What is the Romberg test?

What is the Romberg Test?

The Romberg test is a bedside neurological examination that assesses dorsal-column proprioceptive function by asking the patient to stand with feet together, first with eyes open and then with eyes closed—a positive result (loss of balance only when eyes are closed) indicates dysfunction of the spinal cord's dorsal columns or peripheral proprioceptive pathways, not cerebellar disease. 1, 2

Test Procedure and Execution

• The patient stands with feet together and arms at their sides in a safe environment where the examiner can catch them if they fall 2
• The examiner should position themselves close enough to prevent injury and be prepared to provide support if significant instability occurs 2
• Observe the patient for at least 20-30 seconds with eyes closed to allow adequate time for instability to manifest 2
• The test environment must be safe to prevent falls, particularly in patients with baseline instability 2

Interpretation: What a Positive Result Means

• A positive Romberg sign occurs when balance is lost only with eyes closed, demonstrating that the patient relies on visual input to compensate for impaired proprioception 1, 2
• This pattern specifically indicates dysfunction of the dorsal-column proprioceptive pathways of the spinal cord, which transmit peripheral proprioceptive information to the brain 1, 2
• A positive Romberg excludes cerebellar disease as the primary cause—cerebellar ataxia produces instability regardless of whether eyes are open or closed 1, 3
• The test distinguishes sensory ataxia (positive Romberg) from cerebellar ataxia (Romberg-negative, with instability persisting with eyes open) 1, 3

Clinical Significance and Differential Diagnosis

The Romberg Test Identifies Sensory Pathway Dysfunction

• The test evaluates the function of the dorsal columns of the spinal cord, which are responsible for proprioception 2
• A positive result indicates a deficit in proprioceptive pathways, particularly in the dorsal columns or peripheral sensory nerves 2
• Sensory ataxia results from damage to dorsal root ganglia, dorsal columns, or peripheral sensory nerves—not the cerebellum 3

Key Causes of a Positive Romberg Sign

Spinal cord pathology (dorsal-column lesions):

• Subacute combined degeneration due to vitamin B12 deficiency is the most critical reversible cause that must be identified early 1, 2
• Copper-deficiency myelopathy mimics B12 deficiency but requires distinct treatment 1, 2
• Multiple sclerosis involving the posterior columns can produce a positive Romberg 1
• Spinal cord compression from tumor or degenerative disease frequently presents with a positive sign 1

Peripheral sensory neuropathies:

• Diabetic polyneuropathy with large-fiber sensory loss may generate a positive Romberg 1
• Chronic inflammatory demyelinating polyneuropathy (CIDP) can affect proprioception 1
• Chemotherapy-induced peripheral neuropathy (platinum agents, taxanes, vinca alkaloids) can impair dorsal-column function 1

Metabolic and infectious causes:

• Neurosyphilis (tabes dorsalis) produces a classic positive Romberg sign 1, 3
• HIV-associated myelopathy is a recognized cause of dorsal-column dysfunction 1

Variants and Advanced Applications

Vestibular Romberg Test (Foam Romberg)

• Standing on compliant foam with eyes closed is more a test of vestibular function than proprioceptive function 4
• Trunk sway on foam with eyes closed is significantly greater in vestibulopathy than in sensory neuropathy 5, 6
• A refined vestibular Romberg quotient—comparing standing on foam versus firm support with eyes closed—can reliably distinguish vestibulopathy from sensory ataxia 6
• Conversely, patients with sensory neuropathy show greater imbalance on firm ground (eyes closed) than on foam 5

Walking Romberg Test

• The walking Romberg test asks patients to walk 5 meters with eyes open, then repeat with eyes closed 7
• Swaying, instability, or inability to complete the walk with eyes closed is interpreted as positive 7
• The walking Romberg is more sensitive than the traditional Romberg test for detecting proprioceptive gait deficits, particularly in cervical myelopathy (positive in 74.5% vs. 17% for traditional Romberg) 7

Critical Pitfalls to Avoid

• Do not attribute a positive Romberg to cerebellar disease—cerebellar ataxia yields instability with eyes both open and closed (Romberg-negative pattern) 1, 2, 3
• Prompt assessment of vitamin B12 is essential—subacute combined degeneration progresses rapidly but is reversible with early therapy 1, 2
• Evaluate copper status when B12 deficiency is suspected, as copper deficiency mimics B12 deficiency but requires separate treatment 1, 2
• Obtain a thorough medication history, as many drugs (metronidazole, isoniazid, chemotherapeutic agents) cause sensory neuropathy 1, 2
• The Romberg test should be interpreted within the comprehensive context of the broader neurological examination, not as an isolated finding 8

Safety Considerations

• Ensure the testing environment is safe to prevent injury, and position close enough to catch the patient if they begin to fall 2
• Consider using additional assistance for obese patients or those with significant baseline instability 2
• Avoid the Romberg test in patients with severe cervical stenosis, vertebrobasilar insufficiency, or significant vascular disease where rapid position changes pose risk 2