Continuing Education Activity

This Romberg test illustrates a diagnostic, non-technical, physical test that identifies a specific neurologic impairment. The purpose of this evaluation, administered by any trained individual, is to identify a particular impairment in patients with specific proprioception difficulties for purposes of intervention and improving patient outcomes. The Romberg sign removes the visual and vestibular components that contribute to maintaining balance and can thus identify a proprioception-related neurologic disease. The Romberg sign is said to be positive in a patient who is able to stand with his feet placed together and eyes open but paradoxically sways or falls while closing his eyes. This activity covers the proper execution and interpretation of the Romberg test as a diagnostic tool.

Objectives:

• Outline the types of conditions that would lead a practitioner to perform the Romberg test.
• Describe the process for performing the Romberg test.
• Review the potential results of the Romberg test and their clinical significance.
• Summarize how interprofessional discussion can incorporate the results from the Romberg test may lead to a better understanding of the etiology of the patient's proprioception difficulties and may lead to developing a more narrowed strategy for improving care coordination and the patient's overall outcome.

Introduction

The Romberg's sign or Romberg's test is named after a European neurologist, Mortiz Romberg; historically, this was described by Marshall Hall, Moritz Romberg, and Bernardus Brach.[1] Initially, this sign was tethered specifically with tertiary syphilis patients who exhibited neurologic signs of late-stage disease referred to as locomotor ataxia or tabes dorsalis.[2][3]

When examining a patient's neurological effects from sequelae involving late-stage syphilis, the Romberg sign became a precise test to determine the integrity of the dorsal column pathway of the brain and spinal cord, which controls proprioception. Proprioception is the sense of awareness of the position and movement of the body. Romberg described this sign as a severe postural impairment in a darkroom setting or with eyes closed of patients with severe damage to the posterior dorsal columns of the spinal cord. Used as a precise clinical tool, the Romberg test is positive if a patient cannot maintain an upright stance with vision eliminated or in the darkness.[2] 

Often the Romberg test can be confused as a sign of cerebellar disease, but this test demonstrates the effects of posterior column disease. Normal stance in a person is governed by the integrity of vision, proprioception, and vestibular function.[4] The ability to gauge actual proprioception status can be confounded by the vestibular and vision somatosensory system, which may compensate for vestibular function and vision.[5] The Romberg sign removes the visual and vestibular components that contribute to maintaining balance and can thus identify a proprioception-related neurologic disease. 

The Romberg sign is said to be positive in a patient who can stand with his feet placed together and eyes open but paradoxically sways or falls while closing his eyes, thereby eliminating his visual cues.[6]

Anatomy and Physiology

Neuroanatomy 

The dorsal column is a three-order neuronal pathway that functions as a method of signal transmission throughout the spinal cord to the brainstem. This pathway specifically controls conscious appreciation of vibration, fine touch, 2-point discrimination, and proprioception.[7] Specifically, in cases of neurosyphilis, or tabes dorsalis, there is demyelination of the axonal fibers of the posterior column or dorsal pathway of the spinal cord. This demyelination leads to severe sensory deficits of the pathway, including position sense or proprioception.[7]

Anatomically, the cerebellum is also involved in truncal and extremity balance and coordination. It is inferior to the occipital lobe; it contains two lateral hemispheres lesions and one medial vermis. The cerebellum is associated with the movement of the body and is part of the human brain, which allows the body to make voluntary and coordinated movements and balance.[8]

Although the cerebellum is also involved with coordination, Romberg's test detects the integrity of the posterior dorsal columns and proprioception, the body's awareness of its own movement and position in space. It is important to understand that a negative Romberg test does not confirm cerebellar dysfunction, but the clinician may rule in the etiology of ataxia due to cerebellar damage. It is crucial to note that both the dorsal column and cerebellar damage may result in ataxia.[7]

Physiology and Disease States Affecting Proprioception 

Sensorimotor integration of the body is dually controlled by cerebellar input and the posterior column medial lemniscus tracts. The dorsal columns carry proprioception sense (sense of position and joint sense). Important sensory inputs to maintain balance include three peripheral modalities: vision, the vestibular apparatus, and proprioception.[9]

Another disease state that involves the dorsal column and proprioception disruptive behavior is the late complication of vitamin B12 deficiency, termed subacute combined degeneration of the spinal cord (SCD). This condition is an example of the degeneration of the posterior column pathway due to the disrupted formation of myelin and, thus, nerve transmission through saltatory conduction.[7] 

