracts surgery, hip or knee replacement, foot reconstruction/toe re-positioning, and gastric sleeves (for weight loss for easier mobility).

Wellbeing scores for those with baclofen pumps or tendon release were within 0.1 of the overall average, indicating that having surgery is unlikely to be a factor in wellbeing, although the survey has not captured any changes in wellbeing resulting from the surgeries.

The table below shows that around 80% of people with HSP have not had surgery for their HSP, around one in 6 have had one type of surgery, and a small number have had more than one type of surgery. Surgery is more common in the USA (27% having had surgery) and Australia (25% having had surgery). Surgery is least common in Brasil and Canada (88% not having had surgery in each country).

Table 43 – Number of types of surgeries

Number of types of surgeries?	Respondents
None	259 (82%)
1	39 (12%)
2	15 (5%)
3	2
4	1
5 or more	0

Wellbeing Conclusions

Throughout this report the different factors which have been shown to have the greatest association with people’s wellbeing have been identified. The tables below draw together the factors which have the strongest associations with people’s wellbeing, either positive or negative. The number of respondents given is the total number which have or don’t have the factor, irrespective of if they gave a wellbeing score. The needs reported in Section 8 identified that information on improving mental health and wellbeing was a key need, and many of the needs identified have large over-laps with the issues identified in these tables.

Positive Wellbeing Effect

These factors are associated with people who have a wellbeing which is better than average.

Table 44 – Positive Wellbeing Factors

Factor	Respondents	Wellbeing
See rehabilitation specialist several times a year	17	(50.5)	(+7.6)
Medical professionals understanding your HSP very well	29	48.6	+5.7
Understanding HSP very well	58	48.4	+5.5
Mobility aids some of the time, not consider yourself disabled	15	(47.9)	(+5.0)
See specialist for other symptoms more than monthly	10	(47.8)	(+4.9)
See physiotherapist several times a year	34	47.6	+4.7
Already take part in digital exercise classes	56	47.4	+4.5
Not using mobility aids and not considering yourself disabled	27	46.2	+3.3
See physiotherapist more than monthly	160	46.1	+3.2
Getting adequate treatment after having been taken seriously	139	46.0	+3.1

Negative Wellbeing Effect

These factors are associated with people who have a wellbeing which is lower than average.

Table 45 – Negative Wellbeing Factors

Factor	Respondents	Wellbeing
Delaying or avoiding advice due to embarrassment about HSP	48	35.6	-7.3
Medical professionals not understanding your HSP at all	66	37.1	-5.8
Having SPG7 (diagnosis)	30	37.9	-5.0
Understanding HSP somewhat	63	39.7	-3.2
Seeing a physiotherapist a few times	74	39.8	-3.1

Several of these factors are related to understanding of HSP, either peoples own or that of medical professionals they see. Other factors are around perceptions of HSP, embarrassment or the point at which people consider themselves to be disabled. There are also factors around the frequency which some types of medical professionals are seen.  

Those who understand HSP have a significantly higher wellbeing than those who understand it somewhat, and Section 8 identifies details of the types of information which people find important. People particularly wish to know about the potential progression of HSP, the burden of symptoms and day-to-day progression.

Understanding of HSP is also reflected in the needs reported in Section 8. Here, needs around having better information on treatments, on finding and communicating with relevant healthcare professionals were strongly identified needs, with several making comments on the need to be heard and understood. Communication issues may be relevant when considering the Ox-PAQ social engagement domain results.

The Importance of Wellbeing

Many of the factors in these tables are not connected with mobility, symptoms or other issues directly related to HSP. The wellbeing factors may therefore not form part of routine discussions with medical professionals which frequently focus on mobility, pain, continence and the other direct issues or symptoms.

It is important to remember that it is possible to take action to improve some of these other factors. It is not necessary to accept, for example, that people are embarrassed about their HSP or lack understanding about HSP. Help is available for some factors, and getting such help may improve wellbeing.

These results show that those that already take part in digital exercise classes have a higher wellbeing, and there are many people who would like to take part in such classes, particularly in Brasil, USA and Canada. Needs around stretches, exercises and appropriate physical activities were identified as important in Section 8.

People may wish to consult with a doctor or other professional to advise on the best approach for any such change they wish to make. Potential areas where changes could be made include:

• Decreasing embarrassment about HSP 
• Increasing personal understanding about HSP 
• Helping medical professionals understand what HSP is like for you 
• Seeing relevant medical professionals at appropriate intervals

Helping healthcare professionals understand HSP and its effects on individuals is an important factor with potential to improve wellbeing in many countries. The effect appears to be more marked in Brasil where people with HSP are often not taken seriously or not believed about their symptom severity.