Chapter 7 – Romberg Test
Welcome to the seventh installment of “Inconceivable: medical terms that don’t mean what you think they mean.”
You are evaluating a patient with ataxia. As part of your physical exam, you have the patient ambulate and you notice that she is very unsteady on her feet. You then have the patient stand with her feet together and she is unable to maintain her balance without your assistance. You document “positive Romberg,” but is that accurate?
The Romberg test is a physical exam maneuver used to differentiate between motor (cerebellar) and sensory (dorsal column) ataxia. A positive Romberg test requires worsening of ataxia when a patient closes his or her eyes. Unsteadiness standing with feet together is an objective measure to confirm the patient’s subjective ataxia but is not considered a positive Romberg test.
To correctly perform the test, have the patient stand with feet together and eyes open. Next, have the patient close his or her eyes; this removes the visual input contributing to balance and forces the patient to rely only on proprioception from sensory signals transmitted up the dorsal column of the spinal cord. If the patient fails to maintain balance with eyes closed, the Romberg test is positive, and the patient’s ataxia is likely NOT because of a cerebellar problem. Take note, you will likely not be able to successfully perform the Romberg on patients who have motor ataxia as they will be too unsteady even with eyes open.
Who was Dr. Romberg? Moritz Heinrich Romberg was a German physician born in 1795. He first described his eponymous sign in patients with syphilis suffering from tabes dorsalis. Only later was it noted that it applied to any proprioceptive deficit from the lower extremities. Interestingly, Dr. Romberg was also the first to describe the typical pupillary deficit in tertiary syphilis, before Dr. Douglas Argyll Robertson. Makes you wonder what Romberg did in his free time to make him so interested in syphilis…
A positive Romberg test is a loss of balance when eyes are closed indicating a sensory neuropathy as the etiology for the patient’s ataxia.
Bickley, Lynn S., Peter G. Szilagyi, and Barbara Bates. 2007. Bates’ guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.
Pearce JMS. Romberg and His Sign. European Neurology. 2015, 53: 210–3.