Due to the demyelination, the nerve impulse conduction is disrupted, resulting in clinical proprioceptive impairment. In addition to the late sequelae of Vitamin B12 deficiency, a clinical state involving the vasculature of the spinal cord can also result in clinical manifestations such as ataxia and proprioceptive deficit. Posterior cord syndrome is a clinical disease resulting from posterior spinal artery infarction. This sequel can involve impairment of vibration sense, proprioception, and loss of reflexes below the lesion with sparing of pain and temperature sensation.[7] 

Lastly, in a spinal cord hemisection, known as Brown-Sequard syndrome, the posterior column pathway of the spinal cord is usually affected. Most cases of Brown-Sequard syndrome are related to trauma. The classic clinical picture involves ipsilateral hemiparesis, loss of vibration and proprioception, and contralateral loss of pain and temperature.[7]

These disease states mentioned above may all result in ataxia as well as many other physical manifestations. To rule out certain disease states, such as Brown-Sequard syndrome, as the etiology for a proprioceptive deficit, taking a thorough past medical history (including trauma history)is crucial. The role of the evaluator is vital for early goal-directed care. 

Indications

The Romberg maneuver is a commonly performed test during the neurological exam. It is a valuable clinical sign to evaluate the integrity of the dorsal columns of the spinal cord and is particularly useful in patients with ataxia or severe incoordination.[9] 

Although ataxia may develop gradually and insidiously, the screening test is indicated when the patient admits an inability to move around in the dark or even maintain balance when washing their face. In disease states with severe proprioceptive impairment, the patient may even exhibit a noticeable impairment when standing together with the feet.[2] When the patient may display clinical signs or evidence of inability to maintain postural station or the power to stand steady with eyes open or shut, the diagnostic Romberg test and test of postural sway may be indicated.[2]

The Romberg test is quite helpful in a broad range of neurologic disease states in assessing and confirming various neurological conditions including but not limited to Parkinson's disease (causes postural instability and a shuffling gait), Friedreich ataxia (causes staggering gait and frequent falls), Vitamin B12 deficiency (causes ataxia gait), Tertiary syphilis (causes sensory ataxia; impaired proprioception), Normal pressure hydrocephalus in the elderly (truncal ataxia with falls), Wernicke's syndrome (associated with chronic alcoholism which causes limb ataxia), and Ménière's disease.[10]

Romberg sign is positive in:

• Los of proprioception among patients with myelopathies and sensory neuropathies
• Uncompensated unilateral or bilateral vestibular dysfunction, and
• Pathology involving the anterior vermis and the paravermis of the anterior cerebellar lobe.[6]

In cerebellar disease, the patient is often unsteady with the eyes open as well. The patient significantly tends to fall to the side of the affected labyrinth during the test.

The Romberg test or Timed Get Up, and Go Test has also been applied for measuring frailty kinematics and accelerometry index among the aged population.[11] The modified Romberg Test of Standing Balance has also been used for assessing fall risk.[12]

Contraindications

The current literature demonstrates safety in performing the test under the supervision of the clinician and following the correct procedure.

Equipment

No additional medical equipment is necessary for this test. The Romberg test does not require any equipment or instrumentation to diagnose a proprioceptive impairment or injury to the dorsal column medial lemniscus pathway. Although the test can be subject to error, accuracy is based solely on the patient's ability to follow the directions and sequences of the examination. Only a trained medical professional should perform this test and be conducted in a safe environment.

Personnel

Examiners may perform this maneuver alone or with the assistance of another trained medical professional. 

Preparation

The trained professional administering the exam should stand close to the patient as a precautionary measure against loss of balance or falling incidents of the patients during the test.

Technique or Treatment

The patient is asked to remove shoes and stand with both feet together. Next, the examiner instructs the patient to hold their arms next to the body or crossed in front of the body. The first stage of the test involves asking the patient to keep their eyes open while the examiner assesses the patient's body movement relative to balance.

The second stage involves instructing the patient to stand erect with their eyes closed while the examiner notes any balance impairment for a duration of one minute. Swaying of the body may be observed. However, this indicates the proprioceptive balance correction for the lack of visual or vestibular compensation. The Rhomberg test is positive when the patient loses balance with their eyes closed. Loss of balance can be defined as increased body swaying, foot movement in the direction of the fall, or falling. 

The sensitivity of the test 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.[6] 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.[4]

Complications

If performed in the correct setting and manner by a trained medical professional, there are no known complications of this clinical test.

