Neurological examination - confused regarding Rombergs

[Rombergs]

Hello.

I'm a medical student living in Sweden, currently trying to fully grasp the complete neurological examination. I have, however, encountered a question which I can't find the answer to, and hope that you might help with it.

From what I've read, balance is maintained through input from three sensory systems - vision, vestibular and proprioception. Two out of three of these systems need to be intact to maintain balance. Most sources claim that Rombergs test is not a test of cerebellar function, but rather proprioception as a tendency to fall with eyes closed indicate that either vestibular or proprioceptive dysfunction (Romberg's test - Wikipedia). What I dont understand, is how you can tell that a positive Rombergs is due to a proprioceptive dysfunction rather than a vestibular dysfunction. The best explaination I've read is that the test is nonspecific and could indicate either vestibular-, proprioceptive- or cerebellar dysfunction, or even a combination (Romberg's Test - an overview | ScienceDirect Topics.) This is however not mentioned anywhere else, at least not to my knowledge.

Could anyone of you help me understand this better?
Thanks!

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[xenotype]

Your reading is correct. It is very non-specific, but a useful tool for screening for length dependent neuropathies. It is not useful in ER settings where physicians/midlevels that don't understand the limitations of the test think it indicates an acute vestibular lesion. Another confounder is that a posterior column lesion also will cause a positive romberg- the test does not give you any indication where the proprioceptive lesion is and only a careful, thorough neuroexam will ferret that out- often there is more than one process going on such as a cervical myelopathy from canal stenosis plus diabetic neuropathy. Tandem gait is another test that integrates a lot of different systems, thus when it is abnormal it is not so useful for localization.

 

[deathmerchant]

Hello.

I'm a medical student living in Sweden, currently trying to fully grasp the complete neurological examination. I have, however, encountered a question which I can't find the answer to, and hope that you might help with it.

From what I've read, balance is maintained through input from three sensory systems - vision, vestibular and proprioception. Two out of three of these systems need to be intact to maintain balance. Most sources claim that Rombergs test is not a test of cerebellar function, but rather proprioception as a tendency to fall with eyes closed indicate that either vestibular or proprioceptive dysfunction (Romberg's test - Wikipedia). What I dont understand, is how you can tell that a positive Rombergs is due to a proprioceptive dysfunction rather than a vestibular dysfunction. The best explaination I've read is that the test is nonspecific and could indicate either vestibular-, proprioceptive- or cerebellar dysfunction, or even a combination (Romberg's Test - an overview | ScienceDirect Topics.) This is however not mentioned anywhere else, at least not to my knowledge.

Could anyone of you help me understand this better?
Thanks!

Just like most signs and symptoms in neuro and in medicine, its not very specific and there are exceptions and variations. The best you can say with a Rhomberg's is if a person has truncal/wide based ataxia AND if cerebellum is involved or is it more of a sensory/peripheral ataxia.

 

[Rombergs]

Thanks a lot for clarifying, I really appreciate it!

 

[neurodoc]

I have a slightly different take on this based on my clinical experience. IMO the Romberg test is quite useful for detecting dysfunction of proprioception, provided you know how to interpret it. As noted, maintaining static balance depends on intact visual, proprioceptive, and vestibular feedback. A common misconception is it tests cerebellar function. Patients with midline cerebellar disease cannot maintain balance even with intact visual and proprioceptive and even vestibular feedback loops and they will be unsteady with eyes open or closed. You still may be able to use the test in patients with mild cerebellar dysfunction by allowing a slight widening of the base until he's steady with eyes open.

In my experience patients who have vestibular dysfunction show some unsteadiness on Romberg testing that is perceptible even before they close their eyes and which shows little or no improvement with slight widening of the base. The point is that in a patient who is rock steady with eyes open and feet together and who becomes very unsteady with eyes closed almost certainly suffers from proprioceptive malfunction.