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== Purpose<br>  ==
== Purpose<br>  ==


The Romberg test is used to demonstrate the effects of posterior column disease upon human upright postural control. Posterior column disease contains a selectively damage by tabes dorsalis neurosyphilis. Physiotherapists use the Romberg test for testing [[Proprioception|proprioception ]] influences.
The Romberg test is used to demonstrate the effects of posterior column disease upon human upright postural control. Posterior column disease involves selective damaging of the posterior column, known as tabes dorsalis neurosyphilis. The Romberg test is used by physiotherapists for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.  


The Romberg test has been used with little changes for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.
A patient who has a problem with [[proprioception]] can still maintain balance by compensating with vestibular function and vision. In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign.  


A patient who has a problem with proprioception can still maintain balance by using vestibular function and vision. In the Romberg test, the patient is stood up and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign.  
The Romberg test was first described in 1846 and was originally described for the condition tabes dorsalis. Before performing the Romberg test, it is necessary to test other aspects of the patient's balance when potential issues with ataxia or disequilibrium are present. Often, proprioceptive challenges are not the first problems faced by this population. Sometimes, it is more simple. It is important to first assess other aspects of balance impairment in order to rule out confounding factors that could lead to a false positive test<ref name="Goebel">Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 2008.</ref><ref name="Black">Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.</ref>.  


== Epidemiology/Etiology<br>  ==
== Clinically Relevant Anatomy<br>  ==


The Romberg test was first described in 1846 and was originally described for tabes dorsalis. Before we can use the Romberg test, it is necessary to test other aspects of the balance when we have to deal with people with ataxia or disequilibrium. Often proprioception influences are not the first problems these people are facing. Sometimes it is more simple. It is obvious we have to make sure that we don’t use the Romberg test before other aspects are tested. If we execute the test, it is possible that we make the wrong conclusion and that the test is false positive<ref name="Goebel">Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams &amp;amp;amp;amp;amp; Wilkins, 2008.</ref><ref name="Black">Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.</ref>.  
There are three sensory systems that provide input to the cerebellum to maintain truncal stability when the eyes are open:
 
#Vision
#[[Proprioception|Proprioception]]
#Vestibular sense.
 
Only two of the three systems are needed to maintain balance. When visual input is removed, instability due to lack of vision can be teased apart from other sensory impairments. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain the standing position, even when the eyes are open. Note that instability can also be seen with lesions in other parts of the nervous system, such as the upper or lower motor neurons, or the basal ganglia<ref name="Blumenfeld">Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).</ref><ref name="Zelczak">Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).</ref>.  


== Technique<br>  ==
== Technique<br>  ==


=== The normal Romberg test  ===
=== The Original Romberg test  ===
 
The test is performed as follows. The patient has to remove his shoes and stand with his two feet together ([[Picture 1]]). The arms are held next to the body or crossed in front of the body. It is easier to hold the arms extended. The clinician first observes with eyes open and subsequently with eyes closed. The patient tries to maintain his balance. It is essential that the observer stands close to the patient to prevent the potential injury if the patient falls. Note that it is also important when patients close their eyes, they can’t orientate themselves by light, sense or sound, this could influence the test result and cause a false positive result. The only way to score a Romberg test is to count the seconds a patient can stand with the eyes closed. In literature there are no other options for scoring a Romberg test found. To make the Romberg test a little more difficult, the observer has the possibility to disturb the balance of the tested person. In that way is more difficult to maintain balance. An important issue for the observer is that they do not exaggerate. A Romberg test can also be used as follow-up for people with balance and/or proprioception deficits by comparing several tests with each other. When we notice a patient is able to stand for longer periods of time with the eyes closed, this patient’s balance and proprioception deficits are decreased<ref name="Goebel" /><ref name="Johnson">Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.</ref><ref name="Black" /><ref name="Brinkman">Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.</ref>.


<br>There are three sensory systems provide input to the cerebellum to maintain truncal stability when our eyes are open. These are vision, [[Proprioception|proprioception]], and vestibular sense. Only two of the tree systems are needed to maintain balance. When visual input is removed and instability can be brought out. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position, even when their eyes are open. Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia<ref name="Blumenfeld">Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).</ref><ref name="Zelczak">Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).</ref>.<br>Legend of picture 1: [http://www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm http://www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm] Figure 1
The test is performed as follows:  


<span id="1358974803209S" style="display: none;">&nbsp;</span>Obviously the Romberg test is positive when the tested person is not able to maintain balance with their eyes closed. Losing balance can be determined by an increased body sway, placing one foot in the direction of the fall or even falling.  
#The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
#The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
#The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.


