should be included during most neurologic examinations. It should be
performed particularly on all patients who have a complaint of balance
or gait dysfunction or falls, in patients with neuropathies, or in any
other patient in whom proprioceptive dysfunction is suspected.
ability to maintain a stable upright stance depends on the intactness
of two neurologic mechanisms:
Balance (cerebellar and vestibular function)
Sensation (vision or proprioception) to tell you where your feet and legs are in relationship to the ground
stable when upright. When your eyes are open, vision alone is enough to
give you the sensory component of the equation. When your eyes are
closed, the only way to tell where your feet and legs are in relation
to the ground is through proprioceptive (joint position) sense.
Ask the patient to stand with his or her
eyes open and observe that the patient can stand without falling. It’s
not imperative that the feet be touching, but it is best to have the
feet as close together as possible as long as the patient can still
maintain the upward stance with his or her eyes open.
Ask the patient to close his or her eyes.
Observe whether the patient can remain
standing or will fall with his or her eyes closed. You don’t need to
observe for long, approximately 5 seconds at most.
If the patient would clearly fall without
your assistance, help the patient avoid falling. If the patient sways
but appears to be able to maintain balance, try to avoid assisting the
patient unless it is clear that a fall is imminent. In other words,
attempt to observe the patient’s response; try not to be too quick to
assume the patient will fall, but don’t let the patient fall!
The abnormal finding on the Romberg test
is the Romberg sign itself. Patients with a Romberg sign are able to
stand without falling with their eyes open but are unsteady and tend to
fall soon after their eyes are closed.
The finding of a Romberg sign suggests
impairment of joint position (proprioceptive) sensation in the lower
extremities. This is because patients with poor or absent
proprioceptive sensation lose the entire sensory component of their
ability to maintain the upright stance when their eyes are closed.
The impairment of proprioceptive
sensation suggested by a Romberg sign could be due to peripheral
neuropathy or posterior column dysfunction within the spinal cord. When
a Romberg sign is seen, it is likely that other signs of this
dysfunction will also have been found, such as severe vibratory loss in
the lower extremities and abnormal position sense testing in the toes
or feet (see Chapter 30, Examination of
Vibration and Position Sensation). If the proprioceptive dysfunction is
severe enough, patients with a Romberg sign might even have the finding
of a sensory ataxia on gait testing (see Chapter 39, Examination of Gait).
Patients who sway and catch themselves,
particularly at the hips, but regain balance and avoid falling while
keeping their eyes closed, do not have a Romberg sign and, in fact,
have shown you that they have excellent proprioception.
Although often reported as present
(because of inaccurately interpreting the patient’s swaying and
catching him- or herself as a Romberg sign), the Romberg sign is
actually an uncommon finding, because dysfunction of proprioceptive
sensation severe enough to cause a Romberg sign is rare.
Some patients give a history that implies
the same information about proprioceptive dysfunction that a Romberg
sign does. Patients who describe unsteadiness or falling in situations
in which they stand with their eyes closed (such as when walking to the
bathroom at night or when standing in the shower) are describing a
self-tested Romberg sign, and they are likely to have proprioceptive
dysfunction as the cause of their symptoms, regardless of whether they
have a Romberg sign on examination.