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Special Test

Romberg Test

Romberg Test is a neurological examination that is used to test for balance and coordination. It assesses the patient’s ability to stand with the feet parallel and together with the eyes open and then closed for 30s. This test was first described in the 19th century by Mortiz Romberg, European neurologist.

The Romberg sign is often used as part of a neurological examination to diagnose conditions such as peripheral neuropathy, vestibular disorders, multiple sclerosis, and other nervous system disorders that can affect balance and proprioception.

How do you perform the Romberg Test?

The patient is asked to stand on both feet together without shoes, The examiner asks the patient to hold the arms next to or crossed in front of the body.

First: the examiner asks the patient to keep his eyes open while the examiner assesses the patient’s body movement relative to balance.

Second: The patient closes his eyes while the examiner notes any balance impairment for a duration of one minute.

See Also: Gait Cycle
Romberg Test procedure

What is the positive Romberg Test meaning?

With the eyes open, the vision, proprioception, and vestibular systems provide input to the cerebellum to maintain truncal stability. If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open. When the patient closes their eyes, however, visual input is removed, and instability can be provoked (Positive Romberg sign).

Loss of balance can be defined as the increased swaying of the body, foot movement in the direction of the fall, or falling.

Patients with a vestibular lesion tend to fall in the direction of the lesion. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open.

Note that instability can also be seen with lesions in other parts of the nervous system such as the upper motor neuron or upper motor neuron or the basal ganglia, so these should be tested for separately in other parts of the exam.

Romberg Test positive causes, include:

  1. Peripheral neuropathy: Damage to the peripheral nerves, often caused by conditions such as diabetes, can affect a person’s balance and proprioception.
  2. Inner ear disorders: The inner ear is responsible for maintaining balance, and disorders such as vestibular neuritis, Meniere’s disease, and benign paroxysmal positional vertigo (BPPV) can cause balance problems.
  3. Cerebellar ataxia: This is a type of ataxia that affects the cerebellum, the part of the brain responsible for coordinating movement. Cerebellar ataxia can be caused by a variety of conditions, including stroke, multiple sclerosis, and alcohol abuse.
  4. Parkinson’s disease: Parkinson’s disease is a neurodegenerative disorder that can cause balance problems and difficulty with coordination.
  5. Vitamin B12 deficiency: Vitamin B12 is important for nerve function, and a deficiency can lead to peripheral neuropathy and balance problems.
  6. Spinal cord injuries: Damage to the spinal cord can affect a person’s ability to control their movements and maintain their balance.
positive Romberg sign
A: The patient can stand with feet together and eyes open.
B: Falls with eyes closed.
C: In contrast, the patient with a cerebellar lesion cannot stand with feet together and eyes open.

Accuracy

The Romberg test has predictive validity with regard to recurrent falls over a 6-month period in patients with Parkinson’s disease:

  • Sensitivity: 65%
  • Specificity: 90%

The sensitivity of the Romberg sign can be increased by:

  • “Sharpened Romberg test”- narrowing the patient’s base of support with feet in a heel-to-toe tandem position or
  • Conducting the test in foam rubber to nullify the proprioceptive inputs from the foot. Standing with their eyes closed on a compliant instead of a firm surface is a test of the vestibular system rather than that of proprioception.

Tandem Romberg Test

Tandem Romberg Test or Sharpened test is a variation of the original Romberg test.

Tandem Romberg Test assesses the patient’s ability to stand with the feet in the heel-to-toe position with the arms folded across the chest and eyes closed for 1 min. The rationale for this test is the same as for the Romberg test. The ataxic patient will prefer to stand with a wider BOS and will show reluctance when asked to stand with the feet close together.

Tandem Romberg Test
Tandem Romberg Test

Notes

Romberg described this sign in patients with tabes dorsalis and thought it was pathognomonic. He said, “If he is ordered to close his eyes while in the erect posture, he at once commences to totter or swing from side to side; the insecurity of his gait also exhibits itself more in the dark.”

Romberg did not state that the feet should be placed together; that was a later addition. Nor did he comment on where the arms were to be positioned.

Some histrionic patients will sway with eyes closed in the absence of any organic neurologic impairment (false Romberg sign). The toes of the patient with histrionic sway are often extended; the patient with organic imbalance flexes the toes strongly and tries to grip the floor.

The swaying is usually from the hips and may be exaggerated.

Q&A for Patients

What diseases have a positive Romberg test?

1. Peripheral neuropathy: such as diabetes.
2. Inner ear disorders: such as vestibular neuritis, Meniere’s disease, and benign paroxysmal positional vertigo (BPPV).
3. Cerebellar ataxia: Cerebellar ataxia can be caused by a variety of conditions, including stroke, multiple sclerosis, and alcohol abuse.
4. Parkinson’s disease
5. Vitamin B12 deficiency
6. Spinal cord injuries

Is Romberg tests positive in MS?

No, Romberg’s sign is not specific to multiple sclerosis (MS) and can be found in various neurological conditions affecting proprioception. It refers to a loss of balance and increased swaying when standing with feet together and eyes closed. It is a non-specific sign and can be observed in various conditions affecting the sensory and motor pathways in the nervous system. A healthcare professional should evaluate the patient to determine the underlying cause.

Is Romberg test positive in cerebellar ataxia?

Yes, Romberg sign can be positive in cerebellar ataxia. Cerebellar ataxia is a condition that affects the cerebellum, a part of the brain responsible for coordinating movement and balance. When the cerebellum is damaged or dysfunctional, it can lead to difficulties in coordinating movements, including maintaining balance while standing or walking.

References

  1. Forbes J, Cronovich H. Romberg Test. [Updated 2021 Dec 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563187/
  2. Lanska DJ, Goetz CG. Romberg’s sign: development, adoption, and adaptation in the 19th century. Neurology. 2000 Oct 24;55(8):1201-6. PubMed
  3. Halmágyi GM, Curthoys IS. Vestibular contributions to the Romberg test: Testing semicircular canal and otolith function. Eur J Neurol. 2021 Sep;28(9):3211-3219. PubMed
  4. Newton R: Review of tests of standing balance abilities. Brain Injury: [BI] 3: 335–43, 1989.
  5. Simon RP, Aminoff MJ, Greenberg DA: Clinical Neurology, 4th ed.). Stanford, CT, Appleton and Lange, 1999.
  6. Bloem BR, Grimbergen YA, Cramer M, et al.: Prospective assessment of falls in Parkinson , s disease. J Neurol. 248:950–8, 2001
  7. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.
  8. William W.Campbell, Richard J.Barohn. DeJong’s The Neurologic Examination, 8th Edition.
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