K. Jeffrey Miller, DC, MBA
Editor’s Note: This article is the latest installment of Dr. Miller’s periodic “Dynamic Diagnosis” series: concise anecdotes designed to serve as clinical pearls for your practice.
The Romberg test is a neurological procedure used to assess balance and can be used to gauge a patient’s risk of falling. Unfortunately, the test itself is a fall risk. The fall risk is not huge, and falls are not frequent. However, I have encountered a few situations that have influenced how I use and teach the test.
Fortunately, modifications are available to address the situation. The modifications are simple, do not affect the physiology or interpretation of the test, and provide a safety feature not usually associated with the test.
Balance depends on three physiological elements: proprioceptive, visual, and inner ear functions. Romberg challenges these functions, and the test can be amended to enhance its diagnostic utility.
The Basic Romberg Test – and Why It Can Be Risky
In the basic version of Romberg’s, the patient is instructed to stand with his/her feet parallel and together. The patient is then asked to close his/her eyes and maintain this position.
The patient should be able to hold the position for several seconds with minimal or no swaying. This response is the negative test result. In the positive test result, the patient would sway significantly or start to fall.
Instruction for the test usually depicts the patient standing alone or with the doctor nearby to spot the patient. There is not much preventing the patient from hitting the floor if he/she is standing alone, and the situation is not much safer with the doctor spotting the patient. It is hard for anyone to catch and control the dead weight of a falling patient.
The patient and the doctor risk injury in these situations.
The Enhanced (Safer) Version
An enhanced version of the test places the patient’s feet in partial and full tandem positions. It is harder to stand in tandem than with the feet parallel. The test’s sensitivity improves with tandem positioning, but the risk of falling also increases.
To enhance safety, perform the test with the patient approximately 18 inches from the wall, with his/her back to the wall. The doctor stands facing the patient, arms extended, and hands near the patient’s deltoid areas.
If the patient becomes unstable or begins to fall during the test, grab the patient’s shoulders and push the patient against the wall while instructing him/her to open his/her eyes.
This version of performance stabilizes the patient with a positive result, or in the worst-case scenario, the patient will slide down the wall. These situations are pathological test results.
Using an examination room wall to help spot a patient can also be utilized for other tests. The stork test, aka the one-leg standing extension test for spondylolysis or spondylolisthesis, is a good example. Balance issues are created during the test, as the patient is required to stand on one leg and extend the lumbar spine with the eyes open. Even with the eyes open, the test presents safety issues.
One Final Safety Tip
When possible, avoid tests performed with the patient in a standing position. If another test is available that does not require a standing position, tests for the same functions or pathologies, and has similar or better sensitivity and specificity, use it instead.
