Romberg test

Description

This sensory ataxia is a manifestation of impaired proprioception unmasked by loss of visual input.

Romberg test was initially described in tabes dorsalis but is now recognised as a feature of all proprioceptive disorders of the legs and other neuropathies involving the dorsal columns.

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.

History

Earlier accounts of tabes dorsalis or sensory ataxia are noted in the literature and include the following:

1836 – Marshall Hall (1790-1857) described a case of sensory ataxia in 1836 in relation to a patient who

…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.’

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.

1840 – Bernadus Brach was also credited with an early description of tabes dorsalis.

1847 – Robert Bentley Todd provided a particularly detailed account which led Gowers to write:

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

Gowers WR, 1888: 286

1858 – Duchenne described ‘De l’ataxie locomotrice’ [locomotor ataxy]’

Despite these preceding observations it may be argued that only Romberg truly described a clinical test of which he recognised the diagnostic utility.

The feet feel numbed in standing, walking or lying down, and the patient has the sensation as if they were covered in 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.”

Romberg 1846: 795

• Romberg acknowledged Bell for first describing proprioception, or “positional sense”, in 1826.
• Although wasting of the spinal cord and associated roots was remarked upon, the pathophysiological role of the dorsal columns was unrecognised by Romberg (“as yet we possess no microscopic investigation of the atrophied portion”)
• Gowers later 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”. There remains little consensus on how long a patient should stand for however and what degree of postural sway or instability constitutes a positive test. [Gowers WR, 1888 pp289]

Clinical application:

• It has been suggested that uncompensated acute unilateral or bilateral vestibular impairment may also result in a positive Romberg test when vision is eliminated however this is controversial. (Barany 1910, Rogers 1980, Weber 1993)
• Although long-considered useful to discriminate between sensory and cerebellar ataxia, others propose that Romberg’s sign may also occur in pathology affecting the spino-cerebellum in particular. (Mauritz 1979, Deiner 1992)
• Others have argued that the test unnecessarily exposes patients to harm through risk of falling and is superseded by safer methods of testing proprioception. (Turner 2016).
• Variation in positioning, technique and interpretation are all likely affect test specificity and sensitivity.

Associated Persons

• Moritz Heinrich Romberg (1795-1873)
• Sir Charles Bell (1774-1842)
• Marshall Hall (1790-1857)
• Bernadus Brach
• Ernst Horn (1774-1848)
• Robert Bentley Todd (1809-1860)

Alternative names

• Romberg’s sign
• Brauch-Romberg sign

References

• 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
• Todd RB. The cyclopædia of anatomy and physiology. London. 1847; 3: 721
• Romberg MH. Tabes Dorsualis. In: Lehrbuch der Nervenkrankheiten des Menschen. Berlin. 1846; 1: 794-801.
• 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
• Hall M. Lectures on the nervous system and its diseases. 1936 [‘Romberg’s sign’ description pp20]
• 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