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Romberg Test for Imbalance

Timothy C. Hain, MD Page last modified: May 29, 2016

The Romberg test (not Rhomberg test), is a simple and commonly used method of quantifying balance (Rogers, 1980). It is also very flexible because its difficulty can be adjusted to fit most patient situations. The Romberg test is probably most commonly used by police officers -- who use it to detect imbalance due to alcohol intoxication (a cerebellar disturbance).

Rogers (1980) stated: "In the eponymous test described by Romberg in 1846, the erect patient is asked to close his eyes. If he falls, the test is positive and indicates the presence of a dorsal column lesion. Slight modifications have been described in the test but in all cases, great care must be taken to do it carefully. The test compares the stability of eye-opening with that of eye-closure. A positive test does not indicate vestibular or cerebellar disease". Presently, we would not define a positive as a "fall", as we would not want to take the risk of injury, but rather we would define a positive test as an unintended step.

Herein we will discuss how the Romberg test has developed and is presently used.

The Romberg test can be performed with no equipment at all, making it very suitable for large scale deployment.

Variant Romberg tests are also widely used to test for "sobriety" (Burns, 2003). For example, the "One-leg stand" test, which is part of the "standardized field sobriety test", involves standing with one foot about six inches off the ground and count for 30 seconds. Other subtests include oculomotor testing (gaze nystagmus, pursuit), and the "Walk and Turn" test (9 steps, heel-toe, turn on one foot, and return). The general principle of these tests is to assess for unintended steps taken during a balancing task or walking, while being distracted or with vision denied. One would expect that as these tests all have a large amount of variabilty (see pitfalls section below), these even less standardized tests would be even more variable than the Romberg test, and that it might be difficult to draw inferences from performance on these tests. Additionally, persons with neurological or vestibular impairment, would be expected to fail some of the more difficult variants.

Oddly, variants of Romberg tests are not generally used to test for concussion, such as in sports. Rather there is a reliance on neuropsychological type tests. We find this peculiar as one would think that persons who have imbalance would not be safe to return to play.

Currently there are 4 major variants of the Romberg test.

Romberg Test Variants
Test Difficulty
Eyes Open Regular (EORR) Easy
Eyes closed Regular (ECRR) Harder
Eyes open tandem (EOTR) Harder yet
Eyes closed tandem (ECTR) Very difficult

Sometimes the descriptive term "eyes closed" is changed to "sharpened" (e.g. Fitzgerald et al, 1966). We think this is unfortunate as it does not clearly describe what was done. One might "sharpen" a Romberg by having the person do something other than close their eyes -- for example, tilt their head upwards.

The examiner chooses the most difficult variant that the subject might be able to perform, asks the examinee to assume the position, and times their ability to stay in that position for at least 6 seconds. If the examinee has to take a step, then the examiner has them try again, using an easier variant.

Practically then, for a normal persion, an examiner might ask them to "stand like me with, heel to toes", and then once that is done, "Ok, now please close your eyes". If a person can stand like that for 6 seconds, the examiner records "ECTR 6 seconds". Generally 6 seconds is considered normal, although many individuals can stand this way for far longer periods. It is prudent for the examiner to stand next to the patient, with hands next to the patient's shoulders, in case the patient starts to fall in any direction.

The Romberg test is thought to be more reliable if footware is removed -- as larger shoes make the test easier. One would also not want to do Romberg testing on someone wearing spike heels. Socks are generally retained.

If the patient cannot perform the ECTR, then the examiner chooses an easier variant, such as EOTR, and has them try again. It is important to note that if a subject can perform the hardest test -- e.g. the ECTR successfully, there is no need to also check for easier variants. However, one might occasionally want to do this if one is concerned about malingering and looking for inconsistency.

Romberg
Tandem Romberg test -- heel to toe.

There are many Romberg variants -- the simplest is the "Head up ECTR", meaning the head is tilted upwards towards the ceiling. This test is more difficult than any of the other Romberg tests, and in fact, only about 25% of the normal population can perform it.

One can also have individuals perform the Romberg test on a foam block, which makes it much harder as well. This is sometimes called the "modified Romberg" (Agrawal et al, 2011). Of course, this term is very vague and might mean any of the other variant Rombergs discussed above, or standing in tandem while "whistling Dixie" (there are some variants of the Field Sobriety Test that use distraction).

The "Head-shake Romberg test" is a variant where the core test is performed while the patient is shaking their head in the horizontal plane. This makes the test more sensitive to vestibular disorders (Reicke, 1992).