<br>  
<br>  


Film: Noroexam.com - Romberg Test [6] <br>Film: [http://www.youtube.com/watch?v=YBQNwvWgREU http://www.youtube.com/watch?v=YBQNwvWgREU] [9]  
[[Image:Romberg.jpg|243x257px]]  


<br>
The literature does not report alternative methods for scoring a Romberg test.


=== The sharpened or tandem Romberg test ===
To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. It is important that the clinician does not exaggerate the perturbation.


The sharpened or tandem Romberg test is a variation of the original test. The implementation is mostly the same. For this second test, the patient has to place his feet in heel-to-toe position, with one foot directly in front of the other, like we sit on a tandem ([[Picture 2]]). Same routine as with the normal Romberg test: we execute the test first with eyes open and then with eyes closed. The patient crosses his arms over his chest, and the open palm of the hand lies on the opposite shoulder. The person also divides his weight over both his feet and holds his chin parallel with the floor<ref name="Johnson" /><ref name="Black" />. <br>Some persons with obesities, and also older persons may not be able to stand in this position for more than 10 seconds. For these persons the Romberg test doesn’t show much about problems with proprioception or the [[Vestibulo spinal|vestibulospinal system]]<ref name="Goebel" />.<br>
A Romberg test can also be used as follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.  


Legend of picture 2: [http://www.studyblue.com/notes/note/n/ge1-05-falls-dizziness-and-syncope/deck/3222585 http://www.studyblue.com/notes/note/n/ge1-05-falls-dizziness-and-syncope/deck/3222585]&nbsp;
If the clinician observes that the patient is able to stand for longer periods of time with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have decreased<ref name="Goebel" /><ref name="Johnson">Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.</ref><ref name="Black" /><ref name="Brinkman">Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.</ref>.


Film: [http://www.youtube.com/watch?v=NS6XtWFbqjc http://www.youtube.com/watch?v=NS6XtWFbqjc] [10]
The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.  


<br>  
<br>  
{{#ev:youtube|YBQNwvWgREU|300}}


<br>  
<br>  


[[Picture 1]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Romberg.jpg|243x257px]] [[Picture 2]] [[Image:Romberg 2.jpg|369x224px]]  
=== The Sharpened or Tandem Romberg test  ===
 
The Sharpened or Tandem Romberg test is a variation of the original test. The implementation is mostly the same. For this second test, the patient has to place his feet in heel-to-toe position, with one foot directly in front of the other. As with the original Romberg test, the assessment is performed first with eyes open and then with eyes closed. The patient crosses his arms over his chest, and the open palm of the hand lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel with the floor<ref name="Johnson" /><ref name="Black" />. <br>
 
[[Image:Romberg 2.jpg|369x224px]]  
 
Obese and older individuals may be unable to stand in this position for prolonged periods of time. For these populations, the Romberg test does not exclusively demonstrate propropioceptive impairments in comparison to other confounding factors<ref name="Goebel" />.<br>


== Experiences<br>  ==
{{#ev:youtube|NS6XtWFbqjc|300}}


Although a patient with an acute peripheral [[Vestibular lesion|vestibular lesion]] is usually inclined to move towards the side of the problem. It has been shown that chronic vestibular damage (at least partial compensation) does not produce defects in the standard Romberg test. Also a person with proprioceptive problems, accessory to tabes dorsalis couldn’t stand with the eyes closed and feet together<ref name="Goebel" />.<br>Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the normal Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify [[Ataxia|ataxia]]<ref name="Goebel" />.<br>Subject, sex, and age did not have a statistically significant difference for normal subjects between the ages of 20 and 49 years, only the Romberg sharpened test with eyes open provided a significant difference (p&lt; 0.05) between men and women. They also encountered greater instability in subjects less than 20 and more than 50 years of age. When comparing a young and an old cohort, there is a significant difference in performance.
== Variables<br> ==


== Significance<br> ==
Although a patient with an acute peripheral vestibular lesion is usually inclined to move towards the side of the problem, it has been shown that chronic vestibular damage (at least partial compensation) does not produce deficits in the standard Romberg test. As well, an individual with proprioceptive problems, accessory to tabes dorsalis, would be unable to stand with the eyes closed and feet together<ref name="Goebel" />.


Increasing difficulty of the tandem Romberg test for patients was not helpful because it also made the tests more difficult to perform for controls with no symptoms of vestibular disease. It will also be harder to evaluate the test results.By decreasing performance times on the modified on the modified Romberg, there was a concomitant rise in the risk of falling<ref name="Black" /><ref name="Longridge">Longridge NS. Clinical romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.</ref><ref name="Agrawal">Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol  Neurotol, 2011 Oct,32(8):1309–1311.</ref>.&nbsp;
Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the original Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify ataxia<ref name="Goebel" />.  


