Romberg testing (also spelled Rhomberg) is frequently used and too often misunderstood as a screening test for standing balance. It is performed by having the patient stand with feet together and arms either folded across the chest or at the sides. In a clinical setting, if the patient is able to maintain this position with minimal swaying, the patient is then asked to continue standing with eyes closed. When done in a law enforcement setting, an additional variable is added where the patient/suspect is instructed to tilt their head back at the same time.
The examiner makes a relative judgement of stability in eyes-open versus eyes-closed conditions. By closing the eyes, the patient becomes more dependent on proprioceptive feedback, and increased sway is associated with proprioceptive or somatosensory loss. We recently discussed redundancy in the balance system, where one part of the system will “pick up the slack” when another part is impaired. Some have considered the Romberg to be a test of peripheral vestibular function (assuming that the loss of visual feedback would make the patient more dependent on vestibular input, then failure to maintain balance might indicate a weakened vestibular apparatus). This theory has not held up very well, and most vestibular specialists understand that a positive Romberg test (increased sway with eyes closed) is most likely the result of reduction or distortion of tactile feedback associated with a dorsal column lesion.
Patients with cerebellar lesions may also show a pattern of increased sway with eyes closed, but the Romberg test cannot distinguish between patients with proprioceptive loss and cerebellar dysfunction. The cerebellum is more about motor output and control, whereas dorsal column lesions are associated with decreased proprioception from the lower extremities. Patients with compensated vestibular dysfunction will often perform normally on the Romberg test.
For patients complaining of unsteadiness whenever they are on their feet, I use the Romberg test along with an informal tandem gait (heel to toe walking) assessment. If the patient fails the Romberg test, I suspect a deficit in their ability to sense movement (such as proprioceptive loss). If they pass the Romberg test, but cannot perform tandem gait, I suspect a motor control, possibly cerebellar, issue. In other words, it is a quick way to see if a patient is having trouble sensing movement, or trouble generating movement.
For an amusing review of the Romberg test used in law enforcement, click here.
Photo courtesy of https://www.fieldsobrietytests.org/rhombergbalancetest.html