What is the significance of the balance sign (Romberg sign) in a patient?

From the Guidelines

The balance sign, also known as the drift test, is a neurological finding where a patient's arm or leg drifts downward when held in an extended position with eyes closed, indicating subtle weakness, and is particularly useful for detecting mild hemiparesis that might not be obvious during routine strength testing. This test is commonly used in stroke assessment, but can also indicate other conditions affecting the corticospinal tract, such as multiple sclerosis or spinal cord injuries 1. To test for this sign, ask the patient to extend both arms forward with palms up and eyes closed for about 20-30 seconds. If one limb drifts downward, pronates (palm turns down), or shows finger spreading, this suggests weakness on that side, often due to an upper motor neuron lesion in the contralateral hemisphere of the brain.

When performing this test, ensure the patient is seated comfortably and understand that fatigue or inattention can sometimes cause false positive results. The balance sign is an important tool in the neurological examination, as it can help identify subtle deficits in motor control, which can be an early indicator of neurological disease. In the context of Meniere's disease, balance and vestibular function are critical components of the clinical evaluation, and the balance sign can be a useful adjunct to other tests of vestibular function, such as the Dix-Hallpike test or the caloric test 1.

Some key points to consider when evaluating balance and vestibular function in patients with Meniere's disease include:

• The importance of a thorough clinical history and physical examination to identify underlying causes of vestibular symptoms
• The use of standardized tests and measures to assess vestibular function and balance
• The need for individualized treatment plans that take into account the patient's specific symptoms and needs
• The importance of ongoing monitoring and follow-up to assess treatment response and adjust the treatment plan as needed 1.

Overall, the balance sign is a useful tool in the neurological examination, and can provide important information about subtle deficits in motor control and vestibular function. By combining this test with other evaluations and treatments, clinicians can provide comprehensive care for patients with Meniere's disease and other vestibular disorders.

From the Research

Balance Sign

The concept of balance sign is closely related to vestibular function and rehabilitation.

• Vestibular rehabilitation is an exercise-based treatment program designed to promote vestibular adaptation and substitution, which can help improve balance and reduce dizziness 2.
• The goals of vestibular rehabilitation therapy (VRT) include enhancing gaze stability, postural stability, improving vertigo, and improving activities of daily living 2.
• Key exercises for VRT involve head-eye movements, maintaining balance with a reduced support base, and exposing patients to various sensory and motor environments 2.
• Studies have shown that vestibular rehabilitation can be effective in improving balance and reducing dizziness in patients with chronic vestibular symptoms 3, 4.
• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish between peripheral and central etiologies of vestibular dysfunction, which is important for determining the appropriate treatment approach 5.

Vestibular Rehabilitation

• Vestibular rehabilitation is indicated for any stable but poorly compensated vestibular lesion, regardless of the patient's age, cause, and symptom duration and intensity 2.
• The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness has been demonstrated in several studies, with benefits including improvement in vertigo symptom scale, fall risk, balance, and emotional status 3.
• Vestibular rehabilitation can be used to treat various vestibular disorders, including benign paroxysmal positional vertigo (BPPV), unilateral vestibular loss or hypofunction, and bilateral vestibular loss/hypofunction 6.

Treatment Approaches

• Treatment options for patients with dizziness include medication, rehabilitation with physical therapy, surgery, counseling, and reassurance 6.
• Vestibular suppressant medications and vestibular rehabilitation can be used to relieve symptoms of vestibular neuritis 5.
• The Epley maneuver is a canalith repositioning procedure that can be used to treat BPPV 5.