The Romberg's sign or Romberg's test is a phenomenon named by 19th-century European neurologist, Mortiz Romberg. Initially, this sign was tethered specifically with tertiary syphilis patients who exhibited neurologic signs of late-stage disease referred to as locomotor ataxia, or tabes dorsalis.[1]

When examining a patient's neurological effects from sequelae involving late-stage syphilis, the Romberg sign became a precise test to determine the integrity of the dorsal column pathway of the brain and spinal cord, which controls proprioception. Proprioception is the sense of awareness of the position and movement of the body. Romberg described this sign as a severe postural impairment in a darkroom setting or with eyes closed of patients who had severe damage to the posterior dorsal columns of the spinal cord. Used as a precise clinical tool, the Romberg test is positive if a patient is unable to maintain an upright stance with vision eliminated or in the darkness.[1] 

Often the Romberg test can be confused as a sign of cerebellar disease, but instead, this test demonstrates the effects of posterior column disease. The ability to gage true proprioception status can be confounded by the vestibular and vision somatosensory system, which may compensate with vestibular function and vision.[2] The Romberg sign removes the visual and vestibular components that contribute to maintaining balance, and can thus identify specifically a proprioception-related neurologic disease. 

Neuroanatomy 

The dorsal column is a three order neuronal pathway that functions as a method of signal transmission throughout the spinal cord to the brainstem. This pathway specifically controls conscious appreciation of vibration, fine touch, 2-point discrimination, and proprioception.[3] Specifically, in cases of neurosyphilis, or tabes dorsalis, there is demyelination of the axonal fibers of the posterior column or dorsal pathway of the spinal cord. This demyelination leads to severe sensory deficits of the pathway, including position sense or proprioception.[3]

Anatomically, the cerebellum is also involved in truncal and extremity balance and coordination. It is inferior to the occipital lobe; it contains two lateral hemispheres lesions and one medial vermis. The cerebellum is associated with the movement of the body and is part of the human brain, which allows the body to make voluntary and coordinated movements and balance.[4]

Although the cerebellum is also involved with coordination, Romberg's test detects the integrity of the posterior dorsal columns and proprioception, the body's awareness of its own movement and position in space. It is important to understand that a negative Romberg test does not confirm cerebellar dysfunction, but the clinician may rule in the etiology of ataxia due to cerebellar damage. It is crucial to note that both the dorsal column and cerebellar damage may both result in ataxia.[3]

Physiology and Disease States Affecting Proprioception 

Sensorimotor integration of the body is dually controlled by cerebellar input and the posterior column medial lemniscus tracts. The dorsal columns carry proprioception sense (sense of position and joint sense). Important sensory inputs to maintain balance include three peripheral modalities: vision, the vestibular apparatus, and proprioception.[5]

Another disease state that involves the dorsal column and proprioception disruptive behavior is the late complication of vitamin B12 deficiency, termed subacute combined degeneration of the spinal cord (SCD). This condition is an example of the degeneration of the posterior column pathway due to the disrupted formation of myelin and, thus, nerve transmission through saltatory conduction.[3] 

Due to the demyelination, the nerve impulse conduction is disrupted and result in clinical proprioceptive impairment. In addition to the late sequelae of Vitamin B12 deficiency, a clinical state involving the vasculature of the spinal cord can also result in a clinical manifestation such as ataxia and proprioceptive deficit. Posterior cord syndrome is a clinical disease state result from posterior spinal artery infarction. This sequel can involve impairment of vibration sense, proprioception, and loss of reflexes below the lesion with sparing of pain and temperature sensation.[3] 

Lastly, in a hemisection of the spinal cord, known as Brown-Sequard syndrome, the posterior column pathway of the spinal cord is usually affected. Most cases of Brown-Sequard syndrome are related to trauma. The classic clinical picture involves ipsilateral hemiparesis, loss of vibration and proprioception, and contralateral loss of pain and temperature.[3]

These disease states mentioned above may all result in ataxia as well as many other physical manifestations. To rule out certain disease states, such as Brown-Sequard syndrome, as the etiology for a proprioceptive deficit, taking a thorough past medical history, including trauma history, by the evaluator is crucial for early goal-directed care. 

The Romberg maneuver is a commonly performed test during the neurological exam. It is a valuable clinical sign to evaluate the integrity of the dorsal columns of the spinal cord and is particularly useful in patients with ataxia or severe incoordination.[5] 

Although ataxia may develop gradually and insidiously, the screening test is indicated when the patient admits a deficit inability to move around in the dark or even maintain balance when washing his/her face. In disease states with severe proprioceptive impairment, the patient may even exhibit a noticeable degree of impairment when standing with the feet together.[1] When the patient may display clinical signs or evidence of inability to maintain postural station, or the power to stand steady with eyes open or shut, the diagnostic Romberg test and test of postural sway may be indicated.[1]

The Romberg test is quite useful in a broad range of neurologic disease states in assessing and confirming various neurological conditions including but not limited to Parkinson disease (causes postural instability and a shuffling gait), Friedreich ataxia (causes staggering gait and frequent falls), Vitamin B12 deficiency (causes ataxia gait), Tertiary syphilis (causes sensory ataxia; impaired proprioception), Normal pressure hydrocephalus in the elderly (truncal ataxia with falls), and Wernicke's syndrome (associated with chronic alcoholism which causes limb ataxia), and Ménière's disease.[6]

The current literature demonstrates safety in performing the test under the supervision of the patient and following the correct procedure.

No additional medical equipment is necessary for this test. The Romberg test does not require any equipment or instrumentation to diagnose a proprioceptive impairment or injury to the dorsal column medial lemniscus pathway. Although the test can be subject to error, accuracy is based solely on the patient's ability to follow the directions and steps of the examination. Only a trained medical professional should perform this test in a safe environment.