Toe Walking Research Articles

101 Amyotrophic Lateral Sclerosis (ALS) - Not Just a Motor Disease? Isolated Bitter and Sweet Taste Loss in ALS

Specific taste quality deficits in ALS has not heretofore been described. Case Study: A 71 year old right handed female presented with a two year course of progressive reduction in strength in her hands, arms and legs with difficulty tying shoe laces, opening jars, writing and walking. She described nocturnal muscle spasms involving all extremities. Gradually, over eight months prior to presentation, all food began to taste bad and horribly bitter. Associated with no appetite and a seven pounds weight loss. Abnormalities in Neurological examination: Cranial Nerve (CN) examination: CN IX and X: Gag absent bilaterally. Motor examination: Bulk: atrophy in thenar and hypothenar eminences and intrinsics in both upper extremities. Percussion induced fasciculation and myotonia in both shoulders and arms. Fasciculation of tongue with percussion myotonia of tongue. Strength: Intrinsic 4/5 in both upper extremities, 3/5 in abductor policis brevis bilaterally, 3/5 right gastrocnemius soleus, 4/5 bilateral anterior tibialis. Drift testing: left abductor digiti minimi sign. Gait: Heel and toe walking unstable with circumduction of left leg. Tandem gait unstable. Cerebellar: Holmes rebound phenomena positive in the left upper extremity. Deep tendon reflexes: 1+ left brachioradialis. 1+ left triceps. 3+ right ankle jerks. 0 left ankle jerk. Positive jaw jerk. Chemosensory Testing: Normosmia to: Alcohol Sniff Test (46), Pocket Smell Test (3/3) and Retronasal Smell Index (9). Taste Quadrant Testing: ageusia in the palate to sodium chloride and citric acid. Ageusia throughout the palate, tongue and whole mouth to sucrose and quinine hydrochloride. Fungiform papillae count: left 18, right 20 (normal). Lip biopsy (normal). MRI: T2 flair in bilateral corticospinal tracts, left greater than right in the spinal cord and the brain. EMG: fibrillation, positive waves with fasciculation in all four extremities. Voluntary contraction with polyphasic unstable motor unit action potentials. While Lang found no taste loss in ALS (Lang, 2011), Pelletier found reduction in intensity of taste to all modalities in different sectors of the tongue, but paradoxically demonstrated normogeusia in whole mouth taste perception (Pelletier, 2013). Pathological specimens of those with ALS revealed degeneration in the nucleus parabrachialis medialis and tractus trigeminothalamicus dorsalis (Oyanagi, 2015), suggesting that taste deficit may be due to central white matter abnormalities. Sweet taste is localized in the most posterior and rostral aspect of the right insular cortex, immediately adjacent to bitter (Prinster, 2017), suggesting a neighborhood effect phenomena. Weight loss in ALS may be due to sensory distortion and secondary impairment of appetite. It would be worthwhile to investigate those with ALS for evidence of otherwise overlooked gustatory deficits, correction of which may improve appetite and nutritional state.

Recognition of Gait Phases with a Single Knee Electrogoniometer: A Deep Learning Approach

Artificial neural networks were satisfactorily implemented for assessing gait events from different walking data. This study aims to propose a novel approach for recognizing gait phases and events, based on deep-learning analysis of only sagittal knee-joint angle measured by a single electrogoniometer per leg. Promising classification/prediction performances have been previously achieved by surface-EMG studies; thus, a further aim is to test if adding electrogoniometer data could improve classification performances of state-of-the-art methods. Gait data are measured in about 10,000 strides from 23 healthy adults, during ground walking. A multi-layer perceptron model is implemented, composed of three hidden layers and a one-dimensional output. Classification/prediction accuracy is tested vs. ground truth represented by foot–floor-contact signals, through samples acquired from subjects not seen during training phase. Average classification-accuracy of 90.6 ± 2.9% and mean absolute value (MAE) of 29.4 ± 13.7 and 99.5 ± 28.9 ms in assessing heel-strike and toe-off timing are achieved in unseen subjects. Improvement of classification-accuracy (four points) and reduction of MAE (at least 35%) are achieved when knee-angle data are used to enhance sEMG-data prediction. Comparison of the two approaches shows as the reduction of set-up complexity implies a worsening of mainly toe-off prediction. Thus, the present electrogoniometer approach is particularly suitable for the classification tasks where only heel-strike event is involved, such as stride recognition, stride-time computation, and identification of toe walking.

