A positive Romberg’s sign refers to a patient’s inability to maintain balance when standing erect with his feet together and his eyes closed. Normally, the patient should be able to stand with his feet together and his eyes closed with minimal swaying for about 20 seconds (a negative Romberg’s sign). (See Assessing Romberg’s sign, page 586.)
If positive, Romberg’s sign indicates a vestibular or proprioceptive disorder or a disorder of the spinal tracts (the posterior columns) that carry proprioceptive information — the perception of one’s position in space, of joint movements, and of pressure sensations — to the brain. Insufficient vestibular or proprioceptive information causes an inability to execute precise movements and maintain balance without visual cues. Difficulty performing this maneuver with eyes open or closed may indicate a cerebellar disorder.
Obtain the patient’s medical history. Ask him about previous neurologic symptoms and disorders. Once you’ve detected a positive Romberg’s sign, perform other neurologic screening tests. Also, ask the patient if he has noticed sensory changes, such as numbness and tingling in his limbs. If so, when did these changes begin?
First, test proprioception. If the patient can’t maintain his balance with his eyes open, ask him to hop on one foot and then on the other. Next, ask him to do a knee bend and to walk a straight line, placing heel to toe. Lastly, ask him to walk a short distance so you can evaluate his gait.
Test the patient’s awareness of body part position by changing the position of one of his fingers, or any other joint, while his eyes are closed. Ask him to describe the change you’ve made. Next, test the patient’s direction of movement. Ask him to close his eyes and to touch his nose with the index finger of one hand and then with the other. Ask him to repeat this movement several times, gradually increasing his speed. Then test the accuracy of his movement by having him rapidly touch each finger of one hand to the thumb. Next, test sensation in all dermatomes, using a pin to assess sharp/dull differentiation. Also test two-point discrimination by touching two pins (one in each hand) to his skin simultaneously. Does he feel one or two pinpricks? Finally, test and characterize the patient’s deep tendon reflexes (DTRs).
To test the patient’s vibratory sense, ask him to close his eyes; then apply a mildly vibrating tuning fork to a bony prominence such as the medial malleolus. If the patient doesn’t feel the stimulus initially, increase the vibration and then test the knee or hip. This procedure can also be done to test the fingers, elbow, and shoulder.
Early features of multiple sclerosis may include vision changes, diplopia, and paresthesia. Other findings include a positive Romberg’s sign, nystagmus, constipation, muscle weakness and spasticity, and hyperreflexia. The patient may also have dysphagia, dysarthria, incontinence, urinary frequency and urgency, impotence, and emotional instability.
Besides a positive Romberg’s sign, advanced peripheral nerve disease may produce impotence, fatigue, and paresthesia, hyperesthesia, or anesthesia in the hands and feet. Related findings include incoordination, ataxia, burning pain in the affected area, progressive muscle weakness and atrophy, and loss of vibration sense. DTRs may be hypoactive.
Pernicious anemia impairs myelin formation, which causes neurologic damage. A positive Romberg’s sign and loss of proprioception in the lower limbs reflect peripheral nerve and spinal cord damage. Gait changes (usually ataxia), muscle weakness, impaired coordination, paresthesia, and sensory loss may be present. DTRs may be hypoactive or hyperactive. Other findings include a sore tongue, a positive Babinski’s reflex, fatigue, blurred vision, diplopia, and light-headedness.
With spinal cerebellar degeneration, a positive Romberg’s sign accompanies decreased visual acuity, fatigue, paresthesia, loss of vibration sense, incoordination, ataxic gait, and muscle weakness and atrophy. DTRs may be hypoactive.
With spinal cord disease, a positive Romberg’s sign may accompany pain, fasciculations, muscle weakness and atrophy, loss of sphincter tone, and loss of proprioception, vibration, and other senses. DTRs may be hypoactive at the level of the lesion and hyperactive above it.
Besides a positive Romberg’s sign, vestibular disorders commonly cause vertigo. Nystagmus, nausea, tinnitus, hearing loss, and vomiting may also occur.
Help the patient with ambulation, especially in poorly lit areas. Also, keep a night-light on in his room, and raise the side rails of the bed.
Romberg’s sign can’t be tested in children until they can stand without support and follow commands. However, a positive sign in children commonly results from spinal cord disease.
Encourage the patient to ask for assistance and to use visual cues to maintain his balance. Instruct him in the use of assistive devices if necessary.
Review other book chapters online related to Parry Romberg Syndrome:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1 
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