The Romberg test, sometimes spelled Rhomberg, is a commonly used but often misunderstood screening test for standing balance. It involves having the patient stand with feet together and arms either folded across the chest or at the sides. Initially, the patient’s ability to maintain this position with minimal swaying is observed. Subsequently, the patient is asked to stand with eyes closed, increasing their dependence on proprioceptive feedback. Increased sway during this phase is associated with proprioceptive or somatosensory loss.
In some cases, law enforcement settings may introduce an additional variable where the patient/suspect is instructed to tilt their head back while performing the test. The examiner then assesses stability under eyes-open versus eyes-closed conditions. While some have considered the Romberg test to be a measure of peripheral vestibular function, this theory has not been well-supported. Instead, most vestibular specialists understand that a positive Romberg test (increased sway with eyes closed) is likely indicative of reduced tactile feedback associated with a dorsal column lesion.
It is important to note that patients with cerebellar lesions may also exhibit increased sway with eyes closed during the Romberg test. However, the test cannot distinguish between patients with proprioceptive loss and those with cerebellar dysfunction. The cerebellum is more involved in motor output and control, while dorsal column lesions primarily affect proprioception in the lower extremities. Patients with compensated vestibular dysfunction often perform normally on the Romberg test.
As audiologists, incorporating the Romberg test into your evaluation for patients complaining of unsteadiness on their feet can provide valuable insights. When a patient fails the Romberg test, it may suggest a deficit in their ability to sense movement, such as proprioceptive loss.
On the other hand, if a patient passes the Romberg test but struggles with tandem gait (heel to toe walking), it could indicate a motor control issue, possibly related to cerebellar dysfunction. This distinction allows you to quickly identify whether the patient is experiencing trouble sensing movement or generating movement.
Anatomy and Physiology
The dorsal column is a three-order neuronal pathway responsible for transmitting signals from the spinal cord to the brainstem. It controls conscious appreciation of vibration, fine touch, 2-point discrimination, and proprioception.
Diseases such as neurosyphilis, vitamin B12 deficiency, posterior cord syndrome, and Brown-Sequard syndrome can disrupt this pathway, leading to severe sensory deficits, including impaired proprioception.
Although the cerebellum is associated with body movement and coordination, the Romberg test specifically focuses on proprioception and the integrity of the posterior dorsal columns. It is crucial to differentiate between cerebellar and posterior column disease, as both may result in ataxia.
The Romberg test is indicated for patients presenting with imbalance, dizziness, and unprovoked falls. It is particularly valuable in assessing ataxia or severe incoordination.
Conditions warranting the use of the Romberg test include, but are not limited to:
- Parkinson’s disease
- Friedreich ataxia
- Vitamin B12 deficiency
- Tertiary syphilis
- Normal pressure hydrocephalus
- Wernicke’s syndrome
- Ménière’s disease
Conducting the Romberg Test
The Romberg test does not require any specialized equipment. Trained medical professionals can perform the test alone or with assistance from another trained individual. Safety measures must be taken to prevent potential balance loss or falling during the test.
The Romberg test involves two stages. First, the patient stands with feet together and eyes open, and the examiner observes their body movement relative to balance. In the second stage, the patient stands with eyes closed for one minute, and any balance impairment is noted.
A positive Romberg test occurs when the patient loses balance with their eyes closed, indicating proprioceptive imbalance correction due to the lack of visual or vestibular compensation.
A positive Romberg test is a strong indicator of sensory ataxia and suggests underlying postural imbalance caused by myelopathies involving dorsal column deficits. This finding may arise from various conditions, including tabes dorsalis, inherited disorders, metabolic issues, toxic exposures, immunologic conditions, and more. To confirm specific diagnoses, further workup may be necessary, such as utilizing serologic markers and CSF enzyme immunoassay.
The Romberg test remains a valuable clinical tool, easily administered at the bedside, providing essential information for the diagnosis and management of various conditions affecting the dorsal column pathway. By accurately interpreting Romberg test results and engaging in interprofessional discussions, healthcare teams can develop targeted strategies to enhance care coordination and optimize patient outcomes.
Sensory ataxia is a condition characterized by impaired proprioception, leading to difficulties in maintaining balance and coordination. Intoxication, such as alcohol intoxication, can also cause sensory disturbances, affecting the brain’s ability to process proprioceptive information. Both sensory ataxia and intoxication can result in a positive Romberg test, as the loss of proprioceptive feedback increases sway and instability when standing with eyes closed, highlighting the reliance on visual and proprioceptive cues for balance.
It is also important to note that the Romberg test’s significance extends beyond clinical settings, as it has been adopted for use by law enforcement agencies in certain situations (suspicion of drunk driving). For a review of the Romberg test used in law enforcement, click here.
As a fundamental component of the neurological examination, the Romberg test continues to facilitate early detection and intervention for patients experiencing proprioceptive difficulties.
Alan Desmond, AuD, is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. He has written several books and book chapters on balance disorders and vestibular function. He is the co-author of the Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo (BPPV). In 2015, he was the recipient of the President’s Award from the American Academy of Audiology.