Case Report: Lymphatic Drainage Resolves Toe Walking Gait in a Boy with Autism Spectrum Disorder

Case Report: Lymphatic Drainage Resolves Toe Walking Gait in a Boy with Autism Spectrum Disorder

Exploring health professionals' understanding of evidence-based treatment for idiopathic toe walking.

Idiopathic toe walking (ITW) is an exclusionary diagnosis resulting in a child walking on the balls of their feet. Preferred treatment options may be due to the severity of the toe or the health professional preference There are limited guidelines supporting consistent treatment recommendations for this condition. This research aimed to understand agreement between health professionals' knowledge of evidence for common treatment strategies for ITW and if health professionals supported these strategies being used in clinical practice. An international online survey was opened to registered health professionals who treat children with ITW between July 2017 and March 2018. The survey had two components: (a) demographic variables and variables relating to knowledge of evidence about ITW treatments and (b) support for common treatment strategies. Additional data on strategy use, referrals, and preference were collected. Kappa statistics described intra-rater agreement between evidence knowledge and support. Multivariable regression analyses identified factors associated with the 10 most commonly preferred treatments. There were 908 international responses. Kappa agreement for paired correct responses determined a fair agreement for evidence support knowledge for four strategies including watch and wait (Kappa = 0.24), stretching (Kappa = 0.30), sensory integration strategies (Kappa = 0.40), and motor control strategies (Kappa = 0.24) and moderate responses for 13 others. No strategies had greater than moderate agreement between correct knowledge of evidence and strategy support. Profession, location, number of children seen in practice, and not correctly identifying the evidence factored into many of the most commonly used strategies for ITW (p < .05). The results from this study, which confirm a variety of interventions, are utilized in the management of ITW around the world. Furthermore, there remains a disconnection between paediatric health professionals' understanding of the evidence of common treatment strategies of ITW and a consensus for the treatment of this condition.

Commentary on "Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review".

“How should I apply this information?” This valuable systematic review reminds therapists of subtle, but distinct differences between idiopathic toe walking and cerebral palsy. The authors report these differences observed through the application of a number of assessment methods. Standard assessments described by this review include joint range of motion, muscle length and flexibility, and classification of any spasticity (Modified Ashworth Scale). If these are not standard practices, therapists should consider these as assessments which are easily learned and perfected in any practice setting. Nonstandard clinical methods included the use of electromyography or 3-D gait analysis. These improved the clinical picture enabling greater differentiation between the conditions. However, these assessments may be less accessible to therapists, potentially costly, and setting dependent. “What should I be mindful about when applying this information?” Although there is limited discussion of validity or reliability of the assessments, this should not dissuade therapists from applying these measures in practice where possible. This review did not consider of birth complications or developmental history of the child. These additional factors from the history could influence a therapist's referral for nonstandard assessments. These additional nonstandard assessments may place additional cost or time pressure on families, and the results may or may not change treatment course. This review highlights the lack of consensus of measures for differentiating between conditions. It highlights the poorly defined diagnostic criteria for idiopathic toe walking. These differences may impact communication about these conditions between health care providers. It may also impact health care providers to communicate either diagnosis or long-term treatment plan. These inconsistencies may create challenges for parents, particularly if they observe their child being assessed in different ways by each of their health care providers. This warrants consideration for the development of standardized assessment practice for toe-walking gait. Cylie Williams, PhD Antoni Caserta, BPod Department of Physiotherapy, Monash University Frankston, Australia Melissa Chee Parent of a child with idiopathic toe walking

Toddler with frequent falls and neuroregression: Imaging clues!

ABSTRACTLate infantile metachromatic leukodystrophy is an autosomal recessive disorder caused by a deficiency in the enzyme activity of Aryl sulfatase-A. The classical presentation is characterized by gait disturbance, frequent fall, toe walking, impaired swallowing and feeding, seizures, progressive neuroregression, decorticate posture and early death. Here we report a toddler who presented with frequent falls and cognitive regression. Magnetic resonance imaging (MRI) showed a striking leopard skin pattern. Recognition of this pattern on MRI in proper clinical context can serve as a clue to the diagnosis.

