Romberg Sign

Clinical testing varies but commonly the patient stands unsupported with eyes closed and feet together for approximately 30 seconds. A positive test is indicated by loss of balance or unsteadiness which is not seen when the eyes are open.

• The patient stands with feet together, first with eyes open and then closed for ~30 seconds.
• Positive Romberg sign: patient is steady with eyes open but markedly sways or falls with eyes closed.
• Negative Romberg sign: in cerebellar ataxia, where instability is present even with eyes open.

Initially considered pathognomonic for tabes dorsalis, the Romberg test is now applied across conditions affecting:

• Dorsal columns (e.g., neurosyphilis, B12 deficiency, myelopathy)
• Peripheral large-fibre neuropathy (e.g., diabetes, sensory neuronopathies)

Originally considered pathognomonic for tabes dorsalis, it is now recognized in:

• All proprioceptive disorders of the legs
• Sensory neuropathies (e.g., B12 deficiency, peripheral neuropathy)
• Occasionally debated in vestibular dysfunction

Clinical Significance (Modern Perspective)

Romberg’s sign endures as an elegant bedside test but is controversial in modern neurology.

• It translates the patient’s complaint—“I feel unsteady in the dark”—into a reproducible sign, highlighting the integration of proprioceptive, visual, and vestibular input in balance.
• Still regarded as a useful discriminator between sensory and cerebellar ataxia.

However, Turner (2016) argues:

It is neither sensitive nor specific for its original purpose… and the positive result is the patient falling to the floor.

He advocates abandoning the test in favor of safer, targeted methods (e.g., great toe proprioception). Others disagree. Counihan (2016) defends its value:

The essential component of Romberg’s test is the emergence of ataxia on eye closure. It is reproducible and localisable…If properly conducted, Romberg’s test exonerates the cerebellar vermis and remains a reproducible, localisable sign reinforcing anatomical understanding.

Modern debate underscores the tension between clinical tradition and evidence-based safety.

Clinical Caveats

• Technique variability: stance width, duration, and definition of “sway” affect reliability.
• Vestibular disorders: may occasionally cause Romberg positivity, though interpretation is debated (Bárány 1910; Rogers 1980).
• Spino-cerebellar disease: Romberg may occur when proprioceptive pathways within the cerebellum are impaired (Mauritz 1979; Diener 1992).

---

History of Romberg’s sign

1836 – Marshall Hall (1790-1857) In Lectures on the Nervous System and its Diseases, Hall described a patient with sensory ataxia. Hall recognized the compensatory role of vision but did not formalize this observation into a clinical test.

He walks safely while his eyes are fixed upon the ground, but stumbles immediately if he attempts to walk in the dark. His own words are: ‘My feet are numb; I cannot tell in the dark where they are, and I cannot poise myself.

Hall, 1836

1840 – Edward Stanley (1793-1862) presented “A Case of Disease of the Posterior Columns of the Spinal Cord,” top the Royal Medico-Chirurgical Society. He describes a patient with progressive motor impairment of the lower limbs, no sensory loss, and on autopsy:

No disease whatever was found in the anterior columns of the cord. An extensive change of structure and colour was… manifested in the posterior columns, from the pons to the lower end of the cord… The value of this case consists in the distinctness of its phenomena.

Stanley 1840

This was the first clear pathological report of posterior column disease in a patient with preserved sensation, but associated with severe motor impairment (not yet distinguishing sensory ataxia from weakness).

1840 – Bernadus Brach was also credited with an early description of tabes dorsalis. He described patients with tabes dorsalis who “raised their legs slowly to maintain balance” and were “helpless in the dark.” Well summarised in a patients letter to Brach

I must watch carefully every step and stone. I must use my eyes to guide me. In the dark I have no sense of balance… I step so hard on my feet that my soles are sore and inflamed after a short distance.

1840 – Romberg’s teacher, Ernst Horn (1774-1848), observed dorsal cord atrophy at autopsy in a patient with tabes dorsalis, a finding which was further described by five of his post-doctoral students during the period 1817-1827.

1846 – Moritz Heinrich Romberg (1795–1873) provided a detailed account of the pathognomonic phenomenon in his 1846 Lehrbuch der Nervenkrankheiten transforming observation into a clinical sign

The feet feel numbed in standing, walking, or lying down, and the patient has the sensation as if they were covered with a fur… If he is ordered to close his eyes while in the erect posture, he at once commences to totter and swing from side to side; the insecurity of his gait also exhibits itself more in the dark…It is now ten years since I pointed out this pathognomonic sign… in no case have I found it wanting.