Clinical Significance

The Romberg test is a simple bedside test that should be performed on all patients presenting with imbalance, dizziness, and unprovoked falls. A positive Romberg test denotes sensory ataxia as the cause of postural imbalance. Sustaining balance while standing in an upright position depends on the sensory and motor pathways of the brainstem. The sensory pathway involves proprioception and the body's awareness of position and motion in space. Detecting a proprioceptive deficit with a positive Romberg test indicates further workup into myelopathies that may result in dorsal column deficits. Permanent dysfunction and disability may be remediable and treatable in some circumstances with early detection.[9] The classical cause of sensory ataxia is tabes dorsalis; however, a positive Romberg test may result from inherited, metabolic, toxic, immunologic, or other disorders.[9] 

A thorough history and detailed physical examination are essential, as well as using focused laboratory testing as indicated. For example, the clinician may choose to rule out tertiary syphilis using diagnostic studies such as serologic markers and CSF enzyme immunoassay (CSF-EIA).[13] When seen in tertiary syphilis, the disease morbidity resulting from late-stage disease entails prompt action and treatment. Vitamin B12 deficiency resulting in subacute combined degeneration of the cord (SACD) may also result in a positive Romberg test, prompting the clinician to complete further lab testing. 

Modified versions of the Romberg test provide a wide range of clinical applications for balance assessment. Some of these variations include:

• Sharpened Romberg Test (SRT) - used in assessing ataxia in patients recovering the severity of decompression sickness, such as in divers.[14]
  • This test procedure differs from the traditional Romberg Test in the positioning of the feet. Instead of standing with feet shoulder-width apart, the sharpened Romberg test dictates that the feet of the patient align in a strict tandem heel-to-toe position. 
• Single-legged Stance Test (SLST) - is mainly used to assess postural stability and control in the elderly and those with Parkinson's disease.[15]
  • Static balance test serves as a balanced assessment of Parkinson's disease. The process entails assessing how long the patient can maintain a single-leg stance with eyes open. The test ends after 60 seconds, and each leg is tested three times.[15]
• Sitting-rising Test (SRT)- is an easily administered test focused on the assessment of the elderly population as well as stroke victims as a tool to predict mortality risk. 
  • The evaluator instructs the patient to try to sit, rise, and then stand to a position using the minimum amount of support needed. This test is on a point scale, with measures for strength, balance, and integration aspects, with 10 points being the maximum.[16]
• Get-Up and Go Test - assessment of frailty and predictor of a geriatric patient's ability to go outside alone safely.[17]

These variations of the Romberg test mentioned above are utilized depending on the discretion of the evaluator or physician and patient presentation. Not one test is deemed superior to the others, but slight variations in each test may provide a more specific method of detecting a postural imbalance that caters to a particular patient profile. 

Enhancing Healthcare Team Outcomes

Diagnosing and managing neuropathies using the Romberg test may include input from various interprofessional healthcare team members, including an infectious disease specialist, neurologist, internist, and nursing staff. 

The Romberg sign is an easily administered, no-equipment, bedside physical exam maneuver used since its description in the 19th century to help diagnose tabes dorsalis and dorsal column and proprioceptive dysfunction. A positive test is an inability to maintain an erect posture over 60 seconds with eyes closed. Due to its high specificity, a positive Romberg sign is highly suggestive of diagnosing a deficit involving the dorsal column and medial lemniscus pathways. 

The examiner does not need extensive training, but precautions regarding the patient's safety and fall risk must have priority in case balance is lost during the test. The examiner must maintain close proximity with the patient so that the safety of the patient is given utmost priority throughout the exam. Since the Romberg test is not something inherently subjective in each case, the quality of the test is somewhat standardized. 

A few observed variabilities of the test include:

• Range of postural instability that connotes positivity of the test (sway, a step to the side, or a fall). Electric analysis during the Romberg test has shown normal subjects, on average, deviate 6–7% of their body weight in the lateral direction and twice as much in the anteroposterior direction. They also tend to lean more forward with their eyes closed.[18] 
• Significance of the sway at the ankles versus sway at the hips
• Placing the feet together or in tandem
• Conducting the test with bare feet or with footwear worn
• Holding the hands at the side versus extending  forward or laterally
• Need for gentle pulling or pushing of the patient to one side during the test.[6]

Nursing, Allied Health, and Interprofessional Team Monitoring

When the Romberg test was described, the role and function of the vestibular system were not apparent.[4] A positive Romberg test owing to the loss of proprioception impulses should be confirmed by conducting Head impulses and vestibular evoked myogenic potentials to assess the function of semicircular canals and otoliths. A Head Impulse-Nystagmus-Test of Skew (HINTS) test (normal horizontal head impulse, gaze-direction nystagmus, or eye skew deviation) must be performed to rule out posterior circulation stroke.[19] A focused neurological examination for assessing cerebellar signs is also pivotal.