Gowers Sign


Article Author:
Sangam Shrestha


Article Editor:
Sunil Munakomi


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Hajira Basit
Phillip Hynes


Updated:
5/1/2019 4:14:24 PM

Definition/Introduction

There are three Gowers signs described in the medical literature[1]:

  1. Sciatic pain on passive ankle dorsiflexion
  2. The irregularly contracting pupils in syphilis
  3. The characteristic maneuver of climbing up the thighs while standing up seen particularly in Duchenne dystrophy.

In 1879, neurologist Sir William Richard Gowers described the most significant Gowers sign as the characteristic patterns observed in patients with Duchenne muscular dystrophy wherein they 'climb up' their thighs with the aid of their hands to overcome the weakness of their pelvic and proximal lower limb muscles. 

Issues of Concern

The earliest changes observed will be torso flexion, wide-based gait, and equinus posturing which minimizes the workload on the knee extensors. Patients also exaggerate hip abduction, forward pelvic tilt, and the hyper lumbar lordosis compensating for weakened gluteus muscles in facilitating truncal extension. 

The classically described Gowers sign usually presents in advanced stages. However, early, stages mild hand pressure against the thigh and prone crawl position are appreciated.[2] In advanced stages, the hand needs to provide an upward thrust by resting upon the floor.  However, in advanced stages, after contractures ensue, the patient becomes dependent on external aids.[2]

Clinical Significance

Gowers sign presents with any condition that is associated with weakness of the pelvic girdle or proximal muscles of lower extremities such as[2]:

  • Becker muscular dystrophy
  • Limb-girdle and other muscular dystrophies
  • Proximal ascending pseudomyopathic diseases
  • Spinal muscular atrophy
  • Sarcoglycanopathy
  • Polymyositis
  • Discitis
  • Juvenile idiopathic arthritis

A most salient feature in muscular dystrophy is the adoption of a prone position before standing persisting beyond 3 years.[1]

The valley sign, owing to hypertrophic infraspinatus and the deltoid with atrophy of axillary folds can also help to clinch the diagnosis.[3]

There is an increase in serum level of creatine phosphokinase muscle/brain (CPKMB), Nerve conduction velocity (NCV) study will be normal, and electromyography (EMG) will show a myopathic pattern. Muscle biopsy reveals hyaline hypereosinophilic fibers scattered within the vesicles with characteristic crowding of the multinucleated nuclei in the center, degenerative fibers, and fat infiltration.[4]

Nursing Actions and Interventions

Earlier diagnosis facilitates prompt physical therapy and support management as well as in genetic counseling.[2]

The most important aspect is to rule out treatable conditions like discitis that can also present mimicking Gowers sign.


Attributed To: contributed by Dr Sunil Munakomi, MD

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Gowers Sign - Questions

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A 6-year-old child is seen in the clinic. After placing him on the floor, it is observed that he uses his hands and arms to walk up his own body and get off the floor. What is the modality to be chosen to come to a definitive diagnosis in the child?



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A father brought his young son to a clinic with a history of difficulty in standing from a sitting position. When asked to stand up the child braces his or her hands on his knees and thighs to push himself into an upright position. What additional clinical findings would help in further validating the most likely diagnosis?



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Gower sign is most commonly associated with what medical diagnosis?



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The most salient feature seen in male patients with a DMD gene mutation in his X chromosome is which of the following?

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    Gowers WR. Clinical lecture on pseudohypertrophic muscular paralysis. Lancet 1879;ii,73-5. |Date=1879 |Author=William Richard Gowers (1845–1915) - from Wikipedia public domain
Attributed To: Gowers WR. Clinical lecture on pseudohypertrophic muscular paralysis. Lancet 1879;ii,73-5. |Date=1879 |Author=William Richard Gowers (1845–1915) - from Wikipedia public domain



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A patient presents with an inability to rise from a tripod position without placing his hands on his thighs when in the squatting position. Which of the following is the most treatable cause in patients exhibiting this sign?

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    Gowers WR. Clinical lecture on pseudohypertrophic muscular paralysis. Lancet 1879;ii,73-5. |Date=1879 |Author=William Richard Gowers (1845–1915) - from Wikipedia public domain
Attributed To: Gowers WR. Clinical lecture on pseudohypertrophic muscular paralysis. Lancet 1879;ii,73-5. |Date=1879 |Author=William Richard Gowers (1845–1915) - from Wikipedia public domain



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Gowers Sign - References

References

Chang RF,Mubarak SJ, Pathomechanics of Gowers' sign: a video analysis of a spectrum of Gowers' maneuvers. Clinical orthopaedics and related research. 2012 Jul;     [PubMed]
Stathopulu E,Baildam E, Gower's sign in children with juvenile idiopathic arthritis. Rheumatology (Oxford, England). 2003 Aug;     [PubMed]
Kanitkar SA,Kalyan M,Gaikwad AN,Makadia A,Shah H, Limb Girdle Muscular Dystrophy (LGMD): Case Report. Journal of clinical and diagnostic research : JCDR. 2015 Jan;     [PubMed]
Pradhan S, Valley sign in duchenne muscular dystrophy: importance in patients with inconspicuous calves. Neurology India. 2002 Jun;     [PubMed]

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