Romberg 1846; 1: 794–801

1847 – Robert Bentley Todd (1809-1860) provided a particularly detailed account in his Cyclopaedia of Anatomy and Physiology in distinguishing incoordination from paraplegia:

Two kinds of paralysis of motion may be noticed in the lower extremities, the one consisting simply in the impairment or loss of the voluntary motion, the other distinguished by a diminution or total loss of the power of co-ordinating movements. In the latter form, while considerable voluntary power remains, the patient finds great difficulty in walking, and his gait is so tottering and uncertain that his centre of gravity is easily displaced

Todd, 1847 Cyclopaedia Vol III, 721R

This is the first clear separation of sensory ataxia from simple motor weakness, anticipating the core diagnostic principle underlying Romberg’s sign. He went on to infer posterior column involvement:

In two examples of this variety of paralysis I ventured to predict disease of the posterior columns, the diagnosis being founded upon the views of their functions which I now advocate; and this was found to exist on a post-mortem inspection.

Todd, 1847 Cyclopaedia Vol III, 721R

This shows Todd not only described the clinical syndrome but linked it anatomically to the dorsal columns and confirmed his inference at autopsy, decades before systematic neurohistology.

1858 – Duchenne described ‘De l’ataxie locomotrice‘ [locomotor ataxy]’ and obtained for it (with the help of Trousseau) the recognition that previous descriptions had failed to secure.

1888 – William Gowers (1845-1915) added to Romberg’s description by suggesting that the sensitivity of test may be increased “…when the base of support is narrowed by the feet being placed close together, toes and heels”. He went on to credit Todd as the eponymic principle

The credit of the discovery of the disease belongs, if to any one, unquestionably to Todd

Gowers WR, 1888

---

Associated Persons

• Sir Charles Bell (1774-1842) – introduced concept of positional sense (1826)
• Marshall Hall (1790-1857)– earliest vivid description of visual compensation
• Edward Stanley (1793-1862) – pathological association with posterior columns
• Ernst Horn (1774–1848) – linked pathology to dorsal cord degeneration.
• Bernardus Brach (fl. 1830s–1840s)– early descriptive observations
• Moritz Heinrich Romberg (1795-1873)– formalized the clinical test.
• Robert Bentley Todd (1809-1860) – predictive clinicopathological insight.
• Duchenne de Boulogne (1806–1875) – coined locomotor ataxy.
• William Gowers (1845–1915) – refined the test, historic commentary.

---

Alternative names

• Romberg’s sign
• Romberg’s test
• Historic: Brach-Romberg sign

---

References

Historical references

• Hall M. Lectures on the nervous system and its diseases. 1836
• Brach B. Einige Worte über einen nicht hinlänglich beachteten Punkt aus der Physiologie der Nerven und eine eigenthümliche Art von Lähmung. Medicinische Zeitung 1840; 9: 215–17
• Stanley E. A Case of Disease of the Posterior Columns of the Spinal Cord. London medical gazette 1840; 25: 763-764
• Romberg MH. Tabes Dorsualis. In: Lehrbuch der Nervenkrankheiten des Menschen. Berlin. 1846; 1: 794-801.
• Todd RB. Physiology of the nervous system In: The cyclopædia of anatomy and physiology. London. 1847; 3: 721
• Romberg MH. Tabes Dorsalis. In: A Manual of the Nervous Diseases of Man. [Translation Sieveking EH. London: Sydenham society] 1853; 2: 395–401.
• Duchenne GBA. De l’ataxie locomotrice progressive, recherches sur une maladie caractérisée spécialement par les troubles généraux de la coordination des mouvements. Archives générales de médecine, 1858; 12: 641-52
• Gowers WR. Locomotor ataxy (tabes dorsalis: posterior sclerosis). In: A manual of diseases of the nervous system. 1888: 285-323

Review Articles

• Schiller F. Venery, the spinal cord, and tabes dorsalis before Romberg: the contribution of Ernst Horn. J Nerv Ment Dis. 1976 Jul;163(1):1-9
• Mauritz KH, Dichgans J, Hufschmidt A. Quantitative analysis of stance in late cortical cerebellar atrophy of the anterior lobe and other forms of cerebellar ataxia. Brain. 1979 Sep;102(3):461-82.
• Rogers JH. Romberg and his test. J Laryngol Otol. 1980 Dec;94(12):1401-4.
• Diener HC, Dichgans J. Pathophysiology of cerebellar ataxia. Mov Disord. 1992;7(2):95-109.
• Pearce JMS. Romberg’s Sign. J Neurol Neurosurg Psychiatry. 1993 Jan; 56(1): 51.
• Lanska DJ, Goetz CG. Romberg’s sign: development, adoption, and adaptation in the 19th century. Neurology. 2000 Oct 24;55(8):1201-6.
• Pearce J. Marshall Hall and “Romberg’s sign”. J Neurol Neurosurg Psychiatry. 2005; 76(9): 1241
• Turner MR. Romberg’s test no longer stands up. Pract Neurol. 2016 Aug;16(4):316. doi: 10.1136/practneurol-2016-001365.
• Counihan TJ. Romberg Sign and neuromythology. Pract Neurol. 2016 Oct;16(5):421.