Question

Discuss how your balance differs from the Romberg to the sharpened Romberg test.

Answer 1

The Romberg test:

The Romberg test is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal proprioception involving information about the location of the joints. It is also proven to be sensitive and accurate means of measuring the degree of disequilibrium caused by central vertigo, peripheral vertigo and head trauma.

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 for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.

Equilibrium is defined as any condition in which all acting forces are cancelled by each other resulting in a stable balanced system. It is maintained through the sensory information from vestibular, somatosensory and visual systems. A patient who has a problem with Proprioception (Somatosensory) 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 simpler. 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.

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.

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 close 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.

Sharpened 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.

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 proprioceptive impairments in comparison to other confounding factors.

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.

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.

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. A decreased performance time on the modified Romberg is associated with a concomitant rise in the risk of falling.

There is no consensus in the Reliability (Intra and inter) and validity for Romberg's in the literature as the test is more of qualitative rather than quantitative (Objective). However, this test can be used as a quick clinical tool to screen. The introduction of various instruments in the arena of balance assessment and the force platform usage has given the more objective and accurate measurement.