Phacomatosis pigmentokeratotica associated with unilateral toe walking due to short achilles tendon

Phacomatosis pigmentokeratotica (PPK) is characterized by the co-occurrence of speckled lentiginous nevus (nevus spilus) and an organoid nevus with or without extracutaneous involvement. The extracutaneous manifestations may vary widely with musculoskeletal, neurologic, ocular, and vascular findings. The PPK is also associated with an increased risk of cutaneous or extracutaneous tumors. Therefore, the patients with PPK should be followed up regularly for possible malignant transformation. Here, we report a 5-year-old boy with PPK associated with toe walking due to short Achilles tendon, which was not previously reported, to our knowledge.

Outcomes Following Surgical Correction of Toe Walking

Outcomes Following Surgical Correction of Toe Walking

Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review

The purpose of this systematic review is to identify evidence-based examination components that enable a clinician to distinguish between participants with idiopathic toe walking (ITW) and cerebral palsy (CP) to accurately categorize them into their respective movement system diagnosis. Five articles were used that compared key clinical findings, walking characteristics, and muscle firing patterns of participants with CP and ITW. Differences in these components allow participants with CP and ITW to be classified into different movement system diagnoses to better target plan of care. The authors recommend that clinicians perform specific evidence-based tests and measures in accordance with the International Classification of Functioning, Disability and Health model.

Evaluation of Postural Control in Children With Idiopathic Toe Walking

Evaluation of Postural Control in Children With Idiopathic Toe Walking

Long-term follow-up until early adulthood in autosomal dominant, complex SPG30 with a novel KIF1A variant: a case report

BackgroundPathogenic variants in KIF1A (kinesin family member 1A) gene have been associated with hereditary spastic paraplegia (HSP) type 30 (SPG30), encopassing autosomal dominant and recessive, pure and complicated forms.Case presentationWe report the long-term follow-up of a 19 years-old boy first evaluated at 18 months of age because of toe walking and unstable gait with frequent falls. He developed speech delay, mild intellectual disability, a slowly progressive pyramidal syndrome, microcephaly, bilateral optic subatrophy and a sensory axonal polyneuropathy. Brain MRI showed cerebellar atrophy, stable along serial evaluations (last performed at 18 years of age). Targeted NGS sequencing disclosed the de novo c.914C > T missense, likely pathogenic variant on KIF1A gene.ConclusionsWe report on a previously unpublished de novo heterozygous likely pathogenic KIF1A variant associated with slowly progressive complicated SPG30 and stable cerebellar atrophy on long-term follow-up, adding to current knowledge on this HSP subtype.

From cerebral palsy to developmental coordination disorder: Development of preclinical rat models corresponding to recent epidemiological changes.

Cerebral palsy (CP) is a complex syndrome of various sensory, motor and cognitive deficits. Its prevalence has recently decreased in some developed countries and its symptoms have also shifted since the 1960s. From the 1990s, CP has been associated with prematurity, but recent epidemiologic studies show reduced or absent brain damage, which recapitulates developmental coordination disorder (DCD). In previous studies, we developed a rat model based on mild intrauterine hypoperfusion (MIUH) that recapitulated the diversity of symptoms observed in preterm survivors. Briefly, MIUH led to early inflammatory processes, diffuse brain damage, minor locomotor deficits, musculoskeletal pathologies, neuroanatomical and functional disorganization of the primary somatosensory (S1) cortex but not in the motor cortex (M1), delayed sensorimotor reflexes, spontaneous hyperactivity, deficits in sensory information processing, and memory and learning impairments in adult rats. Adult MIUH rats also exhibited changes in muscle contractile properties and phenotype, enduring hyperreflexia and spasticity, as well as hyperexcitability in the sensorimotor cortex. We recently developed a rat model of DCD based on postnatal sensorimotor restriction (SMR) without brain damage. Briefly, SMR led to digitigrade locomotion (i.e., "toe walking") related to ankle-knee overextension, degraded musculoskeletal tissues (e.g., gastrocnemius atrophy), and lumbar hyperreflexia. The postnatal SMR then led to secondary degradation of the hind-limb maps in S1 and M1 cortices, altered cortical response properties and cortical hyperexcitability, but no brain damage. Thus, our 2 rat models appear to recapitulate the diversity of symptoms ranging from CP to DCD and contribute to understanding the emergence and mechanisms underlying the corresponding neurodevelopmental disorders. These preclinical models seem promising for testing strategies of rehabilitation based on both physical and cognitive training to promote adaptive brain plasticity and to improve physical body conditions.

