What is the procedure for performing a Romberg test?

How to Perform the Romberg Test

Test Setup and Patient Positioning

The Romberg test requires the patient to stand with feet together, arms at their sides (or on hips), in a safe environment where falls can be prevented. 1

• Position the patient standing upright with feet placed together (touching or nearly touching) 1
• Arms should be positioned at the patient's sides or placed on their hips 2, 1
• Ensure you are positioned close enough to catch the patient if they begin to fall 2
• The testing environment should be quiet and safe to prevent injury 1

Test Execution

The test involves observing the patient for 20-30 seconds with eyes open, then repeating with eyes closed for the same duration. 1

Phase 1: Eyes Open Baseline

• Have the patient stand in the described position with eyes open 1
• Observe for baseline stability and any existing balance difficulties 1
• This establishes whether instability exists independent of visual input 3

Phase 2: Eyes Closed Testing

• Instruct the patient to close their eyes while maintaining the same stance 1, 4
• Observe for at least 20-30 seconds 1
• Watch for swaying, loss of balance, or inability to maintain position 4
• Be prepared to catch the patient if significant instability occurs 2, 1

Test Interpretation

A positive Romberg sign occurs when the patient demonstrates significant worsening of balance or instability specifically when the eyes are closed, indicating proprioceptive pathway dysfunction in the dorsal columns of the spinal cord. 1, 3

Positive Test Criteria

• Marked increase in body sway when eyes are closed compared to eyes open 1, 5
• Loss of balance or near-falling that occurs only with eye closure 1, 3
• Inability to maintain the standing position with eyes closed 4

Clinical Significance by Pattern

• Sensory ataxia (positive Romberg): Significant instability only with eyes closed indicates dorsal column dysfunction 1, 3
• Cerebellar ataxia (negative Romberg): Instability present with both eyes open and closed, without significant worsening when eyes close 3
• Vestibular dysfunction: May show instability on compliant surfaces even with eyes open 5

Important Clinical Considerations

Enhanced Testing Variations

• Walking Romberg test: Have the patient walk 5 meters with eyes open, then repeat with eyes closed—this detects proprioceptive deficits in 74.5% of cervical myelopathy cases versus only 34% with traditional Romberg 4
• Compliant surface testing: Standing on foam or compliant surfaces with eyes closed tests vestibular function more than proprioception 5

Common Pitfalls to Avoid

• Do not confuse cerebellar ataxia (unstable with eyes open) with sensory ataxia (unstable only with eyes closed) 3
• Ensure adequate observation time of 20-30 seconds, as instability may not be immediately apparent 1
• Do not perform the test in patients with severe baseline instability who cannot stand safely 2
• Recognize that weakness or hypotonia can mimic ataxia and should be distinguished by careful examination 3

Safety Precautions

• Always position yourself to catch the patient if they fall 2, 1
• Consider using additional assistance for obese patients or those with significant baseline instability 2
• Avoid in patients with severe cervical stenosis, vertebrobasilar insufficiency, or significant vascular disease where rapid position changes pose risk 2