Romberg's test

This article is about the neurological examination method. For the method of numerical integration, see Romberg's method.
Spinal cord tracts. Blue are afferents; red are efferents

Romberg's test, Romberg's sign, or the Romberg maneuver is a test used in an exam of neurological function, and also as a test for drunken driving. The exam is based on the premise that a person requires at least two of the three following senses to maintain balance while standing: proprioception (the ability to know one's body in space); vestibular function (the ability to know one's head position in space); and vision (which can be used to monitor [and adjust for] changes in body position).

A patient who has a problem with proprioception can still maintain balance by using vestibular function and vision. In the Romberg test, the standing patient is asked to close his or her eyes. A loss of balance is interpreted as a positive Romberg's test.

The Romberg test is a test of the body's sense of positioning (proprioception), which requires healthy functioning of the dorsal columns of the spinal cord.[1]

The Romberg test is used to investigate the cause of loss of motor coordination (ataxia). A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception. If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature, that is, depending on localized cerebellar dysfunction instead.

It is used as an indicator for possible alcohol or drug impaired driving and neurological decompression sickness.[2][3] When used to test impaired driving, the test is performed with the subject estimating 30 seconds in his head. This is used to gauge the subject's internal clock and can be an indicator of stimulant or depressant use.

Procedure

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 himself or herself. 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 becomes more unsteady with eyes closed.

The essential features of the test are as follows:

  1. the subject stands with feet together, eyes open and hands by the sides.
  2. 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 the patient sways or falls while the patient's eyes are closed.[4]

Patients with a positive result are said to demonstrate Romberg's sign or Rombergism. They can also be described as Romberg's positive. The basis of this test is that balance comes from the combination of several neurological systems, namely proprioception, vestibular input, and vision. If any two of these systems are working the person should be able to demonstrate a fair degree of balance. The key to the test is that vision is taken away by asking the patient to close their eyes. This leaves only two of the three systems remaining and if there is a vestibular disorder (labyrinthine) or a sensory disorder (proprioceptive dysfunction) the patient will become much more imbalanced.

Physiology

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

The main sensory inputs are:

  1. Joint position sense (proprioception), carried in the dorsal columns of the spinal cord;
  2. Vision
  3. Vestibular apparatus

Crucially, the brain can obtain sufficient information to maintain balance if any two of the three systems are intact.

Sensorimotor integration is carried out by the cerebellum and by the dorsal column-medial lemniscus tract. The motor pathway is the corticospinal (pyramidal) tract and the medial and lateral vestibular tracts.

The first stage of the test (standing with the eyes open with hands on hips), demonstrates that at least two of the three sensory pathways is intact, and that sensorimotor integration and the motor pathway are functioning. The patient must stand unsupported with eyes open and hands on hips for 30 seconds. If the patient takes a step or removes a hand from the hip, the timer is stopped. The patient may make two attempts to complete the 30 seconds.

Similar to the sensory organization test, the visual pathway would then be removed by closing the eyes. If the proprioceptive and vestibular pathways are intact, balance will be maintained. But if proprioception is defective, two of the sensory inputs will be absent and the patient will sway then fall. Similar to the Romberg Test, the patient must stand unsupported with eyes closed and hands on hips for 30 seconds. The patient may make two attempts to complete the 30 seconds. [3]

A variation of the Romberg Test, the Sharpened Romberg Test, consists of narrowing the patient’s base of support by placing feet in a heel to toe position. Nonetheless, test instructions do not specify which foot, preferred or non-preferred, should be placed in front of the other. The patient should be instructed to keep hands on hips for the whole 30 seconds. If the patient takes a step or removes hands from hips, the timer is stopped and the patient may attempt the test one more time. [5] The sharpened Romberg does have an early learning effect that will plateau between the third and fourth attempts.[3]

Positive Romberg

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

Romberg and cerebellar function

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;[6] 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. A positive Romberg's test has been shown to be 90% sensitive for lumbar spinal stenosis.[7]

History

The test was named after the German neurologist Moritz Heinrich Romberg[1] (1795-1873), who also gave his name to Parry-Romberg syndrome and Howship-Romberg sign.

See also

References

  1. 1 2 3 Khasnis A, Gokula RM (1 April 2003). "Romberg's test". Journal of Postgraduate Medicine 49 (2): 169–72. PMID 12867698.
  2. ↑ Bridge, Carl J. (1972). Alcoholism and Driving. Charles C Thomas. ISBN 0-398-02243-7.
  3. 1 2 3 Lee CT (September 1998). "Sharpening the Sharpened Romberg". SPUMS Journal 28 (3): 125–32. PMID 11542272.
  4. ↑ Lanska DJ, Goetz CG (October 2000). "Romberg's sign: development, adoption, and adaptation in the 19th century". Neurology 55 (8): 1201–6. doi:10.1212/wnl.55.8.1201. PMID 11071500.
  5. ↑ E. Panaretaki, S. Kostadakos, V. Hatzitaki, G. Grouios. "Standing with one foot in front of the other (sharpened romberg position) : footedness effect". Centro Esportivo Virtual - CEV.
  6. ↑ Blumenfeld H. Romberg Test. neuroexam.com. URL: http://www.neuroexam.com/content.php?p=37. Accessed on: April 22, 2007.
  7. ↑ Katz JN, Harris MB (February 2008). "Clinical practice. Lumbar spinal stenosis". N. Engl. J. Med. 358 (8): 818–25. doi:10.1056/NEJMcp0708097. PMID 18287604.
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