Fregly ataxia battery

An interesting Romberg variant, funded by the military, was described by Fregly and Graybiel (1968). These tests were first done using "rails", basically an "L" shaped piece of metal to standardize the base of support, and performance (either you are on or off the rail). An immense amount of subjects were tested (largely from the military of course), and the battery including Romberg testing. Unfortunately, subjects wore shoes. This variant Romberg battery was reported by Graybiel and Fregley as being highly sensitive to vestibular disturbances. (1966)

There are also many variants of the Romberg test. Some involve more equipment (e.g. Foam/Dome), or a computerized measurement system (e.g. Computerized Dynamic Posturography). The Foam/Dome test is mainly used to comply with Medicare billing requirements so as to charge for doing the Romberg test. The Computerized Dynamic Posturography implementation is very useful in detecting malingering, as well as following balance in a somewhat less subjective way.

 

Fukuda
The author of this page, Dr. Hain, performing the Fukuda test on a mat designed for this purpose.

There are also numerous other tests that measure some aspect of balance such as the Unterberger test, the Walzing test, and the Fukuda test, the Functional reach test, various questionnaires, standing on one foot, Timed up and go test (TUG), Dynamic gait index, Functional Gait assessment, Tinetti FOF, Activies balance confidence (ABC) etc. According to Perennou et al (2005) most of the more quantitative tests are unvalidated. We are particularly dubious about the subjective -- questionnaire assessments of balance such as the ABC, which would seem likely to be widely variable depending on personality. Still they seem better than having no measure at all.

Recently "apps" on smartphones have been developed to quantify the Romberg (Galan-Mercant and Cuesta-Vargas, 2014). This method is far cheaper than static posturography, and seems to us to be a reasonable advance. Similar smartphone apps can be used to quantify rotation, such as from the Fukuda test or the Unterberger test (Whittaker et al, 2014).

Pitfalls with Romberg testing

The main critique of Romberg testing as well as similar upright tests such as the Unterberger test, the Walzing test, and the Fukuda test, is high variability (Black et al, 1982). The eyes-open regular posture is very easy, and everyone passes; the eyes closed, tandem, and foam variants of the Romberg are challenging, and much more variable. (Diamantopoulos et al, 2003). That being accepted, neverthless the ability to perform one of these difficult tests such as the eyes-closed tandem Romberg would still seem useful information. Diamantoupoulos et al (2003) reported that there were no learning effects. We are a little dubious about this, as we have seen patients improve greatly on the spot.

All balance tests tend to worsen with age. This is another pitfall -- one must keep in mind that 20 year olds have better balance (by and large) than 80 year olds.

What is the Romberg test good for ?

Balance is not easy, and one's upright posture is continuously maintained through feedback from eyes, ears, feet, combined with ones internal idea of where one is in space. The original Romberg test compared vision to no-vision, in a regular stance, thus taking away visual feedback. The tandem Romberg, both increases the demands on stability by narrowing the base, as well as reduces useful sensory feedback from the feet. We currently have no common Romberg variant where vestibular input is removed or distorted, but one could imagine ones in which balance was attempted during (for example), caloric irrigation or galvanic stimulation. The head-shake Romberg test is an attempt to do this, but it has not become popular.

In addition to sensory input, the Romberg also assesses the ability of the cerebellum to coordinate movement, and of course also requires adequate power to hold one upright. Thus there are many systems that play a role.

Historically, the Romberg test was used to detect neurosyphilis. In advanced neurosyphilis, the posterior columns of the spinal cord are damaged, reducing feedback from the feet. Severe posterior column disease from syphilis is now encountered rarely. There are still a few persons with advanced posterior column disease from B12 deficiency, or that have other sensory disturbances such as dorsal root ganglion disease.

The tandem-Romberg is more difficult and also reduces proprioceptive input. When combined with eyes-closed, the main remaining sensory input is vestibular input. Thus most patients with severe bilateral vestibular loss are unable to perform ECTR for 6 seconds.

The difference between eyes closed and eyes open Romberg can be used to infer cerebellar disorders, such as for example, alcoholism. Persons with cerebellar ataxia are unsteady with eyes open as well as more unsteady with eyes closed. They are unable to use sensory information as well as persons with a normal central nervous system.

One would expect that the ECTR test would be sensitive to vestibular imbalance, as without vision and with less proprioception, the patient is then forced to rely mainly on their vestibular system. Longridge and Mallinson (2010) were not successful in their implementation of the Romberg test in detecting vestibular disorders. The author of this page has had the opposite experience, and instead believes that Romberg tests are very useful in detecting active vestibular disorders. Perhaps the difference lies in how the test is done. Nevertheless, Jacobson et al (2011) also concluded that a bvaariant of the Romberg test called the "Romberg Test of Standing Balance on Firm and Compliant Support Surfaces (RTSBFCSS)", basically a foam method of sharpening the Romberg, "should not be used as a screening measure for vestibular impairment. "

 


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Copyright August 3, 2016 , Timothy C. Hain, M.D. All rights reserved. Last saved on August 3, 2016