Gowers’ Sign

Gowers sign was first described by the neurologist, Sir William Richard Gowers as a pattern of standing in 21 boys with 'pseudohypertrophic muscular paralysis' in a clinical lecture to the students at University College that was published in the Lancet in 1879. His original description considered the sign as being pathognomonic for children with 'pseudohypertrophic muscular paralysis' as it was present in all his cases. It is now known that this sign occurs in children with proximal muscle (pelvic girdle) weakness or a central hypotonia, such as Duchenne Muscular Dystrophy. Some also consider the sign to occur in older adults with a proximal or central muscle weakness as a strategy they use to raise from a chair.

Dr Gowers' described the pattern of standing as having two features:
(i) the child adopts a prone position on all fours before attempting to stand
(ii) the child 'walks up their legs' with the hands

Gowers sign

William Gowers original depiction of the sign from: Clinical lecture on pseudohypertrophic muscular paralysis. Lancet 1879;ii,73-5

The children with this sign need to use the hands to walk up the legs due to the proximal (hip and back) weakness.

The adopting of a prone position before standing is a part of normal development in toddlers. Wallace and Newton (1989) compared children with a central hypotonia to normal controls and based on their data recommended that children who continue to get into a prone position before after the age of 30 months should be further assessed and a full neurological assessment done if it persists past 3 years.

Chang and Mubarak (2011) developed a point scoring system to determine severity for a subsequent classification:

Points: Maneuvers
0 point: Normal
1 point: Prolonged or strained rise without support
2 points: One hand to thigh or one hand to floor
3 points: Prone crawl position, both hands on floor
4 points: Prone crawl position, both hands on floor, prolonged
5 points: Prone crawl position, one hand on thigh
6 points: Prone crawl position, one hand on thigh, prolonged
7 points: Prone crawl position, both hands on thigh
8 points: Prone crawl position, multiple hands on thigh
9 points: Arises only with the aid of an object to lean on
10 points: Is unable to arise

They then classified Gowers sign as:

Classification:   Scores:   Sitting to standing:
Mild                         1 to 4         Prolonged normal, one-hand maneuvers, or crawl position only
Moderate                5 to 7         Crawl position and one or two hands on thigh
Severe                     8 to 10      Crawl position and multiple hand-to-thigh maneuvers,
use of additional aid, or unable to rise

Differential Diagnosis for a Positive Gowers Sign:
Duchenne Muscular Dystrophy | Juvenile idiopathic arthritis | Becker’s muscular dystrophy | Other muscular dystrophy's | Proximal ascending pseudomyopathic diseases | Spinal muscular atrophy

Related Topics:
Duchenne muscular dystrophy | Neurological Assessment of Child

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