Interventions for idiopathic toe walking.

Interventions for idiopathic toe walking.

Effect of Plantar Flexor Muscle Strengthening on the Gait of Children With Idiopathic Toe Walking: A Study Protocol.

To evaluate the effect of plantar flexor strengthening associated with conventional physical therapy treatment in participants with idiopathic toe walking. Thirty participants, of both sexes diagnosed with idiopathic toe walking, aged 5 and 11 years, will be recruited and randomized into 2 groups: the control group, who will undergo gait training, triceps surae muscle stretching, anterior tibial muscle strengthening, and motor sensory training, and the intervention group, who will undergo the same training as the control group and, additionally, triceps surae muscle strengthening. The intervention will be performed twice a week for 8 weeks. The participants will undergo a 3-dimensional gait kinematic analysis, passive amplitude of dorsiflexion movement, isometric dynamometry of the anterior tibial and triceps surae muscles, motor coordination, quality of life, and perception of the parents regarding the equinus gait at baseline and at the end of treatment. Quality of life will be reevaluated during a 24-week follow-up.

Effect of Ankle Weight during Gait Training on Dorsiflexors Strength in Hemiparetic Children

AbstractBackground: Affected side toe walking is a common problem in hemiparetic cerebral palsy children, that may occur due to spasticity of planter flexors muscles and inhibition of anterior tibial muscles, walking with equines foot lead to abnormal gait pattern, frequent falling down, pain at the metatarsal heads and compensatory reaction that affects hip and trunk and may cause contracture of calf muscle which may need surgery. Using ankle weight during gait training may be an effective treatment tool in hemiparetic children.Aim of Study: The current study was conducted to inves-tigate the effect of using ankle weight during gait training in hemiparetic children.Subjects and Methods: Thirty hemiparetic children par-ticipated in this study, their ages range from 3 to 6 years, all subjects were recruited from the outpatient clinic at the Faculty of Physical Therapy, Cairo University. They were assigned randomly in to two group of equal number; Group A control group received a specific physical therapy program and Group B study group received the same specific physical therapy program as in Group A in addition to weight started 1/2kg placed above ankle of the affected side during gait training. Hand held dynamometer was used to measure ankle dorsiflex-ors muscle strength and Kinovea software was used to measure dorsiflexion angle during initial foot contact.Results: There was a significant increase in ankle dorsi-flexors muscle strength and a significant decrease of dorsi-flexion angle during initial contact in the study group compared to the control group.Conclusion: Ankle weight during gait training can be an effective treatment tool in improving dorsiflexors muscle strength in hemiparetic children.

The use of auditory feedback and edible reinforcement to decrease toe walking among children with autism.

We replicated and extended previous research on the use of auditory feedback to decrease toe walking exhibited by 3 children with autism. After pretreatment screening analyses suggested that toe walking occurred independent of social consequences, we attached squeakers to the heels of each participants' shoes. The squeakers provided auditory feedback when participants walked appropriately (i.e., with a heel-to-toe gait). For all participants, the auditory feedback itself produced increases in appropriate walking. For 1 participant, this feedback was sufficient to reduce toe walking to clinically acceptable levels; however, for 2 other participants, delivery of edible items paired with the auditory feedback was necessary. Intervention effects maintained when the schedule for edible delivery was thinned for all participants. In addition, for 2 participants, effects maintained when the intervention was implemented in a different setting and with a different person with no edibles or a thin schedule of edibles.

