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We outline a pragmatic approach to assessing HSP, highlighting the broad clinical spectrum, \u2018red flags\u2019 that should trigger re-evaluation and the common acquired and genetic mimics. We summarise the relevant clinical and supportive investigations that can narrow the differential diagnosis. We also discuss the strengths and limitations of contemporary genetic testing. Finally, we focus on practical management: multidisciplinary care, spasticity treatments, and proactive recognition and management of additional symptoms outside of spasticity.<\/jats:p>","DOI":"10.1136\/pn-2026-005344","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:20:22Z","timestamp":1790788822000},"page":"pn-2026-005344","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Hereditary spastic paraplegia: a practical approach"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3070-4810","authenticated-orcid":false,"given":"Maeve","family":"Bradley","sequence":"first","affiliation":[{"name":"Dublin Neurological Institute, Mater Misercordiae University Hospital, Dublin, Ireland"},{"name":"Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aicha","family":"Kalfat","sequence":"additional","affiliation":[{"name":"Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK"},{"name":"Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard A","family":"Walsh","sequence":"additional","affiliation":[{"name":"Dublin Neurological Institute, Mater Misercordiae University Hospital, Dublin, Ireland"},{"name":"Health Affairs and School of Medicine, University College Dublin, Dublin, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"Lynch","sequence":"additional","affiliation":[{"name":"Dublin Neurological Institute, Mater Misercordiae University Hospital, Dublin, Ireland"},{"name":"Health Affairs and School of Medicine, University College Dublin, Dublin, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Conor","family":"Fearon","sequence":"additional","affiliation":[{"name":"Dublin Neurological Institute, Mater Misercordiae University Hospital, Dublin, Ireland"},{"name":"Health Affairs and School of Medicine, University College Dublin, Dublin, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2866-7777","authenticated-orcid":false,"given":"Henry","family":"Houlden","sequence":"additional","affiliation":[{"name":"Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK"},{"name":"Department of Molecular Neuroscience, Institute of Neurology, UCL, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"2026093010201704000_pn-2026-005344v1.1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2990.2004.00587.x"},{"key":"2026093010201704000_pn-2026-005344v1.2","doi-asserted-by":"publisher","DOI":"10.1093\/brain\/aww111"},{"key":"2026093010201704000_pn-2026-005344v1.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jns.2016.03.018"},{"key":"2026093010201704000_pn-2026-005344v1.4","doi-asserted-by":"crossref","first-page":"2065","DOI":"10.1007\/s00415-019-09633-1","article-title":"Genotype\u2013phenotype associations in hereditary spastic paraplegia: a systematic review and meta-analysis on 13,570 patients","volume":"268","author":"Erfanian Omidvar","year":"2021","journal-title":"J Neurol"},{"key":"2026093010201704000_pn-2026-005344v1.5","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(08)70258-8"},{"key":"2026093010201704000_pn-2026-005344v1.6","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(83)92879-9"},{"key":"2026093010201704000_pn-2026-005344v1.7","unstructured":"Fearon C , Murray B , Mitsumoto H . 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