What is Romberg's test and how is it used to assess balance and proprioception in patients, particularly older adults or those with neurological conditions?

Romberg's Test: Clinical Explanation and Application

What the Test Measures

Romberg's test evaluates the function of the dorsal columns of the spinal cord, which are responsible for proprioception (position sense), and helps distinguish between sensory ataxia and cerebellar ataxia. 1

The test relies on the principle that normal standing balance requires three sensory inputs: vision, proprioception, and vestibular function. 2 When vision is removed by closing the eyes, patients with impaired proprioception lose a critical compensatory mechanism and become unstable, while those with intact proprioception remain stable. 1

How to Perform the Test Properly

Standard Technique

• Position the patient standing with feet together and arms at their sides. 1
• Ensure the testing environment is safe to prevent falls, and position yourself close enough to catch the patient if they begin to fall. 1
• Observe the patient for at least 20-30 seconds with their eyes closed. 1
• Be prepared to provide immediate support if significant instability occurs, particularly when the patient's eyes are closed. 1

Safety Precautions

• Consider using additional assistance for obese patients or those with significant baseline instability. 1
• Avoid the Romberg test in patients with severe cervical stenosis, vertebrobasilar insufficiency, or significant vascular disease where rapid position changes pose risk. 1

Interpretation of Results

Positive Romberg Sign

A positive test occurs when the patient demonstrates significant instability or falls only when their eyes are closed, indicating a deficit in proprioceptive pathways, particularly in the dorsal columns of the spinal cord. 1, 3 This suggests sensory ataxia rather than cerebellar dysfunction. 3

Negative Romberg Sign

Unsteadiness that does NOT significantly worsen with eye closure indicates cerebellar ataxia, not sensory ataxia. 3 In cerebellar disease, patients are unstable with eyes both open and closed because the problem is not with sensory input but with motor coordination. 3

Clinical Applications

Distinguishing Types of Ataxia

• Sensory ataxia (positive Romberg): Instability worsens dramatically with eyes closed due to dorsal column dysfunction from conditions like peripheral neuropathy, tabes dorsalis, or cervical myelopathy. 1, 3
• Cerebellar ataxia (negative Romberg): Instability persists regardless of visual input, with characteristic findings including wide-based gait, dysmetria, dysdiadochokinesia, truncal instability, dysarthria, and nystagmus. 3
• Vestibular ataxia: Standing with eyes closed on a compliant (foam) surface rather than a firm surface is more a test of vestibular than proprioceptive function. 2

Specific Clinical Scenarios

In cervical myelopathy, a "walking Romberg" variant (asking patients to walk 5 meters with eyes closed) is more sensitive than the traditional standing test, detecting proprioceptive gait deficits in 74.5% of patients versus only 34% with the traditional test. 4 The combination of Hoffman's reflex and walking Romberg sign was positive in 96% of cervical myelopathy patients. 4

In patients with pure sensory neuropathy, quantitative force plate measurements show approximately a twofold increase in body sway when vision is removed (Romberg quotient around 2). 5 However, these patients often display heightened body sway even with eyes open, which can diminish the diagnostic contrast of the test. 5

Common Pitfalls and Limitations

Technical Limitations

• The test cannot be properly performed in patients with cerebellar ataxia because unsteadiness is present regardless of visual input. 3
• Subjective interpretation can be problematic—quantitative measurements using force plates show that even experienced clinicians may miss subtle balance deficits. 6
• The traditional standing test may miss proprioceptive deficits that become apparent only during walking. 4

Diagnostic Considerations

• Do not mistake weakness or hypotonia for ataxia, particularly in children. 3
• Be aware of "pseudoataxia" from functional disorders that can mimic organic disease. 3
• Recognize that lurching gait triggered by head rotation indicates vestibular rather than cerebellar dysfunction. 3
• The Romberg test should be interpreted within the comprehensive context of the broader neurological examination and electrodiagnosis of peripheral nerve function, not in isolation. 5

Enhanced Testing Approaches

For mass screening in elderly populations at risk of falls, instrumented Romberg testing using force plates can identify balance deficits and determine their likely origin (central, vestibular, visual, proprioceptive, or functional). 7 This approach proved rapid, non-invasive, and effective in identifying 145 dysfunctional subjects among 551 elderly females. 7

In patients with cervical spondylotic myelopathy, quantitative force plate measurements during Romberg testing show significantly larger changes in total sway area (14.18 vs 0.02 cm²) and average speed (2.07 vs 0.23 cm/s) compared to normal controls. 6 The presence of long tract signs or cord compression on imaging correlates with worse balance measurements. 6