Romberg test: what it is, how it is done and what the result means

The Romberg test, also called the Romberg sign or Romberg manoeuvre, is a simple part of the neurological examination. It is named after the European neurologist Moritz Romberg (1795 to 1873), who described it in the 19th century as a sign of lost position sense in patients with neurosyphilis (tabes dorsalis). It is quick, safe and needs no equipment, which is why it is still used in clinics and on wards.

Staying upright relies on three sources of information: vision, the balance organs of the inner ear (the vestibular system) and proprioception, the sense of where your body and limbs are in space. If one is weak, the other two usually compensate. The Romberg test works by removing vision, so that any weakness in proprioception or the vestibular system has nothing to hide behind.

You are usually asked to take your shoes off and stand with your feet together, with your arms by your sides or folded across your chest. The examiner stands close to you as a precaution against a fall.

There are two stages. First you stand with your eyes open while the examiner observes how steady you are. Then you close your eyes and the examiner watches for swaying, stepping or falling. StatPearls describes the examiner watching for balance impairment for a duration of one minute with the eyes closed.

• Stage 1: eyes open, feet together, usually steady in most people.

• Stage 2: eyes closed, with the examiner standing close.

• Positive: increased sway, foot movement or falling once the eyes are closed.

• Variations: a sharpened Romberg uses a heel-to-toe stance to make the test more sensitive.

StatPearls says a positive Romberg test denotes sensory ataxia, unsteadiness caused by loss of the position information that comes from the legs and spinal cord. Conditions it lists as causing a positive test include loss of proprioception in myelopathies (spinal cord disorders) and sensory neuropathies, vitamin B12 deficiency affecting the spinal cord, tertiary syphilis, and uncompensated vestibular dysfunction. It also lists disease of the front part of the cerebellum.

A positive result is therefore a reason for further assessment, not an answer. A clinician will usually go on to check sensation, reflexes, strength and walking. StatPearls mentions focused laboratory testing, for example for vitamin B12 deficiency or syphilis, where the findings suggest it.

A paper in Frontiers in Neurology points out that Romberg himself was probably unaware that a similar loss of balance can be caused by vestibular loss, and that this ambiguity complicates interpretation. Marked sway can be seen in both central and peripheral lesions, and in people with acute vestibular symptoms the authors describe eye-movement signs known by the acronym HINTS as more suitable than the Romberg test for separating a central cause such as a posterior circulation stroke from a benign inner ear disorder.

StatPearls adds that a person with cerebellar disease is often unsteady with the eyes open as well, and that a negative Romberg test does not confirm cerebellar dysfunction. In other words, the test is most useful for spotting a problem that depends on vision to stay balanced.

StatPearls describes the Romberg test as a simple bedside test for people presenting with imbalance, dizziness or unexplained falls. You may be asked to do it if you report feeling unsteady in the dark, when washing your face with your eyes closed, or after a change in sensation in the feet. It is also used in assessing fall risk in older adults and in some neurological follow-up.

Next steps depend on the rest of the examination and your history. They may include a fuller neurological examination, blood tests for causes such as vitamin B12 deficiency, further assessment of the spinal cord and nerves, or referral to a neurologist, or to a balance or ear specialist if an inner ear cause is suspected. If a sudden loss of balance comes with other symptoms such as weakness, speech change, double vision or severe headache, that is an emergency and needs urgent care rather than an outpatient test.

Wear comfortable clothing and tell the examiner if you have had falls, joint pain or a condition that makes standing difficult. The examiner stands close by during the test as a precaution, and StatPearls describes modified versions of the test that are used for particular purposes, such as assessing fall risk.