Medial Lower Leg Pain in a Middle-Aged Triathlete

HISTORY: A 43-year-old triathlete presented with left distal medial lower leg pain that started gradually about 2-3 weeks prior to presentation. He denied inciting trauma and described the pain as a 5/10 sharp pain provoked by walking, running, and ankle dorsiflexion and plantarflexion movements. He endorsed mild left distal medial leg swelling but denied leg weakness or numbness and previous injury to this area. He was taking ibuprofen and had seen a chiropractor who performed several treatments including grastin, massage, taping, and a compression sleeve with minimal relief. He was training for his first full Ironman triathlon, scheduled for 12 days from presentation. PHYSICAL EXAMINATION: Gait was non-antalgic. No visible swelling or ecchymoses of the left lower leg. Only tender to palpation in the left distal medial leg near the myotendinous junction of the medial gastrocnemius. Full ROM at the knee and ankle, but left end-range ankle dorsiflexion was painful. Strength was 5/5 about the knee and ankle, but he had pain with toe raises and toe walking on the left. DIFFERENTIAL DIAGNOSIS: 1. Gastrocnemius strain or tear 2. Soleus strain or tear 3. Plantaris strain or tear 4. Achilles tendon injury 5. Posterior tibialis strain or tear 6. Fascial defect/muscle herniation 7. Deep posterior compartment syndrome 8. DVT TEST AND RESULTS: Limited diagnostic ultrasound of the left distal medial leg revealed a near tear of the plantaris tendon near the myotendinous junction with evidence of disruption of tendon fibers and surrounding anechoic fluid. There was neovascularization on color doppler and tenderness to sonopalpation. FINAL/WORKING DIAGNOSIS: Plantaris Tendinopathy TREATMENT AND OUTCOMES: He was encouraged to continue symptomatic treatments with his chiropractor and could also consider kinesiotaping. His goal was to complete the full Ironman, even if he was slower than anticipated and called about one week later to ask if there were additional treatment options. He wished to proceed with experimental sonographically-guided injection of dextrose hyperosmolar solution to the site of pathology of his plantaris tendon, which was performed 4 days prior to the Ironman triathlon. By race day, his pain had improved, and he was able to complete the full Ironman within his original goal time.

PATHOLOGICAL EVALUATION OF NEONATAL FERRET MODELS OF INFLAMMATION‐SENSITIZED HYPOXIA‐ISCHEMIA

BackgroundThere is a need for relevant animal models for encephalopathy of prematurity and neonatal encephalopathy, and the ferret, with a gyrified brain and similar white:gray matter ratio to humans, is an appealing potential model species. The P10 ferret is approximately equivalent to a human infant at 23–26 weeks gestation, and the P21 ferret corresponds to approximately 40 weeks human gestation.MethodsFour different protocols to create ferret models of ischemia related preterm and term injury were evaluated: (1) intraperitoneal lipopolysaccharide (LPS; 5 mg/kg) administration at postnatal day (P)11 followed by consecutive hypoxia/hyperoxia/hypoxia (60min at 9%, 120min at 60%, 30min at 9%) in a humidified chamber with a target intra‐hypoxic rectal temperature of 37°C; (2) carotid artery ligation at P11 in combination with LPS administration and hypoxia/hyperoxia/hypoxia; (3) bilateral carotid artery ligation at P21 with LPS administration and hypoxia/hyperoxia/hypoxia (4) bilateral carotid artery ligation at P17 with LPS administration and hypoxia/hyperoxia/hypoxia, followed by 5 hours of prolonged temperature management to prevent anapyrexia. Control animals received saline vehicle followed by normoxia. Ferrets were followed to P42 or P70 and underwent weekly behavioral testing consisting of negative geotaxis, cliff aversion, and righting, as well as assessment of gait coordination on an automated catwalk. At end point, hematoxylin and eosin (HE) histology, immunohistochemistry (GFAP, MBP, and Olig2), and ex vivo magnetic resonance imaging (MRI) analyses were performed.ResultsNo abnormalities were observed on HE stained sections of P11 ferrets subjected to LPS and hypoxia/hyperoxia/hypoxia, although MRI at P70 showed widespread white matter hyperintensity on T2‐weighted images, and white matter changes within the internal capsule and corpus callosum were also present on MBP and Olig2 immunohistochemistry. Behavioral testing in these animals revealed slower overall reflex development between P28 and P40, smaller hind paw areas consistent with “toe walking”, and significantly greater lateral movement and reduced gait co‐ordination. More pronounced pathology was found in animals that underwent carotid artery ligation, LPS, and hypoxia/hyperoxia/hypoxia at P17 or P21. Gross abnormalities included thinned gyri in the temporal and/or occipital lobes and widening of the longitudinal fissure, with frank areas of cystic tissue loss in the most severely affected animals. Histological abnormalities included neuronal necrosis, vacuolation and cavitation of the neuropil, and gliosis.ConclusionsFerret kits treated with LPS and hypoxia/hyperoxia/hypoxia showed pathological and motor deficits consistent with white matter injury, and more severe injury including neuronal necrosis was observed in animals subjected to bilateral carotid artery ligation. These newborn ferret models may provide an additional platform to assess potential therapies in human encephalopathy of prematurity and neonatal encephalopathy.Support or Funding InformationNIH grant 5R21NS093154‐02 (NICHD)This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Serial ankle casts for patients with idiopathic toe walking: effects on functional gait parameters.

