The Romberg Test: Purpose and Interpretation in Neurological and Vestibular Disorders
The Romberg test is primarily used to evaluate proprioceptive function through the dorsal columns of the spinal cord, with a positive test indicating sensory ataxia, which helps differentiate between cerebellar, vestibular, and sensory causes of balance disorders. 1
Basic Principles and Technique
The Romberg test involves:
- Having the patient stand with feet together
- First with eyes open to establish baseline stability
- Then with eyes closed to assess reliance on visual input
A positive test occurs when:
- The patient maintains balance with eyes open
- The patient demonstrates significant swaying or falls with eyes closed
Physiological Basis
The test evaluates the integration of three sensory inputs critical for balance:
- Vision
- Proprioception (via dorsal columns)
- Vestibular function
When proprioception is impaired, patients can compensate with visual input. Removing visual input (closing eyes) reveals the proprioceptive deficit, causing instability.
Clinical Interpretation
Positive Romberg Test
A positive Romberg test suggests:
- Impaired proprioception through the dorsal columns 1, 2
- Possible sensory ataxia
- Potential pathology in peripheral nerves, spinal cord, or posterior columns
Differential Diagnosis Based on Romberg Test
| Condition | Romberg Test | Other Features |
|---|---|---|
| Sensory neuropathy | Positive | Decreased sensation, areflexia [3] |
| Posterior column disorders | Positive | May have other spinal cord signs |
| Cervical myelopathy | Often positive (74.5% with walking Romberg) | Hoffman's reflex (79%), hyperreflexia [4] |
| Vestibular disorders | May be positive | Nystagmus, vertigo, hearing changes |
| Cerebellar disorders | Negative (unstable with eyes open and closed) | Dysmetria, dysdiadochokinesia |
Advanced Applications and Variations
Walking Romberg Test
The walking Romberg test has shown greater sensitivity than the traditional standing test:
- Patient walks 5 meters with eyes open, then repeats with eyes closed
- Swaying, instability, or inability to complete the walk indicates a positive test
- Detected proprioceptive deficits in 74.5% of cervical myelopathy patients (versus 34% with traditional Romberg) 4
Quantitative Assessment
Modern posturography can quantify Romberg test results:
- Force platforms measure center of pressure changes
- Romberg quotient (sway with eyes closed/sway with eyes open) typically around 2 in patients with sensory neuropathy 3
- However, diagnostic discrimination between patients and controls may be modest 3
Clinical Utility in Specific Disorders
Vestibular Disorders
- While traditionally considered a test of proprioception, the Romberg test can provide information about vestibular function when performed on compliant surfaces 2
- For suspected vestibular disorders like BPPV, the Dix-Hallpike maneuver is more specific and recommended over the Romberg test 1, 5
- Patients with BPPV show poorer balance performance on Romberg testing, with center of pressure shifted toward toes, especially after treatment maneuvers 6
Skew Deviation
- In patients with skew deviation (vertical misalignment of the eyes), a positive Romberg test may indicate underlying vestibular pathology
- Critical to distinguish from 4th nerve palsy as skew deviation may indicate serious conditions requiring urgent imaging (demyelination, stroke, mass lesions) 1
Limitations and Considerations
The Romberg test alone has limited sensitivity and specificity for vestibular disorders
- One study found poor correlation with caloric and vestibular evoked myogenic potential (VEMP) test results 7
False positives can occur in:
- Elderly patients with normal age-related sensory decline
- Patients with anxiety or fear of falling
- Those with musculoskeletal limitations
False negatives can occur in:
- Mild proprioceptive deficits
- Well-compensated vestibular disorders
When to Pursue Further Testing
Consider additional evaluation when:
- Romberg test is positive with no clear cause
- Symptoms persist despite normal Romberg test
- Atypical features are present (asymmetric findings, rapid progression)
Further testing may include:
- Nerve conduction studies/EMG for suspected peripheral neuropathy
- MRI of brain/spine for suspected central pathology
- Vestibular function tests (HINTS examination, VNG) for suspected vestibular disorders 5
Bottom Line
The Romberg test remains a valuable clinical tool for initial assessment of balance disorders, particularly for identifying sensory ataxia. However, it should be interpreted within the context of the complete neurological examination and supplemented with more specific tests when indicated.