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The main difference will affect these aspects:
-Enemies will be harder to beat
-Cargo would be easier to get damaged
-Will be harder to walk/keep the balance
EDIT: Idk if might be wrong on this, but I noticed that after going hard or higher you see less warnings when you about to fall
Personally i struggled with reaching Port Knot City in max difficult so i put it on Hard and was better hahaha
And on harder difficulty, you will burn more time because you'll have to change/repair vehicles more, etc.
Legend of Legends = Hard
Legend of Legends of Legends = Very Hard
So if by "medium" you mean "Normal" then no.
I played my first run offline, the 2nd one I did VH+online, because I knew I wanted to make a crazy mega reaching zipline network that would've been impossible without the help/luck of using at least several/some other player's ziplines in the world.