Romberg's test

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Romberg's test is a neurological test of joint position sense (proprioception). It is positive in patients with sensory ataxia. It is sometimes used as an indicator for a possible drunk driving.

More properly it is a test for loss of position sense (proprioception and semi-circular canals in the middle ear) or sensory ataxia in the legs, and not a test for cerebellar ataxia.

[edit] History

The test was named after the German neurologist Moritz Heinrich Romberg (1795-1873) who also gave his name to Parry-Romberg Syndrome.

[edit] The test

Ask the subject to stand erect with feet together and eyes closed. Stand close by as a precaution in order to stop the person from falling over and hurting themselves. Watch the movement of the body in relation to a perpendicular object behind the subject (corner of the room, door, window etc). A positive sign is noted when a swaying, sometimes irregular swaying and even toppling over occurs. The essential feature is that the patient is unsteadier than with open eyes. With severe intoxication a positive Romberg is seen even with open eyes or in the sitting position.

The essential features of the test are as follows:

• First, the subject stands with feet together, eyes open and hands by the sides.
• Second, the subject closes the eyes while the examiner observes for a full minute.

Because the examiner is trying to elicit whether the patient falls when the eyes are closed, it is advisable to stand ready to catch the falling patient. For large subjects, a strong assistant is recommended.

Romberg's test is positive if, and only if, the following two conditions are both met:

• The patient can stand with the eyes open; and
• The patient falls when the eyes are closed.

The test is not positive if either:

• The patient falls when the eyes are open; or
• The patient sways but does not fall when the eyes are closed.

Patients with a positive result are said to demonstrate Romberg's sign or Rombergism. They can also be described as Romberg's positive.

[edit] The principle

Maintaining balance while standing in the stationary position relies on intact sensory pathways, sensorimotor integration centres and motor pathways.

The main sensory inputs are:

• Joint position sense (proprioception), carried in the dorsal columns of the spinal cord;
• Vision

Crucially, the brain can obtain sufficient information to maintain balance if either the visual or the proprioceptive inputs are intact.

Sensorimotor integration is carried out by the cerebellum. The motor pathway is the corticospinal (pyramidal) tract.

The first stage of the test (standing with the eyes open), demonstrates that at least one of the two sensory pathways is intact, and that sensorimotor integration and the motor pathway are intact.

In the second stage, the visual pathway is removed by closing the eyes. If the proprioceptive pathway is intact, balance will be maintained. But if proprioception is defective, both of the sensory inputs will be absent and the patient will sway then fall.

Romberg's test is not a test of cerebellar function, as it is commonly misconstrued. Patients with cerebellar ataxia will generally be unable to balance even with the eyes open: therefore the test cannot proceed beyond the first step and no patient with cerebellar ataxia can correctly be described as Romberg's positive. Rather, Romberg's test is a test of the proprioception receptors and pathways function.

Romberg's test is positive in conditions causing sensory ataxia such as:

• Conditions affecting the sensory nerves (sensory peripheral neuropathies) such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP);
• Conditions affecting the dorsal columns of the spinal cord such as tabes dorsalis