Pathomechanics of Gowers’ Sign: A Video Analysis of a Spectrum of Gowers’ Maneuvers

Abstract

Background

Gowers’ sign is a screening test for muscle weakness, typically seen in Duchenne muscular dystrophy but also seen in numerous other conditions. The mildest presentations and the variations of Gowers’ sign are poorly described in the literature but are important to recognize to help with early diagnosis of a neuromuscular problem.

Questions/purposes

We therefore (1) defined the characteristics of the mildest forms and the compensatory mechanism used, (2) categorized the spectrum of this sign as seen in various neuromuscular diseases, and (3) provide educational videos for clinicians.

Methods

We videotaped 33 patients with Gowers’ sign and three healthy children. Weakness was categorized as: mild = prolonged or rise using single-hand action; moderate = forming prone crawl position and using one or two hands on thigh; severe = more than two thigh maneuvers, rising with additional aid, or unable to rise.

Results

The earliest changes were exaggerated torso flexion, wide base, and equinus posturing, which reduce hip extension moment, keep forces anterior to the knee, and improve balance. Patients with moderate weakness have wide hip abduction, shifts in pelvic tilt, and lordosis, which reduce knee extension moment, improve hamstrings moment arm, and aide truncal extension. The classic Gowers’ sign (severe) exaggerates all mechanisms.

Conclusions

The classically described Gowers’ sign is usually a late finding. However more subtle forms of Gowers’ sign including mild hand pressure against the thigh and prone crawl position should be recognized by clinicians to initiate additional diagnostic tests.

Level of Evidence

Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. 1.

    Cornelio F, Dworzak F, Morandi L, Fedrizzi E, Balestrini MR, Gondoni L. Functional evaluation of Duchenne muscular dystrophy: proposal for a protocol. Ital J Neurol Sci. 1982;3:323–330.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Gowers WR. Clinical lecture on pseudo-hypertrophic muscular paralysis. Lancet. 1879;2:1–2, 37–39, 73–75, 113–116.

    Google Scholar 

  3. 3.

    Kang PB, Krishnamoorthy KS, Jones RM, Shapiro FD, Darras BT. Atypical presentations of spinal muscular atrophy type III (Kugelberg-Welander disease). Neuromuscular Disord. 2006;16:492–494

    Article  CAS  Google Scholar 

  4. 4.

    Koehler PJ, Bruyn GW, Pearce JMS, eds. Neurological Eponyms. New York, NY: Oxford University Press; 2000.

    Google Scholar 

  5. 5.

    Mirovsky Y, Copeliovich L, Halperin N. Gowers’ sign in children with discitis of the lumbar spine. J Pediatr Orthop B. 2005;14:68–70.

    PubMed  Article  Google Scholar 

  6. 6.

    Pearce JM. Gowers’ sign. J Neurol Neurosurg Psychiatry. 2000;68:149.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Stathopulu E, Baildam E. Gowers’ sign in children with juvenile idiopathic arthritis. Rheumatology (Oxford). 2003;42:1002–1003.

    Article  CAS  Google Scholar 

  8. 8.

    Sutherland DH, Olshen R, Cooper L, Wyatt M, Leach J, Mubarak S, Schultz P. The pathomechanics of gait in Duchenne muscular dystrophy. Dev Med Child Neurol. 1981;23:3–22.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Tyler KL. Origins and early descriptions of “Duchenne muscular dystrophy”. Muscle Nerve. 2003;28:402–422.

    PubMed  Article  Google Scholar 

  10. 10.

    Tyler KL, McHenry LC Jr. Classics in neurology. Fragments of neurologic history: pseudohypertrophic muscular dystrophy and Gowers’ sign. Neurology. 1983;33:88–89.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Visser JJ, Hoogkamer JE, Bobbert MF, Huijing PA. Length and moment arm of human leg muscles as a function of knee and hip-joint angles. Eur J Appl Physiol Occup Physiol. 1990;61:453–460.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Wallace GB, Newton RW. Gowers’ sign revisited. Arch Dis Child. 1989;64:1317–1319.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Zajac FE. Understanding muscle coordination of the human leg with dynamical simulations. J Biomech. 2002;35:1011–1018.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Scott J. Mubarak MD.

Additional information

Each author certifies that he or she, or a member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research.

This study was performed at Rady Children’s Hospital and Health Center.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Video 1 (WMV 14559 kb)

Video 2 (WMV 24796 kb)

Video 3 (WMV 43171 kb)

Video 4 (WMV 41546 kb)

About this article

Cite this article

Chang, R.F., Mubarak, S.J. Pathomechanics of Gowers’ Sign: A Video Analysis of a Spectrum of Gowers’ Maneuvers. Clin Orthop Relat Res 470, 1987–1991 (2012). https://doi.org/10.1007/s11999-011-2210-6

Download citation

Keywords

  • Muscular Dystrophy
  • Spinal Muscular Atrophy
  • Pelvic Tilt
  • Neuromuscular Disease
  • Duchenne Muscular Dystrophy