Romberg's Sign
Romberg's Sign: Excerpt from In a Page: Signs and Symptoms
Romberg testing is used to examine proprioception and, to some extent, cerebellar function. The test is performed by having the patient stand with feet together and eyes closed, which eliminates the visual cues that help to maintain posture. Patients with diminished proprioception begin to fall or move their feet to maintain balance. Patients with vestibular dysfunction may also exhibit Romberg's sign.
Differential Diagnosis
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Myelopathy
–Multiple sclerosis
–Vitamin B12 deficiency
–Structural spinal cord disease
(e.g., spondolytic myelopathy, tumor)
–Infectious myelopathy (e.g., tabes dorsalis, HIV-related vacuolar myelopathy)
Peripheral neuropathy: Affects large diameter,
myelinated fibers
–Vitamin B12 deficiency
–CIDP
–MGUS
–Inherited demyelinating neuropathies
(e.g., Charcot-Marie-Tooth disease)
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Cerebellar dysfunction
–Multiple causes (e.g., CVA, brain tumor)
–Most patients with midline cerebellar
dysfunction have difficulty standing on a narrow base; this effect will not appreciably worsen with eye closure
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Vestibular dysfunction (peripheral)
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Drug intoxication
–Alcohol
–Cisplatin
–Pyridoxine (vitamin B6) overdose
–Anticonvulsant toxicity (especially
phenytoin) may cause difficulty standing on a narrow base, but this may not necessarily worsen with eye closure
-
Friedreich's ataxia
-
Miller-Fisher variant of Guillain-Barré syndrome
-
Paraneoplastic sensory neuropathy
-
Vitamin E deficiency
Workup and Diagnosis
- History and physical examination with comprehensive
neurologic examination
–Elicit Romberg test
–Be sure to focus on other tests of proprioception,
cerebellar function, and strength (e.g., finger-to-nose testing)
–Most patients with a positive Romberg's sign will also exhibit abnormal proprioception and vibratory testing
-
Labs may include CBC, electrolytes, glucose, calcium, BUN/creatinine, ESR, vitamin B12 and folate levels, RPR, drug screen, and serum/urine protein electrophoresis
-
EMG/nerve conduction studies testing is the best way to objectively document or exclude a large-fiber, sensory neuropathy
-
MRI is the most effective imaging option if structural spinal cord or cerebellar disease is suspected
-
CSF examination may reveal elevated protein in CIDP or Miller-Fisher variant of GBS; multiple sclerosis patients may have oligoclonal bands or an elevated IgG index
Treatment
-
Tell patients to be cautious when standing with eyes closed (such as when standing under the shower) or in poor lighting (such as when going to the restroom at night) to prevent falls
-
Assistive devices (e.g., cane, walker) may be useful
-
Surgical therapy may be necessary for compressive myelopathy, such as spondolytic myelopathy
-
Supplementation for deficiency states
–Patients with B12 deficiency require further evaluation to determine the cause of the underlying deficiency and if parenteral supplementation is necessary
-
Eliminate exposure to offending toxic substances
-
Inflammatory demyelinating neuropathies (e.g., CIDP) may improve with steroids or other immunosuppressive drugs, periodic infusion of IVIG, or plasmapheresis
-
Infectious causes may be treated with the appropriate anti-infective agent (e.g., penicillin for tabes dorsalis)
-
Multiple sclerosis is treated with steroids, interferons, glatiramer acetate, mitoxantrone
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Romberg's sign (Professional Guide to Signs & Symptoms (Fifth Edition))
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