PurposeThe aim of the present study was to investigate the functional effects on gait parameters of serial ankle casts for patients with idiopathic toe walking (ITW), in comparison with an unremarkable control group.MethodsA prospective trial with a pre-test–post-test control group design included ten patients with ITW and ten healthy matched children. Children with ITW underwent serial casting to stretch the plantar flexors, with two 14-day periods with walking plaster casts set at the maximum available ankle dorsiflexion. Both groups were assessed clinically and using a functional gait analysis before and after serial casting, as well as at a six-month follow-up visit.ResultsThe normalized plantar heel force increased from 5% pre-interventionally to 79% at the follow-up. The upper ankle-joint angle and the base angle also demonstrated significant changes. Normalized compound action potentials of the medial heads of the gastrocnemius were reduced by 70%. None of these parameters demonstrated any significant differences at the follow-up examination in comparison with the healthy control group. Variations in the displacement of the knee joint on the sagittal plane and of the center of gravity in the transverse plane did not show any significant differences in comparison with the control group.ConclusionThe reduction of muscle tone and lengthening of the ankle plantar flexors led to persistent increased active ankle dorsiflexion with significant long-term improvement of functional kinematic parameters. No significant difference in the gait analysis was found between the ITW group and healthy children six months after treatment.Level of EvidenceLevel II - Therapeutic

Maturation of feedforward toe walking motor program is impaired in children with cerebral palsy.

Voluntary toe walking in adults is characterized by feedforward control of ankle muscles in order to ensure optimal stability of the ankle joint at ground impact. Toe walking is frequently observed in children with cerebral palsy, but the mechanisms involved have not been clarified. Here, we investigated maturation of voluntary toe walking in typically-developing children and typically-developed adults and compared it to involuntary toe walking in children with cerebral palsy. Twenty-eight children with cerebral palsy (age 3-14 years), 24 typically-developing children (age 2-14 years) and 15 adults (mean age 30.7 years) participated in the study. EMG activity was measured from the tibialis anterior and soleus muscles together with knee and ankle joint position during treadmill walking. In typically-developed adults, low step-to-step variability of the drop of the heel after ground impact was correlated with low tibialis anterior and high soleus EMG with no significant coupling between the antagonist muscle EMGs. Typically-developing children showed a significant age-related decline in EMG amplitude reaching an adult level at 10-12 years of age. The youngest typically-developing children showed a broad peak EMG-EMG synchronization (>100 ms) associated with large 5-15 Hz coherence between antagonist muscle activities. EMG coherence declined with age and at the age of 10-12 years no correlation was observed similar to adults. This reduction in coherence was closely related to improved step-to-step stability of the ankle joint position. Children with cerebral palsy generally showed lower EMG levels than typically-developing children and larger step-to-step variability in ankle joint position. In contrast to typically-developing children, children with cerebral palsy showed no age-related decline in tibialis anterior EMG amplitude. Motor unit synchronization and 5-15 Hz coherence between antagonist EMGs was observed more frequently in children with cerebral palsy when compared to typically-developing children and in contrast to typically-developing participants there was no age-related decline. We conclude that typically-developing children develop mature feedforward control of ankle muscle activity as they age, such that at age 10-12 years there is little agonist-antagonist muscle co-contraction around the time of foot-ground contact during toe walking. Children with cerebral palsy, in contrast, continue to co-contract agonist and antagonist ankle muscles when toe walking. We speculate that children with cerebral palsy maintain a co-contraction activation pattern when toe walking due to weak muscles and insufficient motor and sensory signalling necessary for optimization of feedforward motor programs. These findings are important for understanding of the pathophysiology and treatment of toe walking.