== Key research<br>  ==
Subject, sex, and age do not create a statistically significant difference between normal subjects between the ages of 20 and 49 years; only the Romberg sharpened test with eyes open provided a significant difference (p&lt; 0.05) between men and women. Greater instability in subjects less than 20 and more than 50 years of age was also exhibited. When comparing a young and an old cohort, there is a significant difference in performance.


Book: Joel A. Goebel, Practical Management of the Dizzy Patient, 2008<br>Article: F. Owen Black, Normal Subject Postural Sway during the Romberg Test, Americal Journal of OtoJaryngology, 1982,&nbsp; 3, 309-318<br>
Increasing the difficulty of the tandem Romberg test for patients is not helpful because it also makes the tests more difficult to perform for controls with no symptoms of vestibular disease. This would also make it harder to evaluate the test results. Decreased performance times on the modified Romberg is associated with a concomitant rise in the risk of falling<ref name="Black" /><ref name="Longridge">Longridge NS. Clinical romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.</ref><ref name="Agrawal">Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol  Neurotol, 2011 Oct,32(8):1309–1311.</ref>.&nbsp;  


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==

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Purpose
[edit | edit source]

The Romberg test is used to demonstrate the effects of posterior column disease upon human upright postural control. Posterior column disease involves selective damaging of the posterior column, known as tabes dorsalis neurosyphilis. The Romberg test is used by physiotherapists for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.

A patient who has a problem with proprioception can still maintain balance by compensating with vestibular function and vision. In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign.

The Romberg test was first described in 1846 and was originally described for the condition tabes dorsalis. Before performing the Romberg test, it is necessary to test other aspects of the patient's balance when potential issues with ataxia or disequilibrium are present. Often, proprioceptive challenges are not the first problems faced by this population. Sometimes, it is more simple. It is important to first assess other aspects of balance impairment in order to rule out confounding factors that could lead to a false positive test[1][2].

Clinically Relevant Anatomy
[edit | edit source]

There are three sensory systems that provide input to the cerebellum to maintain truncal stability when the eyes are open:

  1. Vision
  2. Proprioception
  3. Vestibular sense.

Only two of the three systems are needed to maintain balance. When visual input is removed, instability due to lack of vision can be teased apart from other sensory impairments. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain the standing position, even when the eyes are open. Note that instability can also be seen with lesions in other parts of the nervous system, such as the upper or lower motor neurons, or the basal ganglia[3][4].

Technique
[edit | edit source]

The Original Romberg test[edit | edit source]

The test is performed as follows:

  1. The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
  2. The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
  3. The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.


Romberg.jpg

The literature does not report alternative methods for scoring a Romberg test.

To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. It is important that the clinician does not exaggerate the perturbation.

A Romberg test can also be used as follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.

If the clinician observes that the patient is able to stand for longer periods of time with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have decreased[1][5][2][6].

The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.



The Sharpened or Tandem Romberg test[edit | edit source]

The Sharpened or Tandem Romberg test is a variation of the original test. The implementation is mostly the same. For this second test, the patient has to place his feet in heel-to-toe position, with one foot directly in front of the other. As with the original Romberg test, the assessment is performed first with eyes open and then with eyes closed. The patient crosses his arms over his chest, and the open palm of the hand lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel with the floor[5][2].

Romberg 2.jpg

Obese and older individuals may be unable to stand in this position for prolonged periods of time. For these populations, the Romberg test does not exclusively demonstrate propropioceptive impairments in comparison to other confounding factors[1].

Variables
[edit | edit source]

Although a patient with an acute peripheral vestibular lesion is usually inclined to move towards the side of the problem, it has been shown that chronic vestibular damage (at least partial compensation) does not produce deficits in the standard Romberg test. As well, an individual with proprioceptive problems, accessory to tabes dorsalis, would be unable to stand with the eyes closed and feet together[1].

Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the original Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify ataxia[1].

Subject, sex, and age do not create a statistically significant difference between normal subjects between the ages of 20 and 49 years; only the Romberg sharpened test with eyes open provided a significant difference (p< 0.05) between men and women. Greater instability in subjects less than 20 and more than 50 years of age was also exhibited. When comparing a young and an old cohort, there is a significant difference in performance.

Increasing the difficulty of the tandem Romberg test for patients is not helpful because it also makes the tests more difficult to perform for controls with no symptoms of vestibular disease. This would also make it harder to evaluate the test results. Decreased performance times on the modified Romberg is associated with a concomitant rise in the risk of falling[2][7][8]. 

Recent Related Research (from Pubmed)[edit | edit source]


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References
[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 2008.
  2. ↑ 2.0 2.1 2.2 2.3 Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.
  3. ↑ Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).
  4. ↑ Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).
  5. ↑ 5.0 5.1 Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.
  6. ↑ Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.
  7. ↑ Longridge NS. Clinical romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.
  8. ↑ Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol Neurotol, 2011 Oct,32(8):1309–1311.


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